Technical Review 5

Measures of Patient Safety Based on Hospital 

Administrative DataCThe Patient Safety Indicators

Prepared for:

Agency for Healthcare Research and Quality

Department of Health and Human Services 

U.S. Public Health Service 

2101 East Jefferson Street 

Rockville, MD 20852 

www.ahrq.gov

Contract No. 290-97-0013

Prepared by:

University of California San FranciscoBStanford Evidence-based Practice Center

Kathryn M. McDonald, M.M. (Stanford) 

Principal Investigator

Patrick S. Romano, M.D., M.P.H. (UC-Davis) 

Jeffrey Geppert, J.D. (Stanford) 

Sheryl M. Davies, M.S. (Stanford) 

Bradford W. Duncan, M.D. (Stanford) 

Kaveh G. Shojania, M.D. (UCSF) 

Investigators

Angela Hansen, B.A. (Stanford) 

EPC Research Assistant 

AHRQ Publication No. 02-0038 

August 2002
The authors of this report are responsible for its content. Statements in the report should not be 

construed as endorsement by the Agency for Healthcare Research and Quality (AHRQ) or the U.S. 

Department of Health and Human Services of a particular drug, device, test, treatment, or other 

clinical service. 

This report may be used, in whole or in part, as the basis for development of clinical practice 

guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage 

policies. Endorsement by the Agency for Healthcare Research and Quality or the U.S. Department 

of Health and Human Services of such derivative products may not be stated or implied. 

AHRQ is the lead Federal agency charged with supporting research designed to improve the quality 

of health care, reduce its cost, address patient safety and medical errors, and broaden access to 

essential services. AHRQ sponsors and conducts research that provides evidence-based 

information on health care outcomes; quality; and cost, use, and access. The information helps 

health care decisionmakersCpatients and clinicians, health system leaders, and policymakersCmake 

more informed decisions and improve the quality of health care services.

Acknowledgments

The investigators would like to acknowledge the following individuals and organizations 

for their aid in this report: Doug Staiger, Dept. of Economics, Dartmouth College for his 

help in developing statistical methods; Ros McNally, National Primary Care Research 

and Development Centre, University of Manchester, who aided in the EMBASE7

literature search; American Health Information Management Association for providing 

ICD-9-CM coding expertise; the various professional organizations listed in this report 

and their staff for submitting nominations for the clinical review panels; the clinical 

panelists, listed in Appendix B. The investigators also acknowledge the contributions of 

Anne Elixhauser, Ph.D., and Marlene Miller, M.D., M.Sc., Agency for Healthcare 

Research and Quality (AHRQ), and Margaret Coopey, R.N., M.G.A., M.S.A., AHRQ 

Task Order Officer. 

This document is in the public domain and may be used and reprinted without permission. 

AHRQ appreciates citation as to source, and the suggested format is provided below: 

McDonald K, Romano P, Geppert J, et al. Measures of Patient Safety Based on Hospital 

Administrative DataCThe Patient Safety Indicators. Technical Review 5 (Prepared by the 

University of California San FranciscoBStanford Evidence-based Practice Center under 

Contract No. 290-97-0013). AHRQ Publication No. 02-0038 . Rockville, MD: Agency for 

Healthcare Research and Quality. August 2002. 

ISBN 1-58763-121-0 

ii 
iii

Structured Abstract 

Objectives. Concerns have mounted about the complexities of the health care system 

potentially causing significant unintended adverse effects. With a major national interest 

in addressing patient safety issues, a wide spectrum of individuals and organizations are 

working toward developing methods and systems to detect, characterize, and report 

potentially preventable adverse events. One approach is to develop screening measures 

based on routinely collected administrative data, such as the patient safety indicators 

(PSIs) reported here. The purpose of the PSI project is to report 1) literature-based 

evidence on potential PSIs, 2) clinician panel review results of potential indicators, 3) 

empirical analyses on a subset of indicators, and 4) recommendations regarding potential 

PSIs. 

Methods. A four-pronged strategy to collect validation data and descriptive information 

was used: 1) background literature review, 2) structured clinical panel reviews of 

candidate PSIs, 3) expert review of ICD-9-CM codes in candidate PSIs, and 4) empirical 

analyses of the potential candidate PSIs. Evidence from these four sources was used to 

modify and select the most promising indicators for use as a screening tool to provide an 

accessible and low-cost approach to identifying potential problems in the quality of care 

related to patient safety. 

Main results. A review of previously reported measures in the literature, and of medical 

coding manuals, resulted in identification of over 200 ICD-9-CM codes representing 

potential patient safety problems. Most of these codes were grouped into clinically 

meaningful indicators either based on previous indicator definitions or on clinical and 

coding expertise. Based on literature review of the published evidence related to their 

validity, several potential PSIs were eliminated. Because of the limited validation 

literature available on PSIs and complications indicators from which many PSIs were 

derived, the research team conducted a clinical panel review process to assess the face 

validity and to guide refinements to the initial definitions of the 34 most promising PSIs. 

Response to a questionnaire by clinicians (i.e., physicians from a number of specialties, 

nurses, and pharmacists) for each indicator, augmented by coding review and initial 

empirical testing, provided the basis for selecting the indicators expected to be most 

useful for screening for potentially preventable adverse events. Twenty hospital level

PSIs are recommended for implementation as the initial AHRQ PSI set (designated 

Accepted indicators). 

 

Conclusions and future research. Future validation work should focus on the sensitivity 

and specificity of these indicators in detecting the occurrence of a complication; the 

extent to which failures in processes of care at the system or individual level are detected 

using these indicators; the relationship of these indicators with other measures of quality, 

such as mortality; and further explorations of bias and risk adjustment. Enhancements to 

administrative data are worth exploring in the context of further validation studies that 

utilize data from other sources. The current development and evaluation effort will best 

be augmented by a continuous communication loop between users of these measures, 
iv

researchers interested in improving these measures, and policy makers with influence 

over the resources aimed at data collection and patient safety measurement. 

 
v 

Contents 

Structured Abstract ........................................................................................................................ iii 

Summary ..........................................................................................................................................1

Technical Review: 

Chapter 1. Introduction..................................................................................................................13 

Using Administrative Data ......................................................................................................13 

Patient Safety Indicators Evidence Project..............................................................................14 

Anticipated Uses of Evidence Report......................................................................................15 

Chapter 2. Methodology ................................................................................................................17 

Section 2A. Conceptual Framework and Definitions ..............................................................17 

Evaluation Framework.......................................................................................................18 

Section 2B. Literature Review Methods..................................................................................19 

Section 2C. Development of Initial Candidate List of Indicators............................................21 

Identifying Potential Indicators .........................................................................................21 

Initial Selection of Indicators.............................................................................................24 

Coding Review...................................................................................................................25 

Section 2D. Clinician Panel Review Methods.........................................................................25 

Panel Selection...................................................................................................................26 

Panel Composition.............................................................................................................26 

Initial Evaluation................................................................................................................27 

Conference Call .................................................................................................................28 

Final Evaluation.................................................................................................................28 

Tabulation of Results .........................................................................................................28 

Surgical Panels...................................................................................................................30 

Section 2E. Empirical Methods ...............................................................................................32 

Purpose of Analyses...........................................................................................................32 

Analysis Approach.............................................................................................................32 

Empirical Analysis Statistics .............................................................................................36 

Chapter 3. Results ..........................................................................................................................39 

Section 3A. Literature Review Results....................................................................................39 

Background........................................................................................................................39 

General Issues in Using Complications To Screen for Quality Problems.........................42 

Specific Review of the Evidence for Indicators ................................................................46 

Accepted Indicators ...........................................................................................................48 

Accepted Obstetric Indicators............................................................................................59 

Experimental Indicators.....................................................................................................60 

Experimental Obstetric Indicators .....................................................................................66 

Section 3B. Indicator Selection ...............................................................................................68 

Section 3C. Overall Clinician Panel Review Results ..............................................................76 

Application of Quality Indicators ......................................................................................76 

Purpose of Quality Indicators ............................................................................................76 

Importance of Risk Adjustment or Stratification...............................................................77 

Understanding of Data .......................................................................................................78 

Charting, Coding and Reporting........................................................................................79

Summary ............................................................................................................................79 
vi 

Section 3D. Detailed Panel Results by Indicator.....................................................................80 

Accepted Indicators ...........................................................................................................83 

Accepted Obstetric Indicators..........................................................................................111 

Experimental Indicators...................................................................................................113 

Experimental Obstetric Indicators ...................................................................................126 

Section 3E. Comparative Empirical Results..........................................................................130 

Accepted Hospital Level Indicators.................................................................................131 

Experimental Hospital Level Indicators ..........................................................................140 

Accepted Area Indicators.................................................................................................142 

Chapter 4. Conclusions ................................................................................................................145 

Potential Uses of PSIs............................................................................................................147 

Relationship of This Project to Other Quality Initiatives ......................................................149 

Limitations and Future Research ...........................................................................................152 

References....................................................................................................................................155 

Appendixes: 

A. Inventory of Potential Patient Safety Indicators..............................................................165 

B. Clinician Review Panels ..................................................................................................179

C. Sample of Information Sent to Panelists..........................................................................191 

D. Empirical Methods Details ..............................................................................................201 

E. Details of Indicator Definitions .......................................................................................223 

F. Detailed Results for Rejected Indicators .........................................................................283 

G. Detailed Empirical Results ..............................................................................................313 

H. Comparison of PSIs with CSP Indicators and Miller et al. PSIs .....................................341 

I. Definitions of Indicators Presented to Panelists ..............................................................347 

J. Peer Reviewers ................................................................................................................359

Acronyms Used in This Report....................................................................................................363 

List of Tables, Figures, and Flow Diagrams

Summary Tables

1S. Strength of Evidence Literature for PSIs...................................................................................4 

2S. Summary of Evidence for Accepted Hospital Level PSIs.........................................................5 

3S. Use of Patient Safety Indicators ................................................................................................9 

Text Tables

1. Electronic Search Strategy for Articles Pertaining to Patient Safety Indicators .....................20 

2. Multi-specialty Panelist Composition......................................................................................27 

3. Criteria for Agreement Status ..................................................................................................29 

4. Definitions for Overall Appropriateness of Indicator..............................................................30 

5. Surgical Panel Composition ....................................................................................................31 

6. Precision Tests .........................................................................................................................37 

7. Bias Tests.................................................................................................................................38 

8. Relatedness Tests.....................................................................................................................38 
vii 

9. Summary of Strength of Evidence in Literature for Accepted Indicators ...............................47 

10. Summary of Strength of Evidence in Literature for Experimental Indicators.........................48 

11. Accepted Indicators (provider and area level).........................................................................69 

12. Experimental Indicators...........................................................................................................70 

13. Rejected Indicators ..................................................................................................................71 

14. Groupings Based on Preventability .........................................................................................72 

15. Grouping Based on Medical Error...........................................................................................72 

16. Suggested Initial Further Research for Experimental Indicators.............................................73 

17. Indicators Reviewed by Panel Type ........................................................................................81

18. Summary of Minimum Bias in Hospital Level Rates............................................................139 

19. Additional Cases Identified by Area Level Indicators...........................................................143 

20. Use of Patient Safety Indicators.............................................................................................148 

21. Relationship of PSIs to Other Indicator Sets .........................................................................150 

22. Indicator Level Practices Included in Making Health Care Safer.........................................151 

Figures

1. Summary of Mean Hospital Level Rates.......................................................................132 

2. Summary of Standard Deviations in Hospital Level Rates ..............................................133 

3. Summary of Signal Standard Deviation in Hospital Level Rates......................................136 

4. Summary of Signal Share in Hospital Level Rates .........................................................137 

5. Summary of Signal Ratio in Hospital Level Rates..........................................................138 

Flow Diagrams

1. Process for the Selection of Indicators............................................................................75 
1

Summary 

Introduction 

The longstanding cornerstone of medicine “first, do no harm” exists because of 

the fragility of life and health during medical care encounters, and represents the medical 

profession’s understanding that patient safety has always been an important part of 

quality health care. Recently, however, concerns and evidence have mounted about the 

complexities of the health care system potentially causing patient deaths and significant 

unintended adverse effects. With a major national interest in addressing patient safety 

issues, a wide spectrum of individuals and organizations are working toward developing 

methods and systems to detect, characterize, and report potentially preventable adverse 

events. These activities are crucial precursors to prioritizing areas for action and for 

studying the effects of approaches to reduce sources of medical error. 

As part of this activity, the Evidence-based Practice Center (EPC) at the 

University of California San Francisco and Stanford University (UCSF-Stanford), with 

collaboration from the University of California Davis, was commissioned by the Agency 

for Healthcare Research and Quality (AHRQ) to review and improve the evidence base 

related to potential patient safety indicators (PSIs) that can be developed from routinely 

collected administrative data. For the purposes of this report, PSIs refer to measures that 

screen for potential problems that patients experience resulting from exposure to the 

health care system, and that are likely amenable to prevention by changes at the level of 

the system. 

Reporting the Evidence 

The primary goal of this report is to document the evidence from a variety of 

sources on potential measures of patient safety suitable for use based on hospital 

discharge abstract data. The approach to identification and evaluation of PSIs presented 

in this report serves as the basis for development of a third module for the AHRQ QI tool 

set (referred to as the HCUP II in previous work by the UCSF-Stanford EPC reporting on 

the research underpinning the refinement of the initial AHRQ HCUP QIs, available on 

AHRQ’s web site at http://www.achq.gov/data/hcup/qirefine.htm). This third module will 

be the Patient Safety Indicators (PSIs), which focus on potentially preventable instances 

of harm to patients, such as surgical complications and other iatrogenic events. The two 

other modules are the Prevention Quality Indicators, based on hospital admissions that 

might have been avoided through high-quality outpatient care; and the Inpatient Quality 

Indicators, consisting of inpatient mortality, utilization of procedures for which there are 

questions of overuse, underuse, or misuse; as well as volume of procedures for which 

higher volume is consistently associated with lower mortality. 

Purpose of the PSIs 

Like the companion AHRQ Quality Indicators (QIs) screening tool set refined by 

the UCSF-Stanford EPC, the PSIs are a starting point for further analysis to reduce 

preventable errors through system or process changes. Additionally, these measures are 
2

likely to support the public mandate for aggregate statistical reporting to monitor trends 

over time, as planned for the National Quality Report. 

Scope of the Project 

This report reviews previous studies and presents new empirical evidence for 

identifying potential patient safety problems based on one potentially important source of 

data: computerized hospital discharge abstracts from the AHRQ Healthcare Cost and 

Utilization Project (HCUP). Therefore, the measures considered needed to be defined 

using variables that are available from most state-level hospital administrative data. Data 

elements in these sets include International Classification of Disease, Clinical 

Modification (ICD-9-CM) discharge diagnosis and procedure codes; dates of admission, 

discharge and major procedures; age; gender; and diagnostic related group (DRG). Data 

from outside the hospital stay (e.g., post-hospital mortality or readmissions) were not 

used because most state databases do not accommodate linkages between datasets. The 

HCUP State Inpatient Databases (SID) is an example of such a common denominator 

hospital discharge dataset, and was used for the development of the AHRQ PSIs, reported 

here. The PSIs presented in this report therefore relate to inpatient care, and the adverse 

events that have either a high likelihood or at least a reasonable possibility of being 

iatrogenic. These two constraints – the data source and the location of care—guided the 

development and evaluation of a promising set of patient safety indicators. 

Following from these constraints, the PSIs by necessity capture adverse events 

that may, but possibly are not, related to medical care. They do not capture “near misses” 

or other undocumented adverse events. They also do not include adverse events related to 

a number of important patient safety concerns that are not reliably specified using ICD-9-

CM, the official codes assigned to diagnoses and procedures associated with hospital 

utilization in the United States. Based on previous validation work and the limitations 

inherent in the data source, PSIs derived from discharge data capture a mixture of adverse 

events, including those that are almost certainly preventable and those that current best 

practices and error-mitigating systems of care have not been able to prevent. However, 

the evidence is presented for their promise as a low-cost screen for potential quality 

concerns to guide further investigations with additional data gathering and information 

collection. 

Methodology 

Following the previous refinement of quality indicators described in a companion 

technical report from the EPC, and published by AHRQ, an evaluation framework for 

validity testing (i.e., face validity, precision, minimum bias, and construct validity) was 

applied to each candidate PSI. Specifically, a four pronged strategy to collect validation 

data and descriptive information included two aspects of the previous work: a 

background literature review, and empirical analyses of the potential candidate PSIs 

using the HCUP SID. In addition to these approaches of the previous project, expert 

coders from the American Health Information Management Association (AHIMA) were 

consulted, and clinical panel reviews of potential indicators were conducted based on a 

process adapted from the RAND organization and University of California Los Angeles 

(RAND/UCLA) Appropriateness Method. 
3

Evidence from these four sources was used to modify and select the most 

promising indicators for use as a screening tool to provide an accessible and low-cost 

approach to identifying potential problems in the quality of care related to patient safety. 

The methods applied provide baseline information on the ability of a fairly broad range of 

discharge-based PSIs to identify systematic differences across hospitals, and potentially 

to monitor trends on a national or regional basis. 

Results 

A review of previously reported measures in the literature (e.g. Complications 

Screening Program by Iezzoni et al, Patient Safety Indicators by Miller et al), and of 

medical coding manuals, resulted in identification of over 200 ICD-9-CM codes 

representing potential patient safety problems. Most of these codes were grouped into 

clinically meaningful indicators either based on previous indicator definitions or on 

clinical and coding expertise. Based on literature review of the published evidence 

related to their validity, several potential PSIs were eliminated. Because of the limited 

validation literature available on PSIs and complications indicators from which many 

PSIs were derived, the research team conducted a clinical panel review process to assess 

the face validity and to guide refinements to the initial definitions of the 34 most 

promising PSIs. Response to a questionnaire by clinicians (i.e., physicians from a 

number of specialties, nurses, and pharmacists) for each indicator, augmented by coding 

review and initial empirical testing, provided the basis for selecting the indicators 

expected to be most useful for screening for potentially preventable adverse events. 

Tables 1S and 2S summarize the strength of the evidence literature, definitions, and key 

findings for the set of 20 hospital level PSIs that are recommended for implementation as 

the initial AHRQ PSI set (designated Accepted indicators). 
4

Table 1S. Strength of Evidence Literature for PSIs 

Indicator Coding

Construct 

Explicit 

Process 

Construct 

Implicit 

Process 

Construct 

Staffing 

Complications of anesthesia 0 0 0 0 

Death in low mortality DRGs + 0 + 0 

Decubitus ulcer - 0 0 ± 

Failure to rescue + 0 0 ++ 

Foreign body left in during procedure 0 0 0 0 

Iatrogenic penumothorax 0 0 0 0 

Infection due to medical care 0 0 0 0 

Postoperative hip fracture + + + 0 

Postoperative hemorrhage or hematoma ± ± + 0 

Postoperative physiologic and metabolic 

derangements - 0 0 - 

Postoperative respiratory failure + ± + ± 

Postoperative PE or DVT + + + ± 

Postoperative sepsis ± 0 0 - 

Technical difficulty with procedure ± 0 0 0 

Transfusion reaction 0 0 0 0 

Postoperative wound dehiscence 0 0 0 0 

Birth trauma - 0 0 0 

Obstetric trauma – vaginal delivery with 

instrumentation 

+ 0 0 0 

Obstetric trauma – vaginal delivery without 

instrumentation + 0 0 0 

Obstetric trauma – cesarean delivery + 0 0 0 

a Level of evidence 

(-) Published evidence suggests that the indicator lacks validity in this domain (i.e., less than 50% sensitivity or predictive value; 

explicit or implicit process failure rates no more frequent than among control patients). 

(0) No published evidence regarding this domain of validity. 

(±) Published evidence suggests that the indicator may be valid in this domain, but different studies offer conflicting results (although 

study quality may account for these conflicts). 

(+) Published evidence suggests that the indicator IS valid, or is likely to be valid, in this domain (i.e., one favorable study). 

(++) There is strong evidence supporting the validity of this indicator in this domain (i.e., multiple studies with consistent results, or 

studies showing both high sensitivity and high predictive value). b Coding: Sensitivity is the proportion of patients who suffered an adverse event, based on detailed chart review or prospective data 

collection, for whom that event was coded on a discharge abstract or Medicare claim. Predictive value is the proportion of patients 

with a coded adverse event who were confirmed as having suffered that event, based on detailed chart review or prospective data

collection. 

Construct, explicit process: Adherence to specific, evidence-based or expert-endorsed processes of care, such as appropriate use of 

diagnostic modalities and effective therapies. Our construct is that hospitals that provide better processes of care should experience 

fewer adverse events. 

Construct, implicit process: Adherence to the “standard of care” for similar patients, based on global assessment of quality by 

physician chart reviewers. Our construct is that hospitals that provide better overall care should experience fewer adverse events. 

Construct, staffing: Our construct is that hospitals that offer more nursing hours per patient day, better nursing skill mix, better 

physician skill mix, or more experienced physicians, should have fewer adverse events. c Note that when content validity is exceptionally high, as for transfusion reaction or iatrogenic pneumothorax, construct validity 

becomes less important. 
5

Table 2S. Summary of Evidence for Accepted Hospital Level PSIs 

Panel concerns of validitya 

Indicator name 

Definition 

Rare 

Condition 

definition varies 

Underreporting/ 

screening 

Adverse 

consequences 

Stratification 

suggested 

Unclear 

preventability 

Heterogeneous 

severity 

Case mix bias 

Complications of anesthesia 

Cases of anesthetic overdose, reaction, or endotrachial tube misplacement per 100 surgery discharges. Excludes codes for drug use and self-inflicted injury. 

 X X 

Death in low mortality DRGsd 

In-hospital deaths per 100 patients in DRGs with less than 0.5% mortality.c Exclude trauma, immunocompromised 

and cancer patients. 

 X 

Decubitus ulcer 

Cases of decubitus ulcer per 100 discharges with a length of stay greater than 4 days. Exclude patients with paralysis or in MDC 9,d or patients admitted from a long 

term care facility. 

 X X X 

Failure to rescue 

Deaths per 100 patients having developed specified complications of care during hospitalization. Exclude patients admitted from long term care facility and patients transferred to or from other acute care facility. 

 X X X X 

Foreign body left during procedure 

Discharges with foreign body accidentally left in during procedure per 100 discharges. X X 

Iatrogenic pneumothorax 

Cases of iatrogenic pneumothorax per 100 discharges. Exclude trauma, thoracic surgery, lung or pleural biopsy or cardiac surgery patients. 

Infection due to medical care 

Cases of secondary ICD-9-CM codes 999.3 or 996.62 per 100 discharges. Exclude patients with immunocompromised state or cancer. 

 X X 

Postoperative hemorrhage or hematoma 

Cases of hematoma or hemorrhage requiring a procedure per 100 surgical discharges. Excludes obstetric admissions. 

 X X 

Postoperative hip fracture 

Cases of in-hospital hip fracture per 100 surgical discharges. Exclude patients in MDC 8, with conditions suggesting fracture present on admission. 

 X 

Postoperative physiological and metabolic derangement 

Cases of specified physiological or metabolic derangement per 100 elective surgical discharges. Exclude patients with principle dx of diabetes and with diagnoses suggesting increased susceptibility to derangement. Exclude obstetric admissions. 

 X 
6

Panel concerns of validitya 

Indicator name 

Definition 

Rare 

Condition 

definition varies 

Underreporting/ 

screening 

Adverse 

consequences 

Stratification 

suggested 

Unclear 

preventability 

Heterogeneous 

severity 

Case mix bias 

Postoperative PE or DVT 

Cases of deep vein thrombosis or pulmonary embolism per 100 surgical discharges. Exclude obstetric patients. X X 

Postoperative respiratory failure 

Cases of acute respiratory failure per 100 elective surgical discharges. Exclude MDC 4 and 5 and obstetric admissions. 

 X X 

Postoperative septicemia 

Cases of septicemia per 100 elective surgery patients, with length of stay more than 3 days. Exclude principle dianosis of infection, or any dx of immunocompromised state or cancer, and obstetric admissions. 

 X X 

Postoperative wound dehiscence 

Cases of reclosure of post-operative disruption of abdominal wall per 100 cases of abdominopelvic surgery. Excludes obstetric admissions. 

 X 

Technical difficulty with procedure 

Cases of technical difficulty (e.g. accidental cut or laceration during procedure) per 100 discharges. Excludes obstetric admissions. 

 X X 

Transfusion reaction 

Cases of transfusion reaction per 100 discharges X X 

Birth trauma – injury to neonate 

Cases of birth trauma per 100 liveborn births. Excludes some preterm infants, and infants with osteogenic imperfecta. 

 X X X 

Obstetric trauma – cesarean delivery 

Cases of obstetric trauma (4th degree lacerations, other 

obstetric lacerations) per 100 cesarean deliveries. X X 

Obstetric trauma – vaginal delivery with instrument 

Cases of obstetric trauma (4th degree lacerations, other 

obstetric lacerations) per 100 instrument assisted vaginal deliveries. X X 

Obstetric trauma – vaginal delivery w/o instrument 

Cases of obstetric trauma (4th degree lacerations, other 

obstetric lacerations) per 100 vaginal deliveries without instrument assistance. X X 

a Concerns raised by panels included the following: Rare: Some events are relatively rare, and thus may not have adequate statistical power for some providers. 
7

Condition definition varies: Conditions covered by this indicator include conditions for which diagnosis may be subjective, depending on the threshold of the physician. 

clinical state may not have the same diagnosis. Under-reporting/screening: These conditions may not be systematically reported leading to an artificially low rate, or may be routinely screened for, leading to a higher r

compared to those that do not. Adverse consequences: Use of these indicators may have undesirable effects, such as increasing inappropriate antibiotic use. Stratification suggested: Indicator includes some high risk patient groups which should be stratified when examining rates. 

Unclear preventability: As compared to other PSIs these conditions may be less subject to the control of the health system, and thus less preventable. 

Heterogeneous severity: These indicators include codes that encompass several levels of severity of that condition that cannot be ascertained by the codes. 

Case mix bias: These indicators were felt to be particularly subject to systematic bias due to the case mix of the provider. DRG and comorbidity risk adjustment may or m

concern. Denominator unspecific: The denominators for these indicators are less than ideal, because the true population at risk could not be identified completely clearly using IC

patients are likely included that are not truly at risk, or some patients that are at risk are not included. 

b Bias ratings are based on a series of tests of bias using DRG and comorbidity risk adjustment. Those indicators flagged with ‘X+’ demonstrated substantial bias, and sh

indicators flagged with ‘X’ also demonstrated some bias. Those without a flag did not demonstrate substantial bias in empirical tests, but may nonetheless be substantiall

detectable by the bias tests. Those with marked with N/A did not undergo empirical testing of bias due to lack of systematic variation. 

c DRGs that are divided into “with complications and comorbidities” and “without complications and comorbidities” are only included if both divisions have mortality rad DRG: Diagnostic Related Group; MDC: Major Diagnostic Category e Rates represent the average rate of indicator for a nationwide sample of hospitals. Standard deviation is reported between providers. 
8

Several accepted patient safety indicators were also modified into area level 

indicators, which were designed to assess the total incidence of the adverse event within 

geographic areas. For example, the transfusion reaction indicator can be specified at both 

the hospital and area level. Transfusion reactions that occur after discharge from a 

hospitalization would result in a readmission. The area level indicator includes these 

cases, while the hospital level restricts the number of transfusion reactions to only those 

that occur during the same hospitalization that exposed the patient to this risk. The five 

hospital level indicators that have area level analogs are Iatrogenic Pneumothorax, 

Transfusion Reaction, Infection Due to Medical Care, Wound Dehiscence, Foreign Body 

Left in During Procedure, and Technical Difficulty with Medical Care. 

 In addition to the accepted PSIs, another 17 indicators show promise, though have 

more concerning limitations. These were designated “experimental” and examined 

empirically. They performed empirically somewhat less well than the accepted indicators 

empirically. In addition, the concerns raised about various aspects of these indicators 

during the clinical panel discussions limit their potential usefulness. However, with 

possible further refinements to the underlying coding of data and to the indicator 

definitions, these indicators have the potential to measure what they purport to identify. 

For example, Reopening of Surgical Wound, while conceptually a useful PSI, requires 

further information to exclude cases that are planned during staged operations for 

example, and requires coding changes in order to capture only similarly serious 

reopening procedures. 

Conclusions 

This project took a four pronged approach to the identification, development and 

evaluation of PSIs that included use of literature, clinician panels, expert coders and 

empirical analyses. For the best-performing subset of PSIs, this project has demonstrated 

that rates of adverse events differ substantially and significantly across hospitals. The 

literature review and the findings from the clinical panels combined with data analysis 

provide evidence to suggest that a number of discharge-based PSIs may be useful screens 

for organizations, purchasers, and policymakers to identify safety problems at the 

hospital level, as well as to document systematic area level differences in patient safety 

problems. 

Few adverse events captured by administrative data are unambiguous enough for 

a great deal of certainty that every case identified reflects medical error. Most adverse 

events identified by the PSIs have a variety of causes in addition to potential medical 

error leading to the adverse event, including underlying patient health and factors that do 

not vary systematically. Clinician panelists rated only two of the accepted indicators as 

very likely to reflect medical error: 1.) “Transfusion reaction” and 2.) “Foreign body left 

in during a procedure.” As is expected for indicators of this case-finding type, these 

indicators proved to be very rare with less than 1 per 10,000 cases at risk. All other 

accepted indicators identify adverse events which represent a spectrum of likelihood of 

reflecting either medical error or potentially preventable complications of care, but 

cannot be expected to identify only cases in these categories. 
9

Potential Uses of PSIs 

Because the PSIs are intended for use as an initial, efficient screen to target areas for 

further data exploration, the primary goal is to find indicators that guide those interested 

in quality improvement and patient safety to areas where there are systematic differences 

between hospitals or geographic areas. These systematic differences may relate to 

underlying processes or structures that an organization could change to improve patient 

care and safety. These errors may be attributed to human error on the part of physicians 

or nurses, or system deficiencies. On the other hand, the systematic differences will 

sometimes correspond to coding practices, patient characteristics not captured by 

administrative data, or other factors. These will be dead ends to some degree. In the 

application of these PSIs, users will be determining how well patient safety problems are 

identified at the level of groups of patients. Sharing experiences about application of 

these PSIs, researchers and health care practitioners will build on the information 

highlighted in this report about each indicator, as well as the set of PSIs. 

 At the national or state level, these indicators could be used to monitor the 

frequency of potential patient safety problems, to determine whether the rates are 

increasing or decreasing over time, and to explore large variations among settings of care. 

While the indicators were primarily developed at the hospital level, some were also 

implemented to provide an analogous area level measure, and analyses show that 

additional cases are in fact identified that correspond to care received at one institution, 

and the potentially iatrogenic complication addressed in another hospital. Clearly, the 

locus of control and the ability to study the potential underlying causes for an adverse 

event is simpler in the case of the hospital level PSIs. However, trends over time in area 

rates, as well as aggregations of the hospital level rates are likely to reveal points of 

leverage outside of individual institutions. No measure is perfect. Each is suited to its 

designed purpose. Methods of aggregating across groups of PSIs still need to be tested. 

This report provides the background for “safe” use of a tool that has the potential to guide 

prevention of medical error, reductions of potentially preventable complications, and 

quality improvement in general. Table 3S provides examples of potential uses and 

potentially inappropriate uses. 

Table 3S. Use of patient safety indicators 

User Potential Uses Potential Inappropriate Uses 

Case-finding indicators 

 Provider Identification of events for further 

investigation. 

Identification of cases for disciplinary action. 

Comparison of rates. 

 Public Health Surveillance of events. Use of indicators in formal evaluation of 

providers. 

 Research Flagging of cases for use in research 

studies. 

Comparison of rates. 

Rate-based indicators 

 Provider Surveillance of rates for internal quality 

improvement investigations. 

Physician-level investigation. 

Use of rates for disciplinary action or formal 

evaluation. 

 Public Health Surveillance of rates. Examination of area 

rates over time, by region, by hospital 

type. 

Public reporting of provider level rates. 

 Research Use with other measures of quality to 

determine relationships of PSIs with 

structural, process or other aspects of 

care. 

Use in research as a definitive measure of 

quality of care. 
10

Limitations and Future Research 

Many important concerns cannot currently be monitored well using administrative 

data, such as adverse drug events. Just as administrative data limited specific indicators 

chosen, the use of administrative data tends to favor specific types of indicators. The PSIs 

evaluated in this report contain a large proportion of surgical indicators, rather than 

medical or psychiatric. Medical complications are often difficult to distinguish from 

comorbidities that are present on admission. In addition medical populations tend to be 

more heterogeneous than surgical, especially elective surgical populations, making it 

difficult to account for case-mix. Panelists often expressed that indicators were more 

applicable to patient safety when limited to elective surgical admissions. 

The initial validation evaluations reviewed and performed for the PSIs leave 

substantial room for further research with detailed chart data and other data sources. 

Future validation work should focus on the sensitivity and specificity of these indicators 

in detecting the occurrence of a complication; the extent to which failures in processes of 

care at the system or individual level are detected using these indicators; the relationship 

of these indicators with other measures of quality, such as mortality; and further 

explorations of bias and risk adjustment. 

Enhancements to administrative data are worth exploring in the context of further 

validation studies that utilize data from other sources. For example, as with other quality 

indicators, the addition of timing variables may prove particularly useful in order to 

identify whether or not a complication was present on admission, or occurred during the 

hospitalization. While some of the complications that are present on admission may 

indeed reflect adverse events of care in a previous hospitalization or outpatient care, 

many may reflect comorbidities instead of complications. A second example area, linking 

of hospital data over time and with outpatient data and other hospitalizations, would 

allow inclusion of complications that occur after discharge, and likely would increase the 

sensitivity of the PSIs. 

 The current development and evaluation effort will best be augmented by a 

continuous communication loop between users of these measures, researchers interested 

in improving these measures, and policy makers with influence over the resources aimed 

at data collection and patient safety measurement. 
 

Technical Review 

13

Chapter 1. Introduction 

The often cited Institute of Medicine Report, To Err is Human: Building a Safer 

Health System1

 crystallized widespread public concern about the need to take action to 

reduce the occurrence of apparently common, serious medical errors. Achieving this goal 

involves identifying errors in practice, and undertaking initiatives to avoid and prevent 

them. It also requires national and regional attention to monitor and report to the public 

about patient safety. Widespread consensus exists that health care organizations can 

reduce patient injuries by learning from successful safety-improvement initiatives in 

other industries. Such initiatives have focused on systematically reducing opportunities 

for errors to occur, by improving the environment for safety. These diverse steps range 

from technical changes, such as implementing electronic medical record systems, to 

cultural ones, such as improving staff awareness of patient safety risks. Clinical process 

interventions also have strong evidence for reducing the risk of adverse events related to 

a patient’s exposure to hospital care.2 However, local and national initiatives may be 

better prioritized and evaluated through the use of adequate data on patient safety 

problems. This report reviews previous studies and presents new empirical evidence on 

one potentially important source of such data: computerized hospital discharge abstracts 

from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and 

Utilization Project (HCUP). Analyses of these and similar inexpensive, readily available 

administrative data sets may provide a screen for potential medical errors, and a method 

for monitoring trends over time. 

Using Administrative Data 

Although prior studies of the utility of routinely available administrative data sets, 

like the HCUP Nationwide Inpatient Sample (NIS), leave many questions unanswered 

and raise some important concerns, the careful use of these sources of information holds 

promise for screening in order to target further data collection and analysis. The ability to 

assess all patients at risk for a particular patient safety problem, along with the relative 

low cost, are particular strengths of these data sets. However, two broad areas of concern 

also hold true for these data sets. First, questions about the clinical accuracy of dischargebased diagnosis coding lead to concerns about the interpretation of reported diagnoses 

that may represent safety problems. Specifically, administrative data are unlikely to 

capture all cases of a complication, regardless of the preventability, without false 

positives and false negatives (sensitivity and specificity). Further, when the codes are 

accurate in defining an event, the clinical vagueness inherent in the description of the 

code itself (e.g., “hypotension”), may lead to a highly heterogeneous pool of clinical 

states represented by that code. A final issue in accuracy of any data source used for 

identifying patient safety problems is the possibility of incomplete reporting, as medical 

providers might fear adverse consequences to reputation, disciplinary action, and lawsuits 

as a result of “full disclosure” in potentially public records such as discharge abstracts. 

A second area of concern relates to the limited information about the ability of 

these data to distinguish adverse events in which no error occurred from true medical 

errors. A number of factors, such as the heterogeneity of clinical conditions included in 

some codes, lack of information about event timing available in these data sets, and 
14

limited clinical detail for risk adjustment, contribute to the difficulty in identifying 

complications that represent medical error or may be at least in some part preventable. 

These factors may exist for other sources of patient safety data as well. For example, they 

have been raised in the context of the Joint Commission on Accreditation of Healthcare 

Organizations (JCAHO) implementation of a “sentinel event” program geared at 

identifying serious adverse events that may be related to underlying safety problems. 

Given the importance of patient safety, it is perhaps surprising that only a 

relatively limited literature exists related to the potential use of discharge data and other 

widely-used data sources in documenting patient safety problems and improving patient 

safety. While these limited studies have identified some discharge-based measures 

applicable to addressing patient safety problems that seem highly predictive of true 

errors, many discharge-based measures appear to have relatively low sensitivity and 

specificity for identifying potentially preventable complications or true errors. 

However, virtually all of these studies failed to account for many potentially 

avoidable limitations of discharge data, including measurement error (“noise”) and bias. 

Moreover, most of these studies have been conducted at the patient level, and have 

focused on answering the question: does the discharge information identify a patient 

safety problem in this particular case? Despite the fact that most initiatives to improve 

patient safety focus on organizational or process change, almost no studies have 

addressed the question: can discharge data be used to identify systematic patient safety 

problems, and thereby target areas for opportunity at the level of groups of patients? 

Patient Safety Indicators Evidence Project 

The Evidence-based Practice Center (EPC) at the University of California San 

Francisco and Stanford University (UCSF-Stanford), with collaboration from the 

University of California Davis, contracted with the AHRQ to review and improve the 

evidence base related to potential patient safety indicators (PSIs) that can be developed 

from administrative data. The term “patient safety indicator,” for the purposes of this 

report, refers to measures that screen for potential problems that patients experience 

resulting from exposure to the health care system, and that are likely amenable to 

prevention by changes at the level of the system. The key intent of the PSIs are thus as a 

“screening tool” or “starting point” for further analysis to reduce “potentially preventable 

errors” through system or process changes. 

In addition to the need for data to guide quality improvement initiatives, there is a 

public mandate to monitor patient safety as part of quality in general. Measures are 

needed for aggregate statistical reporting, as planned for the National Quality Report. The 

PSIs developed and evaluated by the EPC will be shared with the AHRQ directed task 

force charged to develop this national report regarding national, regional (e.g., Northeast, 

South, Midwest,West) and state statistics about health care quality and patient safety. 

This report follows the approach of a previous quality indicator development and 

evaluation project described in a companion technical report from the EPC, and 

published by AHRQ (available at: http://www.achq.gov/data/hcup/qirefine.htm).3

Similarly, this report takes a multifaceted approach to evaluating the validity of potential 

indicators, applying the same validation framework. This report documents the 

background literature review and empirical analyses performed to develop 
15

recommendations for and provide information about AHRQ PSIs. In addition, the project 

included consultation with expert coders from the American Health Information 

Management Association (AHIMA), and clinical panel reviews based on a process 

adapted from RAND and the University of California Los Angeles (RAND/UCLA) 

Appropriateness Method. We present new evidence on the ability of a broad range of 

discharge-based PSIs to identify systematic differences across hospitals, and potentially 

to monitor trends on a national or regional basis. The research reported here reflects an 

examination of the face validity of these indicators, and as such is subject to limitations. 

Primarily, due to the paucity of evidence available in the literature, this review relied on 

the expert opinion of clinician panels. The limitations are fully discussed in the final 

chapter of this report. Further research will be needed to establish the validity of these 

indicators in identifying potential patient safety concerns. 

The PSIs developed here follow some of the same goals as the refined quality 

indicators (QIs) reviewed in the companion report. AHRQ QIs (referred to as HCUP II 

Quality Indicators in the companion report)3

 were developed as a screening tool to 

provide an accessible and low-cost approach to identifying potential problems in quality 

of care for organizations that lack the resources to develop their own quality assessment 

program. The initial version of the QI software was based mostly on quality measures 

already reported in the literature. The principal requirement was that the measures could 

be derived from common denominator discharge data sets comprised of variables that are 

available from most state-level hospital administrative data. Data elements in these sets 

include, but may not be limited to, International Classification of Disease, Clinical 

Modification (ICD-9-CM) discharge diagnosis and procedure codes; dates of admission, 

discharge and major procedures; age; gender; and diagnostic related group (DRG). In 

addition, the measures could not require linkages outside the hospital stay (e.g., posthospital mortality or readmissions) because most state databases do not accommodate 

such linkages. The HCUP State Inpatient Databases (SID) is an example of such a 

common denominator discharge data set, and was used for the development of the AHRQ 

PSIs, reported here. While similar goals for the development of the previous AHRQ QIs 

apply to the PSIs reported here, the relevant literature is considerably less extensive. 

Consequently, we review the literature in a more general way for indicators as a whole, 

and for specific indicators we only review those studies validating the indicator use, 

rather than the clinical soundness of the concept of the indicator. As a result, we devote 

more attention to the development and validation of the most promising PSIs. 

The report reviews the methods applied in our survey of discharge-based patient 

safety indicators, further development and selection of indicators, detailed clinician panel 

review, and empirical analysis of the most promising indicators. The bulk of the report 

then presents the results of these activities. We conclude with recommendations about 

how the most promising discharge-based PSIs can be applied and improved. 

Anticipated Uses of Evidence Report 

The approach to identification and evaluation of PSIs presented in this report 

serves as the basis for development of Version 1.0 of AHRQ PSI software. The primary 

goal of the report is to document the evidence, both from the literature, clinician review 

and data analysis, on suitable PSIs that can be derived from hospital discharge abstract 
16

data. By transparently inventorying and evaluating potential indicators and risk 

adjustment strategies, we anticipate that this report will provide detailed context for users 

who apply these measures to facilitate identifying promising areas for researching and 

improving patient safety in a number of settings. The clear message throughout this 

report is that these indicators are developed for use as an initial screen that can target 

promising areas for in-depth review. 

The discharge-based PSIs may be useful screens for organizations, purchasers, 

and policymakers to identify problems at the hospital level, as well as to document 

systematic area level differences in potentially preventable adverse events or patient 

safety problems. Additionally, PSI rates would be amenable to monitoring over time by 

region (e.g., geographical area, nation), setting (e.g., urban vs. rural) or specific hospital 

type (e.g., teaching vs. community, large vs. small). The PSI rates calculated at the state 

or national level would also be useful to individual hospitals seeking to compare their 

own performance to a benchmark. However, these measures are not designed, nor are 

they suitable for public reporting for the purpose of comparing providers because of the 

limitations of discharge-based data sources, although public reporting at the aggregate 

level (e.g., state or national) may be appropriate. Further discussion of the appropriate 

uses of these indicators is included in Chapter 4, Conclusions. 

Finally, this report may also serve as a reference for background material on 

patient safety measurement using routinely collected administrative data, and as a 

summary for the current state of discharge-based patient safety indicators and risk 

adjustment methods. In addition to the companion technical report on quality indicators, 

it documents a novel integration of evidence-based methods with other approaches to 

develop and evaluate health care measures related to patient safety. 
17

Chapter 2. Methodology 

Section 2A. Conceptual Framework and Definitions 

 In approaching the task of evaluating patient safety indicators based on 

administrative data, we developed a conceptual framework and standardized definitions 

of commonly used terms. In the literature, the distinctions between medical error, adverse 

events, complications of care, and other terms pertinent to patient safety are not well 

established and are often used interchangeably. In this report, the terms medical error, 

adverse events or complications, and similar concepts are defined as follows: 

• Quality: “Quality of care is the degree to which health services for individuals and 

populations increase the likelihood of desired health outcomes and are consistent with 

current professional knowledge.” In this definition, “the term health services refers to a 

wide array of services that affect health...(and) applies to many types of health care 

practitioners (physicians, nurses, and various other health professionals) and to all 

settings of care...”4

 

• Quality indicators: Screening tools for the purpose of identifying potential areas of 

concern regarding the quality of clinical care. For the purpose of this report, we focus on 

indicators that reflect the quality of care inside hospitals. Quality indicators may assess 

any of the four system components of health care quality, including patient safety (see 

below), effectiveness (i.e., “providing services based on scientific knowledge to all who 

could benefit, and refraining from providing services to those not likely to benefit), 

patient centeredness, and timeliness (i.e., “minimizing unnecessary delays").4

• Patient safety: “Freedom from accidental injury,” or “avoiding injuries or harm to 

patients from care that is intended to help them.” Ensuring patient safety “involves the 

establishment of operational systems and processes that minimize the likelihood of errors 

and maximizes the likelihood of intercepting them when they occur.” 5

• Patient safety indicators: Specific quality indicators which also reflect the quality of 

care inside hospitals, but focus on aspects of patient safety. Specifically, PSIs screen for 

problems that patients experience as a result of exposure to the healthcare system, and 

that are likely amenable to prevention by changes at the system or provider level. 

• Medical error: “The failure of a planned action to be completed as intended (i.e., 

error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning).”1

The definition includes errors committed by any individual, or set of individuals, working 

in a health care organization. 

• Complication or adverse event: “An injury caused by medical management rather 

than by the underlying disease or condition of the patient.”6

 In general, adverse events 

prolong the hospitalization, produce a disability at the time of discharge, or both. Used in 

this report, complication does not refer to the sequelae of diseases, such as neuropathy as 
18

a “complication” of diabetes. Throughout the report, “sequelae” is used to refer to these 

conditions. 

• Preventable adverse event: An adverse event attributable to error is a “preventable 

adverse event.”6

 A condition for which reasonable steps may reduce (but not necessarily 

eliminate) the risk of that complication occurring. 

• Case finding indicators: Indicators for which the primary purpose is to identify 

specific cases in which a medical error may have occurred, for further investigation. 

• Rate based indicators: Indicators for which the primary purpose is to identify the 

rate of a complication rather than to identify specific cases. 

 While the definitions above are intended to distinguish between events that are 

less preventable, from those that are more preventable, the difference is best described as 

a spectrum. To conceptualize this spectrum we developed the following three categories 

of conditions: 

1. Conditions which could be either a comorbidity or a complication. These 

conditions, inasmuch as they are present on admission, and not caused by medical 

management, but rather due to the patient’s underlying disease, include conditions 

such as congestive heart failure. It is extremely difficult to distinguish 

complications from comorbidities for these conditions using administrative data. 

As a result, these conditions were not considered in this report. 

2. Conditions which are likely to reflect medical error. These conditions, such as 

foreign body accidentally left during a procedure, are likely to have been caused 

by medical error. Most of these conditions appear infrequently in administrative 

data, and thus rates of events lack the precision to allow for comparisons between 

providers. However, these conditions may be the subject of case finding 

indicators. 

3. Conditions which conceivably, but not definitively reflect medical error. These 

conditions represent a spectrum of preventability between the previous two 

categories from those which are mostly unpreventable to those which are mostly 

preventable (i.e., category 2 above). Because of the uncertainty regarding the 

preventability of these conditions and the likely heterogeneity of cases with the 

condition, indicators utilizing these conditions are less useful as case finding 

indicators. However, examining the rate of these conditions may highlight 

potential areas of concern. 

Evaluation Framework 

To evaluate the soundness of each indicator we applied the same framework as 

was applied in the companion QI report.3 This included six areas of evidence: 
19

 Framework for Evaluating the Quality Indicators

1. Face validity: Does the indicator capture an aspect of quality that is widely 

regarded as important and subject to provider or public health system 

control? Consensual validity expands face validity beyond one person to 

the opinion of a panel of experts. 

2. Precision: Is there a substantial amount of provider or community level 

variation that is not attributable to random variation? 

3. Minimum bias: Is there either little effect on the indicator of variations in 

patient disease severity and comorbidities, or is it possible to apply risk 

adjustment and statistical methods to remove most or all bias? 

4. Construct validity: Does the indicator perform well in identifying true (or 

actual) quality of care problems?

5. Fosters real quality improvement: Is the indicator insulated from perverse 

incentives for providers to improve their reported performance by avoiding 

difficult or complex cases, or by other responses that do not improve 

quality of care?

6. Application: Has the measure been used effectively in practice? Does it 

have potential for working well with other indicators? 

A full discussion of this framework is available in the companion QI report.3

Since the literature surrounding PSIs is sparse, this report uses a variety of techniques to 

evaluate each indicator. Specifically, face validity (consensual validity) was evaluated 

using a structured panel review (Section 2D. Clinician Panel Review Methods), minimum 

bias was explored empirically (Section 3E. Comparative Empirical Results) and briefly 

during the panel review, and construct validity was evaluated using the limited literature 

available (Section 3A. Literature Review Results). 

 The relative importance of each of these evaluation areas may differ for the PSIs 

as compared to the QIs. For indicators which are primarily designed to screen only for 

medical error, precision and minimum bias may be less important, since these events are 

relatively rare, and in general are better utilized as case-finding indicators. For these 

indicators comparisons between rates are less relevant. However, for rate-based 

indicators, concerns of precision and minimum bias remain, if indicators are used in any 

comparison of rates (comparison to national averages, peer group, etc.). 

Section 2B. Literature Review Methods 

The literature searches performed in connection with assessing potential HCUP 

QIs in previous work3

 identified many references relevant to potential PSIs. In addition, 

we performed the electronic searches outlined below for articles published before 

February 2002 followed by hand searching the bibliographies of identified references. 

Members of the project team were queried to supplement this list, based on their personal 
20

knowledge of recent work in the field. Because Iezzoni et al.’s Complications Screening 

Program (CSP)7 included numerous candidate indicators, we also performed an author 

search using her name. Forthcoming articles and Federal reports in press, but not 

published, were also included when identified through personal contacts. The search 

strategy is shown in Table 1. 

Table 1. Electronic Search Strategy for Articles Pertaining to Patient Safety Indicators 

 MEDLINE® Search String EMBASE® Search String 

1) medical error [mh] OR iatrogenic 

disease [mh] OR sentinel 

surveillance [mh] OR safety [mh] 

1) iatrogenic disease [em] OR health 

survey [em] OR danger, risk, safety 

& related phenomenon[em] OR drug 

safety [em] OR error[em]/all 

exploded 

2) (adverse [ti] AND events [ti]) OR 

complications [ti] OR iatrogenesis 

[ti] OR iatrogenic [ti] 

2) (adverse AND events).ti OR 

complication$.ti OR iatrogen$.ti OR 

mistake$.ti OR error$.ti 

3) epidemiologic studies [mh] OR 

quality of health care [mh] OR 

comparative study [mh] OR 

disease/classification [mh] 

3) health care quality[em] OR 

epidemiology[em] 

4) (#1 OR #2) AND #3 4) (#1 OR #2) AND #3 

5) health services research [mh] OR 

abstracting and indexing [mh] OR 

medical records [mh] OR medical 

audit [mh] OR hospitalization [mh] 

OR patient readmission [mh] OR 

patient discharge [mh] 

5) health services research[em] OR 

documentation[em] OR medical 

record[em] OR medical audit[em] OR 

hospitalization[em] OR child 

hospitalization[em] OR hospital 

admission[em] 

6) reproducibility of results [mh] OR 

sensitivity and specificity [mh] 

6) reproducibility[em] OR 

reproducib$.kw OR (sensitive$ or 

specific$).kw 

7) #4 AND #5 AND #6 7) #4 AND #5 AND #6 

8) #7 BUTNOT (case report [mh] OR 

case* [ti] OR report [ti] OR editorial 

[pt] OR comment [pt] OR letter [pt]) 

Limits: English Language 

MEDLINE® and EMBASE® database search from January, 1990 to February, 2002. 

Abbreviations: [mh] = [MeSH terms], [ti] = [Title word]

Three-hundred twenty six articles were identified from the MEDLINE® search. 

Articles were screened using both the titles and abstracts. To qualify for abstraction, an 

article must have described, evaluated, or validated a potential indicator of medical 

errors, patient safety, or potentially preventable complications based on International 

Classification for Diseases -Ninth Revision-Clinical Modifications (ICD-9-CM) coded 

administrative (hospital discharge or claims) data. Some indicators were also considered 

if they appeared to be readily translated into ICD-9-CM, even if the original authors did 

not use ICD-9-CM codes. 

This search was adapted slightly and repeated using the OVID interface with 

EMBASE®8

, limited to articles published from January 1990 through the end of first 
21

quarter 2002. Our EMBASE® search identified 463 references. These articles were 

screened in the same manner, after elimination of articles that had already been identified 

using MEDLINE®9 and the other approaches described above. Only 9 additional articles 

met criteria for abstraction. 

Section 2C. Development of Initial Candidate List of 

Indicators 

Indicators that measured rates of complications at both the hospital level and area 

level were considered. A flow diagram outlining the selection of indicators is included in 

Section 3B. Indicator Selection. Two types of indicators were considered: hospital level 

and area level. The intent of a hospital level indicator is to provide a measure of the 

potentially preventable complication for patients who received their initial care and the 

complication of care within the same hospitalization. On the other hand, the intent of an 

area level indicator is to capture all cases of the potentially preventable complication that 

occur in a given area (e.g., metropolitan service area or county). Thus, hospital level 

measures typically include only cases where a secondary diagnosis code flags a 

potentially preventable complication since the patient was being hospitalized for a 

different principal diagnosis. In contrast, area level measures would be specified to 

include principal diagnosis, as well as secondary diagnoses, for the complications of care, 

thereby adding cases where a patient’s risk of the complication occurred in a separate 

hospitalization. The denominator specification for these two types of indicators is 

described in Section 2E. Empirical Methods. 

The literature search located relatively few indicators amenable to identifying 

patient safety concerns (see Appendix A) that could be defined using unlinked 

administrative data. The majority of such indicators were from the Complications 

Screening Program (described below).7 Several similar, but less comprehensive, 

measures of potentially preventable complications were identified from other sources in 

the literature. 

Identifying Potential Indicators

Complications Screening Program

The Complications Screening Program (CSP) was developed by Lisa Iezzoni et 

al.7

 for the purpose of identifying potentially preventable complications of adult medical 

and surgical hospital care, using commonly available administrative data. The algorithm 

utilizes discharge abstract data, specifically, ICD-9-CM diagnosis and procedure codes, 

patient age, sex, DRG, and date of procedure, to identify 28 complications “that raise 

concern about the quality of care based on the rate of such occurrence at individual 

hospitals.” 7 The CSP was initially developed using the clinical judgment of the 

developers, complemented by “detailed consideration of the ICD-9-CM codebook, and an 

extensive review” of the literature on health services research, quality assurance, and 

clinical indicators.7 Each of the complications is applied to some or all of the following 

specified “risk pools” separately: major surgery, minor surgery, invasive cardiac 

procedure, endoscopy, medical patients, all patients. In addition, specified inclusion and 
22

exclusion criteria are applied to each complication. These criteria are aimed at ensuring 

that the complication developed in-hospital, as opposed to being present on admission, 

and that the complication was potentially preventable. 

 Iezzoni and colleagues published a series of four papers in the mid 1990s on the 

face validity and construct validity of the CSP.7, 10-12 First, they asked each of 29 

physicians who were not involved in the development of the CSP to review 100 randomly 

selected hospital discharge abstracts, including 53 flagged and 47 not flagged by the 

algorithm. These physicians were asked whether “on the basis of your review, is there 

anything about this summary that would make you want to review the care rendered at 

hospitals with high rates of this type of case for potentially avoidable quality-of-care 

problems.” Of the 30 cases targeted by a majority of physicians, the CSP flagged 28 

(sensitivity=93%); of the 70 cases not targeted by a majority of physicians, the CSP 

screens also did not flag 45 (specificity=64%). Second, they reported relationships 

between the CSP and hospital characteristics, patient characteristics, and utilization. 

Using California discharge abstract data, researchers found that patients with CSPdefined complications were more likely to be older, to die before discharge, to have 

longer lengths of stay, and to incur higher hospital charges, than cases with none of these 

complications. Having a chronic condition raised the probability of experiencing a 

complication (after adjusting for age), especially among major surgery patients, but the 

predictive power of models that used these chronic conditions to predict complications 

was relatively poor. More surprisingly, larger and major teaching hospitals, including 

hospitals equipped to perform open heart surgery, appeared to have higher complication 

rates than smaller and non-teaching hospitals. However, all findings appeared to be 

dependent on the risk pool being examined.7, 10-12 It was also notable that hospital ranks 

based on indirectly standardized CSP complication rates were not significantly correlated 

with hospital ranks based on indirectly standardized Medicare mortality rates (with the 

exception of medical cases, among whom the correlation was inverse). Intra-hospital 

correlations across the six risk pools were weak. 

 Four later studies were designed to test criterion and construct validity by 

validating the data used to construct CSP screens, validating the screens as a flag for 

actual quality problems, and validating the replicability of hospital-level results using 

different data sources.13-16 First, Iezzoni et al. trained expert coders to re-abstract ICD-9-

CM diagnosis and procedure codes on a random sample of hospital records from 

Connecticut and California, and then assessed how often CSP trigger codes were 

corroborated by re-review of the medical record.13 The predictive value of medical 

complications was relatively poor, because 58% of the flagged complications in this risk 

pool were actually present at admission. Corroboration rates were often even lower when 

Iezzoni et al. used objective clinical criteria, abstracted by nurses, to diagnose 

complications.14 The last two studies in this series utilized implicit physician review and 

explicit nurse review to identify potential quality-of-care problems and process-of-care 

failures, respectively, among CSP-flagged cases and unflagged controls. These studies 

also raised concerns about the validity of the CSP, as for most indicators flagged cases 

were no more likely than unflagged controls to have suffered explicit process 

failures.15, 16 It should be noted that potential process failures were perhaps undetectable 

by this study, because of limitations in medical record documentation. Details of the 
23

performance of the individual complications are contained in Section 3A. Literature 

Review Results. 

 The Complications Screening Program has been purchased by HCIA-Sachs (now 

Solucient), although additional development and research completed by this company 

was not available to the researchers of this report. 

Miller et al. PSIs

Researchers at AHRQ reviewed all ICD-9-CM codes implemented in or before 

1999 identifying codes that possibly describe medical errors or reflect the consequences 

of such errors.17 Examples of codes identified by AHRQ include iatrogenic 

pneumothorax, iatrogenic hypotension, and several “external cause-of-injury codes” (Ecodes). In addition, AHRQ researchers reviewed all codes included in the CSP indicators. 

AHRQ investigators applied clinical and coding knowledge to identify those codes most 

likely to identify medical error. These codes included foreign body left in during a 

procedure, suture of laceration codes, and several other sentinel event codes. These 

efforts at AHRQ provided the foundation for the candidate list of potential PSIs for this 

report. This initial set of PSIs will be referred to in this report as the Miller et al. PSIs.17

UCSF-Stanford EPC Development

The EPC team reviewed and updated the Miller et al. PSIs. Additions included 

relevant codes from the 2000 and 2001 revisions of ICD-9-CM, and selected codes from 

the CSP, such as those not clearly reflective of medical error, but representing a 

potentially preventable complication. This process was guided principally by conceptual 

considerations. For example, postoperative acute myocardial infarction was included 

since recent evidence suggests that it is a potentially preventable complication.2 A few 

codes were also deleted from the initial list based on a review of ICD-9-CM coding 

guidelines, described in Coding Clinics for ICD-9-CM and the American Hospital 

Association’s ICD-9-CM Coding Handbook. For example, the code 259.3 for 

hypoglycemic coma specifically excludes patients with diabetes mellitus, the population 

for which this complication is most preventable. This process of updating the Miller et al. 

PSIs resulted in a list of over 200 ICD-9-CM codes (valid in 2001) potentially related to 

medical error. 

Codes were then grouped into indicators. Where feasible, codes were compiled as 

they were in the CSP, or in some cases the Miller et al. PSIs,17 depending on which 

grouping yielded more clinically homogeneous groups. In most cases the resulting 

indicators were not identical to the CSP indicators, although they were closely related, as 

some of the specific codes included in the original CSP had been eliminated after our 

review of coding guidelines. Five indicators were identical to the CSP indicators. The 

remaining codes were then incorporated into the most appropriate CSP-based indicator, 

or were grouped into clinically meaningful concepts to define novel indicators. Exclusion 

criteria were added based on CSP methods and clinical judgment. As a result, over 40 

patient safety indicators were defined that, while building on prior work, reflected 

significantly changed measures to focus more narrowly on the most preventable 

complications. 

Indicators were defined with both a numerator (complication of interest) and a 

denominator (population at risk). Different patient subpopulations have inherently 
24

different risks for developing a complication, with some patients having almost no risk. 

Thus, for each indicator a specified population at risk was specified as a denominator. 

The intention was to restrict the complication (and consequently the rate) to a more 

homogeneous population who are actually at risk for that complication. The population at 

risk for the candidate indicators tended to be narrower than the combination of all risk 

pools available in the CSP definitions, and was intended to reflect the population for 

which the complication is more likely to reflect a potentially preventable complication. In 

general, the population at risk corresponded to one risk pool (e.g., major surgery) from 

the CSP, if applicable, or was defined more narrowly. 

Initial Selection of Indicators 

After the development of this list of potential indicators, a subset of indicators 

was selected to undergo face validity testing by clinician panels (see Section 2D. 

Clinician Panel Review Methods). Two sources of information guided the selection 

process. 

First, validation data from previous studies were reviewed and thresholds were set 

for indicator retention of CSP based indicators. Four studies were identified that 

evaluated the CSP indicators. Three of these studies,13-15 examined the predictive value of 

each indicator in identifying a complication that occurred in-hospital, regardless of 

whether this complication was due to medical error or was preventable. Coder, physician 

and nurse reviewers examined medical charts and used specified criteria to judge whether 

or not the flagged complication had indeed occurred during the hospitalization (as 

opposed to being present on admission, or not having occurred at all). In a fourth study,16

nurses identified specific process failures that may have contributed to complications. In 

order to be retained as a potential PSI, at least one of the first three studies corroborating 

the ICD-9-CM code with an actual in-hospital complication needed to demonstrate a 

positive predictive value of at least 75%, meaning that 3 out of 4 patients identified by 

the measure did indeed have the complication of interest. In addition, the positive 

predictive value of a "process failure" identified in the fourth study needed to reach or 

exceed 46%, which was the average rate for surgical cases that were not flagged by any 

of the CSP indicators. In other words, by this criterion, potential PSIs must have 

demonstrated that approximately half or more of the patients flagged received care where 

a process failure contributed to a complication, indicating a potentially preventable error. 

As a result, we only retained CSP-derived indicators that were at least somewhat 

predictive of objectively defined process failures, or medical errors. 

Second, specific changes to previous definitions or constructs of indicators fell 

into the following general categories that were considered for the initial selection by the 

team of this candidate set for face validity testing, as well as discussed during the 

clinician panel review process (see Section 2D. Clinician Panel Review Methods): 

1. Changes to the denominator definitions (inclusion or exclusion criteria), 

intended to reduce bias due to the inclusion of atypical patients or to improve 

generalizability to a broader set of patients at risk. 
25

2. Elimination of selected ICD-9-CM codes from numerator definitions, 

intended to focus attention on more clinically significant complications, or 

complications more likely to result from medical errors. 

3. Addition of selected ICD-9-CM codes to numerator definitions, intended to 

capture related complications that could result from the same or similar 

medical errors. 

4. Division of a single indicator into two or more related indicators, intended to 

create more clinically meaningful and conceptually coherent indicators. 

5. Stratification or adjustment by relevant patient characteristics, intended to 

reflect fundamental clinical differences among procedures (e.g., vaginal 

delivery with or without instrumentation) and the complications that result 

from them, or fundamental differences in patient risk (e.g., decubitus ulcer in 

lower-risk versus high-risk patients). 

A total of 34 indicators, intended to be applied to all age groups, were retained for 

face validity testing by clinician panels (Appendix A). Because of the primary intent in 

the development of these indicators to detect potentially preventable complications 

related to health care exposure, the final definitions for this set of indicators represented 

mostly new measures that built upon previous work. 

Coding Review 

Concurrent with clinician panel review, we contracted with a consultant from 

AHIMA to review each of the 34 indicators. The consultant, an expert in ICD-9-CM 

coding guidelines, reviewed each code for accuracy of capturing the questioned 

complication and population at risk, according to current coding guidelines. She 

consulted additional resources, including members of the central staff of ICD-9-CM, as 

appropriate. In some cases, additional codes or other refinements to the indicators were 

suggested, based on current coding guidelines. For example, clarification of the 

procedure codes included in the indicator "Reopening of a surgical site" revealed that the 

nature of these codes was substantially different than what the team and panels had 

assumed. This resulted in a change to the overall rating of this indicator. 

Section 2D. Clinician Panel Review Methods 

A structured review of each indicator was undertaken to evaluate the face validity 

(from a clinical perspective) of the indicators. Specifically, the panels approach sought to 

establish consensual validity, which “extends face validity from one expert to a panel of 

experts who examine and rate the appropriateness of each item....”18 The methodology 

for the structured review was adapted from the RAND/UCLA Appropriateness Method19

and consisted of an initial independent assessment of each indicator by clinician panelists 

using an initial questionnaire, a conference call among all panelists, followed by a final 

independent assessment by clinician panelists using the same questionnaire. The panel 

process served to refine definitions of some indicators, add new measures, and dismiss 

indicators with major concerns from further consideration. 
26

This standardized panel approach, although differing somewhat from the 

approach used in this report, was used to evaluate potential indicators of primary care 

quality20, 21 as well as ambulatory care sensitive conditions.22

Panel Selection 

Twenty-one professional clinical organizations were invited to submit 

nominations. These organizations were selected based on the applicability of the specialty 

or subspecialty to our quality indicators. Organizations that represented general 

practitioners (e.g., general surgeons, internists, critical care physicians, perioperative 

nurses, and critical care nurses) were asked to nominate more panelists than those 

representing sub-specialties. Fifteen organizations submitted nominations: American 

Association of Critical-Care Nurses; American Academy of Family Physicians; 

American College of Cardiology; American College of Nurse-Midwives; American 

College of Obstetricians and Gynecologists; American College of Physicians/American 

Society of Internal Medicine; American College of Radiology; American College of 

Surgeons; American Geriatric Society; Association of Perioperative Nurses; American 

Society of Anesthesiologists; American Society of Health-system Pharmacists; American 

Thoracic Society; Association of Women's Health Obstetric and Neonatal Nurses; and 

National Association of Inpatient Physicians. 

These professional organizations nominated a total of 162 clinicians. Each 

nominee was invited to participate in the evaluation. In order to be eligible to participate, 

nominees were required to spend at least 30% of their work time on patient care, 

including hospitalized patients. Ninety-two nominees accepted this invitation. Five 

nominees were ineligible to participate. Nominees were asked to provide information 

regarding their practice characteristics, including specialty and subspecialty and setting 

(i.e., urban vs. rural location, region of country, and service to underserved populations), 

information regarding primary hospital of practice (i.e., funding source) and personal 

information (i.e., clinical education history, academic affiliation). 

For assignments to each panel, a list of applicable specialties was identified for 

the indicators to be evaluated by a given panel. Panelists were selected so that each panel 

had diverse membership in terms of practice characteristics and setting. Thus, when a 

specific area was over-represented by the pool of eligible nominees, randomly drawn 

members from that specific sub-group were contacted first to fill the panels. In addition, 

conference call scheduling logistics influenced assignments. Fifty-seven of the eligible 

panelists accepted the invitation to participate on specific panels. Four did not participate 

in the conference call, and thus were removed from the panels. All other panelists (53) 

completed the evaluation in full. 

Panel Composition 

Eight panels were formed. Complications of medical care indicators were 

examined by two panels. Surgical complications indicators were reviewed by three 

panels. Another panel assessed indicators related to procedural complications. Finally, 

two panels examined obstetric complications indicators. Participants in the panels are 

listed in Appendix B. All panels had diversity in the geographic location of panelists, and 

the type of practice (see Table 2). 
27

Table 2. Multi-specialty Panel Composition 

Characteristic % (N) 

Gender 

 Female 38% (20) 

Academic Affiliationa

 Yes 64% (34) 

 No 26% (14) 

 Not reported 9% (5) 

Geographic Region 

 East 26% (14) 

 West 21% (11) 

 South 21% (11) 

 Midwest 32% (17) 

Community 

 Urban 49% (26) 

 Suburban 19% (10) 

 Rural 16% (9) 

 Not reported 15% (8) 

Funding of Primary Hospital 

 Private 42% (22) 

 Public 32% (17) 

 Both 6% (3) 

 Not Reported 21% (11) 

Patient Population Served 

 Underserved 47% (25) 

 General 28% (15) 

 Not reported 25% (13) 

1

Clinical and/or research affiliation 

Initial Evaluation 

After agreeing to evaluate each indicator, panelists were sent information (see 

Appendix C) regarding administrative data, ICD-9-CM coding, assignment of Diagnostic 

Related Groups (DRGs) and Major Diagnostic Categories (MDCs), and specific 

definitions for “adverse events or complications,” “preventability,” and “medical error.” 

The definitions of these terms, including distinctions are available in Appendix C and in 

Section 2A. Framework and Definitions. Panelists were presented with four to five 

indicators. The standardized text used to describe each ICD-9-CM code was presented 

along with the specific numeric code. Exclusion and inclusion criteria were also given, as 

well as the clinical rationale for the indicator and the specification criteria. Panelists were 

provided potential questions regarding the indicator definition that the study team 

planned to explore during the conference call. 

Each of the 5 to 9 panelists from a given panel provided input for a given 

indicator by completing a 10-item questionnaire (see Appendix C). This questionnaire 

asked panelists to consider the ability of this indicator to screen out conditions present on 

admission, the potential preventability of the complication and the ability of the indicator 

to identify medical error. In addition, the questionnaire asked panelists to consider the 
28

potential bias, reporting or charting problems, potential for gaming the indicator, and 

adverse effects of implementing the indicator. Finally, panelists were invited to suggest 

changes to the indicator. 

Conference Call 

Following the submission of the initial evaluation questionnaires, all panelists 

participated in a 90-minute conference call for their panel to discuss the indicators. The 

purpose of each conference call was to allow panelists to discuss their opinions regarding 

each indicator. Following the instructions in the RAND/UCLA method where the 

primary goal of interaction between panelists is to allow room for varied opinions about 

the appropriateness of an indicator, panelists were explicitly told that consensus was not 

the goal of discussion. In some cases, panelists agreed on proposed changes to the 

indicator definitions, and such consensus was noted and the definition was modified 

accordingly before the final round of rating. Each call was moderated by a team member 

(KM), who directed the structure of the call, and ensured that all panelists had a chance to 

share their opinions. Also present was a technical expert, who answered questions 

regarding administrative data and coding (PR), and a silent observer, who maintained 

comprehensive notes of the call (SD). All team members refrained from offering opinion 

regarding indicators during the call. Each indicator was discussed for approximately 15 

minutes. Agenda items were set based on the feedback received from the initial 

evaluation, and in general focused on points of disagreement among panelists. Panelists 

were prompted throughout the process to consider the appropriate population at risk for 

each indicator (specifically inclusion and exclusion criteria) in addition to the 

complication of interest. However, if panelists wished to discuss other aspects of the 

indicator, this discussion was allowed within the time allotted for that indicator. If time 

remained at the end of a call, topics that were not fully addressed previously were 

revisited. 

Final Evaluation 

Following each conference call, changes to each indicator were made where 

suggested by panelists. In each case, near consensus of the panelists must have been 

reached during the conference call for the change to be implemented. The indicators were 

then redistributed to panelists along with questionnaires used in the initial evaluation. 

Each indicator description included explication of any definition changes made and the 

reason. Panelists were asked to re-rate each indicator based on their current opinion. They 

were asked to keep in mind the discussion during the conference call. 

Tabulation of Results 

To examine the results of the panels, we applied a modified version of the 

“appropriateness” criteria outlined in the RAND/UCLA Appropriateness Method. Results 

from the final evaluation questionnaire were used to calculate median scores from the 9 

point scale for each question and to categorize the degree of agreement among panelists 

(see Table 3). Median scores determined the level of acceptability of the indicator, and 
29

dispersion of ratings across the panel for each applicable question determined the 

agreement status. Therefore the median and agreement status were independent 

measurements for each question. The following six criteria covered in the questionnaire 

were used to identify the panel opinions (i.e., median, agreement status category) on the 

following aspects of the indicator: 

1. Overall usefulness of the indicator, 

2. Likelihood that indicator measures a complication and not a comorbidity 

(specifically, present on admission), 

3. Preventability of complication, 

4. Extent to which complication is due to medical error, 

5. Likelihood that complication is charted given that it occurs; and 

6. Extent that indicator is subject to bias (systematic differences, such as case 

mix that could affect the indicator, in a way not related to quality of care). 

These evaluations are included in the summary of results for each indicator (Section 

3D. Detailed Panel Results by Indicator). 

Table 3. Criteria for Agreement Status 

Category Panel size Criteria 

8-10 panelists Two or fewer members rated indicator outside 

specific three-point range (1-3.9, 4-6.9, 7-9) in which 

the median falls. 

Agreement 

5-7 panelists One or fewer panelists rated indicator outside 

specific three-point range (1-3.9, 4-6.9, 7-9) in which 

the median falls. 

8-10 panelists Three or more panelists rated indicator in each of the 

extreme three-point ranges (1-3.9, 7-9). 

Disagreement 

5-7 panelists Two or more panelists rated indicator in each of the 

extreme three point ranges (1-3.9, 7-9). 

Indeterminate 

Agreement 

All panel sizes Any panel rating not qualifying as either “agreement” 

or “disagreement” by above criteria. 

We used the ratings regarding the overall appropriateness of the indicator (i.e., 

criterion number 1 above based on question #8 on questionnaire in Appendix C) to assess 

the overall usefulness as a screen for potential patient safety problems (see Table 4). The 

median score and agreement category for this usefulness question were combined into 

modified RAND groupings. Akin to the RAND “Appropriate” level, we created two 

categories, “Acceptable” and “Acceptable (-).” “Acceptable (-)” refers to indicators 

which were considered acceptable, but this distinction was not as clear as for those 

receiving a pure “Acceptable” rating. The RAND “Uncertain” level was likewise divided 

into two parts, “Unclear,” and the slightly worse category, “Unclear (-).” The RAND 

“Inappropriate” level was defined identically but named “Unacceptable.” These 

designations, along with some initial administrative data testing and subsequent coding 

clarifications, were used to triage indicators into three sets: Accepted Indicators, 
30

Experimental Indicators, and Rejected Indicators (see Tables 11-13 in Section 3B. 

Indicator Selection). 

Table 4. Definitions for Overall Appropriateness of Indicator 

Acceptable Median falls between 7 and 9 (inclusive of both), agreement 

Acceptable (-): Median falls between 7 and 9 (inclusive of both), indeterminate 

agreement 

Unclear: Median falls between 7 and 9 (inclusive of both), disagreement, OR 

Median falls between 5 and 7 (inclusive of neither), agreement or 

indeterminate agreement 

Median between 4 and 5 (inclusive of both), agreement, 

indeterminate agreement or disagreement, OR 

Unclear (-): 

Median falls between 1 and 3.9 with disagreement. 

Unacceptable: Median falls between 1 and 3.9, agreement or indeterminate 

agreement. 

Surgical Panels 

The multi-specialty panels had limited surgeon participation because of the need 

to include a variety of specialties without expanding the panel. No surgical subspecialties 

were represented, and each panel had at most two participating surgeons. As a result of 

panelists frequently requesting more surgical input for some of the indicators, we 

convened three additional panels consisting of only surgeons from various subspecialties 

to complete a second round of review. The method of review was identical to the 

previous panels. The surgeons reviewed the same indicators as were reviewed by the 

initial multi-specialty panels. Each panel received the same combinations of indicators, in 

their originally proposed form, with two exceptions. One panel received "Minor 

Perioperative Physical Injuries" and another "Malignant Hypertension" in addition to the 

group of four indicators originally reviewed as a packet by a multi-specialty panel. These 

two additional surgical indicators were created based on suggestions by the multispecialty panels during the discussion of an indicator called “Complications of 

Anesthesia.” 

Sixteen organizations representing surgical subspecialties were invited to 

nominate ten panelists. Nine organizations submitted at least one nomination, including: 

American Association of Hip and Knee Surgeons; American Association of Hand 

Surgeons; American Association of Neurological Surgeons; American Academy of 

Orthopedic Surgeons; American Society of Colon and Rectal Surgeons; American 

Urologic Association; North American Spine Society; Society of Thoracic Surgeons; and 

American Society of Transplant Surgeons. In addition to recruiting subspecialists, we 

contacted state chapters of the American College of Surgeons from the five most 

populous states, to obtain one or two nominations of general surgeons. Four of the 22 

contacted chapters sent nominations: San Diego, Southern California, Metropolitan 

Chicago, and Central Pennsylvania. We received names of 79 nominees, forty-two of 

whom accepted our invitation to participate. Twenty-five were assigned to panels, based 

on their availability to participate and their subspecialty. Three panels were constructed 
31

with a variety of specialties represented (see Appendix B). Two panelists did not 

complete the entire review. 

 The demographic composition of the surgical panel (see Table 5) differed 

significantly from that of the multi-specialty panels only by gender (p<.05), with more 

males on the surgical panels than on the multi-specialty panels. No other differences were 

significant. 

Table 5. Surgical Panel Composition 

Characteristic % (N) 

Gender 

 Female 9% (2) 

Academic Affiliation 

 Yes 87% (20) 

 No 13% (3) 

Geographic Region 

 East 26% (6) 

 West 17% (4) 

 South 30% (7) 

 Midwest 26% (6) 

Community 

 Urban 39% (9) 

 Suburban 17% (4) 

 Rural 17% (4) 

 Not reported 26% (6) 

Hospital Affiliation 

 Private 52% (12) 

 Public 22% (5) 

 Both 9% (2) 

 Not Reported 17% (4) 

Population 

 Underserved 43% (10) 

 General 22% (5) 

 Not reported 35% (8) 

Surgical panelists followed the same procedure as the multi-specialty panels in 

rating each indicator. In order to ensure that similar topics were discussed in the 

conference calls of both the multi-specialty and surgical panels, and to obtain surgeon 

feedback on changes suggested by the multi-specialty panels, agendas for the conference 

calls included those topics discussed by the multi-specialty panels (though the source of 

these topics was not noted). As with the multi-specialty panels, the agenda also included 

concerns and areas of disagreement based on panelists’ responses to the first round 

questionnaire. Panelists then re-rated each indicator based on the suggestions of their own 

panel. In some cases the final definitions suggested by consensus in the surgical panel 

calls, and therefore proposed in the second-round questionnaire differed substantially 

from those rated by the multi-specialty panels. For these cases, the study team reviewed 

the reasons for differences in definitions proposed, and defined the indicator based on 

input from both panels if possible. Panel results for each indicator note any differences 
32

between panels, and explain final decisions regarding indicator definitions and 

acceptability. 

Section 2E. Empirical Methods 

Purpose of Analyses 

Empirical analyses were conducted to provide additional information about the 

indicators. These analyses were intended not as decision making tools, but rather 

explorations into the characteristics of the indicators. Specifically, these analyses explore 

the frequency and variation of the indicators, the potential bias, based on limited risk 

adjustment, and the relationship between indicators. 

Analysis Approach 

Data Sources

The data sources used in the empirical analyses were the 1997 Florida State 

Inpatient Database (SID) (for initial testing and development; 1995-1997 used for 

persistence analysis) and the 1997 State Inpatient Databases (SID) for 19 HCUP 

participating states, referred to in this report as the National SID, (for the final empirical 

analysis). The Florida SID consists of about 2,000,000 discharges from over 200 

hospitals, and was chosen because it is a large diverse state. The National SID consists of 

about 19,000,000 discharges from over 2,300 hospitals. The National SID contains allpayer data on hospital inpatient stays from participating states (Arizona, California, 

Colorado, Connecticut, Florida, Illinois, Iowa, Kansas, Maryland, Massachusetts, 

Missouri, New Jersey, New York, Oregon, Pennsylvania, South Carolina, Tennessee, 

Washington, Wisconsin). All discharges from participating States’ community hospitals 

are included in the SID database, which defines community hospitals as nonfederal, 

short-term, general, and other specialty hospitals, excluding long-term hospitals and 

hospital units of long-term care institutions, psychiatric hospitals, and 

alcoholism/chemical dependency treatment facilities. A complete description of the 

content of the SID, including details of the participating States’ discharge abstracts, can 

be found on the Agency for Healthcare Research and Quality web site 

(www.ahrq.gov/data/hcup/hcupsid.htm). Because the Florida SID was used only for 

initial testing and development, the empirical results reported are from the National SID. 

Descriptive results from the Florida SID are reported for comparison to ensure that the 

hospital level results were similar in both data sources. Differences between Florida and 

national results are pointed out in the text. The National SID data were also used for the 

construction of area measures, with data from the U.S. Census Bureau used to construct 

the denominator of these rates. 

Reported Patient Safety Indicators 

Three sets of patient safety indicators were examined. First, the Accepted patient 

safety indicators met the face validity criteria established through the literature review 

and clinician panel review. Second, the Experimental patient safety indicators did not 
33

meet those criteria, but appeared to warrant further testing and evaluation. Third, several 

Accepted patient safety indicators were modified into area indicators, which were 

designed to assess the total incidence of the adverse event within geographic areas. For 

example, we constructed an indicator for “Transfusion reaction” at both the hospital and 

area level. Transfusion reactions that occur after discharge from a hospitalization would 

result in a readmission. The area level indicator includes these cases, while the hospital 

level restricts the number of transfusion reactions to only those that occur during the 

same hospitalization that exposed the patient to this risk. 

All potential indicators were examined empirically by developing and conducting 

statistical tests for precision, bias, and relatedness of indicators. For each indicator, we 

calculated five different estimates of hospital performance. First, we calculated the raw 

indicator rate using the number of adverse events in the numerator divided by the number 

of discharges in the population at risk by hospital. For the area indicators, the 

denominator is the population of the Metropolitan Statistical Area (MSA), New England 

County Metropolitan Area (for the New England states) or county (for non-MSA areas) 

of the hospital. Second, we adjusted the raw indicator using a logistic regression to 

account for differences among hospitals (and areas) in demographics (specifically, age 

and gender). Age was modeled using a set of dummy variables to represent 10-year 

categories except for young children whose age categories are narrower (i.e., less than 1, 

1-4, 5-14, 15-24, 25-34, 35-44, 45-54, 55-64, 65-74, 75-84, and 85 or more years), along 

with a parallel set of age-gender interactions. Because of sparse cells, certain age 

categories were combined or omitted for selected indicators, such as the obstetric 

indicators. Third, we adjusted the raw indicator to account for differences among 

hospitals in age, gender and modified DRG category (as described below). Fourth, we 

adjusted the raw indicator to account for differences among hospitals in age, gender, 

modified DRG and comorbidities (defined using an adaptation of the AHRQ comorbidity 

software) of patients. Finally, we applied mutlivariate signal extraction (MSX) methods 

to adjust for reliability by estimating the amount of “noise” (i.e., variation due to random 

error) relative to the amount of “signal” (i.e., systematic variation in hospital performance 

or the ‘reliability’) for each indicator. This or similar “reliability adjustment” has been 

used in the literature for similar purposes.23, 24 Mutlivariate methods (taking into account 

correlations among indicators in order to extract additional ‘signal’) were applied to most 

of the accepted indicators. The exceptions were Death in Low Mortality DRGs and 

Failure to Rescue. Only univariate signal extraction methods (smoothing) were applied 

to these two indicators and to the experimental indicators, because these indicators 

possibly cover broader clinical concepts. Correlations between these indicators and other 

indicators may not reflect correlations due to quality of care, and thus inclusion of these 

indicators may adversely affect the MSX approximations. For additional details on the 

empirical methods, refer to the companion EPC HCUP Quality Indicator Report, 

published by AHRQ (http://www.ahrq.gov/data/hcup/qirefine.htm). Additional details on 

the modifications made to the DRG and comorbidity categories are described below. 

Hospital Fixed Effects 

In our risk-adjustment models, we calculated hospital fixed effects using the 

standard method with logistic models of first estimating the predicted value for each 

discharge, then subtracting the actual outcome from the predicted, and averaging the 
34

difference for each hospital to get the hospital fixed effect estimate. In the companion 

Quality Indicator Report,3 we used linear regression models with hospital fixed effects 

included, arguing that the logistic approach yielded biased estimates due to the omission 

of a variable (the hospital) correlated with both the dependent (e.g., in-hospital mortality) 

and the independent (e.g., age, gender, APR-DRG) variables in the model. Given the rare 

occurrence of many of the PSI, however, the logistic approach may be more appropriate 

for this application. Linear methods assume that the distribution of the error term is 

normally distributed. This assumption is violated when the outcome is dichotomous. The 

QI means were generally an order of magnitude higher than the PSI means, so the 

assumption was not as problematic. However, the most appropriate method depends on 

the particular characteristics of each indicator, whether QI or PSI. To the extent that bias 

is a concern, accounting for the clustering of patients by using a hospital fixed effect is 

advantageous. To the extent that extreme values are a concern, then imposing structure 

on the error term with logistic methods is advantageous. In the end, the two approaches 

can be compared in terms of how much difference it makes in the relative assessment of 

provider performance. This is an issue that warrants further analysis, in order to better 

understand the trade-offs and limitations of each approach, and under what conditions 

and for what indicators each approach might best apply. 

 Specifically, the risk-adjusted “raw” estimate of a hospital’s performance is 

constructed in two steps. In the first step, if we denote whether or not the event 

associated with a particular indicator Yk

 (k=1,...,K) was observed for a particular patient 

i in year t (t=1,...,T), then the regression to construct a risk-adjusted “raw” estimate of a 

particular patient’s performance on each indicator can be written as: 

 

(1) Yk

it = Zit Πkt + ξkit , where 

Yk

it is the kth PSI for patient i in year t (i.e., whether or not the event associated with 

the indicator occurred on that discharge); 

Zit is a vector of patient covariates for patient i in year t (i.e., the patient-level 

measures used as risk adjusters); 

Πk

t is a vector of parameters in each year t, giving the effect of each patient risk 

adjuster on indicator k (i.e., the magnitude of the risk adjustment associated with each 

patient measure); and 

ε

k

it is the unexplained residual in this patient-level model. 

 

 In the second step, we estimated the hospital effect by subtracting the resulting 

predictions from this patient-level regression from the actual observed patient-level 

outcomes, and taking the mean of this difference for each hospital. That is, for each 

hospital j (j=1,...,J), 

(2) Mk

jt = Ykijt – (Zit Πkt + ξkit), where 

 

Mk

jt is the “raw” adjusted measure for indicator k for hospital j in year t (i.e., the 

hospital “fixed effect” in the patient-level regression); and 

Zit is the vector of patient covariates for patient i in year t estimated in Step 1. 
35

 In addition to age, sex, and age*sex interactions as adjusters in our model, we also 

included a modified DRG and comorbidity category for the admission. 

Modified DRG Categories 

We made two modifications to the Centers for Medicare and Medicaid Services 

(CMS, formerly Health Care Financing Administration) Diagnosis-Related Groups 

(DRGs). First, we collapsed adjacent DRG categories that were separated by the 

presence or absence of comorbidities or complications. For example, DRGs 076 

(OTHER RESP SYSTEM OPERATING ROOM PROCEDURES W CC) and 077 

(OTHER RESP SYSTEM OPERATING ROOM PROCEDURES W/O CC) were 

grouped into one category. The purpose was to avoid adjusting for the complication we 

were trying to measure. Appendix D Section 1 lists the categories that were grouped. 

Second, we excluded from the logistic models most of the super-MDC DRG categories. 

Excluding these categories also avoids adjusting for the complications we were trying to 

measure. For example, tracheostomies (DRG 482-483) often result from potentially 

preventable respiratory complications that require long-term mechanical ventilation. 

Similarly, operating room procedures unrelated to the principal diagnosis (DRG 468, 

477) often result from potentially preventable complications that require surgical repair 

(i.e., fractures, lacerations). Appendix D Section 2 lists the super-MDC categories that 

were excluded and other DRGs that were excluded because they were no longer valid. 

In the companion technical report on quality indicators, the risk adjustment 

method implemented All Patient Refined (APR)-DRGs, a refinement of DRGs to capture 

different levels of complications. However, patient safety indicators, designed to detect 

potentially preventable complications, require a risk adjustment approach that does not 

inherently remove the differences between patients based on their complications. The 

APR-DRGs could be modified to remove applicable complications, on an indicator by 

indicator basis, but implementation of such an approach was beyond the scope of the 

current project. In this report, APR-DRG risk adjustment was not implemented. 

Modified Comorbidity Software 

To adjust for comorbidities, we used an updated adaptation of AHRQ 

Comorbidity Software (http://www.ahrq.gov/data/hcup/comorbid.htm). The ICD-9-CM 

codes used to define the comorbidity categories were modified to address four main 

issues. First, we excluded comorbidity categories in the current software that include 

conditions likely to represent potentially preventable complications in certain settings, 

such as after elective surgery. Specifically, three DRG categories (cardiac arrhythmia, 

coagulopathy, and fluid/electrolyte disorders) were removed from the comorbidity 

adjustment. Second, most adaptations were designed to capture acute sequelae of chronic 

comorbidities, where both conditions are represented by a single ICD-9-CM code. For 

example, the definition of hypertension was broadened to include malignant 

hypertension, which usually arises in the setting of chronic hypertension. Unless these 

"acute on chronic" comorbidities are captured, some patients with especially severe 

comorbidities would be mislabeled as not having conditions of interest. Third, the 

comorbidity definitions did not include obstetric comorbidity codes, which are relevant 

for our obstetric indicators. Codes, when available, for these comorbidities in obstetric 
36

patients were added. Fourth, slight updating was necessary based on recent ICD-9-CM 

code changes. Modifications made to the AHRQ comorbidity software are explained in 

detail in Appendix D, Section 3. 

Low Mortality DRGs 

 In order to be included in the “Low Mortality DRG” indicator, the DRG had to 

have an overall in-hospital mortality rate (based on the National SID sample) of less than 

0.5%. In addition, if a DRG category was split based on the presence of comorbidities or 

complications, then we only included the category if both DRGs (with and without 

comorbidities or complications) met the mortality threshold. Otherwise the category was 

not included in the “Low mortality DRG” PSI. The indicator is reported as a single 

measure and stratified into medical (adult and pediatric), surgical (adult and pediatric), 

neonatal, obstetric and psychiatric DRGs. The 126 DRGs included in the measure are 

listed in Appendix D, Section 4 by stratification category. 

Empirical Analysis Statistics 

Using these methods we constructed a set of statistical tests to examine precision, 

bias, and relatedness of indicators for all accepted hospital level indicators, and precision 

and bias for all accepted area level and experimental indicators. Each of the key statistical 

test results was summarized and explained in the overview section of the companion 

HCUP Quality Indicator report.3 Tables 6-8 provide a summary of the statistical analyses 

and their interpretation. 
37

Table 6. Precision Tests Measure Statistic/ Adjustments Interpretation Precision. Is most of the variation in an indicator at the level of the hospital? Do smoothed estimates of quality leaprecise measures? a. Observed variation in indicator 

• Hospital Level 

Standard Deviation 

• Hospital Level 

Skew Statistic 

• Unadjusted • Age-gender 

adjusted 

• Modified DRG 

adjusted 

• Modified AHRQ 

Comorbidity adjusted 

Risk adjustment can either increase or decreasvariation. If increase, then differences in patient mask provider differences. If decrease, then diffpatient characteristics account for provider diff

b. MSX methods • Signal Standard 

Deviation 

• Signal Share • Signal Ratio 

• Reliability 

adjusted 

Estimates what percentage of the observed varhospitals reflects systematic differences versus Signal share is a measure of how much of the to(patient and provider) is potentially subject to h
38

Table 7. Bias Tests Measure Statistic Interpretation Bias. Does risk adjustment change our assessment of relative hospital performance, after accounting for reliabilitygreatest among the best or worst performers, or overall? What is the magnitude of the change in performance? 

Spearman Rank Correlation Coefficient (Before and After Risk Adjustment) 

Risk adjustment matters to the extent that it alteof relative hospital performance. This test deteroverall. 

Average Absolute Value Of Change Relative To Mean (After Risk Adjustment) 

This test determines whether the absolute chanwas large or small relative to the overall mean. 

Percentage of The Top 10% Of Hospitals That Remains The Same (After Risk Adjustment) 

This test measures the impact at the highest ratworse performers). 

Percentage of The Bottom 10% Of Hospitals That Remains The Same (After Risk Adjustment) 

This test measures the impact at the lowest ratebetter performers). 

MSX methods: unadjusted vs. age, sex, Modified DRG, Comorbidity risk adjustment 

Percentage of hospitals that move more than two deciles in rank (up or down) (After Risk Adjustment) 

This test determines the magnitude of the relati

Table 8. Relatedness Tests Measure Statistic Interpretation 3. Relatedness of indicators. Is the indicator related to other indicators in a way that makes clinical sense? Do noise and bias make the relationship clearer? a. Correlation of indicator with other indicators 

Spearman correlation coefficient Are indicators correlated with other indicators i

might expect? 

b. Factor loadings of indicator 

Factor loadings, based on Spearman correlation, Principal Component Analysis 

Do indicators load on factors with other indicatexpect? 
39

Chapter 3. Results 

 The results are presented in four sections. Within each section, the indicators are 

presented within their final designated set – Accepted or Experimental, in alphabetical 

order. Non-obstetric indicators are followed by obstetric indicators, also in alphabetical 

order. The results for each of the rejected indicators are contained in Appendix F. The 

first section presents the results of the literature review. The second section presents the 

overall results of the clinician review; the third section also reports the results for the 

clinician review, but for specific indicators. The final section contains the comparative 

empirical results. 

 Obstetric indicators are grouped together in the results presentations to convey a 

number of differences from the other PSIs more clearly. First, the obstetric indicators, for 

the most part, were created after a review of the ICD-9-CM codes. There is little or no 

precedent for using most of these indicators, and little literature based evidence 

discussing these complications as measures of quality of care. In addition, little evidence 

of the coding validity of obstetric codes exists. Second, at the end of the clinician review 

it appeared that the obstetric panels treated similar complications differently from the 

other panels. For example, the diagnosis code for wound dehiscence was rejected by the 

multi-specialty panel, due to the ambiguity of the code. The obstetric panel, however, 

accepted the ambiguity of the parallel code for cesarean wound dehiscence. Third, an 

entirely different set of physicians and nurses, as well as only a subset of hospitals 

provide obstetric care. Fourth, empirical analyses found that obstetric PSIs on average 

tend to have considerably higher rates than non-obstetric PSIs. In addition, DRG and 

comorbidity risk adjustment is likely inadequate for these indicators (DRGs are split only 

by delivery type and the presence or absence of any complication or comorbidity, and the 

comorbidities examined in the risk adjustment are rare in this population and potentially 

not the most important comorbidities for which to risk adjust). A factor analysis found 

that these indicators tend to load onto one factor, while non-obstetric indicators appear to 

load on a separate factor, for the most part. Because of these considerations, the obstetric 

indicators are presented separately in this report, following the non-obstetric indicators in 

each subsection. 

Section 3A. Literature Review Results 

Background 

In the context of widespread current interest in measuring and improving patient 

safety, potential quality indicators related to potentially preventable complications of 

medical care merit special attention. In this section, we review the literature on the 

application of administrative data to screening for such complications 

The seminal studies that defined the epidemiology of medical errors6, 25, 26 were 

based on a methodology that was pioneered by the California Medical Association 

(CMA) in 1976.27 Specially trained nurses and medical records administrators screened 

inpatient records for any of 18 possible indicators of an adverse event.28 Records that met 

one or more of these criteria were then reviewed independently by two board-certified 

physicians to identify “injuries due to medical management”; all differences were 
40

reconciled by a third independent reviewer. Injuries “caused by the failure to meet 

standards reasonably expected of the average physician...” were labeled as “negligent” 

adverse events. Another seminal study employed “ethnographers trained in qualitative 

observational research” who prospectively identified “situations in which an 

inappropriate decision was made...” by attending all rounds, nursing sign-outs, case 

conferences, and other “organized settings in which health care providers discussed 

adverse events.”29 Neither of these methodologies use ICD-9-CM codes to identify 

adverse events. Another set of studies defined postoperative adverse events based on 

unusual occurrences and key clinical findings that are included in a proprietary clinical 

data system.30-33 Some investigators have defined adverse events de novo, based on 

clinical experience and prior literature.34-37 Others have estimated the incidence of 

adverse drug events using various pharmacy-based surveillance systems.38, 39

By contrast, relatively few studies have evaluated ICD-9-CM diagnosis or 

procedure codes as a method for finding adverse events or medical errors. Numerous 

investigators have proposed various ICD-9-CM definitions of adverse events or medical 

errors; some are limited to specific conditions or procedures40-43 while others are 

applicable to broad groups of hospitalized patients.10, 11, 44-48 However, most of these 

investigators initially validated their measures principally by assessing content validity7

or by demonstrating that they were associated with substantially higher mortality, longer 

lengths of stay, and higher charges at the patient level,40, 47, 48 even after adjusting for 

demographic characteristics and comorbidities.10, 12 Brailer et al.47 also found a strong 

association at the patient level (at 6 hospitals) between their proprietary (CareScience, 

Inc.), comorbidity-adjusted complication measure and a composite measure of 15 

different adverse events (based on Maryland Hospital Association indicators). Among 

these 15 categories, inpatient mortality and unscheduled return to the operating room or 

special care unit (among others) were strongly associated with comorbidity-adjusted 

complications. Several other proprietary systems (e.g., Risk adjusted Major 

Complications, HealthGrades, Inc.; CareEnhance Resource Management Systems, 

McKesson Health Solutions; Disease Staging, MEDSTAT, Santa Barbara CA; 

Performance Measurement, QuadraMed, Larkspur CA; Intelligent Disease Analysis, 

MedAI Inc., Orlando FL) that estimate crude or risk adjusted complication rates based on 

administrative data have never been publicly validated. 

Although these early studies generally supported the validity of using 

administrative data to ascertain adverse events, they also identified several sources of 

concern: 

1. The ratio of observed to predicted complications, based on ICD-9-CM codes 

(predominantly 997.xx through 999.9x) from 776 acute care hospitals, increased 

substantially between 1983 and 1984, reflecting the impact of prospective 

payment on the reporting of complications.45 Conversely, recent evidence 

suggests a significant decrease between 1997 and 1998 in the coding of acute 

posthemorrhagic anemia and selected other complications among Medicare 

inpatients undergoing hip and femur procedures (perhaps in response to the 

Office of the Inspector General’s aggressive compliance program).49 

Proprietary data from Solucient, LLC also suggest a sudden 35% decrease in 

risk adjusted complications across nearly 3,000 hospitals between 1998 and 

1999.50
41

2. Unlike analogous ratios for mortality and readmissions, hospitals’ ratios of 

observed to predicted complications varied significantly by region and hospital 

case-mix index; such associations would not be expected for a valid measure.45

In other studies, ICD-9-CM coded complications were more frequent at large 

hospitals than at smaller hospitals,10 and complication rates were higher at large 

hospitals and academic medical centers.11, 41 These findings contradict 

numerous studies suggesting better outcomes and processes of care, for at least 

some conditions, at high-volume and teaching hospitals.51-53 The most plausible 

explanations for this finding (i.e., greater unmeasured severity of illness, more 

frequent use of invasive therapies, and more aggressive coding of complications 

at teaching hospitals) suggest the possibility of substantial bias in comparing 

performance across hospitals of different types. 

3. There was minimal association between measures of risk adjusted complications 

and other outcome measures (e.g., rates of death, readmission, and major 

morbidity) at the hospital level (Spearman r=-0.01 to -0.05, 46; partial r=0.09-

0.1147; Spearman r=-0.01 for surgical patients, r=-0.12 for medical patients).11

Although this finding has been interpreted as “desirable because (complications 

measures are) intended to provide information not captured by other outcome 

measures”,47 it is concerning that complication measures correlate so poorly 

with somewhat better validated measures of quality. 54-65 Two studies of adverse 

events after coronary artery bypass surgery represent notable exceptions to these 

findings. Specifically, risk adjusted death rates were significantly correlated 

with risk adjusted complication rates, according to Ghali et al. (r=0.73-0.74 

[p<0.01]43), and risk adjusted “major nonfatal” complication rates, according to 

Hartz et al. (r=0.31 and r=0.79 [p=0.035], before and after eliminating a single 

outlier.)66

4. Logistic regression models to predict complications, using information available 

from administrative data, are generally weaker than models to predict death or 

readmission, with receiver operating curve areas or c-statistics (measuring the 

model’s ability to discriminate between patients with and without adverse 

outcomes) of 0.6-0.710, 41-43 and R-squared statistics (correlating observed and 

expected complication rates at the hospital level) of 0.42-0.4845 or 0.16 (for 

medical cases) to 0.42 (for major surgery).11 The difficulty of predicting 

complications suggests that underlying patient characteristics or other 

unmeasured factors may introduce even more bias than in comparative 

evaluations of other outcomes. 

