PSI-17: Birth Trauma

Is anyone reviewing PSI-17? I recently began reviewing as our rate is high. at our facility, CDI does not typically review OB/newborns so this is new for me. So far, all of the cases have been for coded cases of 'facial bruising'. It appears that this is being coded when it is part of the assessment after delivery. It seems inappropriate that this should be resulting in a PSI.

I looked for guidance regarding the coding of birth injuries and the only relevant coding clinic I found is very old. CC1994Q1p8

Insignificant conditions or signs or symptoms that resolve without treatment are not coded.

Example: At the time of initial examination an infant is noted to have acrocyanosis, molding of the scalp and facial bruising from the birth process. Later, a nurse notes a fine rash and states that the infant initially had some problem sucking. All of these conditions are resolved or are resolving by discharge. There has been no workup or treatment given for any of these conditions. Unless the physician lists them as definitive diagnoses, do not assign codes for these conditions. See also the Second Quarter Coding Clinic 1989, page 14.


However, I don't see anything in I-10...


Does anyone have any additional information about when/under what circumstances a birth injury should be coded. I am especially interested in any resources I can bring back to our coders.


thanks!


Katy

Comments

  • Katy, what ICD-10 code are the quality folks citing?

    From: https://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V60-ICD10/TechSpecs/PSI_17_Birth_Trauma_Rate–Injury_to_Neonate.pdf

    The only possible one I see is P154 - Birth Injury to Face.  The only includes I see for that from the code book is "Facial Congestion".

    I do not think P154 includes incidental facial bruising (all 9 of my wee ones had it, all 9 were never treated!)

    Good question!

    Mark
  • I guess they could cite P158 - other specified birth injury.  Again, I sincerely believe incidental facial bruising would not quality as a "Birth Injury".

    The intent of the PSI is for real injuries like facial fractures, lacerations, injuries that the hospital could conceivably control or prevent.

    Mark
  • Hi Mark!


    They are coding P15.4.


    This is such a normal condition, it seems inappropriate....

  • and yes, I agree its inappropriate, but they are basically saying that "this is where the pathways takes us" and since the provider is documenting it, it needs to be coded....
  • Yikes!  I would take that up with the Coding, and Quality folks and the Medical Director.  It would be a shame for you folks to be giving yourself numerator inclusions that are not deserved or justified because some coding education is needed...

    Mark
  • Yes, I am in discussion with the coding manager now. I just wish there was some concrete guidance because they are uncomfortable not coding if the MD documents it.

    May submit to coding clinic....

  • This is relevant as an example of how/when to code select conditions.

    VOLUME 3 FOURTH QUARTER

    NUMBER 4 2016, Page 60

    Congenital Sacral Dimple

    A new code that describes a congenital sacral dimple (Q82.6) has been created at the request of the American Academy of Pediatrics to uniquely identify this condition. Congenital sacral dimples are indentations in the skin of the lower back. They are a relatively common condition in neonates which may be benign in nature. However, sacral dimples with accompanying nearby tuft of hair or certain types of skin discoloration may indicate a serious underlying abnormality of the spine or spinal cord such as spina bifida or tethered cord syndrome. It is appropriate to code congenital anomalies when identified by the provider, since they can have implications for further evaluation.

    Coding advice or code assignments contained in this issue effective with discharges October 1, 2016.

    Katy: I just sent you something pertinent from the AHA  ICD-10 Coding Handbook which I can't paste here.

  • Is facial bruising an expected outcome? A common or universal occurrence? How many of us have seen newborns in the hospital *without* facial bruising?  Clinically, P154 does not apply as facial is not injurious. Hematomas are not bruising, contusions are not bruising.  Seems some nuts and bolt clinical and coding alignment can help!

    Mark
  • I agree that bruising should not be uniformly deemed a significant, reportable condition in this group.  This would not require unexpected resources and resolve prior to discharge, having no implication for current or future care.  That is my personal interpretation, supported by the earlier citations from C. Clinic which are still in effect until such time any advice is changed or modified in C. Clinic.
  • Thanks Mark and Paul,


    this has been very helpful. Just going to go over this stuff and hopefully do some coding education :)

  • Jumping in here.  I do some neonatal reviews.  For the neonatal MDs, the terms of birth injury/birth trauma are not used lightly and they are reluctant to use those terms due to the implications of that diagnosis. Facial bruising, unless it's deemed as significant and requiring treatment,  would not be captured using a birth injury code, such as P15.4.  Personally,  I would want to have a linkage between the facial bruising and birth injury or birth trauma ('facial bruising due to birth trauma') to capture the P15.4.  And, that said, I would not query for linkage. Personally, I think that he birth process is traumatic and facial bruising is integral to the birth process.   

  • Definitely in agreement with everything said. We currently aren't reviewing this particular PSI, but I went back and looked at ones flagged since 10/2015 and I only found one that appeared to be true "birth injury". Keep us posted Katy, I am sure with a little education everything will straighten out.

    Jeff

  • Thanks Karen and Jeff! I really appreciate your input. Working on getting these rebilled now :)


    Katy

  • I am the Coding Educator for our facility, and we have had this same issue.  We continually work with our Neonatal Nurse Practitioners to give the coders guidance on NB issues.  Coding guideline A.19 has put the coders between a rock and a hard place -that is why they are coding those items, but they do need education and the facility needs to determine from the discussion with the clinicians if a facility guideline is needed that indicates when to query.
  • Hi friends!
    I do review all PSI via the AHRQ software each month. We had the same issue!  It took some coding education-they are now using P54.5 "neonatal cutaneous hemorrhage" POA,  which is NOT triggering the PSI.  I also asked the physicians to use that terminology as well.   It's pretty silly. 
    Cari
  • Greetings,
    At Cooper CDI is responsible for review of all PSIs / HACs and we have been able to overturn >50% consistently either by coding correction or clarification. We removed over 60% last year.   We have been extremely successful with PSI 17 because it seems that just about anything is coded as an injury on a newborn.  We've even seen diaper rash (described as excoriation to buttock) coded as a birth injury.  We've decreased this PSI by >80%.  Always remember that the physician has let you know it is a actual injury and relate it to the the birth process, and even then it must meet the definition for reporting an additional diagnosis:  treatment, workup, etc.  Just because neosporin is applied to a little scratch does not necessarily constitute a reportable diagnosis.  Lets always keep perspective and think about clinical significance.  Coding education has been a challenge because we have utilized contract coders, but are getting away from that as quickly as possible.   Don't even get me started on PSI 4, in which POA is not an exclusion.  ugh.   
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