It should be noted that problems 2-4 above may not be unique to administrative 

data, but may apply to clinically derived measures of complications as well. For example, 

two studies by the same researchers, using different data sources, found no correlations 

between risk adjusted complication measures and hospital/operator volume for PTCA and 

CABG.35, 67 Studies based on MedisGroups32 68 data have confirmed that complications, 

adjusting for patient risk, are more frequent at large hospitals, hospitals with approved 

residency training programs, hospitals with high nurse-to-bed ratios and high proportions 

of board-certified anesthesiologists, and hospitals that offer subspecialty services (e.g., 

magnetic resonance imaging, bone marrow transplantation) - precisely the hospitals that 
42

would be expected to provide better care. There was essentially no association at the 

hospital level between measures of risk adjusted complications and risk adjusted 

mortality for CABG (r=0.07, p=0.58),32 and a weak association (r=0.21, 95% CI 0.04-

0.38)69 for elective adult general surgery after full risk adjustment (i.e., r=0.55, 95% CI 

0.38-0.72 without risk adjustment). Similarly, the Department of Veterans’ Affairs (VA) 

National VA Surgical Risk Study found significantly higher risk adjusted, 30-day 

postoperative morbidity at teaching hospitals than at non-teaching hospitals for general, 

orthopedic, urologic, and vascular (but not thoracic, neurologic, or otolaryngologic) 

surgery, 70 and essentially no association with risk adjusted mortality at the hospital level 

(r=-0.01 overall, range r=-0.03 for neurosurgery to r=0.28 for otolaryngologic surgery).60

Finally, discrimination in predicting complications has also been relatively weak (c<0.79) 

in these detailed clinical data systems.31, 33, 60, 69

General Issues in Using Complications To Screen for Quality 

Problems 

The companion technical report on the development of the AHRQ Quality 

Indicators describes three3 areas important to the evaluation of a measure (i.e., precision, 

minimum bias and construct validity) that are pertinent to potential PSIs. 

Precision 

As with mortality rates, variations in complication rates may reflect random 

variation. However, the higher incidence of most complications compared to mortality 

reduces random variation, and provides an important incentive for using complication 

rates as quality measures. In addition, precision may be less important for PSIs than for 

other types of QIs. To the extent that these indicators capture preventable iatrogenesis, 

the precision with which prevalence is estimated at the provider level may be 

unimportant. The primary intended use of these indicators is not to compare performance 

across providers, but instead to assess the overall performance of the health care system 

at the regional, state, or national level, and to provide a screening tool that providers can 

use to identify cases that merit internal review. 

It should be noted that the ICD-9-CM codes that are most likely to represent 

preventable adverse events are also relatively rare (see detailed reviews below). The ICD9-CM codes for general complications are more common, but are subject to considerable 

coding error and may include a mix of preventable and non-preventable events. Efforts to 

focus on ICD-9-CM coded complications that are likely to reflect medical errors will 

inevitably increase random variation across providers. 

Minimum Bias 

All quality indicators, including the proposed PSIs, are susceptible to bias of three 

general types: selection effects, confounding, and misclassification. Selection bias arises 

when the sample available for quality measurement is not representative of the target 

population. In the current context, this problem arises principally for conditions that may 

be treated, or procedures that may be performed, in either inpatient or outpatient (shortstay) settings. For these conditions and procedures, HCUP data may not adequately 
43

represent the population of interest. For example, in areas where freestanding birthing 

centers have a substantial market share, PSI rates based on HCUP data are likely to be 

biased. 

Confounding arises in comparing PSI rates across hospitals, health systems, or 

regions because of differences in patients’ underlying risk of these events. Patients who 

undergo certain procedures, or have certain diagnoses, are inherently at higher risk of 

experiencing adverse events, including adverse events due to medical error. Age is also a 

known risk factor for medical error, although its effect may be explained by the greater 

clinical complexity of care for elderly patients and their greater exposure to potential 

hazards.6, 26 Well-established clinical prediction rules allow risk adjustment for patients 

experiencing perioperative cardiac and pulmonary complications71-77, but risk adjustment 

systems remain relatively unstudied for most other complications 78. Specific clinical 

prediction rules have been developed for morbidity after coronary artery bypass 

surgery,79 carotid endarterectomy,80-83, and percutaneous coronary interventions,84 but not 

for many other high-risk procedures. In general, clinical factors such as the serum 

albumin level and functional status37 are clearly associated with the risk of adverse events 

among both medical and surgical inpatients. These factors potentially confound the 

observed associations between hospital categories and adverse event rates,25, 52 as well as 

the performance ranking of individual hospitals. For example, Hartz et al.35 reported that 

the Wisconsin hospital with the highest unadjusted rate of major complications after 

Coronary Artery Bypass Graft (CABG) had an adjusted relative odds of 0.98, placing it 

right in the middle after risk adjustment. 

Multiple studies have explored the relative performance of risk adjustment models 

for mortality, using administrative versus clinical data (or proprietary systems based on 

such data).85-90 Although there is less evidence regarding the relative performance of risk 

adjustment models for adverse events, the same findings are likely to apply. For example, 

Hartz et al. reported c statistics of 0.71 using ICD-9-CM codes, and 0.80 using clinical 

variables, to predict adverse outcomes after stroke among Medicare patients.91

Substantial opportunity for confounding bias therefore exists when provider-specific 

adverse event rates are compared. 

Misclassification bias is likely to result from variation in coding practices across 

hospitals. As detailed below, we carefully reviewed the available literature to select PSIs 

for which the positive predictive value of coding appears to be at least 75%. However, 

there is less evidence on sensitivity (i.e., undercoding) than on predictive value (i.e., 

overcoding), so several of the accepted and experimental indicators may suffer from 

significant undercoding. Based on current guidelines that only require coding of 

“conditions that affect patient care in terms of requiring clinical evaluation... therapeutic 

treatment...diagnostic procedures...extended length of hospital stay...increased nursing 

care and/or monitoring,”92 we avoided including potentially inconsequential diagnoses in 

the PSI definitions. However, we could not always do so, due to the ambiguity of ICD-9-

CM. One recent study suggests that the sensitivity of coding postoperative complications 

after elective back surgery varies markedly across hospitals, such that about half of the 

difference in risk-adjusted complication rates between low and high outlier hospitals is 

attributable to reporting variation.93
44

Construct Validity

The literature identifies only a small number of explicit processes of care that 

have proven beneficial in randomized, placebo-controlled trials for preventing certain 

complications: (1) thromboembolism prophylaxis for most major surgeries94-102; (2) 

perioperative antibiotics for a smaller but still substantial number of surgical 

procedures103-110; (3) perioperative nutritional support for severely malnourished patients 

requiring laparotomy, thoracotomy111, 112 and hip fracture repair113; (4) perioperative beta 

blockers to prevent cardiac complications among high-risk patients undergoing 

cardiac,114 noncardiac115 or vascular116 surgery; and (5) antiplatelet agents to prevent 

early restenosis after percutaneous coronary interventions.117, 118 Other potential 

interventions to improve patient safety have been thoroughly reviewed in a recent report.2

To our knowledge, no additional studies to date have linked these specific processes of 

care with differences in risk adjusted rates of adverse outcomes across hospitals or 

physicians. 

Given the small number of evidence-based processes-of-care related to the 

prevention of adverse events, one could argue for broad explicit review criteria that 

incorporate standards of care based on expert recommendations, rather than insisting on 

processes strongly supported by evidence. Condition-specific provider adherence 

measures of this type have been associated with the risk of in-hospital complications 

among adults admitted for diabetes and chronic obstructive pulmonary disease (COPD), 

but not congestive heart failure (CHF).36 Iezzoni and colleagues developed a similar set 

of review instruments to compare Medicare cases flagged by the Complications 

Screening Program (CSP) in California and Connecticut in 1994 with unflagged cases.16

Even with this broader look at processes of care, flagged cases did not differ significantly 

from unflagged cases in terms of the prevalence of generic quality problems. Specifically, 

53% of 351 flagged surgical cases demonstrated one or more of 17 process-of-care 

problems, versus 46% of 140 unflagged surgical cases. Among medical cases, 5% of both 

flagged and unflagged cases demonstrated one or more process-of-care problems. None 

of the specific flags proved useful in identifying patients with a higher risk of these 

generic process deficiencies, except deep vein thrombosis/pulmonary embolism 

(DVT/PE) (11% flagged versus 4% unflagged, p=0.09) and miscellaneous complications 

(62% flagged versus 46% unflagged, p=0.06). 

Implicit review is based upon global assessment of quality of care by physician 

peers.119 In another recent evaluation of the Complications Screening Program, Weingart 

and colleagues15 compared flagged and unflagged cases on the prevalence of quality 

problems identified by implicit review. Physician reviewers identified potential quality 

problems in 29.5% of flagged surgical cases and 15.7% of flagged medical cases, 

compared with 2.1% of unflagged medical and surgical controls. However, substantial 

variation across specific screens was noted. Potential quality problems were identified in 

50% of surgical cases flagged for DVT/PE, but only 5% of surgical cases flagged for 

postoperative pneumonia. Potential quality problems were identified in less than 20% of 

medical cases flagged by each screen, except for post-procedural hemorrhage or 

hematoma (31%). Of two other studies involving structured implicit review by 

physicians as a “gold standard” for quality assessment, one confirmed the potential value 

of various morbidity-based screening tools based on nurse/staff review,120 but another 

found that quality of care was equal between patients with and without complications, 
45

and between hospitals with low and high risk adjusted complication rates.121 In neither of 

these studies did the authors report the predictive validity of specific adverse outcome 

measures. 

Part of the difficulty with linking adverse events and processes of care relates to 

the inherent lack of reproducibility in implicit assessments of quality. For instance, a 

well-known study in the 1980s examining deaths due to pneumonia, myocardial 

infarction and stroke reported inter-rater reliability for physicians’ judgment of 

“preventable death” as 0.11, 0.51 and 0.55, respectively122. (The first value falls in the 

range conventionally regarded as “poor,” while the other two values indicate “moderate” 

agreement.) In the Harvard Medical Practice Study, physician reviewers exhibited 

substantial agreement in identifying the presence of adverse events (kappa=0.61), but 

only “fair” agreement in identifying negligent care (kappa=0.24).6 Two later studies 

reported moderate agreement among physician reviewers for the presence of an adverse 

event (kappa = 0.41-0.57), but only fair agreement for the judgment of preventability 

(kappa = 0.30)123 or negligence (kappa = 0.19-0.24).124 Weingart et al. reported 

borderline poor agreement among physician reviewers about both the presence of a CSP 

complication (kappa=0.22) and a potential quality problem (kappa = 0.22).15 Agreement 

was somewhat better in the National VA Surgical Risk Study, in which physicians used a 

5-point scale to rate overall quality of care (ICC=0.40-0.56).121 A more recent study 

examined the impact of discussion between reviewers on agreement in assessing 

preventability of adverse events.125 The authors created 7 different pairs among 13 

reviewers participating in the study. They showed that discussion between the two 

physicians in a pair substantially improved their assessment of an adverse event as 

iatrogenic from (kappa = 0.46 to 0.71). However, the agreement across pairs remained 

relatively unchanged by discussion (kappa = 0.36 before to 0.40 after discussion). 

In the absence of identifiable differences in processes-of-care in most cases 

studied, residual variation in complication rates after risk adjustment presumably reflects 

either unmeasured processes of care or differences in patients' baseline risk of 

complications that are not captured through risk adjustment. By definition, these 

concepts are difficult to measure, making it difficult to establish the construct validity of 

many potential PSIs. 

Finally, correlations between adverse events and structural characteristics of 

hospitals have been cited as evidence of construct validity. However, these findings are 

often difficult to interpret because of uncertainty about which structural characteristics 

are truly associated with better care. Structural characteristics are also often difficult to 

modify; hence, identifying them has limited value for quality improvement. In evaluating 

the Complications Screening Program, Iezzoni and colleagues found that large hospitals, 

hospitals performing open heart surgery, and members of the Council of Teaching 

Hospitals (COTH) had 10-33% more complications than expected across most risk pools, 

whereas small hospitals, hospitals without open heart surgery facilities, and nonmembers 

of COTH, had 4-26% fewer complications than expected.11 Similarly, patients at 

hospitals with fewer than 100 beds consistently had a 22-49% lower risk of complications 

than patients at hospitals with 500 or more beds.10 A study of factors associated with 

adverse events after surgery, based on AHRQ’s original HCUP Quality Indicators, 

revealed associations between four of these nine indicators and registered nurse staffing 

(as detailed below), including three of the five indicators that were judged a priori to be 
46

“nurse-sensitive.”126 Differences in risk-adjusted QI rates across regions and hospital 

ownership categories were also noted. In evaluating a Risk-Adjusted Complications 

Index (RACI) based on administrative data, DesHarnais and colleagues found that 

hospitals’ risk-adjusted complication rates were positively associated with their range of 

services, but not with their ownership, size, or teaching status.46 Conversely, Myers found 

significantly higher complication rates after hysterectomy at teaching hospitals than at 

nonteaching hospitals.41 These findings are probably attributable to bias from 

unmeasured case mix or differential reporting of complications. Studies based on chart 

review have suggested that major teaching hospitals experience more complications than 

nonteaching hospitals, but they are better at “rescuing” patients after complications, and 

relatively few of their complications (especially adverse drug events) are due to 

negligence.25, 32, 52 Patient volume should be inversely associated with valid outcome 

rates, at least for procedures requiring technical skill, but the literature on this topic has 

generally focused on mortality and resource use, with complications of percutaneous 

coronary interventions127-135 and stroke after endarterectomy the notable exceptions.136 

With the exception of a few recent studies on nurse staffing and hospital outcomes,126, 137, 

138 analyses of structural aspects of care have not been particularly helpful in establishing 

the construct validity of morbidity indicators based on administrative data, or suggesting 

interventions to improve patient outcomes. 

Specific Review of the Evidence for Indicators 

 The potential patient safety indicators identified through literature and coding 

reviews are listed in Appendix A. These indicators were assigned to one of three 

categories: Accepted PSIs, Experimental PSIs and Rejected PSIs. Those in the last 

category were removed from further analyses based on evidence of poor coding or 

construct validity, poor ratings by panelists, or inability to implement the desired 

specification after receiving expert coding input. Indicators in the Accepted indicator set 

were rated favorably by clinical panels as being useful screens for potentially preventable 

complications. Finally, those in the Experimental indicator set fell between the other two 

categories, and underwent less extensive empirical analyses. This set is not recommended 

without considerable further testing, as described in Section 3B, Indicator Selection. 

This section reviews the literature on the derivation and validity of each indicator, 

or the ICD-9-CM codes upon which it is based. We briefly compare the definitions 

reported in the literature with the final PSI definition. More detailed descriptions of the 

definitions, and explanations of differences, are presented in section 3D, Detailed 

Clinician Panel Results by Indicator. Literature reviews were performed on all indicators 

including those that were rejected based on poor panel ratings, and some that were 

rejected for other reasons. Literature reviews for those indicators are not presented in this 

section, but are presented in Appendix F. For each indicator, we report separately on 

whether it is coded accurately (“coding validity”) and whether it is empirically associated 

with substandard quality or errors in processes of care (“construct validity”). 

The literature review results are provided to help researchers and providers assess 

the usefulness of each indicator in their own epidemiologic or quality improvement work. 

It was beyond the scope of this project to review clinical studies linking specific 

processes of care to specific, prospectively ascertained complications. Much of this 
47

literature has been summarized in a recent AHRQ report on evidence-based practices to 

prevent medical errors.2

 For example, numerous randomized controlled trials have 

proven that thromboembolism prophylaxis reduces the risk of postoperative DVT/PE, 

and therefore that higher DVT/PE rates are likely to be associated with poorer quality of 

care. This literature review focuses instead on the validity of complication indicators 

based on ICD-9-CM diagnosis and/or procedure codes. Tables 9 and 10 summarize the 

strength of evidence for each Accepted and Experimental indicator respectively. 

Table 9. Summary of Strength of Evidence in Literature for Accepted Indicators

Indicator Codinga,b

Construct 

Explicit 

Processa,b

Construct 

Implicit 

Processa,b

Construct 

Staffinga,b

Complications of anesthesia 0 0 0 0 

Death in low mortality DRGs + 0 + 0 

Decubitus ulcer - 0 0 ± 

Failure to rescue + 0 0 ++ 

Foreign body left in during procedure 0 0 0 0 

Iatrogenic penumothorax 0 0 0 0 

Infection due to medical care 0 0 0 0 

Postoperative hip fracture + + + 0 

Postoperative hemorrhage or hematoma ± ± + 0 

Postoperative physiologic and metabolic 

derangements - 0 0 - 

Postoperative respiratory failure + ± + ± 

Postoperative PE or DVT + + + ± 

Postoperative sepsis ± 0 0 - 

Technical difficulty with procedure ± 0 0 0 

Transfusion reaction 0 0 0 0 

Postoperative wound dehiscence 0 0 0 0 

Birth trauma - 0 0 0 

Obstetric trauma – vaginal delivery with 

instrumentation 

+ 0 0 0 

Obstetric trauma – vaginal delivery without 

instrumentation + 0 0 0 

Obstetric trauma – cesarean delivery + 0 0 0 

a Level of evidence 

(-) Published evidence suggests that the indicator lacks validity in this domain (i.e., less than 50% sensitivity or predictive value; 

explicit or implicit process failure rates no more frequent than among control patients). 

(0) No published evidence regarding this domain of validity. 

(±) Published evidence suggests that the indicator may be valid in this domain, but different studies offer conflicting results (although 

study quality may account for these conflicts). 

(+) Published evidence suggests that the indicator IS valid, or is likely to be valid, in this domain (i.e., one favorable study). 

(++) There is strong evidence supporting the validity of this indicator in this domain (i.e., multiple studies with consistent results, or 

studies showing both high sensitivity and high predictive value). b Coding: Sensitivity is the proportion of patients who suffered an adverse event, based on detailed chart review or prospective data 

collection, for whom that event was coded on a discharge abstract or Medicare claim. Predictive value is the proportion of patients 

with a coded adverse event who were confirmed as having suffered that event, based on detailed chart review or prospective data

collection. 

Construct, explicit process: Adherence to specific, evidence-based or expert-endorsed processes of care, such as appropriate use of 

diagnostic modalities and effective therapies. Our construct is that hospitals that provide better processes of care should experience 

fewer adverse events. 

Construct, implicit process: Adherence to the “standard of care” for similar patients, based on global assessment of quality by 

physician chart reviewers. Our construct is that hospitals that provide better overall care should experience fewer adverse events. 

Construct, staffing: Our construct is that hospitals that offer more nursing hours per patient day, better nursing skill mix, better 

physician skill mix, or more experienced physicians, should have fewer adverse events. c Note that when content validity is exceptionally high, as for transfusion reaction or iatrogenic pneumothorax, construct validity 

becomes less important. 
48

Table 10. Summary of Strength of Evidence in Literature for Experimental Indicatorsa 

Indicator Coding 

Construct 

Explicit 

Process 

Construct 

Implicit 

Process 

Construct 

Staffing 

Postoperative aspiration pneumonia + ± + + 

CABG following PTCA + 0 0 ++ 

Decubitus ulcer in high-risk patients - 0 0 0 

Postoperative fractures potentially related to 

falls + 0 0 0 

Intraoperative nerve compression injuries 0 0 0 0 

Malignant hyperthermia 0 0 0 0 

Postoperative acute myocardial infarction ++ - + - 

Postoperative iatrogenic complications – 

cardiac 

± 0 + 0 

Postoperative iatrogenic complications – 

nervous system 

0 0 0 0 

Postoperative reopening of surgical site + - + 0 

Postoperative suture of laceration + 0 + + 

Obstetric wound complications – cesarean ± 0 0 0 

Obstetric wound complications – vaginal ± 0 0 0 

Other obstetric complications of delivery ± 0 0 0 

Third or fourth degree obstetric lacerations + 0 0 0 

Uterine rupture + 0 0 0 

Postpartum urinary tract infection - 0 0 0 

a

 See footnotes to Table 9. 

Accepted Indicators 

Complications of Anesthesia 

Source. A subset of this indicator was originally proposed by Iezzoni et al.10 as 

part of the CSP (CSP 21, “Complications relating to anesthetic agents and other CNS 

depressants”). Their definition also includes poisoning due to centrally acting muscle 

relaxants (968.0) and accidental poisoning by nitrogen oxides (E869.0), which were 

omitted from this PSI. Their definition excludes other codes included in this PSI, 

namely, poisoning by other and unspecified general anesthetics and external cause of 

injury codes for “endotracheal tube wrongly placed during anesthetic procedure” 

(E876.3) and adverse effects of anesthetics in therapeutic use (E938.1-E938.9). 

Evidence 

We were unable to find evidence on validity from prior studies. 

Death in Low Mortality DRGs 

Source. This indicator was originally proposed by Hannan et al. as a criterion for 

targeting “cases that would have a higher percentage of quality of care problems than 

cases without the criterion, as judged by medical record review.”139 An alternative form 

of this indicator focused on “primary surgical procedures,” rather than DRGs, with less 

than 0.5% inpatient mortality. 
49

Evidence 

Construct validity. Based on two-stage implicit review of 8,109 randomly 

selected deaths from 104 New York hospitals in 1985-86, Hannan et al. found that 

patients in low-mortality DRGs (<0.5%) were 5.2 times more likely than all other 

patients who died (9.8% versus 1.7%) to have received “care that departed from 

professionally recognized standards,” after adjusting for patient demographic, 

geographic, and hospital characteristics. In 15 of these 26 cases (58%) of substandard 

care, the patient’s death was attributed at least partially to that care. The association with 

substandard care was stronger for the DRG-based definition of this indicator than for the 

procedure-based definition (5.7% versus 1.7%, OR=3.2). We were unable to find other 

evidence on the validity of this indicator. 

Decubitus Ulcer 

Source. This indicator was originally proposed by Iezzoni et al.10 as part of the 

CSP (CSP 6, “cellulitis or decubitus ulcer”). Their definition also includes cellulitis of the 

upper extremity (682.3-682.4), which was omitted from this PSI. Needleman and 

Buerhaus137 identified decubitus ulcer as an “Outcome Potentially Sensitive to Nursing,” 

but unlike this PSI their definition includes cellulitis of any site (682). The American 

Nurses Association, its state associations, and the California Nursing Outcomes Coalition 

have identified the total prevalence of inpatients with Stage I, II, III, or IV pressure ulcers 

(based on clinical data collection) as a “nursing-sensitive quality indicator for acute care 

settings.”140

Evidence 

Coding validity. No evidence on validity is available from CSP studies. Geraci et 

al.141 confirmed only 2 of 9 episodes of pressure ulcers (707.0) reported on discharge 

abstracts of Veterans Affairs (VA) patients hospitalized in 1987-89 for congestive heart 

failure (CHF), chronic obstructive pulmonary disease (COPD), or diabetes; the sensitivity 

for a nosocomial ulcer was 40% (2/5). Among Medicare hip fracture patients from 297 

hospitals in 1985-86, Keeler et al.51 confirmed 6 of 9 (67%) reported pressure ulcers, but 

failed to ascertain 89 additional cases (6% sensitivity) using ICD-9-CM codes. In the 

largest study to date, Berlowitz et al.142 found that the sensitivity of a discharge diagnosis 

of pressure ulcer among all patients transferred from VA hospitals to VA nursing homes 

in 1996 was 31% overall, or 54% for stage IV (deep) ulcers. The overall sensitivity 

increased modestly since 1992 (26.0%), and was slightly but statistically significantly 

better among medical patients than among surgical patients (33% versus 26%). 

Construct validity. Needleman and Buerhaus137 found that nurse staffing was 

inconsistently associated with the occurrence of pressure ulcers among medical patients 

from 799 hospitals in 11 states in 1997, and was independent of pressure ulcers among 

major surgery patients. Nursing skill mix (RN hours/licensed nurse hours) was 

significantly associated (in the expected direction) with the pressure ulcer rate among 352 

and 295 California hospitals in 1992 and 1994, respectively, and also among 126 and 131 

New York hospitals in the same years.138 Total licensed nurse hours per acuity-adjusted 

patient day were inconsistently associated with the rate of pressure ulcers. 
50

Failure To Rescue 

Source. This indicator was originally proposed by Silber et al.31 as a more 

powerful tool than the risk adjusted mortality rate to detect true differences in patient 

outcomes across hospitals. The underlying premise was that better hospitals are 

distinguished not by having fewer adverse occurrences but by more successfully averting 

death among (i.e., rescuing) patients who experience such complications. Silber et al’s 

original definition was based on key clinical findings abstracted from the medical records 

of 2,831 cholecystectomy patients and 3,141 transurethral prostatectomy patients 

admitted to 531 hospitals in 1985. The key postoperative diagnoses that defined the 

denominator at risk of “ failure to rescue” included cardiac arrhythmias, congestive heart 

failure, cardiac arrest, pneumonia, pulmonary embolus, pneumothorax, renal dysfunction, 

stroke, wound infection, and unplanned return to surgery. 

More recently, Needleman and Buerhaus137 adapted failure to rescue to 

administrative data sets, hypothesizing that this outcome might be sensitive to nurse 

staffing. Their denominator definition included the ICD-9-CM codes for sepsis, 

pneumonia (including aspiration), acute upper gastrointestinal bleeding, shock, 

cardiac/respiratory arrest, deep vein thrombosis (DVT), and pulmonary embolus (PE). 

Evidence 

Construct validity. Silber and colleagues have published a series of studies 

establishing the construct validity of failure to rescue rates through their associations with 

hospital characteristics and other measures of hospital performance. Among patients 

admitted for cholecystectomy and transurethral prostatectomy, failure to rescue was 

independent of severity of illness at admission, but was significantly associated with the 

presence of surgical housestaff and a lower percentage of board-certified 

anesthesiologists.31 The adverse occurrence rate was independent of this hospital 

characteristic. In a larger sample of 74,647 patients who underwent general surgical 

procedures in 1991-92, lower failure to rescue rates were found at hospitals with high 

ratios of registered nurses to beds.68 Failure rates were strongly associated with risk 

adjusted mortality rates, as expected, but not with complication rates.143 Finally, among 

16,673 patients admitted for coronary artery bypass surgery, failure rates were lower 

(whereas complication rates were higher) at hospitals with magnetic resonance imaging 

facilities, bone marrow transplantation units, or approved residency training programs.32 

More recently, Needleman and Buerhaus137 confirmed that higher registered nurse 

staffing (RN hours/adjusted patient day) and better nursing skill mix (RN hours/licensed 

nurse hours) were consistently associated with lower failure to rescue rates among major 

surgery patients from 799 hospitals in 11 states in 1997, even using administrative data to 

define complications. An increase from the 25th to the 75th percentile on these two 

measures of staffing was associated with 5.9% (95% CI, 1.5% to 10.2%) and 3.9% (95% 

CI, -1.1% to 8.8%) decreases, respectively, in the rate of failure-to-rescue among major 

surgery patients.138 These associations were inconsistent among medical patients, in that 

nursing skill mix was associated with the failure-to-rescue rate (rate ratio 0.81, 95% CI 

0.66-1.00) but aggregate registered nurse staffing was not (rate ratio 1.00, 95% CI 0.99-

1.01). An increase from the 25th to the 75th percentile on nursing skill mix was associated 

with a 2.5% (95% CI, 0.0% to 5.0%) decrease in the failure-to-rescue rate among medical 

patients. 
51

Foreign Body Left in During Procedure 

Source. This indicator was originally proposed by Iezzoni et al.10 as part of the 

Complications Screening Program (CSP “sentinel events”), along with gas gangrene, 

CNS abscess, anoxic brain injury, accidental puncture or laceration, wound dehiscence, 

and ABO/Rh transfusion reactions (all of which were omitted from this PSI). It was also 

included as one component of a broader indicator (“adverse events and iatrogenic 

complications”) in AHRQ’s original HCUP Quality Indicators.144 It was proposed by 

Miller et al. 17 in the “Patient Safety Indicator Algorithms and Groupings.” Based on 

expert consensus panels, McKesson Health Solutions included this indicator in its 

CareEnhance Resource Management Systems, Quality Profiler Complications Measures 

Module. 

Evidence

We were unable to find evidence on validity from prior studies, which is likely 

due to the rarity of this diagnosis. 

Iatrogenic Pneumothorax

Source. This diagnosis code was proposed by Miller et al.17 as one component of 

a broader indicator (“iatrogenic conditions”) in the “Patient Safety Indicator Algorithms 

and Groupings.” It was also included as one component of a broader indicator (“adverse 

events and iatrogenic complications”) in AHRQ’s Version 1.3 HCUP Quality Indicators.

Evidence 

We were unable to find evidence on validity from prior studies, which is probably 

because this diagnosis code was introduced in 1994. 

Infection Due to Medical Care 

Source. This indicator was originally proposed by Iezzoni et al. as part of the 

Complications Screening Program (CSP 11, “miscellaneous complications”). Their 

definition also includes other specified and unspecified complications of procedures or 

medical care, air embolism, persistent postoperative fistula, minor transfusion reactions, 

and an array of external cause of injury codes representing various “misadventures” and 

“abnormal reaction of patient” during medical care, including aspiration (which were 

omitted from this PSI).10 The University HealthSystem Consortium adopted the CSP 

indicator for major (#2933) and minor (#2961) surgery patients. A much narrower 

definition, including only 999.3 (“other infection after infusion, injection, transfusion, 

vaccination”) was proposed by Miller et al.17 in the “Patient Safety Indicator Algorithms 

and Groupings.” The American Nurses Association and its state associations have 

identified the number of laboratory-confirmed bacteremic episodes associated with 

central lines per critical care patient day as a “nursing-sensitive quality indicator for acute 

care settings.”140
52

Evidence 

No evidence on validity is available from CSP studies, because this code was 

grouped with “miscellaneous complications.” Geraci et al.141 grouped this code with 

sepsis (see below). Keeler et al.51 grouped this code with pneumonia and hip joint 

infection. We were unable to find other evidence on the validity of this indicator. 

Postoperative Hemorrhage or Hematoma 

Source. This indicator was originally proposed by Iezzoni et al.10 as part of the 

Complications Screening Program (CSP 24, “post-procedural hemorrhage or 

hematoma”), although their definition allowed either procedure (i.e., control of 

hemorrhage) or diagnosis (i.e., hemorrhage, hematoma, or seroma) codes. By contrast, 

the current definition requires either a hemorrhage diagnosis with an associated 

procedure to control that hemorrhage, or a hematoma diagnosis with an associated 

procedure to drain that hematoma. The University HealthSystem Consortium adopted the 

CSP indicator for medical (#2804), cardiac procedure (#2912), and major surgery 

(#2947) patients. It was also included as one component of a broader indicator (“adverse 

events and iatrogenic complications”) in AHRQ’s original HCUP Quality Indicators.144

Evidence 

Coding validity. The original CSP definition had a relatively high confirmation 

rate among major surgical cases in the FY1994 Medicare inpatient claims files from 

California and Connecticut (83% by coders’ review, 57% by physicians’ review, 52% by 

nurse-abstracted clinical documentation, and 76% if nurses also accepted physicians’ 

notes as adequate documentation). 13-15 Its confirmation rate was moderate among 

medical cases (49% by coders’ review, 55% by physicians’ review, 29% by nurseabstracted clinical documentation, and 65% if nurses also accepted physicians’ notes), 

partially because some cases were present at admission. An earlier study of elderly 

Medicare beneficiaries from Massachusetts, Alabama, Iowa, and New York in FY1993 

revealed poorer confirmation rates of 34% (35/104) among major surgical cases (of 

whom 17 or 49% lacked laboratory or clinical evidence of significant blood loss) and 

28% (24/85) among medical cases (of whom 10 or 42% lacked laboratory or clinical 

evidence of significant blood loss).145 

Among 185 total knee replacement patients from 5 Ontario hospitals in 1984-90, 

Hawker et al.146 found that the sensitivity and predictive value of hemorrhage codes 

(definition not given) were 57% (8/14) and 80% (8/10), respectively. Faciszewski et al.147

aggregated postoperative hemorrhage or hematoma (998.1) with wound dehiscence 

(998.3), and reported a pooled confirmation rate of 17% (1/6) with 3% (1/34) sensitivity 

of coding among 310 patients who underwent spinal fusion at the Marshfield Clinic in 

1991-92 (given an unusually broad clinical definition of these wound complications). 

Romano et al.93 identified 6 of 16 episodes of hemorrhage or hematoma (998.1) using 

discharge abstracts of diskectomy patients at 30 California hospitals in 1990-91; there 

were no false positives. 

At least two studies have estimated the validity of hemorrhage codes using a gold 

standard based on transfusion “requirement.” Hartz and Kuhn identified only 146 of 568 

(26%) episodes of bleeding (defined as requiring return to surgery or transfusion of at 
53

least 6 units of blood products) by applying this indicator (998.1) to Medicare patients 

who underwent coronary artery bypass surgery in Wisconsin in 1990-91; the predictive 

value was 75% (146/195).66 In comparison with the VA’s National Surgical Quality 

Improvement Program database from 123 hospitals in 1994-95, in which hemorrhage is 

defined by transfusion of at least four units of blood products within 30 days after 

surgery, the ICD-9-CM diagnosis (998.1) had a sensitivity of 13% and a predictive value 

of 10%.148

Construct validity. Explicit process of care failures in the CSP validation study 

were relatively frequent among major surgical cases with CSP 24, but not among medical 

cases (66% and 13%, respectively), after excluding patients who had hemorrhage or 

hematoma at admission.16 Cases flagged on this indicator and unflagged controls did not 

differ significantly on a composite of 17 generic process criteria. Similarly, cases flagged 

on this indicator and unflagged controls did not differ significantly on a composite of 4 

specific process criteria for major surgical cases and 2 specific process criteria for 

medical cases in the earlier study of elderly Medicare beneficiaries from Massachusetts, 

Alabama, Iowa, and New York.145 Physician reviewers identified potential quality 

problems in 37% of major surgery patients and 31% of medical patients with CSP 24 

(versus 2% of unflagged controls for each risk group).15

Postoperative Hip Fracture 

Source. This indicator was originally proposed by Iezzoni et al.10 as part of the 

CSP (CSP 25, “in-hospital hip fracture or fall”). Their definition also includes any 

documented fall, based on external cause of injury codes, which was omitted from this 

PSI. Needleman and Buerhaus 137 considered in-hospital hip fracture as an “Outcome 

Potentially Sensitive to Nursing,” based on input from their Technical Expert Panel, but 

discarded it because the “event rate was too low to be useful.” The American Nurses 

Association, its state associations, and the California Nursing Outcomes Coalition have 

identified the number of patient falls leading to injury per 1,000 patient days (based on 

clinical data collection) as a “nursing-sensitive quality indicator for acute care 

settings.”140

Evidence 

Coding validity. The original CSP definition had an adequate confirmation rate 

among major surgical cases in the FY1994 Medicare inpatient claims files from 

California and Connecticut (57% by coders’ review, 71% by physicians’ review), but a 

very poor confirmation rate among medical cases (11% by both coders’ and physicians’ 

review).13, 15 This problem was attributable to the fact that most hip fractures among 

medical inpatients were actually comorbid diagnoses present at admission rather than 

complications of hospital care. Nurse reviews were not performed. 

Construct validity. Explicit process of care failures in the CSP validation study 

were relatively frequent among cases with CSP 25 (76% of major surgery patients, 54% 

of medical patients), after excluding patients who had hip fractures at admission, but 

unflagged controls were not evaluated on the same criteria.16 Physician reviewers 

identified potential quality problems in 24% of major surgery patients and 5% of medical 

patients with CSP 25 (versus 2% of unflagged controls for each risk group).15
54

Postoperative Physiologic and Metabolic Derangements 

Source. This indicator was originally proposed by Iezzoni et al.10 as part of the 

CSP (CSP 20, “postoperative physiologic and metabolic derangements”). Their definition 

also includes (non-diabetic) hypoglycemic coma (251.0), postoperative shock (998.0), 

and oliguria/anuria (788.5), which were omitted from this PSI, but it excludes several 

codes that were included in this PSI, namely, diabetes with hyperosmolarity, diabetes 

with other (hypoglycemic) coma, and acute renal failure. The University HealthSystem 

Consortium adopted the CSP indicator for major surgery patients (#2945). Needleman 

and Buerhaus137 identified postoperative physiologic/metabolic derangement as an 

“Outcome Potentially Sensitive to Nursing,” but they added fluid and electrolyte 

disorders (276) to the original CSP 20. Hannan et al. had earlier focused an analogous 

indicator exclusively on those fluid and electrolyte disorders.139 

Evidence 

Coding validity. No evidence on validity is available from CSP studies. Geraci et 

al.141 confirmed (by serum chemistry) only 5 of 15 (33%) episodes of acute renal failure 

(584, 586) and 12 of 34 (35%) episodes of hypoglycemia (E932.3, 251.0, 251.2, 962.3) 

reported on discharge abstracts of VA patients hospitalized in 1987-89 for CHF, COPD, 

or diabetes. The sensitivity for a 2.0 mg/dL or greater increase in serum creatinine was 

28% (5/18), while the sensitivity for symptomatic diabetic hypoglycemia less than 70 

mg/dL was 16% (12/76). Romano et al.93 identified 2 of 2 episodes of acute renal failure 

or hypoglycemia (251.0, 251.2, E932.3, 584.x) using discharge abstracts of diskectomy 

patients at 30 California hospitals in 1990-91; there were no false positives. In 

comparison with the VA’s National Surgical Quality Improvement Program database 

from 123 hospitals in 1994-95, in which acute renal failure is defined as requiring 

dialysis within 30 days after surgery, ICD-9-CM diagnoses (585 or 788.5) had a 

sensitivity of 8% and a predictive value of 4%.148

Construct validity. Based on two-stage review of 8,109 randomly selected deaths 

from 104 New York hospitals in 1985-86, Hannan et al.139 reported that cases with a 

secondary diagnosis of fluid and electrolyte disorders were no more likely to have 

received care that departed from professionally recognized standards than cases without 

that code (2.2% versus 1.7%, OR=1.13), after adjusting for patient demographic, 

geographic, and hospital characteristics. However, these ICD-9-CM codes were omitted 

from the accepted AHRQ PSI. Needleman and Buerhaus137 found that nurse staffing was 

independent of the occurrence of metabolic derangement among major surgery patients 

from 799 hospitals in 11 states in 1997. 

Postoperative Pulmonary Embolism or Deep Vein Thrombosis 

Source. This indicator was originally proposed by Iezzoni et al.10 as part of the 

CSP (CSP 22, “venous thrombosis and pulmonary embolism”), although their definition 

was slightly narrower. It was one of AHRQ’s original HCUP Quality Indicators144 for 

major surgery and invasive vascular procedure patients. Needleman and Buerhaus137

identified DVT/PE as an “Outcome Potentially Sensitive to Nursing,” using the same 

CSP definition. The Health Care Financing Administration (now CMS) selected “venous 

thrombosis or pulmonary embolism following selected inpatient surgical procedures” as 
55

one of its surveillance measures of Medicare quality of care.149 A code introduced in 

1995 (415.11) that maps to this indicator in the final AHRQ PSI was proposed by Miller 

et al.17 as one component of a broader indicator (“iatrogenic conditions”) in the “Patient 

Safety Indicator Algorithms and Groupings.” 

Evidence 

Coding validity. CSP 22 had a moderately high confirmation rate among major 

surgical cases in the FY1994 Medicare inpatient claims files from California and 

Connecticut (59% by coders’ review, 70% by physicians’ review, 60% by nurseabstracted clinical documentation, and 68% if nurses also accepted physicians’ notes as 

adequate documentation). Its confirmation rate among medical cases was poor (32% by 

coders’ review, 28% by physicians’ review, 32% by nurse-abstracted clinical 

documentation, and 39% if nurses also accepted physicians’ notes as adequate 

documentation) because many cases were present at admission.13-15

Geraci et al.34 confirmed only 1 of 6 episodes of DVT (451.1x) or PE (415.1) 

reported on discharge abstracts of Veterans Affairs (VA) patients hospitalized in 1987-89 

for CHF, COPD, or diabetes; the sensitivity was 100% (1/1). Among Medicare hip 

fracture patients from 297 hospitals in 1985-86, by contrast, Keeler et al.51 confirmed 11 

of 20 (88%) reported PE cases, and failed to ascertain just 6 cases (65% sensitivity) using 

ICD-9-CM codes. For DVT (451.x, 453.x, 997.2), they found just 1 of 6 cases using ICD9-CM codes (but no false positive codes). Among 185 total knee replacement patients 

from 5 Ontario hospitals in 1984-90, Hawker et al.146 found that the sensitivity and 

predictive value of DVT codes (definition not given) were 50% (4/8) and 100%, 

respectively. Romano et al.93 identified 5 of 6 episodes of thromboembolic disease 

(415.1x, 451.1x, 451.2, 451.8x, 451.9, 453.2, 453.8, 453.9) using discharge abstracts of 

diskectomy patients at 30 California hospitals; there was one false positive. In 

comparison with the VA’s National Surgical Quality Improvement Program database 

from 123 hospitals in 1994-95, the ICD-9-CM diagnosis of PE (415.1) had a sensitivity 

of 49% and a predictive value of 48% for PE within 30 days after surgery.148 Although 

Best et al. also reported on the ability to use administrative data to find cases of DVT, 

their results cannot be interpreted due to misapplication of ICD-9-CM. 

Other studies using the California patient discharge data set have demonstrated 

that ICD-9-CM codes for DVT and PE have high predictive value when listed as the 

principal diagnosis for readmissions after major orthopedic surgery (i.e., 17/17 or 100%) 

or after inferior vena cava filter placement (i.e., 64/65 or 98%).150 However, these 

findings do not directly address the validity of DVT/PE as a secondary diagnosis among 

patients treated by anticoagulation. 

Construct validity. Explicit process of care failures in the CSP validation study 

were relatively frequent among both major surgical and medical cases with CSP 22 (72% 

and 69%, respectively), after disqualifying cases in which DVT/PE was actually present 

at admission.16 Major surgical cases flagged on this indicator and unflagged controls 

differed marginally (11% versus 4%, p=0.09) on a composite of 17 generic process 

criteria; medical cases and controls were not evaluated on the same criteria. Physician 

reviewers identified potential quality problems in 50% of major surgery patients and 20% 

of medical patients with CSP 22 (versus 2% of unflagged controls for each risk group).15 
56

Needleman and Buerhaus137 found that nurse staffing was independent of the 

occurrence of DVT/PE among both major surgical or medical patients from 799 hospitals 

in 11 states in 1997. However, Kovner and Gergen reported that among 506 community 

hospitals in the 1993 NIS, having more registered nurse hours and non-RN hours per 

adjusted patient day were both associated with a lower rate of DVT/PE after major 

surgery.126 Nurse staffing was not associated with the rate of DVT/PE after invasive 

vascular procedures. 

Postoperative Respiratory Failure 

Source. This indicator was originally proposed by Iezzoni et al.10 as part of the 

CSP (CSP 3, “postoperative pulmonary compromise”). Their broader definition also 

includes not just respiratory failure, but also pulmonary congestion, other (or 

postoperative) pulmonary insufficiency, and acute pulmonary edema, which were omitted 

from this PSI. The University HealthSystem Consortium (#2927) and AHRQ’s original 

HCUP Quality Indicators144 adopted the CSP indicator for major surgery patients. 

Needleman and Buerhaus137 identified postoperative pulmonary failure as an “Outcome 

Potentially Sensitive to Nursing,” using the original CSP definition. 

Evidence 

Coding validity. CSP 3 had a relatively high confirmation rate among major 

surgical cases in the FY1994 Medicare inpatient claims files from California and 

Connecticut (72% by coders’ review, 75% by physicians’ review).13, 15 Nurse reviews 

were not performed. An earlier study of elderly Medicare beneficiaries from 

Massachusetts, Alabama, Iowa, and New York in FY1993 revealed a similarly high 

confirmation rate of 72% (66/92) among major surgical cases, although 27% of those 

patients (18/66) had inadequate clinical documentation of the diagnosis.145 

Geraci et al.34 confirmed 1 of 2 episodes of respiratory failure (518.81, 518.82) 

reported on discharge abstracts of VA patients hospitalized in 1987-89 for CHF or 

diabetes; the sensitivity for respiratory decompensation requiring mechanical ventilation 

was 25% (1/4). Best et al.148 reported on the ability to use administrative data to find 

cases of “unplanned intubation,” but their results cannot be interpreted due to 

misapplication of ICD-9-CM. 

Construct validity. Explicit process of care failures in the CSP validation study 

were slightly but not significantly more frequent among major surgical cases with CSP 3 

than among unflagged controls (52% versus 46%).16 Indeed, cases flagged on this 

indicator were significantly less likely than unflagged controls (24% versus 64%) to have 

at least one of four specific process-of-care problems in the earlier study of elderly 

Medicare beneficiaries from Massachusetts, Alabama, Iowa, and New York.145 Physician 

reviewers identified potential quality problems in 20% of major surgery patients with 

CSP 3 (versus 2% of unflagged controls).15 

Needleman and Buerhaus137 found that nurse staffing was independent of the 

occurrence of pulmonary failure among major surgery patients from 799 hospitals in 11 

states in 1997. However, Kovner and Gergen reported that among 506 community 

hospitals in the 1993 NIS, having more registered nurse hours per adjusted patient day 

was associated with a lower rate of “pulmonary compromise” after major surgery.126
57

Postoperative Sepsis 

Source. This indicator was originally proposed by Iezzoni et al.10 as part of the 

Complications Screening Program (CSP 7, “septicemia”), although their definition also 

includes unspecified bacteremia, which was omitted from this PSI. Needleman and 

Buerhaus 137 identified sepsis as an “Outcome Potentially Sensitive to Nursing,” using the 

same CSP definition. 

Evidence 

Coding validity. No evidence on validity is available from CSP studies. 

Barbour151 reported that only 38% (53/141) of discharge abstracts from 5 VA medical 

centers in 1990 with a diagnosis of sepsis (038.x) actually had hospital-acquired sepsis. 

However, this review was not limited to cases with a secondary diagnosis of sepsis, and 

sensitivity could not be evaluated. Massanari et al.152 identified 79% of cases of 

“nosocomial bacteremia” using 1984 hospital discharge data from the University of Iowa, 

but no definitions were provided. Geraci et al.34 confirmed (by blood culture) only 2 of 

15 episodes of sepsis or “other infection” (038.x, 999.3) reported on discharge abstracts 

of VA patients hospitalized in 1987-89 for CHF, COPD, or diabetes; the sensitivity for a 

positive blood culture was 50% (2/4). Romano et al.93 identified 2 of 3 episodes of sepsis 

or bacteremia (038.x, 707.0) using discharge abstracts of diskectomy patients at 30 

California hospitals in 1990-91; there were no false positives. Belio-Blasco et al.153

reported that “discharge forms” had a sensitivity of 18% (7/39) and a specificity of 100% 

for identifying nosocomial bacteremia among surgical patients in a Spanish teaching 

hospital. In comparison with the VA’s National Surgical Quality Improvement Program 

database from 123 hospitals in 1994-95, in which “systemic sepsis” is defined by a 

positive blood culture and systemic manifestations of sepsis within 30 days after surgery, 

the ICD-9-CM diagnosis (038.x) had a sensitivity of 37% and a predictive value of 

30%.148

Construct validity. Needleman and Buerhaus 137 found that nurse staffing was 

independent of the occurrence of sepsis among both major surgical or medical patients 

from 799 hospitals in 11 states in 1997.

Postoperative Wound Dehiscence 

Source. An indicator on this topic (998.3) was originally proposed by Hannan et 

al. to target “cases that would have a higher percentage of quality of care problems than 

cases without the criterion, as judged by medical record review.”139 The same code was 

also included as one component of a broader indicator (“adverse events and iatrogenic 

complications”) in AHRQ’s original HCUP Quality Indicators.144 Iezzoni et al.10

identified an associated procedure code for reclosure of an abdominal wall dehiscence 

(54.61), and included both codes in the CSP (CSP “sentinel events” and CSP 9, 

“reopening of surgical site,” respectively). Miller et al.17 suggested the use of both codes 

(as “wound disruption”) in the original “AHRQ PSI Algorithms and Groupings.” 

Evidence 

Coding validity. No evidence on validity is available from CSP studies. Among 

185 total knee replacement patients from 5 Ontario hospitals in 1984-90, Hawker et al.146
58

found that the sensitivity and predictive value of 998.3 were both 100% (4/4). 

Faciszewski et al.147 aggregated wound dehiscence (998.3) with postoperative 

hemorrhage or hematoma (998.1), and reported a pooled confirmation rate of 17% (1/6) 

with 3% (1/34) sensitivity of coding among 310 patients who underwent spinal fusion at 

the Marshfield Clinic in 1991-92 (given an unusually broad clinical definition of these 

wound complications). In comparison with the VA’s National Surgical Quality 

Improvement Program database from 123 hospitals in 1994-95, in which dehiscence is 

defined as fascial disruption within 30 days after surgery, the ICD-9-CM diagnosis of 

wound dehiscence (998.3) had a sensitivity of 25% and a predictive value of 23%.148 This 

code (998.3) was ultimately removed from the accepted PSI because our clinical panel 

was concerned that the ICD-9-CM definition was too broad and failed to distinguish skin 

from fascial separation. 

Construct validity. Based on two-stage review of 8,109 randomly selected deaths 

from 104 New York hospitals in 1985-86, Hannan et al.139 reported that cases with a 

secondary diagnosis of 998.3 (wound disruption) were 3.0 times more likely to have 

received care that departed from professionally recognized standards than cases without 

that code (4.3% versus 1.7%), after adjusting for patient demographic, geographic, and 

hospital characteristics. In 3 of these 7 cases (44%) of substandard care, the patient’s 

death was attributed at least partially to that care. However, this code was removed from 

the accepted PSI after discussions with our clinical panel. 

Technical Difficulty With Procedure 

Source. This indicator was originally proposed by Iezzoni et al.10 as part of the 

CSP, although unlike the final PSI, its codes were split between two CSP indicators (CSP 

27, “technical difficulty with medical care,” and “sentinel events”). The latter indicator 

also includes gas gangrene, CNS abscess, anoxic brain injury, foreign body left in, wound 

dehiscence, and ABO/Rh transfusion reactions, all of which were omitted from this PSI. 

The former indicator also includes failure of sterile precautions, mechanical failure of 

instrument or apparatus, and “contaminated or infected blood, other fluid, drug,” etc, 

although these codes were not included in the final definition of this PSI. It was also 

included as one component of a broader indicator (“adverse events and iatrogenic 

complications”) in AHRQ’s original HCUP Quality Indicators.144 The University 

HealthSystem Consortium adopted CSP 27 as an indicator for medical (#2806) and major 

surgery (#2956) patients. Miller et al. 17 also split this set of ICD-9-CM codes into two 

broader indicators (“miscellaneous misadventures” and “E codes”) in the original 

“AHRQ PSI Algorithms and Groupings.” Based on expert consensus panels, McKesson 

Health Solutions included one component of this PSI (998.2, “Accidental Puncture or 

Laceration”) in its CareEnhance Resource Management Systems, Quality Profiler 

Complications Measures Module. 

Evidence 

Coding validity. No evidence on validity is available from CSP studies. A study 

of laparoscopic cholecystectomy in 18 Ontario hospitals in 1991-95154 found that 95% 

(99/104) of patients with an ICD-9 code of 998.2 or E870.0 had a confirmed injury to the 

bile duct or gallbladder. However, only 27% had a clinically significant injury that 

required any intervention; sensitivity of reporting was not evaluated. A similar study of 
59

all cholecystectomies performed in Western Australia between 1988 and 1994 reported 

that these two ICD-9 codes had a sensitivity of 40% (19/48) and a predictive value of 

23% (19/84) in identifying bile duct injuries.155 Among 185 total knee replacement 

patients from 5 Ontario hospitals in 1984-90, Hawker et al.146 found that the sensitivity 

and predictive value of codes describing “miscellaneous mishaps during or as a direct 

result of surgery” (definition not given) were 86% (6/7) and 55% (6/11), respectively. 

Romano et al.93 identified 19 of 45 episodes of accidental puncture or laceration (998.2, 

E870.0, or related procedure) using discharge abstracts of diskectomy patients at 30 

California hospitals in 1990-91; there was one false positive. 

Transfusion Reaction 

Source. This indicator was originally proposed by Iezzoni et al.10 as part of the 

Complications Screening Program (CSP “sentinel events”), along with gas gangrene, 

CNS abscess, anoxic brain injury, accidental puncture or laceration, wound dehiscence, 

and foreign body left in (all of which were omitted from this PSI). It was also included as 

one component of a broader indicator (“adverse events and iatrogenic complications”) in 

AHRQ’s original HCUP Quality Indicators.144 It was proposed by Miller et al. 17 in the 

original “AHRQ PSI Algorithms and Groupings,” although their definition also includes 

minor transfusion reactions (999.8), which was omitted from this PSI. 

Evidence 

We were unable to find evidence on validity from prior studies, most likely 

because this complication is quite rare. 

Accepted Obstetric Indicators 

Birth Trauma – Injury to Neonate 

Source. This indicator has been widely used in the obstetric community, although 

it is most commonly based on chart review rather than administrative data. It was 

proposed by Miller et al.17 in the original “AHRQ PSI Algorithms and Groupings,” 

although their definition also includes injury to the brachial plexus (767.6), which was 

excluded from this PSI. Based on expert consensus panels, McKesson Health Solutions 

included a broader version of this indicator (767.xx) in its CareEnhance Resource 

Management Systems, Quality Profiler Complications Measures Module. 

Evidence

Coding validity. A study of 669 newborns at Georgetown University Hospital 

who had a discharge diagnosis of birth trauma (codes not specified) found that only 25% 

(164/669) had sustained a significant injury to the head, neck, or shoulder.156 The 

remaining patients either had superficial injuries or injuries inferior to the neck. We were 

unable to find other evidence on the validity of this indicator. Towner et al. linked 

California maternal and infant discharge abstracts from 1992 through 1994, but they used 

only infant discharge abstracts to describe the incidence of neonatal intracranial injury, 

and they did not report the extent of agreement between the two data sets.157

 
60

Obstetric Trauma (All Delivery Types) 

Source. An overlapping subset of this indicator (third or fourth-degree perineal 

laceration [664.2x-664.3x]) has been adopted by the Joint Commission for the 

Accreditation of Healthcare Organizations (JCAHO) as a core performance measure for 

“pregnancy and related conditions” (PR-25). (The JCAHO indicator was less preferred by 

the clinical panelists than a definition restricted to fourth degree lacerations, so the 

JCAHO definition was retained for exploration as an Experimental indicator.) Based on 

expert consensus panels, McKesson Health Solutions included the JCAHO indicator in its 

CareEnhance Resource Management Systems, Quality Profiler Complications Measures 

Module. Fourth degree laceration (664.3x), one of the codes mapped to this PSI, was 

included as one component of a broader indicator (“obstetrical complications”) in 

AHRQ’s original HCUP Quality Indicators.144

Evidence 

Coding validity. In a stratified probability sample of 1,611 vaginal and cesarean 

deliveries from 51 California hospitals in 1992-93, the weighted sensitivity and predictive 

value of coding for third and fourth degree lacerations and vulvar/perineal hematomas 

(based on either diagnosis or procedure codes) were 89% (311/340) and 90% (311/337), 

respectively.158 The authors did not report coding validity for third and fourth degree 

lacerations separately. We were unable to find other evidence on validity from prior 

studies. 

Experimental Indicators 

Aspiration Pneumonia 

Source. This indicator was originally proposed by Iezzoni et al.10 as part of the 

CSP (CSP 2, “aspiration pneumonia”). Needleman and Buerhaus137 identified 

postoperative pneumonia as an “Outcome Potentially Sensitive to Nursing,” but their 

definition aggregated bacterial, aspiration (507.0), and “hypostatic” (514) pneumonia. 

The University HealthSystem Consortium adopted the CSP indicator for major surgery 

patients (#2924). 

Evidence 

Coding validity. CSP 2 had a moderate confirmation rate among major surgical 

cases in the FY1994 Medicare inpatient claims files from California and Connecticut 

(77% by coders’ review, 59% by physicians’ review, 50% by nurse-abstracted clinical 

documentation, and 85% if nurses also accepted physicians’ notes as adequate 

documentation).13-15 Geraci et al.34 confirmed (by chest radiography) 0 of 7 episodes of 

aspiration pneumonia (482.9, 507.0) reported on discharge abstracts of VA patients 

hospitalized in 1987-89 for CHF, COPD, or diabetes; the sensitivity for a new alveolar 

infiltrate was 0% (0/5). 

Construct validity. Explicit process of care failures in the CSP validation study 

were relatively frequent among major surgical cases with CSP 2 (69%), after excluding 

two patients who had aspiration pneumonia at admission.16 Cases flagged on this 

indicator and unflagged controls did not differ significantly on a composite of 17 generic 
61

process criteria. Physician reviewers identified potential quality problems in 21% of 

major surgery patients with CSP 2 (versus 2% of unflagged controls).15 

Needleman and Buerhaus137 found that higher registered nurse staffing (RN 

hours/adjusted patient day) and better nursing skill mix (RN hours/licensed nurse hours) 

were consistently associated with the occurrence of pneumonia (including aspiration and 

“hypostatic” pneumonia) among medical patients from 799 hospitals in 11 states in 1997. 

An increase from the 25th to the 75th percentile on these two measures of staffing was 

associated with 2.7% (95% CI, -0.4% to 5.8%) and 6.4% (95% CI, 2.8% to 10.0%) 

decreases, respectively, in the rate of pneumonia.159 Skill mix was “weakly” associated 

with the rate of pneumonia among major surgical patients. Nursing skill mix was 

significantly associated (in the expected direction) with the pneumonia rate among 352 

and 295 California hospitals in 1992 and 1994, respectively, but not among 126 and 131 

New York hospitals in the same years.138 Total licensed nurse hours per acuity-adjusted 

patient day were not associated with the pneumonia rate, except in California in 1994, 

where the association was actually positive. 

CABG Following PTCA 

Source. This indicator was developed by the University HealthSystem 

Consortium (#2906) to identify patients who experienced a complication of PTCA that 

required urgent surgical repair. This indicator has been used in several studies of PTCA 

outcomes and the relationship between volume and outcome.127-135

Evidence 

We were unable to find evidence on validity from prior studies, except insofar as 

higher hospital angioplasty volume has consistently been associated with lower risk of 

CABG following PTCA.127-135 Physician volume generally has an independent effect on 

the risk of CABG following PTCA, confirming that this measure is sensitive to operator 

experience and skill,132-135 although some recent data suggest that this effect may 

disappear at high-volume hospitals.160 One study involving Medicare inpatient claims 

from 1987 through 1990 also showed that CABG following PTCA was slightly less 

frequent at hospitals with “major” medical school affiliations than at other hospitals.131

Decubitus Ulcer in High-Risk Patients 

Source. This variation of Accepted PSI “Decubitus ulcer” was designed in 

response to concerns that the accepted indicator excludes the subset of patients at highest 

risk of developing pressure ulcers if they receive inadequate care in the hospital. It 

differs from Accepted PSI “Decubitus Ulcer” in that the denominator population is 

limited to patients with hemiplegia, paraplegia, or quadriplegia, and patients admitted 

from long term care facilities. The American Nurses Association, its state associations, 

and the California Nursing Outcomes Coalition have identified the total prevalence of 

inpatients with Stage I, II, III, or IV pressure ulcers (based on clinical data collection) as 

a “nursing-sensitive quality indicator for acute care settings.”140
62

Evidence 

We were unable to find evidence on validity from prior studies, but this is simply 

a modified version of an indicator on the accepted list. Validity may be lower in this 

setting, if a substantial proportion of pressure sores are pre-existing, but may be higher if 

these patients are especially sensitive to the effects of suboptimal nursing care. 

In-Hospital Fractures Possibly Related to Falls 

Source. This indicator was developed by our clinical panels, based on Accepted 

indicator “Postoperative hip fracture.” Needleman and Buerhaus 137 considered inhospital fall or fracture as an “Outcome Potentially Sensitive to Nursing,” based on input 

from their Technical Expert Panel, but discarded it because the “event rate was too low to 

be useful.” The American Nurses Association, its state associations, and the California 

Nursing Outcomes Coalition have identified the number of patient falls leading to injury 

per 1,000 patient days (based on clinical data collection) as a “nursing-sensitive quality 

indicator for acute care settings.”140

Evidence 

Coding validity. Among 185 total knee replacement patients from 5 Ontario 

hospitals in 1984-90, Hawker et al.146 found that the sensitivity and predictive value of 

“fall and fracture” codes (definition not given) were 80% (4/5) and 100%, respectively. 

We were unable to find other evidence for this indicator. 

Intraoperative Nerve Compression Injuries 

Source. A subset of this indicator (brachial plexus lesions [353.0]) was originally 

proposed by Iezzoni et al.10 as part of the CSP (CSP 13, “postoperative complications 

relating to central or peripheral nervous system”). The University HealthSystem 

Consortium adopted this CSP indicator for major surgery patients (#2934). However, this 

indicator was extensively revised after discussions with our clinical panels. 

Evidence 

We were unable to find evidence on validity from prior studies, because this 

complication is quite rare. Best et al.148 reported on the ability to use administrative data 

to find cases of “other neurologic” (including peripheral nerve) deficits, but their results 

cannot be interpreted due to misapplication of ICD-9-CM. 

Malignant Hyperthermia 

Source. This indicator was created after review of ICD-9-CM codes, and 

discussions with our clinical panel. 

Evidence 

We were unable to find evidence on validity from prior studies, because this 

diagnosis code was introduced in 1998. 
63

Postoperative Acute Myocardial Infarction 

Source. This indicator was originally proposed by Iezzoni et al.10 as part of the 

CSP (CSP 14, “postoperative acute myocardial infarction”). The University 

HealthSystem Consortium (#2935) and AHRQ’s original HCUP Quality Indicators144

adopted this CSP indicator for major surgery patients. 

Evidence 

Coding validity. CSP 14 had a high confirmation rate among major surgical 

cases in the FY1994 Medicare inpatient claims files from California and Connecticut 

(84% by coders’ review, 95% by physicians’ review, 81% by nurse-abstracted clinical 

documentation, and 89% if nurses also accepted physicians’ notes as adequate 

documentation).13-15 An earlier study of elderly Medicare beneficiaries from 

Massachusetts, Alabama, Iowa, and New York in FY1993 revealed a similarly high 

confirmation rate of 84% (69/82) among major surgical cases, although 39% of those 

patients (27/69) had neither electrocardiographic nor enzyme evidence supporting the 

diagnosis.145

Geraci et al.141 identified 0 of 3 AMI episodes (410.x1) using the discharge 

abstracts of VA patients hospitalized in 1987-89 for CHF, COPD, or diabetes. In 

comparison with the VA’s National Surgical Quality Improvement Program database 

from 123 hospitals in 1994-95, the ICD-9-CM diagnosis of AMI (410.xx) had a 

sensitivity of 58% and a predictive value of 47% for Q-wave infarctions within 30 days 

after surgery.148? By contrast, the 1985 National DRG Validation Study suggested that the 

sensitivity of ICD-9-CM 410.xx exceeds 75%, even when it is coded as a secondary 

diagnosis (n=67) rather than as the reason for admission.161

Construct validity. Explicit process of care failures in the CSP validation study 

were only moderately frequent among major surgical cases with CSP 14 (46%).16 Cases 

flagged by this indicator and unflagged controls differed significantly (p<0.02) on a 

composite of 17 generic process criteria, but the latter group actually demonstrated worse 

performance. Similarly, cases flagged on this indicator were significantly less likely than 

unflagged controls (29% versus 57%) to have at least one of seven specific process-ofcare problems in the earlier study of elderly Medicare beneficiaries from Massachusetts, 

Alabama, Iowa, and New York.145 Physician reviewers identified potential quality 

problems in 22% of major surgery patients with CSP 14 (versus 2% of unflagged 

controls).15 Kovner and Gergen reported that among 506 community hospitals in the 

1993 NIS, having more registered nurses per adjusted patient day was not associated with 

lower rates of AMI after major surgery.126

Postoperative Iatrogenic Complications – Cardiac System 

Source. This indicator was originally proposed by Hannan et al. as a criterion for 

targeting “cases that would have a higher percentage of quality of care problems than 

cases without the criterion, as judged by medical record review.”139 It was endorsed by 

Iezzoni et al.10 as one component of a much broader indicator (CSP 26, “iatrogenic 

complications”) in the CSP. The definition of that indicator includes central nervous 

system, cardiac, peripheral vascular, respiratory, gastrointestinal, urinary, and unspecified 
64

amputation stump complications, as well as complications affecting other body systems. 

It was also included as one component of a broader indicator (“adverse events and 

iatrogenic complications”) in AHRQ’s original HCUP Quality Indicators.144 The 

University HealthSystem Consortium adopted this CSP indicator for cardiac procedure 

patients (#2913). 

Evidence 

Coding validity. CSP 26 had a very high confirmation rate among major surgical 

cases in the FY1994 Medicare inpatient claims files from California and Connecticut 

(92% by coders’ review) and a borderline confirmation rate among medical cases (59% 

by coders’ review).13 Physician reviews were not performed. Faciszewski et al. 147

confirmed only 20% (2/10) of reported cases of cardiac complications (997.1) among 310 

patients who underwent spinal fusion at the Marshfield Clinic in 1991-92. The sensitivity 

of coding for this complication was 40% (2/5). Among 185 total knee replacement 

patients from 5 Ontario hospitals in 1984-90, Hawker et al.146 found that the sensitivity 

and predictive value of cardiac complication codes (definition not given) were 67% (6/9) 

and 86% (6/7), respectively. Romano et al. 93 identified 2 of 5 episodes of cardiac 

complications (with 2 false positives) using discharge abstracts of diskectomy patients at 

30 California hospitals in 1990-91. 

Construct validity. Explicit process of care failures in the CSP validation study 

were slightly but not significantly more frequent among cases with CSP 26 (58% 

surgical, 9% medical) than among unflagged controls (46% surgical, 5% medical). Based 

on two-stage review of 8,109 randomly selected deaths from 104 New York hospitals in 

1985-86, Hannan et al.139 reported that cases with a secondary diagnosis of 997.1 

(cardiac) were 3.4 times more likely to have received care that departed from 

professionally recognized standards than cases without that code (7.1% versus 1.7%), 

after adjusting for patient demographic, geographic, and hospital characteristics. In 25 of 

these 33 cases (76%) of substandard care, the patient’s death was attributed at least 

partially to that care. 

Postoperative Iatrogenic Complications – Nervous System 

Source. This diagnosis code was originally proposed by Iezzoni et al.10 as one 

component of a much broader indicator (CSP 26, “iatrogenic complications”), which was 

part of the CSP. Their definition includes central nervous system, cardiac, peripheral 

vascular, respiratory, gastrointestinal, urinary, and unspecified amputation stump 

complications, as well as complications affecting other body systems. It was also 

included as one component of a broader indicator (“adverse events and iatrogenic 

complications”) in AHRQ’s original HCUP Quality Indicators.144 The University 

HealthSystem Consortium adopted this CSP indicator for cardiac procedure patients 

(#2913). 

Evidence 

Coding validity. CSP 26 had a very high confirmation rate among major surgical 

cases in the FY1994 Medicare inpatient claims files from California and Connecticut 

(92% by coders’ review) and a borderline confirmation rate among medical cases (59% 
65

by coders’ review).13 Physician reviews were not performed. Romano et al.93 identified 1 

of 2 episodes of CNS complications (with 4 false positives) using discharge abstracts of 

diskectomy patients at 30 California hospitals in 1990-91. 

Construct validity. Explicit process of care failures in the CSP validation study 

were slightly but not significantly more frequent among cases with CSP 26 (58% 

surgical, 9% medical) than among unflagged controls (46% surgical, 5% medical). 

Reopening of Surgical Site 

Source. This indicator was originally proposed by Iezzoni et al.10 as part of the 

CSP (CSP 9, “reopening of surgical site”), although their definition was slightly broader 

than the proposed PSI (i.e., it includes revision of corrective procedure on heart (35.95) 

and reclosure of postoperative disruption of the abdominal wall (54.61)). The University 

HealthSystem Consortium adopted this CSP indicator for major surgery patients (#2930). 

Evidence 

Coding validity. CSP 9 had a relatively high confirmation rate among major 

surgical cases in the FY1994 Medicare inpatient claims files from California and 

Connecticut (97% by coders’ review, 61% by physicians’ review, 84% by nurseabstracted clinical documentation).13-15 

Construct validity. Explicit process of care failures in the CSP validation study 

were only moderately frequent among major surgical cases with CSP 9 (43%), after 

excluding one patient who had this complication at admission,16 but unflagged controls 

were not evaluated on the same criteria. Physician reviewers identified potential quality 

problems in 48% of major surgery patients with CSP 9 (versus 2% of unflagged 

controls).15

 

Suture of Laceration 

Source. This indicator was originally proposed by Iezzoni et al.10 as part of the 

CSP (CSP 17, “procedure-related perforation or laceration”). Their definition includes 

diagnosis codes (not included in this PSI) for spontaneous perforation of the esophagus 

(530.4), intestine (569.83), gallbladder (575.4), or bile duct (576.3), as well as procedure 

codes for repair of various organ lacerations. It was utilized by Miller et al.17 in the 

original “AHRQ PSI Algorithms and Groupings,” although their definition added suture 

of laceration of diaphragm (34.82), small intestine (46.73), and anus (49.71). These 

additional codes were included in this PSI, along with a few more codes (e.g. laceration 

of nerve). The University HealthSystem Consortium adopted this CSP indicator for major 

surgery patients (#2941). 

Evidence 

Coding validity. This cluster is very similar to CSP 17, which had a relatively 

high confirmation rate among major surgical cases in the FY1994 Medicare inpatient 

claims files from California and Connecticut (71% by coders’ review, 58% by 

physicians’ review, 69% by nurse-abstracted clinical documentation, and 75% if nurses 

also accepted physicians’ notes as adequate documentation).13-15 The CSP criteria were 

not fully successful in excluding pre-admission trauma, but it is not clear which code(s) 
66

accounted for this problem. An earlier study of elderly Medicare beneficiaries from 

Massachusetts, Alabama, Iowa, and New York in FY1993 revealed a similar 

confirmation rate of 70% (65/93) among major surgical cases, although 18% of those 

patients (12/65) lacked clear physical examination evidence of the diagnosis.145

Construct validity. Physician reviewers identified potential quality problems in 

36% of major surgery patients with CSP 17 (versus 2% of unflagged controls).15 In the 

New York SID from 1997, nursing expertise (full-time and part-time RNs as a proportion 

of all licensed nurses) below the statewide median level was associated with a higher 

unadjusted rate of this indicator (24 versus 15 events per 10,000 discharges).17

Experimental Obstetric Indicators 

 

Obstetric Wound Complications – Cesarean Delivery 

Source. Disruption of a cesarean wound (674.1x) was proposed by Miller et al.17

as part of a broader indicator (“obstetrical misadventures”) in the original “AHRQ PSI 

Algorithms and Groupings.” It was also included as one component of a broader indicator 

(“obstetrical complications”) in AHRQ’s original HCUP Quality Indicators.144

Evidence 

Coding validity. Weiss et al.162 reviewed 636 deliveries in Massachusetts 

hospitals in 1990-97 reported to have had cesarean wound disruption (674.1x), and found 

that 29% (179/636) were actually uterine ruptures before or during labor. Therefore, the 

maximum possible predictive value of this diagnosis was 71%. In a stratified probability 

sample of 1,611 vaginal and cesarean deliveries from 51 California hospitals in 1992-93, 

the sensitivity and predictive value of wound disruption, hematoma, or infection (based 

on either diagnosis or procedure codes) were 27% and 91%, respectively.163 We were 

unable to find other evidence on validity from prior studies. 

Obstetric Wound Complications – Vaginal Delivery 

Source. This variation of the above PSI was designed as a “sister” measure for 

vaginal deliveries, based on review of ICD-9-CM codes and discussions with the clinical 

panel. Perineal wound disruption (674.2x), one of the codes mapped to this PSI, was also 

included as one component of a broader indicator (“obstetrical complications”) in 

AHRQ’s original HCUP Quality Indicators. 

Evidence 

Coding validity. In a stratified probability sample of 1,611 vaginal and cesarean 

deliveries from 51 California hospitals in 1992-93, the weighted sensitivity and predictive 

value of wound disruption, hematoma, or infection (based on either diagnosis or 

procedure codes) were 27% (18/37) and 91% (18/21), respectively.163 We were unable to 

find other evidence on validity from prior studies. 
67

Other Obstetric Complications 

Source. These diagnosis codes were proposed by Miller et al. 17 as part of a 

broader indicator (“obstetrical misadventures”) in the original “AHRQ PSI Algorithms 

and Groupings.” They include codes 668.x and 669.x (pulmonary, cardiac, and central 

nervous system complications, other specified and unspecified complications of 

anesthesia or sedation, shock and other major complications of obstetric procedures, 

acute postpartum renal failure). All of the codes mapped to this PSI were included as part 

of a broader indicator (“obstetrical complications”) in AHRQ’s original HCUP Quality 

Indicators.144

Evidence 

Coding validity. In a stratified probability sample of 1,611 vaginal and cesarean 

deliveries from 51 California hospitals in 1992-93, the weighted sensitivity and predictive 

value of coding for cardiac (668.1x, 995.4) and pulmonary (668.2x) complications of 

obstetric anesthesia or analgesia were 24% (8/16) and 97% (8/9), respectively.163 The 

authors did not report coding validity for the other components of this PSI. We were 

unable to find other evidence on validity from prior studies. 

Postpartum Urinary Tract Infection 

Source. This indicator was created after review of ICD-9-CM codes and 

discussions with the clinical panel. The definition is specific to “infections of the 

genitourinary tract” that are labeled as postpartum complications, although some of these 

infections may have originated in the antepartum period. 

Evidence 

Coding validity. In a stratified probability sample of 1,611 vaginal and cesarean 

deliveries from 51 California hospitals in 1992-93, the weighted sensitivity and predictive 

value of postpartum urinary tract infection were 20% (5/13) and 41% (5/8), 

respectively.163 We were unable to find other evidence on validity from prior studies, 

because this indicator has not previously been used as a measure of quality. 

Third or Fourth Degree Obstetric Lacerations 

Source. This indicator has been adopted by the JCAHO as a core performance 

measure for “pregnancy and related conditions” (PR-25). A revised version of this 

indicator, based on input from our clinical panel, qualified as Accepted indicators, 

“Obstetric trauma.” 

Evidence 

Coding validity. In a stratified probability sample of 1,611 deliveries from 51 

California hospitals in 1992-93, the weighted sensitivity and predictive value of coding 

for third and fourth degree lacerations and vulvar/perineal hematomas (based on either 

diagnosis or procedure codes) were 89% (311/340) and 90% (311/337), respectively.158
68

The authors did not report coding validity for third and fourth degree lacerations 

separately. We were unable to find other evidence on validity from prior studies. 

Uterine Rupture 

Source. This indicator has been widely used for monitoring the impact of vaginal 

birth after cesarean delivery, which is associated with an increased incidence of uterine 

rupture.164, 165

Evidence 

Coding validity. Weiss et al.162 reviewed 615 deliveries in Massachusetts 

hospitals in 1990-97 reported to have had uterine rupture before or during labor (665.0x, 

665.10, 665.11), and confirmed 51% (306/615). The maximum possible sensitivity was 

64% (306/480), because some uterine ruptures were miscoded as cesarean wound 

disruption (674.1x). We describe this estimate as the “maximum possible sensitivity” 

because false negatives were only captured if they were miscoded with 674.1. 

 Construct validity. Although we found no data on how often quality-of-care 

problems are associated with uterine rupture, Gregory et al. showed that women in 

California who delivered at hospitals with high attempted VBAC (vaginal birth after 

cesarean) rates in 1995 were more likely to have successful VBAC, but also more likely 

to experience uterine rupture, than women who delivered at hospitals with lower VBAC 

rates. This finding is consistent with the construct that high uterine rupture rates reflect 

an overly aggressive approach to VBAC. Induction of labor with prostaglandins has been 

associated with a major increase in the risk of uterine rupture (RR=15.6).164, 165

Section 3B. Indicator Selection 

Indicator selection consisted of a multi-stage process, shown in Flow Diagram 1. 

Promising indicators identified from the literature or other sources were assessed for face 

validity by clinicians through a structured process. The first round specifications of 

indicators were usually modified to varying extents based on clinical and coding input. 

Then for each indicator, the revised specification was rated by panelists on a number of 

dimensions, but most importantly the likely usefulness of the indicator as a screen for 

potentially preventable complications of care. The usefulness rating provided the primary 

filter by which indicators were grouped into three categories representing the more 

promising to less useful indicators — a.) Accepted, b.) Experimental, or c.) Rejected. 

Table 11 provides a summary of Accepted PSIs and the panel ratings show that these 

indicators were rated as fairly useful by either practically all of the panelists (Acceptable) 

or most with minimal dissent from those rating it lower (Acceptable (-)). Table 12 lists 

the Experimental PSIs, those measures which panelists were less sanguine about than 

those in the Accepted indicator set or that were more problematic to specify according to 

the intent of the panel discussion. Each indicator in the Experimental indicator set has 

some positive characteristics, along with some relatively important potential limitations. 

Table 13 lists Rejected indicators, indicators that received low ratings by the panelists, 

and did not merit further exploration. The footnotes to these tables summarize 

idiosyncratic reasons for the categorization rationale. 
69

Table 11. Accepted Indicators (provider and area level) 

Indicator Name Multi-specialty Panel 

Evaluationa

Surgical Panel 

Evaluationa Definition Used 

Complications of anesthesia 3 Acceptable (-) Surgical 

Death in low mortality DRGs M2 Acceptable 

Decubitus ulcer M1 Acceptable 

Failure to rescue M2 Acceptable 

Foreign body left in during 

procedureb 

S2 Acceptable 2 Acceptable (-) Same 

Iatrogenic pneumothoraxb P1 Acceptable 

Infection due to medical careb M1 Acceptable (-) 

Postoperative hemorrhage or 

hematomad S1 Acceptable (-) 3 Acceptable Surgical 

Postoperative hip fracturec M1 Acceptable 

Postoperative physiologic and 

metabolic derangements 

S3 Acceptable (-) 3 Unclear Surgical 

Postoperative respiratory failure S2 Unclear 2 Acceptable (-) Surgical 

Postoperative pulmonary embolism 

or deep venous thrombosis 

S1 Acceptable (-) 1 Acceptable Same 

Postoperative sepsis M1 Acceptable (-) 

Postoperative wound dehiscenceb S2 Acceptable (-) 2 Acceptable (-) Surgical 

Technical difficulty with procedureb P1 Acceptable 

Transfusion reactionb S3 Acceptable 3 Acceptable Same 

Birth trauma-injury to neonate O1 Acceptable 

Obstetric trauma - cesarean sectione O1 Acceptable (-) 

Obstetric trauma - vaginal with 

instrumente

O1 Acceptable (-) 

Obstetric trauma - vaginal without 

instrumente

O1 Acceptable (-) 

a M, P, O, S refer to Medical, Procedure, Obstetric or Surgery Multi-specialty Panels and their identifying number (see 

Appendix B for further detail). 1,2,3 refers to the Surgical Panel, if reviewed by Surgical Panel (see Appendix B). 

“Acceptable” indicates that the indicator was rated as useful by almost all panelists. “Acceptable (-)” indicates that the 

indicator was rated as useful by most panelists, although a few rated it as less useful (but not as poor). “Unclear” 

indicates that panelists rated the usefulness of the indicator as moderate. Panel overall ratings are described in detail 

Clinician Panel Review Methods (Section 2D) under Tabulation of Results subsection. b Provider and area level indicators specified for this indicator. 

c

 Panel requested other fractures in addition to hip fracture, but empirical analyses indicated concerns about ability to 

operationalize well enough for accepted list. 

d

 Codes for post-op hemorrhage or hematoma were expanded to include 5th digits in October 1996, and therefore this 

indicator is invalid before that date. 

e

 Obstetric trauma indicators were not rated separately, though panelists were informed that the indicator would be split 

into three types of delivery. 
70

Table 12. Experimental Indicators

Indicator Name Multi-specialty Panel 

Evaluationa Surgical Panel Evaluationa Definition Used 

Aspiration pneumonia S2 Unclear 2 Unclear Same 

CABG after PTCAb P1 Acceptable 

Decubitus ulcer in high risk 

patientsc 

 

In-hospital fractures possibly 

related to fallsd

M1 Acceptable 

Intraoperative nerve compression 

injuriese 

S3 Acceptable 3 Acceptable Surgical 

Malignant hyperthermiaf S3 Acceptable 1 Acceptable (-) Same 

Postoperative acute myocardial 

infarctiong 

S1 Unclear (-) 3 Acceptable (-) Surgical 

Postoperative iatrogenic 

complications – cardiac systemh 

P1 Not rated 

separately 

 

Postoperative iatrogenic 

complications – nervous systemh,i 

P1 Not rated 

separately 

 

Reopening of surgical sitej S2 Unclear 3 Acceptable (-) Surgical 

Suture of lacerationk S2 Acceptable 2 Unclear (-) Surgical 

Obstetric wound complicationscesarean section O2 Acceptable 

Obstetric wound complicationsvaginal delivery O2 Unclear 

Other obstetric complications O2 Unclear 

Post-partum urinary tract infection O2 Acceptable (-) 

Third or fourth degree obstetric 

laceration (JCAHO)l 

 

Uterine rupturem 

a M, P, O, S refer to Medical, Procedure, Obstetric or Surgery Multi-specialty Panels and their identifying number (see 

Appendix B for further detail). 1,2,3 refers to the Surgical Panel, if reviewed by Surgical Panel (see Appendix B). 

“Acceptable” indicates that the indicator was rated as useful by almost all panelists. “Acceptable (-)” indicates that the 

indicator was rated as useful by most panelists, although a few rated it as less useful (but not as poor). “Unclear” 

indicates that almost all panelists rated the usefulness of the indicator as moderate. 

”Unclear (-)” indicates that most of the panelists rated the usefulness as moderate, although a few rated it as less useful. 

Panel overall ratings are described in detail Clinician Panel Review Methods (Section 2D) under Tabulation of Results 

subsection. 

b Accepted by panel, but lack of review by physicians performing PTCA led to demoting indicator. 

c Indicator suggested by panel, with concerns, and by AHRQ. d

This indicator was defined as closely to the panel suggestion as possible, but empirical analysis showed higher fracture 

rates in non-elderly men. Further analysis led to exclusions and a more limited list of fractures to reduce the likelihood 

of capturing fractures unrelated to falls. However, the problem still persists to some degree. We therefore demoted the 

indicator to the experimental list and retained a CSP based version of the hip fracture indicator on the accepted list. e This indicator is extremely rare, leading to questions regarding coding and operationalization. This indicator requires 

the code 997.09 which was not added until October 1995. This indicator is invalid before that date. f This code (995.86) was added in October 1998 and thus this indicator is invalid before this date. Although accepted by 

panels, with one dissent, we cannot evaluate because data sources date only to 1997. g This indicator was rejected by the multi-specialty panel (median=4), but accepted by the surgical panel. 

h These indicators, although accepted by panel were demoted due to concern that panel discussions were not 

comprehensive enough to justify acceptance for each of the split indicators. i Codes for iatrogenic nervous system complications were expanded to include 5th digits in October 1995, and therefore 

this indicator is invalid before that date. 

j Accepted by surgical panel only, but concerns about operationalization remain and cannot be easily resolved. 

k This indicator was rejected by surgical panel (median = 5), accepted by multi-specialty. 

l This indicator is a core JCAHO indicator, not reviewed by panel, although 4th degree lacerations are part of the 

Obstetric Trauma indicator on the Accepted Listing. 

m This indicator was split off from other Obstetric complications, due to questions on operationalization of panel 

requests and strong arguments for splitting.
71

Table 13. Rejected Indicators

Indicator Name Multi-specialty Panel 

Evaluationa Surgical Panel Evaluationa Definition Used 

Dosage complications M2 Unclear (-) 

Iatrogenic hypotension P1 Unclear (-) 

Intestinal infection due to C. difficile M1 Unclear (-) 

PO Iatrogenic complications – 

digestive complicationsb

P1 Not rated 

separately 

 

PO Iatrogenic complications – 

respiratory complicationsb

P1 Not rated 

separately 

 

PO Iatrogenic complications – 

urinary complicationsb

P1 Not rated 

separately 

 

PO Iatrogenic complications – 

vascular complicationsc

P1 Not rated 

separately 

 

Postoperative pneumonia S1 Unclear (-) 3 Unclear Same 

Unexpected LOS/Conditional LOS M2 Unclear Unable to 

specify panel 

suggestions 

Obstetric thrombosis or embolism O2 Unclear (-) 

Puerperal infection O2 Unclear (-) 

 a M, P, O, S refer to Medical, Procedure, Obstetric or Surgery Multi-specialty Panels and their identifying number (see 

Appendix B for further detail). “Unclear” indicates that almost all panelists rated the usefulness of the indicator as 

moderate. ”Unclear (-)” indicates that most of the panelists rated the usefulness as moderate, although a few rated it as 

less useful. Panel overall ratings are described in detail Clinician Panel Review Methods (Section 2D) under Tabulation 

of Results subsection. 

b

Panel accepted the concept of capturing a set of iatrogenic complications, but empirical analyses suggests that most 

complications in this category are clinically insignificant. 

c

Panel accepted, but covers same complications as vascular complications indicator, which is more complete measure.

 The degree to which panelists perceived indicators as preventable (e.g., “Foreign 

body left in during procedure,” “Decubitus ulcer,” “Obstetric trauma-cesarean section”) 

tended to relate to the usefulness rating. In other words, the higher the rating for 

usefulness, the higher the rating for preventability. All indicators in the Accepted 

indicator set received a median rating of at least 6 by one or more panels (on a scale from 

1 to 9 where higher scores represent the opinion that a complication is preventable). 

However, some rejected indicators that panelists thought would surely be preventable 

(e.g., dosage complications received a median score of 8) were rated poorly overall 

because of problems with the indicator (e.g., that it would be inconsistently documented). 

The adapted UCLA/RAND method may be applied to the preventability ratings to 

identify complications felt by panelists to be more or less preventable, although this 

rating does not take into account other potential pitfalls of indicators, such as bias or 

charting practices. Table 14 shows the results of this categorization for the preventability 

ratings for the Accepted indicators. 

 For most indicators, panelists rated the medical error scale lower than the 

preventability scale. However, several indicators had relatively high scores (median, 7 –

8) equivalent for both of these scales – “Foreign body left in during procedure,” 

“Decubitus ulcer,” “Iatrogenic pneumothorax,” “Dosage complications,” “In-hospital 

fracture,” and “Transfusion reaction.” Again, the UCLA/RAND method may be applied 

to the medical error ratings. Table 15 demonstrates the wider dispersion in Accepted 

indicators when medical error ratings are used. 
72

Table 14. Groupings Based on Preventability 

Acceptable Acceptable (-) Unclear Unclear (-) 

Decubitus ulcer Comp. of anesthesia Death in low 

mortality DRG 

Failure to rescue 

Foreign body Infection due to 

med. care 

PO hemmorhage/ 

hematoma 

PO physio. or 

metab. derangement 

Iatrogenic 

pneumothoraxa 

PO PE or DVTb PO pulmonary 

compromise 

In-hosp. fracturea Transfusion 

reaction 

PO wound 

dehiscence 

Tech. diff. with 

procedure 

Birth trauma Postoperative 

sepsis 

OB trauma (all 

delivery types) 

Post-partum UTI OB wound comp. – 

c-sect a

Panel ratings based on definitions different than final definitions. For “Iatrogenic pneumothorax,” the rated 

denominator was restricted to patients receiving thorocentesis or central lines; the final definition expands the 

denominator to all patients (with same exclusions). For “In-hospital fracture” panelists rated the broader Experimental 

indicator, which was replaced in the Accepted set by “Postoperative hip fracture” due to operationalization concerns. b

Vascular complications rated as Unclear (-) by surgical panel. 

Table 15. Grouping Based on Medical Error 

Acceptable Acceptable (-) Unclear Unclear (-) 

Decubitus ulcerg Comp. of 

anesthesiag 

Death in low mort. 

DRG 

Failure to rescue 

Foreign bodyc, g In-hosp. fracturea, g Infection due to 

med. care 

PO hemmorhage/ 

hematoma

Iatrogenic 

pneumothoraxa, g 

Transfusion 

reactiond, g 

PO PE or DVTb PO pulmonary 

compromise 

 PO wound 

dehiscencee Birth trauma 

 Postoperative 

sepsis 

OB trauma 

 Tech. diff. with 

procedure 

 PO physio. or meta. 

Derangementf

a

Panel ratings based on definitions different than final definitions. (See Table 14 footnote) b

Vascular complications rated as Unacceptable by surgical panel. 

c

Foreign body rated as Acceptable (-) by surgical panel. d

Transfusion reaction rated as Unclear (-) by surgical panel. 

e

PO wound dehiscence rated as Unclear (-) by surgical panel. f

PO physiologic and metabolic derangement rated as Unclear (-) by surgical panel. g

Rated highly on both preventability and medical error questions. 

 Although the Accepted indicators did have relatively high ratings regarding the 

overall usefulness of the indicator, the panel review only addressed the face validity of 

the indicators. Additional research will be required to establish the validity of all 

indicators. In general, Accepted indicators have more compelling validity based on the 

current findings than do Experimental indicators. Each of the Experimental indicators is 

subject to one or more major concerns that tend to group into three categories. First, 

panelists rated some of the Experimental indicators lower than the Accepted indicators 

because they had concerns regarding the construct validity of the indicator (the ability of 
73

the indicator to measure potentially preventable complications). Additional research 

utilizing other sources of data, such as medical charts, will help to determine the 

construct validity of these indicators. Although all indicators have no or little current 

evidence regarding their construct validity, panelists felt particularly concerned about 

those indicators designated as Experimental. Second, a few indicators either did not have 

adequate panel review, or were not evaluated by panels (since they were added after the 

panel review). These indicators should be reviewed by clinical panels with appropriate 

composition (e.g., inclusion of cardiac surgeons and interventional cardiologists for 

“CABG after PTCA”). Finally, a few indicators were of interest to the panels, but could 

not be operationalized adequately within the project timeframe and resources, and will 

therefore require investigation into whether available codes capture the complication of 

interest and risk pool adequately. Table 16 identifies the suggested research for each of 

the Experimental indicators. 

Table 16. Suggested Initial Further Research for Experimental Indicators 

Indicator 

Construct Validity Clinician Panel Review Operationalization Review 

Aspiration pneumonia X 

CABG after PTCA X 

Decubitus ulcer in high risk patients X X 

In-hospital Fractures possibly related to falls X 

Intraoperative nerve compression injuries X X 

Malignant hyperthermia X X 

Postoperative acute myocardial infarction X Xa 

Postoperative iatrogenic complications – cardiac system X 

Postoperative iatrogenic complications – nervous system X 

Reopening of surgical site X 

Suture of laceration X Xa 

Obstetric wound complications – cesarean section X 

Obstetric wound complications - vaginal delivery X 

Other obstetric complications X 

Post-partum urinary tract infection X 

Third or fourth degree obstetric laceration (JCAHO) X 

Uterine rupture X X a

Indicators were accepted by one panel, but rejected by another. Additional review may aid in interpreting these 

differences of opinion. 

Most of the indicators were specified to include pediatric patients. To assess the 

applicability of the indicators to the pediatric population, rates were also calculated for 

the following age strata: less than one year, 1 – 14 years, 15 – 24 years and 25 years and 

older (see Appendix G, Supplemental Tables 3 and 4). Many indicators appear to have 

similar rates across all pediatric patients as adults. However, the mechanisms of 

complication development may differ in the pediatric population. For instance, DVTs in a 

pediatric population may be more reflective of catheter care and use than perioperative 
74

prevention strategies. Where mechanisms or risk factors may differ from the adult 

population, they are noted in Section 3D. 

 The remaining portions of the report focus on reporting more details about these 

indicators. Section 3C. Overall Clinician Review Results provides general themes related 

to these indicators and highlighted by the panel discussions. Section 3D. Detailed Panel 

Results by Indicator, provides details on the definition choices made for each indicator, 

and the concerns raised specific to each indicator. Section 3E. Comparative Empirical 

Results, relates the findings of the empirical analyses for indicators in the Accepted and 

Experimental indicator sets. Appendix E provides the detailed specification for the final 

definitions used for each indicator, and Section 3D. Detailed Panel Results by Indicator 

also includes the basic definition and rationale for each indicator. As previously noted, all 

of the results for and brief descriptions of the Rejected indicators are presented in 

Appendix F. 
75

Miller et al. Patient 

Safety Indicators 

Initial list of PSI codes (200+ codes) 

Specific codes obtained 

from a review of 

ICD-9-CM 

Potential indicators reported in literature, 

including Complications Screening 

Program 

34 indicators reviewed by multispecialty panels 

2 indicators created by multispecialty panels 

20 indicators assigned to Accepted set 

17 indicators assigned to Experimental set 

11 indicators rejected 

15 indicators reviewed by 

surgical panels 

Final PSI set 

Grouping of codes and assignment of 

inclusion/exclusion criteria based on CSP, 

Miller et al. PSIs and clinical knowledge. 

Selection of indicators for review based on 

coding knowledge and validity evidence 

reported in the literature. 

Changes to indicators based on 

panel review and professional 

coding input. 

Indicators assigned to sets 

based on panel ratings. 

Final revisions to indicators 

based on final coding input, and 

exploratory analyses. 

40+ preliminary indicators 

Selected codes included based on 

clinical logic and knowledge of 

coding practices 

Flow Diagram 1. Process for the Selection of Indicators 

Additional indicators were added postreview to experimental set based on 

panel suggestions. Some indicators split 

into several indicators based on panel 

suggestion. 
76

Section 3C. Overall Clinician Panel Review Results 

During the course of the clinician review, panelists discussed and offered both 

specific suggestions regarding a specific indicator, as well as general themes about 

quality indicator use. These "themes" provided important insights into how quality 

improvement and indicators are viewed by clinicians, how such indicators are likely to be 

used and interpreted, and the validity of such indicators from a clinical perspective. 

While our sample of clinicians was diverse, it is not a nationally representative sample, as 

these individuals were nominated and volunteered to participate. Nevertheless, the 

themes that consistently arose in the process are important to address in the development 

and use of quality indicators. While many of these themes reflect areas covered in 

previous studies, the novel, though not surprising, finding is that clinician panelists 

considered these areas vital to discuss as they provided input about the development of 

patient safety and complications indicators. 

Application of Quality Indicators 

Panelists repeatedly discussed that the validity of quality indicators is dependent 

on the intended use (e.g., public reporting of provider rates versus internal quality 

improvement). For example, an indicator designed to be more specific increases the 

surety that the indicator will most certainly flag only cases where a medical error or 

process failure has occurred. The tradeoff, as with any diagnostic test, is that the indicator 

will then be less sensitive, missing true instances of error. For internal quality 

improvement, it may be more useful to identify changes in rates of complications that 

may signal a potential process flaw. While this approach is less precise in terms of 

yielding only cases of high concern, it would likely identify a broader range of potential 

quality concerns. For public reporting of provider rates, however, a choice to emphasize 

sensitivity over specificity in designing indicators may lead to misinterpretation about a 

particular providers’ performance, as some that may use such data may be unfamiliar 

with the extensive list of caveats that must be considered when interpreting results for 

each quality indicator. The primary goal of the AHRQ quality indicators is to implement 

screening tools, meaning that further investigation is expected to certify that an abnormal 

rate is indeed due to a quality problem. Nonetheless, panelists remained concerned that if 

these indicators were used to report rates publicly, such limitations would be obscured. 

Purpose of Quality Indicators 

Indicators may be designed for a variety of uses. There is a distinction between 

the use of QIs as "case finding tools" and as "quality improvement" tools. Case finding 

tools are primarily used to identify a specific case or patient in which a quality problem 

may have led to the outcome in question. In some cases, this may be used for case 

investigation, mortality and morbidity discussions, or negligence attributions. Another 

way to use the indicators is as quality improvement tools, in which the rate of a 

complication provides the most useful information. Unlike case finding tools, this 

approach focusing on complication rates admits that not each case will reflect negligence 

or medical error. However, hospitals with extremely high rates compared to similar 
77

institutions may have cause for concern. Interventions may be able to reduce the rate of a 

complication, but not always prevent a complication from occurring in a particular 

patient. Panelists were told that this indicator set is designed as a quality improvement 

tool. Like indicators used for public reporting of provider rates, indicators used for case 

finding must be much more specific than quality improvement tools, since imprecision 

from a more sensitive measure may cause problems. Panelists expressed concern that 

some of the indicators under development may be construed as case finding tools, despite 

being designed and validated as quality improvement tools. In this event, physicians or 

other clinicians may be unfairly accused of negligence in a particular case, when, in fact, 

the clinician could not have prevented the outcome for that particular patient. 

Importance of Risk Adjustment or Stratification 

Panelists noted that for many indicators, case mix, screening and charting 

practices, and other factors vary systematically between providers. Panelists discussed 

alternatives to address such bias, as outlined below. 

For many indicators, the exclusion of certain high risk populations, such as 

trauma patients, may increase the homogeneity of the population at risk. Such restrictions 

would decrease bias that could result from inconsistent distribution among hospitals of 

high risk populations. In some cases, panelists favored such exclusions when the 

population was at such a high risk, that most of the complications would not be 

preventable. Panelists noted that this approach has the undesired effect of obscuring 

outstanding quality care, where some providers may be better at preventing complications 

in high risk patients. This difference would be very important to illuminate, leading some 

panelists to suggest stratification rather than exclusions. 

 Stratification has the advantage of allowing providers to view rates of 

complications in patients with varying risks of developing that complication. Such 

stratification would remove bias caused by high risk patients. For instance, deep vein 

thromboses (DVT) and pulmonary embolism (PE) are more common after some 

orthopedic surgeries. Providers specializing in orthopedic surgery may appear to have an 

abnormally high rate of DVT/PE, although the rate is due primarily to case mix. Stratified 

rates would allow the provider to view the orthopedic surgical complications rates 

separately from other lower risk procedures, allowing exploration of whether the high 

rate was indeed due to the provider’s orthopedic surgery case-mix. Panelists suggested 

stratifying some indicators by primary procedure type, trauma, elective and urgent 

admission, and specified comorbidities. In addition to singling out potentially high risk 

strata, stratification may aid in illuminating the source of a particularly high rate, beyond 

case mix differences. For demonstration, panelists noted that DVT and PE are identified 

differently by different providers. Some providers specifically screen for DVT after 

surgery, while others do not. Thus, providers that screen will appear to have a higher rate, 

simply because they detect more DVTs. Stratification by DVT rate versus PE rate would 

allow providers to identify whether a high rate is driven by a higher rate of DVTs, which 

may be due to screening, or whether the more serious and less ambiguous PE rate is also 

high. The review of each specific indicator notes suggestions that panelists made 

regarding stratification. 
78

 In some cases, stratification may not be the best or only approach. Panelists noted 

that case mix adjustment is desirable for many indicators, especially when a variety of 

factors, such as age, sex, principal procedure or diagnosis, and comorbidities, may 

influence the likelihood of complications occurring, and when many of these factors vary 

systematically by providers. Under these circumstances, case-mix adjustment may be 

easier to interpret than stratification or other approaches. However, case-mix adjustment 

has many caveats, especially when limited to administrative data. Panelists noted that for 

many of these indicators, risk adjustment using administrative data is a blunt tool. 

Additional clinical data would provide much better risk adjustment information. Such 

data are likely to differ by indicator, and often would require chart review. However, 

even some risk adjustment may indicate whether or not there is a possibility that a high 

rate could be due to differences in case mix. While many panelists expressed concern that 

without risk adjustment indicator results would be misconstrued as due to poor quality of 

care, some panelists also expressed that blaming high rates on case mix differences may 

not be appropriate. Their point of view was that adequate risk adjustment could reveal 

under what circumstances high complication rates appear attributable to case mix 

differences. 

Understanding of Data 

Throughout the structured review process, it was clear that some panelists had 

sophisticated knowledge of administrative data and ICD-9-CM coding, while many 

panelists were unclear about the limitations of administrative data. To remedy this 

problem, we provided panelists with information on coding and administrative data. 

Throughout the conference call we clarified any misconceptions regarding the available 

data. Through these interventions, panelists’ understanding appeared sufficient regarding 

the limited nature of administrative data. However, we did note that before this education, 

panelists often assumed that administrative data were clinically rich, containing 

information on physiological data or very specified diagnoses or procedures. Most 

panelists were unaware of how ICD-9-CM codes were assigned; unaware that such codes 

are based on the physician notes and are therefore subject to differences in physicians’ 

diagnosis and charting practices. Panelists were also often unaware that the precise 

timing of a diagnosis or procedure was impossible to ascertain with most administrative 

data. The variety of baseline knowledge regarding administrative data from which 

indicators are constructed suggests potential future problems in interpretation. Physicians 

and other clinicians, as well as the public and other end users may assume that the data 

from which indicators are created are detailed, and therefore that indicators or risk 

adjustment procedures are more clinically valid than is true. A lack of understanding of 

administrative data may promote inappropriate use of indicators. Without understanding 

data elements captured in an indicator specification, users of indicators may have 

difficulties determining what additional data collection efforts might help explain varying 

rates observed by providers. It should be noted that while some panelists appeared to 

believe that administrative data were more detailed, others had great skepticism about its 

use (see below). 
79

Charting, Coding and Reporting 

Panelists expressed skepticism about the quality of coding for some of the 

indicators, stemming from a variety of problems ranging from incentives to chart events 

to possible inexperience of coders assigning ICD-9-CM codes. Panelists noted that there 

are many reasons why a physician may not chart a diagnosis or procedure. First, some of 

the reviewed complications, such as "failure of sterile procedures" or "suture of 

laceration" when the laceration is minor, may not be coded by some physicians because 

they may not seem to be clinically significant. In these cases the "rate" of a complication 

is related mostly to the detail of the physician notes, and thus may be biased. In some 

cases, there may be disincentive to specifically chart a complication of questionable 

clinical importance. The culture of a hospital may discourage reporting of errors, if a 

physician feels that they will be punished for reporting the error. Thus, hospitals with 

good reporting programs for medical error may appear to have poorer quality of care than 

hospitals that do not encourage error reporting. 

 In some cases, the clinical significance of a complication may be very clear, and 

will usually be charted. However, panelists noted that there still may be variation in 

charting these complications. Since ICD-9-CM codes are assigned based on physicians’ 

written notes, the exact term a physician uses to describe a condition effects the code 

assigned. For instance, pneumonia and atelectasis may be used by different physicians to 

describe the same clinical findings, resulting in different ICD-9-CM codes. In addition, 

physicians may have differing clinical thresholds and diagnostic practices when 

identifying a condition. In the pneumonia example, some physicians may diagnose 

pneumonia using chest x-ray findings, while others may require positive results from a 

broncoscopy before documenting the diagnosis. Again, these variations result in varying 

"rates" without true variation in the rate of the actual complication. Even when the 

complication is clearly defined, some indicators require that the complication be labeled 

as the direct result of a procedure or medical care, or "iatrogenic". Panelists reported that 

such a link is often not included in the chart. If another code is available, such as is the 

case for hypotension, for instance, that code is likely to be assigned. Coders, by direction, 

and because they are not physicians, do not make inferences during coding to correct 

some of these variations. In fact, panelists repeatedly expressed skepticism about the 

accuracy of coding from physician notes, although specific observations of inaccuracy 

were not reported. 

Summary 

Throughout our clinical panel review process, we identified recurring themes 

relating to the usefulness of indicators in a clinical setting. Panelists noted that many 

problems associated with indicators might not be accurately noted when interpreting 

indicators in a clinical setting, and generally expressed concern regarding the use of these 

indicators as definitive quality measures or for public reporting. However, panelists did 

express interest and indicated a need for such quality indicators, especially for nonpunitive internal quality monitoring and improvement. 
80

Section 3D. Detailed Panel Results by Indicator 

This section reports the results of the clinician panel’s ratings and discussion of 

each indicator. Medical, procedure and obstetric related indicators were reviewed by 

multi-specialty panels. A subset of indicators was then reviewed by surgical panels. The 

table (Table 17) below summarizes the genealogy or history of panel reviews for each 

indicator; letters in parentheses after an indicator show the final disposition of the 

indicator based on panel and other findings. Rejected means that the indicator was not 

retained for further evaluations, usually due to low ratings by the panelists. These 

rejected indicators are in addition to ones that were not even evaluated by clinical panels. 

Experimental indicates that the indicator was of some potential use as a patient safety 

indicator, but had generated some reasonable concerns that would need to be explored 

through chart reviews or other methods that were outside of the scope of this project. 

These indicators were evaluated as an Experimental indicator set in the empirical 

analysis. The final disposition, Accepted means that an indicator as specified after panel 

input was thought to be useful as a screen for potentially preventable complications of 

care. These Accepted indicators were evaluated empirically in detail. In this section, 

Accepted indicators are presented first, in alphabetical order; non-obstetric indicators are 

followed by obstetric indicators. Next Experimental indicators are presented, also in 

alphabetical order; again, non-obstetric indicators are followed by obstetric indicators. 

For explanation of the isolation of obstetric indicators see the introduction to this chapter. 

The results for each Rejected indicator are found in Appendix F. 

Each indicator review follows the same pattern. First, a brief description of the 

indicator rationale is given followed by the final definition of the indicator. The definition 

shown reflects the suggested changes made by the panel. The original definitions 

presented to the panel may be found in Appendix I. The final definition is followed by 

the final post-conference call ratings for each indicator. These ratings are usually based 

on the definition provided. In cases where changes were made after the panel’s final 

rating, an explanation is included in the narrative. Finally, two sections describe the input 

of the panel. The first section, “Changes to the indicator” documents suggested and 

implemented changes to the definition and the rationale for each. Definitional changes 

included changes to both the complication of interest and the population at risk. The 

second section, “Concerns not addressable by changes” documents any concerns raised 

during the conference call and subsequent ratings about the indicator. 
81

Table 17. Indicators Reviewed by Panel Type 

Multi-specialty Panelb Surgical Panelb 

Indicatora 

Pre Conf. Call Post Conf. 

Call 

Pre Conf. 

Call 

Post Conf. 

Call 

Final 

Designationc

Aspiration pneumonia XXX XXX XXX XXX Experimental 

Birth trauma - injury to 

neonate XXX XXX Accepted 

CABG following PTCA XXX XXX Experimental 

Complications of anesthesiad XXX XXX XXX XXX Accepted 

Death in low mortality DRGs XXX XXX Accepted 

Decubitus ulcer XXX XXX Accepted 

Decubitus ulcer in high-risk 

patiente Experimental 

Dosage complications XXX XXX Rejected 

Failure to rescuef XXX XXX Accepted 

Foreign body left in during 

procedure XXX XXX XXX XXX Accepted 

Iatrogenic hypotension XXX XXX Rejected 

Iatrogenic pneumothorax XXX XXX Accepted 

Infection due to medical care XXX XXX Accepted 

In-hospital fractures possibly 

related to fallsg XXX Experimental 

Intestinal infection due to 

Clostridium difficile XXX XXX Rejected 

Intraoperative nerve 

compression injuriesi XXX XXX XXX Experimental 

Malignant hyperthermiaj XXX XXX XXX Experimental 

Obstetric thrombosis or 

embolism XXX XXX Rejected 

Obstetric trauma-cesarean 

section Accepted 

Obstetric trauma-vaginal with 

instrument Accepted 

Obstetric trauma- vaginal 

without instrument 

Obstetric 

traumak

Obstetric 

traumak

 Accepted 

Obstetric wound 

complications-cesarean 

section delivery 

XXX Experimental 

Obstetric wound 

complications-vaginal 

delivery 

Obstetric 

Wound 

Complicationsl 

XXX Experimental 

Other obstetric complications XXX XXX Experimental 

Postoperative acute 

myocardial infarction XXX XXX XXX XXX Experimental 

Postoperative hemorrhage or 

hematoma XXX XXX XXX XXX Accepted 

Postoperative iatrogenic 

complications-cardiac 

system 

 Experimental 

Postoperative iatrogenic 

complications-digestive Rejected 

Postoperative iatrogenic 

complications-nervous 

Postoperative 

iatrogenic 

complicationsm 

Postoperative 

iatrogenic 

complications

 Experimental 
82

Multi-specialty Panelb Surgical Panelb 

Indicatora 

Pre Conf. Call Post Conf. 

Call 

Pre Conf. 

Call 

Post Conf. 

Call 

Final 

Designationc

Postoperative iatrogenic 

complications-respiratory Rejected 

Postoperative iatrogenic 

complications-urinary Rejected 

Postoperative iatrogenic 

complications-vascular 

 

 Rejected 

Postoperative hip fractureh XXX Accepted 

Postoperative physiologic 

and metabolic derangements XXX XXX XXX XXX Accepted 

Postoperative pneumonia XXX XXX XXX XXX Rejected 

Postoperative respiratory 

failure XXX XXX XXX XXX Accepted 

Postoperative pulmonary 

embolism or deep venous 

thrombosis 

XXX XXX XXX XXX Accepted 

Postoperative sepsis XXX XXX Accepted 

Postoperative wound 

dehiscence XXX XXX XXX XXX Accepted 

Post-partum UTI XXX Experimental 

Puerperal infection XXX XXX Rejected 

Reopening of surgical site XXX XXX XXX XXX Experimental 

Suture of laceration XXX XXX XXX XXX Experimental 

Technical difficulty with 

procedure XXX XXX Accepted 

Transfusion reaction XXX XXX XXX XXX Accepted 

Unexpected LOS/ Conditional 

LOSn XXX XXX Rejected 

Uterine Ruptureo Experimental a

Obstetric and non-obstetric indicators are included in this table for ease of finding indicators on table. b

XXX denotes indicator was reviewed. 

c

Accepted and experimental indicators were empirically evaluated; rejected indicators were not. 

d

Multi-specialty panel suggested that this indicator be dropped and suggested two indicators (minor peri-operative physical injuries 

and malignant hyperthermia) in lieu of indicator. Surgical panel reviewed and revised original indicator. e

Indicator was created after clinical panel reviews based on panel suggestion, underwent empirical evaluation only. f

Clinicians on multi-specialty panel evaluated 2 failure to rescue indicators with different definitions. Both definitions were 

combined into the single "Failure to rescue" indicator following the conference call. g

Original indicator was titled "Postoperative hip fracture and fall" prior to conference call; the new indicator reflects suggested 

change of panel. h

Indicator was accepted in lieu of the suggested indicator due to difficulty operationalizing the suggested indicator “in-hospital 

fractures, possibly due to falls” i

Original indicator was titled "Minor-perioperative physical injury." Indicator name changed to "Intraoperative nerve compression 

injury" when corneal abrasion and lip laceration were eliminated from the definition. 

j

Indicator was created based on panel suggestion following discussion of “Complications of Anesthesia” indicator. k

Indicator was stratified according to delivery type following final rating due to panelist suggestions. l Indicator was stratified according to delivery type following initial rating due to panelist suggestions. mIndicator was split into 5 indicators, reflecting the individual complication codes included in the indicator. For the final rating, 

panelists were informed of the intention to split the indicator, but panelists provided only one rating. n

Multi-specialty panel reviewed 2 definitions, selecting “Unexpected LOS” for further consideration. o

Indicator was created after clinical panels reviewed the “Other obstetric complications” Indicator 
83

The review of each indicator includes the indicator name, description with rationale, 

definition, panel ratings and a summary of panel comments. More detailed specifications of 

indicators are documented in Appendix E. The six questions about aspects of the indicator (e.g., 

how preventable the complication is) were rated by panelists on a scale from 1 to 9, with the 

higher numbers relating to better patient safety measures, with one exception. In the case of the 

question related to how subject an indicator might be to bias (e.g., effects of case mix), a lower 

rating corresponds to a better patient safety indicator. Each rating table shows the panel median 

score, as well as the level of agreement, where “agreement” corresponds to little dispersion of 

opinion, “indeterminate” means that the opinion ranged but did not reach the point of clear 

“disagreement”, the final category where there were panelists with diametrically different 

opinions. Section 2D. Clinician Panel Review Methods provides details on agreement 

categorization. The indicators are organized according to final designation as accepted or 

experimental, with non-obstetric indicators preceding obstetric indicators. Indicators that were 

reviewed, but ultimately rejected can be found in Appendix F. 

 

Accepted Indicators 

Complications of Anesthesia 

This indicator is intended to flag cases of specific complications due to anesthesia that 

can be clearly identified using administrative data. Specifically, the final definition captures 

cases flagged by External Cause-of-Injury Codes (E-Codes) and complications codes for adverse 

effects from the administration of therapeutic drugs, and the overdose of anesthetic agents used 

primarily in therapeutic settings. 

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM diagnosis codes for [anesthesia complications] in 

any secondary diagnosis field per 100 discharges. 

Denominator All [surgical] discharges. 

Exclude patients with codes for poisoning due to anesthetics [E855.1, 968.1-4, 

968.7] AND any diagnosis code for [active drug dependence], [active 

nondependent abuse of drugs], or [self- inflicted injury]. 

Post-Conference Call Panel Ratingsa 

Question Median

 (MS) 

Agreement status 

 (MS) 

Median 

 (S) 

Agreement status 

(S) 

Overall rating Not Rated 7 Indeterminate 

Not present on admission Not Rated 5.3 Indeterminate 

Preventability Not Rated 7.5 Indeterminate 

Due to medical error Not Rated 7.3 Indeterminate 

Charting by physicians Not Rated 5.3 Indeterminate 

Bias (lower rating favorable) Not Rated 6.8 Disagreement a

Multi-specialty Panel – Surgical Complications 3 

Surgical Panel – Surgical Complications 3 
84

Multi-specialty Panel Results 

This panel agreed that this indicator should be dropped as originally defined. They 

suggested the creation of two alternate indicators related to complications of anesthesia: 

“Malignant hyperthermia” and “Minor perioperative injuries”. Thus, this indicator was not rated 

after discussion by this panel. 

Concerns not addressable by changes. This panel felt strongly that shock due to 

anesthesia was too nebulous of a diagnosis. This diagnosis varies widely depending on the 

charting and judgment, and this diagnosis may represent many varied physiological states. In 

addition, there was concern that shock was expected in certain situations, such as major 

abscesses. Finally, in many instances shock may not be clearly attributable to anesthesia, as it 

may have arisen from a variety of causes. The panel suggested this code be omitted. 

 The panel also expressed concern regarding the code for incorrect placement of 

endotrachial tube. Panelists were unsure what events would be assigned this code. They noted 

that in surgery, misplacement would be corrected immediately, and likely would not be charted. 

If the tube could not be placed correctly, the patient would be awakened. They noted that these 

few cases do not represent medical error. Indeed, they noted that true misplacement that resulted 

in harm to the patient does represent medical error, but they expressed skepticism over whether 

or not this code would be limited to those situations. 

 Panelists suggested several additional situations that could be monitored. A few 

situations, such as anoxic brain damage, did not have specific ICD-9-CM codes. Air embolism 

was included in another indicator. Suggestions for monitoring malignant hyperthermia and lip 

lacerations were included in new indicators. 

Surgical Panel Results 

Changes to the indicator. The surgical panel also expressed concern about the code for 

shock due to anesthesia. In addition to the concerns expressed by the multi-specialty panel, this 

panel specifically noted that shock may be labeled as hypotension instead of shock. They also 

noted that shock due to anesthesia is not always preventable. For these reasons, they suggested 

removing the code. 

 The panel suggested instead adding a variety of additional codes that may be used for 

reactions to and overdose of anesthetics. These codes include so-called “E-codes” for adverse 

effects of the administration of therapeutic drugs. Panelists did express concern that E-codes are 

not consistently coded, but agreed that they should be tracked nonetheless. Other codes included 

a series of codes representing accidental poisoning by anesthetics, limited to anesthetics that are 

not commonly used as recreational drugs, with specific exclusions to reduce the chance that 

poisoning was present on admission. 

 Concerns not addressable by changes. No other concerns were added. 

Summary Across Panels 

The two panels suggested different, almost entirely new, indicators, rejecting the original 

definition for this indicator. As a result all ratings were considered separately. The multispecialty panel created two indicators that were rated separately. The surgical panels revised the 

definition of this indicator, and rated its overall usefulness as relatively favorable. As such, this 

indicator was retained in the Accepted provider level indicator set. 
85

Panelists had concerns about the frequency of coding of these complications, especially 

since the use of E-codes is considered voluntary and appears to vary widely between providers. 

Plausibly a “reaction” may be described without attributing it to anesthetic. Another concern is 

that some of these cases would be present on admission (e.g., due to recreational drug use). 

Ideally, this indicator would be used with a coding designation that distinguishes conditions 

present on admission from those that develop in-hospital. However, this is not available in the 

administrative data used to define this indicator, and so this concern was addressed by 

eliminating codes for drugs that are commonly used as recreational drugs. While this does not 

eliminate the chance that these codes represent intentional or accidental overdose on the part of 

the patient, it should eliminate many of these cases. 

Death in Low Mortality Drgs 

This indicator is intended to identify in-hospital deaths in patients unlikely to die during 

hospitalization. The underlying assumption is that when patients admitted for an extremely lowmortality condition or procedure die, a health care error is more likely to be responsible. Patients 

experiencing trauma, or having an immunocompromised state or cancer are excluded, as these 

patients have higher non-preventable mortality. 

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator All discharges with disposition of "deceased" per 100 population at risk. 

Denominator Patients in DRGs with less than 0.5% mortality rate, based on NIS 1997 [low 

mortality DRG]. If a DRG is divided into "without/with complications" both 

DRGs must have mortality rates below 0.5% to qualify for inclusion. 

Exclude patients with any code for [trauma], [immunocompromised] state, or 

[cancer]. 

Post-Conference Call Panel Ratingsa

Question Median Agreement status 

Overall rating 7.5 Agreement 

Not present on admission Not applicable Not applicable 

Preventability 6 Indeterminate agreement 

Due to medical error 6 Indeterminate agreement 

Charting by physicians 9 Agreement 

Bias (lower rating is favorable) 4.5 Indeterminate agreement a

 Medical Complications 2 Multi-specialty Panel 

Changes to the indicator. Panelists suggested no changes to this indicator. 

Concerns not addressable through changes. Panelists expressed some concern 

regarding bias inherent in this indicator. Specifically, panelists noted that hospital case-mix may 

affect the rate of death in low mortality DRGs. Patients referred from skilled nursing facilities, 

those with certain comorbidities and older patients may be at higher risk of dying. Risk 

adjustment for comorbidities and age was highly advocated. Panelists also suggested that social 

factors play a role, with socio-economic status being correlated with many other risk factors that 
86

may affect the health and healing of the patient. Some panelists advocated for stratification by 

insurance status. Finally, panelists noted that some hospitals accept transfers from other 

hospitals. At times, these transfers are very appropriate, but sometimes the transfer occurs too 

late for the receiving hospital to prevent death. If these scenarios occur systematically, this 

indicator could be biased against referral centers. Panelists also expressed that hospital size may 

be a factor. Since deaths in these DRGs are rare, hospitals that have very few patients may be 

more affected by random variation. 

 Despite the concerns expressed regarding bias in the low mortality DRG indicator, 

panelists noted that this indicator was of great interest. Panelists noted that although many deaths 

in these DRGs are likely to be non-preventable and not due to medical error, that all deaths in 

low mortality DRGs should be subject to internal review, and that high rates may indicate a 

quality problem. However, panelists were quick to emphasize use of this indicator as a screening 

tool for internal quality improvement efforts. Given potential bias and questions about the extent 

of preventability, panelists advocated that this indicator not be subject to public reporting. 

Summary 

 

The overall usefulness of this indicator was rated as favorable by panelists, and as such it 

was retained in the Accepted provider level indicator set. To standardize the indicator, since the 

denominator of this indicator includes many heterogeneous patients cared for by different 

services, this indicator should be stratified by DRG type (i.e., medical, surgical, psychiatric, 

obstetric, pediatric) when used as an indicator of quality. 

Decubitus Ulcer 

This indicator is intended to flag cases of in-hospital decubitus ulcers. It is related to a 

complications indicator developed as part of the Complications Screening Program,7

 although it 

omits several of the original codes for cellulitis. In order to better screen out cases of decubitus 

ulcer that are present on admission, this indicator limits its definition of decubitus ulcer to 

secondary diagnoses (meaning decubitus ulcer was not labeled as the principal diagnosis). In 

addition, this indicator excludes patients that have a length of stay less than 4 days, as it is 

unlikely that a decubitus ulcer would develop within this period of time. Finally, this indicator 

excludes patients who are particularly susceptible to decubitus ulcer, namely patients with major 

skin disorders (MDC 9) and paralysis. 

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM code of 707.0 in any secondary diagnosis field per 

100 discharges.

Denominator All [medical] and [surgical] discharges. 

Include only patients with a length of stay of more than 4 days. 

Exclude patients in MDC 9 or patients with any diagnosis of [hemiplegia, 

paraplegia, or quadriplegia].

Exclude patients admitted from a [long term care facility]. 

 
87

Post-Conference Call Panel Ratingsa 

Question Median Agreement status 

Overall rating 8 Agreement 

Not present on admission 8 Agreement 

Preventability 8 Agreement 

Due to medical error 8 Agreement

Charting by physicians 7 Indeterminate agreement 

Bias (lower rating is favorable) 3 Indeterminate agreement a

 Medical Complications 1 Multi-specialty Panel 

Changes to the indicator. The original definition of this indicator was based on the 

Complications Screening Program.7 This included an exclusion for patients older than 80 years 

of age, since these patients may be more likely to have pre-existing decubiti. Panelists felt that 

this exclusion was undesirable, as it eliminates patients who should be monitored. Panelists 

instead suggested that patients admitted from a long-term care facility be excluded, as these 

patients may have an increased risk of having decubiti present on admission. 

 The original definition included only patients with a length of stay of 10 days or more, to 

better ensure that the decubiti developed within the admission in question. Panelists agreed that 

this length of stay was too long, limiting the indicator to only the most ill patients. Instead, 

panelists agreed to limit the indicator to patients with length of stay to 4 days or more, a 

limitation utilized for this indicator in a study by Needleman et al.137

 Concerns not addressable through changes. Most panelists had few concerns 

regarding this indicator. In general panelists felt that this complication was preventable, and in 

many cases reflects medical error, although a small number of cases may not be preventable. 

One panelist suggested that little published evidence exists regarding practices that providers 

may adopt to reduce decubitus ulcer rates. 

 Some panelists had minimal concern that reporting of decubiti may vary by providers. 

Specifically, staging of decubitus ulcers affects the charting of the complication, with earlier 

stage ulcers reported more variably than later stage ulcers. Nurses were noted to be more vigilant 

than physicians in reporting ulcers; however, nursing notes are not considered when assigning 

ICD-9-CM diagnosis codes. In addition, some facilities routinely screen for decubitus ulcers as 

part of quality improvement programs, while other facilities do not. Hospitals that screen would 

have an artificially high rate of ulcers as compared to other hospitals. If this concern is 

demonstrated in reality, than this indicator may be somewhat biased. 

 A final source of potential bias is case mix. Panelists noted that very ill patients may be at 

higher risk for developing decubiti, and therefore hospitals that care for sicker patients may have 

higher rates of this complication. In addition, one panelist noted that since patients admitted from 

long-term care facilities are excluded, that hospitals admitting more patients from these facilities 

may appear better than other facilities. 

 Although panelists chose to retain the exclusion of high risk patients, many panelists 

expressed interest in tracking decubiti in a higher risk population. It was felt that bias may result 

from adding these patients to the population at risk. On the other hand, the high risk population is 

one for which vigilance of the treatment team should be high and may have a substantial effect. 

They suggested, that if possible in the future, that high risk patients also be tracked separately. 
88

An indicator for this purpose was added to the experimental set because of its face validity, but 

need for further testing. 

 

Summary 

The overall usefulness indicator was rated as very favorable by panelists. Although 

panelists felt that this complication most often reflected medical error, concerns regarding the 

systematic screening for ulcers and reliability of coding, especially for early stage ulcers brought 

into question that assertion. Thus, this indicator appears to be best used as a rate based indicator, 

despite its high rating on the medical error question. This indicator was retained in the Accepted 

provider level indicator set. 

 This indicator includes pediatric patients. Pressure sores are very unusual in children, 

except among the most critically ill children (who may be paralyzed to improve ventilator 

management) and children with chronic neurologic problems. 

Failure To Rescue 

This indicator is intended to identify patients that die following the development of a 

complication. The underlying assumption is that good hospitals may not be able to prevent 

complications, but they identify these complications quickly and treat them aggressively to 

prevent adverse sequelae, such as death. The original definition of this indicator was developed 

by Silber et al.31 and was based on clinical data, focusing on complications of cardiac surgery 

that were serious and often non-preventable. Jack Needleman and colleagues, in a recent study, 

operationalized failure to rescue using administrative data only, across a wide range of surgical 

and medical patients.137 Needleman’s list of complications was closely related to the 

complications defined in the Complications Screening Program.7 These complications include 

exclusions designed to avoid counting patients with the complication present on admission. In 

this definition, Needleman used patients identified under his modified definition as having a 

serious iatrogenic complication as the population at risk. Patients that transferred to or from 

another hospital are excluded. Patients admitted from a long-term facility are also excluded. 

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator All discharges with disposition of "deceased" per 100 population at risk.

Denominator Discharges with potential complications of care listed in [failure to rescue]

definition (i.e., pneumonia, DVT/PE, sepsis, acute renal failure, shock/cardiac 

arrest, or GI hemorrhage/acute ulcer). Exclusion criteria specific to each 

diagnosis. 

Exclude patients [transferred to acute care facility]. 

Exclude patients [transferred from acute care facility]

Exclude patients admitted from a [long-term care facility].
89

Post-Conference Call Panel Ratingsa 

Question Median Agreement status 

Overall rating 7 Agreement 

Not present on admission 7 Indeterminate agreement 

Preventability 5 Agreement 

Due to medical error 5 Indeterminate agreement 

Charting by physicians 8 Agreement 

Bias (lower rating is favorable) 4 Disagreement a

Medical Complications 2 Multi-specialty Panel 

Changes to the indicator. Panelists were asked for additional suggestions of 

complications to be included in the denominator of this indicator. Panelists unanimously 

suggested that acute renal failure be added. 

 Panelists expressed concern regarding patients with “do not resuscitate” (DNR) status. In 

cases where this DNR status is not a direct result of poor quality of care, it would be contrary to 

patient desire and poor quality of care to rescue a patient. In addition, very old patients, or 

patients with advanced cancer or human immunodeficiency virus (HIV) may not desire or may 

be particularly difficult to rescue from these complications. As a result, several changes were 

suggested for this indicator. These changes include the stratification of this indicator by age, such 

that patients over 75 years may be examined separately from younger patients. In addition, 

panelists suggested the exclusion of patients admitted from long term care facilities. Although 

these changes do not directly nor completely address panelist concerns, they may improve ability 

to interpret results. 

 Panelists also noted that transfer practices may play a role in this indicator. As patients 

that develop some complications may be transferred to more specialized hospitals, referral 

centers may not always be able to rescue that patient, particularly if the transfer occurs too late. 

In this case the referral care center would appear to have poorer quality than the hospital in 

which the complication arose in the first place. Thus, patients who have been transferred to or 

from another acute care facility are also excluded from this indicator. 

 Concerns not addressable through changes. Panelists expressed some concern over 

the validity of this indicator, although it was eventually accepted by panelists for inclusion. Some 

panelists wanted to see additional validity work on the concept that failure to rescue is a valid 

marker of quality of care. Others were concerned that although the concept may be valid, that it 

would be very difficult to operationalize this indicator well, with varied definitions of 

complications, difficulty ascertaining whether the complication occurred in-hospital, and the lack 

of adjustment for the many factors that influence the ability and appropriateness of the hospital 

to rescue a patient from these complications. 

 Panelists noted that several adverse incentives may be introduced by implementing this 

indicator. In particular, since some type of adjustment may be desirable, this indicator may 

encourage the upcoding of complications and comorbidities to inflate the denominator or 

manipulate risk adjustment. Others noted that this indicator could encourage irresponsible 

resource use and allocation, although this is likely to be a controversial idea. Finally, panelists 

emphasized that this indicator should be used internally by hospitals, as it is not validated for 

public reporting. 
90

Summary 

 The overall usefulness of this indicator was rated favorably and as such it is included in 

the Accepted provider level indicator set. However, this indicator may be fundamentally 

different than other indicators reviewed in this report, as it may reflect different aspects of 

quality of care (effectiveness in rescuing a patient from a complication versus preventing a 

complication). For this reason, this indicator has been considered separately from other 

indicators in this report. 

 This indicator includes children. It is important to note that children beyond the neonatal 

period inherently recover better from physiological stress and thus may have a higher rescue rate. 

Foreign Body Left in During Procedure 

This indicator is intended to flag cases of a foreign body accidentally left in body during 

a procedure. It is based on an indicator developed as part of the Complications Screening 

Program,7

 although all codes are considered sentinel events in that system. The indicator is 

defined both on the area level by including all cases, and on the hospital level by restricting cases 

to those flagged by a secondary diagnosis or procedure code. 

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for [foreign body left in during procedure]

in any secondary diagnosis field per 100 surgical discharges.

Denominator All [medical] and [surgical] discharges.

Post-Conference Call Panel Ratingsa 

Question Median 

(MS) 

Agreement status 

(MS) 

Median 

(S) 

Agreement status 

(S) 

Overall rating 8 Agreement 7 Indeterminate 

Not present on admission 8 Agreement 7 Agreement 

Preventability 8 Agreement 7.5 Agreement 

Due to medical error 8 Agreement 7 Indeterminate 

Charting by physicians 7 Agreement 8 Indeterminate 

Bias (lower rating favorable) 3.5 Indeterminate 4 Indeterminate a

Multi-specialty Panel – Surgical Complications 2 

Surgical Panel – Surgical Complications 2 

Multi-specialty Panel Results 

Changes to the indicator. Panelists were queried regarding the addition of the code for 

the removal of foreign body from the peritoneal cavity. This code may include some foreign 

bodies accidentally left in during abdominal surgery when the physician has not specified that 

the foreign body was not accidentally left in, or the coder chooses to use this code instead of the 

998 code. This procedure code was included in Iezonni’s CSP.7

 Panelists agreed that this code 
91

would also pick up some important events, although this code does not specify that the foreign 

body must be left in accidentally. 

 Concerns not addressable by changes. Panelists noted that each case of foreign body 

left in during procedure needed examination. Some automated systems do report this 

complication when a foreign body is actually left in intentionally. In addition, other cases may 

require a foreign body to remain. As some codes do not specify that the foreign body must 

accidentally be left in the body during procedure, some of these foreign bodies may be left in the 

patient intentionally. This code can be used when a granuloma occurs from a suture accidentally 

left in the body. Panelists agreed that such granulomas are substantially different in terms of 

morbidity from other foreign bodies accidentally left in during a procedure. They recommended 

that the percentage of suture granulomas be ascertained when using this indicator. 

Some patients seem to be more likely to have foreign bodies left in during a procedure. 

Although panelists agreed that these patients (e.g., trauma) should not be excluded, except in the 

case of removal of foreign body from the abdominal cavity (e.g., possible gun shots). Panelists 

suggested that users of this indicator examine these cases closely. Panelists suggested that this 

indicator be adjusted for emergency surgery or type of procedure. 

Surgical Panel Results 

Changes to the indicator. Panelists suggested no changes to this indicator. 

 Concerns not addressable by changes. Panelists, especially orthopedic surgeons, noted 

that some foreign bodies are left in on purpose. This occurs frequently, such as when a k-wire or 

a drill bit breaks off during a procedure. To remove the foreign body may cause more damage 

than to leave it in. In this case, surgeons felt that the foreign body did not reflect a medical error. 

The panelists felt that this indicator should be stratified or risk adjusted for the type of procedure. 

Panelists were concerned about the coding of this indicator. Specifically, this coding requires the 

physician to note that the foreign body was accidentally left in. There was concern that this 

additional information would not always be reported. Because of this situation, some physicians 

have a higher rate than others. Therefore, physicians who do not specify that a foreign body was 

left in accidentally would not be flagged by this indicator. Panelists also noted that some foreign 

bodies left in do not cause substantial morbidity, although the foreign body may be removed, 

resulting in a diagnosis code or an E-code. Some foreign bodies do not represent a clinically 

significant complication. 

Panelists noted that the population at risk included both medical and surgical patients, but 

not all of these patients are at risk. The panelists felt that limiting to surgical patients would 

decrease the sensitivity of this indicator substantially. However, it should be made clear that not 

all patients in the denominator are actually at risk. Therefore, some hospitals may appear to have 

a lower rate if they have less medical patients who have undergone invasive procedures. 

The surgical panel was also queried about removing the code related to removal of 

foreign body from peritoneal cavity. However, this panel felt that the category was too broad, 

and could easily include a number of cases where no foreign body was left in. For this reason, 

they suggested that this code not be included. 

Summary Across Panels 

Both panels believed that this indicator was useful in identifying cases of a foreign body 

left in during a procedure. They suggested that since this indicator was likely to yield few cases, 
92

that each case identified be examined carefully by the hospital. Since both panels did not agree to 

add the code for removal of foreign bodies in the peritoneal cavity, this code was not included. 

Given the favorable rating of the overall usefulness of this indicator, it is included in the 

Accepted provider level indicator set. An area level analog of this indicator was included in the 

Accepted area level indicator set. 

Iatrogenic Pneumothorax 

This indicator is intended to flag cases of pneumothorax caused by medical care. The 

area level indicator is intended to capture all cases of iatrogenic pneumothorax, not only those 

occurring in-hospital. The provider level indicator is restricted to secondary diagnosis of 

iatrogenic pneumothorax, and is intended to flag cases occurring during the hospitalization. To 

exclude patients that may be more susceptible to non-preventable iatrogenic pneumothorax, or 

patients with miscoded traumatic pneumothorax, this indicator excludes all trauma patients. 

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk

Numerator Discharges with ICD-9-CM code of 512.1 in any diagnosis field per 100 

discharges.

Denominator All discharges. 

Exclude patients with any diagnosis of [trauma]. 

Exclude patients with any code indicating [thoracic surgery] or [lung or pleural 

biopsy] or assigned to [cardiac surgery].

 

Post-Conference Call Panel Ratingsa 

Question Median Agreement status 

Overall rating 7.5 Agreement 

Not present on admission 8 Agreement 

Preventability 8 Agreement 

Due to medical error 8 Agreement 

Charting by physicians 7 Indeterminate agreement 

Bias (lower rating is favorable) 3 Indeterminate agreement a

Procedural Complications 1 Multi-specialty Panel 

Changes to the indicator. The original definition of this indicator included all patients, 

surgical and medical. Panelists noted that pneumothorax can arise from different causes, 

primarily as a result of a procedure, or from barotrauma in ventilated patients. They noted that 

although ventilator management matters, pneumothorax arising from barotrauma is much less 

straightforward than that arising from procedures such as central line placement. Thus, panelists 

suggested that the indicator would better reflect quality of care, if it were restricted to patients 

receiving a central line, Swan-Ganz catheter, or thorocentesis (see summary paragraph below, as 

this change was ultimately removed). 
93

 Pneumothorax is an expected complication of some procedures, namely thoracic surgery 

and pleural or lung biopsy. Panelists felt that these patients should be excluded, since 

pneumothorax may not be preventable in those patients. 

 Concerns not addressable through changes. Panelists noted that pneumothorax is a 

good marker of operator skill. In particular, panelists postulated a clear “July effect” of increased 

rates when new residents begin performing such procedures. 

A few panelists noted that it would be helpful to know the exact procedure associated 

with the pneumothorax, specifically the approach of the central line placement (e.g., subclavian, 

jugular). Panelists did express concern that some patients with a recorded central line placement 

may also be ventilated. In this case it would be impossible to tell from administrative data 

whether the complication arose from the central line placement procedure or from barotrauma. 

 Finally, it should be noted that this indicator includes Peripherally Inserted Central 

Catheter (PICC) line placement as well as central line placement, due to coding constraints. 

Panelists felt that this was not of concern. They noted that an appropriate replacement of use of 

central line access with PICC lines might occur to some degree as a result of implementing this 

indicator. 

Summary 

 Panelists rated the overall usefulness of this indicator favorably, although the definition 

rated included the suggested denominator, limited to patients receiving a central line, Swan-Ganz 

catheter or thorocentesis. However, exploratory empirical analyses found that this denominator 

was not reliably defined using administrative data, as these procedures appeared to be underreported. Thus, the ratings reported reflect a definition that could not be operationalized, and 

must be considered in that context. Although the panelists noted that this complication, given the 

definition rated, reflected medical error, the actual final definition of this indicator includes cases 

which may be less reflective of medical error. Specifically, this indicator includes patients in 

whom a pneumothorax resulted from barotrauma, including patients with acute respiratory 

distress syndrome. Thus, this indicator may not as clearly detect medical error as suggested by 

the panel ratings. 

 Panelists expressed concern that some approaches of placing a central line (e.g., 

subclavian) may be more likely to result in pneumothorax than other approaches (e.g., internal 

jugular). However, other complications, such as complications of the carotid artery would be 

more common with internal jugular approaches. Thus, if providers simply change approach they 

may have a decrease in pneumothorax, but an increase in other unmeasured complications. 

 This indicator includes children, which was not discussed by panelists. It should be noted 

that the smaller anatomy of children may increase the technical complexity of these procedures 

in this population (especially among neonates). However, these procedures are less likely to be 

performed in this population in unmonitored settings. 

 Given the high overall rating of the indicator, and the great interest in identifying this 

complication, this indicator was included in the Accepted provider level indicator set. An area 

level analog of this indicator was included in the Accepted area level indicator set. 

Infection Due to Medical Care 

This indicator is intended to flag cases of infection due to medical care, specifically those 

related to IV lines and catheters. As an area indicator, it is intended to capture all cases of such 
94

infection, not only those that occur in-hospital. Defined as a hospital level indicator, it captures 

cases based on secondary diagnosis, and is therefore limited to those infections associated with 

the same hospitalization. This indicator excludes patients with potential immunocompromised 

states (e.g., AIDS, cancer, transplant), as they may be more susceptible to such infection. 

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk

Numerator Discharges with ICD-9-CM code of 999.3 or 996.62 in any diagnosis field per 

100 discharges.

Denominator All [medical] and [surgical] discharges. 

Excludes patients with any diagnosis code for [immunocompromised] state or 

[cancer].

Post-Conference Call Panel Ratingsa 

Question Median Agreement status 

Overall rating 8 Indeterminate agreement 

Not present on admission 7 Indeterminate agreement 

Preventability 7 Indeterminate agreement 

Due to medical error 6 Indeterminate agreement

Charting by physicians 7 Agreement 

Bias (lower rating is favorable) 3.5 Indeterminate agreement a

 Medical Complications 1 Multi-specialty Panel 

Changes to the indicator. The original definition of this indicator included several ICD9-CM codes representing infections that may arise as a result of medical care, including 

intravenous (IV) and catheter infections and infection due to contaminated or infected blood or 

other substance. Panelists felt that these two codes identified two very different complications 

and should not be combined. They felt that the former code, which focused on IV and catheter 

infections, was most useful for quality improvement, while the latter code is likely to be very 

rare and poorly reported. For this reason, panelists agreed that this indicator should only include 

the code for "other infection due to medical care," focusing on IV and catheter infections. A 

second code was added after consultation with a coding specialist, as this code also is used to 

denote catheter infections. 

 Panelists expressed that the existing exclusion criteria for this indicator needed revision. 

The original definition excluded trauma patients, as these patients may be at a higher risk for 

these types of infection. The panel agreed unanimously that these patients should be tracked and 

therefore included in the population at risk. Panelists did feel that immunocompromised patients 

were at a higher risk of developing these complications, and that these infections may be less 

preventable in this population. Therefore, the panel agreed to exclude immunocompromised 

patients from the population at risk. 

 Concerns not addressable through changes. Panelists noted that while many of these 

infections are preventable, even with the best of care, there is a normal underlying rate of these 

infections. Panelists also expressed concern over the charting of this indicator. Panelists noted 

that charting of these infections is likely to be varied, and reflect differences in documenting 
95

clinically less significant infections, or the aggressiveness of treating such infections. Despite the 

potential of bias due to charting or under-reporting, panelists for the most part felt that these 

complications were important to track. Finally, as with other indicators tracking infections, 

concern regarding the potential overuse of prophylactic antibiotics remains. 

Summary 

 Panelists rated the overall usefulness of this indicator favorably, and they expressed 

particular interest in tracking IV and catheter related infections. This indicator was retained as in 

the Accepted provider level indicator set. An area level analog of this indicator was included in 

the Accepted area level indicator set. 

 This indicator includes children and neonates, which was not specifically discussed by 

panelists. It should be noted that high-risk neonates are at particularly high risk for catheterrelated infections. 

Postoperative Hemorrhage and Hematoma 

This indicator is intended to flag cases of hemorrhage or hematoma following a surgical 

procedure. It is based on an indicator developed as part of the Complications Screening 

Program.7

 This indicator limits hemorrhage and hematoma codes to secondary procedure and 

diagnosis codes in order to isolate those hemorrhages that can truly be linked to a surgical 

procedure. For the same reason, this indicator eliminates all procedures to control hemorrhages 

that take place before the principal procedure. To ensure that the reported hematoma or 

hemorrhage is a clinically significant complication, such diagnoses must be accompanied by a 

procedure code, indicating clinical intervention. 

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for [postoperative hemorrhage] or

postoperative hematoma] in any secondary diagnosis field AND code for 

postoperative [control of hemorrhage] or [drainage of hematoma] 

(respectively) in any secondary procedure code field per 100 surgical discharges. 

Procedure code for postoperative control of hemorrhage or hematoma must occur 

on the same day or after the principal procedure.

Denominator All [surgical] discharges. 

Exclude all obstetric admissions (MDC 14 and 15).
96

Post-Conference Call Panel Ratingsa 

Question Median 

(MS) 

Agreement status 

(MS) 

Median 

(S) 

Agreement status 

(S) 

Overall rating 7 Indeterminate 7 Agreement 

Not present on admission 8 Agreement 8 Agreement 

Preventability 8 Agreement 6 Indeterminate 

Due to medical error 4.5 Indeterminate 5 Agreement 

Charting by physicians 7 Agreement 8 Agreement 

Bias (lower rating favorable) 5 Disagreement 3 Disagreement a

Multi-specialty Panel – Surgical Complications 1 

Surgical Panel – Surgical Complications 1 

Multi-specialty Panel Results 

Changes to the indicator. Panelists did not suggest any changes to this indicator to 

address concerns. 

Concerns not addressable through changes. Panelists noted that risk of developing 

postoperative hemorrhage or hematoma differs in complicated and uncomplicated cases. They 

suggested that an exclusion be added for patients with coagulopathies or for those on 

anticoagulant medication. However, this exclusion cannot be adequately implemented using 

administrative data. They suggested that this indicator be risk adjusted, rather than using 

exclusions of complicated cases. This panel felt that examining the overall rate followed by 

further investigations would be more useful than creating a homogenous denominator of 

uncomplicated cases. This panel noted that postoperative hemorrhage and severe hematoma are 

captured frequently because they require a return to the operating room. However, some 

panelists expressed that during the re-operative procedure, it is often difficult to find the source 

of the hemorrhage. They questioned whether or not surgical technique influenced the rate of 

postoperative hemorrhage or hematoma. Overall, this panel deferred to the surgical specialists in 

reviewing this indicator. 

Surgical Panel Results 

Changes to the indicator. The panelists noted that seromas are often clinically 

insignificant complications. They expressed that this complication is not of interest and should 

be removed from the indicator. The panel also noted that some hematomas may be insignificant, 

but that those requiring a procedure are highly significant and should be tracked. The panelists 

expressed the desire to have any diagnosis code linked to a procedure for drainage of hematoma.

The procedure for drainage of hematoma is not specific to hematoma but may also include 

draining of other fluids, including abscesses or seromas. Because of this non-specificity of 

procedure codes, all procedure codes must be paired with a diagnosis code for hemorrhage or 

hematoma in order to be included in this indicator. Panelists felt that this specification would 

limit the flagged complications to those reflecting higher morbidity of patients. 

 Concerns not addressable through changes. Surgical panelists noted that post-surgical 

hemorrhage or hematoma occurs in non-surgical patients undergoing invasive procedures such as 

those undergoing PTCA or cardiac catheterization. They noted that this is an important 
97

population that is not covered by this indicator. They also noted that additional patients would be 

missed if they were admitted for hematoma after an outpatient surgery or if they were discharged 

before the hemorrhage or hematoma occurred and then readmitted to the hospital. Panelists felt 

that these patients were particularly import to track. However, the administrative data used in this 

project do not allow for tracking readmissions, or admissions after outpatient surgery. Panelists 

noted that some patients may be at higher risk for developing a postoperative hemorrhage or 

hematoma. Specifically, like the multi-specialty panel, the surgical panel was concerned about 

patients with coagulopathies, and those on anticoagulants. They suggested that where possible, 

this indicator be stratified for patients with underlying clotting differences. They also noted that 

patients admitted for trauma may be at a higher risk for developing postoperative hemorrhage or 

may have a hemorrhage diagnosed that occurred during the trauma. They also suggest that this 

indicator be stratified for trauma and non-trauma patients. 

Summary Across Panels 

Because the multi-specialty panelists suggested further surgical input for this indicator, 

the changes to definitions suggested by the surgical panel were implemented. The ratings of the 

surgical panelists were considered more valid, and resulted in the indicator being included in the 

Accepted provider level indicator set. 

Postoperative Hip Fracture 

In-Hospital Fractures Possibly Related To Falls 

(Initially reviewed: “In-hospital hip fracture and fall”; see Summary below) 

This indicator is intended to flag cases of in-hospital fracture, specifically hip fractures 

for one version of the indicator, and a broader group of fractures possibly related to falls for 

another version of the indicator. It is related to an indicator developed as part of the 

Complications Screening Program.7 This indicator limits diagnosis codes to secondary diagnosis 

codes in order to eliminate fractures that were present on admission. It further excludes patients 

in MDC 8 (musculoskeletal disorders) and patients with indications for trauma or cancer, or 

principal diagnoses of seizure, syncope, stroke, coma, cardiac arrest, or poisoning, as these 

patients may have a fracture present on admission. 

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM code for [fracture] in any secondary diagnosis field 

per 100 surgical discharges.

Denominator All [surgical] discharges. 

Exclude all patients with diseases and disorders of the musculoskeletal system 

and connective tissue (MDC 8). 

Excludes patients with principal diagnosis codes for [seizure], [syncope], 

[stroke], [coma], [cardiac arrest], [anoxic brain injury], [poisoning], 

[delirium or other psychoses], [trauma], [minor trauma and/or physical 

abuse], indication of [alcohol or drug abuse], or [self-inflicted injury].

Exclude patients with any diagnosis of [metastatic cancer], [lymphoid 

malignancy] or [bone malignancy]. 

Exclude patients 17 years of age or younger. 
98

Post-Conference Call Panel Ratingsa 

Question Median Agreement status 

Overall rating 8 Agreement 

Not present on admission 7 Indeterminate agreement 

Preventability 8 Agreement 

Due to medical error 7 Indeterminate agreement

Charting by physicians 8 Agreement 

Bias (lower rating is favorable) 3 Indeterminate agreement a

Medical Complications 1 Multi-specialty Panel

Changes to the indicator. Panelists noted the following:

In-hospital falls. Panelists expressed concern that physicians would variably report inhospital falls. Therefore, providers who record falls less would appear to have higher quality, 

without actually having lower rates of falls. In addition, panelists were concerned that the 

definitions of "fall" may vary. Although coding conventions require that any recorded fall result 

in a medical intervention or injury, that intervention could be screening x-rays or other 

procedures. Panelists were concerned that some clinically insignificant falls would be variably 

reported. Overall, panelists agreed unanimously that falls should not be tracked in this indicator, 

and these codes were removed. 

Expansion of tracked fractures. Panelists agreed that in-hospital hip fractures were severe 

complications that increase patient morbidity and resource consumption. Panelists also reported 

that many preventable falls and injuries in hospitals do not result in hip fractures, but other types 

of fractures, including other extremity fractures. Panelists agreed that all fractures occurring in 

the hospital setting were important to track. This indicator specification was expanded to include 

all types of fractures. (However, empirical testing of this specification revealed a 

disproportionate number of fractures in younger men, raising the concern that the administrative 

data exclusions were not adequately limiting the population at risk, as these fractures seemed 

more likely to occur as a result of trauma rather than in-hospital falls. Thus, it was felt that this 

change could not be implemented. As a result, the panel ratings, which were clearly based on the 

indicator measuring in-hospital fractures, would be more applicable to the “In-hospital fracture 

possibly related to falls” Experimental indicator which shows increasing prevalence with 

increasing patient age, as expected.) 

Addition of exclusions. In response to the final questionnaire, panelists suggested that 

patients with delirium may be at higher risk for having fractures present on admission. In 

response, patients with a principal diagnosis of delirium were excluded from the population at 

risk. In addition, panelists noted that patients with lymphoma or bone cancer are at a higher risk 

for non-preventable fractures in-hospital. These patients were also excluded from the population 

at risk for both of the empirically tested indicator definitions (i.e., in-hospital hip fracture on the 

accepted indicator set, and in-hospital fractures possibly related to falls on the experimental 

indicator set). 

Concerns not addressable through changes. After implementing the changes listed 

above, a few relatively minor concerns remained. Panelists rated this indicator very well, despite 

these concerns. Several panelists expressed a desire to expand the population at risk to medical 
99

patients in addition to surgical patients. This change was not implemented based on data reported 

by Iezzoni et al.15 in relation to their "In-hospital hip fracture and fall" indicator. They reported 

that only 11% of "flagged" cases of in-hospital hip fracture in medical patients actually 

represented true cases of this complication, with most of the "false positives" representing 

fractures that were present on admission. On the other hand, 51%-71% of "flagged" cases in 

surgical patients represented true occurrences of in-hospital hip fractures and falls. To minimize 

the number of "false positive" cases, we chose to limit this indicator to surgical patients, who are 

less likely to have such a fracture present on admission (given our exclusions to the population at 

risk). 

 Panelists did express that given the occurrence of an in-hospital fracture, some of these 

fractures may not be preventable by good quality care. Fractures may be more likely in the aged 

and frail population, who have weaker bones, and are more vulnerable to falls. This may result in 

some slight bias for this indicator for hospitals that care for more of these patients. Finally, in the 

effort to prevent some falls, adverse effects may occur. One panelist expressed concern that 

deconditioning may be a particularly dangerous side effect of efforts to reduce fractures by 

decreasing the mobilization of elderly patients. 

Summary 

Although this indicator was initially presented as "In-hospital hip fracture and fall," 

panelists unanimously suggested that falls should be eliminated from this indicator and that all 

in-hospital fractures should be included. The resulting indicator implemented both of these 

changes, and was termed "In-hospital fracture possibly related to falls." The exclusion of 

children was added after empirical analysis revealed that children did not have a substantial 

number of cases in the numerator. Ratings are reported for this specification. However, the “Inhospital hip fracture” indicator was selected for inclusion in the Accepted provider level 

indicator set, as a subset of the preferred specification of a broader group of fractures related to 

in-hospital falls. The more inclusive fracture indicator was retained on the Experimental 

indicator set because of both its potential usefulness and its need for further validation to assure 

restriction to the intended group of patients who likely experience in-hospital fall. 

 

Postoperative Physiologic and Metabolic Derangements 

This indicator is intended to flag cases of selected postoperative metabolic or physiologic 

complications. It is based on an indicator developed as part of the Complications Screening 

Program.7

 The population at risk is limited to elective surgical patients, as patients undergoing 

non-elective surgery may develop less preventable derangements. In addition, each diagnosis has 

specific exclusions, designed to reduce the number of flagged cases in which the diagnosis was 

present on admission or was more likely to be non-preventable. 

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for [physiologic and metabolic 

derangements] in any secondary diagnosis field per 100 surgical discharges. 

Discharges with acute renal failure (subgroup of physiologic and metabolic 

derangements) must be accompanied by a procedure code for dialysis (39.95, 

54.98).
100

Denominator All [elective] [surgical] discharges. 

Exclude patients with both a diagnosis code of ketoacidosis, hyperosmolarity or 

other coma (subgroups of physiologic and metabolic derangements coding) AND 

a principal diagnosis of [diabetes].

Exclude patients with both a secondary diagnosis code for acute renal failure 

(subgroup of physiologic and metabolic derangements coding) AND a principal 

diagnosis of [acute myocardial infarction], [cardiac arrhythmia], [cardiac 

arrest], [shock], [hemorrhage] or [gastrointestinal hemorrhage].

Exclude all obstetric admissions (MDC 14 and 15).

Post-Conference Call Panel Ratingsa

Question Median 

(MS) 

Agreement status 

(MS) 

Median 

(S) 

Agreement status 

(S) 

Overall rating 8 Indeterminate 6.8 Indeterminate 

Not present on admission 7.5 Indeterminate 7 Indeterminate 

Preventability 7 Indeterminate 6 Disagreement 

Due to medical error 6 Indeterminate 5.3 Disagreement 

Charting by physicians 7 Indeterminate 7 Indeterminate 

Bias (lower rating favorable) 6 Indeterminate 3.5 Indeterminate a

Multi-specialty panel – Surgical Complications 3 

Surgical panel – Surgical Complications 3 

Multi-specialty Panel Results 

Changes to the indicator. The multi-specialty panel suggested several changes to this 

indicator. First, they agreed that diabetic comas be added in addition to diabetic ketoacidosis. 

They noted that hyperosmolar coma is less clearly medical error than hypoglycemic coma, but 

that both should be tracked. They also supported the addition of hyponatremia to the indicator, 

suggesting that appropriate fluid management should prevent this complication when it is 

clinically severe. They conceded that both minor and major hyponatremia would be caught by 

this indicator, and noted that further investigation would be needed to examine only the severe 

cases. Finally, this panel supported the removal of shock from this indicator, noting that this 

diagnosis is nebulous and subject to interpretation. Thus, it is impossible to know what 

physiological state exactly is represented by this code. 

 In addition to changes in the numerator, this panel supported the limitation of the 

population at risk to elective surgery patients. This panel felt that only these patients could be 

appropriately screened and managed preoperatively in an effort to prevent these complications. 

Patients admitted emergently or urgently may not have the same opportunity for assessment, and 

thus complications in these patients may be less preventable. 

 Concerns not addressable through changes. Panelists noted that the coding of some 

metabolic and physiologic complications may be lacking. Specifically they noted that if the 

episode is relatively transient, such as in some cases of diabetic ketoacidosis, then the physician 

may not code the episode. In other cases, some physicians may be quite vigilant in recording 

small physiologic disturbance, such as minor oliguria, resulting in the capture of non-clinically 
101

significant events in this indicator. Similarly, they noted that acute renal failure is a vague 

diagnosis, and that use of specific creatinine levels would be a better indicator of renal failure. 

Surgical Panel Results 

Changes to the indicator. The surgical panel suggested most of the same changes 

supported by the multi-specialty panel, for similar reasons, and some additional changes. 

Panelists supported the removal of shock and addition of diabetic comas, as well as the limitation 

of the population at risk to elective surgical patients. However, the panel did not support the 

addition of hyponatremia. They noted that most hyponatremia is clinically insignificant, and does 

not constitute a serious adverse event. They further argued that a diagnosis of hyponatremia 

represents a variety of severities and that it was impossible to distinguish easily which events 

were clinically significant. 

 Panelists expressed similar concerns about oliguria and anuria as they did about 

hyponatremia. They expressed that oliguria is difficult to define and in many patients difficult to 

prevent. The varied preventability and definitions introduce extreme bias to this indicator. For 

this reason, they argued that these codes be dropped from the indicator. Acute renal failure also 

suffers from the problem of varied definitions. What one doctor calls acute renal failure, another 

may not. In addition, the inclusion of this code may help to shift patients to a higher paying 

DRG, increasing its use artificially. To ensure that the only renal failure cases that are picked up 

are those that are clinically severe, this panel suggested that acute renal failure be included only 

when it is paired with a procedure code for dialysis. 

 Finally, panelists questioned the exclusion of MDC 8. This exclusion was included to 

exclude patients with hemodialysis who are at increased risk of developing acute renal failure 

which is not due to medical error. However, panelists felt that this exclusion was too broad and 

did not really identify patients who were at increased risk for acute renal failure after surgery 

which is not due to medical error. 

 Concerns not addressable through changes. No additional concerns were discussed 

during the conference call. 

Summary Across Panels 

The two indicators proposed by each panel differed substantially in their definitions. For 

this reason it was necessary to select a definition. The inclusion of hyponatremia could not 

adequately be specified, as it was difficult to exclude patients that are at a high risk of developing 

this complication. The multi-specialty panel also expressed similar concerns over oliguria and 

acute renal failure as the surgical panel, although they did not feel as strongly about these 

concerns. Because these concerns were expressed by both panels, we chose the most 

conservative indicator, that proposed by the surgical panel. This indicator is included in the 

Accepted provider level indicator set, given the high overall rating of the indicator. 

This indicator includes children, which was not specifically discussed by the panel. It 

should be noted that the incidence of these complications is a function of the underlying 

prevalence of diabetes and renal impairment which are less common among children than among 

adults. 
102

Postoperative Respiratory Failure 

(formerly Postoperative pulmonary compromise) 

This indicator is intended to flag cases of Postoperative respiratory failure, specifically 

respiratory failure. It is based on an indicator developed as part of the Complications Screening 

Program.7 This indicator limits the code for respiratory failure to secondary diagnosis codes in 

order to eliminate respiratory failure that was present on admission. It further excludes patients 

who have major respiratory or circulatory disorders, as these patients may have respiratory 

failure present on admission, or may be more likely to develop such compromise after surgical 

procedures. This indicator also limits the population at risk to elective surgery patients, as these 

patients were judged to be at a lower risk for non-preventable complications. 

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for acute respiratory failure (518.81) in any 

secondary diagnosis field per 100 surgical discharges.

Denominator All [elective] [surgical] discharges. 

Exclude patients with respiratory or circulatory diseases (MDC 4 and MDC 5). 

Exclude all obstetric admissions (MDC 14 and 15)

Post-Conference Call Panel Ratingsa 

a

Multi-specialty panel – Surgical Complications 2 

Surgical panel – Surgical Complications 2 

Multi-specialty Panel Results 

Changes to the indicator. The panel suggested that only acute respiratory failure and 

acute edema of lung, unspecified be used. These complications were felt to be the only 

complications from the original definitions that are more likely to be preventable, and for which 

variations in rates might be meaningful in reference to the quality of care. 

 Panelists felt that the population at risk should be limited to patients undergoing elective 

surgical procedures, as complications in these patients were felt to be more preventable 

compared with non-elective surgery cases. In addition, panelists suggested that trauma patients 

should be excluded, as some pulmonary complications are expected in the course of treatment 

for trauma. 

Question Median 

(MS) 

Agreement status 

(MS) 

Median 

(S) 

Agreement status 

(S) 

Overall rating 6.5 Indeterminate 7 Indeterminate 

Not present on admission 6.5 Indeterminate 8 Agreement 

Preventability 6 Indeterminate 6 Indeterminate 

Due to medical error 4.5 Agreement 4 Agreement 

Charting by physicians 6 Indeterminate 8 Agreement 

Bias (lower rating favorable) 6 Indeterminate 6 Indeterminate 
103

Concerns not addressable by changes. Panelists noted that this indicator is “messy,” in 

that even with the more conservative definition, preventability of these complications in some 

patients is dubious. Further, panelists expressed concern that the clinical definition of these 

complications may vary from provider to provider. 

Surgical Panel Results 

Changes to the indicator. Panelists felt that only acute respiratory failure should be 

retained in this indicator. They noted that this is a clinically significant event that is at least 

partially preventable. ICD-9-CM coding guidelines state "Respiratory failure is a life-threatening 

disorder that requires close patient monitoring and evaluation, with aggressive management 

usually requiring placement of the patient in a monitored bed, aggressive respiratory therapy, 

and/or mechanical ventilation."166

 Panelists felt that mechanical ventilation is a hard clinical endpoint, and thus, there 

would be less variation in the severity of the conditions captured by this indicator. All other 

codes in the original indicator definition were considered to be either less preventable or 

nebulous as to their clinical significance, and thus were eliminated. 

 The surgical panel agreed that the population at risk should be limited to elective surgical 

patients for similar reasons as the multi-specialty panel. 

 Concerns not addressable by changes. Panelists expressed concern that acute 

respiratory failure is affected by case mix and type of surgery. For instance, patients undergoing 

hepatic resections or patients that are immunocompromised or malnourished may be more likely 

to develop these complications. As a result, this indicator may be subject to some bias. 

Summary Across Panels 

Both panels rated the overall usefulness of this indicator as relatively favorable. The 

surgical panel proposed a more conservative indicator than the multi-specialty panel. Since it 

was beyond the scope of our study to inquire of the multi-specialty panel regarding the more 

conservative definition, the more conservative definition was retained as an Accepted provider 

level indicator. 

Postoperative Pulmonary Embolism or Deep Venous Thrombosis

This indicator is intended to flag cases of postoperative venous thromboses and 

embolism, specifically pulmonary embolism (PE) and deep venous thromobosis (DVT). It is 

closely related to an indicator developed as part of the Complications Screening Program.7

 This 

indicator limits vascular complications codes to secondary diagnosis codes in order to eliminate 

complications that were present on admission. It further excludes patients who have principal 

diagnosis of DVT, as these patients are likely to have had PE/DVT present on admission. 
104

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for [deep vein thrombosis] or [pulmonary 

embolism] in any secondary diagnosis field per 100 surgical discharges.

Denominator All [surgical] discharges. 

Exclude patients with a principal diagnosis of [deep vein thrombosis].

Exclude all obstetric admissions (MDC 14 and 15). 

Exclude patients with secondary procedure code 38.7 when this procedure occurs 

on the day of or previous to the day of the principal procedure.

Panelists suggested that this indicator be reported for PE and DVT separately. Thus, this 

indicator would be reported by the software as three rates - the overall thromboembolism rate, 

the PE rate, and the DVT rate (all other codes). Panelists felt that the reporting of PE and DVT 

separately would allow users to distinguish rates which may be higher than expected due to 

routine postoperative screening for DVT, or other differences in diagnostic methods. 

Post-Conference Call Panel Ratingsa 

Question Median 

(MS) 

Agreement status 

(MS) 

Median 

(S) 

Agreement status 

(S) 

Overall rating 7 Indeterminate 7 Agreement 

Not present on admission 7 Indeterminate 7 Agreement 

Preventability 7 Indeterminate 6 Disagreement 

Due to medical error 6 Indeterminate 3 Indeterminate 

Charting by physicians 7 Indeterminate 7 Indeterminate 

Bias (lower rating favorable) 5 Indeterminate 6.5 Indeterminate a

Multi-specialty panel – Surgical Complications 1 

Surgical Panel – Surgical Complications 1 

Multi-specialty Panel Results 

Changes to the indicator. Panelists expressed concern about the code for venous 

embolism, and thrombosis of the vena cava. Panelists felt that these complications were not 

preventable through the same mechanisms as the other diagnoses included in the definition (e.g., 

pulmonary embolism, phlebitis and thrombophlebitis, femoral vein or other deep vessels, etc.). 

Although some vena cava thromboses may result from intra vena cava (IVC) filters, the panel 

was concerned that the pathophysiology of thrombosis in this setting is quite different, and that 

the decision to place an IVC involves a difficult balancing of risks and benefits. For this reason 

the code for venous embolism of thrombosis of the vena cava was removed from the definition 

of this indicator. 

Concerns not addressable through changes. There were no other additional concerns 

regarding this indicator expressed during the conference call. 
105

Surgical Panel Results 

Changes to the indicator. This panel expressed concerns regarding the code for 

phlebitis for venous embolism and thrombosis of the vena cava. They felt that the data on IVC 

filters were still inconclusive and that venous embolism and thrombosis of the vena cava 

represented a different type of complication than the other codes. They recommended that the 

code for venous embolism of thrombosis of the vena cava be deleted from the indicator 

definition. 

Panelists were concerned that reporting pulmonary embolism and deep venous 

thrombosis together may be misleading. Panelists noted that, although in many cases pulmonary 

embolism and deep venous thrombosis are simply different manifestations of the same 

complication, deep vein thrombosis is reported more variably. Several panelists noted that some 

hospitals routinely screen patients for deep vein thrombosis, while others do not. In addition, 

deep vein thrombosis is diagnosed by various methods. While some providers require ultrasound 

verification, others require clinical symptoms in order to diagnose deep vein thrombosis. These 

differences in diagnosis may lead to bias for this indicator. For this reason, panelists suggested 

that this indicator include reporting of three rates: the overall thrombosis embolism and the 

pulmonary embolism rate together, the pulmonary embolism rate alone, and the deep vein 

thrombosis embolism rate alone. This suggestion will be incorporated into the final software for 

this indicator. 

Concerns not addressable through changes. It is widely documented that the risk for 

DVT/PE varies greatly according to the type of procedure performed. As clotting is more 

common in peripheral orthopedic procedures, these surgeries have a higher postoperative 

vascular complication rate than other types of surgeries. Panelists noted, that because of this 

difference in underlying risk for deep vein thrombosis or pulmonary embolism, that this indicator 

should be adjusted or stratified according to surgical procedure types. Panelists also noted that 

despite varying causes for developing DVT/PE that preventative techniques currently exist and 

the proper use of these techniques should reduce the rate of venous thrombosis or pulmonary 

embolism. Panelists did note that the literature surrounding preventative techniques is limited to 

deep vein thrombosis and may or may not be generalized to pulmonary embolism. 

Summary Across Panels 

Both panels rated the overall usefulness of this indicator relatively highly as compared to 

other indicators. Panelists expressed interest in tracking for the DVT/PE in surgical patients. 

They noted that preventative techniques should decrease the rate of this indicator. Both 

recommended the same changes to the indicator. The surgical panel also suggested reporting of 

pulmonary embolism and deep vein thrombosis separately in the software. This indicator was 

retained in the Accepted provider level indicator set. 

This indicator includes children, which was not specifically discussed by our panelists. It 

should be noted that in the absence of specific thrombophilic disorders, postoperative 

thromboembolic complications in children are most likely to be secondary to venous catheters 

rather than venous stasis in the lower extremities. 
106

Postoperative Sepsis 

This indicator is intended to flag cases of nosocomial Postoperative sepsis. It is closely 

related to a complications indicator developed as part of the Complications Screening Program.7

In order to better screen out cases of sepsis that are present on admission this indicator limits its 

definition of sepsis to secondary diagnoses (meaning sepsis was not labeled as the principal 

diagnosis). In addition this indicator excludes patients that have principal diagnoses of infection, 

as it is likely that these patients may have developed sepsis due to these infections, and patients 

which had a length of stay less than 3 days, as it is unlikely that nosocomial sepsis may have 

developed in such a short time. This indicator limits the population at risk to patients only with 

certain medical conditions, as these patients are not at as high a risk for sepsis as other patients 

(e.g., patients that have undergone procedures of a contaminated structure). Finally, this indicator 

excludes patients who are particularly susceptible to non-preventable sepsis, namely patients 

with potential immunocompromised states (e.g., Acquired Immune Deficiency Syndrome 

(AIDS), cancer, transplant). 

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM code for [sepsis] in any secondary diagnosis field per 

100 discharges in the population at risk.

Denominator All [elective] [surgical] discharges. 

Exclude patients with a principal diagnosis of [infection], or any code for 

[immunocompromised] state, or [cancer].

Include only patients with a length of stay of more than three days. 

Exclude all obstetric admissions (MDC 14 and 15).

Post-Conference Call Panel Ratingsa

Question Median Agreement status 

Overall rating 8 Indeterminate agreement 

Not present on admission 8 Agreement 

Preventability 6.5 Agreement 

Due to medical error 6 Indeterminate agreement

Charting by physicians 8 Agreement 

Bias (lower rating is favorable) 3 Indeterminate agreement a

 Medical Complications 1 Multi-specialty Panel

Changes to the indicator. The original definition of this indicator, based on Iezzoni et 

al.’s CSP,7

 limited the population at risk to patients in certain MDCs and DRGs for which it was 

judged that sepsis would be a potentially preventable complication. Panelists felt that this 

population at risk was too broad, and may include patients that either had sepsis present on 

admission, or patients with conditions predisposing patients to sepsis. In addition, this definition 

excluded some patients for which sepsis would be preventable. Panelists agreed that limiting this 

indicator to all surgery patients undergoing elective surgery was a better way to capture patients 
107

for which sepsis is a potentially preventable complication, primarily through pre-surgical 

screening and appropriate prophylactic therapy. 

Concerns not addressable through changes. Panelists expressed few additional 

concerns regarding this indicator during the conference call and the subsequent evaluation. Some 

concern was expressed over the varying clinical definitions of "sepsis." Providers may have 

different thresholds and methods of diagnosing a patient as septic, leading to some bias for this 

indicator. Some panelists also expressed that this complication was less of a concern than other 

complications rated, and that it would be very rare in the population at risk. Finally, two panelists 

expressed concern about increased inappropriate antibiotic use resulting from the implementation 

of this indicator. 

Summary 

 Panelists rated the overall usefulness of this indicator favorably, although they were less 

sure that this complication was reflective of medical error. Given the overall rating, this indicator 

was retained in the Accepted provider level indicator set. 

 This indicator includes children, which was not specifically discussed by the panel. It 

should be noted that high-risk neonates are at particularly high risk for catheter-related 

infections. 

Postoperative Wound Dehiscence in Abdominopelvic Surgical Patients 

This indicator is intended to flag cases of wound dehiscence in patients who have 

undergone abdominal and pelvic surgery. The area level indicator is intended to capture all cases 

of wound dehiscence, not only those occurring in-hospital. The hospital level indicator is 

restricted to secondary diagnoses, and is intended to capture cases occurring during the same 

hospitalization. 

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for reclosure of postoperative disruption of 

abdominal wall (54.61) in any secondary procedure field per 100 discharges.

Denominator All [abdominopelvic] surgical discharges. 

Exclude all obstetric admissions (MDC 14 and 15).

Post-Conference Call Panel Ratingsa 

Question Median 

(MS) 

Agreement status 

(MS) 

Median 

(S) 

Agreement status 

(S) 

Overall rating 7.5 Indeterminate 7 Indeterminate 

Not present on admission 7.5 Indeterminate 8 Agreement 

Preventability 6 Agreement 7 Indeterminate 

Due to medical error 6 Agreement 5 Indeterminate 

Charting by physicians 7 Agreement 8 Indeterminate 

Bias (lower rating favorable) 4 Indeterminate 7 Indeterminate a

Multi-specialty panel – Surgical Complications 2 

Surgical panel – Surgical Complications 2 
108

Multi-specialty Panel Results 

Changes to the indicator. Panelists felt that the diagnosis code for postoperative wound 

disruption would include both minor and severe wound dehiscence, without a means of 

distinguishing between the two. Panelists felt that a majority would be clinically insignificant 

minor dehiscences, and preferred to limit the indicator to cases in which a procedure was 

performed. 

 Panelists felt that cancer patients should not be excluded, as most of these patients are not 

at a significant increased risk for the development of non-preventable wound dehiscence. 

Concerns not addressable by changes. Panelists reported that the risk of developing 

wound dehiscence varies with patient factors such as age and comorbidities. If these factors 

varied systematically by institution, this indicator could be subject to some bias. 

Surgical Panel Results 

Changes to the indicator. Panelists suggested the removal of the diagnosis code for 

postoperative wound disruption for similar reasons as the multi-specialty panel. As a result, the 

only code left was limited to abdominal and pelvic surgical patients, and the population at risk 

was modified to reflect this. 

 The surgical panel suggested that trauma, cancer, and immunocompromised patients be 

included as they were interested in tracking these patients, and felt that these patients would not 

add a sufficient amount of false positives to raise concern. These groups could be examined more 

closely on further evaluation of this indicator. 

Concerns not addressable by changes. Like the multi-specialty panel, the surgical 

panel noted that patient health is an important factor underlying the risk of developing 

postoperative wound dehiscence. Patients with comorbidities and older patients may be at higher 

risk. 

Summary Across Panels 

Both panels suggested similar indicators, although the surgical panel suggested that the 

indicator include trauma, cancer, and immunocompromised patients. The surgical panel 

definition was retained in the Accepted provider level indicator set. An area level analog of this 

indicator was included in the Accepted area level indicator set. 

Technical Difficulty With Procedure 

This indicator is intended to flag cases of complications that arise due to technical 

difficulties in medical care, specifically those involving an accidental puncture or laceration. It is 

based on an indicator developed as part of the Complications Screening Program.7

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM code denoting [technical difficulty] (e.g., accidental 

cut, puncture, perforation or laceration during a procedure) in any secondary 

diagnosis field per 100 discharges.

Denominator All [medical] and [surgical] discharges. 

Exclude all obstetric admissions (MDC 14 and 15).
109

Post-Conference Call Panel Ratingsa 

Question Median Agreement status 

Overall rating 7 Agreement 

Not present on admission 8 Agreement 

Preventability 7 Agreement 

Due to medical error 6 Indeterminate agreement 

Charting by physicians 6 Indeterminate agreement 

Bias (lower rating is favorable) 5 Indeterminate agreement a

 Procedural Complications 1 Multi-specialty Panel 

Changes to the indicator. The original definition of this indicator included several 

complications that could arise from difficulty in performing a procedure, including failure of 

sterile precautions, performance of an inappropriate operation, emphysema arising from a 

procedure, cataract fragments in the eye following cataract surgery, and air embolism. However, 

panelists felt that most of these codes were of questionable clinical significance, variably 

reported, and not of interest for inclusion in this indicator. As a result, panelists suggested 

retaining only the two codes for accidental puncture, cut, perforation or hemorrhage during a 

procedure. 

Concerns not addressable through changes. Panelists noted that even with the retained 

codes, reporting is likely to be variable. Some panelists felt that only major situations are likely 

to be coded, and that this may be appropriate. However, it is unclear how the culture of quality 

improvement in a hospital would affect the coding of this complication. Some physicians may be 

reluctant to record the occurrence of this complication for fear of punishment. Panelists also 

noted that some of these occurrences are not preventable. However, panelists noted that a high 

rate may be indicative of poor quality of care. 

Summary 

 Panelists rated the overall usefulness of this indicator favorably, although they were less 

sure that this complication was reflective of medical error. Given the overall rating, this indicator 

was retained in the Accepted provider level indicator set. 

 This indicator includes children, which was not specifically discussed by the panel. It 

should be noted that the smaller anatomy of children may increase the technical complexity of 

procedures. 

Transfusion Reaction 

This indicator is intended to flag cases of major reactions due to transfusions (ABO and 

Rh). The area level indicator is intended to capture all cases of transfusion reactions, not only 

those occurring in-hospital. The hospital level indicator is restricted to patients who have a 

secondary diagnosis of transfusion reaction, as is intended to flag cases occurring during 

hospitalization. 
110

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for [transfusion reaction] in any secondary 

diagnosis field per 100 discharges.

Denominator All [medical] and [surgical] discharges. 

Post-Conference Call Panel Ratingsa 

Question Median 

(MS) 

Agreement status 

(MS) 

Median 

(S) 

Agreement status 

(S) 

Overall rating 8 Agreement 7.8 Agreement 

Not present on admission 7 Agreement 7.5 Agreement 

Preventability 7 Disagreement 8 Indeterminate 

Due to medical error 7 Indeterminate 5.3 Disagreement 

Charting by physicians 8 Indeterminate 7.5 Agreement 

Bias (lower rating favorable) 6 Disagreement 2.5 Agreement a

Multi-specialty Panel – Surgical Complications 3 

Surgical Panel – Surgical Complications 3 

Multi-specialty Panel Results 

Changes to the indicator. Panelists expressed concern that the code 999.8, “other 

transfusion reaction,” was nebulous and may include reactions caused by minor antigens in 

patients with complex hematologic histories who may have been sensitized by multiple prior 

transfusions. These complications were seen as less preventable than Rh or ABO incompatability 

reactions, and clinically different. For this reason this panel suggested that this code be removed 

from this indicator. 

Panelists also noted that while trauma patients may be at higher risk for developing 

transfusion reactions, as it may be occasionally appropriate to use blood without cross-matching, 

reactions in these patients should be monitored and may be preventable. For this reason panelists 

suggested that trauma patients be added to the population at risk, but that this subgroup should be 

examined closely.

Concerns not addressable through changes. No other concerns were reported by this 

panel. 

Surgical Panel Results 

Changes to the indicator. The surgical panel suggested the same changes to this 

indicator as the multi-specialty panel for similar reasons. 

Concerns not addressable through changes. No other concerns were reported by this 

panel. 

Summary Across Panels 

Both panels rated the overall usefulness of this indicator highly and suggested similar 

changes to the definition. The indicator is part of the Accepted provider level indicator set. An 

area level analog of this indicator was included in the Accepted area level indicator set. 
111

This indicator only includes those events which actually result in additional medical care. 

Thus, near misses and errors in which no harm or little harm results are not included in this 

indicator. Some minor reactions may be missed, although the panel suggested that these minor 

reactions are less clearly due to medical error than the Rh or ABO reactions included in the 

indicator. 

Accepted Obstetric Indicators 

Birth Trauma – Injury to Neonate 

This indicator is intended to flag cases of birth trauma for infants born alive in a hospital. 

It excludes patients born pre-term, as birth trauma in these patients may be less preventable than 

for full-term infants. 

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for [birth trauma] in any diagnosis 

field per 100 liveborn births.

Denominator All [liveborn] infants. 

Exclude infants with a subdural or cerebral hemorrhage (subgroup of birth 

trauma coding) AND any diagnosis code of [pre-term infant] (denoting a 

birth weight of less than 2,500 g and less than 37 weeks gestation). 

Exclude infants with injury to skeleton (767.3, 767.4) AND any diagnosis 

code of osteogenesis imperfecta (756.51).

Post-Conference Call Panel Ratingsa 

Question Median Agreement status 

Overall rating 8 Agreement 

Not present on admission 8 Agreement 

Preventability 7 Indeterminate agreement 

Due to medical error 6 Disagreement 

Charting by physicians 7 Indeterminate agreement 

Bias (lower rating is favorable) 4 Indeterminate agreement a

 Obstetric Complications of Delivery 1 Panel

 

 Changes to the indicator. Panelists felt that injury to the brachial plexus often includes 

injuries that are transient and minor, and therefore may be reported variably. Thus, they 

suggested removing this code. 

 Panelists suggested two specific exclusions. First, they suggested that pre-term infants 

with low birth weight be excluded from the population at risk for intracranial hemorrhage, due to 

concern that some of these injuries would not be preventable in pre-term infants, who have very 

fragile bridging veins and may also be at risk for hypoxic injury. Second, they suggested that 

infants with osteogenesis imperfecta be excluded from the population at risk for injury to 

skeleton, as these complications are not preventable in these infants. 
112

Concerns not addressable through changes. Panelists noted that some infants are 

prone to birth injuries, such as babies with shoulder dystocia or large babies. Panelists suggested 

that predicting these types of deliveries is difficult, and such complications in these babies are 

often not preventable. Panelists also felt that patients with no or little prenatal care should be 

treated differently than those with prenatal care. However, these patients cannot be accurately 

identified using administrative data. 

Summary 

Panelists felt that this indicator was very useful. Although it may not indicate medical 

error, it does capture potentially preventable complications. It should be noted that panelists were 

particularly conflicted about the ability of this indicator to detect medical error, with some 

panelists feeling that it clearly does and others that it clearly does not. Given the relatively high 

overall rating, this indicator was retained as part of the Accepted provider level indicator set. 

Obstetric Trauma (All Delivery Types Reviewed in One Indicator) 

This indicator is intended to flag cases of potentially preventable trauma during delivery 

in women delivering during the index hospitalization. 

Final Definition: Obstetric Trauma - Vaginal With Instrument 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for [obstetric trauma] in any diagnosis or procedure 

field per 100 instrument assisted vaginal deliveries.

Denominator All [vaginal delivery] discharges with any procedure code for [instrument assisted 

delivery].

Final Definition: Obstetric Trauma - Vaginal Without Instrument 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for [obstetric trauma] in any diagnosis or 

procedure field per 100 instrument assisted vaginal deliveries.

Denominator All [vaginal delivery] discharges. 

Exclude [instrument assisted delivery]. 

Final Definition: Obstetric Trauma - Cesarean Section 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for [obstetric trauma] in any diagnosis or 

procedure field per 100 cesarean deliveries.

Denominator All [cesarean delivery] discharges.

Post-Conference Call Panel Ratingsa 

Question Median Agreement status 

Overall rating 7 Indeterminate agreement 

Not present on admission Not applicable Not applicable 

Preventability 7 Agreement 

Due to medical error 5 Disagreement 

Charting by physicians 8 Agreement 

Bias (lower rating is favorable) 4 Indeterminate agreement a

 Obstetric Complications of Delivery 1 Panel
113

Changes to the indicator. The original definition of this indicator included both 3rd and 

4th degree lacerations. Panelists, citing some evidence, felt that 3rd degree lacerations are variably 

reported, and thus rates would be more reflective of reporting than of the actual rate. If reporting 

were standardized, panelists were interested in retaining 3rd degree lacerations, but as 

standardization cannot be guaranteed with administrative data, this indicator was limited to 4th

degree lacerations as well as other major lacerations. 

 Panelists noted that the risk of trauma varies substantially by delivery type, and that 

indications for different modes of delivery may vary systematically between hospitals. Thus, 

panelists suggested that this indicator be split into 3 different indicators – vaginal delivery 

without instrument, instrument assisted delivery, and cesarean section. 

Concerns not addressable through changes. Panelists noted that while this indicator is 

of use (with one panelist dissenting), it is not a pure indicator of medical error. Many cases of 

trauma will not be preventable, but an unusually high rate would be worth investigating for 

potential quality problems. Specifically, panelists noted that overuse of episiotomy, may be 

associated with high rates of obstetrical trauma. 

 Panelists noted that the obstetrical trauma rate is best interpreted in the context of 

additional data. Notably, since providers may shift more patients to cesarean sections rather than 

perform instrument assisted deliveries, which may increase trauma rates, a provider’s cesarean 

section rate should be monitored simultaneously. In addition, providers may want to interpret 

this indicator in the context of epidural anesthesia rate and perinatal mortality. 

Summary 

Panelists rated the overall usefulness of this indicator favorably, although they suggested 

that this indicator be stratified. Panelists rated this indicator as one entity, although it was 

eventually split into three indicators: vaginal delivery with instrument, vaginal delivery without 

instrument, and cesarean section. Given the high overall rating, all three indicators were retained 

as part of the Accepted provider level indicator set. Also, a JCAHO 3rd and 4th degree laceration 

indicator was tested in the empirical analyses as part of the Experimental indicator set. 

Experimental Indicators 

Aspiration Pneumonia 

This indicator is intended to flag cases of perioperative aspiration pneumonia. It is based on an 

indicator developed as part of the Complications Screening Program,7

 although this indicator 

adds two “E-codes”. This indicator limits aspiration pneumonia codes to secondary diagnosis 

codes in order to eliminate aspiration pneumonia that was present on admission. It further 

excludes patients with a primary diagnosis of seizure, trauma, drug overdose or poisoning, as 

these patients may have aspiration pneumonia or a precursor condition present on admission. 
114

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for [aspiration pneumonia] in any secondary 

diagnosis field per 100 surgical discharges.

Denominator All [elective] [surgical] discharges. 

Exclude patients with a principal diagnosis of [seizure], [trauma], [drug 

overdose], or [poisoning]. 

Exclude all obstetric admissions (MDC 14 and 15).

Post-Conference Call Panel Ratingsa 

Question Median 

(MS) 

Agreement status 

(MS) 

Median 

(S) 

Agreement status 

(S) 

Overall rating 6 Indeterminate 6.5 Indeterminate 

Not present on admission 7 Agreement 8 Indeterminate 

Preventability 6 Indeterminate 6 Indeterminate 

Due to medical error 6 Disagreement 5.3 Indeterminate 

Charting by physicians 7 Indeterminate 5.3 Agreement 

Bias (lower rating favorable) 5 Indeterminate 3 Indeterminate a

Multi-specialty panel – Surgical Complications 3 

Surgical panel – Surgical Complications 3 

Multi-specialty Panel Results 

Changes to the indicator. The panel suggested that the population at risk may be too 

broad, as patients undergoing emergent or urgent surgery may not have adequate time before 

surgery to screen patients for risk factors, including having food matter in the stomach. These 

patients are more susceptible to aspirating perioperatively. For this reason, this panel suggested 

the population at risk be limited to patients undergoing elective surgery only. 

 Concerns not addressable through changes. Panelists expressed concern about the 

diagnosis of this complication. Different physicians diagnose pneumonia differently, with some 

relying on clinical factors such as chest x-ray and sputum analysis, and others requiring 

broncoscopy to verify the diagnosis. In addition, some physicians may not label the pneumonia 

as due to “aspiration” but simply as pneumonia. Panelists noted that such differences may lead to 

bias for this indicator. 

 Panelists also noted that the preventability of aspiration pneumonia varies depending on 

the timing of the aspiration. Aspirations occurring during surgery and in the recovery room are 

often preventable using preoperative interventions. Pneumonia resulting from these aspirations 

may be further preventable through administration of medications peri-operatively. However, 

aspirations that occur later in a hospitalization, for instance in an intensive care unit while a 

patient is intubated, are less preventable. Because it is impossible to distinguish the timing of the 

complication using administrative data, this concern cannot be addressed through changes to the 

indicator definition. 
115

Surgical Panel Results 

Changes to the indicator. The surgical panel suggested limiting the population at risk to 

patients undergoing elective surgery for similar reasons as the multi-specialty panel. They also 

added that even with the exclusions of trauma, seizure, drug overdose and poisoning patients that 

it is impossible to tell whether patients admitted emergently or urgently aspirated before 

admission or perioperatively.

 Concerns not addressable through changes. The surgical panel also expressed concern 

regarding the diagnosis of aspiration pneumonia for similar reasons as the multi-specialty panel. 

Also like the multi-specialty panel, the surgical panel expressed concern about the varied 

preventability of this complication. They suggested, in addition, that the timing of the aspiration 

be tracked carefully, if at all possible. They expanded that elderly and highly medicated patients 

are more likely to aspirate later in a hospitalization. 

 

Summary Across Panels 

Both panels expressed equivocation about this indicator. While the idea of tracking 

preventable aspiration pneumonia was of interest, the panels expressed skepticism about whether 

or not it can be done with administrative data. Both panels suggested the same revisions to this 

indicator, which are incorporated in the definition of this indicator. The overall rating of this 

indicator did not meet criteria for full acceptance, and thus this indicator was retained only in the 

Experimental indicator set. 

CABG Following PTCA 

This indicator is intended to flag cases where CABG follows a PTCA in the same 

hospitalization, presumably due to complications of that procedure. This indicator was adapted 

from several published studies, which used CABG after PTCA to examine operator proficiency 

in relation to procedure volume. 127-134, 160 

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for [CABG] in any procedure field per 100 

discharges with PTCA in any procedure field. 

CABG must occur on the same day or the day after the PTCA procedure.

Denominator All discharges with ICD-9-CM code for [PTCA] in any procedure field.

Post-Conference Call Panel Ratingsa 

Question Median Agreement status 

Overall rating 7 Agreement 

Not present on admission Not reported Not reported 

Preventability Not reported Not reported 

Due to medical error Not reported Not reported 

Charting by physicians Not reported Not reported 

Bias (lower rating is favorable) Not reported Not reported a

Procedural Complication 1 Multi-specialty Panel 
116

Summary 

Overall this indicator was rated as useful, although the panelists were interested in having 

more cardiologists consulted. The only cardiologist on the panel rated the indicator as very poor. 

As the other panelists do not perform or care for PTCA patients, and since we were unable to 

review this indicator with a panel of cardiologists, we assigned this indicator as to the 

Experimental indicator set, requiring further review. The remaining results from the multispecialty panel are not reported due to panelists’ concerns about rating this indicator. 

 The denominator for this indicator includes children that receive PTCA, however, this is 

rare, except in the setting of underlying coronary artery anomalies or cardiac transplantation. 

Decubitus Ulcer in High Risk Patients 

(See “Decubitus ulcer” in Accepted indicators section. This Experimental indicator was not rated 

by panelists.)

In-Hospital Fractures Possibly Related to Falls 

(See “In-hospital hip fracture” in Accepted indicators section.) 

Intraoperative Physical Injuries 

(Re-named to: “Intraoperative nerve compression injuries,” after exclusion of corneal abrasions 

and lip lacerations) 

This indicator is intended to flag cases of minor physical trauma caused by the handling 

of patients in the peri-operative period, particularly the unconscious and/or anesthetized patient. 

Trauma patients are excluded as these patients may have such complications on admission. 

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM code for [nerve compression injuries] AND a 

diagnosis code of 997.09 in any secondary diagnosis field per 100 surgical 

discharges.

Denominator All [surgical] discharges. 

Exclude patients with a principal diagnosis of [trauma].

Exclude patients with a principal diagnosis of [disorders of the peripheral 

nervous system] or [dorsopathies]. 

Post-Conference Call Panel Ratingsa 

Question Median 

(MS) 

Agreement status 

(MS) 

Median 

(S) 

Agreement status 

(S) 

Overall rating 8 Agreement 8 Agreement 

Not present on admission 7 Agreement 8 Agreement 

Preventability 8 Agreement 8 Agreement 

Due to medical error 7 Agreement 5 Disagreement 

Charting by physicians 7 Agreement 5 Indeterminate 

Bias (lower rating favorable) 5 Disagreement 4 Indeterminate a

Multi-specialty panel – Surgical Complications 3 

Surgical panel – Surgical Complications 1 
117

Multi-specialty Panel Results

 This indicator was suggested by the multi-specialty panel in lieu of the complications of 

anesthesia. It was not rated in the initial evaluation, and was briefly discussed for 

operationalization reasons during the conference call. The panelists suggested that lip 

lacerations, corneal abrasions and brachial plexopathy be used as complications of surgery. 

Surgical Panel Results 

Changes to the indicator. The surgical panel felt that superficial injuries to the cornea 

were not of interest to track, as they are temporary and clinically less significant injuries. In 

addition, this panel suggested that potentially minor lip lacerations be eliminated, leading to the 

elimination of the code for uncomplicated open wound to the lip. 

 The surgical panel suggested that additional nerve compression injuries, such as injuries 

to the ulnar nerve, as they felt that these injuries are important to track as well. 

Concerns not addressable through changes. Panelists felt that if these injuries could 

be accurately detected, it would be of great interest to track. They noted that these injuries, while 

they often resolve, are distressing to patients, and rather preventable. Panelists did suggest 

however, that some of these injuries would not be reliably charted by the physician. 

Summary Across Panels 

 Both panels agreed that the indicator captured complications that affected the patient, and 

that were likely to be preventable with careful patient handling. The indicator was slated for the 

Accepted indicator set, but further information about specification based on coding input raised 

concerns. For example, lip laceration could not be reliably detected through administrative data, 

leading to the renaming of this indicator to better reflect the remaining codes, nerve compression 

injuries. In addition, corneal abrasions were included in the specification rated by the panelists, 

but ophthalmology specialists would need to be consulted to assess the face validity of including 

this complication. Concerns about charting from the panelists, along with coding conventions 

related to a relatively new pertinent code used in the indicator (997.09) resulted in demoting the 

indicator to the Experimental indicator set. 

 Recent evidence has suggested that patient factors, such as previous subclinical nerve 

dysfunction, may play a large role in nerve compression injuries.167 In exploring this indicator, 

attention should be paid to the potential preventability of these complications. In addition, these 

conditions are much less common among children than among adults. 

Malignant Hyperthermia 

This indicator is intended to flag cases of malignant hyperthermia. Cases of trauma are 

excluded, as these patients may be more susceptible to complications. 
118

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for malignant hyperthermia (995.86) in any 

diagnosis field per 100 surgical discharges.

Denominator All [surgical] discharges. 

Exclude all obstetric admissions (MDC 14 and 15).

Post-Conference Call Panel Ratingsa

Question Median 

(MS) 

Agreement status 

(MS) 

Median 

(S) 

Agreement status 

(S) 

Overall rating 7 Agreement 7.5 Indeterminate 

Not present on admission 8 Agreement 8.8 Agreement 

Preventability 7 Indeterminate 5.5 Indeterminate 

Due to medical error 6 Disagreement 3.3 Indeterminate 

Charting by physicians 8 Agreement 8.5 Agreement 

Bias (lower rating favorable) 2 Agreement 1.5 Agreement a

Multi-specialty panel – Surgical Complications 3 

Surgical panel – Surgical Complications 3 

Multi-specialty Panel Results 

Changes to the indicator. No changes were suggested for this indicator. 

Concerns not addressable through changes. This indicator was created by the panel 

during the conference call. As a result panelists only commented on this indicator through 

written comments. Some panelists noted that this complication is only preventable if a family or 

personal history of malignant hyperthermia is detected preoperatively. If the question is not 

asked, or the history ignored, then the complication is undoubtedly due to medical error. 

However, when the family history is not known or reported by the patient when asked, then the 

complication is not preventable. Therefore, this rare complication would need to be examined on 

a case by case basis. 

Surgical Panel Results 

Changes to the indicator. No changes were suggested for this indicator.

Concerns not addressable through changes. Panelists expressed similar concern about 

two opposing aspects of this indicator, with the complication almost entirely preventable or 

impossible to prevent based on prior knowledge of family history. They also noted that this rare 

complication must be considered on a case by case basis. 

 Panelists also noted that a more appropriate denominator would be all procedures in 

which anesthesia is used. However, it is impossible to define the denominator as all procedures 

with anesthesia using administrative data. Thus some complications may be missed, as a result of 

limiting the population at risk to surgical cases. 

Summary Across Panels 

The overall usefulness of this indicator was rated relatively highly by both panels, with 

the caveat that some cases are not entirely preventable. Panelists appeared to have conflicting 
119

opinions about this indicator, although the final rating did not reflect disagreement. While most 

panelists agreed that when a family history is known and proper screening and/or preventative 

measures are not taken, that this is a clearly preventable complication. However, the frequency 

of this complication occurring under those circumstances is likely to be rare. More frequently, a 

family history is unknown or unclear, and in these cases there is no link to quality of care. It has 

been suggested that death due to malignant hyperthermia may be a better measure than malignant 

hyperthermia alone, however, this idea was not reviewed by the panels, nor empirically 

examined. This code was implemented in 1998, and thus this indicator could not be analyzed 

empirically using available data. For this reason this indicator was assigned to the Experimental 

indicator set. 

Postoperative Acute Myocardial Infarction (AMI) 

This indicator is intended to flag cases of postoperative AMI. It is similar to an indicator 

developed as part of the Complications Screening Program.7 Codes denoting a “subsequent 

episode of care” for AMI are not included. This indicator limits AMI codes to secondary 

diagnosis codes in order to eliminate AMIs that were present on admission. It includes only 

patients undergoing elective surgery, and excludes patients who are undergoing cardiac surgery, 

as these patients may be more likely to develop an AMI perioperatively. 

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for [Acute Myocardial Infarction] in any 

secondary diagnosis field per 100 non-cardiac surgical discharges. 

Denominator [Elective], [surgical] discharges. 

Exclude patients undergoing [cardiac surgery]. 

Exclude all obstetric admissions (MDC 14 and 15).

Post-Conference Call Panel Ratingsa 

Question Median 

(MS) 

Agreement status 

(MS) 

Median 

(S) 

Agreement status 

(S) 

Overall rating 4 Indeterminate 7 Indeterminate 

Not present on admission 7 Indeterminate 8 Agreement 

Preventability 5 Indeterminate 6 Disagreement 

Due to medical error 4 Indeterminate 5 Indeterminate 

Charting by physicians 7 Indeterminate 8 Agreement 

Bias (lower rating favorable) 5 Disagreement 6 Indeterminate a

Multi-specialty panel – Surgical Complications 1 

Surgical panel – Surgical Complications 1 

Multi-specialty Panel Results

Changes to the indicator. Panelists felt that the risk of acute myocardial infarction 

varies greatly depending on the comorbidities of the patient, the type of procedure, and the 
120

urgency of the procedure. While preventative interventions (e.g., use of beta-blockers in high 

risk patients) may decrease the postoperative AMI rate, these interventions may be impossible to 

implement for urgent cases, where there is not adequate time for appropriate screening and risk 

stratification. In addition, beta-blockers may be inappropriate for trauma patients. Due to these 

concerns, the panel felt it was best to limit the population at risk to elective surgical patients, 

who could be appropriately assessed before surgery. 

Concerns not addressable through changes. Panelists expressed concerns over the 

preventability of this complication in some patients. Some patients may be appropriately 

screened, and assessed, but may have some risk factors. However, the benefits of surgery may 

outweigh the risk of AMI. Panelists advocated that some established algorithms of AMI risk, 

such as that adopted by the American Society of Anesthesiologists, may be helpful in 

appropriately risk adjusting this indicator. However, the clinical detail required for these 

algorithms is not available in administrative data. As a result, this panel strongly encouraged the 

use of this indicator only for internal reporting, noting the caveat that many AMIs may not have 

been preventable. Some panelists felt that examining the appropriate use of beta-blockers 

directly would be a more appropriate indicator. 

 In addition to the known risk factors in patients, unknown coronary artery disease may 

predispose a patient to having a non-preventable postoperative AMI. 

Surgical Panel Results 

 

Changes to the indicator. The surgical panel questioned the exclusion of MDC 5, as 

this MDC included vascular surgery patients. Unlike patients undergoing cardiac surgery, for 

whom it is difficult to establish whether or not an AMI actually occurred, AMI in vascular 

patients can be established. Panelists felt that vascular surgery patients were an important 

population at risk for this complication, and thus should not be excluded. The exclusion of MDC 

5 was removed, and cardiac surgery patients were excluded using the existing exclusion criteria 

based on DRGs and ICD-9-CM codes. 

 The surgical panel advocated for the limitation of the population at risk to elective 

surgery for similar reasons as the multi-specialty panel. However, they noted that many of the 

AMIs in this risk group would not be preventable, since they would be unexpected. 

Concerns not addressable through changes. The surgical panel also expressed concern 

over the variable preventability of this complication. They noted that the preventability of this 

complication depends on the risk factors of the patient. Interventions exist to reduce the chance 

of AMI in patients with known cardiac artery disease. However, some patients may have 

unknown disease, or other unknown risk factors. These patients could not receive preventative 

interventions. In addition, the panel noted that older patients are at higher risk, and advocated for 

stratification of older patients. 

Summary Across Panels 

The two panels reached different conclusions regarding the usefulness of this indicator 

(i.e., rejected by multi-specialty panel, accepted by surgical panel). Neither panel was considered 

to carry more weight because of their unique knowledge of the complication. As a result, the 

panel scoring was combined, which resulted in this indicator being assigned to the Experimental 

indicator set. In addition, the multi-specialty panel did not discuss the removal of the exclusion 
121

of MDC 5. However, the objection to the exclusion appeared clinically sound. For this reason it 

was retained in the final definition. 

Many patients experiencing postoperative AMI have pre-existing subclinical or clinical 

coronary artery disease. These diseases are rare in children. 

Postoperative Iatrogenic Complications 

(All complications reviewed in one indicator) 

This indicator is intended to flag cases of postoperative iatrogenic complications. It is 

closely related to an indicator developed as part of the Complications Screening Program.7 This 

indicator limits complication codes to secondary diagnosis codes in order to eliminate 

complications that were present on admission. 

 

Final Definition: Postoperative Iatrogenic Complications - Nervous System Complications 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes of [iatrogenic nervous system complications]

in any secondary diagnosis field per 100 surgical discharges.

Denominator All [surgical] discharges. 

Exclude all obstetric admissions (MDC 14 and 15).

Final Definition: Postoperative Iatrogenic Complications - Cardiac Complications 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes of 997.1 in any secondary diagnosis field per 

100 surgical discharges.

Denominator All [surgical] discharges. 

Exclude all obstetric admissions (MDC 14 and 15).

Final Definition: Postoperative Iatrogenic Complications –Digestive System Complications 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Secondary dx codes of iatrogenic complication of digestive system (997.4)

Denominator [Surgical] patients

Final Definition: Postoperative Iatrogenic Complications – Respiratory Complications 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Secondary dx code of iatrogenic complication of respiratory system (997.3)

Denominator [Surgical] patients

Final Definition: Postoperative Iatrogenic Complications – Urinary Complications 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Secondary dx code of iatrogenic complications of urinary system (997.5) 

Denominator [Surgical] patients

Final Definition: Postoperative Iatrogenic Complications – Vascular Complications 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Secondary dx code of iatrogenic peripheral vascular complication (997.2) 

Denominator [Surgical] patients
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Post-Conference Call Panel Ratingsa 

Question Median Agreement status 

Overall rating Not reported Not reported 

Not present on admission Not reported Not reported 

Preventability Not reported Not reported 

Due to medical error Not reported Not reported 

Charting by physicians Not reported Not reported 

Bias (lower rating is favorable) Not reported Not reported a

 Procedural Complications 1 Multi-specialty Panel 

After the panelists rated this indicator, the project team received additional pertinent 

details about coding conventions for iatrogenic complications coded with 997.xx. These 

conventions would have been important to the discussion of the indicator, and would have likely 

influenced the ratings by panelists. As a result, the actual ratings are not reported. The indicator 

also included 6 distinct clinical areas that could be defined separately: urinary, digestive, 

respiratory, vascular, cardiac, and nervous system. Empirical analysis of patients who receive 

these codes was used to determine that four of the six were capturing clinically minor 

complications that may not be of interest to track. The remaining two areas, cardiac and nervous 

system, appeared to be identifying cases of potentially serious clinical complications. Thus, 

cardiac and nervous system iatrogenic complications were retained on the experimental indicator 

list for further empirical evaluation. However, it would have not been appropriate to include 

these two indicators in the Accepted indicator set since a clinical panel did not fully assess their 

face validity. Thus, these two indicators were assigned to the Experimental set, and all others 

were not considered further. 

Reopening of Surgical Site 

This indicator is intended to flag cases where a surgical site is reopened. It is closely 

related to an indicator developed as part of the Complications Screening Program.7

 This indicator 

limits reopening codes to secondary procedure codes in order to eliminate scheduled reopening 

of surgical sites. To further ensure that the reopening of a surgical site is associated with a 

principal procedure, the reopening must occur at least one day after the principal procedure. 

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for [reopening of a surgical site] in any 

secondary procedure field per 100 surgical discharges. 

Reopening of surgical site must occur at least one day after the principal 

procedure. 

Revision of vascular procedure 39.49 must occur within 24 hours of principal 

procedure.

Denominator All [surgical] discharges.
123

Post-Conference Call Panel Ratingsa 

a

Multi-specialty panel – Surgical Complications 2 

Surgical panel – Surgical Complications 2 

Multi-specialty Panel Results 

Changes to the indicator. Panelists felt the codes for revision of the heart or a vascular 

procedure were inherently different from other reopening of surgical site codes. Therefore these 

codes were removed from the definition. Panelists also felt that trauma patients may undergo 

reopening of surgical sites as a planned procedure. For this reason they suggested that trauma 

patients be excluded from this indicator. Finally, this panel felt that immunocompromised 

patients may undergo reopening of surgical site that is not preventable due to wound infection or 

other complications. Therefore these patients were excluded. 

Concerns not addressable by changes. Panelists felt that the preventability of this 

indicator depends on the reason for reopening. In addition, panelists felt that patient factors such 

as comorbidities or immunocompromised state may increase the likelihood that a patient would 

develop this complication. 

Surgical Panel Results 

 

Changes to the indicator. Panelists suggested the removal of the code for a correction 

procedure on the heart, for similar reasons as the multi-specialty panel. However, they rejected 

the removal of the code for revision of vascular procedure, instead opting for the limitation to 

procedures occurring within 24 hours of the principal procedure. It was felt that these early 

complications are most likely preventable, due to poor technique or poor patient selection. 

Concerns not addressable by changes. Panelists noted that some procedures are 

purposely staged procedures, and that these procedures should be removed. However, it is 

impossible to remove all staged procedures using ICD-9-CM codes. In addition, some patients 

may be at higher risk of reopening, such as when a patient undergoes the removal of failed 

hardware after an orthopedic surgery. 

SummaryAcross Panels 

The definition of this indicator relies on ICD-9-CM codes which are defined as 

reopenings that cannot be defined using another ICD-9-CM code. Thus, reopenings that result in 

a more complicated procedure than simply a reopening of the surgical site would not be captured 

by this indicator. Panelists were not aware of this caveat when rating this indicator, and it was 

Question Median 

(MS) 

Agreement status 

(MS) 

Median 

(S) 

Agreement status 

(S) 

Overall rating 6 Indeterminate 7 Indeterminate 

Not present on admission 7 Agreement 7 Indeterminate 

Preventability 7 Indeterminate 7 Indeterminate 

Due to medical error 6 Indeterminate 6 Indeterminate 

Charting by physicians 7.5 Agreement Agreement 

Bias (lower rating favorable) 3.5 Agreement 5 Indeterminate 
124

felt then that their ratings did not truly reflect the actual nature of this indicator. In addition, 

panelists requested that planned reopenings such as staged procedures be excluded. The 

operationalization of this suggestion was beyond the scope of this study, as it would have 

required a full review of ICD-9-CM procedure codes. Thus, this indicator was retained only in 

the Experimental indicator set. 

Suture of Laceration 

This indicator is intended to flag cases of lacerations during a surgical procedure, which 

result in a suturing procedure. It is closely related to a indicator developed as part of the 

Complications Screening Program,7 although it does add codes for the suture of laceration of 

diaphragm, blood vessel, small intestine, and anus. This indicator limits suture of laceration 

codes to secondary procedure codes in order to isolate those lacerations that can truly be linked 

to a surgical procedure. For the same reason, this indicator eliminates all sutures of lacerations 

that take place before the principal procedure. 

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for [suture of laceration] in any secondary 

procedure field per 100 surgical discharges. 

Suture of laceration must occur on the same day or after the principal procedure.

Denominator All [surgical] discharges. 

Exclude patients with any diagnosis code for [foreign body] or [trauma].

Exclude all obstetric admissions (MDC 14 and 15).

Post-Conference Call Panel Ratingsa 

Question Median 

(MS) 

Agreement status 

(MS) 

Median 

(S) 

Agreement status 

(S) 

Overall rating 8 Agreement 5 Indeterminate 

Not present on admission 7 Agreement 7 Agreement 

Preventability 8 Agreement 6 Indeterminate 

Due to medical error 7 Indeterminate 6 Indeterminate 

Charting by physicians 8 Indeterminate 6 Indeterminate 

Bias (lower rating favorable) 4 Indeterminate 5 Indeterminate a

Multi-specialty panel – Surgical Complications 2 

Surgical panel – Surgical Complications 2 

Multi-specialty Panel Results 

Changes to the indicator. Panelists expressed concern that lacerations vary in 

morbidity. Some lacerations, minor in nature, would be considered routine during a procedure, 

and may not be reported, depending on the detail of the surgical notes. Some surgeons, however, 

may report these minor lacerations leading to bias in reporting of lacerations. Panelists agreed 
125

that some more serious lacerations are important complications to track. To ensure that 

lacerations are consistently reported and are of sufficient morbidity to cause concern, this panel 

suggested that the indicator be limited to lacerations that require a return to the operating room. 

Administrative data do not allow for tracking returns to the operating room that occur on the 

same day of the principal procedure. The only option to implement the suggestion would be to 

limit suture of laceration codes to those occurring the day following the procedure or later. 

Concerns not addressable by changes. No additional concerns were raised during the 

conference call of surgical panels. 

Surgical Panel Results 

Changes to the indicator. Unlike the multi-specialty panel, the surgical panel disagreed 

with the exclusion requiring a return to the operating room, because this required that the suture 

of laceration occur one day after or following. They felt that this exclusion would limit the 

number of flagged complications to a very small number making the indicator less useful. 

The panel noted that the listed lacerations do not include lacerations that may occur 

during all procedures. As a result, they suggested several types of lacerations that should be 

included in the indicator, including obstetric and gynecological lacerations. Obstetric lacerations 

are included in another indicator. For this reason these codes were not added. However 

gynecological lacerations were added as were urological and nerve suture of laceration codes. 

Concerns not addressable by changes. The surgical panel also noted that many 

lacerations occurring during surgery are trivial in nature. They thought that these lacerations are 

less likely to be recorded by the physician, and are less important to track. Many panelists felt 

that the exclusion of the trivial lacerations from this indicator would be desirable, as this 

restriction would limit complications to those causing significant morbidity for the patient. 

Panelists noted that patient characteristics and procedure type greatly affect risk of a 

laceration occurring. Lacerations may occur as an expected complication of the procedure, 

during complex procedures on complicated structures, such as some types of hand surgery. It 

was also noted that re-surgery or repeat surgery is the major risk factor for suture of laceration, 

due to a build up of scar tissue. They noted that this case-mix difference is not addressable by 

limiting the indicator to elective surgery. Since re-surgery cannot be adjusted for using 

administrative data, panelists recommended that re-surgery rates be examined when using this 

indicator. 

Summary Across Panels 

The two panels arrived at slightly different definitions. The first panel required a return to 

the operating room, which was rejected by the second all surgeon panel. Empirical analysis 

revealed that this restriction significantly lowers the number of cases. Since the second panel had 

more expertise, the surgical panel’s definition was retained for further analysis. The surgical 

panel rated the overall usefulness of this indicator relatively low and the multi-specialty panel 

rated this definition very highly, so this indicator was assigned to the Experimental indicator set. 
126

Experimental Obstetric Indicators 

Obstetric Wound Complications - Cesarean Section Delivery 

This indicator is intended to flag cases of potentially preventable delivery wound 

complications in women delivering by cesarean section during the index hospitalization. 

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for [cesarean wound complications] in any 

diagnosis field per 100 deliveries.

Denominator All [cesarean delivery] discharges.

Post-Conference Call Panel Ratingsa 

Question Median Agreement status 

Overall rating 7.5 Agreement 

Not present on admission 8.5 Agreement 

Preventability 6.5 Indeterminate agreement 

Due to medical error 2.5 Indeterminate agreement 

Charting by physicians 7 Indeterminate agreement 

Bias (lower rating is favorable) 5 Agreement a

 Obstetric Complications 2 Panel

Changes to the indicator. This indicator was originally presented as a combined 

indicator of all obstetric wound complications (cesarean and vaginal). Panelists felt that wound 

complications of cesarean delivery differed substantially from those of vaginal delivery in both 

cause and preventability. For this reason they suggested that these complications be split into two 

separate indicators, and that the more useful indicator would be limited to cesarean deliveries. 

Concerns not addressable through changes. Panelists expressed concern that the 

severity and layer of the wound dehiscence could not be determined using this indicator. Thus 

both superficial disruptions and deep fascial disruptions are combined into one indicator. If 

possible, panelists felt that the deeper wound disruptions should be tracked more closely than 

superficial disruptions. However, this is not possible with the current coding conventions. 

Panelists noted that wound complications are less preventable in some subgroups, such as 

patients with overall poor tissue health, diabetics, and those having had a prior c-section, and that 

these risk factors are more common in patients with lower socioeconomic status. Thus, panelists 

expressed concern that some bias may be present for this indicator based on patient case mix. 

Finally, some panelists felt that the use of this indicator could lead to the inappropriate 

overuse of antibiotics. 

Summary 

 Panelists rated the overall usefulness of this indicator favorably. However, they rated the 

extent to which this indicator reflected medical error as very poor. Because these indicators are 

intended to identify potential patient safety problems, the lack of literature supporting this 
127

indicator and the panel’s equivocality regarding the indicator, this indicator was assigned to the 

Experimental indicator set. 

Obstetric Wound Complications - Vaginal Delivery 

This indicator is intended to flag cases of potentially preventable delivery wound 

complications in women delivering during the index hospitalization. 

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for [perineal wound complications] in any 

diagnosis field per 100 deliveries.

Denominator All [vaginal delivery DRGs]. 

Post-Conference Call Panel Ratingsa 

Question Median Agreement status 

Overall rating 6.5 Indeterminate agreement 

Not present on admission 8 Agreement 

Preventability 4 Indeterminate agreement 

Due to medical error 3 Indeterminate agreement 

Charting by physicians 6 Indeterminate agreement 

Bias (lower rating is favorable) 5 Indeterminate agreement a

Obstetric Complications 2 Panel 

Changes to the indicator. This indicator was originally presented as a combined 

indicator of all obstetric wound complications (cesarean and vaginal). Panelists felt that wound 

complications of cesarean delivery differed substantially from that of vaginal delivery in both 

cause and preventability. For this reason they suggested that these complications be split into two 

separate indicators. For patients who deliver vaginally, panelists agreed that diagnosis codes for 

vulval and perineal hematoma should be added as they felt that these complications may be 

preventable. 

Concerns not addressable through changes. Panelists felt that some case mix bias may 

result from differing preventability of this complication. Patients having poor tissue health, poor 

nutrition, underlying conditions such as diabetes, or undergoing operative vaginal delivery would 

be more susceptible to this complication. Panelists also noted that many perineal wound 

disruptions are not apparent until after hospital discharge. Thus a large percentage of these 

wound disruptions would be missed using inpatient administrative data. Finally, panelists 

expressed concern that the use of this indicator may lead to a higher cesarean section rate, as 

physicians avoid operative delivery or episiotomies. 

Summary 

 Panelists were uncertain about the usefulness of this indicator and they clearly noted that 

this complication is not reflective of medical error. Because of the ambiguity of this indicator, 

this indicator was retained in the Experimental indicator set for further investigation. 
128

Other Obstetric Complications

Uterine Rupture

This “other obstetric complications” indicator is intended to flag cases of potentially 

preventable delivery complications in women delivering during the index hospitalization. The 

“Uterine rupture” indicator became a separate indicator based on panel input, and is intended to 

flag cases of uterine rupture in women who have undergone a trial of labor. 

Final Definition: Other Obstetric Complications 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for [other obstetrical complications] in any 

diagnosis field per 100 deliveries.

Denominator All [deliveries].

Final Definition: Uterine rupture 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for [rupture of uterus during or after labor] 

in any diagnosis field per 100 deliveries with trial of labor.

Denominator All deliveries with a [trial of labor]. 

Post-Conference Call Panel Ratingsa 

Question Median Agreement status 

Overall rating 6.5 Indeterminate Agreement 

Not present on admission 8 Agreement 

Preventability 5 Indeterminate Agreement 

Due to medical error 5 Indeterminate Agreement 

Charting by physicians 8 Agreement 

Bias (lower rating is favorable) 5 Indeterminate Agreement a

 Obstetric Complications 2 Panel

Changes to the indicator. Panelists suggested that the rate of uterine rupture be adjusted 

for vaginal birth after cesarean section (VBAC) rate, as these patients are well documented to be 

at higher risk of uterine rupture. To address the intent of this suggestion, a separate indicator was 

specified to measure the rate of uterine rupture only for patients who have a trial of labor. 

Panelists rated the “Other obstetric complications” indicator, with uterine rupture included, but 

adjusted for VBAC rate. The implementation of the “Uterine rupture” indicator occurred after 

the panelists’ final evaluation. 

Concerns not addressable through changes. Panelists expressed concern that the 

preventability of these heterogeneous and relatively rare complications varies by the 

complication. They noted that a majority of these complications are not easily preventable, 

although some are minimized if a diagnosis is made and treatment promptly started. They noted 

that patient comorbidities and factors influence some of these complications, and that referral 

centers receive more of these patients than other centers. 
129

Panelists were concerned that differences in coding may affect this indicator. For 

instance, some benign uterine ruptures, so called uterine windows, may be coded, when they are 

clinically insignificant. Panelists were not interested in tracking these minor complications, but 

the restrictions of administrative data make tracking only severe complications impossible. 

Summary 

 Panelists were uncertain about the usefulness of this indicator and they clearly noted that 

this complication is not reflective of medical error. Because of the ambiguity of this indicator, 

this indicator was retained in the Experimental indicator for further investigation. Also stemming 

from this indicator was a separate uterine rupture indicator. Although panelists requested that 

uterine rupture be combined with other complications, such that this currently widely discussed 

complication would not be singled out, the requested risk adjustment for trial of labor after 

cesarean was not easily operationalized when uterine rupture was combined with other 

complications for which this risk adjustment was inappropriate. The uterine rupture indicator 

was also retained in the Experimental indicator set. 

Post-partum Urinary Tract Infection (UTI) 

This indicator is intended to flag cases of potentially preventable puerperal urinary tract 

infections in women delivering during the index hospitalization. This indicator excludes patients 

with infection of the amniotic cavity, as infection in these patients is more likely to be present on 

admission or non-preventable. This indicator was suggested by one of the obstetric complication 

panels. 

Final Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM code of 646.62 or 646.64 in any diagnosis per 100 

deliveries.

Denominator All [cesarean delivery] and [vaginal delivery] discharges

Post-Conference Call Panel Ratingsa 

Question Median Agreement status 

Overall rating 7 Indeterminate agreement 

Not present on admission 5 Indeterminate agreement 

Preventability 7 Indeterminate agreement 

Due to medical error 3.5 Indeterminate agreement 

Charting by physicians 7 Indeterminate agreement 

Bias (lower rating is favorable) 3.5 Indeterminate agreement a

 Obstetric Complications 2 Panel 

Changes to the indicator. This indicator was suggested and created by the panel, due to 

the interest in tracking post-partum urinary tract infections. 

Concerns not addressable through changes. Several concerns about this indicator 

were raised, although most panelists remained interested in tracking this complication, since its 

use may decrease unnecessary catheterization. Panelists felt that some hospitals may have a 
130

higher rate of these complications due to patient case mix. Specifically, they noted that patients 

with other infections or overall poor health are more likely to develop these complications. These 

factors vary systematically with socioeconomic status. Also, patients that undergo operative 

delivery or regional anesthesia may be at higher risk of developing post-partum UTI. Further, 

they noted that many of these complications develop after discharge. Thus, there may be 

significant underreporting resulting from the exclusive use of inpatient data. Finally, panelists 

expressed concern that the use of this indicator would lead to the inappropriate overuse of 

antibiotics. 

Summary 

 Panelists rated the overall usefulness of this indicator favorably. However, they rated the 

extent to which this indicator reflected medical error as very poor. Because these indicators are 

intended to identify potential patient safety problems, the lack of literature supporting this 

indicator and the panels equivocality regarding the indicator, this indicator was assigned to the 

Experimental indicator set. 

Third or Fourth Degree Obstetric Laceration 

(This indicator was not reviewed. See “Obstetric trauma” in Accepted indicators section for 

discussion.) 

Uterine Rupture 

(See “Other obstetric complications.”) 

Section 3E. Comparative Empirical Results 

Extensive empirical analyses were conducted on indicators accepted by the clinical 

panels as having met minimum criteria for face validity (i.e., Accepted Hospital Level Indicators, 

Accepted Area Level Indicators). These analyses were intended to provide additional 

information about indicators, rather than as decision making tools regarding the validity of these 

indicators. Additional research exploring the validity of these indicators is discussed in Chapter 

4. The analyses included in this report are intended to provide guidance for future research and 

use of these indicators, and include statistical measures of reliability, bias, relatedness of 

indicators and persistence over time, in addition to adjusting for demographics, DRG and 

comorbidities. MSX methods, correlation analysis and factor models investigated relationships 

among the set of accepted indicators in order to identify potential underlying constructs (e.g., 

processes of care or structural characteristics) common to some or all of the indicators.1

 

1

 The empirical analyses reported, except for raw rates, reflect a prior version of the indicator definitions (e.g., 

specified software) than specified in Appendices D and E. In this prior version of the software used in this report 

three differences were present. First, for the indicator “Postoperative hemorrhage or hematoma,” procedure codes 

for control of hemorrhage and hematoma were combined into a single category, applied to either diagnosis, resulting 

in a 20% increase in this indicator’s rate compared to the final definition. Second, “Postoperative hip fracture” 

included pediatric patients, a group seldom experiencing this condition. Third, in the comorbidity software, when 

fifth digits specified the presence of more than one comorbidity, only one comorbidity was assigned (renal failure, if 

present, or congestive heart failure, if renal failure was not present). It is anticipated that these minor changes would 

not affect the overall results of these analyses. 
131

Less extensive empirical analyses were conducted on the Experimental Hospital Level 

Indicators, including statistical measures of reliability and bias, with adjustments for 

demographics, DRG and comorbidities. Because there was no a priori reason to suspect an 

underlying construct common to these heterogeneous measures, no attempt was made to identify 

one. Therefore each of the experimental indicators are meant to be evaluated separately and 

subjected to further investigation and refinement. Although there are exceptions, in general the 

experimental indicators tend to have less systematic hospital level variation than the accepted 

indicators, but do not appear to be more or less biased. 

All of the findings on bias reflect the level of information available for risk adjustment 

using HCUP SID data, and may therefore not apply to data sets that have more clinically detailed 

data elements. The presence of “high bias” mentioned in this section suggests that risk 

adjustment, using administrative data elements, is necessary to interpret hospital level 

differences in the rates of these indicators. However, for all indicators, the risk adjustment that is 

possible using HCUP data may or may not be adequate to correct potential bias. 

The text in this section makes reference to numbered tables that can be found in 

Appendix G. The figures and tables contained in this section graphically or categorically 

summarize the numerical results in the Appendix G tables. 

The empirical evidence presented here is intended to guide future use and development of 

these PSIs. As such, the relevance on any particular piece of empirical evidence will depend on 

the purpose of the analysis being conducted. However, among the accepted non-obstetric 

hospital level indicators, five of the measures that appear to perform well on several different 

dimensions, including reliability, bias, relatedness of indicators, and persistence over time, are 

the following: “Complications of anesthesia,” “Postoperative wound dehiscence,” “Postoperative 

hemorrhage or hematoma,” “Death in low mortality DRGs,” and “Postoperative hip fracture.” 

The other 11 non-obstetric accepted indicators often perform well, and provide useful 

information for their intended purpose. The obstetric indicators (“Birth trauma,” “Obstetric 

trauma - vaginal delivery with instrumentation,” “Obstetric trauma - vaginal delivery without 

instrumentation,” “Obstetric trauma – cesarean section,”) also tend to perform well, though 

partly because of the higher rates and consequently large amount of variation among providers in 

these indicators; and partly because only age and gender risk adjustment was applied, so that the 

indicators showed little apparent bias. 

Accepted Hospital Level Indicators 

 An analysis of the overall rates of PSIs in the National SID found that the least frequent 

PSI is Transfusion Reaction, with only 16 cases in Florida and 129 cases in the National SID in 

1997. The most frequent PSIs are “Obstetric trauma – vaginal delivery without instrumentation” 

and “Failure to rescue,” with 120,858 and 135,085 cases in the National SID, respectively. The 

total number of adverse events (numerator), the total number of patients at risk (denominator), 

and the overall rate in Florida and the National SID for each accepted patient safety indicator can 

be found in Appendix G Table 1. The rates for the Florida SID used for initial testing, and the 

National SID were generally similar. 

The mean hospital rates for each indicator in the National SID are depicted in Figure 1 

below. A comparison of the National SID mean hospital rates and the Florida SID show that 

these rates are similar (see Appendix G Table 2), although the standard deviation and skew 

statistic (which is a measure of the symmetry of the hospital level distribution) are greater in the 
132

National SID than in Florida, especially for the relatively rare PSI. This is likely true for most 

individual states; the greater number of the hospitals in the National SID increases the detection 

of occurrence for infrequent events. Also noteworthy in this analysis is that some indicators have 

a substantial number of hospitals that do not have any discharges in the denominator. For the 

obstetric indicators in particular, about one-fourth of hospitals have no deliveries at risk. 

Figure 1. Summary of Mean Hospital Level Rates 

0.00

0.05

0.10

0.15

0.20

0.25

TRANSFUSION REACTION FOREIGN BODY LEFT INCOMPLICATIONS OF ANESTHESIA IATROGENIC PNEUMOTHORAX POSTOP PHYSIO METAB DERANGDEATH IN LOW MORT DRGS POSTOP HIP FRACTURE INFECTION DUE TO MED CARE POSTOP HEMORR OR HEMAT TECH DIFFICULTY W PROC POSTOP WOUND DEHIS POSTOP RESP FAILUREOB TRAUMA C-SECTION POSTOP PE OR DVT BIRTH TRAUMA POSTOP SEPSIS DECUBITUS ULCER OB TRAUMA VAGINAL WO INSTRFAILURE TO RESCUE OB TRAUMA VAGINAL W INSTR

PSI

Mean Rate

The rates vary considerably across measures, from a high of 20.3% for “Obstetric trauma 

– vaginal delivery with instrumentation” to a low of 0.001% for “Transfusion reaction” (which 

represents 129 cases in the National SID in 1997). “Obstetric trauma – vaginal delivery without 

instrumentation” and “Failure to rescue” also have much higher rates than the other PSI, which 

are generally 2% or less. 

The apparent standard deviations, as shown in Figure 2, (unadjusted for risk or reliability) 

also vary considerably among the measures, from a high of 14.2 percentage points for “Obstetric 

trauma - vaginal delivery with instrumentation” (relative to a mean of 20.3 percentage points) to 

a low of less than 0.1 percentage points for “Iatrogenic pneumothorax,” “Transfusion reaction” 

and “Foreign body left during procedure.” The non-obstetric measures with the greatest amount 

of hospital level variation in absolute magnitude are “Failure to rescue,” “Postoperative sepsis” 

and “Decubitus ulcer.” Among the obstetric indicators, “Obstetric trauma (with and without 
133

instrumentation)” has the most variance. Relative to the mean hospital level rate, the measures 

with the greatest hospital level variation are “Postoperative physiological and metabolic 

derangement,” and “Death in low mortality DRGs.” In other words, some of these measures 

have low rates of occurrence, so the absolute magnitude of the variance is small, but the degree 

of spread in the rates is relatively large. 

Figure 2. Summary of Standard Deviations in Hospital Level Rates 

0.00

0.05

0.10

0.15

0.20

0.25

TRANSFUSION REACTION FOREIGN BODY LEFT INIATROGENIC PNEUMOTHORAX INFECTION DUE TO MED CARE TECH DIFFICULTY W PROCPOSTOP HEMORR OR HEMATPOSTOP RESP FAILURE POSTOP HIP FRACTURE COMPLICATIONS OF ANESTHESIA POSTOP WOUND DEHISPOSTOP PHYSIO METAB DERANG DEATH IN LOW MORT DRGS POSTOP PE OR DVT OB TRAUMA C-SECTION DECUBITUS ULCER POSTOP SEPSIS BIRTH TRAUMA OB TRAUMA VAGINAL WO INSTRFAILURE TO RESCUE OB TRAUMA VAGINAL W INSTR

PSI

Standard Deviation

The hospital level variation tends to be skewed toward the right, meaning that there is a 

long right-hand tail of hospitals with higher rates (see Appendix G, Table 3). The most highly 

skewed measures are “Complications of anesthesia,” “Postoperative physiological and metabolic 

derangement,” and “Death in low mortality DRGs,” with a median skew statistic for all 

indicators of 10.0. Examples of the distributions may be found in Appendix G, Figures 1 and 2. 

These figures show the distribution of hospital level rates for “Decubitus ulcer” (with a median 

rate of 1.6%, a mean rate of 2.1% and skew statistic of 3.57) and “Birth trauma” (with a median 

rate of 0.25%, a mean rate of 0.94% and a skew statistic of 11.85). Hospitals with zero rates are 

excluded from the figures, which comprise 10% and 25% for “Decubitus ulcer” and “Birth 

trauma,” respectively. 
134

Risk Adjustment 

 Three levels of risk adjustment were applied to the measures using a logistic model. 

First, the hospital level measures were adjusted for age, gender and age-gender interactions. The 

age groups are the standard age categories used by the National Center for Health Statistics 

(NCHS) in their descriptive statistics, namely 0, 1-4, 5-14, 15-24, 25-34, 35-44, 45-54, 55-64, 

65-74, 75-84 and 85+. Next, the measures were adjusted for age, gender, and modified DRG 

category. The categories were modified to combine separate DRGs with and without 

complications, and to exclude the super-MDC DRGs (e.g., Tracheostomies). Finally, the 

measures were adjusted for age, gender, DRG and comorbidity, using a modified version of the 

AHRQ comorbidity software. Details are provided in Section 2E Empirical Methods. 

 Overall, age-gender risk adjustment tended to increase the level of apparent hospital level 

variation by about 2% (see Appendix G, Table 3). Given the low rates of occurrence, 

“Transfusion reaction” and “Foreign body left in during procedure” were not risk adjusted for 

technical reasons, although there may be conceptual reasons to risk adjust these indicators. The 

impact was greatest on “Postoperative respiratory failure,” “Postoperative hemorrhage or 

hematoma,” “Postoperative wound dehiscence,” and “Death in low mortality DRGs,” and 

minimal on most other indicators. The rates tend to be slightly more skewed, meaning that 

differences in the age-gender mix were masking differences in rates, but several measures are 

slightly more skewed, meaning that some of the higher rates could be accounted for by 

differences in the age-gender mix of the population at-risk. 

 In addition to age-gender risk adjustment, DRG and comorbidity risk adjustment was 

performed (see Appendix G Table 4). The obstetric measures are not adjusted for DRG. The 

“Death in low mortality DRGs” indicator is also not adjusted for DRG. Rather, the indicator is 

stratified by DRG group, namely medical (adult and pediatric), surgical (adult and pediatric), 

neonatal, obstetric and psychiatric (See Appendix G, Table 1). Relative to age-gender 

adjustment, the overall impact of DRG adjustment was greater, decreasing hospital level 

variation by 4.1%. Comorbidity adjustment decreased variation by 1.6%. Most of the variation 

among hospitals explained by the risk adjustment was accounted for by DRG, with incremental 

amounts accounted for by the comorbidity categories, although comorbidity adjustment was 

relatively more important for some indicators. DRG risk adjustment had the biggest impact on 

“Technical difficulty with procedure,” “Failure to rescue,” “Infection due to medical care,” and 

Postoperative PE or DVT.” Comorbidity risk adjustment had the biggest impact on 

“Postoperative respiratory failure,” “Infection due to medical care,” “Decubitus ulcer,” and 

“Postoperative sepsis.” Variation in “Postoperative hemorrhage or hematoma” and “Death in 

low mortality DRGs” actually increased slightly. 

Reliability Adjustment 

 The effect of the reliability adjustment was examined by the statistics on the signal 

standard deviation, signal share and signal ratio (see Appendix G, Table 5). Hospitals with fewer 

than three patients in the denominator were not included in the reliability adjustment. 

Multivariate methods (taking into account correlations among indicators in order to extract 

additional 'signal') were applied to most of the accepted indicators. The exceptions were “Death 

in low mortality DRGs” and “Failure to rescue.” Only univariate smoothing methods were 

applied to these two indicators. Overall, the reliability adjustment reduced the hospital level 
135

variation dramatically. On average, over one-half of the apparent hospital level variation, even 

after risk adjustment, was estimated to be attributable to noise. The measures that were affected 

the most by reliability adjustment in terms of reduction in the hospital level standard deviation 

were “Postoperative physiological and metabolic derangement,” “Postoperative sepsis,” and 

“Postoperative hemorrhage or hematoma.” The measures that were affected the least were 

“Birth trauma,” “Iatrogenic pneumothorax” and “Technical difficulty with procedure.” (For 

examples of the distribution of indicators see Appendix G, Figures 3 and 4.) These figures show 

the distribution of hospital rates for “Decubitus ulcer” and “Birth trauma” after risk and 

reliability adjustment. 

MSX Statistics 

The MSX statistics give estimates of the degree of total hospital level variation accounted 

for by signal and noise, and the degree of total variation (hospital and patient) accounted for by 

signal. Signal standard deviation is an estimate of the systematic variation (‘signal’) among 

hospitals (See Figure 3). The higher the signal standard deviation, the greater the opportunity to 

identify hospital characteristics associated with higher (or lower) rates. The non-obstetric 

measures with the most signal are “Failure to rescue,” “Decubitus ulcer” and “Postoperative PE 

or DVT.” Among the obstetric measures, “Obstetric trauma - vaginal delivery (with and without 

instrumentation)” and “Birth trauma” have the most signal. For “Decubitus ulcer,” the signal 

variance represents a difference of 60 adverse events (20 to 80 with a mean of 50) per hospital 

between the bottom and top hospitals in the middle two-thirds of the distribution. The measures 

with the least signal are “Postoperative hemorrhage or hematoma,” “Infection due to medical 

care” and “Iatrogenic pneumothorax. The measures “Transfusion reaction” and “Foreign body 

left during procedure” have no signal, meaning no detectable systematic hospital level variation. 

The signal share (see Figure 4) is a measure of the share of total variation (hospital and 

patient) accounted for by the signal (hospital). The higher the share is, the relatively more 

important the hospital in accounting for the rate. The lower the share is, the less important the 

hospital, and the more important other potential factors (e.g., patient characteristics). The nonobstetric measures with the higher signal share are “Death in low mortality DRGs,” “Decubitus 

ulcer” and “Failure to rescue.” “Birth trauma” and “Obstetric trauma - vaginal delivery (with 

and without instrumentation)” have the highest share among the obstetric indicators. The overall 

low levels of the share of total variation accounted for by hospitals is an indication that there are 

many other factors that influence these rates besides the hospital. 

Finally, signal ratio is a measure of how much of the observed variation is signal and how 

much is noise (see Figure 5). The ratio is affected both by the amount of signal and by the 

amount of noise. In other words, the signal ratio will be high even in the absence of much signal, 

if the amount of noise is also low. For the PSIs, the ratios tend to be high even with little signal 

because the hospital sample sizes are very large for most of the indicators, which makes the 

hospital estimates precise (i.e., low noise). The higher the signal ratio, the more likely that 

observed differences in risk adjusted rates reflect true differences in hospital performance. The 

lower the signal ratio, the more likely that observed differences in risk adjusted rates reflect a 

large degree of noise. Non-obstetric indicators with the highest signal ratio are “Death in low 

mortality DRGs,” “Decubitus ulcer” and “Iatrogenic pneumothorax.” Among the obstetric 

indicators, “Birth trauma - injury to neonate” and “Obstetric trauma - vaginal delivery without 
136

instrumentation” have the highest ratio. Indicators with the lowest signal ratio are “Postoperative 

hemorrhage or hematoma,” “Postoperative sepsis” and “Postoperative wound dehiscence.” 

Figure 3. Summary of Signal Standard Deviation in Hospital Level Rates 

0.00

0.01

0.02

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POSTOP HEMORR OR HEMAT INFECTION DUE TO MED CARE IATROGENIC PNEUMOTHORAX POSTOP PHYSIO METAB DERANG POSTOP HIP FRACTURE COMPLICATIONS OF ANESTHESIA POSTOP WOUND DEHISPOSTOP RESP FAILURETECH DIFFICULTY W PROCPOSTOP SEPSIS DEATH IN LOW MORT DRGS POSTOP PE OR DVT OB TRAUMA C-SECTION DECUBITUS ULCER FAILURE TO RESCUE OB TRAUMA VAGINAL WO INSTRBIRTH TRAUMA OB TRAUMA VAGINAL W INSTRFOREIGN BODY LEFT INTRANSFUSION REACTION 

PSI

Signal Standard Deviation

Minimum Bias 

 The effect of age, gender, DRG and comorbidity risk adjustment on the relative ranking 

of hospitals, compared to no risk adjustment, was assessed using five measures of impact. Both 

the unadjusted and risk adjusted measures were adjusted for reliability, in order to remove the 

impact of noise on the assessment of potential bias. Also, even if risk adjustment reduces the 

apparent level of hospital level variation, the relative rank may not be affected if the distribution 

of the adjusters does not vary systematically across hospitals. A large impact on the relative 

ranking means that the measures are biased based on the patient characteristics we observe from 

the administrative data. Minimal or no impact means that the measures are not biased based on 

the characteristics we observe (although there might be characteristics that we do not observe 

using administrative data that are related to the patient’s risk of experiencing an adverse event). 

 The first measure is a relative rank correlation statistic (a measure of the impact of 

adjustment on the assessment of relative hospital performance). The second measure is the 

average absolute magnitude of the change in unadjusted – adjusted rate for each hospital (a 

measure of the relative importance of adjustment). The third and fourth measures are the 
137

percentage of hospitals that remain in the top (or bottom) 10% of the distribution after 

adjustment (measures of the impact on the highest and lowest hospitals). The last measure is the 

percentage of hospitals that change more than two deciles in the distribution after adjustment (a 

measure of the impact throughout the distribution). According to the rank correlation, the 

indicators most affected in terms of the relative ranking of hospitals are “Failure to rescue,” 

“Decubitus ulcer,” “Technical difficulty with procedure,” “Postoperative PE or DVT,” “Death in 

low mortality DRGs,” “Iatrogenic pneumothorax,” “Postoperative sepsis” and “Postoperative 

respiratory failure.” The least affected indicators are “Birth trauma - injury to neonate,” 

“Obstetric trauma - vaginal delivery without instrumentation” and “Complications of 

anesthesia.” DRG risk adjustment could not be applied to the obstetric indicators, because 

obstetric DRGs are divided only by the mode of delivery and the presence or absence of 

complications or comorbidities. Also, comorbidity adjustment may not be as applicable to the 

obstetric population, and in some specific instances (see Appendix D) could not be applied to 

obstetric indicators, as applicable ICD-9-CM codes were not available. 

 

Figure 4. Summary of Signal Share in Hospital Level Rates 

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0.03

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0.09

0.12

0.15

POSTOP HEMORR OR HEMATINFECTION DUE TO MED CARE IATROGENIC PNEUMOTHORAX POSTOP SEPSIS POSTOP PHYSIO METAB DERANG TECH DIFFICULTY W PROCPOSTOP RESP FAILUREPOSTOP WOUND DEHISPOSTOP HIP FRACTURE POSTOP PE OR DVT COMPLICATIONS OF ANESTHESIA OB TRAUMA C-SECTION DECUBITUS ULCER FAILURE TO RESCUE OB TRAUMA VAGINAL WO INSTRDEATH IN LOW MORT DRGS OB TRAUMA VAGINAL W INSTRBIRTH TRAUMA FOREIGN BODY LEFT INTRANSFUSION REACTION 

PSI

Signal Share
138

Figure 5. Summary of Signal Ratio in Hospital Level Rates 

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0.90

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POSTOP HEMORR OR HEMATPOSTOP SEPSIS POSTOP WOUND DEHISPOSTOP RESP FAILUREPOSTOP PHYSIO METAB DERANGOB TRAUMA C-SECTION FAILURE TO RESCUE POSTOP HIP FRACTURE INFECTION DUE TO MED CARE POSTOP PE OR DVT OB TRAUMA VAGINAL W INSTRCOMPLICATIONS OF ANESTHESIA TECH DIFFICULTY W PROCIATROGENIC PNEUMOTHORAX DECUBITUS ULCER OB TRAUMA VAGINAL WO INSTRDEATH IN LOW MORT DRGS BIRTH TRAUMA FOREIGN BODY LEFT INTRANSFUSION REACTION 

PSI

Signal Ratio

In terms of absolute magnitude of the change in adjusted rate, the impact is greatest for 

“Failure to rescue,” “Technical difficulty with procedure,” and “Death in low mortality DRGs.” 

Along with “Decubitus ulcer,” “Failure to rescue,” “Technical difficulty with procedure” and 

“Death in low mortality DRGs” also have the greatest impact at the upper tail of the distribution, 

meaning that accounting for these patient characteristics accounts for the very high rates of these 

indicators for some hospitals. 

 Overall, if one were to create a simple score based on the five measures of potential bias 

(e.g., ranking the indicators 1 to 20 for each bias measures, and summing the ranks), the most 

biased measures would be “Failure to rescue,” “Technical difficulty with procedure,” “Decubitus 

ulcer” and “Postoperative PE or DVT.” The least biased measures would be “Postoperative 

hemorrhage and hematoma” and “Complications of anesthesia.” This is summarized in Table 18. 

Obstetric measures in general also demonstrate little bias, although these indicators were 

subjected to less risk adjustment than the other indicators. However, these categories are not 

definitive. Each bias measure stands on its own as a measure of performance, depending on the 

purpose of the analysis. Also, as mentioned in the introduction, more clinically detailed 

information than is available in the HCUP SID may yield different conclusions. What is certain 

is that unadjusted rates for the ‘high’ bias measures are likely to be misleading. 
139

Table 18. Summary of Minimum Bias in Hospital Level Rates 

High Bias Medium Bias Low Bias 

Failure to rescue Postoperative hip fracture Postoperative hemorrhage 

or hematoma 

Technical difficulty with 

procedure 

Iatrogenic pneumothorax Complications of 

anesthesia 

Decubitus ulcer Postoperative physiological 

and metabolic derangement 

Postoperative PE or DVT Infection due to medical 

care 

Death in low mortality DRGs Postoperative wound 

dehiscence 

Postoperative sepsis 

Postoperative respiratory 

failure 

 

Relatedness of Indicators 

 To investigate the relationship between indicators, we examine the hospital level 

Spearman correlations among the measures, and conduct a factor analysis using principal factor 

analysis based on the Spearman correlations (with a varimax rotation in order to maximize the 

loadings on each factor). The correlations between the measures can be found in Appendix G 

Table 7. If a measure is valid, it should be correlated with related measures that reflect similar 

aspects of hospital performance or hospital characteristics. For example, “Obstetric trauma – 

vaginal delivery without instrumentation” is correlated with “Obstetric trauma – vaginal delivery 

with instrumentation” (a correlation of 0.545, p<.0001). For the most part the measures are 

positively correlated (p<.05), with the exception of “Postoperative respiratory failure” and 

“Failure to rescue,” which are negatively correlated with several other indicators. “Technical 

difficulty with procedure” is positively correlated with several other measures, including 

“Infection due to medical care” (0.306, p<.0001) and “Iatrogenic pneumothorax” (0.318, 

p<.0001). It is not expected that all indicators would be strongly correlated with each other, as 

different aspects of quality may be reflected by each indicator. 

 Two factor analyses were conducted to examine the relationship and possible underlying 

“factors.” The first analyses combined obstetric and non-obstetric indicators. This factor analysis 

reflects the correlation results and suggests that there are two “factors” or underlying constructs 

common among all the PSI. Appendix G, Table 8 shows the factor loadings and share of 

variation explained for each factor and for each PSI. There are two factors that explain almost 

all of the systematic variation among the PSIs (the remaining, unexplained variation is unique to 

each PSI). The first factor tends to be associated with the obstetric indicators and the surgical 

indicators, while the second factor tends to be associated with medical indicators, although two 

post-operative PSIs are included. The indicators with the highest loadings on the first factor, 

which explains about 10-20% of the variation for those PSIs and over one-half of the systematic 

variation among all PSIs, include “Infection due to medical care,” “Technical difficulty with 

procedure,” and “Obstetric trauma – vaginal delivery (with and without instrumentation),” 

“Decubitus ulcer,” “Postoperative respiratory failure,” ” and “Postoperative sepsis” indicators 

load most heavily on the second factor, which explains about one-third of the systematic 
140

variation. A second factor analysis was conducted, removing the obstetric indicators. The 

removal of the obstetric indicators did not result in an obvious change to the factor results. 

 Overall, there is significant hospital level variation common among the patient safety 

indicators, and that variation is concentrated into two independent dimensions. Some underlying 

construct is potentially identifiable. However, most of the variation is unique to each PSI, 

meaning that to a large degree the indicators each measure an independent dimension of 

performance. 

Persistence of Rates Over Time 

 Persistence was examined using the Florida SID from 1995-1997 (See Appendix G, 

Table 8). Two important points emerged from this examination. First, the rates are consistent 

from year to year, suggesting that at least for the years considered no fundamental changes in 

coding or practice confound comparison across years. The exception is “Postoperative 

hemorrhage or hematoma” which relies on ICD-9-CM codes adopted in October, 1996. Second, 

hospital performance is consistent from year to year for many of the indicators. “Decubitus 

ulcer,” “Technical difficulty with procedure,” “Obstetric trauma - vaginal delivery without 

instrumentation,” and “Infection due to medical care,” all have year to year correlations in excess 

of 0.70 for 1995-96 and 1996-97. “Decubitus ulcer” and “Technical difficulty with procedure” 

have correlations across a two year time period in excess of 0.70. But most of the indicators are 

correlated from year to year, meaning that hospitals that are above average tend to remain above 

average, at least over a three year period. 

Experimental Hospital Level Indicators 

 Analyses of the experimental indicators show that the least frequent PSI is “Intraoperative nerve compression injury,” with only 7 cases in Florida and 102 cases in the National 

SID in 1997. The most frequent PSIs are “Postoperative iatrogenic complication – cardiac,” and 

“3rd or 4th degree obstetric laceration,” with 83,502 and 99,383 cases in the National SID, 

respectively. The total number of adverse events (numerator), the total number of patients at risk 

(denominator), and the overall rate in Florida and the National SID for each experimental PSI 

can be found in Appendix G Table 9. The rates vary considerably across measures, from a high 

of 6.1% for “Decubitus ulcer in high risk patients” to a low of 0.001% for “Intra-operative nerve 

compression injury” (which represents 7 cases in the National SID in 1997). Like the accepted 

PSIs, the rates between the Florida and National SID are similar. 

The apparent standard deviations (unadjusted for reliability) also vary considerably 

among the measures, from a high of 6.5 percentage points for “Decubitus ulcer in high risk 

patients” (relative to a mean of 6.2 percentage points) to a low of less than 0.37 percentage 

points for “Uterine rupture” and “Intra-operative nerve compression injury.” “Malignant 

Hyperthermia,” which relies on an ICD-9-CM code that was not in use in 1997 was not assessed. 

The measures with the greatest amount of hospital level variation in absolute magnitude are 

“Decubitus ulcer in high risk patients,” “3rd or 4th degree obstetric laceration” and “In-hospital 

fractures related to falls.” 

Also like the accepted PSIs, the hospital level variation tends to be skewed toward the 

right, meaning that most hospitals are slightly less than the mean, with a long right-hand tail of 

hospitals with higher rates. The most highly skewed measures are “In-hospital fractures possibly 
141

related to falls,” “Wound complication of vaginal delivery,” “Uterine rupture,” and “Aspiration 

pneumonia,” with a median skew statistic among all indicators of 9.2 which primarily reflects the 

low rates of occurrence, meaning that most providers have rates near zero, giving little latitude 

for a left-hand tail to the distribution. 

Risk Adjustment 

 Overall, age-gender risk adjustment tended to reduce the level of apparent hospital level 

variation by about 0.4% (see Appendix G, Table 11). Given the low rate of occurrence, “Intraoperative nerve compression injury” was not included in the risk adjustment. The impact was 

greatest on “Postoperative iatrogenic complication – nervous system” and “Reopening of a 

surgical site,” and least on “Post-Operative AMI.” The rates tend to be slightly more skewed, 

meaning that differences in the age-gender mix of the population at-risk masked some of the 

difference in rates. 

Relative to age-gender adjustment, the overall impact of DRG adjustment on the hospital 

level variation was much greater, reducing variation by about 3.8% (see Appendix G, Table 12). 

Comorbidity adjustment decreased the apparent variation among hospitals by 1.1%. DRG risk 

adjustment had the biggest impact on “Postoperative iatrogenic complications – cardiac,” 

“Decubitus ulcer in high risk patients” and “Reopening of a surgical site.” Comorbidity risk 

adjustment had the biggest impact on “Decubitus ulcer in high risk patients,” “Other obstetric 

complications” and “Reopening of a surgical site.” 

Reliability Adjustment 

 The effect of the reliability adjustment, based only on univariate smoothing methods, was 

examined along with the statistics on the signal standard deviation, signal share and signal ratio 

(See Appendix G, Table 13). Hospitals with fewer than three patients in the denominator were 

not included in the reliability adjustment. Overall, the reliability adjustment reduced the hospital 

level variation dramatically. On average, one-half of the apparent hospital level variation, even 

after risk adjustment, was estimated to be attributable to noise. The measures that were affected 

the most by reliability adjustment were “Uterine rupture,” “In-hospital fractures possibly related 

to falls” and “Wound complication of vaginal delivery.” “Aspiration pneumonia,” 

“Postoperative AMI” and “Intra-operative nerve compression injury” had no signal, meaning no 

systematic hospital level variation. The measures that were impacted the least were “3rd or 4th 

degree obstetric laceration,” “Other obstetric complications” and “Postoperative iatrogenic 

complication – cardiac.” 

Univariate Smoothing Statistics 

Like the MSX statistics, the univariate smoothing statistics give estimates of the degree 

of total hospital level variation accounted for by signal and noise, and the degree of total 

variation (hospital and patient) accounted for by signal. Signal standard deviation is an estimate 

of the systematic variation (‘signal’) among hospitals. The measures with the most signal are 

“Decubitus ulcer in high risk patients,” “3rd or 4th degree obstetric laceration” and 

“Postoperative iatrogenic complications - cardiac.” The measures with the least signal are 

“Uterine rupture” and “Wound complication of vaginal delivery,” in addition to “Aspiration 
142

pneumonia,” “Postoperative AMI” and “Intra-operative nerve compression injury” which had no 

signal. 

The signal share is a measure of the share of total variation (hospital and patient) 

accounted for by the signal. The measures with the higher signal share are “3rd or 4th degree 

obstetric laceration,” “Decubitus ulcer in high risk patients” and “Postoperative iatrogenic 

complications - cardiac.” The overall low level of the share of total variation accounted for by 

hospitals is an indication that there are many other factors that influence these rates besides the 

hospital. 

 Finally, signal ratio is a measure of how much of the observed variation is signal and how 

much is noise. The higher the signal ratio, the more likely that observed differences in risk 

adjusted rates reflect true differences in hospital performance. Indicators with the highest signal 

ratio are “3rd or 4th degree obstetric laceration,” “Postoperative iatrogenic complication – 

cardiac” and “Other obstetric complication.” Indicators with the lowest signal ratio are “Uterine 

rupture,” “Wound complication of vaginal delivery” and “CABG after PTCA.” 

Minimum Bias 

 Bias was measured using the same techniques as were used in the analyses of the 

accepted indicators (See Appendix G, Table 14). The same caveats apply to the experimental 

indicators as the accepted indicators. According to the rank correlation, the indicators most 

affected in terms of relative rank are “Postoperative iatrogenic complications – cardiac,” 

“Decubitus ulcer in high risk patients” and “Reopening of a surgical site.” The least affected 

indicators are “CABG after PTCA” and “3rd or 4th degree obstetric laceration,” which was not 

included in the DRG risk adjustment, because obstetric DRGs are divided only by the mode of 

delivery and the presence or absence of complications or comorbidities. “CABG after PTCA” is 

similar. 

Overall, if one were to create a simple score based on the five measures of potential bias 

(ranking each indicator 1 to 17, and summing the ranks), the most biased measures are 

“Postoperative iatrogenic complications – cardiac,” “Decubitus ulcer in high risk patients,” 

“Reopening of a surgical site” and “Postoperative iatrogenic complication - nervous system.” 

The least biased measures are “CABG after PTCA” and “3rd or 4th degree obstetric laceration.” 

Similar to the accepted indicators, caveats about interpretation of bias are necessary. In addition, 

the experimental indicators are not considered a related set, so comparisons across indicators are 

not as appropriate as in the case of accepted indicators where they are at least related based on 

their more likely detection of potentially preventable adverse events. 

Accepted Area Indicators 

Unadjusted and adjusted area level rates were also calculated for the area level indicators 

(see Appendix G, Table 15). The unit of analysis is the MSA or county (in rural areas). These six 

indicators are accepted patient safety indicators that were modified into area indicators to assess 

the total incidence of the adverse event within geographic areas. The modification generally was 

to use principal rather than secondary diagnosis codes, and to use the area population as the 

denominator. The number of additional adverse events identified using the area definition is 

listed in Table 19. 
143

Table 19. Additional Cases Identified by Area Level Indicators 

Number of adverse events 

Indicator 

Hospital 

Definition 

Area 

Definition % Increase 

Iatrogenic pneumothorax 16,815 19,892 16.8% 

Transfusion reaction 131 142 8.1% 

Infection due to medical care 27,457 49,419 58.8% 

Wound dehiscence 2,401 2,609 8.3% 

Foreign body left in during 

procedure 

1,631 1,943 17.5% 

Technical difficulty with 

procedure 

46,707 50,659 8.1% 

The rates vary considerably across measures, from a high a 23.5 per 100,000 population 

for “Infection due to medical care” to a low of 0.08 per 100,000 for “Transfusion reactions” 

(which represents 142 cases in the National SID in 1997) (See Appendix G, Table 15). 

The apparent standard deviations (unadjusted for reliability) also vary considerably 

among the measures, from a high of 43.7 per 100,000 for “Technical difficulty with procedure” 

(relative to a mean of 23.5 per 100,000) to a low of less than 2.1 per 100,000 for “Foreign body 

left in during procedure” and “Transfusion reaction.” The measures with the greatest amount of 

area level variation in absolute magnitude are “Technical difficulty with procedure,” “Infection 

due to medical care,” and “Iatrogenic pneumothorax.” 

Risk Adjustment 

 Only age and gender risk adjustment, with age-gender interactions, was applied to the 

area measures. The age groups are the standard age categories used by the Census Bureau in 

their descriptive statistics, namely 0-4, 5-9, 10-14, 15-19, 20-24, 25-29, 30-34, 35-39, 40-44, 45-

49, 50-54, 55-59, 60-64, 65-69, 70-74, 75-79, 80-84, and 85+. 

 Overall, age-gender risk adjustment tended to increase the level of apparent hospital level 

variation by about 8% (See Appendix G, Table 15). A similar increase was noted for all six area 

level indicators. The rates tend to be slightly more skewed after adjustment for age and gender, 

meaning that the age and gender distribution among the counties was obscuring some of the true 

differences in rates. 
144
145

Chapter 4. Conclusions 

This project took a four pronged approach to the identification, development and 

evaluation of PSIs. First, literature was reviewed for general background about patient safety 

measures that are or could be specified from administrative data. Second, a diverse group of 

clinicians assessed the face validity of potential PSIs, using an adaptation of the RAND/UCLA 

Appropriateness methods. Third, professionals who abstract the medical records to assign ICD9-CM codes and other resources on coding were consulted for specific concerns about whether 

the intent of an indicator could be implemented well based on current coding guidelines. Finally, 

the most promising measures were statistically analyzed using routinely collected discharge data 

from hospitals in order to determine rates, examine effects of risk and reliability adjustments, and 

to make comparisons among the indicators. 

 When examining the results of this report, it is useful to return to the original framework 

in which two types of potential indicators were discussed. The first type of indicator is that 

which is likely to reflect medical error. These indicators are difficult to define using 

administrative data. Few adverse events are clear cut enough for this designation, with most 

having a variety of causes in addition to potential medical error leading to the adverse event, 

including underlying patient health and factors that do not vary systematically. As expected, 

physician panelists rated few indicators as very likely to reflect medical error. Six indicators 

were rated as such by most panelists: “Decubitus ulcer,” “Iatrogenic pneumothorax,” 

“Transfusion reaction,” “Complications of anesthesia,” “Foreign body accidentally left during 

procedure,” and “In-hospital fracture.” However, two of these indicators could not be defined 

using administrative data exactly as the panel specified in order to reduce contamination with 

less preventable complications (“Iatrogenic pneumothorax,” and “In-hospital fracture”), and two 

suffer from serious concerns regarding coding, presence on admission and heterogeneous 

severity included within the code (“Decubitus ulcer” and “Complications of anesthesia”). Thus, 

only two indicators remained that could be defined as “most likely to reflect medical error,” 

those being “Transfusion reaction” and “Foreign body left in during a procedure.” As is expected 

for indicators of this type, these indicators proved to be very rare with less than 1 per 10,000 

cases at risk. Application of statistical tests of precision was limited by the fact that these 

indicators had no systematic variation. This confirms that these indicators are best used as casefinding indicators, or as area indicators to examine prevalence of these errors, as the rates of 

these indicators are mostly driven by non-systematic variation. 

 All other indicators that were rated as acceptable by panelists, fall into that more broad 

category of indicators which do not clearly identify medical error, but may reflect some quality 

concerns, including a potential for medical error. In general these indicators fall somewhere on a 

spectrum of preventability, with not every case being avoidable given optimal quality of care. 

Some indicators have a higher degree of preventability than others, but factors such as provider 

case mix and non-systematic variation may influence the overall preventability inherent in an 

indicator. For this reason it is impossible to “rank” these indicators as “more likely to reflect 

medical error” to “less likely to reflect medical error”, although panelists’ ratings of 

preventability may provide some guidance from one source of face validity. In addition, the 

source of “error” may vary by provider and over time, reinforcing the screening use of these 

indicators – some may be primarily caused by human error and others by system problems. 

Because of these variations within each indicator, a single case “flagged” by any of these 
146

indicators may or may not have been preventable through optimal care, and thus these indicators 

are less efficient as case finding tools. 

 Despite the relative difficulty of these indicators in identifying specific cases where 

medical error may have occured, they can be rather useful when examining rates of events. 

Inasmuch as rates are somewhat stable over time and represent systematic differences, these 

differences are likely to reflect true differences in the occurrence of a complication in patient 

populations. Individual complexities of each case influence the overall rate of a complication 

much less than the specific outcome for that case, and thus, non-systematic differences in patient 

complexity are more likely to be “washed out.” Systematic differences due to causes besides true 

quality problems (e.g., case mix or coding practices) remain a concern for these indicators, as 

such bias may cause good quality providers to appear poor. Adequate risk adjustment, or 

refraining from comparing dissimilar providers would aid in this problem, but perfect methods 

are unlikely even with the best of data. In addition, while these indicators demonstrated some 

systematic variation, much of the variation between providers remains at the discharge level. 

This means that small differences between providers, even with perfect risk adjustment, may not 

actually reflect true differences in performance for these indicators. However, larger differences 

and differences that persist over time are more likely to reflect true differences, and are useful in 

identifying probable areas of concern for further investigation. Simply put, because of the nature 

of these indicators, they should not be used as a metric of absolute performance (e.g., for grading 

of providers or public reporting that compares providers). However, these indicators may be 

particularly useful as a low cost screen for potential quality and safety problems. Where a 

provider has a higher rate for a particular indicator than a benchmark, an extraction of additional 

information on the patients flagged by the indicator would likely lead to either of two positive 

outcomes – 1.) reassurance that there is not a quality problem, but a data gathering inadequacy 

that perhaps could be improved at the local or national level to improve the ability to detect 

quality problems, or 2.) identification of the source of the high rate that requires improvement in 

processes or systems of care, which would benefit the quality of care for future patients. 

 During the course of the study, it became apparent that the obstetric indicators should be 

viewed differently than the other non-obstetric indicators. In general, these indicators had a 

higher rate, more variation, and thus higher precision. Risk adjustment available for these 

indicators was minimal, and thus, systematic bias related to case mix could not be assessed. 

Finally, examination of the panel results and comparison of decisions made by non-obstetric 

panels with those made by the obstetric panels suggested that the obstetric indicators included 

complications expressly rejected by the other panels. The complications may have less 

association with medical error or process failures, although this assertion cannot be verified with 

this study. 

For the best-performing subset of PSIs, this project has demonstrated that rates of adverse 

events differs substantially and significantly across hospitals. The literature review and the 

findings from the clinical panels provide evidence to suggest that a number of discharge-based 

PSIs may be useful screens for organizations, purchasers, and policymakers to identify potential 

safety problems at the hospital level, as well as to document systematic area level differences in 

potential patient safety problems. 
147

Potential Uses of PSIs 

At the national or state level, these indicators could be used to monitor the frequency of 

potential patient safety problems, to determine whether the rates are increasing or decreasing 

over time, and to explore large variations among settings of care. As noted by panelists, not all 

indicators are equally poised to identify potential patient safety problems. This report was 

intended to provide evidence on the development and face validity of these indicators, and the 

evidence available does not allow for fine tuned classifications of indicators which are very 

likely to detect patient safety problems from those that are less likely. Future research will 

provide additional evidence that will inform the best uses of these indicators. 

While the indicators were primarily developed at the hospital level, some were also 

implemented to provide an analogous area level measure, and analyses show that additional 

cases are in fact identified that correspond to care received at one institution, and the potentially 

iatrogenic complication addressed in another hospital. Clearly, the locus of control and the 

ability to study the potential underlying causes for an adverse event is simpler in the case of the 

hospital level PSIs. However, trends over time in area rates, as well as aggregations of the 

hospital level rates are likely to reveal points of leverage outside of individual institutions. No 

measure is ideally suited to every purpose. Methods of aggregating across groups of PSIs still 

need to be tested. This report provides the background for “safe” use of a tool that has the 

potential to guide prevention of medical error, reductions of potentially preventable 

complications, and quality improvement in general. Table 20 summarizes additional information 

on uses of the PSIs. 

Because the PSIs are intended for use as an initial, efficient screen to target areas for 

further data exploration, the primary goal is to find indicators that guide those interested in 

quality improvement and patient safety to areas where there are systematic differences between 

hospitals or geographic areas. These systematic differences may relate to underlying processes or 

structures that an organization could change to improve patient care and safety. These errors may 

be attributed to human error on the part of physicians or nurses, or system deficiencies or both. 

On the other hand, the systematic differences will sometimes correspond to coding practices, 

patient characteristics not captured by administrative data, or other factors. These will be dead 

ends to some degree. In the application of these PSIs, users will have an opportunity to 

determine how well patient safety problems are identified at the level of groups of patients. 

Sharing experiences with these PSIs, researchers and health care practitioners will have a chance 

to build on the information highlighted in this report about each indicator, as well as the set of 

PSIs. 

Thus, application of these indicators to a variety of settings and additional data gathering 

will accomplish two vital next steps for patient safety. First, these attempts will shed light on 

which indicators and under what circumstances PSIs provide useful information. Second, in 

those cases where potentially preventable errors are identified with relative ease through these 

tools, health care providers and managers will have an opportunity to implement potential 

preventative strategies ranging from technologies to processes to new ways of organizing care. 

The effectiveness of these strategies can be assessed at many levels, including the effects on the 

PSI rates. 
148

Table 20. Use of Patient Safety Indicators 

User Inappropriate Use Scenario Appropriate Use Scenario 

Case-finding indicators  Provider A hospital uses the transfusion reaction 

indicator to punish a physician involved in the incident. PROBLEM: Flagging of the case does not necessarily guarantee that a medical error has occurred at the physician or system level. Further such punishment may reduce voluntary reporting of errors. 

A hospital identifies a case of transfusion reaction occurring in-hospital. They undertake a root-cause analysis to highlight potential problems that may be resolved in order to prevent future events. 

 Public Health A public health organization uses provider 

level indicators for use in formal evaluation of providers in area. PROBLEM: Flagging of cases does not ensure medical error and such use may decrease reporting. 

A state health department uses the area level indicator for foreign body to survey the incidence of such events in that state. 

 Research Researchers compare rates of case-based 

indicators to identify providers with more medical error to those with less. PROBLEM: Lack of signal between providers makes such comparisons unreliable. 

Researchers use these indicators to identify cases in a large database wheevents related to medical error may have occurred. They examine the characteristics of patients flagged compared to matched patients not flagged. 

Rate-based indicators  Provider A hospital uses an indicator to identify 

differences in rates between physicians within the hospital. PROBLEM: The number of cases by physician is likely to be zero or very small. Even if such rates are used for purely quality improvement initiatives, physician level rates for most indicators are likely to be unreliable. 

A teaching hospital observes that their rate of decubitus ulcer is consistenhigher than the peer group average for other teaching hospitals in thregion. After ruling out such explanations as differences in coding screening practices, and assuring that case mix is comparable to othteaching hospitals, the hospital uses resources such as peer-reviewliterature and government reports to identify processes of care or systfailures that may account for the higher rate. 

 Public Health A state health department publishes the 

rate for each indicator by provider in a report to highlight quality concerns by provider. PROBLEM: These indicators are not designed to be used for public reporting by provider, and such use may lead to incorrect conclusions about provider quality. 

A state health department uses the area level infection due to medical caindicator to examine the overall rate of this indicator in the state. Thcompare the result of the area level indicator to the provider level indicator determine how many of these complications occur post-discharge or on outpatient basis, and are serious enough to require hospitalization later. 

 Research Researchers use quality indicators as a 

definitive measurement of quality. PROBLEM: Many factors besides quality may contribute to rate differences. 

Researchers use quality indicators to examine the relationship between hrates on PSIs with high rates on other quality measures, such as mortameasures. 
149

Relationship of This Project to Other Quality Initiatives 

This report is one of many efforts to clarify the problem of patient safety in the 

national health care system. Together these efforts are likely to provide a more complete 

picture of medical error. Other indicator or measurement sets have been developed, some 

of which were used in the development of this measure set. Table 21 describes these 

measures and their relationship to the PSIs. 

 Another USCF-Stanford Evidence-based Practice Center report evaluated the 

practices that may improve patient safety in a hospital setting. Some practices evaluated 

in the report are designed to reduce the events measured in some indicators. Table 22 

outlines the overlap between these reports. As users of the PSIs identify potential safety 

problems, references to scientific evaluations such as Making Health Care Safer: A 

Critical Analysis of Patient Safety Practices2 will be vital in determining appropriate 

interventions and potential failures in processes. 
150

Table 21. Relationship of PSIs to Other Indicator Sets 

Description Relationship to PSIs 

VA National Surgical Quality Improvement Program (NSQIP)148

An ongoing QI program by VA since 1994. Standardized data collection on adverse events following surgery. 

Data collection utilizes standardized definiclinical criteria in some cases. Although deindicators are similar to the PSIs . Adverse over the years. Data on post operative pnedeficit, renal failure, DVT, PE, wound dehissepsis capture some of the same complicabut operationalizations are vastly different

Miller et al PSIs (published in Health Services Research)17

A set of 12 PSIs and a summary measure designed to maximize potential of identifying medical error through administrative data. 

PSIs were designed as case finding tools fwere used as a starting point for the PSIs ifinal definitions differ between the two setsrejected by the panels. Details are available 

Complications Screening Program7 A set of indicators designed to flag complications that occur in-hospital 

(e.g., in-hospital hip fracture, postoperative pneumonia). This set has been validated and studied widely. 

The CSP indicators that have been shown identifying in hospital complications were for the PSIs in this report, although final dethe two sets. Some CSP indicators were reDetails are available in Appendix H. 

National Quality Forum’s (NQF) reportable events5 A set of case-finding tools designed to flag cases of potential medical 

error. These events are defined to be serious adverse events resulting in death or disability (e.g., wrong site surgery, serious medication error). 

The NQFs reportable events are based on dinformation, unlike the PSIs. Most of the reidentifiable using administrative data. Definaccidentally left during a procedure, transfdecubitus ulcer are included, but differ from 

National Quality Report (NQR)168 A Congressionally mandated report outlining the nationwide state of 

healthcare quality. This report will not compare providers. The first set of indicators and the accompanying report are due in 2003. 

The NQR is separate from the PSIs, althougto be considered for the report. The report topics besides patient safety, and will utiliz

sources. 
151

Table 22. Indicator Level Practices Included in Making Health Care Safer aIndicator name Corresponding chapter in practices report Practices reviewed Complications of anesthesia None None Death in low mortality DRGs None None Decubitus ulcer Prevention of Pressure Ulcers in Older Patients 

(Chapter 27) 

Pressure relieving devices 

Failure to rescue None None Foreign body accidentally left during procedure 

The Retained Surgical Sponge (Chapter 22) Sponge and instrument counts 

Iatrogenic pneumothorax Ultrasound Guidance of Central Vein 

Catheterization (Chapter 21) 

Ultrasound guidance of central vein cathe

Infection due to medical care Prevention of Intravascular Catheter-Associated 

Infections (Chapter 16) 

Maximum barrier precautions during centinsertion, use of central venous catheters antiseptic agents, use of chlorhexidine glvenous catheter insertion site, other prac

Postoperative hip fracture Prevention of Falls in Hospitalized or 

Institutionalized Older People (Chapter 26) 

ID bracelets for high-risk patients, interveof physical restraints, bed alarms, speciainjuries, hip protectors. 

Postoperative hemorrhage or hematoma None None Postoperative physiological and metabolic derangement 

None None 

Postoperative respiratory failure None None Postoperative pulmonary embolism or deep venous thrombosis 

Prevention of Venous Thromboembolism (Chapter 31) 

Graduated elastic stockings, intermittent dose unfractionated heparin, low moleculand aspirin. 

Postoperative wound dehiscence Prevention of Surgical Site Infections (Chapter 20) (Wound dehiscence only accounts for som

considered in this chapter.) Prophylactic antibiotics, perioperative noperioperative oxygen, perioperative gluco

Postoperative sepsis None None Technical difficulty with procedure None None Transfusion reaction None (Mentioned in context of Chapter 43. 

Prevention of Misidentifications, a major cause of transfusion reactions) 

None 

Birth trauma – injury to neonate None None Obstetric trauma (all delivery types) None None Obstetric wound complications – c-section Prevention of Surgical Site Infections (Chapter 20) Reviewed in the context of all surgical wo

wound dehiscence. 

Post-partum urinary tract infection Prevention of Nosocomial Urinary Tract Infections 

(Chapter 15) 

Reviewed in the context of all hospitalized 

a This table outlines practices reviewed in the EPC Evidence Report, Making Health Care Safer: A Critical Review of Patient Safety Practices.2 This r

independently of indicator development, therefore chapters listed may only briefly address the adverse event described by the indicator, and may not eentire population at risk. 
152

Limitations and Future Research 

 The methodology of this report included several key choices that led to some 

limitations. The goal of this study was to identify and evaluate indicators that could be 

constructed using administrative data, because these data are readily available and less 

costly than more detailed clinical data. We chose to limit our search to indicators that 

could be operationalized currently, instead of identifying indicators which have the 

potential for being operationalized with administrative data in the future. As a result, 

those patient safety concerns addressed in this indicator set are only a subset of the most 

prevalent, important or preventable problems. Many important concerns cannot currently 

be monitored well using administrative data (e.g., adverse drug events). As administrative 

data improves, many more important and potentially more useful indicators are likely to 

emerge. 

 Just as administrative data limited specific indicators chosen, the use of 

administrative data tends to favor specific types of indicators. The PSIs evaluated in this 

report contain a large proportion of surgical indicators, rather than medical or psychiatric. 

This is not to imply that patient safety is not a concern outside of surgery, rather, these 

indicators tend to be more feasible to define using administrative data for surgical 

populations. Medical complications are often difficult to distinguish from comorbidities 

that are present on admission.13 In addition medical populations tend to be more 

heterogeneous than surgical, especially elective surgical populations, making it difficult 

to account for case-mix. Panelists often felt that indicators were more likely to reflect 

preventable events when limited to elective surgical admissions. As data become better, 

the addition of patient safety indicators for the medical and psychiatric populations will 

be critical. 

 The intended purpose of these indicators guided the choices made in specifying 

them. Specifically, tradeoffs between specificity (e.g., the likelihood that the indicator 

will not flag cases that do not qualify as a patient safety event) and sensitivity (e.g., the 

likelihood that the indicator will flag cases that do qualify as a patient safety event) were 

considered in conjunction with the use or misuse of these indicators as they move into the 

public sector. Many complications included in these indicators are more likely in some 

specified subpopulation. For instance, decubitus ulcers are more likely in patients with 

paralysis. Since they are more likely to occur, complications in these populations may 

also be less preventable or be more likely to be present on admission. Nonetheless, 

interventions to prevent complications may be particularly important in these high risk 

groups – it is these very patients for which providers need to be particularly vigilant in 

preventing that complication from occurring. The inclusion of high risk patients, given 

the limitations of these indicators, would ultimately mean a decrease in the specificity of 

these indicators, or the ability to have a high yield of patients in whom true safety 

problems are present. However, to exclude these patients, as was done for many 

indicators, would sacrifice the sensitivity of these indicators, or the ability to identify as 

many patients as possible for whom true safety problems may be present. 

 The evaluation of indicators included in this report reflects only part of the 

validity testing needed. The structured panel review was intended to assess the face 

validity of the indicators. However, limitations of such a review should be noted. Several 

panels were utilized in the review of the indicators; thus panel level differences may be 
153

present, leading to differences in the evaluation of indicators. Further, panelists were not 

required to support opinion with empirical evidence from the literature, thus panelists’ 

review represents the opinions of these clinicians. Also, panelists may have interpreted 

the questions about characteristics of the indicators differently, which is particularly 

problematic for small sample sizes. Finally, although children were included in the 

population at risk for most indicators, clinicians that care for children were not included 

in the non-obstetric panels. Team members that specialize in pediatrics (PSR, MM) 

advised regarding the applicability of these indicators along the way. However, further 

panelist review and research into the applicability of these indicators to children is 

necessary. The empirical analyses were intended to demonstrate the precision and bias of 

the indicator; these tests are more descriptive then evaluative in nature. The tests of 

precision are affected by the frequency of an event; thus higher frequency indicators tend 

to have higher precision. This does not imply that these indicators are in fact superior to 

other indicators. In addition, bias tests were not intended to rule out all potential bias, as 

indicators that are not affected by risk adjustment may be biased in a way that is not 

captured by the limited risk adjustment utilized in this study. This is a particular problem 

for obstetric indicators, where risk adjustment often only accounted for the age of the 

mother, as other appropriate risk adjustment factors were generally not available in the 

data. 

 These initial evaluations of these indicators demonstrated that they are promising, 

both in terms of face validity and relative precision. Further research should continue to 

explore the validity of these indicators, such as the construct validity of these indicators. 

This research should validate the indicators using other data, such as detailed chart data. 

Validation should focus on the sensitivity and specificity of these indicators in detecting 

the occurrence of a complication, the extent to which failures in processes of care at the 

system or individual level are captured using these indicators, the relationship of these 

indicators with other measures of quality, such as mortality, and explorations of bias and 

risk adjustment. A recent study examined the relationship between ICD-9-CM identified 

complications and those identified through standardized clinical data collection.148

Similar efforts, comparing these PSIs with other measures of patient safety using other 

data sources will shed additional light on the comparative validity of these indicators. 

Research may also utilize additional data elements, such as “present on admission 

coding” available in some states to identify the ability of these indicators to detect 

complications occurring in-hospital. All validity research must include thoughtful 

deliberations about the standard of validity for these types of indicators. Given that these 

indicators are intended for screening purposes, a lower standard of construct validity (the 

ability of these indicators to detect patient safety problems) may be appropriate than 

indicators intended as definitive measures. 

In addition to research aimed at validating these PSIs, future research should 

focus on the appropriate and practical application of these indicators. Effort should be put 

forth in establishing appropriate and potentially flexible benchmarks for the PSIs, such as 

means, medians, modes, or points of inflection (i.e., point where the slope of the 

distribution changes) of peer group, regional or statewide providers. Careful attention 

should also be paid to the understanding of these indicators by clinicians and other end 

users to ensure that data are appropriately interpreted and fully utilized. 
154

 The future of patient safety measurement depends in part on the improvement of 

administrative data. The addition of timing variables may prove particularly useful. In 

identifying complications it is necessary to determine whether or not a complication was 

present on admission, or occurred during the hospitalization. While some of the 

complications that are present on admission may indeed reflect adverse events of care in 

a previous hospitalization or outpatient care, many may reflect comorbidities instead of 

complications. Some states have included a “sixth digit,” present on admission 

designation. These are promising for use in quality indicators. Additional timing 

distinctions were mentioned during the panel discussions. Specifically, for some 

complications, occurring in close temporal proximity to surgery or admission was more 

or less desirable than timing that was more remote. For instance, panelists suggested that 

aspirations leading to pneumonia that occurred during or immediately after surgery were 

potentially preventable complications, but that aspirations that occur later in the 

hospitalization were less preventable. Thus, while administrative data do not currently 

contain such distinctions, the timing of an adverse event may prove to be a useful data 

element. 

 The second area of data improvement would be to allow the linking of hospital 

data over time and with outpatient data. Many complications may not occur or be 

diagnosed until after discharge, especially when length of stays are relatively short. 

Presumably these complications either result in another admission, or are diagnosed and 

treated on an outpatient basis. For example, the area-level indicators “Infection due to 

medical care” identified almost twice as many complications as the provider-level 

indicator, suggesting that many infections occur after discharge or following outpatient 

care and eventually result in hospitalization. Currently, these complications are not 

detected by the provider-level PSIs, potentially producing misleading results. The 

inclusion of complications that occur after discharge would increase the sensitivity of the 

PSIs. 

 As highlighted during the structured panel review, it is essential that users 

understand the limitations and benefits of these indicators in practical use. Clarification 

about data, vigilance in ensuring the proper use of these indicators, updating indicators to 

reflect new evidence and practices, and continuous, open communication between 

clinicians, medical coders and users of these indicators will be essential for their 

continued success. 

The current development and evaluation effort will best be augmented by a 

continuous communication loop between users of these measures, researchers interested 

in improving these measures, and policy makers with influence over the resources aimed 

at data collection. Surely, some indicators will be more useful than others, based on 

further information and research about them. The conclusions of the companion technical 

report on quality indicators from the EPC, and published by AHRQ 

[http://www.achq.gov/data/hcup/qirefine.htm], offers further pertinent detail about future 

research and activities aimed at improvements in the ability to measure the consequences 

– intended and unintended—of medical care. 
155

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Appendix A 

Inventory of Potential Patient Safety Indicators 

This appendix lists the indicators identified by the literature review and personal contacts of the 

project team. To qualify for this list, the indicator needs to measure a potentially preventable 

complication of care. In addition, it must be possible or likely that the indicator could be defined 

based on administrative, unlinked data. For each indicator, the current users or developer are 

shown, whether the indicator was reviewed by a clinical panel in this project, whether the indicator 

was evaluated empirically, and why it was selected for or excluded from panel review. 
See References at end of table. 

Note: Almost without exception, original indicator definition differs from final tested definition, based on panel feedback and coding c

“Panel” column means that the indicator, in some form, was reviewed by the clinical panels for this project. The “Empirical” column dindicators that were accepted (“x”) from those classified as experimental (“e”). 

166

APPENDIX A. INVENTORY OF POTENTIAL PATIENT SAFETY INDICATORS 

Measure Type and Clinical 

Domain 

Indicator Name Current Users or 

Developers 

Pane

l 

Emp

i

r

i

ca

l 

Reason for selecti

exclusion from clini

review. 

Proxy-Outcome measures:  All discharges, length of 

stay 

• HQI ValiData Conceptually less connect

safety compared with nex

 Conditional length of stay • Literature 

Silber 

x Adequate previous validat

 Unexpected length of stay • Literature 

Kuykendall1

x Adequate previous validat

Outcomes measures: Aspiration pneumonia • Complications 

Screening Program 

• Needleman 

and Buerhaus2

• University 

HealthSystem Consortium 

x e Adequate previous validat

 Bacteraemia • Literature: 

Ansari (Australia)3

 Related to septicemia indi

 CABG following PTCA • University 

HealthSystem Consortium 

• Literature4-12

x e Adequate previous validat

 Cardiac event or emergency • Complications 

Screening Program 

 No previous validation. 
See References at end of table. 

Note: Almost without exception, original indicator definition differs from final tested definition, based on panel feedback and coding c

“Panel” column means that the indicator, in some form, was reviewed by the clinical panels for this project. The “Empirical” column dindicators that were accepted (“x”) from those classified as experimental (“e”). 

167

 Cellulitis • Complications 

Screening Program 

 No previous validation. 

 Complications of 

anesthesia/ Anesthesia related events 

• Complications 

Screening Program 

x x Final definition differs sub

from original CSP indicat

 Death in low mortality 

DRGs 

• Hannan et al.13 x x Adequate previous validat

 Death within one or two 

days of surgical procedure 

• Hannan et al.13

• University 

HealthSystem Consortium 

 Decubitus Ulcer • Complications 

Screening Program 

• Needleman 

and Buerhaus2

• American 

Nurses Association 

• California 

Nursing Outcomes Coalition 

 x Subset of cellulitis indicat

after review of ICD-9-CM 

 Decubitus Ulcer in High 

Risk Patient 

• none e Suggested by panelists. 

 Dosage complications • none x Created after review of IC

codes. 

 Failure to rescue (2 

alternative definitions) 

• Silber et al.14• Needleman 

and Buerhaus2

x x Adequate previous validat

 Foreign body left in during 

procedure 

• Miller et al.15

• McKesson Health 

Systems Solutions

x x Created from codes in sen

codes and a review of ICDcodes. 

 Iatrogenic hypotension • Miller et al 

PSIs15

x Created after review of IC

codes. 
See References at end of table. 

Note: Almost without exception, original indicator definition differs from final tested definition, based on panel feedback and coding c

“Panel” column means that the indicator, in some form, was reviewed by the clinical panels for this project. The “Empirical” column dindicators that were accepted (“x”) from those classified as experimental (“e”). 

168

 Iatrogenic pneumothorax • Miller et al 

PSIs15

x x Created after review of IC

codes. 

 Infection due to medical 

care 

• Miller et al 

PSIs15

x x Created after review of IC

codes and Complications program. 

 In-hospital burns • Hannan et al.13 Inadequate previous valid In-hospital fractures 

possibly related to falls 

• None x e Suggested by panel as exp

fracture indicator. 

 In-hospital hip fracture (and 

falls) 

• Complications 

Screening Program 

• Needleman 

and Buerhaus2

• American 

Nurses Association 

• California 

Nursing Outcomes Coalition 

x x Adequate previous validat

definition excluded falls. 

 Intestinal infection due to C. 

difficile

• None x Subset of postoperative in

indicator. Created after re9-CM codes. 

 Intraoperative nerve 

compression injuries 

• None x e Suggested by panelists. 

 Malignant hyperthermia • None x e Suggested by panelists ba

discussion of complicationanesthesia indicator. 

 Mechanical complication 

(Device implant) 

• Complications 

Screening Program 

• University 

HealthSystem Consortium 

• HCUP 

 Poor validity in published 
See References at end of table. 

Note: Almost without exception, original indicator definition differs from final tested definition, based on panel feedback and coding c

“Panel” column means that the indicator, in some form, was reviewed by the clinical panels for this project. The “Empirical” column dindicators that were accepted (“x”) from those classified as experimental (“e”). 

169

 Miscellaneous 

complications 

• Complications 

Screening Program 

 Inadequate previous valid

 Nosocomial/iatrogenic 

disease 

• Sagamore 

Health 

 Requires additional data. 

 Peri-operative 

complications 

• IMSystem 

• University 

HealthSystem Consortium 

 Proprietary measures. 

 Perforation diagnosis • Miller et al15 Eliminated due to coding  Post- or intraoperative 

shock due to anesthesia 

• Complications 

Screening Program 

 Included in original comp

anesthesia indicator. 

 Postoperative acute 

myocardial infarction (AMI) 

• Complications 

Screening Program 

• University 

HealthSystem Consortium 

• HCUP 

x e Adequate previous validat

 Postoperative cardiac 

anomaly 

• Complications 

Screening Program 

 No previous validation. 

 Postoperative central 

nervous system (CNS) or peripheral (PNS) complication 

• Complications 

Screening Program 

• University 

HealthSystem Consortium 

 No previous validation. 

 Postoperative cerebral 

infarction 

• Complications 

Screening Program 

• University 

HealthSystem Consortium 

 Poor validity in published 
See References at end of table. 

Note: Almost without exception, original indicator definition differs from final tested definition, based on panel feedback and coding c

“Panel” column means that the indicator, in some form, was reviewed by the clinical panels for this project. The “Empirical” column dindicators that were accepted (“x”) from those classified as experimental (“e”). 

170

 Postoperative coma • Complications 

Screening Program 

• Needleman 

and Buerhaus2

 No previous validation. 

 Postoperative GI 

hemorrhage or ulceration following non-GI surgery 

• Complications 

Screening Program 

• University 

HealthSystem Consortium 

• HCUP • Needleman 

and Buerhaus2

 Poor validity in published 

 Postoperative hemorrhage 

or hematoma 

• Complications 

Screening Program 

• HCUP • University 

HealthSystem Consortium 

x x Adequate previous validat

 Postoperative iatrogenic 

complications - Nervous 

• Complications 

Screening Program 

• University 

HealthSystem Consortium 

• HCUP 

x e Adequate previous validat

of CSP/UHC/HCUP indic

 Postoperative Iatrogenic 

Complications -Cardiac 

• Originally part 

of general iatragenic complications indicator (see above) 

x e See above 

 Postoperative Iatrogenic 

Complications -Urinary 

• See above x See above 
See References at end of table. 

Note: Almost without exception, original indicator definition differs from final tested definition, based on panel feedback and coding c

“Panel” column means that the indicator, in some form, was reviewed by the clinical panels for this project. The “Empirical” column dindicators that were accepted (“x”) from those classified as experimental (“e”). 

171

 Postoperative Iatrogenic 

Complications -Respiratory 

• See above x See above 

 Postoperative Iatrogenic 

Complications -Digestive 

• See above x See above 

 Postoperative Iatrogenic 

Complications -Vascular 

• See above x See above 

 Postoperative infections (not 

pneumonia or wound infection) 

• Complications 

Screening Program 

• University 

HealthSyste Consortium 

• Needleman 

and Buerhaus2

 Poor validity in published 

 Postoperative physiologic 

and metabolic derangements 

• Complications 

Screening Program 

• University 

HealthSystem Consortium 

• Needleman 

and Buerhaus2

• Hannan et al.

13

x x Adequate previous validat

 Postoperative pneumonia • Complications 

Screening Program 

• University 

HealthSystem Consortium 

• HCUP 

x Adequate previous validat
See References at end of table. 

Note: Almost without exception, original indicator definition differs from final tested definition, based on panel feedback and coding c

“Panel” column means that the indicator, in some form, was reviewed by the clinical panels for this project. The “Empirical” column dindicators that were accepted (“x”) from those classified as experimental (“e”). 

172

 Postoperative pulmonary 

compromise 

• Complications 

Screening Program 

• University 

HealthSystem Consortium 

• HCUP • Needleman 

and Buerhaus2

x x Adequate previous validat

 Postoperative thrombosis 

and embolism 

• Complications 

Screening Program 

• Ansari 

(Australia)3

• HCUP • Needleman 

and Buerhaus2

• CMS16

x x Adequate previous valida

 Postoperative urinary tract 

complications 

• Complications 

Screening Program 

• HCUP 

 No previous validation. 

 Postoperative wound 

dehiscence 

• Hannan et al.13 x x Subset of the CSP indicato

"Reopening of Surgical Si

 Primary blood infection • IMSystem Related to septicemia indi Reopening of surgical site • Complications 

Screening Program 

• University 

HealthSystem Consortium 

x e Adequate previous validat
See References at end of table. 

Note: Almost without exception, original indicator definition differs from final tested definition, based on panel feedback and coding c

“Panel” column means that the indicator, in some form, was reviewed by the clinical panels for this project. The “Empirical” column dindicators that were accepted (“x”) from those classified as experimental (“e”). 

173

 Return to operating room • Maryland 

Quality Indicator 

• University 

HealthSystem Consortium 

• Ansari 

(Australia) 3

 Requires additional data. 

 Septicemia • Complications 

Screening Program 

• Needleman 

and Buerhaus2

x x Adequate previous validat

 Sentinel events • Complications 

Screening Program 

 Many specific events inclu

separate indicators. 

 Shock or cardiopulmonary 

arrest in hospital 

• Complications 

Screening Program 

• Needleman 

and Buerhaus2

 Inadequate previous valid

 Specific drug events/ 

Complications relating to drugs 

• Complications 

Screening Program 

• Hannan13

 Poor validity in published 

 Surgical patient injury • University 

HealthSystem Consortium 

 Proprietary measure. 

 Surgical technical difficulty • University 

HealthSystem Consortium 

 Proprietary measure. 
See References at end of table. 

Note: Almost without exception, original indicator definition differs from final tested definition, based on panel feedback and coding c

“Panel” column means that the indicator, in some form, was reviewed by the clinical panels for this project. The “Empirical” column dindicators that were accepted (“x”) from those classified as experimental (“e”). 

174

 Suture of laceration 

(Laceration, perforation injury) 

• Complications 

Screening Program 

• Miller et al.15

• University 

HealthSystem Consortium 

x e Suture of laceration is a su

CSP indicator. 

 Technical difficulty with 

care (procedure) 

• Complications 

Screening Program 

• University 

HealthSystem Consortium 

• McKesson 

Health Solutions 

• Miller et al.15

x x Adequate previous validat

 Transfer to other hospital • Literature: 

Bates et al.17

 Requires additional data. 

 Transfusion Reaction/ 

Complications with blood products 

• Complications 

Screening Program 

• Miller et al.15

x x Adequate previous validat

 Vent Pneumonia • IMSystem Requires additional data.  Wound Infection/ Surgical 

site infection 

• Complications 

Screening Program 

• IMSystem • Ansari 

(Australia) 

• CARE • HCUP 

 Poor validity in published 

 Obstetric  Fetal death • none x Created after review of IC

codes, but not actually feaimplement with HCUP da
See References at end of table. 

Note: Almost without exception, original indicator definition differs from final tested definition, based on panel feedback and coding c

“Panel” column means that the indicator, in some form, was reviewed by the clinical panels for this project. The “Empirical” column dindicators that were accepted (“x”) from those classified as experimental (“e”). 

175

 Complications of 

therapeutic abortion 

• none x Created after review of IC

codes, but removed due to operationalization concern

 Birth trauma-injury to 

neonate 

• Miller et al.15

• McKesson Health 

Solutions

x x Created after review of IC

codes. 

 Third or fourth degree 

obstetric laceration 

• JCAHO 

• McKesson 

Health Solutions 

 e Panelists preferred to restr

degree lacerations (part of trauma indicator). 

 Obstetric trauma - vaginal 

without instrument 

• none x x Created after review of IC

codes. 

 Obstetric trauma, - vaginal 

with instrument 

• none x x Created after review of IC

codes. 

 Obstetric trauma - cesarean 

section 

• none x x Created after review of IC

codes. 

 Obstetric wound 

complications - cesarean section delivery 

• none x x Created after review of IC

codes. 

 Obstetric wound 

complications – vaginal delivery 

• none x e Created after review of IC

codes. 

 Obstetric vascular 

complications 

• none x Created after review of IC

codes. 

 Other obstetric 

complications of delivery 

• Miller et al.15 x e Created after review of IC

codes. 

 Post-partum urinary tract 

infection 

• none x x Suggested by panelists. 

 Puerperal infection • none x Created after review of IC

codes. 

 Uterine Rupture • none x e Suggested by panelists.  Psychiatric  Attempted suicide • Sagamore 

Health 

 Requires additional data. 
See References at end of table. 

Note: Almost without exception, original indicator definition differs from final tested definition, based on panel feedback and coding c

“Panel” column means that the indicator, in some form, was reviewed by the clinical panels for this project. The “Empirical” column dindicators that were accepted (“x”) from those classified as experimental (“e”). 

176

 Psychiatric hospital 

termination AMA (Against medical advice) 

• JCAHO 

• University 

HealthSystem Consortium 

 Requires additional data. 
177

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ML, Geraci JM. Identifying complications and 

low provider adherence to normative practices 

using administrative data. Health Serv Res 

1995;30(4):531-54. 

2. Needleman J, Buerhaus PI, Mattke S, 

Stewart M, Zelevinsky K. Nurse Staffing and 

Patient Outcomes in Hospitals. Boston, MA: 

Health Resources Services Administration; 2001 

February 28. Report No.: 230-99-0021. 

3. Ansari MZ, Collopy BT, McDonald IG. 

Establishing thresholds for adverse patient 

outcomes. Int J Qual Health Care 1996;8(3):223-

30. 

4. Ritchie JL, Phillips KA, Luft HS. 

Coronary angioplasty. Statewide experience in 

California. Circulation 1993;88(6):2735-43. 

5. Ritchie JL, Maynard C, Chapko MK, 

Every NR, Martin DC. Association between 

percutaneous transluminal coronary angioplasty 

volumes and outcomes in the Healthcare Cost and 

Utilization Project 1993-1994. Am J Cardiol 

1999;83(4):493-7. 

6. Ho V. Evolution of the volume-outcome 

relation for hospitals performing coronary 

angioplasty. Circulation 2000;101(15):1806-11. 

7. Maynard C, Every NR, Chapko MK, 

Ritchie JL. Institutional volumes and coronary 

angioplasty outcomes before and after the 

introduction of stenting. Eff Clin Pract 

1999;2(3):108-13. 

8. Jollis JG, Peterson ED, DeLong ER, 

Mark DB, Collins SR, Muhlbaier LH, et al. The 

relation between the volume of coronary 

angioplasty procedures at hospitals treating 

Medicare beneficiaries and short-term mortality. 

N Engl J Med 1994;331(24):1625-9. 

9. Jollis JG, Peterson ED, Nelson CL, 

Stafford JA, DeLong ER, Muhlbaier LH, et al. 

Relationship between physician and hospital 

coronary angioplasty volume and outcome in 

elderly patients. Circulation 1997;95(11):2485-

91. 

10. Hannan EL, Racz M, Ryan TJ, 

McCallister BD, Johnson LW, Arani DT, et al. 

Coronary angioplasty volume-outcome 

relationships for hospitals and cardiologists. 

JAMA 1997;277(11):892-8. 

11. McGrath PD, Wennberg DE, Malenka 

DJ, Kellett MA, Jr., Ryan TJ, Jr., JR OM, et al. 

Operator volume and outcomes in 12,998 

percutaneous coronary interventions. Northern 

New England Cardiovascular Disease Study 

Group. J Am Coll Cardiol 1998;31(3):570-6. 

12. McGrath PD, Wennberg DE, Dickens 

JD, Jr., Siewers AE, Lucas FL, Malenka DJ, et al. 

Relation between operator and hospital volume 

and outcomes following percutaneous coronary 

interventions in the era of the coronary stent. 

Jama 2000;284(24):3139-44. 

13. Hannan EL, Bernard HR, O'Donnell JF, 

Kilburn H, Jr. A methodology for targeting 

hospital cases for quality of care record reviews. 

Am J Public Health 1989;79(4):430-6. 

14. Silber JH, Rosenbaum PR, Williams SV, 

Ross RN, Schwartz JS. The relationship between 

choice of outcome measure and hospital rank in 

general surgical procedures: implications for 

quality assessment. Int J Qual Health Care 

1997;9(3):193-200. 

15. Miller M, Elixhauser A, Zhan C, Meyer 

G. Patient Safety Indicators: Using 

Administrative Data to Identify Potential Patient 

Safety Concerns. Health Services Research 

2001;36(6 Part II):110-132. 

16. Dicker R, Han L, Macone J. Quality of 

Care Surveillance Using Administrative Data, 

1996. In: Quality Resume No. 2. Baltimore, MD: 

HCFA; 1998. 

17. Bates DW, O'Neil AC, Petersen LA, Lee 

TH, Brennan TA. Evaluation of screening criteria 

for adverse events in medical patients. Med Care 

1995;33(5):452-62. 
Appendix B 

Clinician Review Panels 

This appendix includes information about the composition of the eight multi-specialty 

panels, and the three surgical panels. Following the identifying name for each panel, the 

indicators reviewed are shown, and then the members of the panel are listed. Finally, the 

professional organization that nominated the panelist is listed. 

 

 181

APPENDIX B. CLINICIAN REVIEW PANELS 

MEDICAL COMPLICATIONS 1 (MULTISPECIALTY)

Indicators Reviewed

Decubitus ulcer 

Infection due to medical care 

Intestinal infection due to C. difficile

In-hospital hip fracture and falls 

In hospital fractures possibly related to falls 

Septicemia 

Desmond Birkett, MD, Surgeon 

Burlington, MA 

Department of General Surgery, Lahey Clinic 

Nominated by the American College of Surgeons 

Eric A. Coleman, MD, MPH, Geriatrician 

Denver, CO 

University of Colorado Health Science Center 

Nominated by the American Geriatric Society 

John Crabtree, MD, Surgeon 

Bellflower, CA 

Kaiser Permanente Bellflower Medical Center 

Nominated by the American College of Surgeons 

Kathleen Ellstrom, MS, PhD, Critical care nurse 

Grand Terrace, CA 

Kaiser Foundation Hospital – Riverside 

Nominated by the American Association of Critical-Care Nurses 

Sunil Kripalani, MD, MSc, Hospitalist 

Atlanta, GA 

Emory University School of Medicine 

Nominated by the National Association of Inpatient Physicians 

Peter Lindenauer MD, MSc, Hospitalist 

Springfield, MA 

Baystate Medical Center, Division of Healthcare Quality 

Tufts University School of Medicine 

Nominated by the National Association of Inpatient Physicians 

Jim Webster, MD, MS, Internist 

Chicago, IL 

Northwestern University Medical School 

Nominated by the American College of Physicians 
 

 182

MEDICAL COMPLICATIONS 2 (MULTISPECIALTY)

Indicators Reviewed

Dosage complications 

Unexpected LOS / Conditional LOS 

Failure to rescue (2 definitions) 

Death in low mortality DRGs 

Michael Barrett, MD, Internist and Cardiologist 

Blue Bell, PA 

Medical College of Pennsylvania Hospital 

Nominated by the American College of Physicians 

William Golden, MD, Professor of medicine, Internist 

Little Rock, AR 

University of Arkansas for Medical Sciences 

Nominated by the American College of Physicians 

Constantine Manthous, MD, Critical care physician

Hamden CT 

Yale University 

Nominated by the American Thoracic Society 

Brenda Snyder, RN, MS, CNS, CCRN, Critical care nurse

Evans, CO 

University of Northern Colorado 

Nominated by the American Association of Critical-Care Nurses

Mark W. Thomas, RPh, MS, Pharmacist, Pediatrics 

Minneapolis, MN 

Children's Hospital and Clinics-Minneapolis, St. Paul 

Nominated by the American Society of Health-system Pharmacists

Mark Williams, MD, Hospitalist 

Atlanta, GA 

Emory University of Medicine 

Nominated by the National Association of Inpatient Physicians

Charles Yowler, MD, Surgeon, Critical Care - Burn Surgery 

Cleveland, OH 

Case Western Reserve University 

Nominated by the American College of Surgeons 

OBSTETRIC COMPLICATIONS OF DELIVERY 1 (MULTISPECIALTY)

Indicators Reviewed

Birth trauma - injury to neonate 

Complications of therapeutic abortion (removed due to operationalization concerns) 

Fetal Death (removed due to operationalization concerns 
 

 183

Obstetric trauma - cesarean section 

Obstetric trauma - vaginal with instrument 

Obstetric trauma - vaginal without instrument 

Patricia Creehan, RNC, MSN, Perinatal clinical nurse specialist 

Palos Heights, IL 

Palos Community Hospital 

Nominated by the Association of Women's Health - Obstetric and Neonatal Nurses 

Neal F. Devitt, MD, Family practitioner 

Santa Fe, NM 

University of New Mexico 

Nominated by the American Academy of Family Physicians 

Robert B. Gherman, MD, Obstetrician - maternal, fetal medicine 

Chesapeake, VA 

Uniformed Services 

University of the Health Sciences 

Nominated by the American College of Obstetricians and Gynecologists 

Stephen Ratcliffe, MD, MSPH, Family practitioner 

Salt Lake City, UT 

University of Utah 

Nominated by the American Academy of Family Physicians 

Allan T. Sawyer, MD, Obstetrician 

Glendale, AZ 

Thunderbird Samaritan Medical Center 

Nominated by the American College of Obstetricians and Gynecologists 

Joan Slager, CNM, MSN, Certified nurse-Midwife 

Kalamazoo, MI 

Bronson Women's Service 

Nominated by the American College of Nurse-Midwives 

Naomi Stotland, MD, Clinical Instructor, Obstetrician

San Francisco, CA

Institute for Health Policy Studies, University of California San Francisco 

Nominated by the EPC Contact 

OBSTETRIC COMPLICATIONS 2 (MULTISPECIALTY) 

Indicators Reviewed

Puerperal infection 

Obstetric vascular complications 

Obstetric wound complications - cesarean section 

Obstetric wound complications - vaginal delivery 

Other obstetric complications of delivery 

Urinary tract infection 
 

 184

Mark Deutchman, MD, Family practitioner 

Denver, CO 

University of Colorado 

Nominated by the American Academy of Family Physicians 

Jan Kriebs, CNM, FACNM, Certified nurse-Midwife 

Bowie, MD 

University of Maryland, Assistant Professor 

Nominated by the American College of Nurse-Midwives 

David Nagey, MD, PhD, Obstetrician, maternal-fetal medicine 

Baltimore, MD 

Johns Hopkins University 

Nominated by the American College of Obstetricians and Gynecologists 

Nancy Petit, MD, Obstetrician 

Newark, DE 

Uniformed Services - University of the Health Sciences 

Nominated by the American College of Obstetricians and Gynecologists 

Vickie Waymire, RNC, MSN, Perinatal clinical nurse specialist 

Lincoln, NE 

Saint Elizabeth Regional Medical Center 

Nominated by the Association of Women's Health - Obstetric and Neonatal Nurses 

Cynthia Woo, MD, Obstetrician 

Bay Area, CA 

Stanford Hospital 

EPC Contact 

PROCEDURAL COMPLICATIONS 1 (MULTISPECIALTY) 

Indicators Reviewed

Iatrogenic hypotension 

Iatrogenic pneumothorax 

CABG following PTCA 

Technical difficulty with procedure 

Postoperative iatrogenic complications – (cardiac, nervous, respiratory, digestive, vascular, 

urinary) 

W. Barton Campbell, M.D, FACC, Cardiologist and critical care physician 

Nashville, TN 

Vanderbilt University 

Nominated by the American College of Cardiology 

Curtis A. Lewis, MD, Interventional radiologist 

Atlanta, GA 

Emory University School of Medicine 

Nominated by the American College of Radiology 
 

 185

Patricia A. Numann, MD, Surgeon 

Syracuse, NY 

State University of New York – Upstate Medical University 

Nominated by the American College of Surgeons 

Patricia O’Malley, RN, PhD, CCRN, CNS, Clinical nurse specialist, Cardiology services 

Dayton, OH 

Miami Valley Hospital 

Nominated by the American Association of Critical-Care Nurses 

Paul V. O’Moore, MD, Interventional radiologist 

Abington, PA 

Abington Memorial Hospital 

Nominated by the American College of Radiology 

Josh Ofman, MD, MSHS, Internist and Gastroenterologist 

Beverly Hills, CA 

University of California- Los Angeles School of Medicine 

Nominated by the American College of Physicians 

Jean M. Reeder, PhD,RN, FAAN, Perioperative nurse & Healthcare consultant 

Anacortes, WA 

Nominated by the Association of Peri-Operative Registered Nurses 

Stephen D. Small, MD, Anesthesiologist 

Chicago, IL 

University of Chicago 

Nominated by the American Society of Anesthesiologists 

SURGICAL COMPLICATIONS 1 (MULTISPECIALTY)

Indicators Reviewed

Postoperative acute myocardial infarction 

Postoperative hemorrhage and hematoma 

Postoperative pneumonia 

Postoperative pulmonary embolism or deep vein thrombosis 

Charles Bethea, MD, Cardiologist 

Oklahoma City, OK 

Duke Clinical Research Institute 

Nominated by the American College of Cardiology 

John Hunt, MD, MPH, Trauma surgeon, critical care 

New Orleans, LA 

Health Science Center - Louisiana State University 

Nominated by the American College of Surgeons 

Franco Laghi, MD, Critical care physician 

Maywood, IL 

Loyola University 
 

 186

Nominated by the American Thoracic Society 

John Nelson, MD, FACP, Internist/Hospitalist 

Bellevue, WA 

Overlake Hospital Medical Center 

Nominated by the National Association of Inpatient Physicians 

Carol A. Petersen, RN, BSN, MAOM, CNOR, Perioperative nursing specialist 

Denver, CO 

Center for Nursing Practice 

Nominated by the Association of Peri-Operative Registered Nurses 

Bruce Williams, MSN, RN, Critical care nurse specialist 

Orangeburg, SC 

The Regional Medical Center - of Orangeburg and Calhoun Counties 

Nominated by the American Association of Critical-Care Nurses 

Preston Winters, MD, FACP, Internist 

White Plains, NY 

White Plains Hospital Center 

Nominated by the American College of Physicians 

SURGICAL COMPLICATIONS 2 (MULTISPECIALTY)

Indicators Reviewed

Postoperative pulmonary compromise 

Reopening of surgical site 

Suture of laceration 

Postoperative wound dehiscence 

Foreign body left in during procedure 

Robert Kozol, MD, MSA, Surgeon 

Farmington, CT 

University of Connecticut 

Nominated by the American College of Surgeons 

Steven Liu, MD, Hospitalist 

Atlanta, GA 

Emory University School of Medicine 

Nominated by the National Association of Inpatient Physicians 

Lenora Maze, MSN, Critical care nurse 

Indianapolis, IN 

Wishard Health Services 

Nominated by the Substitute for American Association of Critical-Care Nurses Nominee 

Valerie Palda, MD, MSc, Internist 

Toronto, ON 

University of Toronto 

Nominated by the American College of Physicians 
 

 187

Sanjay Saint, MD, MPH, Hospitalist 

Ann Arbor, MI 

University of Michigan Medical School 

Nominated by the National Association of Inpatient Physicians 

Patrice Spera, RN, MS, Perioperative nurse 

Seminole, FL 

Tampa General Hospital 

Nominated by the Association of Peri-Operative Registered Nurses 

SURGICAL COMPLICATIONS 3 (MULTISPECIALTY) 

Indicators Reviewed

Aspiration pneumonia 

Transfusion reaction 

Postoperative physiologic and metabolic derangements 

Complications of anesthesia 

Malignant hyperthermia 

Intraoperative physical injuries 

Janet Davies, MSN, Critical care nurse 

Mt. Laurel, NJ 

South Jersey Hospital System 

Nominated by the American Association of Critical-Care Nurses 

Jesse Hall, MD, Critical care physician 

Chicago, IL 

University of Chicago 

Nominated by the American Thoracic Society 

Jeanne M. Huddleston, MD, Hospitalist 

Rochester, MN 

Mayo Clinic 

Nominated by the National Association of Inpatient Physicians 

Deborah G. Spratt, CNOR, CNAA, Nurse manager- surgery 

Avon, NY 

University of Rochester 

Nominated by the Association of Peri-Operative Registered Nurses 

Mary Ellen Warner, MD, Anesthesiologist 

Rochester, MN 

Mayo Clinic 

Nominated by the American Society of Anesthesiologists 

SURGICAL COMPLICATIONS 1 (SURGICAL)

Indicators Reviewed

Postoperative acute myocardial infarction
 

 188

Postoperative pulmonary embolism or deep vein thrombosis 

Postoperative pneumonia 

Intraoperative physical injuries 

Post-surgical hemorrhage or hematoma 

Rodney Appell, MD, Female urologist 

Houston, TX 

Baylor College of Medicine 

Nominated by the American Urologic Association 

Alan Freeland, MD, Orthopedic surgeon 

Jackson, MS 

University of Mississippi Medical Center 

Nominated by the American Academy of Hand Surgeon) 

Patricia Howson, MD, MSc, Orthopedic surgeon 

Redwood City, CA 

Kaiser Permanente 

Nominated by the American Academy of Orthopedic Surgeons 

William Hozak, MD, Orthopedic surgeon 

Philadelphia, PA 

Jefferson Medical School 

Nominated by the American Association of Hip and Knee Surgeons 

Mathew Indeck, MD, General Surgeon -trauma surgery 

Danville, PA 

Jefferson College of Medicine 

Nominated by the American College of Surgeons 

Bruce Kaufman, MD, Pediatric neurosurgeon 

Milwaukee, WI 

Medical College of Wisconsin 

Nominated by the American Association of Neurological Surgeons 

SURGICAL COMPLICATIONS 2 (SURGICAL)

Indicators Reviewed

Foreign body left in during procedure 

Postoperative pulmonary compromise 

Reopening of surgical site 

Suture of laceration 

Postoperative wound dehiscence 

Joseph Basler, MD, PhD, Urologist 

San Antonio, TX 

University of Texas Health Science Center 

Nominated by the American Urologic Association 
 

 189

John Fung, MD, Transplant surgeon 

Pittsburgh, PA 

University of Pittsburgh 

Nominated by the American Society of Transplant Surgeons 

Charles Kenny, MD, Orthopedic surgeon 

Stockbridge, MA 

Fairview Hospital 

Nominated by the American Academy of Orthopedic Surgeons 

John Kestle, MD, MSc, Pediatric neurosurgeon 

Salt Lake City, UT 

University of Utah 

Nominated by the American Association of Neurological Surgeons 

Michael Klassen, MD, Joint and arthroscopic surgeon 

Monterey, CA 

Community Hospital of the Monterey Peninsula 

Nominated by the American Academy of Orthopedic Surgeons 

George Lucas, MD, Orthopedic surgeon - hand surgery 

Wichita, KS 

University of Kansas, Wichita 

Nominated by the American Academy of Hand Surgeon 

Dennis Maiman, MD, PhD, Neurosurgeon- spine surgery 

Milwaukee, WI 

Froedert Memorial Lutheran Hospital 

Nominated by the North American Spine Society 

Richard Nelson, MD, Colon and rectal surgeon 

Chicago, IL 

University of Illinois 

Nominated by the American Society of Colon and Rectal Surgeons 

Michael Stamos, MD, Colon and rectal surgeon 

Torrance, CA 

University of California - Los Angeles School of Medicine 

Nominated by the American College of Surgeons 

SURGICAL COMPLICATIONS 3 (SURGICAL)

Indicators Reviewed 

Aspiration pneumonia 

Complications of anesthesia 

Postoperative physiologic and metabolic derangements 

Transfusion reaction 

Malignant Hyperthermia 
 

 190

Robert Florin, MD, Spine surgeon 

Whittier, CA 

University of Southern California School of Medicine 

Nominated by the American Association of Neurological Surgeons 

Stephen Haines, MD, Pediatric neurosurgeon - skull base lesions 

Charleston, SC 

Medical University of South Carolina 

Nominated by the American Association of Neurological Surgeons 

Goran Klintmalm, MD, PhD, Transplant surgeon - liver transplantation 

Dallas, TX 

Baylor Institute of Transplantation Sciences 

Baylor University Medical Center 

Nominated by the American Society of Transplant Surgeons 

Steven Kraus, MD, Female urologist 

San Antonio, TX 

University of Texas Health Science Center 

Nominated by the American Urologic Association 

Deborah Nagle, MD, Colon and rectal surgeon 

Philadelphia, PA 

Graduate Hospital MCP-Hahnemann 

Nominated by the American Society of Colon and Rectal Surgeons 

Richard Strain, MD, Orthopedic surgeon 

Hollywood, FL 

University of Miami Medical School 

Nominated by the American Academy of Orthopedic Surgeons 
Appendix C 

Sample of Information Sent to Panelists 

This appendix duplicates materials sent to panelists. 

Section 1 includes the instructions and definitions sent to panelists, as well as a key 

illustrating the indicator definitions in Sections 2 and 3. 

Section 2 includes a sample indicator definition sheet sent prior to the conference call. 

Section 3 includes a sample indicator definition sheet sent after the conference call. 

Section 4 includes the questionnaire for rating each indicator sent before and after the 

conference call. 

193

APPENDIX C. SAMPLE OF INFORMATION SENT TO PANELISTS 

Section 1. Directions sent to panelists 

The questionnaires in this packet each describe one potential patient safety indicator and ask for your 

feedback on specific aspects of that indicator. You must fill out one questionnaire for each indicator. Please 

answer all questions on this form. You may comment in the sections provided below each question, or on a 

separate sheet of paper. Comments are not required. We expect that completing each form will take about 

15-20 minutes to complete. 

All indicators are defined using ICD-9-CM diagnostic and procedure codes, obtained from administrative 

data. We do not expect that most physicians or nurses will be familiar with these codes and thus we provide 

explanations of all codes. 

• ICD-9-CM codes are usually assigned using the physician’s charted notes by trained coders. 

• Each patient discharged from an inpatient facility is given a principal diagnosis, which represents the 

condition principally responsible for occasioning the patient’s admission, and a list of secondary 

diagnosis codes. 

• Major procedures that involve use of the operating room or risk to the patient are also coded. 

• Codes between 996 and 999 are always “complications of surgical and medical care.” 

• Codes beginning with ‘E’ refer to the external cause of any injury that the patient sustained. 

Some indicators limit eligible patients to certain groups, including DRGs and MDCs. 

• DRGs are “Diagnostic Related Groups.” They are defined by the Health Care Financing 

Administration (HCFA). One DRG is assigned to each patient per admission. The assigned DRG 

reflects many factors including the principal diagnosis, listed secondary diagnoses, age, and major 

procedures. 

• MDCs are “Major Diagnostic Categories” and are defined using DRGs. DRGs involving the same 

body system are generally grouped together to form one MDC. 

• All other eligible patient limitations (e.g. trauma, immunocompromised) are derived from ICD-9 codes 

alone. 

For the purpose of this study we will use the definitions of Brennan et al1

 of negligence and complications 

(adverse events). We have created a standard definition of preventable. 

• Negligence (medical error): Care that falls below the standard reasonably expected of average 

physicians in their community. 

• Complication: An injury that is caused by medical management (rather than the underlying disease) 

and that prolongs the hospitalization, or produces a disability at the time of discharge, or both. 

• Preventable: Condition for which reasonable clinical steps may reduce (but not necessarily eliminate) 

the risk of that complication occurring. 

 

1

 Brennan, TA, Leape, LL, Laird, NM, Herbert, L et al. Incidence of adverse events and negligence in 

hospitalized patients. Results of the Harvard Medical Practice Study I. New Engl J Med, 1997 Feb 

7;324(6):370-6. 
194
195

Section 2. Example indicator definition sheet sent to panelists prior to conference 

call 

POSTOPERATIVE ACUTE MYOCARDIAL INFARCTION 

Relationship to quality: Identifies cases of potentially preventable myocardial infarction 

following a surgical procedure. 

Indicator definition: 

 Number of patients with postoperative AMIs (see definition and exclusions below) 

per 100 eligible surgical admissions (population at risk). 

Definition of AMI: Definition of population at risk: 

Patients eligible to be included in this indicator:

Secondary diagnosis code for AMI: 

• Acute myocardial infarction (includes 

only unspecified or initial episode of 

care for cardiac infarction, coronary 

embolism, occlusion, rupture or 

thrombosis) [410.00-410.91 except if 5th 

digit = 2] 

a. All non-cardiac surgical patients. 

b. Patient must not be undergoing cardiac 

surgery. 

c. Patient must not be in the following 

MDCs: 

• Diseases and Disorders of the 

Circulatory System [5]

Clinical rationale 

This indicator is intended to flag cases of postoperative AMI. It is identical to an indicator 

developed by Lisa Iezzoni as part of the Complications Screening Program. Codes denoting a 

“subsequent episode of care” for AMI are not included. This indicator limits AMI codes to 

secondary diagnosis codes in order to eliminate AMIs that were present on admission. It further 

excludes patients which have major circulatory disorders, or who are undergoing cardiac surgery, 

as these patients may be more likely to develop an AMI peri-operatively. 
196

Section 3. Example indicator definition sheet sent to panelists after conference call 

Note: Bold “Changes to indicator” text was added for post-panel conference call 

review.

POSTOPERATIVE ACUTE MYOCARDIAL INFARCTION 

Relationship to quality: Identifies cases of potentially preventable myocardial infarction 

following a surgical procedure. 

Indicator definition: 

 Number of patients with postoperative AMIs (see definition and exclusions below) 

per 100 eligible surgical admissions (population at risk). 

Definition of AMI: Definition of population at risk: 

Patients eligible to be included in this indicator:

Secondary diagnosis code for AMI: 

• Acute myocardial infarction (includes 

only unspecified or initial episode of 

care for cardiac infarction, coronary 

embolism, occlusion, rupture or 

thrombosis) [410.00-410.91 except if 5th 

digit = 2] 

a. All non-cardiac elective surgical patients. 

b. Patient must not be undergoing cardiac surgery. 

Clinical rationale 

This indicator is intended to flag cases of postoperative AMI. It is identical to an indicator 

developed by Lisa Iezzoni as part of the Complications Screening Program. Codes denoting a 

“subsequent episode of care” for AMI are not included. This indicator limits AMI codes to 

secondary diagnosis codes in order to eliminate AMIs that were present on admission. It further 

excludes patients which have major circulatory disorders, or who are undergoing cardiac surgery, 

as these patients may be more likely to develop an AMI peri-operatively. 

Changes to indicator 

1. The eligible population was restricted to elective surgeries only. The panel was concerned 

that this complication is less preventable after emergency surgery than after elective 

surgery, because there is little opportunity for preoperative assessment and risk reduction 

before emergency surgery. The weighing of risks and benefits in high-risk patients does not 

apply to emergency surgery. Therefore, we have now proposed focusing this indicator only 

on elective surgery patients, for whom postponement or cancellation of surgery, and 

perioperative beta blockade, are usually viable options. 

2. The exclusion for patients in MDC 5 was eliminated, such that vascular surgery patients 

would be included. Panelists felt that this was a group for which postoperative AMI was a 

serious complication that could be preventable in some cases. Patients undergoing cardiac 

surgery continue to be excluded from this indicator. 
197

Section 4. Questionnaire sent before and after panel discussion 

Panelist name: 

Indicator name: POSTOPERATIVE ACUTE MYOCARDIAL INFARCTION

1. To what extent is this indicator likely to identify the occurrence of an adverse event or complication (as 

opposed to having the condition present on admission)? 

 1 2 3 4 5 6 7 8 9 

Not at all likely Very likely 

Comments: 

2. To what extent is the occurrence of this complication likely to be preventable (as opposed to being an 

expected result of the patient’s underlying conditions and/or procedures)? 

 1 2 3 4 5 6 7 8 9 

Not at all likely Very likely 

Comments: 

3. To what extent is this complication likely to represent true medical error or negligence (as opposed to lack 

of ideal or perfect medical care)? 

 1 2 3 4 5 6 7 8 9 

Not at all likely Very likely 

Comments: 
198

Panelist name: 

Indicator name: POSTOPERATIVE ACUTE MYOCARDIAL INFARCTION

4. How often is this complication, when it occurs, clearly charted in medical records by physicians? 

 1 2 3 4 5 6 7 8 9 

Never charted Always charted 

Comments: 

5. To what extent is this indicator subject to bias (meaning that some hospitals will be judged as low quality 

because they systematically differ from other hospitals in some aspect, such as severity of the case mix, that 

is not due to poor quality care)? 

 1 2 3 4 5 6 7 8 9 

Not at all biased Very biased 

What are the factors that contribute to the bias? 

6. Are there ways that providers or health systems could easily appear to better their performance on this 

indicator, without actually improving the quality of care that they provide? 

7. Are there adverse outcomes that could result from implementing this indicator? 
199

Panelist name: 

Indicator name: POSTOPERATIVE ACUTE MYOCARDIAL INFARCTION

8. What is your overall rating of the usefulness of this indicator? 

 1 2 3 4 5 6 7 8 9 

Highly discourage use Highly recommend use 

Please discuss you reasons for assigning the overall rating above. 

9. Would you suggest any changes to the definition of this indicator? Please specify changes and give 

rationale supporting proposed changes. 

10. Is there anything else that you would like us to know about this indicator? 
Appendix D 

Empirical Methods Details 

This appendix gives details about risk adjustment (DRG and comorbidity) and death in low 

mortality DRGs. 

Section 1 lists adjacent DRGs which differ by the distinction of “with comorbidities and 

complications” as opposed to “without comorbidities and complications” that were grouped for 

the purpose of risk adjustment. 

Section 2 lists the super-MDC categories and non-valid DRGs that were excluded from risk 

adjustment. 

Section 3 lists details of the adaptation of the AHRQ Comorbidity Software, with the rationale 

for each adaptation. 

Section 4 lists the DRGs included in the denominator of the indicator “Death in low mortality 

DRGs” by stratification. 

203

APPENDIX D. EMPIRICAL METHODS DETAILS 

Section 1. DRG Categories Grouped in the PSI Risk Adjustment 

DRG DRG Label 

007 

008 

PERIPH & CRANIAL NERVE & OTHER NERV SYST PROC W CC 

W/O CC 

010 

011 

NERVOUS SYSTEM NEOPLASMS W CC 

W/O CC 

016 

017 

NONSPECIFIC CEREBROVASCULAR DISORDERS W CC 

W/O CC 

018 

019 

CRANIAL & PERIPHERAL NERVE DISORDERS W CC 

CRANIAL & PERIPHERAL NERVE DISORDERS W/O CC 

024 

025 

SEIZURE & HEADACHE AGE >17 W CC 

W/O CC 

028 

029 

TRAUMATIC STUPOR & COMA, COMA <1 HR AGE >17 W CC 

W/O CC 

031 

032 

CONCUSSION AGE >17 W CC 

W/O CC 

034 

035 

OTHER DISORDERS OF NERVOUS SYSTEM W CC 

W/O CC 

046 

047 

OTHER DISORDERS OF THE EYE AGE >17 W CC 

W/O CC 

068 

069 

OTITIS MEDIA & URI AGE >17 W CC 

W/O CC 

076 

077 

OTHER RESP SYSTEM O.R. PROCEDURES W CC 

W/O CC 

079 

080 

RESPIRATORY INFECTIONS & INFLAMMATIONS AGE >17 W CC 

W/O CC 

083 

084 

MAJOR CHEST TRAUMA W CC 

W/O CC 

085 

086 

PLEURAL EFFUSION W CC 

W/O CC 

089 

090 

SIMPLE PNEUMONIA & PLEURISY AGE >17 W CC 

W/O CC 

092 

093 

INTERSTITIAL LUNG DISEASE W CC 

W/O CC 

094 

095 

PNEUMOTHORAX W CC 

W/O CC 

096 

097 

BRONCHITIS & ASTHMA AGE >17 W CC 

W/O CC 

099 

100 

RESPIRATORY SIGNS & SYMPTOMS W CC 

W/O CC 

101 

102 

OTHER RESPIRATORY SYSTEM DIAGNOSES W CC 

W/O CC 
204

DRG DRG Label 

110 

111 

MAJOR CARDIOVASCULAR PROCEDURES W CC 

W/O CC 

121 

122 

CIRCULATORY DISORDERS W AMI & MAJOR COMP, DISCHARGED ALIVE 

W/O MAJOR COMP, DISCHARGED ALIVE 

123 

124 

CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH & COMPLEX DIAG 

W/O COMPLEX DIAG 

130 

131 

PERIPHERAL VASCULAR DISORDERS W CC 

W/O CC 

132 

133 

ATHEROSCLEROSIS W CC 

W/O CC 

135 

136 

CARDIAC CONGENITAL & VALVULAR DISORDERS AGE >17 W CC 

W/O CC 

138 

139 

CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC 

W/O CC 

141 

142 

SYNCOPE & COLLAPSE W CC 

W/O CC 

144 

145 

OTHER CIRCULATORY SYSTEM DIAGNOSES W CC 

W/O CC 

146 

147 

RECTAL RESECTION W CC 

W/O CC 

148 

149 

MAJOR SMALL & LARGE BOWEL PROCEDURES W CC 

W/O CC 

150 

151 

PERITONEAL ADHESIOLYSIS W CC 

W/O CC 

152 

153 

MINOR SMALL & LARGE BOWEL PROCEDURES W CC 

W/O CC 

154 

155 

STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W CC 

W/O CC 

157 

158 

ANAL & STOMAL PROCEDURES W CC 

W/O CC 

159 

160 

HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL AGE >17 W CC 

W/O CC 

161 

162 

INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17 W CC 

W/O CC 

164 

165 

APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC 

W/O CC 

166 

167 

APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC 

W/O CC 

168 

169 

MOUTH PROCEDURES W CC 

W/O CC 

170 

171 

OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC 

W/O CC 
205

DRG DRG Label 

172 

173 

DIGESTIVE MALIGNANCY W CC 

W/O CC 

174 

175 

G.I. HEMORRHAGE W CC 

W/O CC 

177 

178 

UNCOMPLICATED PEPTIC ULCER W CC 

W/O CC 

180 

181 

G.I. OBSTRUCTION W CC 

W/O CC 

182 

183 

ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE >17 W CC 

W/O CC 

188 

189 

OTHER DIGESTIVE SYSTEM DIAGNOSES AGE >17 W CC 

W/O CC 

191 

192 

PANCREAS, LIVER & SHUNT PROCEDURES W CC 

W/O CC 

193 

194 

BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W CC 

W/O CC 

195 

196 

CHOLECYSTECTOMY W C.D.E. W CC 

W/O CC 

197 

198 

CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC 

W/O CC 

205 

206 

DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W CC 

W/O CC 

207 

208 

DISORDERS OF THE BILIARY TRACT W CC 

W/O CC 

210 

211 

HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE >17 W CC 

W/O CC 

218 

219 

LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE >17 W CC 

W/O CC 

223 MAJOR SHOULDER/ELBOW PROC, OR OTHER UPPER EXTREMITY PROC W CC 

224 SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC, W/O CC 

226 

227 

SOFT TISSUE PROCEDURES W CC 

W/O CC 

228 

229 

MAJOR THUMB OR JOINT PROC,OR OTH HAND OR WRIST PROC W CC 

HAND OR WRIST PROC, EXCEPT MAJOR JOINT PROC, W/O CC 

233 

234 

OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC 

W/O CC 

240 

241 

CONNECTIVE TISSUE DISORDERS W CC 

W/O CC 

244 

245 

BONE DISEASES & SPECIFIC ARTHROPATHIES W CC 

W/O CC 

250 

251 

FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE >17 W CC 

W/O CC 
206

DRG DRG Label 

253 

254 

FX, SPRN, STRN & DISL OF UPARM,LOWLEG EX FOOT AGE >17 W CC 

W/O CC 

257 

258 

TOTAL MASTECTOMY FOR MALIGNANCY W CC 

W/O CC 

259 

260 

SUBTOTAL MASTECTOMY FOR MALIGNANCY W CC 

W/O CC 

263 

264 

SKIN GRAFT &/OR DEBRID FOR SKN ULCER OR CELLULITIS W CC 

W/O CC 

265 

266 

SKIN GRAFT &/OR DEBRID EXCEPT FOR SKIN ULCER OR CELLULITIS W CC 

W/O CC 

269 

270 

OTHER SKIN, SUBCUT TISS & BREAST PROC W CC 

W/O CC 

272 

273 

MAJOR SKIN DISORDERS W CC 

W/O CC 

274 

275 

MALIGNANT BREAST DISORDERS W CC 

W/O CC 

277 

278 

CELLULITIS AGE >17 W CC 

W/O CC 

280 

281 

TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE >17 W CC 

W/O CC 

283 

284 

MINOR SKIN DISORDERS W CC 

W/O CC 

292 

293 

OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC 

W/O CC 

296 

297 

NUTRITIONAL & MISC METABOLIC DISORDERS AGE >17 W CC 

W/O CC 

300 

301 

ENDOCRINE DISORDERS W CC 

W/O CC 

304 

305 

KIDNEY,URETER & MAJOR BLADDER PROC FOR NON-NEOPL W CC 

W/O CC 

306 

307 

PROSTATECTOMY W CC 

W/O CC 

308 

309 

MINOR BLADDER PROCEDURES W CC 

W/O CC 

310 

311 

TRANSURETHRAL PROCEDURES W CC 

W/O CC 

312 

313 

URETHRAL PROCEDURES, AGE >17 W CC 

W/O CC 

318 

319 

KIDNEY & URINARY TRACT NEOPLASMS W CC 

W/O CC 

320 

321 

KIDNEY & URINARY TRACT INFECTIONS AGE >17 W CC 

W/O CC 
207

DRG DRG Label 

323 

324 

URINARY STONES W CC, &/OR ESW LITHOTRIPSY 

W/O CC 

325 

326 

KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE >17 W CC 

W/O CC 

328 

329 

URETHRAL STRICTURE AGE >17 W CC 

W/O CC 

331 

332 

OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE >17 W CC 

W/O CC 

334 

335 

MAJOR MALE PELVIC PROCEDURES W CC 

W/O CC 

336 

337 

TRANSURETHRAL PROSTATECTOMY W CC 

W/O CC 

346 

347 

MALIGNANCY, MALE REPRODUCTIVE SYSTEM, W CC 

W/O CC 

348 

349 

BENIGN PROSTATIC HYPERTROPHY W CC 

W/O CC 

354 

355 

UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W CC 

W/O CC 

358 

359 

UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC 

W/O CC 

366 

367 

MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W CC 

W/O CC 

370 

371 

CESAREAN SECTION W CC 

W/O CC 

398 

399 

RETICULOENDOTHELIAL & IMMUNITY DISORDERS W CC 

W/O CC 

401 

402 

LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W CC 

W/O CC 

403 

404 

LYMPHOMA & NON-ACUTE LEUKEMIA W CC 

W/O CC 

406 

407 

MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R.PROC W CC 

W/O CC 

413 

414 

OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W CC 

W/O CC 

419 

420 

FEVER OF UNKNOWN ORIGIN AGE >17 W CC 

W/O CC 

434 

435 

ALC/DRUG ABUSE OR DEPEND, DETOX OR OTH SYMPT TREAT W CC 

W/O CC 

442 

443 

OTHER O.R. PROCEDURES FOR INJURIES W CC 

W/O CC 

444 

445 

TRAUMATIC INJURY AGE >17 W CC 

W/O CC 
208

DRG DRG Label 

449 

450 

POISONING & TOXIC EFFECTS OF DRUGS AGE >17 W CC 

W/O CC 

452 

453 

COMPLICATIONS OF TREATMENT W CC 

W/O CC 

454 

455 

OTHER INJURY, POISONING & TOXIC EFFECT DIAG W CC 

W/O CC 

463 

464 

SIGNS & SYMPTOMS W CC 

W/O CC 

478 

479 

OTHER VASCULAR PROCEDURES W CC 

W/O CC 

493 

494 

LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC 

W/O CC 

497 

498 

SPINAL FUSION W CC 

W/O CC 

499 

500 

BACK & NECK PROCEDURES EXCEPT SPINAL FUSION W CC 

W/O CC 

501 

502 

KNEE PROCEDURES W PDX OF INFECTION W CC 

W/O CC 
209

Section 2. Super-MDC and Invalid DRGs Excluded from DRG Risk-Adjustment 

DRG DRG Label 

214 NO LONGER VALID 

215 NO LONGER VALID 

221 NO LONGER VALID 

222 NO LONGER VALID 

438 NO LONGER VALID 

468 EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 

469 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 

470 UNGROUPABLE 

474 NO LONGER VALID 

476 PROSTATIC O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 

477 NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 

482 TRACHEOSTOMY FOR FACE, MOUTH & NECK DIAGNOSES 

483 TRACHEOSTOMY EXCEPT FOR FACE, MOUTH & NECK DIAGNOSES 
210

Section 3. AHRQ Comorbidity Software Coding Changes 

Comorbidity Category ICD-9 Code 

Deleted 

ICD-9 Code Added 

Congestive Heart Failure 40201, 40401, 40403 

Peripheral Vascular Disorder 44100, 44101, 44102, 44103, 4411, 4412, 4413, 4414, 

4415, 4416, 4417, 4419 

Hypertension, uncomplicated 64200, 64201, 64202, 64203, 64204 

Hypertension, complicated 4010, 40200, 40201, 40211, 40291, 40300, 40301, 40310, 

40311, 40390, 40391, 40400, 40401, 40402, 40403, 40411, 

40412, 40413, 40491, 40492, 40493, 40501, 40509, 64210, 

64211, 64212, 64213, 64214, 64220, 64221, 64222, 64223, 

64224, 64270, 64271, 64272, 64273, 64274, 64290, 64291, 

64292, 64293, 64294 

Paralysis 43820, 43821, 43822, 43830, 43831, 43832, 43840, 43841, 

43842, 43850, 43851, 43852, 43853 

Other neurological 3300, 3301, 3302, 3303, 3308, 3309, 3310, 3311, 3312, 

3313, 3314, 3317, 33181, 33189,3452, 3453, 34560, 

34561, 34570, 34571, 78039 

Chronic pulmonary disease 49392 

Diabetes 64800, 64801, 64802, 64803, 64804 

Diabetes, complicated 25080, 25081, 25082, 25083 

Renal failure 40301,40402, 40403, 40413, 40493,V561, V562 

Liver disease 07022, 07023, 07044 

Peptic ulcer disease including 

bleeding 

 V1271 53171, 53191, 53271, 53291, 53371, 53391, 53471, 53491 

Lymphoma 20300, 20301, 20380, 20381 

Blood loss anemia 64820, 64821, 64822, 64823, 64824 

Alcohol abuse 2910, 2913, 30300, 30301, 30302, 30303 

Drug abuse 64830, 64831, 64832, 64833, 64834 

In selecting an appropriate comorbidity adjustment approach, we decided against the use 

of a pre-scored index, instead allowing the comorbidity weights to differ across indicators. In 

choosing among different approaches, we gravitated toward Elixhauser et al. (Medical Care

1998;36:8-27), because the comorbidity list is more complete than alternatives such as the 

Charlson list, incorporates earlier work by Iezzoni and Krakauer, and has passed peer review. 

The Elixhauser et al. list has been independently validated by Stukenborg (Medical Care

2001;39:727-39). Nonetheless, there are four issues with applying the Elixhauser et al. 

comorbidity list to the patient safety indicators: 

1. Some of the comorbidity definitions are conditions likely to represent complications in certain 

settings, such as after elective surgery. The DRG screens help, but do not completely resolve 

this problem. 

2. Several comorbidity definitions exclude "acute on chronic" comorbidities, even though there 

is no alternative code for the chronic component of the comorbidity. Unless the comorbidity 

definitions capture these "acute on chronic" comorbidities, some patients with especially severe 

comorbidities will be mislabeled as not having conditions of interest. 
211

3. The comorbidity definitions do not include obstetric comorbidity codes, which are relevant for 

the obstetric indicators. The ICD-9-CM Coding Handbook instructs coders that 

"Conditions classified in other chapters of ICD-9-CM are reclassified in chapter 11 when they complicate 

the obstetrical experience or are themselves complicated by the fact that the patient is pregnant...Some codes for 

such complications are very specific, and others are very broad. When a code from chapter 11 describes the 

condition adequately, only that code is assigned. It is appropriate, however, to assign an additional code (from a 

different chapter) when it provides needed specificity."

4. The comorbidity definitions need to be updated based on recent ICD-9-CM code changes. 

Issue #1. Comorbidities as Complications

The following three comorbidities are the most likely to be complications in certain 

settings. The number refers to the order of the comorbidity definitions in the AHRQ software. 

2. "Cardiac arrhythmias" includes some conditions which are generally considered trivial or 

inconsequential, such as first degree AV block (426.11), right bundle branch block (426.4), 

premature beats (427.60), unspecified tachycardia (785.0), and cardiac pacemaker in situ 

(V45.01). Because of the fact that these conditions are unlikely to affect treatment of 

hospitalized patients, they are unlikely to be coded. See, for example, Coding Clinic 

1993;10(5):12, "although it can be argued that sick sinus syndrome is an ongoing condition...no 

code assignment is required if no attention or treatment is provided to the condition or device. 

This differs from the ongoing medication administration provided for conditions such as CHF, 

hypertension, or diabetes (which justifies code assignment)...the use of V45.0...is optional." It is 

impossible to generate an unbiased estimate of the true effect of these comorbidities using 

administrative data, due to nondifferential misclassification (i.e., information bias). Even more 

importantly, some cardiac arrhythmias are well described as postoperative complications - most 

notably paroxysmal SVT (427.0), atrial fibrillation (427.31), and unspecified tachycardia 

(785.0), although virtually all of these codes except V45.0x and V53.0x COULD represent 

complications. And even these V codes are problematic, because a properly functioning 

pacemaker (or prosthetic valve) should eliminate the patient's additional risk. 

21. "Coagulopathy" includes several conditions that are well described as postoperative 

complications - most notably "hemorrhagic disorder due to circulating anticoagulants" (286.5), 

which is the code for excessive heparin, "defibrination syndrome" (286.6), which is the code for 

DIC (disseminated intravascular coagulation) syndrome, "acquired coagulation factor 

deficiency" (286.7), which is the code for hypoprothrombinemia due to warfarin, and "secondary 

thrombocytopenia" (287.4), which is the code for drug-induced or transfusion-induced 

thrombocytopenia. Although the approach could try to narrow the definition of this comorbidity 

to include only congenital disorders such as hemophilia, such a modification would substantially 

reduce its frequency and might eliminate its importance as a predictor. 

24. "Fluid and electrolyte disorders" includes several conditions that are well described as 

postoperative complications - most notably hyponatremia (276.1) and fluid overload (276.6). 

Virtually all of these codes COULD represent complications. 
212

SOLUTION: THESE THREE COMORBIDITIES WILL BE EXCLUDED FROM THE 

COMORBIDITY ADJUSTMENT FOR THE PATIENT SAFETY INDICATORS. 

Issue #2. Acute on Chronic Comorbidities 

The following comorbidities are acute complications of chronic conditions not coded 

separately. The number refers to the order of the comorbidity definitions in the AHRQ software. 

1. "Congestive heart failure" excludes all codes for heart failure due to hypertension which is 

described as malignant during the current episode of care (402.01, 404.01, 404.03). This is 

problematic because these codes substitute for (and do not supplement) other codes for 

congestive heart failure (428.x). In adjusting for any increased risk that congestive heart failure 

may confer, the approach should not exclude any etiologic subset of such patients from the 

definition. As noted below, malignant hypertension almost always occurs in the setting of 

underlying chronic hypertension. 

SOLUTION: CONGESTIVE HEART FAILURE WILL BE REDEFINED TO INCLUDE 

402.01, 404.01, AND 404.03, IN ADDITION TO THE OTHER CODES CONTAINED IN 

ELIXHAUSER'S ORIGINAL DEFINITION. 

5. "Peripheral vascular disorders" excludes all codes for ruptured or dissecting aneurysms. This 

is problematic because these codes substitute for (and do not supplement) other aneurysm codes. 

In adjusting for any increased risk that peripheral vascular disease may confer, the approach 

should not exclude the most severely affected patients from the definition. Aneurysm rupture 

may be an acute, occasionally preventable complication, but it occurs in the setting of an 

underlying aneurysm. 

SOLUTION: PERIPHERAL VASCULAR DISORDERS WILL BE REDEFINED TO 

INCLUDE ALL 441.XX CODES, IN ADDITION TO THE OTHER CODES CONTAINED IN 

ELIXHAUSER'S ORIGINAL DEFINITION. 

6. "Hypertension" excludes all codes for malignant hypertension (401.0x, 402.0x, 403.0x, 

404.0x, 405.0x), and all codes for hypertension with either congestive heart failure (402.x1), 

renal failure (403.xx), or both (404.x1, 404.x2, 404.x3). This is problematic because these codes 

substitute for (and do not supplement) the codes for complicated hypertension. In other words, 

the current comorbidity definition would MISS a substantial proportion of patients with chronic 

hypertension, because they also have heart or renal disease secondary to their hypertension. 

Similarly, malignant hypertension arises in the setting of chronic hypertension, which the current 

comorbidity definition would miss. In adjusting for any increased risk that hypertension may 

confer, the approach should not exclude the most severely affected the patients from the 

definition. 

SOLUTION: HYPERTENSION, COMPLICATED WILL BE REDEFINED AS: 401.0, 

402.XX, 403.XX, 404.XX, 405.XX. THE DEFINITION OF HYPERTENSION, 

UNCOMPLICATED WILL REMAIN UNCHANGED. PATIENTS WHO HAVE CODES 

CONSISTENT WITH BOTH COMORBIDITIES WILL BE CLASSIFIED AS 

COMPLICATED. 
213

8. "Other neurological disorders" excludes codes for "petit mal status" (345.2) and "grand mal 

status" (345.3), which are simply acute manifestations of underlying chronic comorbidities. In 

adjusting for any increased risk that epilepsy may confer, the approach should not exclude the 

most severely affected patients from the definition. Epileptic status may be an iatrogenic 

complication, but it occurs in the setting of an underlying neurologic disorder. Similarly, cerebral 

degeneration occurs in the setting of an underlying degenerative disorder. 

SOLUTION: OTHER NEUROLOGICAL DISORDERS WILL BE REDEFINED TO 

INCLUDE ALL 330.X, 331.X, AND 345.XX CODES, IN ADDITION TO THE OTHER 

CODES CONTAINED IN ELIXHAUSER'S ORIGINAL DEFINITION (SEE ALSO CODING 

UPDATE BELOW). 

11. "Diabetes" excludes codes for "diabetes with other specified manifestations" (250.8x), such 

as hypoglycemia. This is problematic because this code substitutes for (and does not 

supplement) other diabetes codes. In other words, the current comorbidity definition would 

MISS patients with diabetes who suffer from other specified complications, such as 

hypoglycemia, during their hospital stay. See Coding Clinic 1994;11(2):12 - "what is the 

appropriate diagnosis code for...necrotizing fasciitis secondary to NIDDM?...assign code 

250.80...as the principal diagnosis." In adjusting for any increased risk that diabetes may confer, 

the approach should not exclude the most severely affected patients from the definition. Diabetic 

hypoglycemia may be an iatrogenic complication, but it occurs in the setting of an underlying 

endocrine disorder. 

SOLUTION: DIABETES, COMPLICATED WILL BE REDEFINED AS 250.40-250.93 AND 

REFERS ONLY TO CHRONIC COMPLICATIONS; ACUTE HYPERGLYCEMIC 

COMPLICATIONS ARE CODED AS 250.10-250.33. 

THE DEFINITION OF DIABETES, UNCOMPLICATED WILL REMAIN UNCHANGED. 

PATIENTS WHO HAVE CODES CONSISTENT WITH BOTH COMORBIDITIES WILL BE 

CLASSIFIED AS COMPLICATED. IF A PSI WILL BE APPLIED TO THE NEONATAL 

POPULATION, THEN THE DEFINITION OF DIABETES, COMPLICATED WILL ALSO 

INCLUDE 775.1 (NEONATAL DIABETES). 

13. "Renal failure" excludes "hypertensive heart and renal disease with congestive heart failure 

and heart failure" (404.13, 404.93). These codes indicate the presence of BOTH renal failure 

and congestive heart failure in the same patient. They substitute for other renal failure codes 

(585-587) in all patients with hypertension, even if the patient's renal failure is not clearly 

attributable to hypertension. In addition, the current definition excludes any renal failure 

associated with malignant hypertension (403.01, 404.02, 404.03), even when the patient's renal 

failure is not clearly attributable to malignant hypertension. In adjusting for any increased risk 

that chronic renal failure may confer, the comorbidity definition does not want to exclude any 

etiologic subset of such patients from the definition. As noted above, malignant hypertension 

almost always occurs in the setting of underlying chronic hypertension. 

SOLUTION: RENAL FAILURE WILL BE REDEFINED TO INCLUDE 403.01, 404.02, 

404.03, 404.13, AND 404.93, IN ADDITION TO THE OTHER CODES CONTAINED IN 

ELIXHAUSER'S ORIGINAL DEFINITION (SEE ALSO CODING UPDATE BELOW). 
214

14. "Liver disease" excludes "chronic viral hepatitis B with hepatic coma" with or without 

hepatitis delta (070.22-070.23) and "chronic hepatitis C with hepatic coma" (070.44), which are 

simply acute manifestations of underlying chronic comorbidities. In adjusting for any increased 

risk that chronic viral hepatitis may confer, the comorbidity definition does not want to exclude 

the most severely affected patients from the definition. Coma may be an acute, occasionally 

preventable complication, but it occurs in the setting of underlying chronic hepatitis. 

SOLUTION: LIVER DISEASE WILL BE REDEFINED TO INCLUDE 070.22, 070.23, AND 

070.44, IN ADDITION TO THE OTHER CODES CONTAINED IN ELIXHAUSER'S 

ORIGINAL DEFINITION. 

15. "Peptic ulcer disease" excludes all acute ulcers, but also all chronic ulcers that present with 

hemorrhage, perforation, or obstruction (or any combination thereof). This is problematic 

because many chronic ulcers hemorrhage or obstruct. In fact, obstruction is a common 

presentation for chronic ulcers, and is relatively unusual among acute or iatrogenic ulcers. The 

problem here is that ICD-9-CM fails to distinguish "chronic" from "unspecified" ulcers. By 

contrast, all of the other comorbidities on this "acute on chronic" list are either inherently chronic 

(i.e., hypertension and cardiac/renal complications thereof, diabetes, peripheral vascular disease, 

epilepsy) or are clearly identified as chronic in ICD-9-CM (i.e., viral hepatitis). We cannot be 

certain that all ulcers labeled as "chronic or unspecified" are actually chronic. However, given 

the time required for an ulcer to cause obstruction, this finding strongly suggests chronicity 

(especially in the absence of hemorrhage or perforation). 

SOLUTION: PEPTIC ULCER DISEASE WILL BE REDEFINED AS: 531.70-531.71, 531.90-

531.91, 532.70-532.71, 532.90-532.91, 533.70-533.71, 533.90-533.91, 534.70-534.71, 534.90-

534.91. 

27. "Alcohol abuse" (291.8x) excludes alcohol withdrawal delirium (291.0) and alcohol 

withdrawal hallucinosis (291.3), despite the fact that these acute conditions occur only in the 

setting of chronic alcohol abuse. Coding Clinic for ICD-9-CM (Second Quarter 1991, p. 11) 

notes that code 291.0 and 291.3 take "precedence over 291.8," making it inappropriate to include 

291.8x and omit 291.0 and 291.3. "If the patient is admitted in withdrawal or if withdrawal 

develops after admission, the withdrawal code is designated as the principal diagnosis." The 

current definition also excludes acute alcoholic intoxication superimposed on alcohol 

dependence (303.0x), which is the sole ICD-9-CM code used to describe chronic alcoholic 

patients who are intoxicated upon presentation. 303.0x substitutes for any other 303 or 305.0 

code in this common situation. In adjusting for any increased risk that alcoholism may confer, 

the comorbidity definition does not want to exclude the most severely affected patients from the 

definition. 

SOLUTION: ALCOHOL ABUSE WILL BE REDEFINED AS: 291.0-291.3, 291.5, 291.8X, 

291.9, 303.00-303.93, 305.00-305.03. 
215

Issue #3. Obstetric Codes 

The obstetric comorbidity code is either an exact match, or broader or narrower than the 

comorbidity definition based on non-obstetric codes. When the match is exact or narrower 

(highlighted in bold), the obstetric code was added to the comorbidity definition for obstetric 

cases because coders are likely to use the obstetric code INSTEAD of the nonobstetric code. 

This is especially true when the nonobstetric codes are accompanied by specific "excludes" notes 

for pregnancy and the puerperium (highlighted in italics). When the match is broader, one might 

argue that the obstetric code does not "describe the condition adequately," and should therefore 

be accompanied by the more specific nonobstetric code (which would more effectively capture 

the cases of interest). In this situation, the obstetric code should NOT be added to the 

cormorbidity definition, because doing so might add numerous patients who do not actually have 

the condition of interest. 

1-4. CHF/arrhythmias/valvular disease/pulmonary circulation - 648.6x ("other cardiovascular 

diseases"). Broader, in that all heart disease (390-398, 410-429) is included. 

5. Peripheral vascular - 648.9x ("other current conditions classifiable elsewhere"). Broader, in 

that all nutritional and vascular problems (260-269, 440-459) are included. 

6. Hypertension - Uncomplicated 642.0x ("benign essential hypertension..."). Complicated 

642.1x ("hypertension secondary to renal disease..."), 642.2x ("other pre-existing 

hypertension..."), 642.7x ("pre-eclampsia or eclampsia superimposed on pre-existing 

hypertension"), 642.9x ("unspecified hypertension..."). Exact match (if comorbidity definition is 

expanded as I suggest in response to problem #2), with excludes notes for nonobstetric codes. 

SOLUTION: ADD TO COMORBIDITY DEFINITION. 

10. Diabetes - 648.0x ("diabetes mellitus"). Exact match (when comorbidity definition is 

expanded to 250.xx as I suggested above in response to issue #2). 

SOLUTION: ADD TO COMORBIDITY DEFINITION. 

12. Hypothyroidism - 648.1x ("thyroid dysfunction"). Broader, in that all thyroid disease (240-

246) is included. 

13. Renal failure - 646.2x ("unspecified renal disease in pregnancy..."). Broader, in that all renal 

disease is included. 

14. Liver disease - 646.7x ("liver disorders in pregnancy"). Broader, in that all liver disease is 

included. 

16. AIDS - 647.6x ("other viral diseases"). Broader, in that all viral diseases except rubella (042, 

050-055, 057-079) are included. 

20. Rheumatoid/collagen vascular diseases - 648.7x ("bone and joint disorders of back, pelvis, 

and lower limbs"). Narrower, in that lupus and other diffuse connective tissue diseases are 

excluded, but broader, in that all dorsopathies and arthropathies (711-738) are included. 
216

SOLUTION: ADD TO COMORBIDITY DEFINITION 

22. Obesity - 646.1x ("edema or excessive weight gain in pregnancy..."). Broader, in that edema 

is also included. 

23. Weight loss - 648.9x ("other current conditions classifiable elsewhere"). Broader, in that all 

nutritional and vascular problems (260-269, 440-459) are included. 

25-26. Blood loss/Deficiency anemias - 648.2x ("anemia"). Broader, in that all anemias (280-

285) are included, but excludes notes apply to nonobstetric codes. 

SOLUTiON: THE EXCLUDES NOTE REQUIRES THAT THE CODE BE ADDED TO THE 

COMORBIDITY DEFINITION. 

27. Alcohol abuse - 648.4x ("mental disorders"). Broader, in that all mental disorders (290-303, 

305-319) are included. 

28. Drug abuse - 648.3x ("drug dependence"). Narrower (matches to 304.xx), in that 

nondependent abuse of drugs is omitted. 

SOLUTION: ADD TO COMORBIDITY DEFINITION. 

29. Psychoses - 648.41, 648.43 ("mental disorders"). Broader, in that all mental disorders (290-

303, 305-319) are included. 

The other comorbidites (e.g., neurologic, pulmonary, gastroenterologic, oncologic, coagulopathy, 

fluid/electrolyte) have no matching obstetric codes in Chapter 11. 

Issue #4. Coding Updates 

ICD-9 coding changes affect the following comorbidities, although the current AHRQ 

comorbidity software is robust to most of these coding changes: 

2. Cardiac arrhythmias - V45.0 is now V45.0x (or V45.00-V45.09) to identify the specific 

cardiac device, as of 10/1/94. V53.3 is now V53.3x (or V53.30-V53.39) to identify the specific 

cardiac device, as of 10/1/94. 

SOLUTION: AHRQ SOFTWARE INCLUDES BOTH OLD AND NEW CODES. NO 

CHANGE IS NECESSARY. 

7. Paralysis - Paralysis due to late effects of cerebrovascular disease was reassigned from 342 or 

344.3-344.4 to new codes under 438 (438.2x = hemiplegia/hemiparesis, 438.3x = monoplegia of 

upper limb, 438.4x = monoplegia of lower limb, 438.5x = other paralytic syndrome) on 10/1/97. 
217

SOLUTION: 438.2X-438.5X WAS ADDED TO THE DEFINITION. 

8. Other neurological disorders - 780.3 was split into 780.31 (febrile convulsions) and 780.39 

(other convulsions) on 10/1/97. 

SOLUTION: ONLY 780.39 IS RELEVANT (FEBRILE CONVULSIONS ARE A BENIGN 

CONDITION OF YOUNG CHILDREN), SO THIS CODE WAS ADDED TO THE 

DEFINITION. 

9. Chronic pulmonary disease - 493.x2 (i.e., 493.92) was added 10/1/00 to denote "acute 

exacerbation" of asthma. 494 was split into 494.0 (without acute exacerbation) and 494.1 (with 

acute exacerbation) on 10/1/00. 

SOLUTION: CURRENT AHRQ SOFTWARE INCLUDES 493.02, 493.12, AND 493.22, BUT 

NOT 493.92, WHICH WAS ADDED TO THE DEFINITION. NO CHANGE REQUIRED TO 

THE 494 CODES (NEW CODES ALREADY INCLUDED). 

13. Renal failure - V56.1 (fitting and adjustment of extracorporeal dialysis catheter) was added 

10/1/95. V56.2 (fitting and adjustment of peritoneal dialysis catheter) was added 10/1/98. 

SOLUTION: V56.1 AND V56.2 WERE ADDED TO THE DEFINITION. 

16. AIDS - 043 and 044 were deleted 10/1/94. 

SOLUTION: AHRQ SOFTWARE INCLUDES BOTH OLD AND NEW CODES. NO 

CHANGE IS NECESSARY. 

17. Lymphoma - 203.0 was split into 203.00 (without mention of remission) and 203.01 (in 

remission) on 10/1/91. 203.8 was split into 203.80 (without mention of remission) and 203.81 

(in remission) on 10/1/91. 

SOLUTION: 203.001-203.01 AND 203.80-203.81 WERE ADDED TO THE DEFINITION. 

22. Obesity - 278.0 was split into 278.00 (obesity unspecified) and 278.01 (morbid obesity) on 

10/1/95. 

SOLUTION: AHRQ SOFTWARE INCLUDES BOTH OLD AND NEW CODES. NO 

CHANGE IS NECESSARY. 

26. Deficiency anemia - A new set of codes for "anemia in chronic illness" (285.21 = end-stage 

renal disease, 285.22 = neoplastic disease, 285.29 = other chronic illness) was added on 10/1/00. 

SOLUTION: AHRQ SOFTWARE INCLUDES BOTH OLD AND NEW CODES. NO 

CHANGE IS NECESSARY. 
218

27. Alcohol abuse - 291.8 was split into 291.81 (alcohol withdrawal) and 291.89 (other specified 

alcoholic psychosis) on 10/1/96. 

SOLUTION: AHRQ SOFTWARE INCLUDES BOTH OLD AND NEW CODES. NO 

CHANGE IS NECESSARY. 
219

Section 4. Low Mortality DRGs Listed by Strata 

DRG DRG Label 

Medical (Adult) 

015 TRANSIENT ISCHEMIC ATTACK & PRECEREBRAL OCCLUSIONS 

021 VIRAL MENINGITIS 

030 TRAUMATIC STUPOR & COMA, COMA <1 HR AGE 0-17 

031 CONCUSSION AGE >17 W CC 

032 CONCUSSION AGE >17 W/O CC 

044 ACUTE MAJOR EYE INFECTIONS 

045 NEUROLOGICAL EYE DISORDERS 

065 DYSEQUILIBRIUM 

068 OTITIS MEDIA & URI AGE >17 W CC 

071 LARYNGOTRACHEITIS 

096 BRONCHITIS & ASTHMA AGE >17 W CC 

097 BRONCHITIS & ASTHMA AGE >17 W/O CC 

125 CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O 

COMPLEX DIAG 

134 HYPERTENSION 

140 ANGINA PECTORIS 

141 SYNCOPE & COLLAPSE W CC 

142 SYNCOPE & COLLAPSE W/O CC 

143 CHEST PAIN 

237 SPRAINS, STRAINS, & DISLOCATIONS OF HIP, PELVIS & THIGH 

243 MEDICAL BACK PROBLEMS 

246 NON-SPECIFIC ARTHROPATHIES 

295 DIABETES AGE 0-35 

317 ADMIT FOR RENAL DIALYSIS 

323 URINARY STONES W CC, &/OR ESW LITHOTRIPSY 

324 URINARY STONES W/O CC 

351 STERILIZATION, MALE 

369 MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM 

DISORDERS 

421 VIRAL ILLNESS AGE >17 

Medical (Pediatric) 

026 SEIZURE & HEADACHE AGE 0-17 

033 CONCUSSION AGE 0-17 

070 OTITIS MEDIA & URI AGE 0-17 

074 OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES AGE 0-17 

091 SIMPLE PNEUMONIA & PLEURISY AGE 0-17 

098 BRONCHITIS & ASTHMA AGE 0-17 

184 ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE 0-17 

190 OTHER DIGESTIVE SYSTEM DIAGNOSES AGE 0-17 

252 FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE 0-17 

255 FX, SPRN, STRN & DISL OF UPARM,LOWLEG EX FOOT AGE 0-17 

279 CELLULITIS AGE 0-17 
220

282 TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE 0-17 

298 NUTRITIONAL & MISC METABOLIC DISORDERS AGE 0-17 

322 KIDNEY & URINARY TRACT INFECTIONS AGE 0-17 

333 OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE 0-17 

396 RED BLOOD CELL DISORDERS AGE 0-17 

422 VIRAL ILLNESS & FEVER OF UNKNOWN ORIGIN AGE 0-17 

446 TRAUMATIC INJURY AGE 0-17 

448 ALLERGIC REACTIONS AGE 0-17 

451 POISONING & TOXIC EFFECTS OF DRUGS AGE 0-17 

Surgical (Adult) 

036 RETINAL PROCEDURES 

037 ORBITAL PROCEDURES 

042 INTRAOCULAR PROCEDURES EXCEPT RETINA, IRIS & LENS 

050 SIALOADENECTOMY 

052 CLEFT LIP & PALATE REPAIR 

053 SINUS & MASTOID PROCEDURES AGE >17 

055 MISCELLANEOUS EAR, NOSE, MOUTH & THROAT PROCEDURES 

057 T&A PROC, EXCEPT TONSILLECTOMY &/OR ADENOIDECTOMY 

ONLY, AGE >17 

063 OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES 

166 APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC 

167 APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC 

218 LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR 

AGE >17 W CC 

219 LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR 

AGE >17 W/O CC 

223 MAJOR SHOULDER/ELBOW PROC, OR OTHER UPPER EXTREMITY 

PROC W CC 

224 SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC, 

W/O CC 

225 FOOT PROCEDURES 

228 MAJOR THUMB OR JOINT PROC, OR OTH HAND OR WRIST PROC 

W CC 

229 HAND OR WRIST PROC, EXCEPT MAJOR JOINT PROC, W/O CC 

232 ARTHROSCOPY 

257 TOTAL MASTECTOMY FOR MALIGNANCY W CC 

258 TOTAL MASTECTOMY FOR MALIGNANCY W/O CC 

261 BREAST PROC FOR NON-MALIGNANCY EXCEPT BIOPSY & 

LOCAL EXCISION 

262 BREAST BIOPSY & LOCAL EXCISION FOR NON-MALIGNANCY 

267 PERIANAL & PILONIDAL PROCEDURES 

289 PARATHYROID PROCEDURES 

290 THYROID PROCEDURES 

293 OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W/O CC 

334 MAJOR MALE PELVIC PROCEDURES W CC 

335 MAJOR MALE PELVIC PROCEDURES W/O CC 
221

336 TRANSURETHRAL PROSTATECTOMY W CC 

337 TRANSURETHRAL PROSTATECTOMY W/O CC 

356 FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE 

PROCEDURES 

358 UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC 

359 UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC 

360 VAGINA, CERVIX & VULVA PROCEDURES 

361 LAPAROSCOPY & INCISIONAL TUBAL INTERRUPTION 

362 ENDOSCOPIC TUBAL INTERRUPTION 

364 D&C, CONIZATION EXCEPT FOR MALIGNANCY 

439 SKIN GRAFTS FOR INJURIES 

441 HAND PROCEDURES FOR INJURIES 

491 MAJOR JOINT & LIMB REATTACHMENT PROCEDURES OF UPPER 

EXTREMITY 

499 BACK & NECK PROCEDURES EXCEPT SPINAL FUSION W CC 

500 BACK & NECK PROCEDURES EXCEPT SPINAL FUSION W/O CC 

Surgical (Pediatric) 

060 TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE 0-17 

062 MYRINGOTOMY W TUBE INSERTION AGE 0-17 

156 STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE 0-17 

163 HERNIA PROCEDURES AGE 0-17 

212 HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE 0-17 

220 LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE 

0-17 

393 SPLENECTOMY AGE 0-17 

Neonatal 

386 EXTREME IMMATURITY OR RESPIRATORY DISTRESS 

SYNDROME, NEONATE 

387 PREMATURITY W MAJOR PROBLEMS 

388 PREMATURITY W/O MAJOR PROBLEMS 

390 NEONATE W OTHER SIGNIFICANT PROBLEMS 

391 NORMAL NEWBORN 

Obstetric 

370 CESAREAN SECTION W CC 

371 CESAREAN SECTION W/O CC 

372 VAGINAL DELIVERY W COMPLICATING DIAGNOSES 

373 VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES 

374 VAGINAL DELIVERY W STERILIZATION &/OR D&C 

375 VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C 

377 POSTPARTUM & POST ABORTION DIAGNOSES W O.R. 

PROCEDURE 

378 ECTOPIC PREGNANCY 

379 THREATENED ABORTION 

380 ABORTION W/O D&C 

381 ABORTION W D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY 

382 FALSE LABOR 
222

383 OTHER ANTEPARTUM DIAGNOSES W MEDICAL COMPLICATIONS 

384 OTHER ANTEPARTUM DIAGNOSES W/O MEDICAL 

COMPLICATIONS 

Psychiatric 

425 ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL 

DYSFUNCTION 

426 DEPRESSIVE NEUROSES 

427 NEUROSES EXCEPT DEPRESSIVE 

428 DISORDERS OF PERSONALITY & IMPULSE CONTROL 

431 CHILDHOOD MENTAL DISORDERS 

432 OTHER MENTAL DISORDER DIAGNOSES 

434 ALC/DRUG ABUSE OR DEPEND, DETOX OR OTH SYMPT TREAT W 

CC 

435 ALC/DRUG ABUSE OR DEPEND, DETOX OR OTH SYMPT TREAT 

W/O CC 

436 ALC/DRUG DEPENDENCE W REHABILITATION THERAPY 
Appendix E 

Details of Indicator Definitions 

This appendix lists coding details for all indicators. It is divided into six sections (described 

below). For each indicator group (accepted, experimental, rejected) the definitions are provided 

in table form. In another section ICD-9-CM level details are presented for terms used in the 

tables (e.g. the codes used to define “hip fracture”). Terms are listed alphabetically and a table of 

contents is provided for ease of use. 

ICD-9-CM codes are updated through 2001. 

Section 1A contains the definition table for the Accepted hospital level indicators. 

Section 1B contains the coding details for the Accepted hospital level indicators. 

Section 2A contains the definition table for the Accepted area level indicators. Coding details are 

available in section 1B. 

Section 3A contains the definition table for the Experimental indicators. 

Section 3B contains the coding details for the Experimental indicators. 

Section 4A contains the definition table for the Rejected indicators. 
224

APPENDIX E. DETAILS OF INDICATOR DEFINITIONS Section 1A. Accepted Hospital-Level Indicator Definitions Items in bold and brackets are fully specified in the ICD-9-CM and DRG listings after this table. Indicator Definition and Numerator Denominator • Complications of anesthesia Discharges with ICD-9-CM diagnosis codes for 

[anesthesia complications] in any secondary diagnosis field per 100 discharges. 

All [surgical] discharges. Exclude patients with codes foanesthetics [E855.1, 968.1-4, 9diagnosis code for [active dru[active nondependent abuse oinflicted injury]. 

• Death in low mortality DRGs Indicator is stratified in 7 subgroup indicators: 

1. Adult surgical 2. Adult medical 3. Pediatric surgical 4. Pediatric medical 5. Psychiatric 6. Obstetric 7. Neonatal 

All discharges with disposition of "deceased" per 100 population at risk. 

All discharges in DRGs with lemortality rate, based on NIS 19mortality DRG]. If a DRG is d"without/with complications" bhave mortality rates below 0.5% inclusion. Exclude patients with any code 

[immunocompromised] state, 

• Decubitus ulcer Discharges with ICD-9-CM code of 707.0 in any 

secondary diagnosis field per 100 discharges. 

All [medical] and [surgical] d

Include only patients with a lenmore than 4 days. Exclude patients in MDC 9 or diagnosis of [hemiplegia, paraquadriplegia].Exclude patients admitted from care facility].

• Failure to rescue All discharges with disposition of "deceased" per 

100 population at risk. 

Discharges with potential complisted in [failure to rescue] defpneumonia, DVT/PE, sepsis, ashock/cardiac arrest, or GI hemulcer). Exclusion criteria specidiagnosis. 
225

Indicator Definition and Numerator Denominator 

Exclude patients [transferred facility]. Exclude patients [transferred facility]Exclude patients admitted from care facility]. 

• Foreign body left in during procedure Discharges with ICD-9-CM codes for [foreign 

body left in during procedure] in any secondary diagnosis field per 100 surgical discharges. 

All [medical] and [surgical] d

• Iatrogenic pneumothorax Discharges with ICD-9-CM code of 512.1 in any 

secondary diagnosis field per 100 discharges. 

All [medical] and [surgical] d

Exclude patients with any diag[trauma].Exclude patients with any code [thoracic surgery] or [lung or or [cardiac surgery].

• Infection due to medical care Discharges with ICD-9-CM code of 999.3 or 

996.62 in any secondary diagnosis field per 100 discharges. 

All [medical] and [surgical] d

Exclude patients with any diag[immunocompromised] state 

• Postoperative hemorrhage or hematoma Discharges with ICD-9-CM codes for 

[postoperative hemorrhage] or [postoperative 

hematoma] in any secondary diagnosis field AND code for postoperative [control of hemorrhage] or [drainage of hematoma] in any secondary procedure code field per 100 surgical discharges. Procedure code for postoperative control of hemorrhage or hematoma must occur on the same day or after the principal procedure. 

All [surgical] discharges. Exclude all obstetric admission

15). 

• Postoperative hip fracture Discharges with ICD-9-CM code for [hip 

fracture] in any secondary diagnosis field per 100 surgical discharges. 

All [surgical] discharges. 

Exclude patients who have mu
226

Indicator Definition and Numerator Denominator 

connective tissue diseases (MDExclude patients with principal for [seizure], [syncope], [strok[cardiac arrest], [poisoning], [delirium and other psychosebrain injury].Exclude patients with any diag[metastatic cancer], [lymphoi

[bone malignancy], [self-infliExclude patients 17 years of ag

• Postoperative physiologic and metabolic 

derangements 

Discharges with ICD-9-CM codes for [physiologic and metabolic derangements] in any secondary diagnosis field per 100 surgical discharges. Discharges with acute renal failure (subgroup of physiologic and metabolic derangements) must be accompanied by a procedure code for dialysis (39.95, 54.98). 

All [elective] [surgical] dischaExclude patients with both a diketoacidosis, hyperosmolarity (subgroups of physiologic and derangements coding) AND a pdiagnosis of [diabetes].Exclude patients with both a secode for acute renal failure (suphysiologic and metabolic deraAND a principal diagnosis of [infarction], [cardiac arrhythmarrest], [shock], [hemorrhag

[gastrointestinal hemorrhageExclude all obstetric admission15). 

• Postoperative pulmonary embolism or deep 

vein thrombosis 

Discharges with ICD-9-CM codes for [deep vein 

thrombosis] or [pulmonary embolism] in any 

secondary diagnosis field per 100 surgical discharges. 

All [surgical] discharges. 

Exclude patients with a princip[deep vein thrombosis].Exclude all obstetric admission15). 
227

Indicator Definition and Numerator Denominator 

Exclude patients with secondar38.7 when this procedure occuprevious to the day of the princ

• Postoperative respiratory failure Discharges with ICD-9-CM codes for acute 

respiratory failure (518.81) in any secondary diagnosis field per 100 surgical discharges. (After 1999, include 518.84). 

All [elective] [surgical] discha

Exclude patients with respiratodiseases (MDC 4 and MDC 5)Exclude all obstetric admission15) 

• Postoperative sepsis Discharges with ICD-9-CM code for [sepsis] in 

any secondary diagnosis field per 100 discharges in the population at risk. 

All [elective] [surgical] discha

Exclude patients with a princip[infection], or any code for [immunocompromised] state, 

Include only patients with a lenmore than three days. Exclude all obstetric admission15). 

• Technical difficulty with procedure Discharges with ICD-9-CM code denoting 

[technical difficulty] (e.g., accidental cut, puncture, perforation or laceration during a procedure) in any secondary diagnosis field per 100 discharges. 

All [medical] and [surgical] d

Exclude all obstetric admission15). 

• Transfusion reaction Discharges with ICD-9-CM codes for 

[transfusion reaction] in any secondary diagnosis field per 100 discharges. 

All [medical] and [surgical] d

• Postoperative wound dehiscence Discharges with ICD-9-CM codes for reclosure 

of postoperative disruption of abdominal wall (54.61) in any secondary procedure field per 100 discharges. 

All [abdominopelvic] surgical 

Exclude all obstetric admission15). 

• Birth trauma- injury to neonate Discharges with ICD-9-CM codes for [birth 

trauma] in any diagnosis field per 100 liveborn births. 

All [liveborn] infants. Exclude infants with a subdurahemorrhage (subgroup of birth AND any diagnosis code of [p(denoting a birth weight of less 
228

Indicator Definition and Numerator Denominator 

less than 37 weeks gestation). Exclude infants with injury to 767.4) AND any diagnosis codimperfecta (756.51). 

• Obstetric trauma - vaginal with instrument Discharges with ICD-9-CM codes for [obstetric 

trauma] in any diagnosis or procedure field per 100 instrument assisted vaginal deliveries. 

All [vaginal delivery] dischar

procedure code for [instrumendelivery]. 

• Obstetric trauma - vaginal without 

instrument 

Discharges with ICD-9-CM codes for [obstetric trauma] in any diagnosis or procedure field per 100 instrument assisted vaginal deliveries. 

All [vaginal delivery] dischar

Exclude [instrument assisted 

• Obstetric trauma - cesarean section Discharges with ICD-9-CM codes for [obstetric 

trauma] in any diagnosis or procedure field per 100 cesarean deliveries. 

All [cesarean delivery] discha
229

Section 1B. Coding Details for Accepted Hospital-Level Indicators Abdominopelvic ...............................................................233 

Active drug dependence...................................................237 

Active nondependent abuse of drugs...............................237 Acute myocardial infarction.............................................237 

Anesthesia complications.................................................238 

Anoxic brain injury ..........................................................238 

Birth trauma......................................................................238 Bone malignancy..............................................................238 

Cancer...............................................................................238 Cardiac arrest....................................................................240 

Cardiac arrhythmia...........................................................240 

Cardiac surgery ................................................................240 

Cesarean delivery .............................................................240 

Coma.................................................................................240 

Control of postoperative hemorrhage ..............................241 Deep vein thrombosis.......................................................241 Delirium and other psychoses ..........................................241 Diabetes ............................................................................241 Drainage of hematoma .....................................................241 

Elective.............................................................................242 Foreign body left in during procedure .............................242 

Gastrointestinal (GI) hemorrhage ....................................242 Hemiplegia, paraplegia, or quadriplegia..........................243 Hemorrhage......................................................................243 

Hip fracture.......................................................................243 

Immunocompromised ......................................................243 

Indications of current drug abuse.....................................244 

Infection............................................................................245 Instrument assisted delivery.............................................245 

Liveborn ...........................................................................245 

Long term care facility....................................................246 

Low mortality...................................................................246 

Lung or pleural biopsy .....................................................248 

Lymphoid malignancy .....................................................248 Medical.............................................................................248 

Metastatic cancer..............................................................251 Obstetric trauma ...............................................................251 

Physiologic and metabolic derangements........................251 

Poisoning..........................................................................252 Postoperative hematoma ..................................................253 

Postoperative hemorrhage or hematoma..........................253 Preterm infant...................................................................253 

Pulmonary embolism .......................................................253 

Seizure ..............................................................................253 

Self inflicted injury ..........................................................253 

Sepsis................................................................................254 

Shock ................................................................................254 

Stroke................................................................................254 

Surgical.............................................................................254 

Syncope ............................................................................257 Technical difficulty ..........................................................257 Thoracic surgery...............................................................258 

Transferred to acute care facility .....................................259 Transferred from acute care facility.................................259 

Transfusion reaction.........................................................259 Trauma .............................................................................259 

Vaginal delivery...............................................................262 

FTR-FAILURE TO RESCUE .........................................262

Abdominopelvic ICD-9-CM procedure codes: 38.04 INCISION OF AORTA 38.06 INCISION OF ABDOMINAL ARTERIES 38.07 INCISION OF ABDOMINAL VEINS 38.14 ENDARTERECTOMY OF AORTA 38.16 ENDARTERECTOMY OF ABDOMINAL 

ARTERIES 

38.34 RESECTION OF AORTA WITH 

ANASTOMOSIS 

38.36 RESECTION OF ABDOMINAL ARTERIES 

WITH ANASTOMOSIS 

38.37 RESECTION OF ABDOMINAL VEINS WITH 

ANASTOMOSIS 

38.44 RESECTION OF AORTA, ABDOMINAL 

WITH REPLACEMENT 

38.46 RESECTION OF ABDOMINAL ARTERIES 

WITH REPLACEMENT 

38.47 RESECTION OF ABDOMINAL VEINS WITH 

REPLACEMENT 

38.57 LIGATION AND STRIPPING OF VARICOSE 

VEINS, ABDOMINAL VEINS 

38.64 OTHER EXCISION OF AORTA, 

ABDOMINAL 

38.66 OTHER EXCISION OF ABDOMINAL 

ARTERIES 

38.67 OTHER EXCISION OF ABDOMINAL VEINS 38.84 OTHER SURGICAL OCCLUSION OF 

AORTA, ABDOMINAL 

38.86 OTHER SURGICAL OCCLUSION OF 

ABDOMINAL ARTERIES 

38.87 OTHER SURGICAL OCCLUSION OF 

ABDOMINAL VEINS 

39.1 INTRA-ABDOMINAL VENOUS SHUNT 39.24 AORTA-RENAL BYPASS 

39.25 AORTA-ILIAC39.26 OTHER INTRA

SHUNT OR BY

40.52 RADICAL EX

LYMPH NODE

40.53 RADICAL EX

NODES 

41.2 SPLENOTOM41.33 OPEN BIOPSY 41.41 MARSUPIALI41.42 EXCISION OF 

SPLEEN 

41.43 PARTIAL SPL41.5 TOTAL SPLEN41.93 EXCISION OF 41.94 TRANSPLANT41.95 REPAIR AND 

SPLEEN 

41.99 OTHER OPER42.40 ESOPHAGECT42.41 PARTIAL ESO42.42 TOTAL ESOPH42.53 INTRATHORA

ANASTOMOSSMALL BOWE

42.54 OTHER INTRA

ESOPHAGOEN

42.55 INTRATHORA

ANASTOMOSCOLON 

42.56 OTHER INTRA

ESOPHAGOC

42.63 ANTESTERNA

ANASTOMOSSMALL BOWE

42.64 OTHER ANTE

ESOPHAGOEN

42.65 ANTESTERNA

ANASTOMOSCOLON 

42.66 OTHER ANTE

ESOPHAGOC

42.91 LIGATION OF 43.0 GASTROSTOM43.19 OTHER GAST43.3 PYLOROMYO43.42 LOCAL EXCIS

TISSUE OF ST
230

43.49 OTHER DESTRUCTION OF LESION OR 

TISSUE OF STOMACH 

43.5 PARTIAL GASTRECTOMY WITH 

ANASTOMOSIS TO ESOPHAGUS 

43.6 PARTIAL GASTRECTOMY WITH 

ANASTOMOSIS TO DUODENUM 

43.7 PARTIAL GASTRECTOMY WITH 

ANASTOMOSIS TO JEJUNUM 

43.81 PARTIAL GASTRECTOMY WITH JEJUNA 

TRANSPOSITION 

43.89 OTHER PARTIAL GASTRECTOMY 43.91 TOTAL GASTRECTOMY WITH 

INTESTINAL INTERPOSITION 

43.99 OTHER TOTAL GASTRECTOMY 44.00 VAGOTOMY, NOS 44.01 TRUNCAL VAGOTOMY 44.02 HIGHLY SELECTIVE VAGOTOMY 44.03 OTHER SELECTIVE VAGOTOMY 44.11 TRANSABDOMINAL GASTROSCOPY 44.15 OPEN BIOPSY OF STOMACH 44.21 DILATION OF PYLORUS BY INCISION 44.29 OTHER PYLOROPLASTY 44.31 HIGH GASTRIC BYPASS 44.39 OTHER GASTROENTEROSTOMY 44.40 SUTURE OF PEPTIC ULCER, NOS 44.41 SUTURE OF GASTRIC ULCER SITE 44.42 SUTURE OF DUODENAL ULCER SITE 44.5 REVISION OF GASTRIC ANASTOMOSIS 44.61 SUTURE OF LACERATION OF STOMACH 44.63 CLOSURE OF OTHER GASTRIC FISTULA 44.64 GASTROPEXY 44.65 ESOPHAGOGASTROPLASTY 44.66 OTHER PROCEDURES FOR CREATION OF 

ESOPHAGOGASTRIC SPHINCTERIC COMPETENCE 

44.69 OTHER REPAIR OF STOMACH 44.91 LIGATION OF GASTRIC VARICES 44.92 INTRAOPERATIVE MANIPULATION OF 

STOMACH 

45.00 INCISION OF INTESTINE, NOS 45.01 INCISION OF DUODENUM 45.02 OTHER INCISION OF SMALL INTESTINE 45.03 INCISION OF LARGE INTESTINE 45.31 OTHER LOCAL EXCISION OF LESION OF 

DUODENUM 

45.32 OTHER DESTRUCTION OF LESION OF 

DUODENUM 

45.33 LOCAL EXCISION OF LESION OR TISSUE 

OF SMALL INTESTINE, EXCEPT DUODENUM 

45.34 OTHER DESTRUCTION OF LESION OF 

SMALL INTESTINE, EXCEPT DUODENUM 

45.41 EXCISION OF LESION OR TISSUE OF 

LARGE INTESTINE 

45.49 OTHER DESTRUCTION OF LESION OF 

LARGE INTESTINE 

45.50 ISOLATION OF INTESTINAL SEGMENT, 

NOS 

45.51 ISOLATION OF SEGMENT OF SMALL 

INTESTINE 

45.52 ISOLATION OF SEGMENT OF LARGE 

INTESTINE 

45.61 MULTIPLE SEGMENTAL RESECTION OF 

SMALL INTESTINE 

45.62 OTHER PARTIAL RESECTION OF SMALL 

INTESTINE 

45.63 TOTAL REMOVAL OF SMALL INTESTINE 45.71 MULTIPLE SEGMENTAL RESECTION OF 

LARGE INTESTINE 

45.72 CESECTOMY 45.73 RIGHT HEMICOLECTOMY 45.74 RESECTION OF TRANSVERSE COLON 45.75 LEFT HEMICOLECTOMY 45.76 SIGMOIDECTOMY 45.79 OTHER PARTIAL EXCISION OF LARGE 

INTESTINE 

45.8 TOTAL INTRA-ABDOMINAL COLECTOMY 45.90 INTESTINAL ANASTOMOSIS, NOS 45.91 SMALL-TO-SMALL INTESTINAL 

ANASTOMOSIS 

45.92 ANASTOMOSIS OF SMALL INTESTINE TO 

RECTAL STUMP 

45.93 OTHER SMALL-TO-LARGE INTESTINAL 

ANASTOMOSIS 

45.94 LARGE-TO-LARGE INTESTINAL 

ANASTOMOSIS 

45.95 ANASTOMOSIS TO ANUS 46.01 EXTERIORIZATION OF SMALL 

INTESTINE 

46.03 EXTERIORIZATION OF LARGE INTESTINE 46.10 COLOSTOMY, NOS 46.11 TEMPORARY COLOSTOMY 46.13 PERMANENT COLOSTOMY 46.20 ILEOSTOMY, NOS 46.21 TEMPORARY ILESOSTOMY 46.22 CONTINENT ILEOSTOMY 46.23 OTHER PERMANENT ILEOSTOMY 46.40 REVISION OF INTESTINA STOMA, NOS 46.41 REVISION OF STOMA OF SMALL 

INTESTINE 

46.42 REPAIR OF PE46.43 OTHER REVIS

INTESTINE 

46.50 CLOSURE OF 46.51 CLOSURE OF 

INTESTINE 

46.52 CLOSURE OF 

INTESTINE 

46.60 FIXATION OF 46.61 FIXATION OF 

ABDOMINAL 

46.62 OTHER FIXAT46.63 FIXATION OF 

ABDOMINAL 

46.64 OTHER FIXAT46.72 CLOSURE OF 

46.74 CLOSURE OF 

INTESTINE, E

46.76 CLOSURE OF 

INTESTINE 

46.80 INTRA-ABDO

INTESTINE, N

46.81 INTRA-ABDO

SMALL INTES

46.82 INTRA-ABDO

LARGE INTES

46.91 MYOTOMY O46.92 MYOTOMY O46.93 REVISION OF 

INTESTINE 

46.94 REVISION OF 

INTESTINE 

46.99 OTHER OPER47.09 OTHER APPE47.19 OTHER INCID47.2 DRAINAGE O47.91 APPENDECTO47.92 CLOSURE OF 47.99 OTHER OPER48.41 SUBMUCOSA48.49 OTHER PULL

RECTUM 

48.5 ABDOMINOP

RECTUM 

48.75 ABDOMINAL 50.0 HEPATOTOM50.12 OPEN BIOPSY 50.21 MARSUPIALI

LIVER 

50.22 PARTIAL HEP
231

50.29 OTHER DESTRUCTION OF LESION OF 

LIVER 

50.3 LOBECTOMY OF LIVER 50.4 TOTAL HEPATECTOMY 50.51 AUXILIARY LIVER TRANSPLANT 50.59 OTHER TRANSPLANT OF LIVER 50.69 OTHER REPAIR OF LIVER 51.03 OTHER CHOLECYSTOSTOMY 51.04 OTHER CHOLECYSTOTOMY 51.13 OPEN BIOPSY OF GALLBLADDER OR 

BILE DUCTS 

51.21 OTHER PARTIAL CHOLECYSTECTOMY 51.22 CHOLECYSTECTOMY 51.31 ANASTOMOSIS OF GALLBLADDER TO 

HEPATIC DUCTS 

51.32 ANASTOMOSIS OF GALLBLADDER TO 

INTESTINE 

51.33 ANASTOMOSIS OF GALLBLADDER TO 

PANCREAS 

51.34 ANASTOMOSIS OF GALLBLADDER TO 

STOMACH 

51.35 OTHER GALLBLADDER ANASTOMOSIS 51.36 CHOLEDOCHOENTEROSTOMY 51.37 ANASTOMOSIS OF HEPATIC DUCT TO 

GASTROINTESTINAL TRACT 

51.39 OTHER BILE DUCT ANASTOMOSIS 51.41 COMMON DUCT EXPLORATION FOR 

REMOVAL OF CALCULUS 

51.42 COMMON DUCT EXPLORATION FOR 

RELIEF OF OTHER OBSTRUCTION 

51.43 INSERTION OF CHOLEDOCHOHEPATIC 

TUBE FOR DECOMPRESSION 

51.49 INCISION OF OTHER BILE DUCTS FOR 

RELIEF OF OBSTRUCTION 

51.51 EXPLORATION OF COMMON DUCT 51.59 INCISION OF OTHER BILE DUCT 51.61 EXCISION OF CYSTIC DUCT REMNANT 51.62 EXCISION OF AMPULLA OF VATER WITH 

REIMPLANTATION OF COMMON DUCT 

51.63 OTHER EXCISION OF COMMON DUCT 51.69 EXCISION OF OTHER BILE DUCT 51.71 SIMPLE SUTURE OF COMMON BILE 

DUCT 

51.72 CHOLEDOCHOPLASTY 51.79 REPAIR OF OTHER BILE DUCTS 51.81 DILATION OF SPHINCTER OF ODDI 51.82 PANCREATIC SPHINCTEROTOMY 51.83 PANCREATIC SPHINCTEROPLASTY 51.89 OTHER OPERATIONS ON SPHINCTER OF 

ODDI 

51.92 CLOSURE OF CHOLECYSTOSTOMY 51.93 CLOSURE OF OTHER BILIARY FISTULA 51.94 REVISION OF ANASTOMOSIS OF BILIARY 

TRACT 

51.95 REMOVAL OF PROSTHETIC DEVICE 

FROM BILE DUCT 

51.99 OTHER OPERATIONS ON BILIARY TRACT 52.01 DRAINAGE OF PANCREATIC CYST BY 

CATHETER 

52.09 OTHER PANCREATOTOMY 52.12 OPEN BIOPSY OF PANCREAS 52.22 OTHER EXCISION OR DESTRUCTION OF 

LESION OR TISSUE OF PANCREAS OR PANCREATIC DUCT 

52.3 MARSUPIALIZATION OF PANCREATIC 

CYST 

52.4 INTERNAL DRAINAGE OF PANCREATIC 

CYST 

52.51 PROXIMAL PANCREATECTOMY 52.52 DISTAL PANCREATECTOMY 52.53 RADIAL SUBTOTAL PANCREATECTOMY 52.59 OTHER PARTIAL PANCREATECTOMY 52.6 TOTAL PANCREATECTOMY 52.7 RADICAL 

PANCREATICODUODENECTOMY 

52.80 PANCREATIC TRANSPLANT, NOS 52.81 REIMPLANTATION 52.82 HOMOTRANSPLANT OF PANCREAS 52.83 HETEROTRANSPLANT OF PANCREAS 52.92 CANNULATION OF PANCREATIC DUCT 52.95 OTHER REPAIR OF PANCREAS 52.96 ANASTOMOSIS OF PANCREAS 52.99 OTHER OPERATIONS ON PANCREAS 53.00 UNILATERAL REPAIR OF INGUINAL 

HERNIA, NOS 

53.01 REPAIR OF DIRECT INGUINAL HERNIA 53.02 REPAIR OF INDIRECT INGUINAL HERNIA 53.03 AIR OF DIRECT INGUINAL HERNIA 53.04 REPAIR OF INDIRECT INGUINAL HERNIA 

WITH GRAFT OR PROSTHESIS 

53.05 REPAIR OF INGUINAL HERNIA WITH 

GRAFT OR PROSTHESIS, NOS 

53.10 BILATERAL REPAIR OF INGUINAL 

HERNIA, NOS 

53.11 BILATERAL REPAIR OF DIRECT 

INGUINAL HERNIA 

53.12 BILATERAL REPAIR OF INDIRECT 

INGUINAL HERNIA 

53.13 BILATERAL R

HERNIA, ONE INDIRECT 

53.14 BILATERAL R

INGUINAL HEPROSTHESIS 

53.15 BILATERAL R

INGUINAL HEPROSTHESIS 

53.16 BILATERAL R

HERNIA, ONE INDIRECT, W

53.17 BILATERAL I

WITH GRAFT 

53.21 UNILATERAL 

HERNIA 

53.29 OTHER UNILA

HERNIORRHA

53.31 BILATERAL R

HERNIA WITH 

53.39 OTHER BILAT

HERNIORRHA

53.41 REPAIR OF U

PROSTHESIS 

53.49 OTHER UMBI53.51 INCISIONAL H53.59 REPAIR OF O

ANTERIOR A

53.61 INCISIONAL H

PROSTHESIS 

53.69 REPAIR OF O

ANTERIOR APROSTHESIS 

53.7 REPAIR OF D

ABDOMINAL 

54.0 INCISION OF 54.11 EXPLORATOR54.19 OTHER LAPA54.22 BIOPSY OF A

UMBILICUS 

54.23 BIOPSY OF PE54.3 EXCISION OR 

OR TISSUE OF UMBILICUS 

54.4 EXCISION OR 

PERITONEAL 

54.59 OTHER LYSIS 

ADHESIONS 

54.63 OTHER SUTU54.64 SUTURE OF P
232

54.71 REPAIR OF GASTROSCHISIS 54.72 OTHER REPAIR OF ABDOMINAL WALLS 54.73 OTHER REPAIR OF PERITONEUM 54.74 OTHER REPAIR OF OMENTUM 54.75 OTHER REPAIR OF MESENTERY 54.92 REMOVAL OF FOREIGN BODY FROM 

PERITONEAL CAVITY 

54.93 CREATION OF CUTANEOPERITONEAL 

FISTULA 

54.94 CREATION OF PERITONEOVASCULAR 

SHUNT 

54.95 INCISION OF PERITONEUM 55.51 NEPHROURETERECTOMY 55.52 NEPHRECTOMY OF REMAINING KIDNEY 55.53 REMOVAL OF TRANSPLANTED OR 

REJECTED KIDNEY 

55.54 BILATERAL NEPHRECTOMY 55.61 RENAL AUTOTRANSPLANTATION 55.69 ULCERATIVE COLITIS, UNSPECIFIED 55.7 NEPHROPEXY 55.83 CLOSURE OF OTHER FISTULA OF 

KIDNEY 

55.84 REDUCTION OF TORSION OF RENAL 55.85 SYMPHYSIOTOMY FOR HORESHOE 

KIDNEY 

55.86 ANASTOMOSIS OF KIDNEY 55.87 CORRECTION OF URETEROPELVIC 

JUNCTION 

55.91 DECAPSULATION OF KIDNEY 55.97 IMPLANTATION OR REPLACEMENT OF 

MECHANICAL KIDNEY 

55.98 REMOVAL OF MECHANICAL KIDNEY 56.51 FORMATION OF CUTANEOUS URETEROILEOSTOMY 56.52 REVISION OF CUTANEOUS URETEROILEOSTOMY 56.61 FORMATION OF OTHER CUTANEOUS 

URETEROSTOMY 

56.62 REVISION OF OTHER CUTANEOUS 

URETEROSTOMY 

56.71 URINARY DIVERSION TO INTESTINE 56.72 REVISION OF URETEROINTESTINAL 

ANASTOMOSIS 

56.73 NEPHROCYSTANASTOMOSIS, NOS 56.74 URETERONEOXYSTOSTOMY 56.75 TRANSURETEROURETEROSTOMY 56.83 CLOSURE OF URETEROSTOMY 56.84 CLOSURE OF OTHER FISTULA OF 

URETER 

56.85 URETEROPEXY 

56.86 REMOVAL OF LIGATURE FROM URETER 56.89 OTHER REPAIR OF URETER 56.95 LIGATION OF URETER 57.71 RADICAL CYSTECTOMY 57.79 OTHER TOTAL CYSTECTOMY 57.82 CLOSURE OF CYSTOSTOMY 57.87 RECONSTRUCTION OF URINARY 

BLADDER 

59.00 RETROPERITONEAL DISSECTION, NOS 59.02 OTHER LYSIS OF PERIRENAL OR 

PERIURETERAL ADHESIONS 

59.09 OTHER INCISION OF PERIRENAL OR 

PERIURETERAL TISSUE 

60.12 OPEN BIOPSY OF PROSTATE 60.14 OPEN BIOPSY OF SEMINAL VESICLES 60.15 BIOPSY OF PERIPROSTATIC TISSUE 60.3 SUPRAPUBIC PROSTATECTOMY 60.4 RETROPUBIC PROSTATECTOMY 60.5 RADICAL PROSTATECTOMY 60.61 LOCAL EXCISION OF LESION OF 

PROSTATE 

60.72 INCISION OF SEMINAL VESICLE 60.73 EXCISION OF SEMINAL VESICLE 60.79 OTHER OPERATIONS ON SEMINAL 

VESICLES 

60.93 REPAIR OF PROSTATE 65.09 OTHER OOPHORECTOMY 65.12 OTHER BIOPSY OF OVARY 65.21 MARSUPIALIZATION OF OVARIAN CYST 65.22 WEDGE RESECTION OF OVARY 65.29 OTHER LOCAL EXCISION OR 

DESTRUCTION OF OVARY 

65.39 OTHER UNLILATERAL OOPHORECTOMY 65.49 OTHER UNILATERAL 

SALPINGOOPHORECTOMY 

65.51 OTHER REMOVAL OF BOTH OVARIES AT 

SAME OPERATIVE EPISODE 

65.52 OTHER REMOVAL OF REMAINING 

OVARY 

65.61 OTHER REMOVAL OF BOTH OVARIES 

AND TUBES AT SAME OPERATIVE EPISODE 

65.62 OTHER REMOVAL OF REMAINING 

OVARY AND TUBE 

65.71 OTHER SIMPLE SUTURE OF OVARY 65.72 OTHER REIMPLANTATION OF OVARY 65.73 OTHER SALPINGO OOPHOROPLASTY 65.79 OTHER REPAIR OF OVARY 65.89 OTHER LYSIS OF ADHESIONS OF OVARY 

AND FALLOPIAN TUBE 

65.92 TRANSPLANT65.93 MANUAL RU65.94 OVARIAN DE65.95 RELEASE OF 65.99 OTHER OPER66.01 SALPINGOTO66.02 SALPINGOST66.31 OTHER BILAT

CRUSHING O

66.32 OTHER BILAT

DIVISION OF 

66.39 OTHER BILAT

OCCLUSION O

66.4 TOTAL UNILA66.51 REMOVAL OF 

AT SAME OPE

66.52 REMOVAL OF 

TUBE 

66.61 EXCISION OR 

OF FALLOPIA

66.62 SALPINGECT

TUBAL PREG

66.63 BILATERAL P

NOS 

66.69 OTHER PART66.71 SIMPLE SUTU66.72 SALPINGO-O66.73 SALPINGO-SA66.74 SALPINGO-U66.79 OTHER REPA66.92 UNILATERAL 

OCCLUSION O

66.97 BURYING OF 

WALL 

68.0 OTHER INCIS

UTERUS 

68.13 OPEN BIOPSY 68.14 OPEN BIOPSY 68.3 SUBTOTAL A

HYSTERECTO

68.4 TOTAL ABDO68.6 RADICAL AB68.8 PELVIC EVISC69.22 OTHER UTER69.3 PARACERVIC

DENERVATIO

69.41 SUTURE OF L69.42 CLOSURE OF 69.49 OTHER REPA
233

Active drug dependence ICD-9-CM diagnosis codes: 304.00 OPIOID TYPE DEPENDENCEUNSPECIFIED 304.01 OPIOID TYPE DEPENDENCECONTINUOUS 304.02 OPIOID TYPE DEPENDENCE-EPISODIC 304.10 BARBITURATE AND SIMILARLY ACTING 

SEDATIVE OR HYPNOTIC DEPENDENCE -UNSPECIFIED 

304.11 BARBITURATE AND SIMILARLY ACTING 

SEDATIVE OR HYPNOTIC DEPENDENCE -CONTINUOUS 

304.12 BARBITURATE AND SIMILARLY ACTING 

SEDATIVE OR HYPNOTIC DEPENDENCE, -EPISODIC 

304.20 COCAINE DEPENDENCE-UNSPECIFIED 304.21 COCAINE DEPENDENCE-CONTINUOUS 304.22 COCAINE DEPENDENCE-EPISODIC 304.30 CANNABIS DEPENDENCE UNSPECIFIED 304.31 CANNABIS DEPENDENCE CONTINUOUS 304.32 CANNABIS DEPENDENCE EPISODIC 304.40 AMPHETAMINE AND OTHER PSYCHO 

STIMULANT DEPENDENCE-UNSPECIFIED 

304.41 AMPHETAMINE AND OTHER PSYCHO 

STIMULANT DEPENDENCE-CONTINUOUS 

304.42 AMPHETAMINE AND OTHER PSYCHO 

STIMULANT DEPENDENCE-EPISODIC 

304.50 HALLUCINOGEN DEPENDENCE 

UNSPECIFIED 

304.51 HALLUCINOGEN DEPENDENCECONTINUOUS 304.52 HALLUCINOGEN DEPENDENCE - 

EPISODIC 

304.60 OTHER SPECIFIED DRUG DEPENDENCE - 

UNSPECIFIED 

304.61 OTHER SPECIFIED DRUG DEPENDENCE -

CONTINUOUS 

304.62 OTHER SPECIFIED DRUG DEPENDENCE -

EPISODIC 

304.70 COMBINATIONS OF OPIOID TYPE DRUG 

WITH ANY OTHER - UNSPECIFIED 

304.71 COMBINATIONS OF OPIOID TYPE DRUG 

WITH ANY OTHER - CONTINUOUS 

304.72 COMBINATIONS OF OPIOID TYPE DRUG 

WITH ANY OTHER - EPISODIC 

304.80 COMBINATIONS OF DRUG EXCLUDING 

OPIOID TYPE DRUG - UNSPECIFIED 

304.81 COMBINATIONS OF DRUG EXCLUDING 

OPIOID TYPE DRUG - CONTINUOUS 

304.82 COMBINATIONS OF DRUG EXCLUDING 

OPIOID TYPE DRUG - EPISODIC 

304.90 UNSPECIFIED DRUG DEPENDENCE -

UNSPECIFIED 

304.91 UNSPECIFIED DRUG DEPENDENCE -

CONTINUOUS 

304.92 UNSPECIFIED DRUG DEPENDENCE -

EPISODIC 

Active nondependent abuse of drugs ICD-9-CM diagnosis codes: 305.00 ALCOHOL ABUSE-UNSPECIFIED 305.01 ALCOHOL ABUSE-CONTINUOUS 305.02 ALCOHOL ABUSE-EPISODIC 305.10 TOBACCO USE DISORDER-UNSPECIFIED 305.11 TOBACCO USE DISORDER - 

CONTINUOUS 

305.12 TOBACCO USE DISORDER -EPISODIC 305.20 CANNABIS ABUSE-UNSPECIFIED 305.21 CANNABIS ABUSE-CONTINUOUS 305.22 CANNABIS ABUSE-EPISODIC 305.30 HALLUCINOGEN ABUSE- UNSPECIFIED 305.31 HALLUCINOGEN ABUSE-CONTINUOUS 305.32 HALLUCINOGEN ABUSE- EPISODIC 305.40 BARBITURATE AND SIMILARLY ACTING 

SEDATIVE OR HYPNOTIC ABUSEUNSPECIFIED 

305.41 BARBITURATE AND SIMILARLY ACTING 

SEDATIVE OR HYPNOTIC ABUSECONTINUOUS 

305.42 BARBITURATE AND SIMILARLY ACTING 

SEDATIVE OR HYPNOTIC ABUSEEPISODIC 

305.50 OPIOID ABUSE-UNSPECIFIED 305.51 OPIOD ABUSE-CONTINUOUS 305.52 OPIOID ABUSE-EPISODIC 305.60 COCAINE ABUSE-UNSPECIFIED 305.61 COCAINE ABUSE-CONTINUOUS 305.62 COCAINE ABUSE-EPISODIC 305.70 AMPHETAMINE OR RELATED ACTING 

SYMPATHOMIMETIC ABUSEUNSPECIFIED 

305.71 AMPHETAMI

SYMPATHOMCONTINUOUS 

305.72 AMPHETAMI

SYMPATHOM

305.80 ANTIDEPRES

UNSPECIFIED 

305.81 ANTIDEPRES

CONTINUOUS 

305.82 ANTIDEPRES

EPISODIC 

305.90 OTHER, MIXE

ABUSE-UNSP

305.91 OTHER, MIXE

ABUSE- CONT

305.92 OTHER, MIXE

ABUSE- EPISO

Acute myocardial infarctICD-9-CM diagnosis code410.00 AMI OF ANTE

EPISODE OF C

410.01 AMI OF ANTE

INITIAL EPISO

410.10 AMI OF OTHE

EPISODE OF C

410.11 AMI OF OTHE

INITIAL EPISO

410.20 AMI OF INFER

EPISODE OF C

410.21 AMI OF INFER

INITIAL EPISO

410.30 AMI OF INFER

EPISODE OF C

410.31 AMI OF INFER

INITIAL EPISO

410.40 AMI OF INFER

CARE UNSPE

410.41 AMI OF INFER

EPISODE OF C

410.50 AMI OF OTHE

EPISODE OF C

410.51 AMI OF OTH

INITIAL EPISO

410.60 AMI TRUE PO

INFARCTION UNSPECIFIED 
234

410.61 AMI TRUE POSTERIOR WALL 

INFARCTION - INITIAL EPISODE OF CARE 

410.70 AMI SUBENDOCARDIAL INFARCTION - 

EPISODE OF CARE UNSPECIFIED 

410.71 AMI SUBENDOCARDIAL INFARCTION - 

INITIAL EPISODE OF CARE 

410.80 AMI OF OTHER SPECIFIED SITES - 

EPISODE OF CARE UNSPECIFIED 

410.81 AMI OF OTHER SPECIFIED SITES - 

INITIAL EPISODE OF CARE 

410.90 AMI UNSPECIFIED SITE - EPISODE OF 

CARE UNSPECIFIED 

410.91 AMI UNSPECIFIED SITE - INITIAL 

EPISODE OF CARE 

Anesthesia complications ICD-9-CM diagnosis codes: E876.3 OTHER AND UNSPECIFIED 

MISADVENTURES DURING MEDICAL CARE, ENDOTRACHEAL TUBE WRONGLY PLACED DURING ANESTHETIC PROCEDURE 

E855.1 OTHER NERVOUS SYSTEM 

DEPRESSANTS 

OTHER CENTRAL NERVOUS SYSTEM DEPRESSANTS AND ANESTHETICS: E938.1 HALOTHANE E938.2 OTHER GASEOUS ANESTHETICS E938.3 INTRAVENOUS ANESTHETICS E938.4 OTHER AND UNSPECIFIED GENERAL 

\ANESTHETICS 

E938.5 SURFACE AND INFILTRATION 

ANESTHETICS 

E938.6 PERIPHERAL NERVE AND PLEXUS 

BLOCKING ANESTHETICS 

E938.7 SPINAL ANESTHETICS E938.9 OTHER AND UNSPECIFIED LOCAL 

ANESTHETICS 

POISONING BY OTHER CENTRAL NERVOUS SYSTEM DEPRESSANTS AND ANESTHETICS: 968.1 HALOTHANE 968.2 OTHER GASEOUS ANESTHETICS 968.3 INTRAVENEOUS ANESTHETICS 968.4 OTHER AND UNSPECIFIED GENERAL 

ANESTHETICS 

968.7 SPINAL ANESTHETICS Anoxic brain injury ICD-9-CM diagnosis codes: 348.1 ANOXIC BRAIN DAMAGE Birth trauma ICD-9-CM diagnosis codes: 767.0 SUBDURAL AND CEREBRAL 

HEMORRHAGE (DUE TO TRAUMA OR TO INTRAPARTUM ANOXIA OR HYPOXIA) 

767.3 INJURIES TO SKELETON (EXCLUDES 

CLAVICLE) 

767.4 INJURY TO SPINE AND SPINAL CORD 767.7 OTHER CRANIAL AND PERIPHERAL 

NERVE INJURIES 

767.8 OTHER SPECIFIED BIRTH TRAUMA 767.9 BIRTH TRAUMA, UNSPECIFIED Bone malignancy ICD-9-CM diagnosis codes (all 4th and 5th digits) : 

170 MALIGNANT NEOPLASM OF BONE AND 

ARTICULAR CARTILAGE 

Cancer ICD-9-CM diagnosis codes( all 4th and 5th digits) : 

140 MALIGNANT NEOPLASM OF LIP 141 MALIGNANT NEOPLASM OF TONGUE 142 MALIGNANT NEOPLASM OF MAJORITY 

SALIVARY GLANDS 

143 MALIGNANT NEOPLASM OF GUM 144 MALIGNANT NEOPLASM OF FLOOR OF 

MOUTH 

145 MALIGNANT NEOPLASM OF OTHER AND 

UNSPECIFIED PARTS OF MOUTH 

146 MALIGNANT NEOPLASM OF 

OROPHARYNX 

147 MALIGNANT 

NASOPHARY

148 MALIGNANT 

HYPOPHARY

149 MALIGNANT 

ILL-DEFINED ORAL CAVIT

150 MALIGNANT 151 MALIGNANT 152 MALIGNANT 

INTESTINE, IN

153 MALIGNANT 154 MALIGNANT 

RECTOSIGMO

155 MALIGNANT 

INTRAHEPAT

156 MALIGNANT 

GALLBLADDBILE DUCTS 

157 MALIGNANT 158 MALIGNANT 

RETROPERIT

159 MALIGNANT 

ILL-DEFINED DIGESTIVE O

160 MALIGNANT 

CAVITIES, MIACCESSORY 

161 MALIGNANT 162 MALIGNANT 

BRONCHUS, A

163 MALIGNANT 164 MALIGNANT 

HEART, AND 

165 MALIGNANT 

ILL-DEFINED RESPIRATORINTRATHORA

170 MALIGNANT 

ARTICULAR C

171 MALIGNANT 

CONNECTIVE 

172 MALIGNANT 174 MALIGNANT 

BREAST 

175 MALIGNANT 

BREAST 

176 KARPOSI’S SA179 MALIGNANT 

PART UNSPEC
235

180 MALIGNANT NEOPLASM OF CERVIX 

UTERI 

181 MALIGNANT NEOPLASM OF EYE 182 MALIGNANT NEOPLASM OF BODY OF 

UTERUS 

183 MALIGNANT NEOPLASM OF OVARY AND 

OTHER UTERINE ADNEXA 

184 MALIGNANT NEOPLASM OF OTHER AND 

UNSPECIFIED FEMALE GENITAL ORGANS 

185 MALIGNANT NEOPLASM OF OTHER AND 

UNSPECIFIED FEMALE GENITAL ORGANS 

186 MALIGNANT NEOPLASM OF TESTIS 187 MALIGNANT NEOPLASM OF PENIS AND 

OTHER MALE GENITAL ORGANS 

188 MALIGNANT NEOPLASM OF BLADDER 189 MALIGNANT NEOPLASM OF KIDNEY 

AND OTHER AND UNSPECIFIED URINARY ORGANS 

190 MALIGNANT NEOPLASM OF EYE 191 MALIGNANT NEOPLASM OF BRAIN 192 MALIGNANT NEOPLASM OF OTHER AND 

UNSPECIFIED PARTS OF NERVOUS SYSTEM 

193 MALIGNANT NEOPLASM OF THYROID 

GLAND 

194 MALIGNANT NEOPLASM OF OTHER 

ENDOCRINE GLANDS AND RELATED STRUCTURES 

195 MALIGNANT NEOPLASM OF OTHER, AND 

ILL-DEFINED SITES 

196 SECONDARY AND UNSPECIFIED 

MALIGNANT NEOPLASM OF LYMPH NODES 

197 SECONDARY MALIGNANT NEOPLASM 

OF RESPIRATORY AND DIGESTIVE SYSTEMS 

198 SECONDARY MALIGNANT NEOPLASM 

OF OTHER SPECIFIED SITES 

199 MALIGNANT NEOPLASM WITHOUT 

SPECIFICATION OF SITE 

200 LYMPHOSARCOMA AND 

RETICULOSARCOMA 

201 HODGKIN’S DISEASE 202 OTHER MALIGNANT NEOPLASMS OF 

LYMPHOID AND HISTIOCYTIC TISSUES 

203 MULTIPLE MYELOMA AND 

IMMUNOPROLIFERATIVE NEOPLASMS 

204 LYMPHOID LEUKEMIA 

205 MYELOID LEUKEMIA 206 MONOCYTIC LEUKEMIA 207 OTHER SPECIFIED LEUKEMIA 208 LEUKEMIA OF UNSPECIFIED CELL TYPE 238.6 NEOPLASM OF UNCERTAIN BEHAVIOR 

OF OTHER AND UNSPECIFIED SITES AND TISSUES, PLASMA CELLS 

273.3 DISORDERS OF PLASMA PROTEIN 

METABOLISM-MACROGLOBULINEMIA 

PERSONAL HISTORY OF MALIGNANT NEOPLASM: V10.00 GASTROINTESTINAL TRACT, 

UNSPECIFIED 

V10.01 TONGUE V10.02 OTHER AND UNSPECIFIED ORAL CAVITY 

AND PHARYNX 

V10.03 ESOPHAGUS V10.04 STOMACH V10.05 LARGE INTESTINE V10.06 RECTUM, RECTOSIGMOID JUNCTION, 

AND ANUS 

V10.07 LIVER V10.09 OTHER GASTROINTESTINAL TRACT V10.11 BRONCHUS AND LUNG V10.12 TRACHEA V10.20 RESPIRATORY ORGAN, UNSPECIFIED V10.21 LARYNX V10.22 NASAL CAVITIES, MIDDLE EAR, AND 

ACCESSORY SINUSES 

V10.29 OTHER RESPIRATORYAND 

INTRATHORACIC ORGANS 

V10.3 BREAST V10.40 FEMALE GENITAL ORGAN, UNSPECIFIED V10.41 CERVIX UTERI V10.42 OTHER PARTS OF UTERUS V10.43 OVARY V10.44 OTHER FEMALE GENITAL ORGANS V10.45 MALE GENITAL ORGAN, UNSPECIFIED V10.46 PROSTATE V10.47 TESTIS V10.48 EPIDIDYMIS V10.49 OTHER MALE GENITAL ORGANS V10.50 URINARY ORGAN, UNSPECIFIED V10.51 BLADDER V10.52 KIDNEY V10.59 OTHER URINARY ORGAN V10.60 LYMPHOSARCOMA AND 

RETICULOSARCOMA 

V10.61 HODGKINS DISEASE V10.62 MYELOID LEUKEMIA 

V10.63 MONOCYTIC V10.69 OTHER LEUKV10.71 LYMPHOSAR

RETICULOSA

V10.72 HODGKINS DV10.79 OTHER LYMP

HEMATOPOIE

V10.81 BONE V10.82 MALIGNANT V10.83 OTHER MALIV10.84 EYE V10.85 BRAIN V10.86 OTHER PARTV10.87 THYROID V10.88 OTHER ENDO

RELATED STR

V10.89 OTHER NEOPV10.9 UNSPECIFIED 

MALIGNANT 

Diagnostic Related Group010 NERVOUS SY

CC 

011 NERVOUS SY

WITHOUT CC 

064 EAR, NOSE, M

MALIGNANC

082 RESPIRATOR172 DIGESTIVE M173 DIGESTIVE M199 HEPATOBILIA

PROCEDURE 

203 MALIGNANC

SYSTEM OR P

239 PATHOLOGIC

MUSCULOSKTISSUE MALI

257 TOTAL MAST

MALIGNANC

258 TOTAL MAST

MALIGNANC

259 SUBTOTAL M

MALIGNANC

260 SUBTOTAL M

MALIGNANC

274 MALIGNANT 

CC 

275 MALIGNANT 

WITHOUT CC 
236

303 KIDNEY, URETER AND MAJOR BLADDER 

PROCEDURES FOR NEOPLASM 

318 KIDNEY AND URINARY TRACT 

NEOPLSMS WITH CC 

319 KIDNEY AND URINARY TRACT 

NEOPLASMS WITHOUT CC 

338 TESTES PROCEDURES FOR 

MALIGNANCY 

344 OTHER MALE REPRODUCTIVE SYSTEM 

OR PROCEDURES FOR MALIGNANCY 

346 MALIGNANCY OF MALE REPRODUCTIVE 

SYSTEM WITH CC 

347 MALIGNANCY OF MALE REPRODUCTIVE 

SYSTEM WITHOUT CC 

354 UTERINE AND ADNEXA PROCEDURES 

FOR NONOVARIAN/ADNEXAL MALIGNANCY WITH CC 

355 UTERINE AND ADNEXA PROCEDURES 

FOR NONOVARIAN/ADNEXAL MALIGNANCY WITHOUT CC 

357 UTERINE AND ADNEXA PROCEDURES 

FOR OVARIAN OR ADNEXAL MALIGNANCY 

363 D AND C, CONIZATION AND 

RADIOIMPLANT FOR MALIGNANCY 

367 MALIGNANCY OF FEMALE 

REPRODUCTIVE SYSTEM WITHOUT CC 

400 LYMPHOMA AND LEUKEMIA WITH 

MAJOR OR PROCEDURES 

401 LYMPHOMA AND NONACUTE LEUKEMIA 

WITH OTHER OR PROCEDURE WITH CC 

402 LYMPHOMA AND NONACUTE LEUKEMIA 

WITH OTHER OR PROCEDURE WITHOUT CC 

403 LYMPHOMA AND NONACUTE LEUKEMIA 

WITH CC 

404 LYMPHOMA AND NONACUTE LEUKEMIA 

WITHOUT CC 

405 ACUTE LEUKEMIAWITHOUT MAJOR OR 

PROCEDURE, AGE 0-17 

406 MYELOPROLIFERATIVE DISORDERS OR 

POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR OR PROCEDURES WITH CC 

407 MYELOPROLIFERATIVE DISORDERS OR 

POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR OR PROCEDURE WITHOUT CC 

408 MYELOPROLIFERATIVE DISORDERS OR 

POORLY DIFFERENTIATED NEOPLASMS WITH OTHER OR PROCEDURES 

409 RADIOTHERAPY 410 CHEMOTHERAPY WITHOUT ACUTE 

LEUKEMIA AS SECONDARY DIAGNOSIS 

411 HISTORY OF MALIGNANCY WITHOUT 

ENDOSCOPY 

412 HISTORY OF MALIGNANCY WITH 

ENDOSCOPY 

413 OTHER MYELOPROLIFERATIVE 

DISORDERS OR POORLY DIFFERENTIATED NEOPLASM DIAGNOSES WITH CC 

414 OTHER MYELOPROLIFERATIVE 

DISORDERS OR POORLY DIFFERENTIATED NEOPLASM DIAGNOSES WITHOUT CC 

473 ACUTE LEUKEMIA WITHOUT MAJOR OR 

PROCEDURE, AGE GREATER THAN 17 

492 CHEMOTHERAPY WITH ACUTE 

LEUKEMIA AS SECONDARY DIAGNOSIS 

Cardiac arrest 

ICD-9-CM codes: 427.5 CARDIAC ARREST Cardiac arrhythmia ICD-9-CM diagnosis codes: 426.0 ATRIOVENTRICULAR BLOCK, 

COMPLETE 

427.0 PAROXYSMAL SUPRAVENTRICULAR 

TACHYCARDIA 

427.1 PAROXYSMAL VENTRICULAR 

TACHYCARDIA 

427.2 PAROXYSMAL TACHYCARDIA, 

UNSPECIFIED 

427.31 ATRIAL FIBRILLATION 427.32 ATRIAL FLUTTER 427.41 VENTRICULAR FIBRILLATION 427.42 VENTRICULAR FLUTTER 427.9 CARDIAC DYSRHYTHMIA Diagnostic Related Groups (DRGs): 138 CARDIAC ARRHYTHMIA AND 

CONDUCTION DISORDERS WITH CC 

139 CARDIAC AR

CONDUCTION 

Cardiac surgery Diagnostic Related Group103 HEART TRAN104 CARDIAC VA

CARDIOTHORCARDIAC CA

105 CARDIAC VA

CARDIOTHORWITHOUT CA

106 CORONARY B107 CORONARY B

CATHETERIZ

108 OTHER CARD109 CORONARY B

CATHETERIZ

110 MAJOR CARD

PROCEDURES 

111 MAJOR CARD

PROCEDURES 

Cesarean delivery Diagnostic related groups 370 CESAREAN S371 CESAREAN SComa ICD-9-CM diagnosis code251.0 OTHER DISOR

INTERNAL SECOMA 

572.2 LIVER ABSCE

CHRONIC LIVCOMA 

780.01 GENERAL SY

CONSCIOUSN

250.20 DIABETES W

TYPE 2 [NONTYPE][NIDDM 
237

UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED 

250.21 DIABETES WITH HYPEROSMOLARITY, 

TYPE 1 [INSULIN DEPENDENT TYPE][NIDDM-TYPE] [JUVENILE TYPE], NOT STATED AS UNCONTROLLED 

250.22 DIABETES WITH HYPEROSMOLARITY, 

TYPE 2 

250.23 DIABETES MELLITUS, DIABETES WITH 

HYPEROSMOLARITY , TYPE 1 [INSULIN DEPENDENT TYPE][NIDMMTYPE][JUVENILE TYPE] UNCONTROLLED 

250.30 DIABETES WITH OTHER COMA, TYPE 2 

NOT STATED AS UNCONTROLLED 

250.31 DIABETES WITH OTHER COMA, TYPE 1 

NOT STATED AS UNCONTROLLED 

250.32 DIABETES MELLITUS, DIABETES WITH 

OTHER COMA, TYPE 2 UNCONTROLLED 

250.33 DIABETES MELLITUS, DIABETES WITH 

OTHER COMA, TYPE 1 UNCONTROLLED 

780.03 GENERAL SYMPTOMS, ALTERATION OF 

CONSCIOUSNESS PERSISTENT VEGETATIVE STATE 

Control of postoperative hemorrhage ICD-9-CM procedure codes: 28.7 CONTROL OF HEMORRHAGE AFTER 

TONSILLECTOMY AND ADENOIDECTOMY 

38.80 OTHER SURGICAL OCCLUSION OF 

UNSPECIFIED SITE 

38.81 OTHER SURGICAL OCCLUSION OF 

INTRACRANIAL VESSELS 

38.82 OTHER SURGICAL OCCLUSION OF 

OTHER VESSELS OF HEAD AND NECK 

38.83 OTHER SURGICAL OCCLUSION OF UPPER 

LIMB VESSELS 

38.84 OTHER SURGICAL OCCLUSION OF 

AORTA, ABDOMINAL 

38.85 OTHER SURGICAL OCCLUSION OF 

THORACIC VESSEL 

38.86 OTHER SURGICAL OCCLUSION OF 

ABDOMINAL ARTERIES 

38.87 OTHER SURGICAL OCCLUSION OF 

VESSELS ABDOMINAL VEINS 

38.88 OTHER SURGICAL OCCLUSION OF 

LOWER LIMB ARTERIES 

38.89 OTHER SURGICAL OCCLUSION OF 

LOWER LIMB VEINS 

39.41 CONTROL OF HEMORRHAGE AFTER 

TONSILLECTOMY AND ADENOIDECTOMY 

39.98 CONTROL OF HEMORRHAGE NOS 49.95 CONTROL OF (POSTOPERATIVE) 

HEMORRHAGE OF ANUS 

57.93 CONTROL OF (POSTOPERATIVE) 

HEMORRHAGE OF BLADDER 

60.94 CONTROL OF (POSTOPERATIVE) 

HEMORRHAGE OF PROSTATE 

Deep vein thrombosis ICD-9-CM diagnosis codes: 451.11 PHLEBITIS AND THROMBOSIS OF 

FEMORAL VEIN (DEEP) (SUPERFICIAL) 

451.19 PHLEBITIS AND THROMBOPHLEBITIS - 

OF DEEP VESSEL OF LOWER EXTREMITIES - OTHER 

451.2 PHLEBITIS AND THROMBOPHLEBITIS OF 

LOWER EXTREMITIES UNSPECIFIED 

451.81 PHLEBITIS AND THROMBOPHLEBITIS OF 

ILIAC VEIN 

451.9 PHLEBITIS AND THROMBOPHLEBITIS OF 

OTHER SITES - OF UNSPECIFIED SITE 

453.8 OTHER VENOUS EMBOLISM AND 

THROMBOSIS OF OTHER SPECIFIED VEINS 

453.9 OTHER VENOUS EMBOLISM AND 

THROMBOSIS OF UNSPECIFIED SITE 

Delirium and other psychoses ICD-9-CM diagnosis codes (includes all 4th and 5th digits) 

290 SENILE AND PRESENILE ORGANIC 

PSYCHOTIC CONDITIONS 

291 ALCOHOLIC PSYCHOSES 292 DRUG PSYCHOSES 293 TRANSIENT ORGANIC PSYCHOTIC 

CONDITIONS 

294 OTHER ORGANIC PSYCHOTIC 

CONDITIONS 

295 SCHIZOPHRENIC DISORDERS 296 AFFECTIVE PSYCHOSES 297 PARANOID STATES 

298 OTHER NONO299 PSYCHOSES W

CHILDHOOD 

Diabetes ICD-9-CM diagnosis code250.0 DIABETES ME

MENTION OF 

250.1 DIABETES W250.2 DIABETES W250.3 DIABETES W250.4 DIABETES W

MANIFESTAT

250.5 DIABETES W

MANIFESTAT

250.6 DIABETES W

MANIFESTAT

250.7 DIABETES W

CIRCULATOR

250.8 DIABETES W

MANIFESTAT

250.9 DIABETES W

COMPLICATI

Drainage of hematoma ICD-9-CM procedure cod18.09 OTHER INCIS54.0 INCISION OF 54.12 REOPENING O

SITE 

59.19 OTHER INCIS

TISSUE 

61.0 INCISION AN

AND TUNICA 

69.98 OTHER OPER

STRUCTURES 

70.14 OTHER VAGI71.09 OTHER INCIS

PERINEUM 

75.91 EVACUATION 

INCISIONAL H

75.92 EVACUATION 

VULVA OR V

86.04 OTHER INCIS

SKIN AND SU
238

Elective ADMISSION TYPE IS RECORDED AS ELECTIVE (ATYPE = 3) Foreign body left in during procedure ICD-9-CM diagnosis codes: 998.4 FOREIGN BODY ACCIDENTALLY LEFT 

DURING A PROCEDURE 

998.7 ACUTE REACTION TO FOREIGN 

SUBSTANCE ACCIDENTALLY LEFT DURING A PROCEDURE 

FOREIGN BODY LEFT IN DURING: E871.0 SURGICAL OPERATION E871.1 INFUSION OR TRANSFUSION E871.2 KIDNEY DIALYSIS OR OTHER 

PERFUSION 

E871.3 INJECTION OR VACCINATION E871.4 ENDOSCOPIC EXAMINATION E871.5 ASPIRATION OF FLUID OR TISSUE, 

PUNCTURE, AND CATHETERIZATION 

E871.6 HEART CATHETERIZATION E871.7 REMOVAL OF CATHETER OR PACKING E871.8 OTHER SPECIFIED PROCEDURES E871.9 UNSPECIFIED PROCEDURE Gastrointestinal (GI) hemorrhage ICD-9-CM diagnosis codes: 456.0 ESOPHAGEAL VARICES WITH BLEEDING 456.20 ESOPHAGEAL VARICES IN DISEASES 

CLASSIFIED ELSEWHERE WITH BLEEDING 

530.7 GASTROESOPHAGEAL LACERATIONHEMORRHAGE SYNDROME 530.82 ESOPHAGEAL HEMORRHAGE 531.00 GASTRIC ULCER ACUTE WITH 

HEMORRHAGE - WITHOUT MENTION OF OBSTRUCTION 

531.01 GASTRIC ULCER ACUTE WITH 

HEMORRHAGE - WITH OBSTRUCTION 

531.20 GASTRIC ULCER ACUTE WITH 

HEMORRHAGE AND PERFORATION - WITHOUT MENTION OF OBSTRUCTION 

531.21 GASTRIC ULCER, ACUTE WITH 

HEMORRHAGE AND PERFORATION - WITH OBSTRUCTION 

531.40 GASTRIC ULCER CHRONIC OR 

UNSPECIFIED WITH HEMORRHAGE -WITHOUT MENTION OF OBSTRUCTION 

531.41 GASTRIC ULCER CHRONIC OR 

UNSPECIFIED WITH HEMORRHAGE - WITH OBSTRUCTION 

531.60 GASTRIC ULCER CHRONIC OR 

UNSPECIFIED WITH HEMORRHAGE AND PERFORATION - WITHOUT MENTION OF OBSTRUCTION 

531.61 GASTRIC ULCER CHRONIC OR 

UNSPECIFIED WITH HEMORRHAGE AND PERFORATION - WITH OBSTRUCTION 

532.00 DUODENAL ULCER ACUTE WITH 

HEMORRHAGE - WITHOUT MENTION OF OBSTRUCTION 

532.01 DUODENAL ULCER ACUTE WITH 

HEMORRHAGE - WITH OBSTRUCTION 

532.20 DUODENAL ULCER ACUTE WITH 

HEMORRHAGE AND PERFORATION -WITHOUT MENTION OF OBSTRUCTION 

532.21 DUODENAL ULCER ACUTE WITH 

HEMORRHAGE AND PERFORATION - WITH OBSTRUCTION 

532.40 DUODENAL ULCER CHRONIC OR 

UNSPECIFIED WITH HEMORRHAGE -WITHOUT MENTION OF OBSTRUCTION 

532.41 DUODENAL ULCER CHRONIC OR 

UNSPECIFIED WITH HEMORRHAGE - WITH OBSTRUCTION 

532.60 DUODENAL ULCER CHRONIC OR 

UNSPECIFIED WITH HEMORRHAGE AND PERFORATION – WITHOUT MENTION OF OBSTRUCTION 

532.61 DUODENAL ULCER CHRONIC OR 

UNSPECIFIED WITH HEMORRHAGE AND PERFORATION - WITH OBSTRUCTION 

533.00 PEPTIC ULCER, SITE UNSPECIFIED 

ACUTE WITH HEMORRHAGE - WITHOUT MENTION OF OBSTRUCTION 

533.01 PEPTIC ULCER, SITE UNSPECIFIED, 

ACUTE WITH HEMORRHAGE - WITH OBSTRUCTION 

533.20 PEPTIC ULCER, SITE UNSPECIFIED, 

ACUTE WITH HEMORRHAGE AND PERFORATION - WITHOUT MENTION OF OBSTRUCTION 

533.21 PEPTIC ULCE

ACUTE WITH PERFORATIO

533.40 PEPTIC ULCE

CHRONIC OR HEMORRHAGOBSTRUCTIO

533.41 PEPTIC ULCE

CHRONIC OR HEMORRHAG

533.60 PEPTIC ULCE

CHRONIC OR HEMORRHAGWITHOUT ME

533.61 PEPTIC ULCE

CHRONIC OR HEMORRHAGWITH OBSTR

534.00 GASTROJEJU

HEMORRHAGOBSTRUCTIO

534.01 GASTROJEJU

HEMORRHAG

534.20 GASTROJEJU

HEMORRHAGWITHOUT ME

534.21 GASTROJEJU

HEMORRHAG

WITH OBSTR

534.40 GASTROJEJU

UNSPECIFIED WITHOUT ME

534.41 GASTROJEJU

UNSPECIFIED WITH OBSTR

534.60 GASTROJEJU

UNSPECIFIED PERFORATIOOBSTRUCTIO

534.61 GASTROJEJU

UNSPECIFIED PERFORATIO

535.01 GASTRITIS A

GASTRITIS W

535.11 GASTRITIS A

GASTRITIS W

535.21 GASTRITIS A

MUCOSAL HYHEMORRHAG
239

535.31 GASTRITIS AND DUODENITIS, 

ALCOHOLIC GASTRITIS, WITH HEMORRHAGE 

535.41 GASTRITIS AND DUODENITIS, OTHER 

SPECIFIED GASTRITIS - WITH HEMORRHAGE 

535.51 GASTRITIS AND DUODENITIS, 

UNSPECIFIED GASTRITIS AND GASTRODUODENITIS - WITH HEMORRHAGE 

535.61 GASTRITIS AND DUODENITIS, 

DUODENITIS - WITH HEMORRHAGE 

537.83 OTHER SPECIFIED DISORDERS OF 

STOMACH AND DUODENUM, ANGIODYSPLASIA OF STOMACH AND DUODENUM - WITH HEMORRHAGE 

562.02 DIVERTICULOSIS OF SMALL INTESTINE -

WITH HEMORRHAGE 

562.03 DIVERTICULITIS OF SMALL INTESTINE -

WITH HEMORRHAGE 

562.12 DIVERTICULOSIS OF COLON - WITH 

HEMORRHAGE 

562.13 DIVERTICULITIS OF COLON - WITH 

HEMORRHAGE 

569.3 HEMORRHAGE OF RECTUM AND ANUS 569.85 ANGIODYSPLASIA OF INTESTINE - WITH 

HEMORRHAGE 

578.0 GASTROINTESTINAL HEMORRHAGE, 

HEMATEMESIS 

578.1 GASTROINTESTINAL HEMORRHAGE, 

BLOOD IN STOOL 

578.9 GASTROINTESTINAL HEMORRHAGE, 

HEMORRHAGE OF GASTROINTESTINAL TRACT, UNSPECIFIED 

Hemiplegia, paraplegia, or quadriplegia ICD-9-CM diagnosis codes (includes all 4th and 5th digits): 

342.0 FLACCID HEMIPLEGIA 342.1 SPASTIC HEMIPLEGIA 342.8 OTHER SPECIFIED HEMIPLEGIA 342.9 HEMIPLEGIA, UNSPECIFIED 343.0 INFANTILE CEREBRAL PALSY, DIPLEGIC 343.1 INFANTILE CEREBRAL PALSY, 

HEMIPLEGIC 

343.2 INFANTILE CEREBRAL PALSY, 

QUADRIPLEGIC 

343.3 INFANTILE CEREBRAL PALSY, 

MONOPLEGIC 

343.4 INFANTILE CEREBRAL PALSY 

INFANTILE HEMIPLEGIA 

343.8 INFANTILE CEREBRAL PALSY OTHER 

SPECIFIED INFANTILE CEREBRAL PALSY 

343.9 INFANTILE CEREBRAL PALSY, 

INFANTILE CEREBRAL PALSY, UNSPECIFIED 

344.0 QUADRIPLEGIA AND QUADRIPARESIS 344.1 PARAPLEGIA 344.2 DIPLEGIA OF UPPER LIMBS 344.3 MONOPLEGIA OF LOWER LIMB 344.4 MONOPLEGIA OF UPPER LIMB 344.5 UNSPECIFIED MONOPLEGIA 344.6 CAUDA EQUINA SYNDROME 344.8 OTHER SPECIFIED PARALYTIC 

SYNDROMES 

344.9 PARALYSIS, UNSPECIFIED 438.2 HEMIPLEGIA/HEMIPARESIS 438.3 MONOPLEGIA OF UPPER LIMB 438.4 MONOPLEGIA OF LOWER LIMB 438.5 OTHER PARALYTIC SYNDROME Hemorrhage ICD-9-CM diagnosis codes: 285.1 ACUTE POSTHEMORRHAGIC ANEMIA 459.0 OTHER DISORDERS OF CIRCULATORY 

SYSTEM, HEMORRHAGE, UNSPECIFIED 

958.2 CERTAIN EARLY COMPLICATIONS OF 

TRAUMA, SECONDARY AND RECURRENT HEMORRHAGE 

998.11 HEMORRHAGE COMPLICATING A 

PROCEDURE 

Hip fracture 

ICD-9-CM diagnosis codes: (includes all 5th digits) 

820.0 FRACTURE OF NECK OF FEMURTRANSCERVICAL FRACTURE, CLOSED 820.1 FRACTURE OF NECK OF FEMURTRANSCERVICAL FRACTURE, OPEN 820.2 FRACTURE OF NECK OF FEMURPERTROCHANTERIC FRACTURE, CLOSED 

820.3 FRACTURE O

PERTROCHAN

820.8 UNSPECIFIED 

CLOSED 

820.9 UNSPECIFIED 

OPEN 

Immunocompromised 

ICD-9-CM diagnosis codedigits) 042 HUMAN IMM

DISEASE 

136.3 PNEUMOCYS279.0 DEFFICIENCY 279.1 DEFFICIENCY 

IMMUNITY 

279.2 COMBINED IM279.3 UNSPECIFIED 279.4 AUTOIMMUN

ELSEWHERE 

279.8 OTHER SPECI

INVOLVING T

279.9 UNSPECIFIED 

MECHANISM 

996.8 COMPLICATI

ORGAN 

V42.0 KIDNEY REPLV42.1 HEART REPLV42.6 LUNG REPLAV42.7 LIVER REPLAV42.81 BONE MARRO

TRANSPLANT 

V42.82 PERIPHERAL 

TRANSPLANT 

V42.83 PANCREAS RV42.84 INTESTINES RV42.89 OTHER REPLICD-9-CM procedure code33.5 LUNG TRANS33.6 COMBINED H

TRANSPLANT

37.5 HEART TRAN41.0 OPERATIONS 

SPLEEN 

50.5 LIVER TRANS55.69 OTHER KIDN
240

52.80 PANCREATIC TRANSPLANT, NOS 52.81 REIMPLANTATION OF PANCREATIC 

TISSUE 

52.83 HETEROTRANSPLANT OF PANCREAS 52.85 ALLOTRANSPLANTATION OF CELLS OF 

ISLETS OF LANGERHANS 

52.86 TRANSPLANTATION OF CELLS OF 

ISLETS OF LANGERHANS, NOS 

Diagnostic Related Groups (DRGs): 488 HIV WITH EXTENSIVE OR PROCEDURE 489 HIV WITH MAJOR RELATED CONDITION 490 HIV WITH OR WITHOUT OTHER 

RELATED CONDITION 

Indications of current drug abuse ICD-9-CM diagnosis codes TOXIC EFFECT OF ALCOHOL: 980.0 ETHYL ALCOHOL 980.1 METHYL ALCOHOL 980.2 ISOPROPYL ALCOHOL 980.3 FUSEL OIL 981 TOXIC EFFECT OF PETROLEUM 

PRODUCTS 

SOLVENTS OTHER THAN PETROLEUM-BASED: 982.0 BENZENE AND HOMOLOGUES 982.1 CARBON TETRACHLORIDE 982.2 CARBON DISULFIDE 982.3 OTHER CHLORINATED HYDROCARBON 

SOLVENTS 

982.4 NITROGLYCOL 982.8 OTHER NONPETROLEUM-BASED 

SOLVENTS 

983.0 TOXIC EFFECT OF CORROSIVE 

AROMATICS 

983.1 TOXIC EFFECT OF ACIDS 983.2 TOXIC EFFECT OF CAUSTIC ALKALIDES 983.9 TOXIC EFFECT OF CAUSTIC, 

UNSPECIFIED 

TOXIC EFFECT OF LEAD AND ITS COMPOUNDS (INCLUDING FUMES): 984.0 INORGANIC LEAD COMPOUNDS 

984.1 ORGANIC LEAD COMPOUNDS 984.8 OTHER LEAD COMPOUNDS 984.9 UNSPECIFIED LEAD COMPOUND TOXIC EFFECT OF OTHER METALS : 985.0 MERCURY AND ITS COMPOUNDS 985.1 ARSENIC AND ITS COMPOUNDS 985.2 MANGANESE AND ITS COMPOUNDS 985.3 BERYLLIUM AND ITS COMPOUNDS 985.4 ANTIMONY AND ITS COMPOUNDS 985.5 CADMIUM AND ITS COMPOUNDS 985.6 CHROMIUM 985.8 OTHER SPECIFIED METALS 985.9 UNSPECIFIED METAL 986 TOXIC EFFECT OF CARBON MONOXIDE TOXIC EFFECT OF OTHER GASES, FUMES, OR VAPORS: 987.0 LIQUEFIED PETROLEUM GASES 987.1 OTHER HYDROCARBON GAS 987.2 NITROGEN OXIDES 987.3 SULFUR DIOXIDE 987.4 FREON 987.5 LACRIMOGENIC GAS 987.6 CHLORINE GAS 987.7 HYDROCYANIC ACID GAS 987.8 OTHER SPECIFIED GASES, FUMES, OR 

VAPORS 

987.9 UNSPECIFIED GAS, FUME, OR VAPOR NOXIOUS SUBSTANCES EATEN AS FOOD: 988.0 FISH AND SHELLFISH 988.1 MUSHROOMS 988.2 BERRIES AND OTHER PLANTS 988.8 OTHER SPECIFIED NOXIOUS 

SUBSTANCES EATEN AS FOOD 

TOXIC EFFECT OF OTHER SUBSTANCES, CHIEFLY NONMEDICINAL AS TO SOURCE: 989.0 HYDROCYANIC ACID AND CYANIDES 989.1 STRYCHNINE AND SALTS 989.2 CHLORINATED HYDROCARBONS 989.3 ORGANOPHOSPHATE AND CARBAMATE 989.4 OTHER PESTICIDES, NEC 989.5 VENOM 989.6 SOAPS AND DETERGENTS 989.7 AFLATOXIN AND OTHER MYCOTOXIN 

[FOOD CONTAMINANTS] 

989.8 OTHER SUBS

NONMEDICIA

989.9 UNSPECIFIED 

NONMEDICIN

291.0 ALCOHOL WI291.1 ALCOHOL AM291.2 OTHER ALCO291.3 ALCOHOL WI291.4 IDIOSYNCRA

INTOXICATIO

291.5 ALCOHOL JE291.8 OTHER SPECI

PSYCHOSIS 

291.81 ALCOHOL WI291.9 ALCOHOLIC DRUG PSYCHOSES: 292.0 DRUG WITHD292.11 DRUG-INDUC

SYNDROME 

292.12 DRUG- INDUC292.2 PATHOLOGIC292.81 DRUG-INDUC292.82 DRUG-INDUC292.83 DRUG-INDUC

292.84 DRUG-INDUC

SYNDROME 

292.89 OTHER SPECI

MENTAL DIS

292.9 UNSPECIFIED 

DISORDER 

(includes all 4th and 5th dig

303.0 ACUTE ALCO303.9 OTHER AND 

.\DEPENDENC

304.0 OPIOID TYPE 304.1 BARBITURAT

SEDATIVE OR 

304.2 COCAINE DE304.3 CANNABIS D304.4 AMPHETAMI

PSYCHOSTIM

304.5 HALLUCINOG304.6 OTHER SPECI304.7 COMBINATIO

WITH ANY O

304.8 COMBINATIO

EXCLUDING 
241

304.9 UNSPECIFIED DRUG DEPENDENCE 305.0 ALCOHOL ABUSE 305.2 CANNABIS ABUSE 305.3 HALLUCINOGEN ABUSE 305.4 BARBITURATE AND SIMILARLY ACTING 

SEDATIVE OR HYPNOTIC ABUSE 

305.5 OPIOID ABUSE 305.6 COCAINE ABUSE 305.7 AMPHETAMINE OR RELATED ACTING 

SYMPATHOMIMETIC ABUSE 

305.8 ANTIDEPRESSANT TYPE ABUSE 305.9 OTHER MIXED OR UNSPECIFIED DRUG 

ABUSE 

Infection ICD-9-CM diagnosis codes: 540.0 ACUTE APPENDICITIS WITH 

GENERALIZED PERITONITIS 

540.1 ACUTE APPENDICITIS WITH 

PERITONEAL ABSCESS 

540.9 ACUTE APPENDICITIS WITHOUT 

MENTION OF PERITONITIS 

541 APPENDICITIS, UNQUALIFIED 542 OTHER APPENDICITIS 562.01 DIVERTICULITIS OF SMALL INTESTINE 

(WITHOUT MENTION OF HEMORRHAGE) 

562.03 DIVERTICULITIS OF SMALL INTESTINE 

WITH HEMORRHAGE 

562.11 DIVERTICULITIS OF COLON (WITHOUT 

MENTION OF HEMORRHAGE) 

562.13 DIVERTICULITIS OF COLON WITH 

HEMORRHAGE 

566 ABSCESS OF ANAL AND RECTAL 

REGIONS 

567.0 PERITONITIS IN INFECTIOUS DISEASES 

CLASSIFIED ELSEWHERE 

567.1 PNEUMOCOCCAL PERITONITIS 567.2 OTHER SUPPURATIVE PERITONITIS 567.8 OTHER SPECIFIED PERITONITIS 567.9 UNSPECIFIED PERITONITIS 569.5 ABSCESS OF INTESTINE 569.61 INFECTION OF COLOSTOMY OR 

ENTEROSTOMY 

572.0 ABSCESS OF LIVER 572.1 PORTAL PYEMIA 

574.00 CALCULUS OF GALLBLADDER WITH 

ACUTE CHOLECYSTITIS - WITHOUT MENTION OF OBSTRUCTION 

574.01 CALCULUS OF GALLBLADDER WITH 

ACUTE CHOLECYSTITS - WITH OBSTRUCTION 

574.30 CALCULUS OF BILE DUCT WITH ACUTE 

CHOLECYSTITIS - WITHOUT MENTION OF OBSTRUCTION 

574.31 CALCULUS OF BILE DUCT WITH ACUTE 

CHOLECYSTITIS - WITH OBSTRUCTION 

574.60 CALCULUS OF GALLBLADDER AND BILE 

DUCT WITH ACUTE CHOLECYSTITIS - WITHOUT MENTION OF OBSTRUCTION 

574.61 CALCULUS OF GALLBLADDER AND BILE 

DUCT WITH ACUTE CHOLECYSTITIS -WITH OBSTRUCTION 

574.80 CALCULUS OF GALLBLADDER AND BILE 

DUCT WITH ACUTE AND CHRONIC CHOLECYSTITIS - WITHOUT MENTION OF OBSTRUCTION 

574.81 CALCULUS OF GALLBLADDER AND BILE 

DUCT WITH ACUTE AND CHRONIC CHOLECYSTITIS - WITH OBSTRUCTION 

575.0 ACUTE CHOLECYSTITIS 575.4 PERFORATION OF GALLBLADDER 576.1 CHOLANGITIS 576.3 PERFORATION OF BILE DUCT Diagnostic Related Groups (DRGs) 020 NERVOUS SYSTEM INFECTION EXCEPT 

VIRAL MENINGITIS 

068 OTITIS MEDIA AND URI, AGE GREATER 

THAN 17 WITH CC 

069 OTITIS MEDIA AND URI, AGE GREATER 

THAN 17 WITHOUT CC 

079 RESPIRATORY INFECTIONS AND 

INFLAMMATIONS, AGE GREATER THAN 17 WITH CC 

080 RESPIRATORY INF ECTIONS AND 

INFLAMMATIONS, AGE GREATER THAN 17 WITHOUT CC 

089 SIMPLE PNEUMONIA AND PLEURISY, 

AGE GREATER THAN 17 WITH CC 

090 SIMPLE PNEUMONIA AND PLEURISY, 

AGE GREATER THAN 17 WITHOUT CC 

126 ACUTE AND SUBACUTE ENDOCARDITIS 238 OSTEOMYELITIS 242 SEPTIC ARTHRITIS 

277 CELLULITIS, 

WITH CC 

278 CELLULITIS, 

WITHOUT CC 

320 KIDNEY AND 

INFECTIONS, WITH CC 

321 KIDNEY AND 

INFECTIONS, WITHOUT CC 

368 INFECTIONS 

SYSTEM 

416 SEPTICEMIA, 

Instrument assisted delivICD-9-CM procedure code72.0 LOW FORCEP72.1 LOW FORCEP

EPISIOTOMY 

72.21 MID FORCEP

EPISIOTOMY 

72.29 OTHER MID F72.31 HIGH FORCEP

EPISIOTOMY 

72.39 OTHER HIGH 72.4 FORCEPS ROT72.51 PARTIAL BRE

FORCEPS TO 

72.53 TOTAL BREE

FORCEPS TO 

72.6 FORCEPS APP

AFTERCOMIN

72.71 VACUUM EX

EPISIOTOMY 

72.8 OTHER SPECI

DELIVERY 

72.9 UNSPECIFIED 

DELIVERY 

LivebornDiagnostic Related Group385 NEONATES, D

ANOTHER AC
242

386 EXTREME IMMATURITY OR 

RESPIRATORY DISTRESS SYNDROME OF NEONATE 

387 PREMATURITY WITH MAJOR PROBLEMS 388 PREMATURITY WITHOUT MAJOR 

PROBLEMS 

389 FULL TERM NEONATE WITH MAJOR 

PROBLEMS 

390 NEONATE WITH OTHER SIGNIFICANT 

PROBLEMS 

391 NORMAL NEWBORN AND ICD-9-CM diagnosis codes (includes 4th and 5th digits) Admission type recorded as (4): 764 SLOW FETAL GROWTH AND FETAL 

MALNUTRITION 

765 DISORDERS RELATING TO SHORT 

GESTATION AND UNSPECIFIED LOW BIRTH WEIGHT 

766 DISORDERS RELATING TO LONG 

GESTATION AND HIGH BIRTH WEIGHT 

767 BIRTH TRAUMA 768 INTRAUTERINE HYPOXIA AND BIRTH 

ASPHYXIA 

769 RESPIRATORY DISTRESS SYNDROME 770 OTHER RESPIRATORY CONDITIONS OF 

FETUS AND NEWBORN 

V30 SINGLE LIVEBORN V31 TWIN, MATE LIVEBORN V32 TWIN, MATE STILLBORN V33 TWIN, UNSPECIFIED V34 OTHER MULTIPLE, MATES ALL 

LIVEBORN 

V35 OTHER MULTIPLE, MATE ALL 

STILLBORN 

V36 OTHER MULTIPLE, MATES LIVE- AND 

STILLBORN 

V37 OTHER MULTIPLE, UNSPECIFIED V39 UNSPECIFIED Long term care facility ADMISSION SOURCE IS RECORDED AS LONGTERM CARE FACILITY (ASOURCE=3) 

Low mortality Diagnostic Related Groups DRGs MEDICAL: 015 TRANSIENT ISCHEMIC ATTACK AND 

PRECEREBRAL OCCLUSIONS 

021 VIRAL MENINGITIS 030 TRAUMATIC STUPOR AND COMA, COMA 

LESS THAN ONE HOUR, AGE 0-17 

031 CONCUSSION, AGE GREATER THAN 17 

WITH CC 

032 CONCUSSION, AGE GREATER THAN 17 

WITHOUT CC 

044 ACUTE MAJOR EYE INFECTIONS 045 NEUROLOGICAL EYE DISORDERS 065 DYSEQUILIBRIUM 068 OTITIS MEDIA AND URI, AGE GREATER 

THAN 17 WITH CC 

071 LARYNGOTRACHEITIS 096 BRONCHITIS AND ASTHMA, AGE 

GREATER THAN 17 WITH CC 

097 BRONCHITIS AND ASTHMA, AGE 

GREATER THAN 17 WITHOUT CC 

125 CIRCULATORY DISORDERS EXCEPT 

ACUTE MYOCARDIAL INFARCTION WITH CARDIAC CATHETERIZATION WITHOUT COMPLEX DIAGNOSIS 

134 HYPERTENSION 140 ANGINA PECTORIS 141 SYNCOPE AND COLLAPSE WITH CC 142 SYNCOPE AND COLLAPSE WITHOUT CC 143 CHEST PAIN 237 SPRAINS, STRAINS AND DISLOCATIONS 

OF HIP, PELVIS AND THIGH 

243 MEDICAL BACK PROBLEMS 246 NONSPECIFIC ARTHROPATHIES 295 DIABETES, AGE 0-35 317 ADMISSION FOR RENAL DIALYSIS 323 URINARY STONES WITH CC AND/OR ESW 

LITHOTRIPSY 

324 URINARY STONES WITHOUT CC 351 STERILIZATION, MALE 369 MENSTRUAL AND OTHER FEMALE 

REPRODUCTIVE SYSTEM DISORDERS 

421 VIRAL ILLNESS, AGE GREATER THAN 17 PEDIATRIC MEDICAL: 

026 SEIZURE AND 033 CONCUSSION070 OTITIS MEDIA 074 OTHER EAR, 

THROAT DIA

091 SIMPLE PNEU

AGE 0-17 

098 BRONCHITIS 184 ESOPHAGITIS

MISCELLANEDISORDERS, 

190 OTHER DIGE

AGE 0-17 

252 FRACTURES, 

DISLOCATIO

AND FOOT, A

255 FRACTURES, 

DISLOCATIOLOWER LEG 

279 CELLULITIS, 282 TRAUMA TO 

TISSUE AND 

298 NUTRITIONA

METABOLIC THAN 17 WIT

322 KIDNEY AND 

INFECTION, A

333 OTHER KIDN

DIAGNOSES, 

396 RED BLOOD C422 VIRAL ILLNE

UNKNOWN O

446 TRAUMATIC 448 ALLERGIC RE451 POISONING A

DRUGS, AGE 

SURGICAL: 036 RETINAL PRO037 ORBITAL PRO042 INTRAOCULA050 SIALOADENE052 CLEFT LIP AN053 SINUS AND M

GREATER TH

055 MISCELLANE

AND THROAT 

057 TONSILLECT

ADENOIDECTEXCEPT TON
243

ADENOIDECTOMY ONLY, AGE GREATER THAN 17 

063 OTHER EAR, NOSE, MOUTH AND 

THROAT OR PROCEDURES 

166 APPENDECTOMY WITHOUT 

COMPLICATED PRINCIPAL DIAGNOSIS WITH CC 

167 APPENDECTOMY WITHOUT 

COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC 

218 LOWER EXTREMITY AND HUMERUS 

PROCEDURES EXCEPT HIP, FOOT AND FEMUR, AGE GREATER THAN 17 WITH CC 

219 LOWER EXTREMITY AND HUMERUS 

PROCEDURES EXCEPT HIP, FOOT AND FEMUR, AGE GREATER THAN 17 WITHOUT CC 

223 MAJOR SHOULDER, ELBOW 

PROCEDURES OR OTHER UPPER EXTREMITY PROCEDURES WITH CC 

224 SHOULDER, ELBOW OR FOREARM 

PROCEDURES EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC 

225 FOOT PROCEDURES 228 MAJOR THUMB OR JOINT PROCEDURES 

OR OTHER HAND OR WRIST PROCEDURES WITH CC 

229 HAND OR WRIST PROCEDURES EXCEPT 

MAJOR JOINT PROCEDURES WITHOUT CC 

232 ARTHROSCOPY 257 TOTAL MASTECTOMY FOR 

MALIGNANCY WITH CC 

258 TOTAL MASTECTOMY FOR 

MALIGNANCY WITHOUT CC 

261 BREAST PROCEDURE FOR 

NONMALIGNANCY EXCEPT BIOPSY AND LOCAL EXCISION 

262 BREAST BIOPSY AND LOCAL EXCISION 

OF NONMALIGNANCY 

267 PERIANAL AND PILONICAL 

PROCEDURES 

289 PARATHYROID PROCEDURES 290 THYROID PROCEDURES 293 OTHER ENDOCRINE, NUTRITIONAL AND 

METABOLIC OR PROCEDURES WITHOUT CC 

334 MAJOR MALE PELVIC PROCEDURES 

WITH CC 

335 MAJOR MALE PELVIC PROCEDURES 

WITHOUT CC 

336 TRANSURETHRAL PROSTATECTOMY 

WITH CC 

337 TRANSURETHRAL PROSTATECTOMY 

WITHOUT CC 

356 FEMALE REPRODUCTION SYSTEM 

RECONCSTRUCTIVE PROCEDURES 

358 UTERINE AND ADNEXA PROCEDURES 

FOR NONMALIGNANCY WITH CC 

359 UTERINE AND ADNEXA PROCEDURES 

FOR NONMALIGNANCY WITHOUT CC 

360 VAGINA, CERVIX AND VULVA 

PROCEDURES 

361 LAPAROSCOPY AND INCISIONAL TUBAL 

INTERRUPTION 

362 ENDOSCOPIC TUBAL INTERRUPTION 364 D AND C, CONIZATION EXCEPT FOR 

MALIGNANCY 

439 SKIN GRAFTS FOR INJURIES 441 HAND PROCEDURES FOR INJURIES 491 MAJOR JOINT AND LIMB 

REATTACHMENT PROCEUDRES OF UPPER EXTREMITY 

499 BACK AND NECK PROCEDURES EXCEPT 

SPINAL FUSION WITH CC 

500 BACK AND NECK PROCEDURES EXCEPT 

SPINAL FUSION WITHOUT CC 

PEDIATRIC SURGICAL: 060 TONSILLECTOMY AND/OR 

ADENOIDECTOMY ONLY, AGE 0-17 

062 MYRINGOTOMY WITH TUBE INSERTION, 

AGE 0-17 

156 STOMACH, ESOPHAGEAL AND 

DUODENAL PROCEDURES, AGE 0-17 

163 HERNIA PROCEDURES, AGE 0-17 212 HIP AND FEMUR PROCEDURES EXCEPT 

MAJOR JOINT PROCEDURES, AGE 0-17 

220 LOWER EXTREMITY AND HUMEROUS 

PROCEDURES EXCEPT HIP, FOOT AND FEMUR, AGE 0-17 

393 SPLENECTOMY, AGE 0-17 OBSTETRIC: 370 CESAREAN SCTION WITH CC 371 CESAREAN SECTION WITHOUT CC 372 VAGINAL DELIVERY WITH 

COMPLICATING DIAGNOSES 

373 VAGINAL DE

COMPLICATI

374 VAGINAL DE

STERILIZATI

375 VAGINAL DE

PROCEDURE AND/OR D AN

377 POSTPARTUM 

DIAGNOSES W

378 ECTOPIC PRE379 THREATENED 380 ABORTION W381 ABORTION W

CURETTAGE 

382 FALSE LABO383 OTHER ANTE

MEDICAL CO

384 OTHER ANTE

WITHOUT ME

NEONATAL: 386 EXTREME IM

RESPIRATORNEONATE 

387 PREMATURIT388 PREMATURIT

PROBLEMS 

390 NEONATE WI

PROBLEMS 

391 NORMAL NEWPSYCHIATRIC: 425 ACUTE ADJU

DISTURBANCDYSFUNCTIO

426 DEPRESSIVE 427 NEUROSIES E428 DISORDERS O

IMPULSE CON

431 CHILDHOOD 432 OTHER MENT434 ALCOHOL/DR

DEPENDENCEOTHER SYMPWITH CC 

435 ALCOHOL/DR

DEPENDENCEOTHER SYMPWITHOUT CC 
244

436 ALCOHOL/DRUG DEPENDENCE WITH 

REHABILITATION THERAPY 

Lung or pleural biopsy ICD-9-CM Procedure codes: 332.6 CLOSED [PERCUTANEOUS] [NEEDLE] 

BIOPSY OF LUNG 

332.8 OPEN BIOPSY OF LUNG 342.4 PLEURAL BIOPSY Lymphoid malignancy ICD-9-CM diagnosis codes( includes 4th and 5th digits): 

200 LYMPHOSARCOMA AND 

RETICULOSARCOMA 

201 HODGKINS DISEASE 202 OTHER MALIGNANT NEOPLASMS OF 

LYMPHOID AND HISTIOCYTIC TISSUE 

203 MULTIPLE MYELOMA AND 

IMMUNOPROLIFERATIVE NEOPLASMS 

204 LYMPHOID LEUKEMIA 205 MYELOID LEUKEMIA 206 MONOCYTIC LEUKEMIA 207 OTHER SPECIFIED LEUKEMIA 208 LEUKEMIA OF UNSPECIFIED CELL TYPE Medical 

Diagnostic Related Groups (DRGs): 009 SPINAL DISORDERS AND INJURIES 010 NERVOUS SYSTEM NEOPLASMS WITH 

CC 

011 NERVOUS SYSTEM NEOPLASMS WITH 

CC 

012 DEGENERATIVE NERVOUS SYSTEM 

DISORDERS 

013 MULTIPLE SCLEROSIS AND 

CEREBELLAR ATAXIA 

014 SPECIFIC CEREBROVASCULAR 

DISORDERS EXCEPT TRANSIENT ISCHEMIC ATTACK 

015 TRANSIENT ISCHEMIC ATTACK AND 

PRECEREBRAL OCCLUSIONS 

016 NONSPECIFIC CEREBROVASCULAR 

DISORDERS WITH CC 

017 NONSPECIFIC CEREBROVASCULAR 

DISORDERS WITHOUT CC 

018 CRANIAL AND PERIPHERAL NERVE 

DISORDERS WITH CC 

019 CRANIAL AND PERIPHERAL NERVE 

DISORDERS WITHOUT CC 

020 NERVOUS SYSTEM INFECTION EXCEPT 

VIRAL MENINGITIS 

021 VIRAL MENINGITIS 022 HYPERTENSIVE ENCEPHALOPATHY 023 NONTRAUMATIC STUPOR AND COMA 024 SEIZURE AND HEADACHE, AGE 

GREATER THAN 17 WITH CC 

025 SEIZURE AND HEADACHE, AGE 

GREATER THAN 17 WITHOUT CC 

026 SEIZURE AND HEADACHE, AGE 0-17 027 TRAUMATIC STUPOR AND COMA, COMA 

GREATER THAN ONE HOUR 

028 TRAUMATIC STUPOR AND COMA, COMA 

LESS THAN ONE HOUR, AGE GREATER THAN 19 WITH CC 

029 TRAUMATIC STUPOR AND COMA, COMA 

LESS THAN ONE HOUR, AGE GREATER THAN 17 WITHOUT CC 

030 TRAUMATIC STUPOR AND COMA, COMA 

LESS THAN ONE HOUR, AGE 0-17 

031 CONCUSSION, AGE GREATER THAN 17 

WITH CC 

032 CONCUSSION, AGE GREATER THAN 17 

WITHOUT CC 

033 CONCUSSION, AGE 0-17 034 OTHER DISORDERS OF NERVOUS 

SYSTEM WITH CC 

035 OTHER DISORDERS OF NERVOUS 

SYSTEM WITHOUT CC 

043 HYPHEMA 044 ACUTE MAJOR EYE INFECTIONS 045 NEUROLOGICAL EYE DISORDERS 046 OTHER DISORDERS OF THE EYE, AGE 

GREATER THAN 17 WITH CC 

047 OTHER DISORDER OF THE EYE, AGE 

GREATER THAN 17 WITHOUT CC 

048 OTHER DISORDERS OF THE EYE, AGE 0-

17 

064 EAR, NOSE, MOUTH AND THROAT 

MALIGNANCY 

065 DISEQUILIBRIA 066 EPISTAXIS 

067 EPIGLOTITIS 068 OTITIS MEDIA 

THAN 17 WIT

069 OTITIS MEDIA 

THAN 17 WIT

070 OTITIS MEDIA 071 LARYNGOTR072 NASAL TRAU073 OTHER EAR, 

THROAT DIATHAN 17 

074 OTHER EAR, 

THROAT DIA

078 PULMONARY 079 RESPIRATOR

INFLAMMAT17 WITH CC 

080 RESPIRATOR

INFLAMMAT17 WITHOUT 

081 SIMPLE PNEU

AGE GREATE

082 RESPIRATOR083 MAJOR CHES084 MAJOR CHES085 PLEURAL EFF086 PLEURAL EFF087 PULMONARY 

RESPIRATOR

088 CHRONIC OB

DISEASE 

089 SIMPLE PNEU

AGE GREATE

090 SIMPLE PNEU

AGE GREATE

091 SIMPLE PNEU

AGE 0-17 

092 INTERSTITIA093 INTERSTITIA

CC 

094 PNEUMOTHO095 PNEUMOTHO096 BRONCHITIS 

GREATER TH

097 BRONCHITIS 

GREATER TH

098 BRONCHITIS 099 RESPIRATOR

WITH CC 
245

100 RESPIRATORY SIGNS AND SYMPTOMS 

WITHOUT CC 

101 OTHER RESPIRATORY SYSTEM 

DIAGNOSES WITH CC 

102 OTHER RESPIRATORY SYSTEM 

DIAGNOSES WITHOUT CC 

121 CIRCULATORY DISORDERS WITH ACUTE 

MYOCARDIAL INFARCTION AND MAJOR COMPLICATION, DISCHARGED ALIVE 

122 CIRCULATORY DISORDERS WITH ACUTE 

MYOCARDIAL INFARCTION WITHOUT MAJOR COMPLICATION, DISCHARGED ALIVE 

123 CIRCULATORY DISORDERS WITH ACUTE 

MYOCARDIAL INFARCTION, EXPIRED 

124 CIRCULATORY DISORDERS EXCEPT 

ACUTE MYOCARDIAL INFARCTION WITH CARDIAC CATHETERIZATION AND COMPLEX DIAGNOSIS 

125 CIRCULATORY DISORDERS EXCEPT 

ACUTE MYOCARDIAL INFARCTION WITH CARDIAC CATHETERIZATION WITHOUT COMPLEX DIAGNOSIS 

126 ACUTE AND SUB ACUTE ENDOCARDITIS 127 HEART FAILURE AND SHOCK 128 DEEP VEIN THROMBOPHLEBITIS 129 CARDIAC ARREST, UNEXPLAINED 130 PERIPHERAL VASCULAR DISORDERS 

WITH CC 

131 PERIPHERAL VASCULAR DISORDERS 

WITHOUT CC 

132 ATHEROSCLEROSIS WITH CC 133 ATHEROSCLEROSIS WITHOUT CC 134 HYPERTENSION 135 CARDIAC CONGENITAL AND VALVULAR 

DISORDERS, AGE GREATER THAN 17 WITH CC 

136 CARDIAC CONGENITAL AND VALVULAR 

DISORDERS, AGE GREATER THAN 17 WITHOUT CC 

137 CARDIAC CONGENITAL AND VALVULAR 

DISORDERS, AGE GREATER THAN 17 WITHOUT CC 

138 CARDIAC ARRHYTHMIA AND 

CONDUCTION DISORDERS WITH CC 

139 CARDIAC ARRHYTHMIA AND 

CONDUCTION DISORDERS WITHOUT CC 

140 ANGINA PECTORIS 141 SYNCOPE AND COLLAPSE WITH CC 142 SYNCOPE AND COLLAPSE WITHOUT CC 

143 CHEST PAIN 144 OTHER CIRCULATORY SYSTEM 

DIAGNOSES WITH CC 

145 OTHER CIRCULATORY SYSTEM 

DIAGNOSES WITHOUT CC 

172 DIGESTIVE MALIGNANCY WITH CC 173 DIGESTIVE MALIGNANCY WITHOUT CC 174 GI HEMORRHAGE WITH CC 175 GI HEMORRHAGE WITHOUT CC 176 COMPLICATED PEPTIC ULCER 177 UNCOMPLICATED PEPTIC ULCER WITH 

CC 

178 UNCOMPLICATED PEPTIC ULCER 

WITHOUT CC 

179 INFLAMMATORY BOWEL DISEASE 180 GI OBSTRUCTION WITH CC 181 GI OBSTRUCTION WITHOUT CC 182 ESOPHAGITIS, GASTROENTERITIS AND 

MISCELLANEOUS DIGESTIVE DISORDERS, AGE GREATER THAN 17 WITH CC 

183 ESOPHAGITIS, GASTROENTERITIS AND 

MISCELLANEOUS DIGESTIVE DISORDERS, AGE GREATER THAN 17 WITHOUT CC 

184 ESOPHAGITIS, GASTROENTERITIS AND 

MISCELLANEOUS DIGESTIVE DISORDERS, AGE 0-17 

185 DENTAL AND ORAL DISEASES EXCEPT 

EXTRACTIONS AND RESTORATIONS, AGE GREATER THAN 17 

186 DENTAL AND ORAL DISEASES EXCEPT 

EXTRACTIONS AND RESTORATIONS, AGE 0-17 

187 DENTAL EXTRACTIONS AND 

RESTORATIONS 

188 OTHER DIGESTIVE SYSTEM DIAGNOSES, 

AGE GREATER THAN 17 WITH CC 

189 OTHER DIGESTIVE SYSTEM DIAGNOSES, 

AGE GREATER THAN 17 WITHOUT CC 

190 OTHER DIGESTIVE SYSTEM DIAGNOSES, 

AGE 0-17 

202 CIRRHOSIS AND ALCOHOLIC HEPATITIS 203 MALIGNANCY OF HEPATOBILIARY 

SYSTEM OR PANCREAS 

204 DISORDERS OF PANCREAS EXCEPT 

MALIGNANCY 

205 DISORDERS OF LIVER EXCEPT 

MALIGNANCY, CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC 

206 DISORDERS O

MALIGNANCALCOHOLIC 

207 DISORDERS O

WITH CC 

208 DISORDERS O

WITHOUT CC 

235 FRACTURES 

236 FRACTURES 237 SPRAINS, STR

OF HIP, PELV

238 OSTEOMYEL239 PATHOLOGIC

MUSCULOSKTISSUE MALI

240 CONNECTIVE 

CC 

241 CONNECTIVE 

WITHOUT CC 

242 SEPTIC ARTH243 MEDICAL BA244 BONE DISEAS

ARTHROPAT

245 BONE DISEAS

ARTHROPAT

246 NONSPECIFIC 247 SIGNS AND S

MUSCULOSKCONNECTIVE 

248 TENDONITIS, 249 AFTERCARE, 

SYSTEM AND 

250 FRACTURES, 

DISLOCATIOAND FOOT, AWITH CC 

251 FRACTURES, 

DISLOCATIOAND FOOT, AWITHOUT CC 

252 FRACTURES, 

DISLOCATIOAND FOOT, A

253 FRACTURES, 

DISLOCATIOLOWER LEG GREATER TH

254 FRACTURES, 

DISLOCATIO
246

LOWER LEG EXCEPT FOOT, AGE GREATER THAN 17 WITHOUT CC 

255 FRACTURES, SPRAINS, STRAINS AND 

DISLOCATIONS OF UPPER ARM AND LOWER LEG EXCEPT FOOT, AGE 0-17 

256 OTHER MUSCULOSKELETAL SYSTEM 

AND CONNECTIVE TISSUE DIAGNOSES 

271 SKIN ULCERS 272 MAJOR SKIN DISORDERS WITH CC 273 MAJOR SKIN DISORDERS WITHOUT CC 274 MALIGNANT BREAST DISORDERS WITH 

CC 

275 MALIGNANT BREAST DISORDERS 

WITHOUT CC 

276 NONMALIGNANT BREAST DISORDERS 277 CELLULITIS, AGE GREATER THAN 17 

WITH CC 

278 CELLULITIS, AGE GREATER THAN 17 

WITHOUT CC 

279 CELLULITIS, AGE 0-17 280 TRAUMA TO SKIN, SUBCUTANEOUS 

TISSUE AND BREAST, AGE GREATER THAN 17 WITH CC 

281 TRAUMA TO SKIN, SUBCUTANEOUS 

TISSUE AND BREAST, AGE GREATER THAN 17 WITHOUT CC 

282 TRAUMA TO SKIN, SUBCUTANEOUS 

TISSUE AND BREAST, AGE 0-17 

283 MINOR SKIN DISORDERS WITH CC 284 MINOR SKIN DISORDERS WITHOUT CC 294 DIABETES, AGE GREATER THAN 35 295 DIABETES, AGE 0-35 296 NUTRITIONAL AND MISCELLANEOUS 

METABOLIC DISORDERS, AGE GREATER THAN 17 WITH CC 

297 NUTRITIONAL AND MISCELLANEOUS 

METABOLIC DISORDERS, AGE GREATER THAN 17 WITHOUT CC 

298 NUTRITIONAL AND MISCELLANEOUS 

METABOLIC DISORDERS, AGE 0-17 

299 INBORN ERRORS OF METABOLISM 300 ENDOCRINE DISORDERS WITH CC 301 ENDOCRINE DISORDERS WITHOUT CC 316 RENAL FAILURE 317 ADMISSION FOR RENAL DIALYSIS 318 KIDNEY AND URINARY TRACT 

NEOPLASMS WITH CC 

319 KIDNEY AND URINARY TRACT 

NEOPLASMS WITHOUT CC 

320 KIDNEY AND URINARY TRACT 

INFECTIONS, AGE GREATER THAN 17 WITH CC 

321 KIDNEY AND URINARY TRACT 

INFECTIONS, AGE GREATER THAN 17 WITHOUT CC 

322 KIDNEY AND URINARY TRACT 

INFECTION, AGE 0-17 

323 URINARY STONES WITH CC AND/ OR 

ESW LITHOTRIPSY 

324 URINARY STONES WITHOUT CC 325 KIDNEY AND URINARY TRACT SIGNS 

AND SYMPTOMS, AGE GREATER THAN 17 WITH CC 

326 KIDNEY AND URINARY TRACT SIGNS 

AND SYMPTOMS, AGE GREATER THAN 17 WITHOUT CC 

327 KIDNEY AND URINARY TRACT SIGNS 

AND SYMPTOMS, AGE 0-17 

328 URETHRAL STRICTURE, AGE GREATER 

THAN 17 WITH CC 

329 URETHRAL STRICTURE, AGE GREATER 

THAN 17 WITHOUT CC 

330 URETHRAL STRICTURE, AGE 0-17 331 OTHER KIDNEY AND URINARY TRACT 

DIAGNOSES, AGE GREATER THAN 17 WITH CC 

332 OTHER KIDNEY AND URINARY TRACT 

DIAGNOSES, AGE GREATER THAN 17 WITHOUT CC 

333 OTHER KIDNEY AND URINARY TRACT 

DIAGNOSES, AGE 0-17 

346 MALIGNANCY OF MALE REPRODUCTIVE 

SYSTEM WITH CC 

347 MALIGNANCY OF MALE REPRODUCTIVE 

SYSTEM WITHOUT CC 

348 BENIGN PROSTATIC HYPERTROPHY 

WITH CC 

349 BENIGN PROSTATIC HYPERTROPHY 

WITHOUT CC 

350 INFLAMMATION OF THE MALE 

REPRODUCTIVE SYSTEM 

351 STERILIZATION, MALE 352 OTHER MALE REPRODUCTIVE SYSTEM 

DIAGNOSES 

366 MALIGNANCY OF FEMALE 

REPRODUCTIVE SYSTEM WITH CC 

367 MALIGNANCY OF FEMALE 

REPRODUCTIVE SYSTEM WITHOUT CC 

368 INFECTIONS 

SYSTEM 

369 MENSTRUAL 

REPRODUCTI

372 VAGINAL DE

COMPLICATI

373 VAGINAL DE

COMPLICATI

376 POSTPARTUM 

DIAGNOSES W

378 ECTOPIC PRE379 THREATENED 380 ABORTION W

382 FALSE LABO383 OTHER ANTE

MEDICAL CO

384 OTHER ANTE

WITHOUT ME

395 RED BLOOD C

GREATER TH

396 RED BLOOD C397 COAGULATIO398 RETICULOEN

IMMUNITY D

399 RETICULOEN

IMMUNITY D

403 LYMPHOMA 

WITH CC 

404 LYMPHOMA 

WITHOUT CC 

405 ACUTE LEUK

PROCEDURE, 

409 RADIOTHERA410 CHEMOTHER

LEUKEMIA A

411 HISTORY OF 

ENDOSCOPY 

412 HISTORY OF 

ENDOSCOPY 

413 OTHER MYEL

DISORDERS ODIFFERENTIADIAGNOSES W

414 OTHER MYEL

DISORDERS ODIFFERENTIADIAGNOSES W

416 SEPTICEMIA, 417 SEPTICEMIA, 
247

418 POSTOPERATIVE AND POSTTRAUMATIC 

INFECTIONS 

419 FEVER OF UNKNOWN ORIGIN, AGE 

GREATER THAN 17 WITH CC 

420 FEVER OF UNKNOWN ORIGIN, AGE 

GREATER THAN 17 WITHOUT CC 

421 VIRAL ILLNESS, AGE GREATER THAN 17 422 VIRAL ILLNESS AND FEVER OF 

UNKNOWN ORIGIN, AGE 0-17 

423 OTHER INFECTIOUS AND PARASITIC 

DISEASES DIAGNOSES 

425 ACUTE ADJUSTMENT REACTIONS AND 

DISTURBANCES OF PSYCHOSOCIAL DYSFUNCTION 

426 DEPRESSIVE NEUROSES 427 NEUROSES EXCEPT DEPRESSIVE 428 DISORDERS OF PERSONALITY AND 

IMPULSE CONTROL 

429 ORGANIC DISTURBANCES AND MENTAL 

RETARDATION 

430 PSYCHOSES 431 CHILDHOOD MENTAL DISORDERS 432 OTHER MENTAL DISORDER DIAGNOSES 433 ALCOHOL/DRUG ABUSE OR 

DEPENDENCE, LEFT AGAINST MEDICAL ADVICE 

434 ALCOHOL/DRUG ABUSE OR 

DEPENDENCE, DETOXIFICATION OR OTHER SYMPTOMATIC TREATMENT WITH CC 

435 ALCOHOL/DRUG ABUSE OR 

DEPENDENCE, DETOXIFICATION OR OTHER SYMPTOMATIC TREATMENT WITHOUT CC 

436 ALCOHOL/DRUG DEPENDENCE WITH 

REHABILITATION THERAPY 

437 ALCOHOL DRUG DEPENDENCE WITH 

COMBINED REHABILITATION AND DETOXIFICATION THERAPY 

444 TRAUMATIC INJURY, AGE GREATER 

THAN 17 WITH CC 

445 TRAUMATIC INJURY, AGE GREATER 

THAN 17 WITHOUT CC 

446 TRAUMATIC INJURY, AGE 0-17 447 ALLERGIC REACTIONS, AGE GREATER 

THAN 17 

448 ALLERGIC REACTIONS, AGE 0-17 449 POISONING AND TOXIC EFFECTS OF 

DRUGS, AGE GREATER THAN 17 WITH CC 

450 POISONING AND TOXIC EFFECTS OF 

DRUGS, AGE GREATER THAN 17 WITHOUT CC 

451 POISONING AND TOXIC EFFECTS OF 

DRUGS, AGE 0-17 

452 COMPLICATIONS OF TREATMENT WITH 

CC 

453 COMPLICATIONS OF TREATMENT 

WITHOUT CC 

454 OTHER INJURY, POISONING AND TOXIC 

EFFECT DIAGNOSES WITH CC 

455 OTHER INJURY, POISONING AND TOXIC 

EFFECT DIAGNOSES WITHOUT CC 

456 NO LONGER VALID 457 NO LONGER VALID 460 NO LONGER VALID 462 REHABILITATION 463 SIGNS AND SYMPTOMS WITH CC 464 SIGNS AND SYMPTOMS WITHOUT CC 465 AFTERCARE WITH HISTORY OF 

MALIGNANCY AS SECONDARY DIAGNOSIS 

466 AFTERCARE WITHOUT HISTORY OF 

MALIGNANCY AS SECONDARY DIAGNOSIS 

467 OTHER FACTORS INFLUENCING HEALTH 

STATUS 

473 ACUTE LEUKEMIA WITHOUT MAJOR OR 

PROCEDURE, AGE GREATER THAN 17 

474 NO LONGER VALID 475 RESPIRATORY SYSTEM DIAGNOSIS 

WITH VENTILATOR SUPPORT 

487 OTHER MULTIPLE SIGNIFICANT 

TRAUMA 

489 HIV WITH MAJOR RELATED CONDITION 490 HIV WITH OR WITHOUT OTHER 

RELATED CONDITION 

492 CHEMOTHERAPY WITH ACUTE 

LEUKEMIA AS SECONDARY DIAGNOSIS 

Metastatic cancer ICD-9-CM diagnosis codes (includes all 4th and 5th digits): 

196 SECONDARY AND UNSPECIFIED 

MALIGNANT NEOPLASM OF LYMPH NODES 

197 SECONDARY 

OF RESPIRATSYSTEMS 

198 SECONDARY 

OF OTHER SP

1990 MALIGNANT 

SPECIFICATIO

Obstetric trauma ICD-9-CM diagnosis code664.30,1,4 TRAUMA T

DURING DEPERINEAL 

665.30, 1, 4 OTHER OB

LACERATI

665.40, 1, 4 OTHER OB

VAGINAL L

665.50, 1, 4 OTHER OB

OTHER INJ

ICD-9-CM procedure code75.50 REPAIR OF C

LACERATION

75.51 REPAIR OF C

LACERATION

75.52 REPAIR OF C

LACERATION

75.61 REPAIR OF C

LACERATION URETHRA 

75.62 REPAIR OF C

LACERATION SPHINCTER A

Physiologic and metaboliICD-9-CM diagnosis codeDIABETES WITH KETO250.10 TYPE 2, OR U

STATED AS U

250.11 TYPE 1 NOT S

UNCONTROL

250.12 TYPE 2 OR UN

UNCONTROL
248

250.13 TYPE 1 UNCONTROLLED DIABETES WITH HYPEROSMOLARITY: 250.20 TYPE 2, OR UNSPECIFIED TYPE, NOT 

STATED AS UNCONTROLLED 

250.21 TYPE 1 NOT STATED AS 

UNCONTROLLED 

250.22 TYPE 2 OR UNSPECIFIED TYPE, 

UNCONTROLLED 

250.23 TYPE 1 UNCONTROLLED DIABETES WITH OTHER COMA: 250.30 TYPE 2, OR UNSPECIFIED TYPE, NOT 

STATED AS UNCONTROLLED 

250.31 TYPE 1 NOT STATED AS 

UNCONTROLLED 

250.32 TYPE 2 OR UNSPECIFIED TYPE, 

UNCONTROLLED 

250.33 TYPE 1 UNCONTROLLED ACUTE RENAL FAILURE: 584.5 WITH LESION OF TUBULAR NECROSIS 584.6 WITH LESION OF RENAL CORTICAL 

NECROSIS 

584.7 WITH LESION OF RENAL MEDULLARY 

[PAPILLARY] NECROSIS 

584.8 WITH OTHER SPECIFIED PATHOLOGICAL 

LESION IN KIDNEY 

584.9 ACUTE RENAL FAILURE, UNSPECIFIED Poisoning ICD-9-CM diagnosis codes (includes 4th and 5th digits): 

960 POISONING BY ANTIBIOTICS 961 POISONING BY OTHER ANTI-INFECTIVES 962 POISONING BY HORMONES AND 

SYNTHETIC SUBSTITUTES 

963 POISONING BY PRIMARILY SYSTEMIC 

AGENTS 

964 POISONING BY AGENTS PRIMARILY 

AFFECTING BLOOD CONSTITUENTS 

965 POISONING BY ANALGESICS, 

ANTIPYRETICS, AND ANTIRHEUMATICS 

966 POISONING BY ANTICONVULSANTS AND 

ANTI-PARKINSONISM DRUGS 

967 POISONING BY SEDATIVES AND 

HYPNOTICS 

968 POISONING BY OTHER CENTRAL 

NERVOUS SYSTEM DEPRESSANTS AND ANESTHETICS 

969 POISONING BY PSYCHOTROPIC AGENTS 970 POISONING BY CENTRAL NERVOUS 

SYSTEM STIMULANTS 

971 POISONING BY DRUGS PRIMARILY 

AFFECTING THE AUTONOMIC NERVOUS SYSTEM 

972 POISONING BY AGENTS PRIMARILY 

AFFECTING THE CARDIOVASCULAR SYSTEM 

973 POISONING BY AGENTS PRIMARILY 

AFFECTING THE GASTROINTESTINAL SYSTEM 

974 POISONING BY WATER, MINERAL, AND 

URIC ACID METABOLISM DRUGS 

975 POISONING BY AGENTS PRIMARILY 

ACTING ON THE SMOOTH AND SKELETAL MUSCLES AND RESPIRATORY SYSTEM 

976 POISONING BY AGENTS PRIMARILY 

AFFECTING SKIN AND MUCOUS MEMBRANE, OPTHAMOLOGICAL, OTORHINOLARYNCOLOGICAL AND DENTAL DRUGS 

977 POISONING BY OTHER AND 

UNSPECIFIED DRUGS AND MEDICINAL SUBSTANCES 

978 POISONING BY BACTERIAL VACCINES 979 POISONING BY OTHER VACCINES AND 

BIOLOGICAL SUBSTANCES 

E850 ACCIDENTAL POISONING BY 

ANALGESICS, ANTIPYRETICS, AND ANTIRHEUMATICS 

E851 ACCIDENTAL POISONING BY 

BARBITURATES 

E852 ACCIDENTAL POISONING BY OTHER 

SEDATIVES AND HYPNOTICS 

E853 ACCIDENTAL POISONING BY 

TRANQUILIZERS 

E854 ACCIDENTAL POISONING BY OTHER 

PSYCHOTROPIC AGENTS 

E855 ACCIDENTAL POISONING BY OTHER 

DRUGS ACTING ON CENTRAL AND AUTONOMIC NERVOUS SYSTEM 

E856 ACCIDENTAL POISONING BY 

ANTIBIOTICS 

E857 ACCIDENTAL POISONING BY OTHER 

ANTI-INFECTIVES 

E858 ACCIDENTAL 

DRUGS 

E860 ACCIDENTAL 

NEC 

E861 ACCIDENTAL 

AND POLISHIDISINFECTANVARNISHES 

E862 ACCIDENTAL 

PETROLEUM SOLVENTS A

E863 ACCIDENTAL 

AGRICULTURCHEMICAL APREPARATIOFOODS AND F

E864 ACCIDENTAL 

CORROSIVES 

E865 ACCIDENTAL 

POISONOUS FPOISONOUS P

E866 ACCIDENTAL 

UNSPECIFIED SUBSTANCES 

E867 ACCIDENTAL 

DISTRIBUTED 

E868 ACCIDENTAL 

UTILITY GAS MONOXIDE 

E869 ACCIDENTAL 

GASES AND V

E951 SUICIDE AND 

POISONING B

E952 SUICIDE AND 

POISONING BVAPORS 

E962 ASSAULT BY E980 POISONING B

SUBSTANCESWHETHER ACPURPOSELY I

E981 POISONING B

USE, UNDETEACCIDENTALINFLICTED 

E982 POISONING B

UNDETERMINACCIDENTALINFLICTED 
249

Postoperative hematoma ICD-9-CM diagnosis codes: 998.12 HEMATOMA COMPLICATING A 

PROCEDURE 

Postoperative hemorrhage or hematoma ICD-9-CM diagnosis codes: 998.11 HEMORRHAGE COMPLICATING A 

PROCEDURE 

Preterm infant ICD-9-CM diagnosis codes: 765.01-765.08 EXTREME IMMATURITY 765.11-765.18 OTHER PRETERM INFANTS Pulmonary embolism ICD-9-CM diagnosis codes: 415.11 IAGTROGENIC PULMONARY EMBOLISM 

AND INFARCTION 

415.19 OTHER PULMONARY EMBOLISM Seizure ICD-9-CM diagnosis codes: 345.00 GENERALIZED NONCONVULSIVE 

EPILEPSY - WITHOUT MENTION OF INTRACTABLE EPILEPSY 

345.01 GENERALIZED NONCONVULSIVE 

EPILEPSY - WITH INTRACTABLE EPILEPSY 

345.10 GENERALIZED CONVULSIVE EPILEPSY - 

WITHOUT MENTION OF INTRACTABLE EPILEPSY 

345.11 GENERALIZED CONVULSIVE EPILEPSY - 

WITH INTRACTABLE EPILEPSY 

345.2 EPILEPSY-PETIT MAL STATUS 345.3 EPILEPSY-GRAND MAL STATUS 

345.40 PARTIAL EPILEPSY, WITH IMPAIRMENT 

OF CONSCIOUSNESS - WITH INTRACTABLE EPILEPSY 

345.41 PARTIAL EPILEPSY, WITH IMPAIRMENT 

OF CONSCIOUSNESS - WITHOUT MENTION OF INTRACTABLE EPILEPSY 

345.50 PARTIAL EPILEPSY, WITHOUT MENTION 

OF IMPAIRMENT OF CONSCIOUSNESS, - WITHOUT MENTION OF INTRACTABLE EPILEPSY 

345.51 PARTIAL EPILEPSY, WITHOUT MENTION 

OF IMPAIRMENT OF CONSCIOUSNESS -WITH INTRACTABLE EPILEPSY 

345.60 INFANTILE SPASMS - WITHOUT 

MENTION OF INTRACTABLE EPILEPSY 

345.61 INFANTILE SPASMS - WITH 

INTRACTABLE EPILEPSY 

345.70 EPILEPSIA PARTIALIS CONTINUA - 

WITHOUT MENTION OF INTRACTABLE EPILEPSY 

345.71 EPILEPSIA PARTIALIS CONTINUA - WITH 

INTRACTABLE EPILEPSY 

345.80 OTHER FORMS OF EPILEPSY - WITHOUT 

MENTION OF INTRACTABLE EPILEPSY 

345.81 OTHER FORMS OF EPILEPSY - WITH 

INTRACTABLE EPILEPSY 

345.90 EPILEPSY, UNSPECIFIED - WITHOUT 

MENTION OF INTRACTABLE EPILEPSY 

345.91 EPILEPSY, UNSPECIFIED - WITH 

INTRACTABLE EPILEPSY 

780.31 FEBRILE CONVULSIONS 780.39 OTHER CONVULSIONS 780.3 CONVULSIONS (OLD CODE NO LONGER 

VALID) 

Self inflicted injury ICD-9-CM diagnosis codes: SUICIDE AND SELF-INFLICTED POISONING BY SOLID OR LIQUID SUBSTANCE: E950.0 ANALGESICS, ANTIPYRETICS, AND 

ANTIRHEUMATICS 

E950.1 BARBITURATES E950.2 OTHER SEDATIVE AND HYPNOTICS E950.3 TRANQUILIZIERS AND OTHER 

PSYCHOTROPIC AGENTS 

E950.4 OTHER SPECIFIED DRUGS AND 

MEDICINAL SUBSTANCES 

E950.5 UNSPECIFIED 

SUBSTANCE 

E950.6 AGRICULTUR

CHEMICAL APREPARATIOFOODS AND F

E950.7 CORROSIVE AE950.8 ARSENIC AND E950.9 OTHER AND 

LIQUID SUBS

SUICIDE AND SELF-INF

GASES IN DOMESTIC UE951.0 GAS DISTRIBE951.1 LIQUEFIED P

DISTRIBUTED 

E951.8 OTHERS UTILE952.0 MOTOR VEHIE952.1 OTHER CARBE952.8 OTHER SPECIE952.9 UNSPECIFIED SUICIDE AND SELF-INFHANGING, STRANGULE953.0 HANGING E953.1 SUFFOCATIOE953.8 OTHER SPECIE954 SUICIDE AND 

BY SUBMERS

SUICIDE AND SELF-INFFIREARMS AND EXPLOE955.0 HANDGUN E955.1 SHOTGUN E955.2 HUNTING RIFE955.3 MILITARY FIE955.4 OTHER AND E955.5 EXPLOSIVES E955.9 UNSPECIFIED E956 SUICIDE AND 

BY CUTTING INSTRUMENT 

SUICIDE AND SELF-INFJUMPING FROM A HIGH E957.0 RESIDENTIAL E957.1 OTHER MAN-E957.2 NATURAL SITE957.3 UNSPECIFIED 
250

SUICIDE AND SELF-INFLICTED INJURY BY OTHER AND UNSPECIFIED MEANS: E958.0 JUMPING OR LYING BEFORE MOVING 

OBJECT 

E958.1 BURNS, FIRE E958.2 SCALD E958.3 EXTREMES OF COLD E958.4 ELECTROCUTION E958.5 CRASHING OF MOTOR VEHICLE E958.6 CRASHING OF AIRCRAFT E958.7 CAUSTIC SUBSTANCES EXCEPT 

POISONING 

E958.8 OTHER SPECIFIED MEANS E958.9 UNSPECIFIED MEANS Sepsis ICD-9-CM diagnosis codes: 038.0 STREPTOCOCCAL SEPTICEMIA 038.10 STAPHYLOCOCCAL SEPTICEMIA, 

UNSPECIFIED 

038.11 STAPHYLOCOCCUS AUREUS 

SEPTICEMIA 

038.19 OTHER STAPHYLOCOCCAL SEPTICEMIA 038.2 PNEUMOCOCCAL SEPTICEMIA 

(STREPTOCOCCUS PNEUMONIAE SEPTICEMIA) 

038.3 SEPTICEMIA DUE TO ANAEROBES SEPTICEMIA DUE TO 038.40 GRAM-NEGATIVE ORGANISM, 

UNSPECIFIED 

038.41 HEMOPHILUS INFLUENZAE 038.42 ESCHERICHIA COLI 038.43 PSEUDOMONAS 038.44 SERRATIA 038.49 SEPTICEMIA DUE TO OTHER GRAMNEGATIVE ORGANISMS 038.8 OTHER SPECIFIED SEPTICEMIAS 038.9 UNSPECIFIED SEPTICEMIA Shock ICD-9-CM diagnosis codes: SHOCK WITHOUT MENTION OF TRAUMA: 785.50 SHOCK, UNSPECIFIED 

785.51 CARDIOGENIC SHOCK 785.59 OTHER Stroke ICD-9-CM diagnosis codes: 430 SUBARACHNOID HEMORRHAGE 431 INTRACEREBRAL HEMORRHAGE 432.0 NONTRAUMATIC EXTRADURAL 

HEMORRHAGE 

432.1 SUBDURAL HEMORRHAGE 432.9 UNSPECIFIED INTRACRANIAL 

HEMORRHAGE 

436 ACUTE, BUT ILL-DEFINED 

CEREBROVASCULAR DISEASE 

OCCLUSION AND STENOSIS OF PRECEREBRAL ARTERIES: 433.01 BASILAR ARTERY, WITH CEREBRAL 

INFARCTION 

433.11 CAROTID ARTERY, WITH CEREBRAL 

INFARCTION 

433.21 VERTEBRAL ARTERY, WITH CEREBRAL 

INFARCTION 

433.31 MULTIPLE AND BILATERAL WITH 

CEREBRAL INFARCTION 

433.81 OTHER SPECIFIED PRECEREBRAL 

ARTERY WITH CEREBRAL INFARCTION 

433.91 OCCLUSION AND STENOSIS OF 

PRECEREBRAL ARTERIES, UNSPECIFIED PRECEREBRAL ARTERY WITH CEREBRAL INFARCTION 

OCCLUSION OF CEREBRAL ARTERIES: 434.01 CEREBRAL THROMBOSIS - WITH 

CEREBRAL INFARCTION 

434.11 CEREBRAL EMBOLISM - WITH 

CEREBRAL INFARCTION 

434.91 CEREBRAL ARTERY OCCLUSION, 

UNSPECIFIED - WITH CEREBRAL INFARCTION 

Surgical Diagnostic Related Groups (DRGs): 

001 CRANIOTOM

EXCEPT FOR 

002 CRANIOTOM

GREATER TH

003 CRANIOTOM004 SPINAL PROC005 EXTRACRAN

PROCEDURES 

006 CARPAL TUN007 PERIPHERAL 

OTHER NERVWITH CC 

008 PERIPHERAL 

OTHER NERVWITHOUT CC 

036 RETINAL PRO037 ORBITAL PRO038 PRIMARY IRI039 LENS PROCED

VITRECTOMY 

040 EXTRAOCUL

ORBIT, AGE G

041 EXTRAOCUL

ORBIT, AGE 0

042 INTRAOCULA

RETINA, IRIS 

049 MAJOR HEAD 050 SIALOADENE051 SALIVARY G

EXCEPT SIAL

052 CLEFT LIP AN053 SINUS AND M

GREATER TH

054 SINUS AND M

0-17 

055 MISCELLANE

AND THROAT 

056 RHINOPLAST057 TONSILLECT

ADENOIDECTEXCEPT TONADENOIDECTTHAN 17 

058 TONSILLECT

ADENOIDECTEXCEPT TONADENOIDECT

059 TONSILLECT

ADENOIDECTTHAN 17 
251

060 TONSILLECTOMY AND/OR 

ADENOIDECTOMY ONLY, AGE 0-17 

061 MYRINGOTOMY WITH TUBE INSERTION, 

AGE GREATER THAN 17 

062 MYRINGOTOMY WITH TUBE INSERTION, 

AGE 0-17 

063 OTHER EAR, NOSE, MOUTH AND 

THROAT OR PROCEDURES 

075 MAJOR CHEST PROCEDURES 076 OTHER RESPIRATORY SYSTEM OR 

PROCEDURES WITH CC 

077 OTHER RESPIRATORY SYSTEM OR 

PROCEDURES WITHOUT CC 

103 HEART TRANSPLANT 104 CARDIAC VALVE AND OTHER MAJOR 

CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION 

105 CARDIAC VALVE AND OTHER MAJOR 

CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION 

106 CORONARY BYPASS WITH PTCA 107 CORONARY BYPASS WITH CARDIAC 

CATHETERIZATION 

108 OTHER CARDIOTHORACIC PROCEDURES 109 CORONARY BYPASS WITHOUT CARDIAC 

CATHETERIZATION 

110 MAJOR CARDIOVASCULAR 

PROCEDURES WITH CC 

111 MAJOR CARDIOVASCULAR 

PROCEDURES WITHOUT CC 

112 PERCUTANEOUS CARDIOVASCULAR 

PROCEDURES 

113 AMPUTATION FOR CIRCULATORY 

SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE 

114 UPPER LIMB AND TOES AMPUTATION 

FOR CIRCULATORY SITE 

115 PERMANENT CARDIAC PACEMAKER 

IMPLANT WITH ACUTE MYOCARDIAL INFARCTION, HEART FAILURE OR SHOCK OR ACID LEAD OR GENERATOR PROCEDURE 

116 OTHER PERMANENT CARDIAC 

PACEMAKER IMPLANT OR PTCA WITH CORONARY ARTERIAL STENT 

117 CARDIAC PACEMAKER REVISION 

EXCEPT DEVICE REPLACEMENT 

118 CARDIAC PACEMAKER DEVICE 

REPLACEMENT 

119 VEIN LIGATION AND STRIPPING 

120 OTHER CIRCULATORY SYSTEM OR 

PROCEDURES 

146 RECTAL RESECTION WITH CC 147 RECTAL RESECTION WITHOUT CC 148 MAJOR SMALL AND LARGE BOWEL 

PROCEDURES WITH CC 

149 MAJOR SMALL AND LARGE BOWEL 

PROCEDURES WITHOUT CC 

150 PERITONEAL ADHESIOLYSIS WITH CC 151 PERITONEAL ADHESIOLYSIS WITHOUT 

CC 

152 MINOR SMALL AND LARGE BOWEL 

PROCEDURES WITH CC 

153 MINOR SMALL AND LARGE BOWEL 

PROCEDURES WITHOUT CC 

154 STOMACH, ESOPHAGEAL AND 

DUODENAL PROCEDURES, AGE GREATER THAN 17 WITH CC 

155 STOMACH, ESOPHAGEAL AND 

DUODENAL PROCEDURES, AGE GREATER THAN 17 WIHOUT CC 

156 STOMACH, ESOPHAGEAL AND 

DUODENAL PROCEDURES, AGE 0-17 

157 ANAL AND STOMAL PROCEDURES WITH 

CC 

158 ANAL AND STOMAL PROCEDURES 

WITHOUT CC 

159 HERNIA PROCEDURES EXCEPT 

INGUINAL AND FEMORAL, AGE GREATER THAN 17 WITH CC 

160 HERNIA PROCEDURES EXCEPT 

INGUINAL AND FEMORAL, AGE GREATER THAN 17 WITHOUT CC 

161 INGUINAL AND FEMORAL HERNIA 

PROCEDURES, AGE GREATER THAN 17 WITH CC 

162 INGUINAL AND FEMORAL HERNIA 

PROCEDURES, AGE GREATER THAN 17 WITHOUT CC 

163 HERNIA PROCEDURES, AGE 0-17 164 APPENDECTOMY WITH COMPLICATED 

PRINCIPAL DIAGNOSIS WITH CC 

165 APPENDECTOMY WITH COMPLICATED 

PRINCIPAL DIAGNOSIS WITHOUT CC 

166 APPENDECTOMY WITHOUT 

COMPLICATED PRINCIPAL DIAGNOSIS WITH CC 

167 APPENDECTOMY WITHOUT 

COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC 

168 MOUTH PROC169 MOUTH PROC170 OTHER DIGE

PROCEDURES 

171 OTHER DIGE

PROCEDURES 

191 PANCREAS, L

PROCEDURES 

192 PANCREAS, L

PROCEDURES 

193 BILIARY TRA

ONLY CHOLEWITHOUT COEXPLORATIO

194 BILIARY TRA

ONLY CHOLEWITHOUT COEXPLORATIO

195 CHOLECYSTE

DUCT EXPLO

196 CHOLECYSTE

DUCT EXPLO

197 CHOLECYSTE

LAPAROSCOPDUCT EXPLO

198 CHOLECYSTE

LAPAROSCOPDUCT EXPLO

199 HEPATOBILIA

PROCEDURE 

200 HEPATOBILIA

PROCEDURE 

201 OTHER HEPA

OR PROCEDU

209 MAJOR JOINT 

REATTACHMLOWER EXTR

210 HIP AND FEM

MAJOR JOINT GREATER TH

211 HIP AND FEM

MAJOR JOINT GREATER TH

212 HIP AND FEM

MAJOR JOINT 

213 AMPUTATION 

SYSTEM AND DISORDERS 

214 NO LONGER 215 NO LONGER 
252

216 BIOPSIES OF MUSCULOSKELETAL 

SYSTEM AND CONNECTIVE TISSUE 

217 WOUND DEBRIDEMENT AND SKIN 

GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 

218 LOWER EXTREMITY AND HUMERUS 

PROCEURES EXCEPT HIP, FOOT AND FEMUR, AGE GREATER THAN 17 WITH CC 

219 LOWER EXTREMITY AND HUMERUS 

PROCEDURES EXCEPT HIP, FOOT AND FEMUR, AGE GREATER THAN 17 WITHOUT CC 

220 LOWER EXTREMITY AND HUMERUS 

PROCEDURES EXCEPT HIP, FOOT AND FEMUR, AGE 0-17 

221 NO LONGER VALID 222 NO LONGER VALID 223 MAJOR SHOULDER/ELBOW 

PROCEDURES OR OTHER UPPER EXTREMITY PROCEDURES WITH CC 

224 SHOULDER, ELBOW OR FOREARM 

PROCEDURES EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC 

225 FOOT PROCEDURES 226 SOFT TISSUE PROCEDURES WITH CC 227 SOFT TISSUE PROCEDURES WITHOUT CC 228 MAJOR THUMB OR JOINT PROCEDURES 

OR OTHER HAND OR WRIST PROCEDURES WITH CC 

229 HAND OR WRIST PROCEDURES EXCEPT 

MAJOR JOINT PROCEDURES WITHOUT CC 

230 LOCAL EXCISION AND REMOVAL OF 

INTERNAL FIXATION DEVICES OF HIP AND FEMUR 

231 LOCAL EXCISION AND REMOVAL OF 

INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR 

232 ARTHROSCOPY 233 OTHER MUSCULOSKELETAL SYSTEM 

AND CONNECTIVE TISSUE OR PROCEDURES WITH CC 

234 OTHER MUSCULOSKELETAL SYSTEM 

AND CONNECTIVE TISSUE OR PROCEDURES WITHOUT CC 

257 TOTAL MASTECTOMY FOR 

MALIGNANCY WITH CC 

258 TOTAL MASTECTOMY FOR 

MALIGNANCY WITHOUT CC 

259 SUBTOTAL MASTECTOMY FOR 

MALIGNANCY WITH CC 

260 SUBTOTAL MASTECTOMY FOR 

MALIGNANCY WITHOUT CC 

261 BREAST PROCEDURE FOR 

NONMALIGNANCY EXCEPT BIOPSY AND LOCAL EXCISION 

262 BREAST BIOPSY AND LOCAL EXCISION 

FOR NONMALIGNANCY 

263 SKIN GRAFT AND/OR DEBRIDEMENT 

FOR SKIN ULCER OR CELLULITIS WITH CC 

264 SKIN GRAFT AND OR DEBRIDEMENT 

FOR SKIN ULCER OR CELLULITIS 

WITHOUT CC 

265 SKIN GRAFT AND OR DEBRIDEMENT 

EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC 

266 SKIN GRAFT AND/OR DEBRIDEMENT 

EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC 

267 PERIANAL AND PILONIDAL 

PROCEDURES 

268 SKIN, SUBCUTANEOUS TISSUE AND 

BREAST PLASTIC PROCEDURES 

269 OTHER SKIN, SUBCUTANEOUS TISSUE 

AND BREAST PROCEDURES WITH CC 

270 OTHER SKIN, SUBCUTANEOUS TISSUE 

AND BREAST PROCEDURS WITHOUT CC 

285 AMPUTATION OF LOWER LIMB FOR 

ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS 

286 ADRENAL AND PITUITARY PROCEDURES 287 SKIN GRAFTS AND WOUND 

DEBRIDEMENTS FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS 

288 OR PROCEDURES FOR OBESITY 289 PARATHYROID PROCEDURES 290 THYROID PROCEDURES 291 THYROGLOSSAL PROCEDURES 292 OTHER ENDOCRINE, NUTRITIONAL AND 

METABOLIC OR PROCEDURES WITH CC 

293 OTHER ENDOCRINE, NUTRITIONAL AND 

METABOLIC OR PROCEDURES WITHOUT CC 

302 KIDNEY TRANSPLANT 

303 KIDNEY, URE

PROCEDURES 

304 KIDNEY, URE

PROCEDURES WITH CC 

305 KIDNEY, URE

PROCEDURES WITHOUT CC 

306 PROSTATECT307 PROSTATECT308 MINOR BLAD

CC 

309 MINOR BLAD

WITHOUT CC 

310 TRANSURETH

CC 

311 TRANSURETH

WITHOUT CC 

312 URETHRAL P

GREATER TH

313 URETHRAL P

GREATER TH

314 URETHRAL P315 OTHER KIDN

OR PROCEDU

334 MAJOR MALE 

WITH CC 

335 MAJOR MALE 

WITHOUT CC 

336 TRANSURETH

WITH CC 

337 TRANSURETH

WITHOUT CC 

338 TESTES PROC

MALIGNANC

339 TESTES PROC

NONMALIGN17 

340 TESTES PROC

NONMALIGN

341 PENIS PROCE342 CIRCUMCISIO343 CIRCUMCISIO344 OTHER MALE 

OR PROCEDU

345 OTHER MALE 

OR PROCEDUMALIGNANC
253

353 PELVIC EVISCERATION, RADICAL 

HYSTERECTOMY AND RADICAL VULVECTOMY 

354 UTERINE AND ADNEXA PROCEDURES 

FOR NONOVARIAN/ADNEXAL MALIGNANCY WITH CC 

355 UTERINE AND ADNEXA PROCEDURES 

FOR NONOVARIAN/ADNEXA PROCEDURES FOR NONOVARIAN/ADNEXAL MALIGNANCY WITHOUT CC 

356 FEMALE REPRODUCTIVE SYSTEM 

RECONSTRUCTIVE PROCEDURES 

357 UTERINE AND ADNEXA PROCEDURES 

FOR OVARIAN OR ADNEXAL MALIGNANCY 

358 UTERINE AND ADNEXA PROCEDURES 

FOR NONMALIGNANCY WITH CC 

359 UTERINE AND ADNEXA PROCEDURES 

FOR NONMALIGNANCY WITHOUT CC 

360 VAGINA, CERVIX AND VULVA 

PROCEDURES 

361 LAPAROSCOPY AND INCISIONAL TUBAL 

INTERRUPTION 

362 ENDOSCOPIC TUBAL INTERRUPTION 363 D AND C, CONIZATION AND 

RADIOIMPLANT FOR MALIGNANCY 

364 D AND C, CONIZATION EXCEPT FOR 

MALIGNANCY 

365 OTHER FEMALE REPRODUCTIVE 

SYSTEM OR PROCEDURES 

370 CESAREAN SECTION WITH CC 371 CESAREAN SECTION WITHOUT CC 374 VAGINAL DELIVERY WITH 

STERILIZATION AND/OR D AND C 

375 VAGINAL DELIVERY WITH OR 

PROCEDURE EXCEPT STERILIZATION AND/OR D AND C 

377 POSTPARTUM AND POSTABORTION 

DIAGNOSES WITH OR PROCEDURE 

381 ABORTION WITH D AND C ASPIRATION 

CURETTAGE OR HYSTERECTOMY 

392 SPLENECTOMY, AGE GREATER THAN 17 393 SPLENECTOMY, AGE 0-17 394 OTHER OR PROCEDURES OF THE BLOOD 

AND BLOOD-FORMING ORGANS 

400 LYMPHOMA AND LEUKEMIA WITH 

MAJOR OR PROCEDURES 

401 LYMPHOMA AND NONACUTE LEUKEMIA 

WITH OTHER OR PROCEDURE WITH CC 

402 LYMPHOMA AND NONACUTE LEUKEMIA 

WITH OTHER OR PROCEDURE WITHOUT CC 

406 MYELOPROLIFERATIVE DISORDERS OR 

POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR OR PROCEDURES WITH CC 

407 MYELOPROLIFERATIVE DISORDERS OR 

POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR OR PROCEDURES WITHOUT CC 

408 MYELOPROLIFERATIVE DISORDERS OR 

POORLY DIFFERENTIATED NEOPLASMS WITH OTHER OR PROCEDURES 

415 OR PROCEDURE FOR INFECTIOUS AND 

PARASITIC DISEASES 

424 OR PROCEDURES WITH PRINCIPAL 

DIAGNOSIS OF MENTAL ILLNESS 

439 SKIN GRAFTS FOR INJURIES 440 WOUND DEBRIDEMENTS FOR INJURIES 441 WOUND HAND PROCEDURES FOR 

INJURIES 

442 OTHER OR PROCEDURES FOR INJURIES 

WITH CC 

443 OTHER OR PROCEDURES FOR INJURIES 458 NO LONGER VALID 459 NO LONGER VALID 461 OR PROCEDURES WITH DIAGNOSES OF 

OTHER CONTACT WITH HEALTH SERVICES 

468 EXTENSIVE OR PROCEDURE 

UNRELATED TO PRINCIPAL DIAGNOSIS 

471 BILATERAL OR MULTIPLE MAJOR JOINT 

PROCEDURES OF LOWER EXTREMITY 

472 NO LONGER VALID 476 PROSTATIC OR PROCEDURE 

UNRELATED TO PRINCIPAL DIAGNOSIS 

477 NONEXTENSIVE OR PROCEDURE 

UNRELATED TO PRINCIPAL DIAGNOSIS 

478 OTHER VASCULAR PROCEDURES WITH 

CC 

479 OTHER VASCULAR PROCEDURES 

WITHOUT CC 

480 LIVER TRANSPLANT 481 BONE MARROW TRANSPLANT 482 TRACHEOSTOMY FOR FACE, MOUTH 

AND NECK DIAGNOSES 

483 TRACHEOSTOMY EXCEPT FOR FACE, 

MOUTH AND NECK DIAGNOSES 

484 CRANIOTOMY FOR MULTIPLE 

SIGNIFICANT TRAUMA 

485 LIMB REATTA

PROCEDURES SIGNIFICANT 

486 OTHER OR PR

SIGNIFICANT 

488 HIV WITH EX491 MAJOR JOINT 

REATTACHMUPPER EXTRE

493 LAPAROSCOP

WITHOUT COEXPLORATIO

494 LAPAROSCOP

WITHOUT COEXPLORATIO

495 LUNG TRANS496 COMBINED A

SPINAL FUSIO

497 SPINAL FUSIO498 SPINAL FUSIO499 BACK AND N

SPINAL FUSIO

500 BACK AND N

SPINAL FUSIO

501 KNEE PROCE

DIAGNOSIS O

502 KNEE PROCE

DIAGNOSIS O

503 KNEE PROCE

PRINCIPAL D

Syncope ICD-9-CM diagnosis code780.2 SYNCOPE ANTechnical difficulty ICD-9-CM diagnosis codeACCIDENTAL CUT, PUNHEMORRHAGE DURINGE870.0 SURGICAL OE870.1 INFUSION OR E870.2 KIDNEY DIAL

PERFUSION 

E870.3 INJECTION O
254

E870.4 ENDOSCOPIC EXAMINATION E870.5 ASPIRATION OF FLUID OR TISSUE, 

PUNCTURE, AND CATHETERIZATION 

E870.6 HEART CATHETERIZATION E870.7 ADMINISTRATION OF ENEMA E870.8 OTHER SPECIFIED MEDICAL CARE E870.9 UNSPECIFIED MEDICAL CARE 998.2 ACCIDENTAL PUNCTURE OR 

LACERATION DURING A PROCEDURE 

Thoracic surgery ICD-9-CM procedure codes: 31.21 MEDIASTINAL TRACHEOSTOMY 31.45 OPEN BIOPSY OF LARYNX OR TRACHEA 31.73 CLOSURE OF OTHER FISTULA OF 

TRACHEA 

31.79 OTHER REPAIR AND PLASTIC 

OPERATIONS ON TRACHEA 

31.99 OTHER OPERATIONS ON TRACHEA 32.09 OTHER LOCAL EXCISION OR 

DESTRUCTION OF LESION OR TISSUE OF BRONCHUS 

32.1 OTHER EXCISION OF BRONCHUS 32.21 PLICATION OF EMPHYSEMATIOUS BLEB 32.22 LUNG VOLUME REDUCTION SURGERY 32.28 ENDOSCOPIC EXCISION OR 

DESTRUCTION OF LESION OR TISSUE OF LUNG 

32.29 OTHER LOCAL EXCISION OR 

DESTRUCTION OF LESION OR TISSUE OF LUNG 

32.3 SEGMENTAL RESECTION OF LUNG 32.4 LOBECTOMY OF LUNG 32.5 COMPLETE PNEUMONECTOMY 32.6 RADICAL DISSECTION OF THORACIC 

STRUCTURES 

32.9 OTHER EXCISION OF LUNG 33.0 INCISION OF BRONCHUS 33.1 INCISION OF LUNG 33.25 OPEN BIOPSY OF BRONCHUS 33.26 CLOSED [PERCUTANEOUS][NEEDLE] 

BIOPSY OF LUNG 

33.27 CLOSED ENDOSCOPIC BIOPSY OF LUNG 33.28 OPEN BIOPSY OF LUNG 33.31 DESTRUCTION OF PHRENIC NERVE FOR 

COLLAPSE OF LUNG (NO LONGER PERFORMED) 

33.32 ARTIFICAL PNEUMOTHORAX FOR 

COLLAPSE OF LUNG 

33.34 THORACOPLASTY 33.39 OTHER SURGICAL COLLAPSE OF LUNG 33.41 SUTURE OF LACERATION OF BRONCHUS 33.42 CLOSURE OF BRONCHIAL FISTULA 33.43 CLOSURE OF LACERATION OF LUNG 33.48 OTHER REPAIR AND PLASTIC 

OPERATIONS ON BRONCHUS 

33.49 OTHER REPAIR AND PLASTIC 

OPERATIONS ON LUNG 

33.50 LUNG TRANSPLANTATION, NOS 33.51 UNILATERAL LUNG TRANSPLANTATION 33.52 BILATERAL LUNG TRANSPLANTATION 33.6 COMBINED HEART-LUNG 

TRANSPLANTATION 

33.92 LIGATION OF BRONCHUS 33.93 PUNCTURE OF LUNG 33.98 OTHER OPERATIONS ON BRONCHUS 33.99 OTHER OPERATIONS ON LUNG 33.29 OTHER DIAGNOSTIC PROCEDURE ON 

LUNG AND BRONCHUS 

33.33 PNEUMOPERITONEUM FOR COLLAPSE 

OF LUNG 

34.01 INCISION OF CHEST WALL 34.02 EXPLORATORY THORACOTOMY 34.03 REOPENING OF RECENT THORACOTOMY 

SITE 

34.05 CREATION OF PLEUROPERITONEAL 

SHUNT 

34.09 OTHER INCISION OF PLEURA 34.1 INCISION OF MEDIASTINUM 34.21 TRANSPLEURAL THORACOSOCOPY 34.22 MEDIASTINOSCOPY 34.23 BIOPSY OF CHEST WALL 34.24 PLEURAL BIOPSY 34.25 CLOSED [PERCUTANEOUS][NEEDLE] 

BIOPSY OF MEDIASTINUM 

34.26 OPEN BIOPSY OF MEDIASTINUM 34.27 BIOPSY OF DIAPHRAGM 34.28 OTHER DIAGNOSTIC PROCEDURES ON 

CHEST WALL, PLEURA, AND DIAPHRAGM 

34.29 OTHER DIAGNOSTIC PROCEDURES ON 

MEDIASTINUM 

34.3 EXCISION OR DESTRUCTION OF LESION 

OR TISSUE OF MEDIASTINUM 

34.4 EXCISION OR DESTRUCTION OF LESION 

OF CHEST WALL 

34.51 DECORTICAT34.59 OTHER EXCIS34.71 SUTURE OF L

WALL 

34.72 CLOSURE OF 34.73 CLOSURE OF 

THORAX 

34.74 REPAIR OF PE34.79 OTHER REPA34.81 EXCISION OF 

DIAPHRAGM 

34.82 SUTURE OF L

DIAPHRAGM 

34.83 CLOSURE OF 34.84 OTHER REPA34.85 IMPLANTATI

PACEMAKER 

34.89 OTHER OPER34.93 REPAIR OF PL34.99 OTHER 

40.61 CANNULATIO40.62 FISTULIZATI40.63 CLOSURE OF 

DUCT 

40.64 LIGATION OF 40.69 OTHER OPER

DUCT 

42.01 INCISION OF 42.09 OTHER INCIS42.10 ESOPHAGOST42.11 CERVICAL ES42.12 EXTERIORIZA

POUCH 

42.19 OTHER EXTE

ESOPHAGUS 

42.21 OPERATIVE E

INCISION 

42.25 OPEN BIOPSY 42.31 LOCAL EXCIS

DIVERTICUL

42.32 LOCAL EXCIS

TISSUE OF ES

42.39 OTHER DEST

TISSUE OF ES

42.40 ESOPHAGECT42.41 PARTIAL ESO42.42 TOTAL ESOPH42.51 INTRATHORA

ESOPHAGOES
255

42.52 INTRATHORACIC 

ESOPHAGOGASTROSTOMY 

42.53 INTRATHORACIC ESOPHAGEAL 

ANASTOMOSIS WITH INTERPOSITION OF SMALL BOWEL 

42.54 OTHER INTRATHORACIC 

ESOPHAGOENTEROSTOMY 

42.55 INTRATHORACIC ESOPHAGEAL 

ANASTOMOSIS WITH INTERPOSITION OF COLON 

42.56 OTHER INTRATHORACIC 

ESOPHAGOCOLOSTOMY 

42.58 INTRATHORACIC ESOPHAGEAL 

ANASTOMOSIS WITH OTHER INTERPOSITION 

42.59 OTHER INTRATHORACIC ANASTOMOSIS 

OF ESOPHAGUS 

42.61 ANTESTERNAL 

ESOPHAGOESOPHAGOSTOMY 

42.62 ANTESTERNAL 

ESOPHAGOGASTROSTOMY 

42.63 ANTESTERNAL ESOPHAGEAL 

ANASTOMOSIS WITH INTERPOSITION OF SMALL BOWEL 

42.64 OTHER ANTESTERNAL 

ESOPHAGOENTEROSTOMY 

42.65 ANTESTERNAL ESOPHAGEAL 

ANASTOMOSIS WITH INTERPOSITION OF COLON 

42.66 OTHER ANTESTERNAL 

ESOPHAGOCOLOSTOMY 

42.68 OTHER ANTESTERNAL ESOPHAGEAL 

ANASTOMOSIS WITH INTERPOSITION 

42.69 OTHER ANTESTERNAL ANASTOMOSIS 

OF ESOPHAGUS 

42.7 ESOPHAGOMYOTOMY 42.81 INSERTION OF PERMANENT TUBE INTO 

ESOPHAGUS 

42.82 SUTURE OF LACERATION OF 

ESOPHAGUS 

42.83 CLOSURE OF ESOPHAGOSTOMY 42.84 REPAIR OF ESOPHAGEAL FISTULA, NEC 42.85 REPAIR OF ESOPHAGEAL STRICTURE 42.86 PRODUCTION OF SUBCUTANEOUS 

TUNNEL WITHOUT ESOPHAGEAL ANASTOMOSIS 

42.87 OTHER GRAFT OF ESOPHAGUS 42.89 OTHER REPAIR OF ESOPHAGUS 44.65 ESOPHAGOGASTROPLASTY 

44.66 OTHER PROCEDURES FOR CREATION OF 

ESOPHAGOGASTRIC SPHINCTERIC COMPETENCE 

81.04 DORSAL AND DORSO-LUMBAR FUSION, 

ANTERIOR TECHNIQUE 

Transferred to acute care facility DISCHARGE DISPOSITION RECORDED AS TRANSFER TO ANOTHER ACUTE CARE FACILITY Transferred from acute care facility ADMISSION SOURCE IS RECORDED AS ACUTE CARE FACILITY Transfusion reaction ICD-9-CM diagnosis codes: 999.6 ABO INCOMPATIBILITY REACTION 999.7 RH INCOMPATIBILITY REACTION E876.0 MISMATCHED BLOOD IN TRANSFUSION Trauma ICD-9-CM diagnosis codes ( includes 4th and 5th digits): 

800 FRACTURE OF VAULT OF SKULL 801 FRACTURE OF BASE OF SKULL 802 FRACTURE OF FACE BONES 803 OTHER AND UNQUALIFIED SKULL 

FRACTURES 

804 MULTIPLE FRACTURES INVOLVING 

SKULL OR FACE WITH OTHER BONES 

805 FRACTURE OF VERTEBRAL COLUMN 

WITHOUT MENTION OF SPINAL CORD INJURY 

806 FRACTURE OF VERTEBRAL COLUMN 

WITH SPINAL CORD INJURY 

807 FRACTURE OF RIB[S] STERNUM, 

LARYNX, AND TRACHEA 

808 FRACTURE OF PELVIS 809 ILL-DEFINED FRACTURES OF BONES OF 

TRUNK 

810 FRACTURE OF CLAVICLE 

811 FRACTURE O812 FRACTURE O813 FRACTURE O814 FRACTURE O815 FRACTURE O817 MULTIPLE FR818 ILL-DEFINED 

LIMB 

819 MULTIPLE FR

BOTH UPPER WITH RIB AN

820 FRACTURE O821 FRACTURE O

PARTS OF FE

822 FRACTURE O823 FRACTURE O824 FRACTURE O825 FRACTURE O

AND METATA

827 OTHER, MUL

FRACTURES 

828 MULTIPLE FR

BOTH LOWER UPPER LIMB, RIB AND STE

829 FRACTURE O830 DISLOCATIO831 DISLOCATIO832 DISLOCATIO833 DISLOCATION 835 DISLOCATIO836 DISLOCATION 837 DISLOCATION 838 DISLOCATIO839 OTHER, MUL

DISLOCATIO

850 CONCUSSION 851 CEREBRAL L

CONTUSION 

852 SUBARACHN

EXTRADURAFOLLOWING 

853 OTHER AND 

INTRACRANIFOLLOWING 

854 INTRACRANI

UNSPECIFIED 

860 TRAUMATIC 861 INJURY TO H
256

862 INJURY TO OTHER AND UNSPECIFIED 

INTRATHORACIC ORGANS 

863 INJURY TO GASTROINTESTINAL TRACT 864 INJURY TO LIVER 865 INJURY TO SPLEEN 866 INJURY TO KIDNEY 867 INJURY TO PELVIC ORGANS 868 INJURY TO OTHER INTRA-ABDOMINAL 

ORGANS 

869 INTERNAL INJURY TO UNSPECIFIED OR 

ILL-DEFINED ORGANS 

870 OPEN WOUND OF OCULAR ADNEXA 871 OPEN WOUND OF EYEBALL 872 OPEN WOUND OF EAR 873 OTHER OPEN WOUND OF HEAD 874 OPEN WOUND OF NECK 875 OPEN WOUND OF CHEST [WALL] 876 OPEN WOUND OF BACK 877 OPEN WOUND OF BUTTOCK 878 OPEN WOUND OF GENITAL ORGANS 

[EXTERNAL] INCLUDING TRAUMATIC AMPUTATION 

879 OPEN WOUND OF OTHER AND 

UNSPECIFIED SITES, EXCEPT LIMBS 

880 OPEN WOUND OF SHOULDER AND 

UPPER ARM 

881 OPEN WOUND OF ELBOW, FOREARM, 

AND WRIST 

882 OPEN WOUND OF HAND EXCEPT FINGER 

ALONE 

884 MULTIPLE AND UNSPECIFIED OPEN 

WOUND OF UPPER LIMB 

887 TRAUMATIC AMPUTATION OF ARM AND 

HAND (COMPLETE) (PARTIAL) 

890 OPEN WOUND OF HIP AND THIGH 891 OPEN WOUND OF KNEE, LEG (EXCEPT 

THIGH) AND ANKLE 

892 OPEN WOUND OF FOOT EXCEPT TOE 

ALONE 

894 MULTIPLE AND UNSPECIFIED OPEN 

WOUND OF LOWER LIMB 

896 TRAUMATIC AMPUTATION OF FOOT 

(COMPLETE) (PARTIAL) 

897 TRAUMATIC AMPUTATION OF LEG(S) 

(COMPLETE) (PARTIAL) 

900 INJURY TO BLOOD VESSELS OF HEAD 

AND NECK 

901 INJURY TO BLOOD VESSELS OF THORAX 902 INJURY TO BLOOD VESSELS OF 

ABDOMEN AND PELVIS 

903 INJURY TO BLOOD VESSELS OF UPPER 

EXTREMITY 

904 INJURY TO BLOOD VESSELS OF LOWER 

EXTREMITY AND UNSPECIFIED SITES 

925 CRUSHING INJURY OF FACE, SCALP, 

AND NECK 

926 CRUSHING INJURY OF TRUNK 927 CRUSHING INJURY OF UPPER LIMB 928 CRUSHING INJURY OF LOWER LIMB 929 CRUSHING INJURY OF MULTIPLE AND 

UNSPECIFIED SITES 

940 BURN CONFINED TO EYE AND ADNEXA 941 BURN OF FACE, HEAD, AND NECK 942 BURN OF TRUNK 943 BURN OF UPPER LIMB, EXCEPT WRIST 

AND HAND 

944 BURN OF WRIST[S] AND HAND[S] 945 BURN OF LOWER LIMB[S] 946 BURNS OF MULTIPLE SPECIFIED SITES 947 BURN OF INTERNAL ORGANS 948 BURNS CLASSIFIED ACCORDING TO 

EXTENT OF BODY SURFACE INVOLVED 

949 BURN, UNSPECIFIED 952 SPINAL CHORD INJURY WITHOUT 

EVIDENCE OF SPINAL BONE INJURY 

953 INJURY TO NERVE ROOTS AND SPINAL 

PLEXUS 

958 CERTAIN EARLY COMPLICATIONS OF 

TRAUMA 

E800 RAILWAY ACCIDENT INVOLVING 

COLLISION WITH ROLLING STOCK 

E801 RAILWAY ACCIDENT INVOLVING 

COLLISION WITH OTHER OBJECT 

E802 RAILWAY ACCIDENT INVOLVING 

DERAILMENT WITHOUT ANTECEDENT COLLISION 

E803 RAILWAY ACCIDENT INVOLVING 

EXPLOSION, FIRE, OR BURNING 

E804 FALL IN, ON, OR FROM RAILWAY TRAIN E805 HIT BY ROLLING STOCK E806 OTHER SPECIFIED RAILWAY ACCIDENT E807 RAILWAY ACCIDENT OF UNSPECIFIED 

NATURE 

E810 MOTOR VEHICLE TRAFFIC ACCIDENT 

INVOLVING COLLISION WITH TRAIN 

E811 MOTOR VEHICLE TRAFFIC ACCIDENT 

INVOLVING RE-ENTERANT COLLISION WITH ANOTHER MOTOR VEHICLE 

E812 OTHER MOTO

ACCIDENT INMOTOR VEHI

E813 MOTOR VEHI

INVOLVING CVEHICLE 

E814 MOTOR VEHI

INVOLVING CPEDESTRIAN 

E815 OTHER MOTO

ACCIDENT INTHE HIGHWA

E816 MOTOR VEHI

DUE TO LOSS COLLISION O

E817 NONCOLLISI

TRAFFIC ACCOR ALIGHTIN

E818 OTHER NONC

TRAFFIC ACC

E819 MOTOR VEHI

UNSPECIFIED 

E820 NONTRAFFIC 

MOTOR-DRIV

E821 NONTRAFFIC 

OTHER OFF-R

E822 OTHER MOTO

ACCIDENT INMOVING OBJ

E823 OTHER MOTO

ACCIDENT INSTATIONARY 

E824 OTHER MOTO

ACCIDENT WALIGHTING 

E825 OTHER MOTO

ACCIDENT ONATURE 

E826 PEDAL CYCLE827 ANIMAL-DRAE828 ACCIDENT IN

RIDDEN 

E829 OTHER ROAD E830 ACCIDENT TO 

SUBMERSION 

E831 ACCIDENT TO 

OTHER INJUR

E832 OTHER ACCID

DROWNING IACCIDENT 
257

E833 FALL ON STAIRS OR LADDERS IN WATER 

TRANSPORT 

E834 OTHER FALL FROM ONE LEVEL TO 

ANOTHER IN WATER TRANSPORT 

E835 OTHER AND UNSPECIFIED FALL IN 

WATER TRANSPORT 

E836 MACHINERY ACCIDENT IN WATER 

TRANSPORT 

E837 EXPLOSION, FIRE, OR BURNING IN 

WATERCRAFT 

E838 OTHER AND UNSPECIFIED WATER 

TRANSPORT ACCIDENT 

E840 ACCIDENT TO POWERED AIRCRAFT AT 

TAKEOFF OR LANDING 

E841 ACCIDENT TO POWERED AIRCRAFT, 

OTHER AND UNSPECIFIED 

E842 ACCIDENT TO UNPOWERED AIRCRAFT E843 FALL IN, ON, OR FROM AIRCRAFT E844 OTHER SPECIFIED AIR TRANSPORT 

ACCIDENTS 

E845 ACCIDENT INVOLVING SPACECRAFT E846 ACCIDENTS INVOLVING POWERED 

VEHICLES USED SOLELY WITHIN THE BUILDINGS AND PREMISES AND INDUSTRIAL OR COMMERCIAL ESTABLISHMENT 

E847 ACCIDENTS TO UNPOWERED AIRCRAFT E848 ACCIDENTS INVOLVING OTHER 

VEHICLES, NEC 

E849 PLACE OF OCCURRENCE E880 FALL ON OR FROM STAIRS OR STEPS E881 FALL ON OR FROM LADDERS OR 

SCAFFOLDING 

E882 FALL FROM OR OUT OF BUILDING OR 

OTHER STRUCTURE 

E883 FALL INTO HOLE OR OTHER OPENING IN 

SURFACE 

E884 OTHER FALL FROM ONE LEVEL TO 

ANOTHER 

E885 FALL ON SAME LEVEL FROM SLIPPING, 

TRIPPING, OR STUMBLING 

E886 FALL ON SAME LEVEL FROM COLLISION, 

PUSHING, OR SHOVING BY OR WITH OTHER PERSON 

E887 FRACTURE, CAUSE UNSPECIFIED E888 OTHER AND UNSPECIFIED FALL E890 CONFLAGRATION IN PRIVATE 

DWELLING 

E891 CONFLAGRATION IN OTHER AND 

UNSPECIFIED BUILDING OR STRUCTURE 

E892 CONFLAGRATION NOT IN BUILDING OR 

STRUCTURE 

E893 ACCIDENT CAUSED BY IGNITION OF 

CLOTHING 

E894 IGNITION OF HIGHLY INFLAMMABLE 

MATERIAL 

E895 ACCIDENT CAUSED BY CONTROLLED 

FIRE IN PRIVATE DWELLING 

E896 ACCIDENT CAUSE BY CONTROLLED 

FIRE IN OTHER AND UNSPECIFIED BUILDING OR STRUCTURE 

E897 ACCIDENT CAUSED BY CONTROLLED 

FIRE NOT IN BUILDING OR STRUCTURE 

E898 ACCIDENT CAUSED BY OTHER 

SPECIFIED FIRE AND FLAMES 

E899 ACCIDENT CAUSED BY UNSPECIFIED 

FIRE 

E910 ACCIDENTAL DROWNING AND 

SUBMERSION 

E913 ACCIDENTAL MECHANICAL 

SUFFOCATION 

E914 FOREIGN BODY ACCIDENTALLY 

ENTERING EYE AND ADNEXA 

E915 FOREIGN BODY ACCIDENTALLY 

ENTERING OTHER ORIFICE 

E916 STRUCK ACCIDENTALLY BY FALLING 

OBJECT 

E917 STRIKING AGAINST OR STRUCK 

ACCIDENTALLY BY OBJECTS OR PERSONS 

E918 CAUGHT ACCIDENTALLY IN OR 

BETWEEN OBJECTS 

E919 ACCIDENTS CAUSED BY MACHINERY E920 ACCIDENTS CAUSED BY CUTTING AND 

PIERCING INSTRUMENTS OR OBJECTS 

E921 ACCIDENT CAUSED BY EXPLOSION OF 

PRESSURE VESSEL 

E922 ACCIDENT CAUSED BY FIREARM AND 

AIR GUN MISSILE 

E923 ACCIDENT CAUSED BY EXPLOSIVE 

MATERIAL 

E924 ACCIDENT CAUSED BY HOT SUBSTANCE 

OR OBJECT, CAUSTIC OR CORROSIVE MATERIAL, AND STEAM 

E925 ACCIDENT CAUSED BY ELECTRIC 

CURRENT 

E926 EXPOSURE TO RADIATION E927 OVEREXERTION AND STRENUOUS 

MOVEMENTS 

E928 OTHER AND 

ENVIRONMECAUSES 

E960 FIGHT, BRAW

E961 ASSAULT BY 

SUBSTANCE, 

E962 ASSAULT BY E963 ASSAULT BY 

STRANGULA

E964 ASSAULT BY E965 ASSAULT BY 

EXPLOSIVES 

E966 ASSAULT BY 

INSTRUMENT 

E967 PERPETRATO

ABUSE 

E968 ASSAULT BY 

MEANS 

E969 LATE EFFECT

INFLICTED B

E970 INJURY DUE 

BY FIREARM

E971 INJURY DUE 

BY EXPLOSIV

E972 INJURY DUE 

BY GAS 

E973 INJURY DUE 

BY BLUNT OB

E974 INJURY DUE 

BY CUTTING INSTRUMENT 

E975 INJURY DUE 

BY OTHER SP

E976 INJURY DUE 

BY UNSPECIF

E977 LATE EFFECT

LEGAL INTER

E978 LEGAL EXECE980 POISONING B

SUBSTANCESWHETHER ACPURPOSELY I

E981 POISONING B

USE, UNDETEACCIDENTALINFLICTED 

E982 POISONING B

UNDETERMINACCIDENTALINFLICTED 
258

E983 HANGING, STRANGULATION, OR 

SUFFOCATION, UNDETERMINED WHETHER ACCIDENTALLY OR PURPOSELY INFLICTED 

E984 SUBMERSION [DROWNING] 

UNDETERMINED WHETHER ACCIDENTALLY OR PURPOSELY INFLICTED 

E985 INJURY BY FIREARMS, AIR GUNS AND 

EXPLOSIVES, UNDETERMINED WHETHER ACCIDENTALLY OR PURPOSELY INFLICTED 

E986 INJURY BY CUTTING AND PIERCING 

INSTRUMENTS, UNDETERMINED WHETHER ACCIDENTALLY OR PURPOSELY INFLICTED 

E987 FALLING FROM HIGH PLACE, 

UNDETERMINED WHETHER ACCIDENTALLY OR PURPOSELY INFLICTED 

E988 INJURY BY OTHER AND UNSPECIFIED 

MEANS, UNDETERMINED WHETHER ACCIDENTALLY OR PURPOSELY INFLICTED 

E989 LATE EFFECTS OF INJURY, 

UNDETERMINED WHETHER ACCIDENTALLY OR PURPOSELY INFLICTED 

E990 INJURY DUE TO WAR OPERATIONS BY 

FIRES AND CONFLAGRATIONS 

E991 INJURY DUE TO WAR OPERATIONS BY 

BULLETS AND FRAGMENTS 

E992 INJURY DUE TO WAR OPERATIONS BY 

EXPLOSION OF MARINE WEAPONS 

E993 INJURY DUE TO WAR OPERATIONS BY 

OTHER EXPLOSION 

E994 INJURY DUE TO WAR OPERATIONS BY 

DESTRUCTION OF AIRCRAFT 

E995 INJURY DUE TO WAR OPERATIONS BY 

OTHER AND UNSPECIFIED FORMS OF CONVENTIONAL WARFARE 

E996 INJURY DUE TO WAR OPERATIONS BY 

NUCLEAR WEAPONS 

E997 INJURY DUE TO WAR OPERATIONS BY 

OTHER FORMS OF UNCONVENTIONAL WARFARE 

E998 INJURY DUE TO WAR OPERATIONS BUT 

OCCURRING AFTER CESSATION OF HOSTILITIES 

E999 LATE EFFECT OF INJURY DUE TO WAR 

OPERATIONS 

Diagnostic Related Groups (DRGs): 002 CRANIOTOMY FOR TRAUMA, AGE 

GREATER THAN 17 

027 TRAUMATIC STUPOR AND COMA, COMA 

GREATER THAN ONE HOUR 

028 TRAUMATIC STUPOR AND COMA, COMA 

LESS THAN ONE HOUR, AGE GREATER THAN 17 WITH CC 

029 TRAUMATIC STUPOR AND COMA, COMA 

LESS THAN ONE HOUR, AGE GREATER THAN 17 WITHOUT CC 

031 CONCUSSION, AGE GREATER THAN 17 

WITH CC 

032 CONCUSSION, AGE GREATER THAN 17 

WITHOUT CC 

072 NASAL TRAUMA AND DEFORMITY 083 MAJOR CHEST TRAUMA WITH CC 084 MAJOR CHEST TRAUMA WITHOUT CC 235 FRACTURES OF FEMUR 236 FRACTURE OF HIP AND PELVIS 237 SPRAINS, STRAINS AND DISLOCATIONS 

OF HIP, PELVIS AND THIGH 

440 WOUND DEBRIDEMENTS FOR INJURIES 441 HAND PROCEDURES FOR INJURIES 442 OTHER OR PROCEDURES FOR INJURIES 

WITH CC 

443 OTHER OR PROCEDURES FOR INJURIES 

WITHOUT CC 

444 TRAUMATIC INJURY, AGE GREATER 

THAN 17 WITH CC 

445 TRAUMATIC INJURY, AGE GREATER 

THAN 17 WITHOUT CC 

446 TRAUMATIC INJURY, AGE 0-17 447 ALLERGIC REACTIONS, AGE GREATER 

THAN 17 

448 ALLERGIC REACTIONS, AGE 0-17 449 POISONING AND TOXIC EFFECTS OF 

DRUGS, AGE GREATER THAN 17 WITH CC 

450 POISONING AND TOXIC EFFECTS OF 

DRUGS, AGE GREATER THAN 17 WITHOUT CC 

451 POISONING AND TOXIC EFFECTS OF 

DRUGS, AGE 0-17 

452 COMPLICATIONS OF TREATMENT WITH 

CC 

453 COMPLICATI

WITHOUT CC 

454 OTHER INJUR

EFFECT DIAG

455 OTHER INJUR

EFFECT DIAG

460 NO LONGER 484 CRANIOTOM

SIGNIFICANT 

485 LIMB REATTA

PROCEDURES SIGNIFICANT 

486 OTHER OR PR

SIGNIFICANT 

487 OTHER MULT

TRAUMAS 

491 MAJOR JOINT 

REATTACHMUPPER EXTRE

Vaginal delivery Diagnostic Related Group372 VAGINAL DE

COMPLICATI

373 VAGINAL DE

COMPLICATI

374 VAGINAL DE

STERILIZATI

375 VAGINAL DE

PROCEDURE AND/OR D AN

FTR-FAILURE TO RESFTR-Acute Renal FailurICD-9-CM diagnosis code

ACUTE RENAL FAILUR584.5 WITH LESION 584.6 WITH LESION 

NECROSIS 

584.7 WITH LESION 

[PAPILLARY] 

584.8 WITH OTHER 

LESION IN KI

584.9 ACUTE RENA
259

ICD-9-CM diagnosis codes exclude: PRINCIPAL DIAGNOSIS OF [AMI], [CARDIAC 

ARRHYTHMIA], [SHOCK] OR [CARDIAC 

ARREST], [HEMORRHAGE]FTR-DVT/PE Include ICD-9-CM diagnosis codes: PHLEBITIS AND THROMBOPHLEBITIS OF: 451.11 FEMORAL VEIN (DEEP) (SUPERFICIAL) 451.19 OTHER 451.2 LOWER EXTREMITIES 451.81 ILIAC VEIN 451.9 UNSPECIFIED SITE ACUTE PULMONARY HEART DISEASE: 415.11 IATROGENIC PULMONARY EMBOLISM 

AND INFARCTION 

415.19 OTHER 453.8 OTHER VENOUS EMBOLISM AND 

THROMBOSIS OF OTHER SPECIFIED VEINS 

453.9 OTHER VENOUS EMBOLISM AND 

THROMBOSIS OF UNSPECIFIED SITE 

Exclude ICD-9-CM codes: PRINCIPAL DIAGNOSIS OF [DEEP VEIN THROMBOSIS] FTR-Pneumonia Include ICD-9-CM diagnosis codes: 507.0 DUE TO INHALATION OF FOOD OR 

VOMITUS 

514 PULMONARY CONGESTION AND 

HYPOSTASIS 

OTHER BACTERIAL PNEUMONIA: 482.0 PNEUMONIA DUE TO KLEBSIELLA 

PNEUMONIAE 

482.1 PNEUMONIA DUE TO PSEUDOMONAS 482.2 PNEUMONIA DUE TO HEMOPHILUS 

INFLUENZAE [H. INFLUENZAE] 

482.30 PNEUMONIA DUE TO STREPTOCOCCUS -

STREPTOCOCCUS, UNSPECIFIED 

482.31 PNEUMONIA DUE TO STREPTOCOCCUS -

GROUP A 

482.32 PNEUMONIA DUE TO STREPTOCOCCUS -

GROUP B 

482.39 PNEUMONIA DUE TO STREPTOCOCCUS -

OTHER STREPTOCOCCUS 

482.40 PNEUMONIA DUE TO STAPHYLOCOCCUS 

-PNEUMONIA DUE TO STAPHYLOCOCCUS, UNSPECIFIED 

482.41 PNEUMONIA DUE TO STAPHYLOCOCCUS 

-PNEUMONIA DUE TO STAPHYLOCCOCCUS AUREUS 

482.49 PNEUMONIA DUE TO STAPHYLOCOCCUS 

-OTHER STAPHYLOCOCCUS PNEUMONIA 

482.81 PNEUMONIA DUE TO OTHER SPECIFIED 

BACTERIA -ANAEROBES 

482.82 PNEUMONIA DUE TO OTHER SPECIFIED 

BACTERIA - ESCHERICHIA COLI [E COLI] 

482.83 PNEUMONIA DUE TO OTHER SPECIFIED 

BACTERIA - OTHER GRAM-NEGATIVE BACTERIA 

482.84 PNEUMONIA DUE TO OTHER SPECIFIED 

BACTERIA - LEGIONNAIRES' DISEASE 

482.89 PNEUMONIA DUE TO OTHER SPECIFIED 

BACTERIA - OTHER SPECIFIED BACTERIA 

482.9 BACTERIAL PNEUMONIA UNSPECIFIED 485 BRONCHOPNEUMONIA, ORGANISM 

UNSPECIFIED 

486 PNEUMONIA, ORGANISM UNSPECIFIED Exclude ICD-9-CM principal diagnosis codes: 480 VIRAL PNEUMONIA 481 PNEUMOCOCCAL PNEUMONIA 

[STREPTOCOCCUS PNEUMONIAE PNEUMONIA] 

482 OTHER BACTERIAL PNEUMONIA 483 PNEUMONIA DUE TO OTHER SPECIFIED 

ORGANISM 

484 PNEUMONIA IN INFECTIOUS DISEASES 

CLASSIFIED ELSEWHERE 

485 BRONCHOPNEUMONIA, ORGANISM 

UNSPECIFIED 

486 PNEUMONIA487 INFLUENZA 507.0 DUE TO INHA

VOMITUS 

514 PULMONARY 

HYPOSTASIS 

997.3 RESPIRATORMDC 4 DISEASES AN

RESPIRATOR

ICD-9-CM secondary diag480 VIRAL PNEUM481 PNEUMOCOC

[STREPTOCOPNEUMONIA

483 PNEUMONIA 

ORGANISM 

484 PNEUMONIA 

CLASSIFIED E

487 INFLUENZA [IMMUNOCOMPROMIFTR-Sepsis Include ICD-9-CM diagnosis code790.7 OTHER NONS

EXAMINATIO

SEPTICEMIA: 038.0 STREPTOCOC038.1X STAPHYLOCO038.2 PNEUMOCOC

[STREPTOCOSEPTICEMIA] 

038.3 SEPTICEMIA 038.40 SEPTICEMIA 

ORGANISM, U

038.41 HEMOPHILUS 

INFLUENZAE

038.42 ESCHERICHIA 038.43 PSEUDOMON038.44 SERRATIA 038.49 OTHER 038.8 OTHER SPECI038.9 UNSPECIFIED 
260

Exclude ICD-9-CM diagnosis codes [IMMUNOCOMPROMISED] LOS>3 DAYS [INFECTION] FTR-Shock or cardiac arrest Include ICD-9-CM diagnosis codes: 995.0 OTHER ANAPHYLACTIC SHOCK 995.4 SHOCK DUE TO ANESTHESIA 998.0 POSTOPERATIVE SHOCK SHOCK DURING OR FOLLOWING LABOR AND DELIVERY: 669.10 SHOCK DURING OR FOLLOWING LABOR 

AND DELIVERY - UNSPECIFIED AS TO EPISODE OF CARE OR NOT APPLICABLE 

669.11 SHOCK DURING OR FOLLOWING LABOR 

AND DELIVERY - DELIVERED, WITH OR WITHOUT MENTION OF ANTEPARTUME CONDITION 

669.12 SHOCK DURING OR FOLLOWING LABOR 

AND DELIVERY - DELIVERED, WITH MENTION OF POSTPARTUM COMPLICATION 

669.13 SHOCK DURING OR FOLLOWING LABOR 

AND DELIVERY - ANTEPARTUM CONDITION OR COMPLICATION 

669.14 SHOCK DURING OR FOLLOWING LABOR 

AND DELIVERY - POSTPARTUM CONDITION OR COMPLICATION 

999.4 ANAPHYLACTIC SHOCK DUE TO SERUM 427.5 CARDIAC ARREST 785.5 SHOCK WITHOUT MENTION OF TRAUMA 785.50 SHOCK, UNSPECIFIED 785.51 CARDIOGENIC SHOCK 785.59 SHOCK WITHOUT MENTION OF 

TRAUMA- OTHER 

799.1 RESPIRATORY ARREST ICD-9-CM procedure codes: 

93.93 NONMECHANICAL METHODS OF 

RESUSCITATION 

99.60 CARDIOPULMONARY RESUSCITATION, 

NOS 

99.63 CLOSED CHEST CARDIAC MASSAGE Exclude: ICD-9-CM diagnosis codes: MDC 4 DISEASES AND DISORDERS OF THE 

RESPIRATORY SYSTEM 

MDC 5 DISEASES AND DISORDERS OF THE 

CIRCULATORY SYSTEM 

Exclude principal diagnosis of [hemorrhage] or [trauma]

FTR-GI hemorrhage/acute ulcer Include: ICD-9-CM diagnosis codes: 456.0 ESOPHAGEAL VARICES WITH BLEEDING 546.20 ESOPHAGEAL VARICES IN DISEASES 

CLASSIFIED ELSEWHERE WITH BLEEDING 

GASTRIC ULCER: 531.30 ACUTE WITHOUT MENTION OF 

HEMORRHAGE OR PERFORATION – WITHOUT MENTION OF OBSTRUCTION 

531.31 ACUTE WITHOUT MENTION OF 

HEMORRHAGE OR PERFORATION - WITH OBSTRUCTION 

531.90 UNSPECIFIED AS ACUTE OR CHRONIC, 

WITHOUT MENTION OF HEMORRHAGE OR PERFORATION - WITHOUT MENTION OF OBSTRUCTION 

531.91 UNSPECIFIED AS ACUTE OR CHRONIC, 

WITHOUT MENTION OF HEMORRHAGE OR PERFORATION - WITH OBSTRUCTION 

DUODENAL ULCER: 532.30 ACUTE WITHOUT MENTION OF 

HEMORRHAGE OR PERFORATION -WTHOUT MENTION OF OBSTRUCTION 

532.31 ACUTE WITHOUT MENTION OF 

HEMORRHAGE OR PERFORATION - WITH OBSTRUCTION 

532.90 UNSPECIFIED AS ACUTE OR CHRONIC, 

WITHOUT MENTION OF HEMORRHAGE 

OR PERFORAOF OBSTRUC

532.91 UNSPECIFIED 

WITHOUT MEOR PERFORA

PEPTIC ULCER: 533.30 SITE UNSPEC

MENTION OF PERFFORATIOBSTRUCTIO

533.31 SITE UNSPEC

MENTION OF PERFORATIO

533.90 SITE UNSPEC

ACUTE OR CHMENTION OF PERFORATIOOBSTRUCTIO

533.91 UNSPECIFIED 

WITHOUT MEOR PERFORA

GASTROJEJUNAL ULCE534.30 ACUTE WITH

HEMORRHAGWITHOUT ME

534.31 ACUTE WITH

HEMORRHAGOBSTRUCTIO

534.90 UNSPECIFIED 

WITHOUT MEOR PERFORAOF OBSTRUC

534.91 UNSPECIFIED 

WITHOUT MEOR PERFORA

530.7 GASTROESOP

HEMORRHAG

530.82 ESOPHAGEAL GASTRIC ULCER: 531.00 ACUTE WITH 

MENTION OF 

531.01 ACUTE WITH 

OBSTRUCTIO

531.10 ACUTE WITH 

MENTION OF 
261

531.11 ACUTE WITH PERFORATION - WITH 

OBSTRUCTION 

531.20 ACUTE WITH HEMORRHAGE AND 

PERFORATION - WITHOUT MENTION OF OBSTRUCTION 

531.21 ACUTE WITH HEMORRHAGE AND 

PERFORATION - WITH OBSTRUCTION 

DUODENAL ULCER: 532.00 ACUTE WITH HEMORRHAGE - WITHOUT 

MENTION OF OBSTRUCTION 

532.01 ACUTE WITH HEMORRHAGE - WITH 

OBSTRUCTION 

532.10 ACUTE WITH PERFORATION - WITHOUT 

MENTION OF OBSTRUCTION 

532.11 ACUTE WITH PERFORATION - WITH 

OBSTRUCTION 

532.20 ACUTE WITH HEMORRHAGE AND 

PERFORATION - WITHOUT MENTION OF OBSTRUCTION 

532.21 ACUTE WITH HEMORRHAGE AND 

PERFORATION - WITH OBSTRUCTION 

PEPTIC ULCER: 533.00 SITE UNSPECIFIED ACUTE WITH 

HEMORRHAGE - WITHOUT MENTION OF OBSTRUCTION 

533.01 SITE UNSPECIFIED ACUTE WITH 

HEMORRHAGE - WITH OBSTRUCTION 

533.10 SITE UNSPECIFIED ACUTE WITH 

PERFORATION - WITHOUT MENTION OF OBSTRUCTION 

533.11 SITE UNSPECIFIED ACUTE WITH -

PERFORATION WITH OBSTRUCTION 

533.20 SITE UNSPECIFIED ACUTE WITH 

HEMORRHAGE AND PERFORATION - WITHOUT MENTION OF OBSTRUCTION 

533.21 SITE UNSPECIFIED ACUTE WITH 

HEMORRHAGE AND PERFORATION -WITHOUT MENTION OF OBSTRUCTION 

GASTROJEJUNAL ULCER: 534.00 ACUTE WITH HEMORRHAGE -WITHOUT 

MENTION OF OBSTRUCTION 

534.01 ACUTE WITH HEMORRHAGE - WITH 

OBSTRUCTION 

534.10 ACUTE WITH PERFORATION - WITHOUT 

MENTION OF OBSTRUCTION 

534.11 ACUTE WITH PERFORATION – WITH 

OBSTRUCTION 

534.20 ACUTE WITH HEMORRHAGE AND 

PERFORATION - WITHOUT MENTION OF OBSTRUCTION 

534.21 ACUTE WITH HEMORRHAGE AND 

PERFORATION - WITH OBSTRUCTION 

GASTRITIS AND DUODENITIS: 535.01 ACUTE GASTRITIS - WITH HEMORRHAGE 535.11 ATROPHIC GASTRITIS - WITH 

HEMORRHAGE 

535.21 GASTRIC MUCOSAL HYPERTROPHY -

WITH HEMORRHAGE 

535.31 ALCOHOLIC GASTRITIS - WITH 

HEMORRHAGE 

535.41 OTHER SPECIFIED GASTRITIS - WITH 

HEMORRHAGE 

535.51 UNSPECIFIED GASTRITIS AND 

GASTRODUODENITIS - WITH HEMORRHAGE 

535.61 DUODENITIS 537.83 ANGIODYSPL

DUODENUM 

562.02 DIVERTICUL

WITH HEMOR

562.03 DIVERTICUL

WITH HEMOR

562.12 DIVERTICUL

HEMORRHAG

562.13 DIVERTICUL

HEMORRHAG

569.3 HEMORRHAG569.85 ANGIODYSPL

HEMORRHAG

578.0 HEMATEMES578.1 BLOOD IN ST578.9 HEMORRHAG

TRACT, UNSP

Exclude MDC 6 DISEASES AN

DIGESTIVE S

MDC 7 DISEASES AN

HEPATOBILIAPANCREAS 

ICD-9-CM principal diagn280.0 SECONDARY 

[CHRONIC] 

285.1 ACUTE POSTTRAUMA OR BURN OR 
262

Section 2A. Accepted Area-Level Indicator Definitions Items in bold and brackets are fully specified in the ICD-9-CM and DRG listings in Section 1B, "Coding Details for Accepted Hospital

Indicator Name Definition and Numerator Denominator 

• Foreign body left in during procedure Discharges with ICD-9-CM codes for [foreign body 

left in during procedure] in any diagnosis field per 100 surgical discharges. 

All [surgical] and [medical

• Iatrogenic pneumothorax Discharges with ICD-9-CM code of 512.1 in any 

diagnosis field per 100 discharges. 

All discharges. Exclude patients with any di[trauma].Exclude patients with any co[thoracic surgery] or [lung 

or assigned to [cardiac surg

• Infection due to medical care Discharges with ICD-9-CM code of 999.3 or 996.62 

in any diagnosis field per 100 discharges. 

All [medical] and [surgical

Excludes patients with any d[immunocompromised] sta

• Technical difficulty with medical care Discharges with ICD-9-CM code denoting an 

[technical difficulty] (e.g. accidental cut, puncture, perforation or laceration during a procedure) in any diagnosis field per 100 discharges. 

All [medical] and [surgical

Exclude all obstetric admiss15). 

• Transfusion reaction Discharges with ICD-9-CM codes for [transfusion 

reaction] in any diagnosis field per 100 discharges. 

All [medical] and [surgical

• Postoperative wound dehiscence Discharges with ICD-9-CM codes for reclosure of 

postoperative disruption of abdominal wall (54.61) in any procedure field per 100 discharges. 

All [abdominopelvic] surgi

Exclude all obstetric admiss15). 
263

Section 3A. Experimental Provider-Level Indicator Definitions

Items in bold and brackets are fully specified in Section 3B, “Coding Details for Experimental Indicators,” after this table. 

INDICATOR NAME DEFINITION and NUMERATOR POPULATION AT RISK (DE

• Aspiration pneumonia Discharges with ICD-9-CM codes for 

[aspiration pneumonia] in any secondary 

diagnosis field per 100 surgical discharges. 

All [elective] [surgical] dischaExclude patients with a princip[seizure], [trauma], [drug ove

[poisoning]. Exclude all obstetric admission15). 

• CABG following PTCA Discharges with ICD-9-CM codes for [CABG] 

in any procedure field per 100 discharges with PTCA in any procedure field. CABG must occur on the same day or the day after the PTCA procedure. 

All discharges with ICD-9-CM [PTCA] in any procedure field

• Decubitus ulcer in high risk patients Discharges with ICD-9-CM code for decubitus 

ulcer (707.0) in any secondary diagnosis code per 100 at risk population. 

All patients with any diagnosis paraplegia, or quadriplagia] admitted from a [long term caExclude patients with a length or equal to 4 days. Exclude patients with diseases the skin, subcutaneous tissue a9). 

• In-hospital fractures possibly related to falls Discharges with ICD-9-CM code for [fracture] 

in any secondary diagnosis field per 100 surgical discharges. 

All [surgical] discharges. 

Exclude all patients with diseaof the musculoskeletal system tissue (MDC 8). Excludes patients with principacodes for [seizure], [syncope], 
264

INDICATOR NAME DEFINITION and NUMERATOR POPULATION AT RISK (DE

[coma], [cardiac arrest], [anoinjury], [poisoning], [delirium psychoses], [trauma], [minor physical abuse], indication of abuse], or [self-inflicted injurExclude patients with any diag[metastatic cancer], [lymphoior [bone malignancy]. 

• Intraoperative nerve compression injuries Discharges with ICD-9-CM code for [nerve 

compression injuries] AND a diagnosis code of 997.09 in any secondary diagnosis field per 100 surgical discharges. 

All [surgical] discharges. 

Exclude patients with a princip[trauma].Exclude patients with a princip[disorders of the peripheral nor [dorsopathies].

• Malignant hyperthermia Discharges with ICD-9-CM codes for malignant 

hyperthermia (995.86) in any diagnosis field per 100 surgical discharges. 

All [surgical] discharges. Exclude all obstetric admission

15). 

• Postoperative iatrogenic complications - 

cardiac system 

Discharges with ICD-9-CM codes of 997.1 in any secondary diagnosis field per 100 surgical discharges. 

All [surgical] discharges. Exclude all obstetric admission15). 

• Postoperative iatrogenic complications - 

nervous system 

Discharges with ICD-9-CM codes of [iatrogenic 

nervous system complications] in any secondary diagnosis field per 100 surgical discharges. 

All [surgical] discharges. Exclude all obstetric admission15). 

• Postoperative acute myocardial infarction Discharges with ICD-9-CM codes for [Acute 

Myocardial Infarction] in any secondary diagnosis field per 100 non-cardiac surgical discharges. 

[Elective], [surgical] discharg

Exclude patients undergoing [cExclude all obstetric admission15). 
265

INDICATOR NAME DEFINITION and NUMERATOR POPULATION AT RISK (DE• Reopening of a surgical site Discharges with ICD-9-CM codes for

[reopening of a surgical site] in any secondary 

procedure field per 100 surgical discharges. Reopening of surgical site must occur at least one day after the principal procedure. Revision of vascular procedure 39.49 must occur within 24 hours of principal procedure. 

All [surgical] discharges. 

• Suture of laceration Discharges with ICD-9-CM codes for [suture of 

laceration] in any secondary procedure field per 100 surgical discharges. Suture of laceration must occur on the same day or after the principal procedure. 

All [surgical] discharges. 

Exclude patients with any diag[foreign body] or [trauma].Exclude all obstetric admission15). 

• Other obstetric complication of delivery Discharges with ICD-9-CM codes for [other 

obstetrical complications] in any diagnosis field per 100 deliveries. 

All [deliveries]. 

• Obstetric wound complications - cesarean 

section delivery 

Discharges with ICD-9-CM codes for [cesarean wound complications] in any diagnosis field per 100 deliveries. 

All [cesarean delivery] discha

• Obstetric wound complications - vaginal 

delivery 

Discharges with ICD-9-CM codes for [perineal wound complications] in any diagnosis field per 100 deliveries. 

All [vaginal delivery DRGs].

• Post-partum urinary tract infection Discharges with ICD-9-CM code of 646.62 or 

646.64 in any diagnosis per 100 deliveries. 

All ([cesarean delivery] and [

delivery] discharges)

• Third or fourth degree obstetric lacerations Discharges with ICD-9-CM codes for [3rd or 

fourth degree lacerations] in any diagnosis field per 100 vaginal deliveries. 

All [vaginal deliveries during Exclude patients with a proced[cesarean section delivery] or for [abortion].

• Uterine rupture Discharges with ICD-9-CM codes for [rupture 

of uterus during or after labor] in any diagnosis field per 100 deliveries with trial of labor. 

All deliveries with a [trial of la
266

Section 3B. Coding Details for Experimental Indicators Acute myocardial infarction.............................................267 

Alcohol or drug abuse ......................................................267 Aspiration pneumonia ......................................................268 

CABG...............................................................................268 Cardiac surgery ................................................................268 

Cesarean section delivery.................................................268 

Cesarean section wound complications...........................268 

Deliveries..........................................................................268 

Disorders of the peripheral nervous system.....................269 Dorsopathies.....................................................................269 

Drug overdose ..................................................................269 Elective.............................................................................270 Foreign body ....................................................................270 

Fracture.............................................................................270 Hemiplegia, paraplegia, or quadriplegia..........................270 Iatrogenic nervous system complications........................270 Long term care .................................................................270 

Nerve compression injuries..............................................270 

Other obstetrical complications .......................................270 Perineal wound complications .........................................271 

Poisoning..........................................................................271 PTCA................................................................................272 

Reopening of a surgical site .............................................272 

Rupture of uterus during or after labor ............................272 

Seizure ..............................................................................272 

Surgical.............................................................................273 

Suture of laceration ..........................................................276 

Third or fourth degree obstetric lacerations.....................276 

Trauma..............................................................................276 Trial of labor.....................................................................280 Vaginal delivery ...............................................................280 

Vaginal delivery during stay ............................................281 

Acute myocardial infarction 

ICD-9-CM diagnosis codes: 410.00 AMI OF ANTEROLATERAL WALL – 

EPISODE OF CARE UNSPECIFIED 

410.01 AMI OF ANTEROLATERAL WALL - 

INITIAL EPISODE OF CARE 

410.10 AMI OF OTHER ANTERIOR WALL – 

EPISODE OF CARE UNSPECIFIED 

410.11 AMI OF OTHER ANTERIOR WALL – 

INITIAL EPISODE OF CARE 

410.20 AMI OF INFEROLATERAL WALL – 

EPISODE OF CARE UNSPECIFIED 

410.21 AMI OF INFEROLATERAL WALL – 

INITIAL EPISODE OF CARE 

410.30 AMI OF INFEROPOSTERIOR WALL – 

EPISODE OF CARE UNSPECIFIED 

410.31 AMI OF INFEROPOSTERIOR WALL –– 

INITIAL EPISODE OF CARE 

410.40 AMI OF INFERIOR WALL - EPISODE OF 

CARE UNSPECIFIED 

410.41 AMI OF INFERIOR WALL - INITIAL 

EPISODE OF CARE 

410.50 AMI OF OTHER LATERAL WALL - 

EPISODE OF CARE UNSPECIFIED 

410.51 AMI OF OTHER LATERAL WALL - 

INITIAL EPISODE OF CARE 

410.60 AMI TRUE POSTERIOR WALL 

INFARCTION - EPISODE OF CARE UNSPECIFIED 

410.61 AMI TRUE POSTERIOR WALL 

INFARCTION - INITIAL EPISODE OF CARE 

410.70 AMI SUBENDOCARDIAL INFARCTION - 

EPISODE OF CARE UNSPECIFIED 

410.71 AMI SUBENDOCARDIAL INFARCTION - 

INITIAL EPISODE OF CARE 

410.80 AMI OF OTHER SPECIFIED SITES - 

EPISODE OF CARE UNSPECIFIED 

410.81 AMI OF OTHER SPECIFIED SITES - - 

INITIAL EPISODE OF CARE 

410.90 AMI UNSPECIFIED SITE - EPISODE OF 

CARE UNSPECIFIED 

410.91 AMI UNSPECIFIED SITE - INITIAL 

EPISODE OF CARE 

Alcohol or drug abuse ICD-9-CM diagnosis codes: 

(includes all 4th and 5th dig291 ALCOHOLIC 292 DRUG PSYCH303 ALCOHOL DE304 DRUG DEPEN305.0 ALCOHOL AB305.2 CANNABIS A305.3 HALLUCINOG305.4 BARBITURAT

SEDATIVE OR 

305.5 OPIOID ABUS305.6 COCAINE AB305.7 AMPHETAMI

SYMPATHOM

305.8 ANTIDEPRES305.9 OTHER MIXE

ABUSE 

980 TOXIC EFFEC981 TOXIC EFFEC

PRODUCTS 

982 TOXIC EFFEC

THAN PETRO

983 TOXIC EFFEC

AROMATICS, ALKALIS 

984 TOXIC EFFEC

COMPOUNDS 

985 TOXIC EFFEC986 TOXIC EFFEC987 TOXIC EFFEC

FUMES, OR V

988 TOXIC EFFEC

SUBSTANCES 

989 TOXIC EFFEC

CHIEFLY NONSOURCE

Aspiration pneumonia ICD-9-CM diagnosis code
267

507.0 PNEUMONITIS DUE TO SOLIDS AND 

LIQUIDS, DUE TO INHALATION OF FOOD OR VOMITUS 

E911 INHALATION AND INGESTION OF FOOD 

CAUSING OBSTRUCTION OF RESPIRATORY TRACT OR SUFFOCATION 

E912 INHALATION AND INGESTION OF OTHER 

OBJECT CAUSING OBSTRUCTION OF RESPIRATORY TRACT OR SUFFOCATION 

CABG 

ICD-9-CM procedure codes 36.10 BYPASS ANASTOMOSIS FOR HEART 

REVASCULARIZATION 

36.11 OPEN HEART VALVULOPLASTY 

WITHOUT REPLACEMENT 

36.12 AORTOCORONARY BYPASS OF TWO 

CORONARY ARTERIES 

36.13 AORTOCORONARY BYPASS OF THREE 

CORONARY ARTERIES 

36.14 AORTOCORONARY BYPASS OF FOUR OR 

MORE CORONARY ARTERIES 

36.15 SINGLE INTERNAL MAMMARYCORONARY ARTERY BYPASS 36.16 BYPASS ANASTOMOSIS FOR HEART 

REVASCULARIZATION, DOUBLE INTERNAL MAMMARY-CORONARY ARTERY BYPASS 

36.17 ABDOMINAL-CORONARY ARTERY 

BYPASS 

36.19 OTHER BYPASS ANASTOMOSIS FOR 

HEART REVASCULARIZATION 

Cardiac surgery Diagnostic Related Groups (DRGs): 103 HEART TRANSPLANT 104 CARDIAC VALVE AND OTHER MAJOR 

CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION 

105 CARDIAC VALVE AND OTHER MAJOR 

CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION 

106 CORONARY BYPASS WITH PTCA 107 CORONARY BYPASS WITH CARDIAC 

CATHETERIZATION 

108 OTHER CARDIOTHORACIC PROCEDURES 110 MAJOR CARDIOVASCULAR 

PROCEDURES WITH CC 

111 MAJOR CARDIOVASCULAR 

PROCEDURES WITHOUT CC 

112 PERCUTANEOUS CARDIOVASCULAR 

PROCEDURES 

Cesarean section delivery ICD-9-CM procedure codes: 74.0 CLASSICAL CESAREAN SECTION 74.1 LOW CERVICAL CESAREAN SECTION 74.2 EXTRAPERITONEAL CESAREAN SECTION 74.4 CESAREAN SECTION OF OTHER 

SPECIFIED TYPE 

74.99 OTHER CESAREAN SECTION OF 

UNSPECIFIED TYPE 

Cesarean section wound complications ICD-9-CM diagnosis codes: 67410 DISRUPTION OF CESAREAN WOUNDUNSPECIFIED AS TO EPISODE OF CARE 

OR NOT APPLICABLE 

67412 DISRUPTION OF CESAREAN WOUNDDELIVERED, WITH MENTION OF 

POSTPARTUM COMPLICATION 

67414 DISRUPTION OF CESAREAN WOUNDPOSTPARTUM CONDITION OR 

COMPLICATION 

67430 OTHER COMPLICATIONS OF 

OBSTETRICAL SURGICAL WOUNDSUNSPECIFIED AS TO EPISODE OF CARE OR NOT APPLICABLE 

67432 OTHER COMP

OBSTETRICADELIVERED, POSTPARTUM 

67434 OTHER COMP

OBSTETRICAPOSTPARTUM COMPLICATI

Deliveries 

Diagnostic Related Group370 CESAREAN S371 CESAREAN S372 VAGINAL DE

COMPLICATI

373 VAGINAL DE

COMPLICATI

374 VAGINAL DE

STERILIZATI

375 VAGINAL DE

PROCEDURE AND/OR D AN

Disorders of the peripherICD-9-CM diagnosis code350 TRIGEMINAL 351 FACIAL NERV352 DISORDERS O

NERVES 

353 NERVE ROOT 354 MONOEURIT

MONOEURIT

355 MONOEURIT356 HEREDITARY 

PERIPHERAL 

357 INFLAMMAT

NEUROPATH

358 MYONEURAL 359 MUSCULAR D

MYOPATHIES 
268

Dorsopathies ICD-9-CM diagnosis codes: 720 ANKYLOSING SPONDYLITIS AND OTHER 

INFLAMMATORY SPONDYLOPATHIES 

721 SPONDYLOSIS AND ALLIED DISORDERS 722 INTERVERTEBRAL DISC DISORDERS 723 OTHER DISORDERS OF CERVICAL 

REGION 

724 OTHER AND UNSPECIFIED DISORDERS 

OF BACK 

Drug overdose ICD-9-CM diagnosis codes: 291 ALCOHOLIC PSYCHOSES 292 DRUG PSYCHOSES 303.00 ACUTE ALCOHOLIC INTOXICATION -

UNSPECIFIED 

303.01 ACUTE ALCOHOLIC INTOXICATION -

CONTINUOUS 

303.02 ACUTE ALCOHOLIC INTOXICATION -

EPISODIC 

NONDEPENDENT ABUSE OF DRUGS: 305.00 ALCOHOL ABUSE - UNSPECIFIED 305.01 ALCOHOL ABUSE - CONTINUOUS 305.02 ALCOHOL ABUSE - EPISODIC 305.20 CANNABIS ABUSE – UNSPECIFIED 305.21 CANNABIS ABUSE – CONTINUOUS 305.22 CANNABIS ABUSE – EPISODIC 305.30 HALLUCINOGEN ABUSE – UNSPECIFIED 305.31 HALLUCINOGEN ABUSE – CONTINUOUS 305.32 HALLUCINOGEN ABUSE – EPISODIC 305.40 BARBITURATE AND SIMILARLY ACTING 

SEDATIVE OR HYPNOTIC ABUSE – UNSPECIFIED 

305.41 BARBITURATE AND SIMILARLY ACTING 

SEDATIVE OR HYPNOTIC ABUSE – CONTINUOUS 

305.42 BARBITURATE AND SIMILARLY ACTING 

SEDATIVE OR HYPNOTIC ABUSE –EPISODIC 

305.50 OPIOID ABUSE – UNSPECIFIED 305.51 OPIOID ABUSE – CONTINUOUS 305.52 OPIOID ABUSE – EPISODIC 305.70 AMPHETAMINE OR RELATED ACTING – 

UNSPECIFIED 

305.71 AMPHETAMINE OR RELATED ACTING – 

CONTINUOUS 

305.72 AMPHETAMINE OR RELATED ACTING – 

EPISODIC 

305.80 ANTIDEPRESSANT TYPE ABUSE – 

UNSPECIFIED 

305.81 ANTIDEPRESSANT TYPE ABUSE – 

CONTINUOUS 

305.82 ANTIDEPRESSANT TYPE ABUSE – 

EPISODIC 

305.90 OTHER MIXED, OR UNSPECIFIED DRUG 

ABUSE – UNSPECIFIED 

305.91 OTHER MIXED, OR UNSPECIFIED DRUG 

ABUSE – CONTINUOUS 

305.92 OTHER MIXED, OR UNSPECIFIED DRUG 

ABUSE – EPISODIC 

965.0 POISONING BY ANALGESICS, 

ANTIPYRETICS, AND ANTIRHEUMATICS, OPIATES AND RELATED NARCOTICS 

967.0 POISONING BY SEDATIVES AND 

HYPNOTICS 

968.5 POISONING BY OTHER CENTRAL 

NERVOUS SYSTEM DEPRESSANT AND ANESTHETICS SURFACE [TOPICAL] AND INFILTRATION ANESTHETICS 

969 POISONING BY PSYCHOTROPIC AGENTS 980 TOXIC EFFECT OF ALCOHOL ACCIDENTAL POISONING BY ANALGESICS, ANTIPYRETICS, AND ANTIRHEYUMATICS: E850.0 HEROIN E850.1 METHADONE E850.2 OTHER OPIATES AND RELATED 

NARCOTICS 

E851 ACCIDENTAL POISONING BY 

BARBITURATES 

E852 ACCIDENTAL POISONING BY OTHER 

SEDATIVES AND HYPNOTICS 

E853 ACCIDENTAL 

TRANQUILIZ

E854 ACCIDENTAL 

PSYCHOTROP

E860 ACCIDENTAL 

NEC 

SUICIDE AND SELF-INFSOLID OR LIQUID SUBSE950.0 ANALGESICS

ANTIRHEYM

E950.1 BARBITURATE950.2 OTHER SEDAE950.3 TRANQUILIZ

PSYCHOTROP

E950.4 OTHER SPECI

MEDICINAL S

E950.5 UNSPECIFIED 

SUBSTANCE 

E980.0 UNDETERMIN

ACCIDENTALINFLICTED – ANTIPYRETIC

E980.1 UNDETERMIN

ACCIDENTALINFLICTED – 

E980.2 UNDETERMIN

ACCIDENTALINFLICTED – HYPNOTICS 

E980.3 UNDETERMIN

ACCIDENTALINFLICTED – OTHER PSYC

Elective ADMISSION TYPE IS RForeign body ICD-9-CM diagnosis code

FOREIGN BODY IN: 
269

933.0 PHARYNX 933.1 LARYNX 934.0 TRACHEA 934.1 MAIN BRONCHUS 934.8 OTHER SPECIFIED PARTS 935.1 MOUTH 935.2 ESOPHAGUS 936 INTESTINE AND COLON 937 ANUS AND RECTUM 938 DIGESTIVE SYSTEM UNSPECIFIED 939.0 GENITOURINARY TRACT, BLADDER AND 

URETHRA 

939.1 FOREIGN BODY IN GENITOURINARY 

TRACT, UTERUS, ANY PART 

Fracture ICD-9-CM diagnosis codes ( include 4th or 5th digits): 

FRACTURE OF VERTEBRAL COLUMN WITH SPINAL CORD INJURY: 806.6 SACRUM AND COCYX CLOSED 806.7 SACRUM AND COCYX OPEN 808 FRACTURE OF PELVIS 810 FRACTURE OF CLAVICLE 811 FRACTURE OF SCAPULA 812 FRACTURE OF HUMERUS 813 FRACUTRE OF RADIUS AND ULNA 820 FRACTURE OF NECK OF FEMUR 821 FRACTURE OF OTHER AND UNSPECIFIED 

PARTS OF FEMUR 

822 FRACTURE OF PATELLA 823 FRACTURE OF TIBIA AND FIBULA 824 FRACTURE OF ANKLE 825 FRACTURE OF ONE OR MORE TARSAL 

AND METATARSAL BONES 

826 FRACTURE OF ONE OR MORE 

PHALANGES OF FOOT 

827 OTHER, MULTIPLE, AND ILL-DEFINED 

FRACTURE OF LOWER LIMB 

828 MULTIPLE FRACTURE INVOLVING BOTH 

LOWER LIMBS, LOWER WITH UPPER LIMB, AND LOWER LIMB(S) WITH RIB(S) AND STERNUM 

829 FRACTURE OF UNSPECIFIED BONES Hemiplegia, paraplegia, or quadriplegia 

ICD-9-CM diagnosis codes (includes 5th digits): 

342.0 FLACCID HEMIPLEGIA 342.1 SPASTIC HEMIPLEGIA 342.8 OTHER SPECIFIED HEMIPLEGIA 342.9 HEMIPLEGIA, UNSPECIFIED 343.0 INFANTILE CEREBRAL PALSY, DIPLEGIC 343.1 INFANTILE CEREBRAL PALSY, 

HEMIPLEGIC 

343.2 INFANTILE CEREBRAL PALSY, 

QUADRIPLEGIC 

343.3 INFANTILE CEREBRAL PALSY, 

MONOPLEGIC 

343.4 INFANTILE CEREBRAL PALSY 

INFANTILE HEMIPLEGIA 

343.8 INFANTILE CEREBRAL PALSY OTHER 

SPECIFIED INFANTILE CEREBRAL PALSY 

343.9 INFANTILE CEREBRAL PALSY, 

INFANTILE CEREBRAL PALSY, UNSPECIFIED 

344.0 QUADRIPLEGIA AND QUADRIPARESIS 344.1 PARAPLEGIA 344.2 DIPLEGIA OF UPPER LIMBS 344.3 MONOPLEGIA OF LOWER LIMB 344.4 MONOPLEGIA OF UPPER LIMB 344.5 UNSPECIFIED MONOPLEGIA 344.6 CAUDA EQUINA SYNDROME 344.8 OTHER SPECIFIED PARALYTIC 

SYNDROMES 

344.9 PARALYSIS, UNSPECIFIED 438.2 HEMIPLEGIA/HEMIPARESIS 438.3 MONOPLEGIA OF UPPER LIMB 438.4 MONOPLEGIA OF LOWER LIMB 438.5 OTHER PARALYTIC SYNDROME 

Iatrogenic nervous system complications ICD-9-CM diagnosis codes: 

997.00 NERVOUS SY

UNSPECIFIED 

997.01 CENTRAL NE

COMPLICATI

997.02 IATROGENIC 

INFARCTION 

997.09 OTHER NERV

COMPLICATI

Long term care ADMISSION TYPE/SOUTERM CARE FACILITY Nerve compression injurICD-9-CM diagnosis code353.0 BRACHIAL PL355.1 MERALGIA P355.3 LESION OF LAOther obstetrical complicICD-9-CM diagnosis code(includes 5th digits): 668.0 PULMONA668.1 CARDIAC C668.2 CENTRAL N

COMPLICA

668.8 OTHER CO

ANESTHESLABOR AN

668.9 UNSPECIFI

ANESTHES

669.1 OTHER CO

AND DELIVCLASSIFIEFOLLOWIN

669.4 OTHER CO

OBSTETRICPROCEDUR
270

669.30, 2, 4 ACUTE RENAL FAILURE FOLLOWING 

LABOR AND DELIVERY 

Perineal wound complications ICD-9-CM diagnosis codes: 674.20 DISRUPTION OF PERINEAL WOUNDUNSPECIFIED AS TO EPISODE OF CARE 

OR NOT APPLICABLE 

674.22 DISRUPTION OF PERINEAL WOUNDDELIVERY, WITH MENTION OF 

POSTPARTUM COMPLICATION 

674.24 DISRUPTION OF PERINEAL WOUNDPOSTPARTUM CONDITION OR 

COMPLICATION 

664.5 VULVAL AND PERINEAL HEMATOMA 665.7 PELVIC HEMATOMA 674.30 OTHER COMPLICATIONS OF 

OBSTETRICAL SURGICAL WOUNDSUNSPECIFIED AS TO EPISODE OF CARE OR NOT APPLICABLE 

674.32 OTHER COMPLICATIONS OF 

OBSTETRICAL SURGICAL WOUNDSDELIVERED, WITH MENTION OF POSTPARTUM COMPLICATION 

674.34 OTHER COMPLICATIONS OF 

OBSTETRICAL SURGICAL WOUNDSPOSTPARTUM CONDITION OR COMPLICATION 

Poisoning ICD-9-CM diagnosis codes (includes 4th and 5th digits): 

960 POISONING BY ANTIBIOTICS 961 POISONING BY OTHER ANTI-INFECTIVES 962 POISONING BY HORMONES AND 

SYNTHETIC SUBSTITUTES 

963 POISONING BY PRIMARILY SYSTEMIC 

AGENTS 

964 POISONING BY AGENTS PRIMARILY 

AFFECTING BLOOD CONSTITUENTS 

965 POISONOING BY ANALGESICS, 

ANTIPYRETICS, AND ANTIRHEUMATICS 

966 POISONING BY ANTICONVULSANTS AND 

ANTI-PARKINSONISM DRUGS 

967 POISONING BY SEDATIVES AND 

HYPNOTICS 

968 POISONING BY OTHER CENTRAL 

NERVOUS SYSTEM DEPRESSANTS AND ANESTHETICS 

969 POISONING BY PSYCHOTROPIC AGENTS 970 POISONING BY CENTRAL NERVOUS 

SYSTEM STIMULANTS 

971 POISONING BY DRUGS PRIMARILY 

AFFECTING THE AUTONOMIC NERVOUS SYSTEM 

972 POISONING BY AGENTS PRIMARILY 

AFFECTING THE CARDIOVASCULAR SYSTEM 

973 POISOING BY AGENTS PRIMARILY 

AFFECTING THE GASTROINTESTINAL SYSTEM 

974 POISONING BY WATER, MINERAL, AND 

URIC ACID METABOLSIM DRUGS 

975 POISONING BY AGENTS PRIMARILY 

ACTING ON THE SMOOTH AND SKELETAL MUSCLES AND RESPIRATORY SYSTEM 

976 POISONING BY AGENTS PRIMARILY 

AFFECTING SKIN AND MUCOUS MEMBRANE, OPTHAMOLOGICAL, OTORHINOLARYNCOLOGICAL AND DENTAL DRUGS 

977 POISONING BY OTHER AND 

UNSPECIFIED DRUGS AND MEDICINAL SUBSTANCES 

978 POISONING BY BACTERIAL VACCINES 979 POISONING BY OTHER VACCINES AND 

BIOLOGICAL SUBSTANCES 

E850 ACCIDENTAL POISONING BY 

ANALGESICS, ANTIPYRETICS, AND ANTIRHEUMATICS 

E851 ACCIDENTAL POISONING BY 

BARBITURATES 

E852 ACCIDENTAL POISONING BY OTHER 

SEDATIVES AND HYPNOTICS 

E853 ACCIDENTAL 

TRANQUILIZ

E854 ACCIDENTAL 

PSYCHOTROP

E855 ACCIDENTAL 

DRUGS ACTINAUTONOMIC 

E856 ACCIDENTAL 

ANTIBIOTICS 

E857 ACCIDENTAL 

ANTI-INFECT

E858 ACCIDENTAL 

DRUGS 

E860 ACCIDENTAL 

NEC 

E861 ACCIDENTAL 

AND POLISHIDISINFECTANVARNISHES 

E862 ACCIDENTAL 

PETROLEUM SOLVENTS A

E863 ACCIDENTAL 

AGRICULTURCHEMICAL APREPARATIOFOODS AND F

E864 ACCIDENTAL 

CORROSIVES 

E865 ACCIDENTAL 

POISONOUS FPOISONOUS P

E866 ACCIDENTAL 

UNSPECIFIED SUBSTANCES 

E867 ACCIDENTAL 

DISTRIBUTED 

E868 ACCIDENTAL 

UTILITY GAS MONOXIDE 

E869 ACCIDENTAL 

GASES AND V

E951 SUICIDE AND 

POISONING B
271

E952 SUICIDE AND SELF-INFLICTED 

POISONING BY OTHER GASES AND VAPORS 

E962 ASSAULT BY POISONING E980 POISONING BY SOLID OR LIQUID 

SUBSTANCES, UNDETERMINED WHETHER ACCIDENTALLY OR PURPOSELY INFLICTED 

E981 POISONING BY GASES IN DOMESTIC 

USE, UNDETERMINED WHETHER ACCIDENTALLY OR PURPOSELY INFLICTED 

E982 POISONING BY OTHER GASES, 

UNDETERMINED WHETHER ACCIDENTALLY OR PURPOSELY INFLICTED 

PTCA ICD-9-CM procedure codes: 36.01 SINGLE VESSEL PERCUTANEOUS 

TRANSLUMINAL CORONARY ANGIOPLASTY [PTCA] OR CORONARY ATHERECTOMY WITHOUT MENTION OF THROMBOLYTIC AGENT 

36.02 SINGLE VESSEL PERCUTANEOUS 

TRANSLUMINAL CORONARY ANGIOPLASTY [PTCA] OR CORONARY ATHERECTOMY WITH MENTION OF THROMBOLYTIC AGENT 

36.05 MULTIPLE VESSEL PERCUTANEOUS 

TRANSLUMINAL CORONARY ANGIOPLSTY [PTCA] OR CORONARY ATHERECTOMY PERFORMED DURING THE SAME OPERATION, WITH OR WITHOUT MENTION OF THROMBOLYTIC AGENT 

36.06 INSERTION OF CORONARY ARTERY 

STENTS 

Reopening of a surgical site ICD-9-CM procedure codes: 

12.3 REOPENING OF CRANIOTOMY SITE 30.2 REOPENING OF LAMINECTOMY SITE 60.2 REOPENING OF WOUND OF THYROID 

FIELD 

34.03 REOPENING OF RECENT THORACOTOMY 

SITE 

39.49 OTHER REVISION OF VASCULAR 

PROCEDURE 

54.12 REOPENING OF RECENT LAPAROTOMY 

SITE 

Rupture of uterus during or after labor ICD-9-CM diagnosis codes: 665.10 RUPTURE OF UTERUS DURING LABORUNSPECIFIED AS TO EPISODE OF CARE 

OR NOT APPLICABLE 

665.11 RUPTURE OF UTERUS DURING LABORDELIVERED, WITH OR WITHOUT 

MENTION OF ANTEPARTUM CONDITION 

Seizure ICD-9-CM diagnosis codes: 345.00 GENERALIZED NONCONVULSIVE 

EPILEPSY - WITHOUT MENTION OF INTRACTABLE EPILEPSY 

345.01 GENERALIZED NONCONVULSIVE 

EPILEPSY - WITH INTRACTABLE EPILEPSY 

345.10 GENERALIZED CONVULSIVE EPILEPSY - 

WITHOUT MENTION OF INTRACTABLE EPILEPSY 

345.11 GENERALIZED CONVULSIVE EPILEPSY - 

WITH INTRACTABLE EPILEPSY 

345.2 EPILEPSY-PETIT MAL STATUS 345.3 EPILEPSY-GRAND MAL STATUS 345.40 PARTIAL EPILEPSY, WITH IMPAIRMENT 

OF CONSCIOUSNESS - WITH INTRACTABLE EPILEPSY 

345.41 PARTIAL EPIL

OF CONSCIOUMENTION OF 

345.50 PARTIAL EPIL

OF IMPAIRMEWITHOUT MEEPILEPSY 

345.51 PARTIAL EPIL

OF IMPAIRMEWITH INTRAC

345.60 INFANTILE S

MENTION OF 

345.61 INFANTILE S

INTRACTABL

345.70 EPILEPSIA PA

WITHOUT MEEPILEPSY 

345.71 EPILEPSIA PA

INTRACTABL

345.80 OTHER FORM

MENTION OF 

345.81 OTHER FORM

INTRACTABL

345.90 EPILEPSY, UN

MENTION OF 

345.91 EPILEPSY, UN

INTRACTABL

780.3 CONVULSION

VALID) 

780.31 FEBRILE CON780.39 OTHER CONVSurgical Diagnostic Related Group001 CRANIOTOM

EXCEPT FOR 

002 CRANIOTOM

GREATER TH

003 CRANIOTOM004 SPINAL PROC005 EXTRACRAN

PROCEDURES 

006 CARPAL TUN
272

007 PERIPHERAL AND CRANIAL NERVE AND 

OTHER NERVOUS SYSTEM PROCEDURES WITH CC 

008 PERIPHERAL AND CRANIAL NERVE AND 

OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC 

036 RETINAL PROCEDURES 037 ORBITAL PROCEDURES 038 PRIMARY IRIS PROCEDURES 039 LENS PROCEDURES WITH OR WITHOUT 

VITRECTOMY 

040 EXTRAOCULAR PROCEDURES EXCEPT 

ORBIT, AGE GREATER THAN 17 

041 EXTRAOCULAR PROCEDURES EXCEPT 

ORBIT, AGE 0-17 

042 INTRAOCULAR PROCEDURES EXCEPT 

RETINA, IRIS AND LENS 

049 MAJOR HEAD AND NECK PROCEDURES 050 SIALOADENECTOMY 051 SALIVARY GLAND PROCEDURES 

EXCEPT SIALOADENECTOMY 

052 CLEFT LIP AND PALATE REPAIR 053 SINUS AND MASTOID PROCEDURES, AGE 

GREATER THAN 17 

054 SINUS AND MASTOID PROCEDURES, AGE 

0-17 

055 MISCELLANEOUS EAR, NOSE, MOUTH 

AND THROAT PROCEDURES 

056 RHINOPLASTY 057 TONSILLECTOMY AND 

ADENOIDECTOMY PROCEDURES EXCEPT TONSILLECTOMY AND/OR ADENOIDECTOMY ONLY, AGE GREATER THAN 17 

058 TONSILLECTOMY AND 

ADENOIDECTOMY PROCEDURES EXCEPT TONSILLECTOMY AND/OR ADENOIDECTOMY ONLY, AGE 0-17 

059 TONSILLECTOMY AND/OR 

ADENOIDECTOMY ONLY, AGE GREATER THAN 17 

060 TONSILLECTOMY AND/OR 

ADENOIDECTOMY ONLY, AGE 0-17 

061 MYRINGOTOMY WITH TUBE INSERTION, 

AGE GREATER THAN 17 

062 MYRINGOTOMY WITH TUBE INSERTION, 

AGE 0-17 

063 OTHER EAR, NOSE, MOUTH AND 

THROAT OR PROCEDURES 

075 MAJOR CHEST PROCEDURES 076 OTHER RESPIRATORY SYSTEM OR 

PROCEDURES WITH CC 

077 OTHER RESPIRATORY SYSTEM OR 

PROCEDURES WITHOUT CC 

103 HEART TRANSPLANT 104 CARDIAC VALVE AND OTHER MAJOR 

CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION 

105 CARDIAC VALVE AND OTHER MAJOR 

CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION 

106 CORONARY BYPASS WITH PTCA 107 CORONARY BYPASS WITH CARDIAC 

CATHETERIZATION 

108 OTHER CARDIOTHORACIC PROCEDURES 109 CORONARY BYPASS WITHOUT CARDIAC 

CATHETERIZATION 

110 MAJOR CARDIOVASCULAR 

PROCEDURES WITH CC 

111 MAJOR CARDIOVASCULAR 

PROCEDURES WITHOUT CC 

112 PERCUTANEOUS CARDIOVASCULAR 

PROCEDURES 

113 AMPUTATION FOR CIRCULATORY 

SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE 

114 UPPER LIMB AND TOES AMPUTATION 

FOR CIRCULATORY SITE 

115 PERMANENT CARDIAC PACEMAKER 

IMPLANT WITH ACUTE MYOCARDIAL INFARCTION, HEART FAILURE OR SHOCK OR ACID LEAD OR GENERATOR PROCEDURE 

116 OTHER PERMANENT CARDIAC 

PACEMAKER IMPLANT OR PTCA WITH CORONARY ARTERIAL STENT 

117 CARDIAC PACEMAKER REVISION 

EXCEPT DEVICE REPLACEMENT 

118 CARDIAC PACEMAKER DEVICE 

REPLACEMENT 

119 VEIN LIGATION AND STRIPPING 

120 OTHER CIRCU

PROCEDURES 

146 RECTAL RESE147 RECTAL RESE148 MAJOR SMAL

PROCEDURES 

149 MAJOR SMAL

PROCEDURES 

150 PERITONEAL 151 PERITONEAL 

CC 

152 MINOR SMAL

PROCEDURES 

153 MINOR SMAL

PROCEDURES 

154 STOMACH, E

DUODENAL PGREATER TH

155 STOMACH, E

DUODENAL PGREATER TH

156 STOMACH, E

DUODENAL P

157 ANAL AND S

CC 

158 ANAL AND S

WITHOUT CC 

159 HERNIA PROC

INGUINAL ANGREATER TH

160 HERNIA PROC

INGUINAL ANGREATER TH

161 INGUINAL AN

PROCEDURESWITH CC 

162 INGUINAL AN

PROCEDURESWITHOUT CC 

163 HERNIA PROC164 APPENDECTO

PRINCIPAL D

165 APPENDECTO

PRINCIPAL D
273

166 APPENDECTOMY WITHOUT 

COMPLICATED PRINCIPAL DIAGNOSIS WITH CC 

167 APPENDECTOMY WITHOUT 

COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC 

168 MOUTH PROCEDURES WITH CC 169 MOUTH PROCEDURES WITHOUT CC 170 OTHER DIGESTIVE SYSTEM OR 

PROCEDURES WITH CC 

171 OTHER DIGESTIVE SYSTEM OR 

PROCEDURES WITHOUT CC 

191 PANCREAS, LIVER AND SHUNT 

PROCEDURES WITH CC 

192 PANCREAS, LIVER AND SHUNT 

PROCEDURES WITHOUT CC 

193 BILIARY TRACT PROCEDURES EXCEPT 

ONLY CHOLECYSTECTOMY WITH OR WITHOUT COMMON DUCT EXPLORATION WITH CC 

194 BILIARY TRACT PROCEDURES EXCEPT 

ONLY CHOLECYSTECTOMY WITH OR WITHOUT COMMON DUCT EXPLORATION WITHOUT CC 

195 CHOLECYSTECTOMY WITH COMMON 

DUCT EXPLORATION WITH CC 

196 CHOLECYSTECTOMY WITH COMMON 

DUCT EXPLORATION WITHOUT CC 

197 CHOLECYSTECTOMY EXCEPT BY 

LAPAROSCOPE WITHOUT COMMON DUCT EXPLORATION WITH CC 

198 CHOLECYSTECTOMY EXCEPT BY 

LAPAROSCOPE WITHOUT COMMON DUCT EXPLORATION WITHOUT CC 

199 HEPATOBILIARY DIAGNOSTIC 

PROCEDURE FOR MALIGNANCY 

200 HEPATOBILIARY DIAGNOSTIC 

PROCEDURE FOR NONMALIGNANCY 

201 OTHER HEPATOBILIARY OR PANCREAS 

OR PROCEDURES 

209 MAJOR JOINT AND LIMB 

REATTACHMENT PROCEDURES OF LOWER EXTREMITY 

210 HIP AND FEMUR PROCEDURES EXCEPT 

MAJOR JOINT PROCEDURES, AGE GREATER THAN 17 WITH CC 

211 HIP AND FEMUR PROCEDURES EXCEPT 

MAJOR JOINT PROCEDURES, AGE GREATER THAN 17 WITHOUT CC 

212 HIP AND FEMUR PROCEDURES EXCEPT 

MAJOR JOINT PROCEDURE, AGE 0-17 

213 AMPUTATION FOR MUSCULOSKELETAL 

SYSTEM AND CONNECTIVE TISSUE DISORDERS 

214 NO LONGER VALID 215 NO LONGER VALID 216 BIOPSIES OF MUSCULOSKELETAL 

SYSTEM AND CONNECTIVE TISSUE 

217 WOUND DEBRIDEMENT AND SKIN 

GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 

218 LOWER EXTREMITY AND HUMERUS 

PROCEURES EXCEPT HIP, FOOT AND FEMUR, AGE GREATER THAN 17 WITH CC 

219 LOWER EXTREMITY AND HUMERUS 

PROCEDURES EXCEPT HIP, FOOT AND FEMUR, AGE GREATER THAN 17 WITHOUT CC 

220 LOWER EXTREMITY AND HUMERUS 

PROCEDURES EXCEPT HIP, FOOT AND FEMUR, AGE 0-17 

221 NO LONGER VALID 222 NO LONGER VALID 223 MAJOR SHOULDER/ELBOW 

PROCEDURES OR OTHER UPPER EXTREMITY PROCEDURES WITH CC 

224 SHOULDER, ELBOW OR FOREARM 

PROCEDURES EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC 

225 FOOT PROCEDURES 226 SOFT TISSUE PROCEDURES WITH CC 227 SOFT TISSUE PROCEDURES WITHOUT CC 228 MAJOR THUMB OR JOINT PROCEDURES 

OR OTHER HAND OR WRIST PROCEDURES WITH CC 

229 HAND OR WRIST PROCEDURES EXCEPT 

MAJOR JOINT PROCEDURES WITHOUT CC 

230 LOCAL EXCIS

INTERNAL FIAND FEMUR 

231 LOCAL EXCIS

INTERNAL FIHIP AND FEM

232 ARTHROSCO233 OTHER MUSC

AND CONNECPROCEDURES 

234 OTHER MUSC

AND CONNECPROCEDURES 

257 TOTAL MAST

MALIGNANC

258 TOTAL MAST

MALIGNANC

259 SUBTOTAL M

MALIGNANC

260 SUBTOTAL M

MALIGNANC

261 BREAST PRO

NONMALIGN

LOCAL EXCIS

262 BREAST BIOP

FOR NONMAL

263 SKIN GRAFT 

FOR SKIN ULCC 

264 SKIN GRAFT 

FOR SKIN ULWITHOUT CC 

265 SKIN GRAFT 

EXCEPT FOR CELLULITIS W

266 SKIN GRAFT 

EXCEPT FOR CELLULITIS W

267 PERIANAL AN

PROCEDURES 

268 SKIN, SUBCU

BREAST PLA

269 OTHER SKIN, 

AND BREAST 

270 OTHER SKIN, 

AND BREAST 
274

285 AMPUTATION OF LOWER LIMB FOR 

ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS 

286 ADRENAL AND PITUITARY PROCEDURES 287 SKIN GRAFTS AND WOUND 

DEBRIDEMENTS FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS 

288 OR PROCEDURES FOR OBESITY 289 PARATHYROID PROCEDURES 290 THYROID PROCEDURES 291 THYROGLOSSAL PROCEDURES 292 OTHER ENDOCRINE, NUTRITIONAL AND 

METABOLIC OR PROCEDURES WITH CC 

293 OTHER ENDOCRINE, NUTRITIONAL AND 

METABOLIC OR PROCEDURES WITHOUT CC 

302 KIDNEY TRANSPLANT 303 KIDNEY, URETER AND MAJOR BLADDER 

PROCEDURES FOR NEOPLASM 

304 KIDNEY, URETER AND MAJOR BLADDER 

PROCEDURES FOR NONNEOPLASMS WITH CC 

305 KIDNEY, URETER AND MAJOR BLADDER 

PROCEDURES FOR NONNEOPLASMS WITHOUT CC 

306 PROSTATECTOMY WITH CC 307 PROSTATECTOMY WITHOUT CC 308 MINOR BLADDER PROCEDURES WITH 

CC 

309 MINOR BLADDER PROCEDURES 

WITHOUT CC 

310 TRANSURETHRAL PROCEDURES WITH 

CC 

311 TRANSURETHRAL PROCEDURES 

WITHOUT CC 

312 URETHRAL PROCEDURES, AGE 

GREATER THAN 17 WITH CC 

313 URETHRAL PROCEDURES, AGE 

GREATER THAN 17 WITHOUT CC 

314 URETHRAL PROCEDURES, AGE 0-17 315 OTHER KIDNEY AND URINARY TRACT 

OR PROCEDURES 

334 MAJOR MALE PELVIC PROCEDURES 

WITH CC 

335 MAJOR MALE PELVIC PROCEDURES 

WITHOUT CC 

336 TRANSURETHRAL PROSTATECTOMY 

WITH CC 

337 TRANSURETHRAL PROSTATECTOMY 

WITHOUT CC 

338 TESTES PROCEDURES FOR 

MALIGNANCY 

339 TESTES PROCEDURES FOR 

NONMALIGNANCY, AGE GREATER THAN 17 

340 TESTES PROCEDURES FOR 

NONMALIGNANCY, AGE 0-17 

341 PENIS PROCEDURES 342 CIRCUMCISION, AGE GREATER THAN 17 343 CIRCUMCISION, AGE 0-17 344 OTHER MALE REPRODUCTIVE SYSTEM 

OR PROCEDURES FOR MALIGNANCY 

345 OTHER MALE REPRODUCTIVE SYSTEM 

OR PROCEDURES EXCEPT FOR MALIGNANCY 

353 PELVIC EVISCERATION, RADICAL 

HYSTERECTOMY AND RADICAL VULVECTOMY 

354 UTERINE AND ADNEXA PROCEDURES 

FOR NONOVARIAN/ADNEXAL MALIGNANCY WITH CC 

355 UTERINE AND ADNEXA PROCEDURES 

FOR NONOVARIAN/ADNEXA PROCEDURES FOR NONOVARIAN/ADNEXAL MALIGNANCY WITHOUT CC 

356 FEMALE REPRODUCTIVE SYSTEM 

RECONSTRUCTIVE PROCEDURES 

357 UTERINE AND ADNEXA PROCEDURES 

FOR OVARIAN OR ADNEXAL MALIGNANCY 

358 UTERINE AND ADNEXA PROCEDURES 

FOR NONMALIGNANCY WITH CC 

359 UTERINE AND ADNEXA PROCEDURES 

FOR NONMALIGNANCY WITHOUT CC 

360 VAGINA, CERVIX AND VULVA 

PROCEDURES 

361 LAPAROSCOPY AND INCISIONAL TUBAL 

INTERRUPTION 

362 ENDOSCOPIC TUBAL INTERRUPTION 

363 D AND C, CON

RADIOIMPLA

364 D AND C, CON

MALIGNANC

365 OTHER FEMA

SYSTEM OR P

370 CESAREAN S371 CESAREAN S374 VAGINAL DE

STERILIZATI

375 VAGINAL DE

PROCEDURE AND/OR D AN

377 POSTPARTUM 

DIAGNOSES W

381 ABORTION W

CURETTAGE 

392 SPLENECTOM393 SPLENECTOM394 OTHER OR PR

AND BLOOD-

400 LYMPHOMA 

MAJOR OR PR

401 LYMPHOMA 

WITH OTHER 

402 LYMPHOMA 

WITH OTHER CC 

406 MYELOPROL

POORLY DIFFWITH MAJOR 

407 MYELOPROL

POORLY DIFFWITH MAJOR WITHOUT CC 

408 MYELOPROL

POORLY DIFFWITH OTHER 

415 OR PROCEDU

PARASITIC D

424 OR PROCEDU

DIAGNOSIS O

439 SKIN GRAFTS 440 WOUND DEB441 WOUND HAN

INJURIES 
275

442 OTHER OR PROCEDURES FOR INJURIES 

WITH CC 

443 OTHER OR PROCEDURES FOR INJURIES 458 NO LONGER VALID 459 NO LONGER VALID 461 OR PROCEDURES WITH DIAGNOSES OF 

OTHER CONTACT WITH HEALTH SERVICES 

468 EXTENSIVE OR PROCEDURE 

UNRELATED TO PRINCIPAL DIAGNOSIS 

471 BILATERAL OR MULTIPLE MAJOR JOINT 

PROCEDURES OF LOWER EXTREMITY 

472 NO LONGER VALID 476 PROSTATIC OR PROCEDURE 

UNRELATED TO PRINCIPAL DIAGNOSIS 

477 NONEXTENSIVE OR PROCEDURE 

UNRELATED TO PRINCIPAL DIAGNOSIS 

478 OTHER VASCULAR PROCEDURES WITH 

CC 

479 OTHER VASCULAR PROCEDURES 

WITHOUT CC 

480 LIVER TRANSPLANT 481 BONE MARROW TRANSPLANT 482 TRACHEOSTOMY FOR FACE, MOUTH 

AND NECK DIAGNOSES 

483 TRACHEOSTOMY EXCEPT FOR FACE, 

MOUTH AND NECK DIAGNOSES 

484 CRANIOTOMY FOR MULTIPLE 

SIGNIFICANT TRAUMA 

485 LIMB REATTACHMENT, HIP AND FEMUR 

PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 

486 OTHER OR PROCEDURES FOR MULTIPLE 

SIGNIFICANT TRAUMA 

488 HIV WITH EXTENSIVE OR PROCEDURE 491 MAJOR JOINT AND LIMB 

REATTACHMENT PROCEDURES OF UPPER EXTREMITY 

493 LAPAROSCOPIC CHOLECYSTECTOMY 

WITHOUT COMMON DUCT EXPLORATION WITH CC 

494 LAPAROSCOPIC CHOLECYSTECTOMY 

WITHOUT COMMON DUCT EXPLORATION WITHOUT CC 

495 LUNG TRANSPLANT 

496 COMBINED ANTERIOR/POSTERIOR 

SPINAL FUSION 

497 SPINAL FUSION WITH CC 498 SPINAL FUSION WITHOUT CC 499 BACK AND NECK PROCEDURES EXCEPT 

SPINAL FUSION WITH CC 

500 BACK AND NECK PROCEDURES EXCEPT 

SPINAL FUSION WITHOUT CC 

501 KNEE PROCEDURES WITH PRINCIPAL 

DIAGNOSIS OF INFECTION, WITH CC 

502 KNEE PROCEDURES WITH PRINCIPAL 

DIAGNOSIS OF INFECTION, WITHOUT CC 

503 KNEE PROCEDURES WITHOUT 

PRINCIPAL DIAGNOSIS OF INFECTION 

Suture of laceration ICD-9-CM procedure codes: 04.3 SUTURE OF CRANIAL AND PERIPHERAL 

NERVES 

29.51 SUTURE OF LACERATION OF PHARYNX 31.61 SUTURE OF LACERATION OF LARYNX 33.41 SUTURE OF LACERATION OF BRONCHUS 33.43 CLOSURE OF LACERATION OF LUNG 34.82 SUTURE OF LACERATION OF 

DIAPHRAGM 

39.30 SUTURE OF UNSPECIFIED BLOOD 

VESSEL 

39.31 SUTURE OF ARTERY 39.32 SUTURE OF VEIN 42.82 SUTURE OF LACERATION OF 

ESOPHAGUS 

44.61 SUTURE OF LACERATION OF STOMACH 46.71 SUTURE OF LACERATION OF 

DUODENUM 

46.73 SUTURE OF LACERATION OF SMALL 

INTESTINE, EXCEPT DUODENUM 

46.75 SUTURE OF LACERATION OF LARGE 

INTESTINE 

48.71 SUTURE OF LACERATION OF RECTUM 49.71 SUTURE OF LACERATION OF ANUS 55.81 SUTURE OF LACERATION OF KIDNEY 56.82 SUTURE OF LACERATION OF URETER 57.81 SUTURE OF LACERATION OF BLADDER 

58.41 SUTURE OF L50.61 CLOSURE OF 51.91 REPAIR OF LA

GALLBLADD

67.61 SUTURE OF L69.41 SUTURE OF L

Third or fourth degree oICD-9-CM diagnosis code664.21 THIRD DEGR

DELIVERED, MENTION OF 

664.31 FOURTH-DEG

LACERATION WITHOUT MECONDITION

Trauma ICD-9-CM diagnosis code800 FRACTURE O801 FRACTURE O802 FRACTURE O803 OTHER AND 

FRACTURES 

804 MULTIPLE FR

SKULL OR FA

805 FRACTURE O

WITHOUT MEINJURY 

806 FRACTURE O

WITH SPINAL 

807 FRACTURE O

LARYNX, AN

808 FRACTURE O809 ILL-DEFINED 

TRUNK 

810 FRACTURE O811 FRACTURE O812 FRACTURE O
276

813 FRACTURE OF RADIUS AND ULNA 814 FRACTURE OF CARPAL BONE[S] 815 FRACTURE OF METACARPAL BONE[S] 817 MULTIPLE FRACTURES OF HAND BONES 818 ILL-DEFINED FRACTURES OF UPPER 

LIMB 

819 MULTIPLE FRACTURES INVOLVING 

BOTH UPPER LIMBS, AND UPPER LIMB WITH RIB AND STERNUM 

820 FRACTURE OF NECK OF FEMUR 821 FRACTURE OF OTHER AND UNSPECIFIED 

PARTS OF FEMUR 

822 FRACTURE OF PATELLA 823 FRACTURE OF TIBIA AND FIBULA 824 FRACTURE OF ANKLE 825 FRACTURE OF ONE OR MORE TARSAL 

AND METATARSAL BONES 

827 OTHER, MULTIPLE, AND ILL-DEFINED 

FRACTURES OF LOWER LIMB 

828 MULTIPLE FRACTURES INVOLVING 

BOTH LOWER LIMBS, LOWER WITH UPPER LIMB, AND LOWER LIMB WITH RIB AND STERNUM 

829 FRACTURE OF UNSPECIFIED BONES 830 DISLOCATION OF JAW 831 DISLOCATION OF SHOULDER 832 DISLOCATION OF ELBOW 833 DISLOCATION OF WRIST 835 DISLOCATION OF HIP 836 DISLOCATION OF KNEE 837 DISLOCATION OF ANKLE 838 DISLOCATION OF FOOT 839 OTHER, MULTIPLE, AND ILL-DEFINED 

DISLOCATIONS 

850 CONCUSSION 851 CEREBRAL LACERATION AND 

CONTUSION 

852 SUBARACHNOID, SUBDURAL, AND 

EXTRADURAL HEMORRHAGE, FOLLOWING INJURY 

853 OTHER AND UNSPECIFIED 

INTRACRANIAL HEMORRHAGE FOLLOWING INJURY 

854 INTRACRANIAL INJURY OF OTHER AND 

UNSPECIFIED NATURE 

860 TRAUMATIC PNEUMOTHORAX 

861 INJURY TO HEART AND LUNG 862 INJURY TO OTHER AND UNSPECIFIED 

INTRATHORACIC ORGANS 

863 INJURY TO GASTROINTESTINAL TRACT 864 INJURY TO LIVER 865 INJURY TO SPLEEN 866 INJURY TO KIDNEY 867 INJURY TO PELVIC ORGANS 868 INJURY TO OTHER INTRA-ABDOMINAL 

ORGANS 

869 INTERNAL INJURY TO UNSPECIFIED OR 

ILL-DEFINED ORGANS 

870 OPEN WOUND OF OCULAR ADNEXA 871 OPEN WOUND OF EYEBALL 872 OPEN WOUND OF EAR 873 OTHER OPEN WOUND OF HEAD 874 OPEN WOUND OF NECK 875 OPEN WOUND OF CHEST [WALL] 876 OPEN WOUND OF BACK 877 OPEN WOUND OF BUTTOCK 878 OPEN WOUND OF GENITAL ORGANS 

[EXTERNAL] INCLUDING TRAUMATIC AMPUTATION 

879 OPEN WOUND OF OTHER AND 

UNSPECIFIED SITES, EXCEPT LIMBS 

880 OPEN WOUND OF SHOULDER AND 

UPPER ARM 

881 OPEN WOUND OF ELBOW, FOREARM, 

AND WRIST 

882 OPEN WOUND OF HAND EXCEPT FINGER 

ALONE 

884 MULTIPLE AND UNSPECIFIED OPEN 

WOUND OF UPPER LIMB 

887 TRAUMATIC AMPUTATION OF ARM AND 

HAND (COMPLETE) (PARTIAL) 

890 OPEN WOUND OF HIP AND THIGH 891 OPEN WOUND OF KNEE, LEG (EXCEPT 

THIGH) AND ANKLE 

892 OPEN WOUND OF FOOT EXCEPT TOE 

ALONE 

894 MULTIPLE AND UNSPECIFIED OPEN 

WOUND OF LOWER LIMB 

896 TRAUMATIC AMPUTATION OF FOOT 

(COMPLETE) (PARTIAL) 

897 TRAUMATIC AMPUTATION OF LEG(S) 

(COMPLETE) (PARTIAL) 

900 INJURY TO B

AND NECK 

901 INJURY TO B902 INJURY TO B

ABDOMEN A

903 INJURY TO B

EXTREMITY 

904 INJURY TO B

EXTREMITY 

925 CRUSHING IN

AND NECK 

926 CRUSHING IN927 CRUSHING IN928 CRUSHING IN929 CRUSHING IN

UNSPECIFIED 

940 BURN CONFI941 BURN OF FAC942 BURN OF TRU943 BURN OF UPP

AND HAND 

944 BURN OF WR945 BURN OF LOW946 BURNS OF M947 BURN OF INT948 BURNS CLAS

EXTENT OF B

949 BURN, UNSPE952 SPINAL CHOR

EVIDENCE OF 

953 INJURY TO N

PLEXUS 

958 CERTAIN EAR

TRAUMA 

E800 RAILWAY AC

COLLISION W

E801 RAILWAY AC

COLLISION W

E802 RAILWAY AC

DERAILMENT COLLISION 

E803 RAILWAY AC

EXPLOSION, 

E804 FALL IN, ON, E805 HIT BY ROLLE806 OTHER SPECI
277

E807 RAILWAY ACCIDENT OF UNSPECIFIED 

NATURE 

E810 MOTOR VEHICLE TRAFFIC ACCIDENT 

INVOLVING COLLISION WITH TRAIN 

E811 MOTOR VEHICLE TRAFFIC ACCIDENT 

INVOLVING RE-ENTERANT COLLISION WITH ANOTHER MOTOR VEHICLE 

E812 OTHER MOTOR VEHICLE TRAFFIC 

ACCIDENT INVOLVING COLLISION WITH MOTOR VEHICLE 

E813 MOTOR VEHICLE TRAFFIC ACCIDENT 

INVOLVING COLLISION WITH OTHER VEHICLE 

E814 MOTOR VEHICLE TRAFFIC ACCIDENT 

INVOLVING COLLISION WITH PEDESTRIAN 

E815 OTHER MOTOR VEHICLE TRAFFIC 

ACCIDENT INVOLVING COLLISION ON THE HIGHWAY 

E816 MOTOR VEHICLE TRAFFIC ACCIDENT 

DUE TO LOSS OF CONTROL, WITHOUT COLLISION ON THE HIGHWAY 

E817 NONCOLLISION MOTOR VEHICLE 

TRAFFIC ACCIDENT WHILE BOARDING OR ALIGHTING 

E818 OTHER NONCOLLISION MOTOR VEHICLE 

TRAFFIC ACCIDENT 

E819 MOTOR VEHICLE TRAFFIC ACCIDENT OF 

UNSPECIFIED NATURE 

E820 NONTRAFFIC ACCIDENT INVOLVING 

MOTOR-DRIVEN SNOW VEHICLE 

E821 NONTRAFFIC ACCIDENT INVOLVING 

OTHER OFF-ROAD MOTOR VEHICLE 

E822 OTHER MOTOR VEHICLE NONTRAFFIC 

ACCIDENT INVOLVING COLLISION WITH MOVING OBJECT 

E823 OTHER MOTOR VEHICLE NONTRAFFIC 

ACCIDENT INVOLVING COLLISION WITH STATIONARY OBJECT 

E824 OTHER MOTOR VEHICLE NONTRAFFIC 

ACCIDENT WHILE BOARDING AND ALIGHTING 

E825 OTHER MOTOR VEHICLE NONTRAFFIC 

ACCIDENT OF OTHER AND UNSPECIFIED NATURE 

E826 PEDAL CYCLE ACCIDENT 

E827 ANIMAL-DRAWN VEHICLE ACCIDENT E828 ACCIDENT INVOLVING ANIMAL BEING 

RIDDEN 

E829 OTHER ROAD VEHICLE ACCIDENTS E830 ACCIDENT TO WATERCRAFT CAUSING 

SUBMERSION 

E831 ACCIDENT TO WATERCRAFT CAUSING 

OTHER INJURY 

E832 OTHER ACCIDENTAL SUBMERSION OR 

DROWNING IN WATER TRANSPORT ACCIDENT 

E833 FALL ON STAIRS OR LADDERS IN WATER 

TRANSPORT 

E834 OTHER FALL FROM ONE LEVEL TO 

ANOTHER IN WATER TRANSPORT 

E835 OTHER AND UNSPECIFIED FALL IN 

WATER TRANSPORT 

E836 MACHINERY ACCIDENT IN WATER 

TRANSPORT 

E837 EXPLOSION, FIRE, OR BURNING IN 

WATERCRAFT 

E838 OTHER AND UNSPECIFIED WATER 

TRANSPORT ACCIDENT 

E840 ACCIDENT TO POWERED AIRCRAFT AT 

TAKEOFF OR LANDING 

E841 ACCIDENT TO POWERED AIRCRAFT, 

OTHER AND UNSPECIFIED 

E842 ACCIDENT TO UNPOWERED AIRCRAFT 

E843 FALL IN, ON, OR FROM AIRCRAFT E844 OTHER SPECIFIED AIR TRANSPORT 

ACCIDENTS 

E845 ACCIDENT INVOLVING SPACECRAFT E846 ACCIDENTS INVOLVING POWERED 

VEHICLES USED SOLELY WITHIN THE BUILDINGS AND PREMISES AND INDUSTRIAL OR COMMERCIAL ESTABLISHMENT 

E847 ACCIDENTS TO UNPOWERED AIRCRAFT E848 ACCIDENTS INVOLVING OTHER 

VEHICLES, NEC 

E849 PLACE OF OCCURRENCE E880 FALL ON OR FROM STAIRS OR STEPS E881 FALL ON OR FROM LADDERS OR 

SCAFFOLDING 

E882 FALL FROM OR OUT OF BUILDING OR 

OTHER STRUCTURE 

E883 FALL INTO H

SURFACE 

E884 OTHER FALL 

ANOTHER 

E885 FALL ON SAM

TRIPPING, OR 

E886 FALL ON SAM

PUSHING, OR OTHER PERS

E887 FRACTURE, CE888 OTHER AND E890 CONFLAGRA

DWELLING 

E891 CONFLAGRA

UNSPECIFIED 

E892 CONFLAGRA

STRUCTURE 

E893 ACCIDENT CA

CLOTHING 

E894 IGNITION OF 

MATERIAL 

E895 ACCIDENT CA

FIRE IN PRIV

E896 ACCIDENT CA

FIRE IN OTHEBUILDING OR 

E897 ACCIDENT CA

FIRE NOT IN 

E898 ACCIDENT CA

SPECIFIED FI

E899 ACCIDENT CA

FIRE 

E910 ACCIDENTAL 

SUBMERSION 

E913 ACCIDENTAL 

SUFFOCATIO

E914 FOREIGN BOD

ENTERING EY

E915 FOREIGN BOD

ENTERING OT

E916 STRUCK ACC

OBJECT 

E917 STRIKING AG

ACCIDENTALPERSONS 
278

E918 CAUGHT ACCIDENTALLY IN OR 

BETWEEN OBJECTS 

E919 ACCIDENTS CAUSED BY MACHINERY E920 ACCIDENTS CAUSED BY CUTTING AND 

PIERCING INSTRUMENTS OR OBJECTS 

E921 ACCIDENT CAUSED BY EXPLOSION OF 

PRESSURE VESSEL 

E922 ACCIDENT CAUSED BY FIREARM AND 

AIR GUN MISSILE 

E923 ACCIDENT CAUSED BY EXPLOSIVE 

MATERIAL 

E924 ACCIDENT CAUSED BY HOT SUBSTANCE 

OR OBJECT, CAUSTIC OR CORROSIVE MATERIAL, AND STEAM 

E925 ACCIDENT CAUSED BY ELECTRIC 

CURRENT 

E926 EXPOSURE TO RADIATION E927 OVEREXERTION AND STRENUOUS 

MOVEMENTS 

E928 OTHER AND UNSPECIFIED 

ENVIRONMENTAL AND ACCIDENTAL CAUSES 

E960 FIGHT, BRAWL, RAPE E961 ASSAULT BY CORROSIVE OR CAUSTIC 

SUBSTANCE, EXCEPT POISONING 

E962 ASSAULT BY POISONING E963 ASSAULT BY HANGING AND 

STRANGULATION 

E964 ASSAULT BY SUBMERSION [DROWNING] E965 ASSAULT BY FIREARMS AND 

EXPLOSIVES 

E966 ASSAULT BY CUTTING AND PIERCING 

INSTRUMENT 

E967 PERPETRATOR OF CHILD AND ADULT 

ABUSE 

E968 ASSAULT BY OTHER AND UNSPECIFIED 

MEANS 

E969 LATE EFFECTS OF INJURY PURPOSELY 

INFLICTED BY OTHER PERSON 

E970 INJURY DUE TO LEGAL INTERVENTION 

BY FIREARMS 

E971 INJURY DUE TO LEGAL INTERVENTION 

BY EXPLOSIVES 

E972 INJURY DUE TO LEGAL INTERVENTION 

BY GAS 

E973 INJURY DUE TO LEGAL INTERVENTION 

BY BLUNT OBJECT 

E974 INJURY DUE TO LEGAL INTERVENTION 

BY CUTTING AND PIERCING INSTRUMENT 

E975 INJURY DUE TO LEGAL INTERVENTION 

BY OTHER SPECIFIED MEANS 

E976 INJURY DUE TO LEGAL INTERVENTION 

BY UNSPECIFIED MEANS 

E977 LATE EFFECTS OF INJURIES DUE TO 

LEGAL INTERVENTION 

E978 LEGAL EXECUTION E980 POISONING BY SOLID OR LIQUID 

SUBSTANCES, UNDETERMINED WHETHER ACCIDENTALLY OR PURPOSELY INFLICTED 

E981 POISONING BY GASES IN DOMESTIC 

USE, UNDETERMINED WHETHER ACCIDENTALLY OR PURPOSELY INFLICTED 

E982 POISONING BY OTHER GASES, 

UNDETERMINED WHETHER ACCIDENTALLY OR PURPOSELY INFLICTED 

E983 HANGING, STRANGULATION, OR 

SUFFOCATION, UNDETERMINED WHETHER ACCIDENTALLY OR PURPOSELY INFLICTED 

E984 SUBMERSION [DROWNING] 

UNDETERMINED WHETHER ACCIDENTALLY OR PURPOSELY INFLICTED 

E985 INJURY BY FIREARMS, AIR GUNS AND 

EXPLOSIVES, UNDETERMINED WHETHER ACCIDENTALLY OR PURPOSELY INFLICTED 

E986 INJURY BY CUTTING AND PIERCING 

INSTRUMENTS, UNDETERMINED WHETHER ACCIDENTALLY OR PURPOSELY INFLICTED 

E987 FALLING FROM HIGH PLACE, 

UNDETERMINED WHETHER ACCIDENTALLY OR PURPOSELY INFLICTED 

E988 INJURY BY OTHER AND UNSPECIFIED 

MEANS, UNDETERMINED WHETHER 

ACCIDENTALINFLICTED 

E989 LATE EFFECT

UNDETERMINACCIDENTALINFLICTED 

E990 INJURY DUE 

FIRES AND C

E991 INJURY DUE 

BULLETS AN

E992 INJURY DUE 

EXPLOSION O

E993 INJURY DUE 

OTHER EXPL

E994 INJURY DUE 

DESTRUCTIO

E995 INJURY DUE 

OTHER AND CONVENTION

E996 INJURY DUE 

NUCLEAR WE

E997 INJURY DUE 

OTHER FORMWARFARE 

E998 INJURY DUE 

OCCURRING HOSTILITIES 

E999 LATE EFFECT 

OPERATIONS 

DIAGNOSTIC RELATED 002 CRANIOTOM

GREATER TH

027 TRAUMATIC 

GREATER TH

028 TRAUMATIC 

LESS THAN OTHAN 17 WIT

029 TRAUMATIC 

LESS THAN OTHAN 17 WIT

031 CONCUSSION

WITH CC 

032 CONCUSSION

WITHOUT CC 
279

072 NASAL TRAUMA AND DEFORMITY 083 MAJOR CHEST TRAUMA WITH CC 084 MAJOR CHEST TRAUMA WITHOUT CC 235 FRACTURES OF FEMUR 236 FRACTURE OF HIP AND PELVIS 237 SPRAINS, STRAINS AND DISLOCATIONS 

OF HIP, PELVIS AND THIGH 

441 WOUND DEBRIDEMENTS FOR INJURIES 441 HAND PROCEDURES FOR INJURIES 442 OTHER OR PROCEDURES FOR INJURIES 

WITH CC 

456 OTHER OR PROCEDURES FOR INJURIES 

WITHOUT CC 

457 TRAUMATIC INJURY, AGE GREATER 

THAN 17 WITH CC 

458 TRAUMATIC INJURY, AGE GREATER 

THAN 17 WITHOUT CC 

459 TRAUMATIC INJURY, AGE 0-17 460 ALLERGIC REACTIONS, AGE GREATER 

THAN 17 

461 ALLERGIC REACTIONS, AGE 0-17 462 POISONING AND TOXIC EFFECTS OF 

DRUGS, AGE GREATER THAN 17 WITH CC 

463 POISONING AND TOXIC EFFECTS OF 

DRUGS, AGE GREATER THAN 17 WITHOUT CC 

464 POISONING AND TOXIC EFFECTS OF 

DRUGS, AGE 0-17 

465 COMPLICATIONS OF TREATMENT WITH 

CC 

466 COMPLICATIONS OF TREATMENT 

WITHOUT CC 

467 OTHER INJURY, POISONING AND TOXIC 

EFFECT DIAGNOSES WITH CC 

468 OTHER INJURY, POISONING AND TOXIC 

EFFECT DIAGNOSES WITHOUT CC 

460 NO LONGER VALID 484 CRANIOTOMY FOR MULTIPLE 

SIGNIFICANT TRAUMA 

488 LIMB REATTACHMENT, HIP AND FEMUR 

PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 

489 OTHER OR PROCEDURES FOR MULTIPLE 

SIGNIFICANT TRAUMA 

490 OTHER MULTIPLE SIGNIFICANT 

TRAUMAS 

491 MAJOR JOINT AND LIMB 

REATTACHMENT PROCEDURES OF UPPER EXTREMITY 

Trial of labor Diagnostic Related Groups (DRGs) 372 VAGINAL DELIVERY WITH 

COMPLICATING DIAGNOSES 

373 VAGINAL DELIVERY WITHOUT 

COMPLICATING DIAGNOSES 

374 VAGINAL DELIVERY WITH 

STERILZATION AND/OR D AND C 

375 VAGINAL DELIVERY WITH OR 

PROCEDURE EXCEPT STERILIZATION AND/OR D AND C 

or ICD-9-CM diagnosis codes (includes all 4th and 5th digits): 653 DISPROPORTION 

660 OBSTRUCTED LABOR 661 ABNORMALITY OF FORCES OF LABOR662 LONG LABOR (Includes all 5th digits): 652.1 BREECH OR OTHER MALPRESENTATION 

SUCCESSFULLY CONVERTED TO CEPHALIC PRESENTATION 

659.0 FAILED MECHANICAL INDUCTION 659.1 FAILED MEDICAL OR UNSPECIFIED 

INDUCTION 

659.2 MATERNAL PYREXIA DURING LABOR, 

UNSPECIFIED 

659.3 GENERALIZED INFECTION DURING 

LABOR 

656.3 FETAL DISTRESS 663.0 PROLAPSE OF CORD 663.1 CORD AROUND NECK, WITH 

COMPRESSION 

663.2 OTHER AND 

ENTANGLEM

663.3 OTHER AND 

ENTANGLEMOF COMPRES

663.4 SHORT CORD 663.5 VASA PREVIA 663.6 VASCULAR L663.8 OTHER UMBI

COMPLICATI

663.9 UNSPECIFIED 

COMPLICATI

Vaginal delivery Diagnostic Related Group372 VAGINAL DE

COMPLICATI

373 VAGINAL DE

COMPLICATI

374 VAGINAL DE

STERILAIZAT

375 VAGINAL DE

PROCEDURE AND/ OR D A

Vaginal delivery during sICD-9-CM diagnosis code# 2 5th digits): 640.8 OTHER SPECI

EARLY PREG

640.9 UNSPECIFIED 

PREGNANCY

641 ANTEPARTUM 

ABRUPTIO PAPREVIA 

642 HYPERTENSI

PREGNANCYPUERPERIUM 

643 EXCESSIVE V644 EARLY OR TH
280

645 LATE PREGNANCY 646 OTHER COMPLICATIONS OF 

PREGNANCY, NEC 

647 INFECTIOUS AND PARASITIC 

CONDITIONS IN THE MOTHER CLASSIFIABLE ELSEWHERE, BUT COMPLICATING PREGNANCY, CHILDBIRTH, OR THE PUERPERIUM 

648 OTHER CURRENT CONDITIONS IN THE 

MOTHER CLASSIFIABLE ELSEWHERE, BUT COMPLICATING PREGNANCY, CHILDBIRTH, OR THE PUERPERIUM

650 NORMAL DELIVERY 651 MULTIPLE GESTATION 652 MALPOSITION AND MALPRESENTATION 

OF FETUS 

653 DISPROPORTION 654 ABNORMALITY OF ORGANS AND SOFT 

TISSUES OF PELVIS 

655 KNOWN OR SUSPECTED FETAL 

ABNORMALITY AFFECTING MANAGEMENT OF MOTHER 

656 OTHER FETAL AND PLACENTAL 

PROBLEMS AFFECTING MANAGEMENT OF MOTHER 

657 POLYHYDRAMNIOS 658 OTHER PROBLEMS ASSOCIATED WITH 

AMNIOTIC CAVITY AND MEMBRANES 

659 OTHER INDICATION FOR CARE OR 

INTERVENTION RELATED TO LABOR AND DELIVERY, NEC 

660 OBSTRUCTED LABOR 661 ABNORMALITY OF FORCES OF LABOR 662 LONG LABOR 663 UMBILICAL CORD COMPLICATIONS 664 TRAUMA TO PERINEUM AND VULVA 

DURING DELIVERY 

665 OTHER OBSTETRICAL TRAUMA 666 POSTPARTUM HEMORRHAGE 667 RETAINED PLACENTA OR MEMBRANES, 

WITHOUT HEMORRHAGE 

668 COMPLICATIONS OF THE 

ADMINISTRATION OF ANESTHETIC OR OTHER SEDATION IN LABOR AND DELIVERY 

669 OTHER COMP

DELIVERY, N

670 MAJOR PUER671 VENOUS COM

PREGNANCY 

672 PYREXIA OF 

THE PUERPER

673 OBSTETRICA674 OTHER AND 

COMPLICATINEC 

675 INFECTIONS 

NIPPLE ASSO

676.91 UNSPECIFIED 

- DELIVEREDMENTION OF 

or V27.0 SINGLE LIVEBORN V27.1 SINGLE STILLBORN V27.2 TWINS, BOTH LIVEBORN V27.3 TWINS, ONE LIVEBORN AND ONE 

STILLBORN 

V27.4 TWINS, BOTH STILLBORN V27.5 OTHER MULTIPLE BIRTH, ALL 

LIVEBORN 

V27.6 OTHER MULTIPLE BIRTH, SOME 

LIBEBORN 

V27.7 OTHER MULTIPLE BIRTH, ALL 

STILLBORN 

V27.9 UNSPECIFIED OUTCOME OF DELIVERY
281

Section 4A. Definitions of Rejected Indicators (after panel discussion and rating) Denominator items in bold and brackets are fully specified in Section 1B, “Coding Details for Accepted Hospital-Level Indicators." 

Indicator Definition and Numerator Population at Risk (Denom

• Obstetric thrombosis or embolism Discharges with ICD-9-CM codes for obstetric thrombosis 

or embolism [DVT –postpartum unspecified (671.40), DVT- delivered with mention of postpartum complication (671.42), DVT - postpartum condition or complication (671.44), Obstetric pulmonary embolism (673.20)] in any diagnosis field per 100 deliveries. 

All deliveries ([vaginal delidelivery]).

• Puerperal infection Discharges with ICD-9-CM codes for major puerperal 

infection [Major puerperal infection, unspecified as to episode of care (670.00), Major puerperal infection, delivered with mention of post-partum complication (670.02), Major puerperal infection, post-partum condition or complication (670.04)] in any diagnosis field per 100 deliveries. 

All deliveries ([vaginal delidelivery]).Exclude patients with a diagantepartum infection of amn1, 3]. 

• Postoperative pneumonia Discharges with ICD-9-CM codes for pneumonia 

[pneumococcal pneumonia (481), other bacterial pneumonia {Klebsiella pneumoniae, pseudomoniae, pseudomonas, Hemophilis pneumoniae, streptococcus, stapnylococcus, anaerobes, E. coli, other gram negative, Legionnaires disease} (482.0-482.99)] in any secondary 

diagnosis field per 100 surgical discharges. 

All [surgical] discharges 

Exclude patients in MDC 4. Exclude patients with any di[immunocompromised] stadiagnosis of AIDS), or [can

• Iatrogenic hypotension Discharges with ICD-9-CM code of 458.2 in any diagnosis 

field per 100 discharges. 

Exclude all obstetric admiss

15). Exclude patients with any di[trauma]

• Intestinal infection due to 

Clostridium difficile

Discharges with ICD-9-CM code of 008.45 in any secondary diagnosis field per 100 discharges. 

Exclude all obstetric admiss

15). 

• Dosage complications Discharges with ICD-9-CM code denoting a dosage 

complication [Failure in dosage. Excessive amount of blood or other fluid during transfusion or infusion (E873.0), Failure in dosage. Incorrect dilution of fluid during infusion. (E873.1), Failure in dosage. Overdose of radiation in therapy (E873.2) Failure in dosage. 

Exclude all obstetric admiss

15). 
282

Inadvertent exposure of patient to radiation during medical care (E873.3) Failure in dosage in electroshock or insulinshock therapy (E873.4), Failure in dosage. Inappropriate too hot or too cold temperature in local application and packing (E873.5), Failure in dosage, Non -administration of necessary drug or medicinal substance (E873.6), Other specific failure in dosage excludes accidental overdose of drug (E873.8) Unspecified failure in dosage (E873.9), Wrong fluid in infusion (E876.1)] in any diagnosis field per 100 discharges. 

• Postoperative iatrogenic 

complications -digestive 

Secondary dx codes of iatrogenic complication of digestive system (997.4) 

[Surgical] patients 

• Postoperative iatrogenic 

complications - respiratory 

Secondary dx code of iatrogenic complication of respiratory system (997.3) 

[Surgical] patients 

• Postoperative iatrogenic 

complications - urinary 

Secondary dx code of iatrogenic complications of urinary system (997.5) 

[Surgical] patients 

• Postoperative iatrogenic 

complications - vascular 

Secondary dx code of iatrogenic peripheral vascular complication (997.2) 

[Surgical] patients 

• Unexpected LOS/Conditional LOS Unexpected: For each patient a predicted length of stay is 

calculated using a multiple linear regression model. The predicted length of stay depends on the principal diagnosis, age, and comorbidities of the patient. Then, an unexpected length of stay percentage is calculated: (actual LOS – predicted LOS)/predicted LOS. Patients whose percentage is in the upper quartile (top 25%) are considered to have unusually long lengths of stay. (Kuykendall, 1995) Conditional: Patients with an extended length of stay have a hospital stay that is longer than the "extended length of stay point" defined as the point in the distribution (days stayed) where, for any particular DRG, the rate of discharge changes from increasing to decreasing. In other words, at some point, for a group of patients within a DRG, fewer patients are discharged than were discharged on the previous day, and more patients are held in the hospital for longer stays (Silber, 1999). 

All [Surgical] and [Medica
Appendix F 

Detailed Results for Rejected Indicators 

This appendix presents the literature review and clinician panel review results for all indicators 

rejected either pre- or post-panel review. It is organized into three sections. 

Section 1 presents the literature review results for indicators rejected pre-panel review. 

Section 2 presents the literature review results for indicators rejected post-panel review. 

Section 3 presents the clinician panel review results for indicators rejected post-panel review. 

285

APPENDIX F. DETAILED RESULTS FOR REJECTED INDICATORS 

Section 1. Literature Review Results for Indicators Rejected Pre-panel Review

Complications of Anesthesia - Shock 

Source. This indicator was originally proposed by Iezzoni et al.1

 as part of the 

CSP (CSP 8, “post or intraoperative shock due to anesthesia”). Shock due to anesthesia 

(995.4) is the sole ICD-9-CM code in their original definition. It was also included as one 

component of a broader indicator (“adverse events and iatrogenic complications”) in 

AHRQ’s original HCUP Quality Indicators.2

Evidence 

We were unable to find evidence on validity from prior studies, because this 

complication is quite rare. 

Complications Relating to Drugs 

Source. This indicator (precise definition not available) was originally proposed 

by Hannan et al. as a criterion for targeting “cases that would have a higher percentage of 

quality of care problems than cases without the criterion, as judged by medical record 

review.”3 It was redefined and endorsed by Iezzoni et al.1 in the CSP (CSP 28, 

“complications related to drugs”), based on major drug classes: antibiotics, antifungals, 

antivirals, non-narcotic and narcotic analgesics, antipyretics, anesthetics, anticoagulants, 

fibrinolytics, blood products, anticonvulsant and anti-Parkinsonian agents, 

sedatives/hypnotics, psychotropics, stimulants, antineoplastics, immunosuppressants and 

antirheumatics, hormones, antiasthmatics, antiarrhythmics and other cardiovascular 

agents. Needleman and Buerhaus 4 considered adverse drug events as an “Outcome 

Potentially Sensitive to Nursing,” based on input from their Technical Expert Panel, but 

discarded it because the “event rate was too low to be useful.” 

Evidence 

Coding validity. This indicator, as defined in CSP, is highly problematic among 

medical cases (10% confirmation by coders, 20% by physicians), apparently because 

most drug-related complications are present at admission.5, 6

Construct validity. Explicit process of care failures in the CSP validation study 

were very unusual among medical cases with CSP 28 (2%), and no more frequent than 

among unflagged controls (5%). Physician reviewers identified potential quality 

problems in 16% of medical patients with CSP 28 (versus 2% of unflagged controls).6

Based on two-stage implicit review of 8,109 randomly selected deaths from 104 New 

York hospitals in 1985-86, Hannan et al.3

 found that cases with a secondary diagnosis of 

“selected drug poisonings” were no more likely to have received care that departed from 

professionally recognized standards than cases without such codes (2.5% versus 1.7%, 

OR=1.09), after adjusting for patient demographic, geographic, and hospital 

characteristics. We were unable to find other evidence on the validity of this indicator. 

Death Within One (or Two) Days of Any Surgical Procedure 

Source. This indicator (with alternative time windows) was originally proposed 

by Hannan et al. as a criterion for targeting “cases that would have a higher percentage of 
286

quality of care problems than cases without the criterion, as judged by medical record 

review.”3 The University HealthSystem Consortium adopted this indicator for procedures 

involving anesthesia (2836). 

Evidence 

Construct validity. Based on two-stage review of 8,109 randomly selected deaths 

from 104 New York hospitals in 1985-86, Hannan et al.3 reported that patients who died 

within one day of a significant surgical procedure (except for cancer or trauma) were 2.8 

times more likely to have received care that departed from professionally recognized 

standards than other patients who died (4.8% versus 1.7%), after adjusting for patient 

demographic, geographic, and hospital characteristics. In 46 of these 59 cases (78%) of 

substandard care, the patient’s death was attributed at least partially to that care. A twoday window detected 35 additional cases of substandard care, but the association between 

second-day deaths and substandard care was weaker (4.4% versus 1.7%, OR=2.0). We 

were unable to find other evidence on the validity of this indicator. 

In-hospital Burns 

Source. This indicator (940.0-949.5) was originally proposed by Hannan et al. as 

a criterion for targeting “cases that would have a higher percentage of quality of care 

problems than cases without the criterion, as judged by medical record review.”3

 

Evidence 

Construct validity. Based on two-stage review of 8,109 randomly selected deaths 

from 104 New York hospitals in 1985-86, Hannan et al.3 reported that cases with a 

secondary diagnosis of burn were not significantly more likely to have received care that 

departed from professionally recognized standards than cases without that code (7.4% 

versus 1.7%, OR=3.4), after adjusting for patient demographic, geographic, and hospital 

characteristics. We were unable to find other evidence on the validity of this indicator. 

Mechanical Complications 

Source. This indicator was originally proposed by Iezzoni et al.1

 as part of the 

CSP (CSP 10, “mechanical complication due to device, implant or graft, except organ 

transplant”). Their definition excludes mechanical complications due to prosthetic heart 

valves, coronary bypass grafts, other vascular devices or grafts, and nervous system 

devices, implants, or graft. The University HealthSystem Consortium and AHRQ’s 

original HCUP Quality Indicators adopted this CSP indicator for major surgery patients 

(2932); Version 1.3 of the QIs included several additional (new) ICD-9-CM updates.2

Evidence 

Coding validity. CSP 10 had a borderline confirmation rate among major surgical 

cases (61% by coders’ review, 56% by physicians’ review, 73% by nurse-abstracted 

clinical documentation).5-7 In comparison with the VA’s National Surgical Quality 

Improvement Program database from 123 hospitals in 1994-95, in which “graft/prosthetic 

failure within 30 days after surgery” is the only mechanical complication qualifying for 

documentation, ICD-9-CM diagnoses (996.0x-996.5x) had a sensitivity of 14% and a 

predictive value of 2%.8
287

Construct validity. Explicit process of care failures in the CSP validation study 

were only moderately frequent among major surgical cases with CSP 10 (33%), after 

excluding a few patients who had mechanical complications at admission, but unflagged 

controls were not evaluated on the same criteria. Physician reviewers identified potential 

quality problems in 31% of major surgery patients with CSP 10 (versus 2% of unflagged 

controls). 6

 Kovner and Gergen reported that among 506 community hospitals in the 1993 

Nationwide Inpatient Sample, having more registered nurse hours per adjusted patient 

day was not associated with rates of mechanical complications due to a device, implant, 

or graft.9

Other Complications of Surgery 

Source. This indicator (996-999) was originally proposed by Hannan et al. as a 

criterion for targeting “cases that would have a higher percentage of quality of care 

problems than cases without the criterion, as judged by medical record review.”3

However, subsequent authors found this list of ICD-9-CM codes to be overly broad, and 

created more specific indicators from the same list of codes. 

Evidence 

Construct validity. Based on two-stage review of 8,109 randomly selected deaths 

from 104 New York hospitals in 1985-86, Hannan et al.3

 reported that cases with a 

secondary diagnosis of 996-999 were 2.5 times more likely to have received care that 

departed from professionally recognized standards than cases without that code (3.7% 

versus 1.7%), after adjusting for patient demographic, geographic, and hospital 

characteristics. In 24 of these 35 cases (69%) of substandard care, the patient’s death was 

attributed at least partially to that care. 

Postoperative Cardiac Abnormalities Except AMI 

Source. This indicator was originally proposed by Iezzoni et al.1 as part of the 

CSP (CSP 15, “postoperative cardiac abnormalities except AMI”). Their definition 

includes complete atrioventricular block, ventricular tachycardia, ventricular fibrillation, 

and functional abnormalities following cardiac surgery among persons less than 65 years 

of age. 

Evidence 

Coding validity. No evidence on validity is available from CSP studies. Geraci et 

al.10 confirmed only 3 of 20 episodes of ventricular tachycardia, fibrillation, or flutter 

(427.1, 427.4x) reported on discharge abstracts of VA patients hospitalized in 1987-89 

for CHF, COPD, or diabetes; the sensitivity for ventricular tachycardia was 43% (3/7). 

We were unable to find other evidence on the validity of this indicator. 

Postoperative Cerebral Infarction 

Source. This indicator was originally proposed by Iezzoni et al.1

 as part of the 

CSP (CSP 1, “postoperative cerebral infarction”). Their definition is limited to infarctions 

secondary to occlusion or stenosis of precerebral or cerebral arteries, and excludes 

nonspecific strokes. The University HealthSystem Consortium adopted this CSP indicator 

for major surgery patients (2919). 
288

Evidence 

Coding validity. CSP 1 had a high confirmation rate among major surgical cases 

(83% by coders’ review, 86% by physicians’ review).5, 6 Nurse reviews were not 

performed. An earlier study of elderly Medicare beneficiaries from Massachusetts, 

Alabama, Iowa, and New York in FY1993 revealed a similarly high confirmation rate of 

78% (43/55) among major surgical cases, although 28% of those patients (12/43) lacked 

clear documentation of a new or worsening neurologic deficit.11 

Geraci et al.12 confirmed 0 of 26 episodes of cerebrovascular disease (436, 437) 

reported on discharge abstracts of VA patients hospitalized in 1987-89 for CHF, COPD, 

or diabetes; the sensitivity for stroke was 0% (0/2). However, the clinical definition of 

this complication (stroke) was much different from the ICD-9-CM definition (“acute, but 

ill-defined” and “other and ill-defined” cerebrovascular disease). Romano et al. identified 

2 of 6 episodes of cerebrovascular disease (433.x-435.1, 435.8, 436) using discharge 

abstracts of diskectomy patients at 30 California hospitals in 1990-91; there was one false 

positive. In comparison with the VA’s National Surgical Quality Improvement Program 

database from 123 hospitals in 1994-95, the ICD-9-CM diagnosis of stroke (431-434.xx, 

436) had a sensitivity of 70% and a predictive value of 6% for acute stroke within 30 

days after surgery.8 The 1985 National DRG Validation Study also suggested that the 

sensitivity of Medicare hospital claims data exceeds 75% for stroke (431, 432.9, 434.x, 

436), even when it is coded as a secondary diagnosis (n=36) rather than as the reason for 

admission. 13 

Hartz and Kuhn identified only 59 of 125 (47%) strokes by applying a related 

indicator (997.0x) to Medicare patients who underwent coronary artery bypass surgery in 

Wisconsin in 1990-91; the predictive value was 54% (59/117).14 Unfortunately, we found 

no evidence on the validity of the specific ICD-9-CM code for postoperative cerebral 

infarction (997.02), which was introduced in 1995. 

Construct validity. Explicit process of care failures in the CSP validation study 

were no more frequent among cases with CSP 1 (43%) than among unflagged controls 

(46%), after excluding one patient who had stroke at admission. Indeed, cases flagged on 

this indicator were no more likely than unflagged controls (49% versus 52%) to have at 

least one of five specific process-of-care problems in the earlier study of elderly 

Medicare beneficiaries from Massachusetts, Alabama, Iowa, and New York.11 Physician 

reviewers identified potential quality problems in 31% of medical patients with CSP 1 

(versus 2% of unflagged controls).6

Postoperative Coma or Stupor 

Source. This indicator was originally proposed by Iezzoni et al.1

 as part of the 

CSP (CSP 18, “postoperative coma or stupor”). Their original definition was limited to 

coma, stupor, and persistent vegetative state. Needleman and Buerhaus4

 identified 

postoperative central nervous system (CNS) complications as an “Outcome Potentially 

Sensitive to Nursing,” but their broader definition also includes acute delirium (293.0), 

reactive confusion (298.2), and reactive depression (309). 

Evidence 

Coding validity. In comparison with the VA’s National Surgical Quality 

Improvement Program database from 123 hospitals in 1994-95, in which only coma 
289

“persisting >24 hours postoperatively” qualifies for documentation, the ICD-9-CM 

diagnosis of coma (780-780.01) had a sensitivity of 16% and an uninterpretable 

predictive value. 8

Construct validity. Needleman and Buerhaus4

 found that nurse staffing was 

inconsistently associated with the occurrence of CNS complications among major surgery 

patients from 799 hospitals in 11 states in 1997, and was independent of CNS 

complications among medical patients. 

Postoperative Complications Related to Urinary Tract Anatomy

Source. This indicator was originally proposed by Iezzoni et al.1

 as part of the 

CSP (CSP 5, “postoperative complications related to urinary tract anatomy”). Their 

definition includes stricture or kinking or ureter and other ureteric obstruction. 

Evidence 

We were unable to find evidence on validity from prior studies, because this 

complication is quite rare. 

Postoperative Gastrointestinal Hemorrhage or Ulceration 

Source. This indicator was originally proposed by Iezzoni et al.1 as part of the 

CSP (CSP 4, “postoperative gastrointestinal hemorrhage or ulceration following non-GI 

surgery”). Their definition includes hemorrhage or acute nontraumatic perforation 

involving the esophagus, stomach, duodenum, jejunum, or unspecified gastrointestinal 

tract. The University HealthSystem Consortium (2928) and AHRQ’s original HCUP 

Quality Indicators adopted this CSP indicator for major surgery patients.2 Needleman and 

Buerhaus4 identified postoperative gastrointestinal hemorrhage as an “Outcome 

Potentially Sensitive to Nursing,” but their definition excludes alcoholic, atrophic, and 

hypertrophic gastritis (535.11, 535.21, 535.31, 535.51, 535.61), excludes hemorrhage due 

to chronic ulcer, and includes acute and unspecified ulcers without hemorrhage or 

perforation. 

Evidence 

Coding validity. CSP 4 had a moderately high confirmation rate among major 

surgical cases (66% by coders’ review, 73% by physicians’ review, 68% by nurseabstracted clinical documentation, and 75% if nurses also accepted physicians’ notes as 

adequate documentation).5-7 An earlier study of elderly Medicare beneficiaries from 

Massachusetts, Alabama, Iowa, and New York in FY1993 revealed a similarly high 

confirmation rate of 83% (68/82) among major surgical cases, although 26% (18/68) of 

those patients lacked laboratory or clinical evidence of significant blood loss.11 

By contrast, Geraci et al.12 confirmed 1 of 10 episodes of gastrointestinal 

hemorrhage (531.0, 531.2, 531.4, 531.6, 532.0, 532.2, 532.4, 532.6, 533.0, 533.2, 533.4, 

533.6, 534.0, 534.2, 534.4, 534.6, 535.1, 537.83, 562.02-562.03, 562.12-562.13, 569.3, 

569.85, 596.7) reported on discharge abstracts of VA patients hospitalized in 1987-89 for 

CHF, COPD, or diabetes; the sensitivity for hemorrhage requiring transfusion was 11% 

(1/9). 

Construct validity. Explicit process of care failures in the CSP validation study 

were only moderately frequent among major surgical cases with CSP 4 (28%), after 
290

excluding one patient who had gastrointestinal hemorrhage at admission.15 Cases flagged 

on this indicator and unflagged controls did not differ significantly on a composite of 17 

generic process criteria. Similarly, cases flagged on this indicator were no more likely 

than unflagged controls (26% versus 22%) to have at least one of four specific processof-care problems in the earlier study of elderly Medicare beneficiaries from 

Massachusetts, Alabama, Iowa, and New York.11 Physician reviewers identified potential 

quality problems in 38% of major surgery patients with CSP 4 (versus 2% of unflagged 

controls).6

Needleman and Buerhaus4

 found that higher registered nurse staffing (RN 

hours/adjusted patient day) and better nursing skill mix (RN hours/licensed nurse hours) 

were consistently associated with the occurrence of upper gastrointestinal hemorrhage 

among medical patients from 799 hospitals in 11 states in 1997, but were independent of 

gastrointestinal hemorrhage among major surgery patients. An increase from the 25th to 

the 75th percentile on these two measures of staffing was associated with 5.2% (95% CI, 

1.4% to 8.9%) and 5.1% (95% CI, 0.5% to 9.7%) decreases, respectively, in the rate of 

upper gastrointestinal hemorrhage among medical patients.16 Kovner and Gergen 

reported that among 506 community hospitals in the 1993 Nationwide Inpatient Sample, 

having more registered nurse hours per adjusted patient day was not associated with rates 

of upper gastrointestinal hemorrhage after major surgery.9

Postoperative Infection 

Source. This indicator was originally proposed by Iezzoni et al.1 as part of the 

CSP (CSP 23, “wound infection”). Their definition, which includes both posttraumatic 

wound infection and unspecified postoperative infection, was included in AHRQ’s 

original HCUP Quality Indicators.2 Needleman and Buerhaus4 identified postoperative 

infection as an “Outcome Potentially Sensitive to Nursing,” using the same CSP 

definition. It was endorsed by Miller et al. 17 in the original “AHRQ PSI Algorithms and 

Groupings,” although their definition excluded posttraumatic wound infection (958.3). 

Evidence 

Coding validity. CSP 23 (including both 998.5x and 958.3) had a high 

confirmation rate among major surgical cases (91% by coders’ review, 61% by 

physicians’ review, 60% by nurse-abstracted clinical documentation), but a poor 

confirmation rate among medical cases (28% by coders’ review, 24% by physicians’ 

review).5-7 Nurse reviews were not performed on medical cases, most of which were 

apparently present at admission. An earlier study of elderly Medicare beneficiaries from 

Massachusetts, Alabama, Iowa, and New York in FY1993 revealed even poorer 

confirmation rates of 43% (40/93) among major surgical cases (of whom 20 or 50% 

lacked physical examination evidence of the diagnosis) and 8% (7/86) among medical 

cases (of whom 2 or 29% lacked physical examination evidence of the diagnosis).11

Keeler et al.18 reported a confirmation rate of 75% (6/8) but a sensitivity of only 

27% (6/22) for postoperative infection (998.5x) among Medicare hip fracture patients 

from 297 hospitals in 1985-86. Massanari et al. 19 identified 45% of cases of “nosocomial 

wound infection” using 1984 hospital discharge data from the University of Iowa, but no 

definitions were provided. Faciszewski et al.20 confirmed 71% (5/7) of reported cases of 

postoperative infection (998.5x) among 310 patients who underwent spinal fusion at the 
291

Marshfield Clinic in 1991-92. The sensitivity of coding for this complication was 28% 

(5/18). Among 185 total knee replacement patients from 5 Ontario hospitals in 1984-90, 

Hawker et al.21 found that the sensitivity and predictive value of unspecified 

postoperative infection codes were both 50% (2/4). Romano et al.22 identified 5 of 8 

episodes of postoperative infection (998.5x, 999.3, 996.62) using discharge abstracts of 

diskectomy patients at 30 California hospitals in 1990-91; there were two false positives. 

Hartz and Kuhn identified only 46 of 385 (12%) infections by applying this indicator 

(998.5, 999.3, 996.6x) to Medicare patients who underwent coronary artery bypass 

surgery in Wisconsin in 1990-91; the predictive value was 84% (46/55).14 Belio-Blasco et 

al.23 reported that “discharge forms” had a sensitivity of 57% (132/230) and a specificity 

of 99.9% for identifying nosocomial surgical wound infection among surgical patients in 

a Spanish teaching hospital. In comparison with the VA’s National Surgical Quality 

Improvement Program database from 123 hospitals in 1994-95, the ICD-9-CM diagnosis 

of wound infection (998.5x) had a sensitivity of 21% and a predictive value of 35% for 

wound infection within 30 days after surgery.8

Construct validity. Explicit process of care failures in the CSP validation study 

were only moderately frequent among major surgical cases with CSP 23 (24%), after 

excluding two patients who had wound infections at admission, and no more frequent 

among medical cases with CSP 23 than among unflagged controls (2% versus 5%, 

respectively). Major surgical cases flagged on this indicator and unflagged controls did 

not differ significantly on a composite of 17 generic process criteria. Similarly, cases 

flagged on this indicator did not differ significantly from unflagged controls (among 

either major surgical or medical cases) on one specific process-of-care problem in the 

earlier study of elderly Medicare beneficiaries from Massachusetts, Alabama, Iowa, and 

New York.11 Physician reviewers identified potential quality problems in 26% of major 

surgery patients and 3% of medical patients with CSP 23 (versus 2% of unflagged 

controls for each risk group).6

 Needleman and Buerhaus4 found that nurse staffing was 

independent of the occurrence of wound infection among major surgery patients from 

799 hospitals in 11 states in 1997. 

Postoperative Infections Except Pneumonia and Wound 

Source. This indicator was originally proposed by Iezzoni et al.1

 as part of the 

CSP (CSP 16, “postoperative infections except pneumonia and wound”). Their original 

definition included Clostridium difficile infection (which we also considered as a separate 

indicator, rejected #3), bacterial meningitis, empyema with or without fistula, mediastinal 

abscess, mediastinitis, acute or unspecified pyelonephritis, acute lymphadenitis. The 

University HealthSystem Consortium adopted this CSP indicator for major surgery 

patients (2937). Needleman and Buerhaus 4

 considered “miscellaneous nosocomial 

infections” as an “Outcome Potentially Sensitive to Nursing,” based on input from their 

Technical Expert Panel, but discarded it after concluding that it was “not codable on the 

basis of discharge abstracts.” 

Evidence 

Coding validity. CSP 16 had a relatively high confirmation rate among major 

surgical cases (72% by coders’ review, 73% by physicians’ review, 73% by nurseabstracted clinical documentation, and 77% if nurses also accepted physicians’ notes as 

adequate documentation).5-7
292

Construct validity. Explicit process of care failures in the CSP validation study 

were only moderately frequent among major surgical cases with CSP 16 (44%), after 

excluding a few patients who had infections at admission, but unflagged controls were 

not evaluated on the same criteria. Physician reviewers identified potential quality 

problems in 40% of major surgery patients with CSP 16 (versus 2% of unflagged 

controls).6

 Nursing skill mix was significantly associated (in the expected direction) with 

the aggregate rate of postoperative infections among 352 and 295 California hospitals in 

1992 and 1994, respectively, but not among 126 and 131 New York hospitals in the same 

years.

24 However, these authors used an entirely different definition of postoperative 

infections, which only partially overlapped the CSP 16 definition. 

Shock or Cardiopulmonary Arrest In-hospital 

Source. This indicator was originally proposed by Iezzoni et al.1

 as part of the 

CSP (CSP 12, “shock or cardiopulmonary arrest in hospital”). Their definition includes 

cardiac arrest, respiratory arrest, shock, and cardiogenic shock. Needleman and 

Buerhaus4

 identified shock or cardiac arrest as an “Outcome Potentially Sensitive to 

Nursing,” but their definition also includes various resuscitative procedures (93.93, 

99.60, 99.63). 

Evidence 

Coding validity. CSP 12 had a borderline confirmation rate among major surgical 

cases (53% by coders’ review, 74% by physicians’ review).5, 6 Nurse reviews were not 

performed. An earlier study of elderly Medicare beneficiaries from Massachusetts, 

Alabama, Iowa, and New York in FY1993 revealed a similar confirmation rate of 72% 

(58/81) among major surgical cases, although 2% (1/58) of those patients lacked clear 

documentation of cardiac arrest, respiratory arrest, hypotension, or poor perfusion.11 

Geraci et al.10 confirmed only 4 of 16 episodes of cardiac arrest (427.5), 

hypotension, or shock (458, 785.5x) reported on discharge abstracts of VA patients 

hospitalized in 1987-89 for CHF, COPD, or diabetes; the sensitivity for cardiac arrest or 

shock was 19% (4/21). Romano et al. identified 3 of 16 episodes of hypotension, shock, 

or cardiac arrest (785.5x, 427.5, 458.9, 998.0, 37.91) using discharge abstracts of 

diskectomy patients at 30 California hospitals in 1990-91; there were no false positives 

(but these findings are driven mostly by hypotension, a far milder diagnosis than shock). 

Although postoperative shock is properly assigned a different code (998.0) than other 

causes of shock, Keeler et al.18 reported a sensitivity of only 2% (1/55), with no false 

positives, for this diagnosis among Medicare hip fracture patients from 297 hospitals in 

1985-86. In comparison with the VA’s National Surgical Quality Improvement Program 

database from 123 hospitals in 1994-95, in which “cardiac arrest” is defined as involving 

cardiopulmonary resuscitation within 30 days after surgery, the ICD-9-CM diagnosis 

(427.5) had a sensitivity of 27% and a predictive value of 56%.8

Construct validity. Explicit process of care failures in the CSP validation study 

were no more frequent among cases with CSP 12 (44%) than among unflagged controls 

(46%), after excluding one patient who had shock at admission. Physician reviewers 

identified potential quality problems in 18% of major surgery patients with CSP 12 

(versus 2% of unflagged controls).6 

Needleman and Buerhaus4

 found that higher registered nurse staffing (RN 

hours/adjusted patient day) and better nursing skill mix (RN hours/licensed nurse hours) 
293

were consistently associated with the occurrence of shock or cardiorespiratory arrest 

among medical patients from 799 hospitals in 11 states in 1997, but were independent of 

these outcomes among major surgery patients. An increase from the 25th to the 75th

percentile on these two measures of staffing was associated with 4.1% (95% CI, -2.5% to 

10.8%) and 9.4% (95% CI, 2.6% to 16.3%) decreases, respectively, in the rate of shock 

or cardiorespiratory arrest among medical patients.16 

Urinary Tract Infection 

Source. This indicator (599.0) was originally developed under the auspices of the 

Healthcare Cost and Utilization Project. Needleman and Buerhaus4

 identified urinary 

tract infection (599.0, 996.64) as an “Outcome Potentially Sensitive to Nursing.” 

Evidence 

Coding validity. Massanari et al.19 identified 62% of cases of “nosocomial urinary 

tract infection” (UTI) using 1984 hospital discharge data from the University of Iowa, but 

no definitions were provided. Geraci et al.10 confirmed only 7 of 86 (8%) episodes of UTI 

(599.x) reported on discharge abstracts of Veterans Affairs (VA) patients hospitalized in 

1987-89 for congestive heart failure (CHF), chronic obstructive pulmonary disease 

(COPD), or diabetes; the sensitivity for a urinary tract infection was 64% (7/11). Romano 

et al.22 identified 17 of 36 episodes of UTI (590.1x, 590.2, 590.8x, 590.9, 595.0, 595.9, 

599.0, 996.64) using discharge abstracts of diskectomy patients at 30 California hospitals 

in 1990-91; there were five false positives. Belio-Blasco et al.23 reported that “discharge 

forms” had a sensitivity of 38% (33/87) and a specificity of 99.9% for identifying 

nosocomial UTIs among surgical patients in a Spanish teaching hospital. In comparison 

with the VA’s National Surgical Quality Improvement Program database from 123 

hospitals in 1994-95, an ICD-9-CM diagnosis of kidney, bladder, or urinary tract 

infection (590.x, 595.x, 599.0) had a sensitivity of 45% and a predictive value of 24% for 

UTIs within 30 days after surgery (excluding catheter-related infections, 996.64).8

Construct validity. Needleman and Buerhaus4 found that higher registered nurse 

staffing (RN hours/adjusted patient day) and better nursing skill mix (RN hours/licensed 

nurse hours) were consistently associated with the occurrence of UTI among medical 

patients from 799 hospitals in 11 states in 1997. An increase from the 25th to the 75th

percentile on these two measures of staffing was associated with 3.6% (95% CI, 1.2% to 

6.0%) and 9.0% (95% CI, 6.1% to 11.9%) decreases, respectively, in the rate of UTI 

among medical patients.16 Nursing skill mix was associated with the UTI rate among 

major surgery patients (rate ratio 0.48, 95% CI 0.38-0.61), but aggregate registered nurse 

staffing was not (rate ratio 0.99, 95% CI 0.98-1.00). An increase from the 25th to the 75th

percentile on nursing skill mix was associated with a 4.9% (95% CI, 0.3% to 9.5%) 

decrease in the rate of UTI among major surgery patients. These findings are consistent 

with Kovner and Gergen, who reported that among 506 community hospitals in the 1993 

Nationwide Inpatient Sample, having more registered nurse hours per adjusted patient 

day was associated with a lower rate of UTI after major surgery.9 Nursing skill mix was 

significantly associated (in the expected direction) with the UTI rate among 352 and 295 

California hospitals in 1992 and 1994, respectively, and among 131 New York hospitals 

in 1994.24 Total licensed nurses were not associated with the UTI rate in either state or 

either time period. 
294

Section 2. Literature Review Results for Indicators Rejected Post-panel Review 

Dosage Complications 

Source. This diagnosis code was originally proposed by Iezzoni et al.1

 as one 

component of a much broader indicator (CSP 28, “complications related to drugs”), 

which was part of the CSP. It was endorsed by Miller et al. 17 as one component of a 

broader indicator (“E codes”) in the original “AHRQ PSI Algorithms and Groupings.” 

Evidence 

Coding validity. This indicator, as defined in CSP, is highly problematic among 

medical cases (10% confirmation by coders, 20% by physicians), apparently because 

most drug-related complications are present at admission.5, 6 The AHRQ definition, and 

the present PSI definition, differ by excluding all of the poisoning codes. No evidence on 

the validity of the E code subset, by itself, is available from prior studies. 

Construct validity. Explicit process of care failures in the CSP validation study 

were very unusual among medical cases with CSP 28 (2%), and no more frequent than 

among unflagged controls (5%). Physician reviewers identified potential quality 

problems in 16% of medical patients with CSP 28 (versus 2% of unflagged controls).6

Based on two-stage implicit review of 8,109 randomly selected deaths from 104 New 

York hospitals in 1985-86, Hannan et al. found that cases with a secondary diagnosis of 

“selected drug poisonings” were no more likely to have received “care that departed from 

professionally recognized standards” than cases without such codes (2.5% versus 1.7%, 

OR=1.09), after adjusting for patient demographic, geographic, and hospital 

characteristics.3 

Iatrogenic Hypotension 

Source. This diagnosis code was proposed by Miller et al.17 as one component of 

a broader indicator (“iatrogenic conditions”), which was part of the original “AHRQ PSI 

Algorithms and Groupings.” It was also included as one component of a broader indicator 

(“adverse events and iatrogenic complications”) in AHRQ’s Version 1.3 HCUP Quality 

Indicators.2

Evidence 

We were unable to find evidence on validity from prior studies, because this 

diagnosis code was introduced in 1995. 

Intestinal Infection Due to Clostridium difficile

Source. This diagnosis code was originally proposed by Iezzoni et al.1

 as one 

component of a much broader indicator (CSP 16, “postoperative infections except 

pneumonia and wound”), which was part of the CSP. 

Evidence 

Coding validity. No evidence on validity is available from CSP studies, because 

this code was grouped with other postoperative infections. Geraci et al.12 identified 0 of 6 

episodes of antibiotic-associated diarrhea using the discharge abstracts of VA patients 

hospitalized in 1987-89 for CHF, COPD, or diabetes. However, the clinical definition of 
295

this complication (antibiotic-associated diarrhea) was much broader than the ICD-9-CM 

definition (Clostridium difficile colitis). 

Postoperative Iatrogenic Complications - Digestive 

Source. This diagnosis code was originally proposed by Iezzoni et al.1

 as one 

component of a much broader indicator (CSP 26, “iatrogenic complications”), which was 

part of the CSP. Their definition includes central nervous system, cardiac, peripheral 

vascular, respiratory, gastrointestinal, urinary, and unspecified amputation stump 

complications, as well as complications affecting other body systems. It was also 

included as one component of a broader indicator (“adverse events and iatrogenic 

complications”) in AHRQ’s original HCUP Quality Indicators.2 The University 

HealthSystem Consortium adopted this CSP indicator for cardiac procedure patients 

(2913). 

Evidence 

Coding validity. CSP 26 had a very high confirmation rate among major surgical 

cases (92% by coders’ review) and a borderline confirmation rate among medical cases 

(59% by coders’ review).5

 Physician reviews were not performed. Faciszewski et al. 20

confirmed 48% (10/21) of reported cases of gastrointestinal complications (997.4) among 

310 patients who underwent spinal fusion at the Marshfield Clinic in 1991-92. The 

sensitivity of coding for this complication was 40% (10/25). Romano et al.22 identified 7 

of 15 episodes of gastrointestinal complications (with 3 false positives) using discharge 

abstracts of diskectomy patients at 30 California hospitals in 1990-91. 

Construct validity. Explicit process of care failures in the CSP validation study 

were slightly but not significantly more frequent among cases with CSP 26 (58% 

surgical, 9% medical) than among unflagged controls (46% surgical, 5% medical). 

Postoperative Iatrogenic Complications - Respiratory 

Source. This diagnosis code was originally proposed by Iezzoni et al.1 as one 

component of a much broader indicator (CSP 26, “iatrogenic complications”), which was 

part of the CSP. Their definition includes central nervous system, cardiac, peripheral 

vascular, respiratory, gastrointestinal, urinary, and unspecified amputation stump 

complications, as well as complications affecting other body systems. It was also 

included as one component of a broader indicator (“adverse events and iatrogenic 

complications”) in AHRQ’s original HCUP Quality Indicators.2

 The University 

HealthSystem Consortium adopted this CSP indicator for cardiac procedure patients 

(2913). 

Evidence 

Coding validity. CSP 26 had a very high confirmation rate among major surgical 

cases (92% by coders’ review) and a borderline confirmation rate among medical cases 

(59% by coders’ review).5

 Physician reviews were not performed. Faciszewski et al.20

confirmed 48% (11/23) of reported cases of respiratory complications (997.3) among 310 

patients who underwent spinal fusion at the Marshfield Clinic in 1991-92. The sensitivity 

of coding for this complication was 55% (11/20). Romano et al.22 identified 2 of 10 
296

episodes of respiratory complications (with 7 false positives) using discharge abstracts of 

diskectomy patients at 30 California hospitals in 1990-91. 

Construct validity. Explicit process of care failures in the CSP validation study 

were slightly but not significantly more frequent among cases with CSP 26 (58% 

surgical, 9% medical) than among unflagged controls (46% surgical, 5% medical). We 

were unable to find other evidence on the validity of this indicator. 

Postoperative Iatrogenic Complications - Urinary 

Source. This indicator was originally proposed by Hannan et al. as a criterion for 

targeting “cases that would have a higher percentage of quality of care problems than 

cases without the criterion, as judged by medical record review.”3

 It was endorsed by 

Iezzoni et al.1

 as one component of a much broader indicator (CSP 26, “iatrogenic 

complications”) in the CSP. The definition of that indicator includes central nervous 

system, cardiac, peripheral vascular, respiratory, gastrointestinal, urinary, and unspecified 

amputation stump complications, as well as complications affecting other body systems. 

It was also included as one component of a broader indicator (“adverse events and 

iatrogenic complications”) in AHRQ’s original HCUP Quality Indicators.2

 The 

University HealthSystem Consortium adopted this CSP indicator for cardiac procedure 

patients (2913). 

Evidence 

Coding validity. CSP 26 had a very high confirmation rate among major surgical 

cases (92% by coders’ review) and a borderline confirmation rate among medical cases 

(59% by coders’ review).5 Physician reviews were not performed. Faciszewski et al. 20

confirmed 56% (5/9) of reported cases of genitourinary complications (997.5) among 310 

patients who underwent spinal fusion at the Marshfield Clinic in 1991-92. The sensitivity 

of coding for this complication was 19% (5/26). Among 185 total knee replacement 

patients from 5 Ontario hospitals in 1984-90, Hawker et al.21 found that the sensitivity 

and predictive value of urinary tract complications (definition not given) were 38% (6/16) 

and 50% (6/12), respectively. Romano et al. identified 5 of 17 episodes of urinary 

complications (996.76, 997.5), with 8 false positives, using discharge abstracts of 

diskectomy patients at 30 California hospitals in 1990-91. Hartz and Kuhn identified only 

18 of 113 (16%) episodes of acute renal failure (defined as an increase in serum 

creatinine of more than 1.0 mg/dL, resulting in a final value greater than 2.5 mg/dL) by 

applying this indicator to Medicare patients who underwent coronary artery bypass 

surgery in Wisconsin in 1990-91; the predictive value was 27% (18/66).14 

Construct validity. Explicit process of care failures in the CSP validation study 

were slightly but not significantly more frequent among cases with CSP 26 (58% 

surgical, 9% medical) than among unflagged controls (46% surgical, 5% medical). Based 

on two-stage review of 8,109 randomly selected deaths from 104 New York hospitals in 

1985-86, Hannan et al.3 reported that cases with a secondary diagnosis of 997.5 (urinary) 

were 3.2 times more likely to have received care that departed from professionally 

recognized standards than cases without that code (6.0% versus 1.7%), after adjusting for 

patient demographic, geographic, and hospital characteristics. In 4 of these 9 cases (44%) 

of substandard care, the patient’s death was attributed at least partially to that care. 
297

Postoperative Iatrogenic Complications - Vascular 

Source. This diagnosis code was originally proposed by Iezzoni et al.1

 as one 

component of a much broader indicator (CSP 26, “iatrogenic complications”), which was 

part of the CSP. Their definition includes central nervous system, cardiac, peripheral 

vascular, respiratory, gastrointestinal, urinary, and unspecified amputation stump 

complications, as well as complications affecting other body systems. It was also 

included as one component of a broader indicator (“adverse events and iatrogenic 

complications”) in AHRQ’s original HCUP Quality Indicators.2 The University 

HealthSystem Consortium adopted this CSP indicator for cardiac procedure patients 

(2913). 

Evidence 

Coding validity. CSP 26 had a very high confirmation rate among major surgical 

cases (92% by coders’ review) and a borderline confirmation rate among medical cases 

(59% by coders’ review).5 Physician reviews were not performed. 

Construct validity. Explicit process of care failures in the CSP validation study 

were slightly but not significantly more frequent among cases with CSP 26 (58% 

surgical, 9% medical) than among unflagged controls (46% surgical, 5% medical). We 

were unable to find other evidence on the validity of this indicator. 

Postoperative Pneumonia 

Source. This indicator was originally proposed by Iezzoni et al.1 as part of the 

CSP (CSP 19, “postoperative pneumonia”). Their definition includes virtually all 

bacterial causes of pneumonia (481-483, 485-486). Needleman and Buerhaus 4 identified 

postoperative pneumonia as an “Outcome Potentially Sensitive to Nursing,” but their 

definition aggregates bacterial, aspiration (507.0), and “hypostatic” (514) pneumonia, 

includes nonspecific respiratory complications (997.3), and excludes pneumococcal (481) 

and atypical (483) pneumonias. The University HealthSystem Consortium (2943) and 

AHRQ’s original HCUP Quality Indicators adopted this CSP indicator for major surgery 

patients.2

Evidence 

Coding validity. CSP 19 had a moderate confirmation rate among major surgical 

cases (unreported by coders’ review, 64% by physicians’ review, 48% by nurseabstracted clinical documentation, and 76% if nurses also accepted physicians’ notes as 

adequate documentation). 6, 7 An earlier study of elderly Medicare beneficiaries from 

Massachusetts, Alabama, Iowa, and New York in FY1993 revealed a similar 

confirmation rate of 76% (75/99) among major surgical cases, although 17% of those 

patients (13/75) lacked radiographic or laboratory evidence supporting the diagnosis.11 

Keeler et al.18 reported a confirmation rate of 75% (30/40) but a sensitivity of 

only 26% (30/116) for pneumonia (482.x, 485, 486, 997.3, 998.5, 999.3) among 

Medicare hip fracture patients from 297 hospitals in 1985-86. All of the false positives in 

that study were due to 900-series codes. Massanari et al.19 identified 61% of cases of 

“nosocomial lower respiratory tract infection” using 1984 hospital discharge data from 

the University of Iowa, but no definitions were provided. Geraci et al.12 confirmed (by 

chest radiography) 0 of 7 episodes of pneumonia (482.9, 507.0) reported on discharge 
298

abstracts of VA patients hospitalized in 1987-89 for CHF, COPD, or diabetes; the 

sensitivity for a new alveolar infiltrate was 0% (0/5). Romano et al. 22 identified 1 of 1 

episode of pneumonia (480.0-487.0, 507.0, 510.x, 513.x), with 3 false positives, using 

discharge abstracts of diskectomy patients at 30 California hospitals in 1990-91. BelioBlasco et al. 23 reported that “discharge forms” had a sensitivity of 44% (29/66) and a 

specificity of 99.9% for identifying nosocomial pneumonia among surgical patients in a 

Spanish teaching hospital. In comparison with the VA’s National Surgical Quality 

Improvement Program database from 123 hospitals in 1994-95, in which pneumonia is 

defined as a radiographic infiltrate associated with purulent sputum, positive culture/viral 

isolation, or seroconversion within 30 days after surgery, ICD-9-CM diagnoses (480-

487.0) had a sensitivity of 38% and a predictive value of 41%.8? Adding “respiratory 

complications” (997.3) to the definition increased the sensitivity for pneumonia to 50%, 

but decreased the positive predictive value to 34%. 

Construct validity. Explicit process of care failures in the CSP validation study 

were very frequent among major surgical cases with CSP 19 (83%), after excluding two 

patients who had pneumonia at admission.15 Cases flagged on this indicator and 

unflagged controls did not differ significantly on a composite of 17 generic process 

criteria. Indeed, cases flagged on this indicator were significantly less likely than 

unflagged controls (20% versus 64%) to have at least one of four specific process-of-care 

problems in the earlier study of elderly Medicare beneficiaries from Massachusetts, 

Alabama, Iowa, and New York.11 Physician reviewers identified potential quality 

problems in only 5% of major surgery patients with CSP 19 (versus 2% of unflagged 

controls).6 The striking discrepancy between the results of explicit nurse review and 

implicit physician review is not explained. 

Needleman and Buerhaus4

 found that higher registered nurse staffing (RN 

hours/adjusted patient day) and better nursing skill mix (RN hours/licensed nurse hours) 

were consistently associated with the occurrence of pneumonia (including aspiration and 

“hypostatic” pneumonia) among medical patients from 799 hospitals in 11 states in 1997. 

An increase from the 25th to the 75th percentile on these two measures of staffing was 

associated with 2.7% (95% CI, -0.4% to 5.8%) and 6.4% (95% CI, 2.8% to 10.0%) 

decreases, respectively, in the rate of pneumonia.16 Skill mix was “weakly” associated 

with the rate of pneumonia among major surgical patients. These findings are consistent 

with Kovner and Gergen, who reported that among 506 community hospitals in the 1993 

Nationwide Inpatient Sample, having more registered nurse hours per adjusted patient 

day was associated with a lower rate of pneumonia after major surgery.9

 Nurse staffing 

was not associated with the rate of pneumonia after invasive vascular procedures. 

Nursing skill mix was significantly associated (in the expected direction) with the 

pneumonia rate among 352 and 295 California hospitals in 1992 and 1994, respectively, 

but not among 126 and 131 New York hospitals in the same years.24 

Unexpected Length of Stay (LOS)/Conditional LOS 

Source. This indicator was originally proposed by Kuykendall et al.25 as a 

relatively unbiased tool to identify potential quality of care problems. The underlying 

premise was that significant complications increase LOS, and therefore unexpectedly 

long LOS may be a marker for inpatient complications. Poor provider adherence to 

normative practices may lead to either unexpectedly short or unexpectedly long LOS. 
299

Evidence 

Kuykendall et al’s original analysis was based on linked medical records and 

administrative data for 1,477 patients who were discharged from 9 VA hospitals in 1987-

89 with a primary diagnosis of diabetes, (COPD), or CHF. They used administrative data 

with or without additional clinical data (e.g., APACHE Acute Physiology Score) to 

derive expected LOS through multiple linear regression. Outliers were defined as patients 

whose deviation from expected LOS (expressed as a proportion of expected LOS) was 

either below the first quartile or above the third quartile. When this method was used to 

identify possible complications, and then compared with detailed chart abstraction, it had 

a sensitivity of 40%, 62%, and 54% for complications of diabetes, COPD, and CHF, 

respectively. By contrast, the sensitivity of the corresponding ICD-9-CM complication 

codes was 26%, 39%, and 33%, respectively. The confirmation rate, or predictive value, 

of unexpectedly high LOS was 20%, 29%, and 27% for diabetes, COPD, and CHF, 

respectively. These estimates were quite similar to the predictive values of ICD-9-CM 

codes (21%, 32%, and 33%, respectively). We were unable to find any independent 

validation of these findings.

More recently, Silber et al. proposed a more complex method for using LOS to 

identify adverse patient outcomes.26 Their method is based on the observation that with 

each passing day, patients are increasingly likely to be discharged until a transition point 

is reached, at which patients become less likely to be discharged the longer they have 

stayed. Silber et al. focus on the minority of patients whose hospital stay is prolonged 

beyond the transition point, and estimate the length of additional stay (LAS) beyond this 

point. Cox proportional hazards models were used to estimate LAS among prolongedstay patients admitted for appendectomy and pneumonia, adjusting for demographic and 

clinical characteristics (e.g., MedisGroups severity score). We were unable to find any 

independent validation of these findings. 

Obstetric Thrombosis or Embolism 

Source. This indicator was created after review of ICD-9-CM codes. 

Evidence 

Coding validity. In a stratified probability sample of 1,611 vaginal and cesarean 

deliveries from 51 California hospitals in 1992-93, the weighted sensitivity and predictive 

value of coding for thromobembolic complications of delivery, using a broader definition 

that included all peripheral vascular complications (997.2) and nonthrombotic pulmonary 

emboli (673.1x, 673.3x, 673.8x), were 0% (0/6) and 100% (6/6), respectively.27 We were 

unable to find evidence on validity from prior studies, because this complication is quite 

rare. 

Puerperal Infection 

Source. This indicator (670.0x) was created after review of ICD-9-CM codes. It 

was also included as one component of a broader indicator (“obstetrical complications”) 

in AHRQ’s original HCUP Quality Indicators.2
300

Evidence 

In a stratified probability sample of 1,611 vaginal and cesarean deliveries from 51 

California hospitals in 1992-93, the weighted sensitivity and predictive value of coding 

for puerperal infection and acute or unspecified endometritis (615.0, 615.9) were 45% 

(45/124) and 98% (45/53), respectively.27 We were unable to find other evidence on 

validity from prior studies. 
301

Section 3. Clinician Panel Review Detailed Results for Rejected Indicators 

Dosage Complications 

This indicator is intended to flag cases of complications due to dosage errors that 

can be identified using administrative data. It is intended to capture all cases of dosage 

complications, not only those occurring in-hospital. 

Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM code denoting a dosage complication 

[Excessive amount of blood or other fluid during transfusion or infusion 

(E873.0), Incorrect dilution of fluid during infusion. (E873.1), Overdose 

of radiation in therapy (E873.2) Inadvertent exposure of patient to 

radiation during medical care (E873.3) Failure in dosage in electroshock 

or insulin-shock therapy (E873.4), Inappropriate too hot or too cold 

temperature in local application and packing (E873.5), Non -

administration of necessary drug or medicinal substance (E873.6), Other 

specific failure in dosage excludes accidental overdose of drug (E873.8) 

Unspecified failure in dosage (E873.9), Wrong fluid in infusion (E876.1)] 

in any diagnosis field per 100 discharges.

Denominator Exclude all obstetric admissions (MDC 14 and 15).

Post-conference call panel ratingsa 

a

 Medical Complications 2 Multispecialty Panel 

Changes to the indicator 

Panelists did not suggest any changes to this indicator. 

Concerns not addressable through changes

Panelists expressed a multitude of concerns regarding this indicator. The 

definition of this indicator included a variety of dosage complications, coded as E873.x. 

These complications do not include failure in dosage of a medicinal substance, or 

accidental poisoning. Adverse drug events are difficult to ascertain from administrative 

data. Panelists felt that the included dosage complications were often of dubious clinical 

importance, and in some cases very rare. Panelists also noted that a better denominator, 

but one that cannot be operationalized using administrative data, would be number of 

doses, rather than all patients most of whom would never have been exposed to the 

treatments measured in this indicator. 

Question Median Agreement status 

Overall rating 4 Disagreement 

Not present on admission 7 Indeterminate agreement 

Preventability 8 Agreement 

Due to medical error 8 Agreeement 

Charting by physicians 3 Indeterminate agreement 

Bias (lower rating is favorable) 4 Indeterminate agreement 
302

 Panelists also expressed great concern regarding the documentation of these events. 

According to panelists, most of these events would not result in significant clinical 

sequelae, and therefore would be unreliably reported. Panelists noted that this indicator 

would have very poor sensitivity, and thus would not be useful. In addition, using an 

indicator with such poor sensitivity may unfairly punish those hospitals with the most 

detailed reporting systems for quality improvement. It may even discourage reporting of 

these events in some facilities. Due to the difficulties with this indicator, panelists felt 

that if this indicator were to be implemented, it would have to be used to identify cases 

for further internal review. 

Summary 

 Because of the serious concerns surrounding this indicator, and since most of these 

could not be addressed using administrative data, panelists rated this indicator as poor 

and suggested that it not be used. Although panelists agreed that when the events did 

occur they were due to error, and expressed interest in following some of these 

complications, as well as other types of dosage complications, potential problems with 

this indicator were considered too great for use. 

Iatrogenic Hypotension 

This indicator is intended to flag cases of hypotension caused by medical care. 

The area level indicator is intended to capture all cases of iatrogenic hypotension, not 

only those occurring in-hospital. The hospital level indicator is restricted to secondary 

diagnoses, and is intended to capture cases occurring during the same hospitalization. 

Trauma patients are excluded as they may be more susceptible to non-preventable 

iatrogenic hypotension. 

Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM code of 458.2 in any diagnosis field per 100 

discharges.

Denominator Exclude all obstetric admissions (MDC 14 and 15). 

Exclude patients with any diagnosis of [trauma]

Post-conference call panel ratingsa 

Question Median Agreement status 

Overall rating 5 Disagreement 

Not present on admission 8 Agreement 

Preventability 4 Indeterminate agreement 

Due to medical error 5 Indeterminate agreement 

Charting by physicians 3 Disagreement 

Bias (lower rating is favorable) 6 Indeterminate agreement a

Procedural Complications Multispecialty Panel 
303

Changes to the indicator 

No changes were made to this indicator, as panelists felt that no changes would 

rectify concerns. 

Concerns not addressable through changes

Panelists had many concerns regarding this indicator, especially related to the 

preventability and charting of this complication. First, panelists commented frequently on 

the unclear preventability of many cases of hypotension. While some cases may result 

from poor management of fluids and medication, hypotension in general often has 

multifactorial etiologies. Comorbidities, such as diabetes or congestive heart failure, or 

even the psychological state of the patient, may contribute to the development of 

hypotension. Panelists expressed concern that the cause of the hypotension is often 

difficult to identify. 

 Panelists also expressed great concern over the documentation of hypotension. The 

term ‘hypotension’ is not intrinsically connected to an objective physiological state. What 

one physician calls ‘hypotension’ another physician may not, depending on the severity 

and duration of the hypotension. This ambiguity leads to variable documentation and 

potentially systematic bias from variability in reporting. One panelist noted that blood 

pressures recorded by anesthesiologists may be rounded, effecting reporting as well. 

Finally, documentation is subject to the vigilance of monitoring of blood pressure. 

Panelists also expressed concern that hypotension may not be labeled often as iatrogenic, 

and thus will be coded elsewhere. 

Summary 

This indicator was rated as poor by panelists, primarily due to concern about the 

reliability of reporting and coding. In addition, many panelists felt that this complication 

may be less preventable than others reviewed. Panelists suggested that this indicator be 

dropped from further consideration. 

Intestinal Infection Due to Clostridium Difficile

This indicator is intended to identify patients that may have acquired an intestinal 

infection (due to C. difficile) in-hospital. In order to eliminate infections present on 

admission, this indicator includes only secondary diagnoses (meaning the infection was 

not designated as the principal diagnosis). 

Definition 

Methods: 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM code of 008.45 in any secondary diagnosis 

field per 100 discharges.

Denominator Exclude all obstetric admissions (MDC 14 and 15).

Benchmark State, regional, or peer group average. 
304

Post-conference call panel ratingsa 

Question Median Agreement status 

Overall rating 3 Disagreement 

Not present on admission 7 Indeterminate agreement 

Preventability 3 Disagreement 

Due to medical error 3 Indeterminate agreement 

Charting by physicians 7 Disagreement 

Bias (lower rating is favorable) 6 Indeterminate agreement a

 Medical Complications 1 Multispecialty Panel 

Changes to the indicator 

None of the concerns raised by panelists were addressed by changing the 

specification of this indicator. 

Concerns not addressable through changes 

Most of the concerns surrounding this indicator were not addressable using 

administrative data. Concerns focused primarily on the potential for bias due to varying 

diagnostic practices, and differences in the number of patients with the infection present 

on admission. Panelists expressed that particularly for patients admitted from long term 

care facilities, some patients might have the disorder present on admission. At times, this 

infection may not be fully symptomatic at admission, but may develop into a fully 

symptomatic condition during the hospitalization. Similarly, the diagnosis of infection 

due to C. difficile is often missed, or not charted as such. A stool culture is required for a 

definitive diagnosis. Often physicians may treat "diarrhea" without actually obtaining a 

culture; in this case "diarrhea not otherwise specified" would be reported, and would 

include cases of C. difficile. The differences in charting may be a significant source of 

bias for this indicator. Specifically, some hospitals may routinely screen for this common 

complication, while others may not. The rate as detected by the indicator may be 

particularly high in facilities that screen. Panelists cautioned that implementation of an 

administrative data indicator for C. difficile has the potential to reduce screening for such 

infections. 

Panelists also expressed that preventability of this complication varies, depending 

on the cause of the complication. Infections that result from cross-contamination between 

patients may be prevented through hand washing, isolation procedures, or other 

precautions. On the other hand, infections may also occur secondary to appropriate 

antibiotic use. 

Summary 

 Panelists rated this indicator as poor due to concerns that this operationalization did 

not exclusively pick up nosocomial infections, and that this complication may not be 

reliably charted or may be screened for in some facilities. Although panelists expressed 

interest in tracking nosocomial C. difficile infections given better data, they suggested 

that this indicator not be considered further due to the multiplicity of concerns. 
305

Postoperative Iatrogenic Complications – Digestive 

Postoperative Iatrogenic Complications – Respiratory 

Postoperative Iatrogenic Complications – Vascular 

Postoperative Iatrogenic Complications - Urinary 

These indicators were rated in one indicator, reported in the “Experimental” 

indicator results section in the main body of the report. 

Postoperative Pneumonia 

This indicator is intended to flag cases of postoperative pneumonia. It is identical 

to an indicator developed as part of the Complications Screening Program. This indicator 

limits pneumonia codes to secondary diagnosis codes in order to eliminate pneumonia 

that was present on admission. It further excludes patients who have major respiratory 

disorders, as these patients may have pneumonia present on admission, or may be more 

likely to develop pneumonia after surgical procedures. Finally, it excludes patients with 

immunosupression, including cancer and AIDS patients, as these patients are particularly 

susceptible to developing pneumonia. 

Defintion 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for pneumonia [pneumococcal 

pneumonia (481), other bacterial pneumonia {Klebsiella pneumoniae, 

pseudomoniae, pseudomonas, Hemophilis pneumoniae, streptococcus, 

stapnylococcus, anaerobes, e. coli, other gram negative, Legionnaires 

disease} (482.0-482.99)] in any secondary diagnosis field per 100 surgical 

discharges.

Denominator All [surgical] discharges 

Exclude patients in MDC 4. 

Exclude patients with any diagnosis of [AIDS], [immunocompromised]

state or [cancer]

Post-conference call panel ratingsa 

Question Median 

(MS) 

Agreement 

status 

(MS) 

Median 

(S) 

Agreement 

status 

(S) 

Overall rating 5 Indeterminate 6 Indeterminate 

Not present on admission 7 Indeterminate 8 Indeterminate 

Preventability 4 Indeterminate 6 Indeterminate 

Due to medical error 2 Agreement 6 Indeterminate 

Charting by physicians 6 Indeterminate 7 Indeterminate 

Bias (lower rating favorable) 7 Agreement 7 Indeterminate a

Multispecialty Panel - Surgical Complications 1 

Surgical Panel – Surgical Complications 1 
306

Multi-specialty Panel Results 

Changes to the indicator 

There were no changes suggested to this indicator that would address the specific 

concerns of the panel. 

Concerns not addressable through changes

Panelists were most concerned about the definition of pneumonia. Different 

physicians utilize different thresholds in diagnosing pneumonia. What some physicians 

may call atelactasis, other physicians may define as pneumonia. In addition, different 

methods are used to diagnose pneumonia. Some physicians may use clinical criteria such 

as examining x-rays for infiltrate, or requiring fever, yellow sputum, or elevated white 

blood cell count. Others may require a positive bronchoscopy culture. Because these 

different thresholds will yield different rates, panelists were concerned about the 

consistency of charting of this complication. They were also concerned that short length 

of stay would result in missing postoperative pneumonia that develops after discharge. 

Similarly, outpatient surgeries also involve risk for post operative pneumonia, but this 

indicator would not capture these cases either. 

Panelists did express that despite the problems with this indicator, they remain 

interested in tracking the pneumonia rate, but believed that current administrative data is 

not the appropriate data source. It would be important and useful to track ventilator 

pneumonia, and other nosocomial pneumonias. They believed that many of these 

pneumonias are preventable, with current interventions, such as bed elevation, cross 

contamination prevention, and when appropriate, prophylactic antibiotics. Panelists were 

concerned about some bias with ventilator pneumonia, specifically the development of 

ventilator pneumonia depends on length of time on the ventilator, and comorbidities in 

the patient, such as serious illness, or immunocompromised state. 

Surgical Panel Results 

Changes to the indicator 

The surgical panel suggested that trauma to the head and chest should be 

excluded. Chest trauma patients may appear to have pneumonia upon x-ray evaluation 

because of pulmonary contusion and or hemorrhage, or may be at higher risk for 

developing non-preventable pneumonia. Head trauma patients may have aspirated at the 

time of trauma leading to pneumonia. Although the diagnosis code for aspiration 

pneumonia is not included in this indicator, pneumonia without specified organisms is 

included and thus, some aspiration pneumonia may appear in this indicator. 

Concerns not addressable through changes

The surgical panel expressed concern regarding potential bias for this indicator, 

given the potential effects of different patient case mix, particularly for some pre-existing 

disease (e.g., pulmonary diseases, diabetes) or behavioral risk factors (e.g., smoking). 

Panelists also indicated that the type of surgery would influence postoperative pneumonia 

rates (e.g., likely elevated rates for chest surgery or abdominal surgery). They suggested 
307

that this indicator be risk adjusted or stratified according to the type of procedure 

performed. 

Summary across Panels 

Both panels rated this indicator relatively poorly. Great concern was expressed 

regarding variation in diagnosis of pneumonia. Internist, intensivists and nurses directly 

treating postoperative pneumonia particularly expressed this concern. Although this 

indicator was not included in the final Accepted or Experimental indicator sets due to the 

concerns raised, panelists were hopeful that clinical measures to track postoperative 

pneumonia rate would be developed. 

Obstetric Thrombosis or Embolism 

This indicator is intended to flag cases of potentially preventable obstetric 

thrombosis or embolism in women delivering during the index hospitalization. 

Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for obstetric thrombosis or embolism 

[DVT –postpartum unspecified (671.40), DVT- delivered with mention of 

postpartum complication (671.42), DVT - postpartum condition or 

complication (671.44), Obstetric pulmonary embolism (673.20)] in any 

diagnosis field per 100 deliveries.

Denominator All deliveries ([vaginal delivery],[cesarean delivery]).

Post-conference call panel ratingsa 

Question Median Agreement status 

Overall rating 3.5 Disagreement 

Not present on admission 6 Indeterminate agreement 

Preventability 2.5 Indeterminate agreement 

Due to medical error 2 Indeterminate agreement 

Charting by physicians 8 Agreement 

Bias (lower rating is favorable) 6.5 Indeterminate Agreement a

Obstetric Complications 2 Panel 

Changes to the indicator 

Panelists suggested no changes to this indicator. 

Concerns not addressable through changes

Panelists expressed strong concern about this indicator. First, panelists questioned 

the preventability of post-partum vascular complications because of their unpredictable 

nature, and primary relationship to patient factors such as substance use and 

comorbidities. Some panelists did note that antepartum vascular complications might be 

preventable; however, it is not possible to track these events using the available 

administrative data. 
308

Summary 

 Panelists rated this indicator as poor, and suggested that this is not a complication that 

was of interest to track and that this indicator should not be considered further. 

Puerperal Infection 

This indicator is intended to flag cases of potentially preventable puerperal 

infections in women delivering during the index hospitalization. This indicator excludes 

patients with infection of the amniotic cavity, as infection in these patients is more likely 

to be present on admission or non-preventable. 

Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Discharges with ICD-9-CM codes for major puerperal infection [Major 

puerperal infection, unspecified as to episode of care (670.00), Major 

puerperal infection, delivered with mention of post-partum complication 

(670.02), Major puerperal infection, post-partum condition or 

complication (670.04)] in any diagnosis field per 100 deliveries.

Denominator All deliveries ([vaginal delivery],[cesarean delivery]).

Exclude patients with a diagnosis code of antepartum infection of 

amniotic cavity [65840, 1, 3].

Post-conference call panel ratingsa 

Question Median Agreement status 

Overall rating 5 Agreement 

Not present on admission 6.4 Indeterminate agreement 

Preventability 4.5 Indeterminate agreement 

Due to medical error 3 Indeterminate agreement 

Charting by physicians 7 Agreement 

Bias (lower rating is favorable) 4.5 Indeterminate agreement a

Obstetric Complications 2 Panel 

Changes to the indicator 

No changes were suggested for this indicator. 

Concerns not addressable through changes 

Several concerns about this indicator were raised as reasons for the poor overall 

rating. Panelists felt that some hospitals may have a higher rate of these complications 

due to patient case mix. Specifically, they noted that patients with sexually transmitted 

diseases or overall poor health are more likely to develop these complications. They 

noted that these factors vary systematically with socioeconomic status. Further, many of 

these complications develop after discharge. Thus, there may be significant 

underreporting resulting from the exclusive use of inpatient data. Finally, panelists 

expressed concern that the use of this indicator would lead to the inappropriate overuse of 

antibiotics. 
309

Summary 

 This indicator was rated less favorably than most other indicators, and panelists had 

no suggestions to improve the indicator. This indicator was not considered further. 

Unexpected LOS/ Conditional LOS 

This indicator is intended to identify patients who have unusually long lengths of stay. It 

is hypothesized that these patients have unusually long stays because they have 

developed major complications. Therefore, this measure is intended as a proxy for 

complications, compensating for problems of undercoding or bias in complications 

measures. This definition of unexpected length of stay was proposed by David 

Kuykendall (1995), although the original definition included demographic and 

longitudinal variables not available using administrative data. 

 

Definition 

Quality Measure Number of events per 100 discharges of population at risk 

Numerator Unexpected: For each patient a predicted length of stay is calculated using 

a multiple linear regression model. The predicted length of stay depends 

on the principal diagnosis, age, and comorbidities of the patient. Then, an 

unexpected length of stay percentage is calculated: 

(actual LOS – predicted LOS)/predicted LOS. Patients whose percentage 

is in the upper quartile (top 25%) are considered to have unusually long 

lengths of stay. (Kuykendall, 1995) 

Conditional: Patients with an extended length of stay have a hospital stay 

that is longer than the "extended length of stay point" defined as the point 

in the distribution (days stayed) where, for any particular DRG, the rate of 

discharge changes from increasing to decreasing. In other words, at some 

point, for a group of patients within a DRG, fewer patients are discharged 

than were discharged on the previous day, and more patients are held in 

the hospital for longer stays (Silber, 1999).

Denominator All [Surgical] and [Medical] patients.

Post-conference call panel ratings 

Question Median Agreement status 

Overall rating 6 Indeterminate 

Not present on admission Not 

applicable 

Not applicable 

Preventability 6 Indeterminate agreement 

Due to medical error 4.5 Indeterminate agreement 

Charting by physicians 8 Agreement 

Bias (lower rating is 

favorable) 

7 Agreement 

Changes to the indicator 

Panelists did not suggest any changes to this indicator. 
310

Concerns not addressable through changes

Panelists had many concerns and mixed feelings about this indicator. Some 

panelists felt that length of stay was influenced by many factors besides quality of care. 

For instance, some providers extend length of stay for social reasons. Patients with little 

outside social support or resources may be unable to obtain home care, may not have 

follow-up medical care, or may have other health conditions that affect their ability to 

heal. For these reasons a patient may be hospitalized longer than other patients with the 

same condition. Panelists felt that if this indicator were to be used, it would be best used 

in comparing hospitals with similar case-mixes of underserved populations. Other factors 

that may influence length of stay that are unrelated to quality of care include age of the 

patient and certain comorbidities that may not be charted. 

 Panelists expressed mixed feeling regarding the validity of this indicator as a whole. 

Some noted that the validity of the concept of unusual length of stay being a proxy for 

complications may be more valid for surgical patients rather than medical patients, for 

whom many additional factors besides the development of complications may affect 

length of stay. Some panelists noted that this indicator is best used internally, as it could 

be misconstrued by the public, and that length of stay may better measure resource use 

rather than clinical quality of care. 

Summary 

Panelists were ambivalent about this indicator. Some felt that this indicator was of 

interest to track, but more felt that this indicator did not have sufficient face validity as a 

complications indicator. Panelists felt that this indicator should not be considered further. 
311

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Appendix G 

Detailed Empirical Results 

This appendix presents the full empirical results for the analyses referenced in Section 3E. 

315 

APPENDIX G. DETAILED EMPIRICAL RESULTS 

This appendix contains the following empirical tables and figures: 

Accepted Indicators 

Table 1. Discharge Level Accepted Patient Safety Indicators, Florida and National SID, 1997 

Table 2. Hospital Level Accepted Patient Safety Indicators, Florida and National SID, 1997 

Table 3. Hospital Level Unadjusted and Age-Gender Adjusted Accepted Patient Safety 

Indicators, National SID, 1997 

Table 4. Hospital Level Risk Adjusted Accepted Patient Safety Indicators, National SID, 1997 

Table 5. Hospital Level Reliability Adjusted Accepted Patient Safety Indicators, National SID, 

1997 

Table 6. Bias Measures, Accepted Patient Safety Indicators, National SID, 1997 

Table 7. Correlations, Accepted Patient Safety Indicators, National SID, 1997 

Table 8a. Factor Loadings, Accepted Patient Safety Indicators, National SID, 1997 

Table 8b. Factor Loadings, Non-obstetric Accepted Patient Safety Indicators, National SID, 1997 

Experimental Indicators 

Table 9. Discharge Level Experimental Patient Safety Indicators, Florida and National SID, 

1997 

Table 10. Hospital Level Experimental Patient Safety Indicators, Florida and National SID, 

1997 

Table 11. Hospital Level Unadjusted and Age-Gender Adjusted Experimental Patient Safety 

Indicators, National SID, 1997 

Table 12. Hospital Level Risk Adjusted Experimental Patient Safety Indicators, National SID, 

1997 

Table 13. Hospital Level Reliability Adjusted Experimental Patient Safety Indicators, National 

SID, 1997 

Table 14. Bias Measures*, Experimental Patient Safety Indicators, National SID, 1997 

Area Indicators 

Table 15. Unadjusted and Risk-Adjusted Area Patient Safety Indicators, National SID, 1997 

Supplemental Tables and Figures 

Supplemental Table 1. Death in Low Mortality DRGs by Category, National SID, 1997 

Supplemental Table 2. Hospital Level Accepted Patient Safety Indicators, Florida, 1995-97 

Supplemental Table 3. Accepted Indicator Discharge Level Rates by Age Strata 

Supplemental Table 4. Percentage of Indicator Numerator or Denominator Represented by Age 

Strata 

Figure 1. Hospital Distribution of Unadjusted PSI3: Decubitus Ulcer 

Figure 2. Hospital Distribution of Unadjusted PSI26: OB Trauma - Vaginal wo Instrument 

Figure 3. Hospital Distribution of Adjusted PSI3: Decubitus Ulcer 

Figure 4. Hospital Distribution of Adjusted PSI26: OB Trauma - Vaginal wo Instrument 
316

Accepted Indicators Table 1. Discharge Level Accepted Patient Safety Indicators, Florida and National SID, 1997  Florida NationPSI Label Num. Den. Rate Num. DenCOMPLICATIONS OF ANESTHESIA 408 533,234 0.00077 3,046 4,906DEATH IN LOW MORTALITY DRGS 280 619,725 0.00045 3,002 6,866DECUBITUS ULCER 12,243 587,557 0.02084 108,042 5,318FAILURE TO RESCUE 17,101 93,216 0.18346 135,085 753FOREIGN BODY LEFT IN DURING PROC 176 1,747,773 0.00010 1,608 16,575IATROGENIC PNEUMOTHORAX 1,551 1,556,307 0.00100 16,574 14,699INFECTION DUE TO MEDICAL CARE 3,276 1,504,601 0.00218 27,060 14,411POSTOP HEMORRHAGE OR HEMATOMA 981 478,323 0.00205 9,387 4,358POSTOP HIP FRACTURE 487 369,503 0.00132 2,918 3,307POSTOP PHYSIO METABOL DERANGMNT 366 228,106 0.00160 2,110 2,310POSTOP PE OR DVT 3,639 476,243 0.00764 34,167 4,340POSTOP RESPIRATORY FAILURE 762 179,162 0.00425 5,349 1,883POSTOP SEPSIS 882 72,485 0.01217 6,635 688POSTOP WOUND DEHISCENCE 238 115,323 0.00206 2,207 1,066TECH DIFFICULTY W PROCEDURE 4,943 1,545,259 0.00320 46,126 14,231TRANSFUSION REACTION 16 1,747,773 0.00001 129 16,575BIRTH TRAUMA 1,936 180,393 0.01073 27,880 2,052OB TRAUMA - C-SECTION 185 41,642 0.00444 2,604 427OB TRAUMA - VAGINAL W INSTRUMENT 2,149 10,593 0.20287 36,906 162OB TRAUMA - VAGINAL WO INSTRUMENT 9,678 126,782 0.07634 120,858 1,470Table 1 shows the total number of adverse events (numerator), the total number of patients at risk (denominator)in Florida and the National SID for each accepted patient safety indicator. Florida was the state used for initial tdevelopment. The rates are shown to compare with the National SID rates, which are similar. 
317

Table 2. Hospital Level Accepted Patient Safety Indicators, Florida and National SID, 1997  Florida NationPSI Label N Rate SD Skew N Rate SD COMPLICATIONS OF ANESTHESIA 191 0.00067 0.00100 2.40109 2,275 0.00080 0DEATH IN LOW MORTALITY DRGS 195 0.00124 0.00608 11.62252 2,344 0.00114 0DECUBITUS ULCER 195 0.02417 0.01850 3.61063 2,342 0.02052 0FAILURE TO RESCUE 194 0.18541 0.05659 -0.11446 2,327 0.17031 0FOREIGN BODY LEFT IN DURING PROC 195 0.00008 0.00015 3.49444 2,349 0.00008 0IATROGENIC PNEUMOTHORAX 195 0.00089 0.00080 2.04115 2,349 0.00086 0INFECTION DUE TO MEDICAL CARE 195 0.00204 0.00223 3.65896 2,349 0.00137 0POSTOP HEMORRHAGE OR HEMATOMA 191 0.00198 0.00231 2.98257 2,272 0.00183 0POSTOP HIP FRACTURE 191 0.00191 0.00560 7.73000 2,269 0.00124 0POSTOP PHYSIO METABOL DERANGT 179 0.00149 0.00341 7.94790 2,122 0.00092 0POSTOP PE OR DVT 191 0.00769 0.00510 1.24004 2,272 0.00695 0POSTOP RESPIRATORY FAILURE 179 0.00530 0.00893 4.96602 2,121 0.00268 0POSTOP SEPSIS 177 0.01197 0.01674 5.25552 2,050 0.01000 0POSTOP WOUND DEHISCENCE 190 0.00212 0.00341 2.92101 2,227 0.00243 0TECH DIFFICULTY W PROCEDURE 195 0.00231 0.00225 2.02898 2,348 0.00242 0TRANSFUSION REACTION 195 0.00001 0.00010 10.39826 2,349 0.00001 0BIRTH TRAUMA 122 0.00965 0.01998 5.40175 1,784 0.00936 0OB TRAUMA - C-SECTION 121 0.00433 0.00597 1.78278 1,756 0.00613 0OB TRAUMA - VAGINAL W INSTRUMENT 121 0.17314 0.10291 0.31238 1,697 0.20359 0OB TRAUMA - VAGINAL WO INSTRUMENT 126 0.06878 0.03665 0.48016 1,805 0.07558 0Table 2 shows the hospital level rates for Florida and the National SID, for comparison. The columns labeled ‘N

hospitals with at least one patient in the at-risk denominator. 
318

Table 3. Hospital Level Unadjusted and Age-Gender Adjusted Accepted Patient Safety Indicators, National SID Unadjusted Rate Age-Gender PSI Label N Rate SD Skew Rate SD COMPLICATIONS OF ANESTHESIA 2,275 0.00080 0.00715 44.36257 0.00082 0.00713 DEATH IN LOW MORTALITY DRGS 2,344 0.00114 0.01194 34.01637 0.00114 0.01284 DECUBITUS ULCER 2,342 0.02052 0.02069 3.57004 0.01777 0.02035 FAILURE TO RESCUE 2,327 0.17031 0.08092 2.13958 0.12169 0.07747 FOREIGN BODY LEFT IN DURING PROC 2,349 0.00008 0.00018 5.38260 IATROGENIC PNEUMOTHORAX 2,349 0.00086 0.00135 5.40259 0.00083 0.00130 INFECTION DUE TO MEDICAL CARE 2,349 0.00137 0.00175 7.14722 0.00136 0.00172 POSTOP HEMORRHAGE OR HEMATOMA 2,272 0.00183 0.00314 8.03155 0.00189 0.00366 POSTOP HIP FRACTURE 2,269 0.00124 0.00594 21.90674 0.00126 0.00609 POSTOP PHYSIO METABOL DERANGT 2,122 0.00092 0.01112 42.82075 0.00103 0.01112 POSTOP PE OR DVT 2,272 0.00695 0.01225 16.20401 0.00696 0.01192 POSTOP RESPIRATORY FAILURE 2,121 0.00268 0.00501 6.15831 0.00293 0.00627 POSTOP SEPSIS 2,050 0.01000 0.02962 20.53298 0.01013 0.02882 POSTOP WOUND DEHISCENCE 2,227 0.00243 0.00877 25.50940 0.00270 0.00945 TECH DIFFICULTY W PROCEDURE 2,348 0.00242 0.00264 2.64406 0.00243 0.00258 TRANSFUSION REACTION 2,349 0.00001 0.00006 19.53736 BIRTH TRAUMA 1,784 0.00936 0.03144 11.85275 0.00922 0.03150 OB TRAUMA - C-SECTION 1,756 0.00613 0.01612 19.02428 0.00628 0.01633 OB TRAUMA - VAGINAL W INSTRUMENT 1,697 0.20359 0.14236 1.02616 0.14700 0.13526 OB TRAUMA - VAGINAL WO INSTRUMENT 1,805 0.07558 0.05789 3.50258 0.06789 0.05818 

Table 3 shows the unadjusted and age-gender adjusted rates for the accepted indicators in the National SI

second column shows the mean hospital level unadjusted rate, defined as the number of adverse events divided b

discharges in the population at risk. The third column shows the standard deviation in the hospital level rates, an

shows the skew statistic, which is defined as the third moment (where the variance is the second moment). The s

measure of how symmetric the hospital level rates are relative to the mean hospital level rate. The more positive 

the longer the right-hand tail of the distribution. The closer to zero it is, the more symmetrical the distribution. Nstatistics indicate a longer the left-hand tail. 
319

Table 4. Hospital Level Risk Adjusted Accepted Patient Safety Indicators, National SID, 1997  DRG Adjusted* Co-morbidity APSI Label N Rate SD Skew Rate SD COMPLICATIONS OF ANESTHESIA 2,275 0.00087 0.00712 44.62686 0.00088 0.00711 DEATH IN LOW MORTALITY DRGS 2,344 0.00114 0.01284 30.11021 0.00115 0.01287 DECUBITUS ULCER 2,342 0.01668 0.01903 3.88522 0.01603 0.01802 FAILURE TO RESCUE 2,327 0.09768 0.06615 2.17070 0.08461 0.06581 FOREIGN BODY LEFT IN DURING PROC 2,349 IATROGENIC PNEUMOTHORAX 2,349 0.00091 0.00127 5.76631 0.00090 0.00127 INFECTION DUE TO MEDICAL CARE 2,349 0.00146 0.00152 6.63907 0.00150 0.00142 POSTOP HEMORRHAGE OR HEMATOMA 2,272 0.00200 0.00363 15.71185 0.00201 0.00363 POSTOP HIP FRACTURE 2,269 0.00129 0.00591 22.90517 0.00131 0.00590 POSTOP PHYSIO METABOL DERANGT 2,122 0.00117 0.01103 41.81183 0.00122 0.01093 POSTOP PE OR DVT 2,272 0.00681 0.01093 17.15800 0.00679 0.01082 POSTOP RESPIRATORY FAILURE 2,121 0.00314 0.00583 9.04823 0.00301 0.00515 POSTOP SEPSIS 2,050 0.01002 0.02759 23.83976 0.01004 0.02691 POSTOP WOUND DEHISCENCE 2,227 0.00277 0.00943 22.05895 0.00286 0.00942 TECH DIFFICULTY W PROCEDURE 2,348 0.00294 0.00207 2.87175 0.00293 0.00207 TRANSFUSION REACTION 2,349 BIRTH TRAUMA 1,784 0.00920 0.03150 11.67889 0.00922 0.03150 OB TRAUMA - C-SECTION 1,756 0.00628 0.01633 18.46636 0.00668 0.01630 OB TRAUMA - VAGINAL W INSTRUMENT 1,697 0.14700 0.13526 1.46571 0.14463 0.13378 OB TRAUMA - VAGINAL WO INSTRUMENT 1,805 0.06786 0.05818 3.64127 0.06786 0.05764 * Age, gender, DRG (except PSI 22, 24, 26, 27, 28, 29, 30); ** Age, gender, DRG, co-morbidity Table 4 shows the mean hospital level risk-adjusted rates, standard deviations and skew statistic for the DRG and adjusted rates. The Obstetric measures are not adjusted for DRG. The Death in Low Mortality DRGs indicator i

DRG. Rather, the indicator is stratified by DRG group, namely medical (adult and pediatric), surgical (adult and obstetric and psychiatric [See supplemental Table 1]. 
320

Table 5. Hospital Level Reliability Adjusted Accepted Patient Safety Indicators, National SID, 1997 

 Reliability* Adjusted MSX Sta

PSI Label N Rate SD Skew 

Signal 

SD Shar

COMPLICATIONS OF ANESTHESIA 2,248 0.00069 0.00147 13.36595 0.00187 0DEATH IN LOW MORTALITY DRGS 2,338 0.00089 0.00531 24.87662 0.00439 0DECUBITUS ULCER 2,338 0.02063 0.01802 3.37971 0.01457 0FAILURE TO RESCUE 2,301 0.17498 0.04803 0.72576 0.04617 0FOREIGN BODY LEFT IN DURING PROC IATROGENIC PNEUMOTHORAX 2,349 0.00093 0.00122 5.96158 0.00143 0INFECTION DUE TO MEDICAL CARE 2,349 0.00154 0.00119 2.76077 0.00134 0POSTOP HEMORRHAGE OR HEMATOMA 2,243 0.00264 0.00052 1.88841 0.00039 0POSTOP HIP FRACTURE 2,241 0.00107 0.00211 11.61516 0.00184 0POSTOP PHYSIO METABOL DERANGT 2,054 0.00084 0.00060 4.58555 0.00054 0POSTOP PE OR DVT 2,243 0.00722 0.00521 5.60448 0.00633 0POSTOP RESPIRATORY FAILURE 2,047 0.00301 0.00241 2.82516 0.00230 0POSTOP WOUND DEHISCENCE 2,193 0.00217 0.00194 3.37005 0.00188 0POSTOP SEPSIS 1,961 0.00976 0.00840 2.90175 0.00869 0TECH DIFFICULTY W PROCEDURE 2,348 0.00259 0.00236 2.81472 0.00279 0TRANSFUSION REACTION BIRTH TRAUMA 1,752 0.00967 0.03157 11.83738 0.04128 0OB TRAUMA - C-SECTION 1,739 0.00618 0.00536 3.82585 0.00590 0OB TRAUMA - VAGINAL W INSTRUMENT 1,625 0.21119 0.09963 0.58224 0.09794 0OB TRAUMA - VAGINAL WO INSTRUMENT 1,758 0.07788 0.04634 1.50907 0.04314 0* Age, gender, DRG, co-morbidity and reliability Table 5 shows the effect of reliability adjustment, and provides statistics on the signal standard deviation, signal Hospitals with fewer than three patients in the denominator were not included in the reliability adjustment. Mult(taking into account correlations among indicators in order to extract additional 'signal') were applied to most of indicators. The exceptions were Death in Low Mortality DRGs and Failure to Rescue. Only univariate smoothinapplied to these two indicators.
321

Table 6. Bias Measures*, Accepted Patient Safety Indicators, National SID, 1997 PSI Label N 

Rank

Corr. Abs. Value

Top 

10% 

Bot 

10% Two Declines

COMPLICATIONS OF ANESTHESIA 2,275 0.987 0.154 0.649 0.951 0.004 DEATH IN LOW MORTALITY DRGS 2,344 0.845 0.289 0.239 0.850 0.128 DECUBITUS ULCER 2,342 0.741 0.280 0.376 0.829 0.262 FAILURE TO RESCUE 2,327 0.417 0.508 0.192 0.419 0.437 FOREIGN BODY LEFT IN DURING PROC 2,349 IATROGENIC PNEUMOTHORAX 2,349 0.873 0.173 0.528 0.885 0.138 INFECTION DUE TO MEDICAL CARE 2,349 0.900 0.170 0.579 0.847 0.103 POSTOP HIP FRACTURE 2,270 0.921 0.219 0.493 0.844 0.079 POSTOP HEMORRHAGE OR HEMATOMA 2,272 0.965 0.043 0.787 0.907 0.038 POSTOP PHYSIO METABOL DERANGT 2,122 0.934 0.249 0.619 0.839 0.054 POSTOP PE OR DVT 2,272 0.837 0.164 0.520 0.747 0.140 POSTOP RESPIRATORY FAILURE 2,121 0.888 0.198 0.635 0.826 0.112 POSTOP SEPSIS 2,050 0.879 0.228 0.648 0.774 0.114 POSTOP WOUND DEHISCENCE 2,227 0.963 0.174 0.768 0.855 0.035 TECH DIFFICULTY W PROCEDURE 2,348 0.796 0.307 0.379 0.826 0.237 TRANSFUSION REACTION 2,349 BIRTH TRAUMA 1,784 0.998 0.032 0.979 0.958 0.000 OB TRAUMA - C-SECTION 1,756 0.972 0.107 0.828 0.828 0.024 OB TRAUMA - VAGINAL W INSTRUMENT 1,697 0.951 0.302 0.761 0.840 0.049 OB TRAUMA - VAGINAL WO INSTRUMENT 1,805 0.987 0.106 0.830 0.909 0.006 

* Reliability adjusted to age, gender, DRG, co-morbidity and reliability adjusted 

Table 6 shows the effect of age, gender, DRG and co-morbidity risk-adjustment on the relative ranking of hospitrisk-adjustment, using five measures of impact. Both the unadjusted and risk-adjusted measures have been adjus

order to remove the impact of noise on the assessment of potential bias. Also, even if risk-adjustment reduces th

hospital level variation, the relative rank may not be affected if the distribution of the adjusters does not vary syshospitals. A large impact on the relative ranking means that the measures are biased based on the patient charact

on the administrative data. A small or no impact means that the measures are not biased based on the characteris(although there might be characteristics that we do not observe that are related to the patient’s risk of experiencin
322

 The first measure is a relative rank correlation statistic (a measure of the impact of adjustment on the assehospital performance). The second measure is the average absolute magnitude of the change in unadjusted – adjuhospital (a measure of the relative importance of adjustment). The third and forth measures are the percentage of 

in the top (or bottom) 10% of the distribution after adjustment (measures of the impact on the highest and lowest 

measure is the percentage of hospitals that change more than two deciles in the distribution after adjustment (a mthroughout the distribution). Table 7. Spearman Correlations, Accepted Patient Safety Indicators, National SID, 1997 

PSI Label 1 2 3 4 6 7 8 9 10 COMPLICATIONS OF ANESTHESIA 1.000 0.033 0.061* -0.024 0.063* 0.147* 0.054* 0.096* -0.008 DEATH IN LOW MORTALITY DRGS 1.000 0.013 0.151* 0.118* 0.126* 0.049* 0.002 0.011 DECUBITUS ULCER 1.000 0.240* 0.024 0.163* 0.153* 0.023 0.116* FAILURE TO RESCUE 1.000 0.099* 0.091* 0.129* -0.026 -0.031 IATROGENIC PNEUMOTHORAX 1.000 0.369* 0.074* 0.142* -0.015 INFECTION DUE TO MEDICAL CARE 1.000 0.048* 0.182* 0.102* POSTOP HIP FRACTURE 1.000 0.044* -0.006 POSTOP HEMORRHAGE OR HEMATOMA 1.000 0.036 POSTOP PHYSIO METABOL DERANGT 1.000 POSTOP RESPIRATORY FAILURE POSTOP PE OR DVT POSTOP SEPSIS TECH DIFFICULTY W PROCEDURE WOUND DEHISCENCE BIRTH TRAUMA OB TRAUMA - VAGINAL W INSTRUMENT OB TRAUMA - VAGINAL WO INSTRUMENT OB TRAUMA - C-SECTION 

* Significant at p < 0.05 
323

Table 7 (Continued). Spearman Correlations, Accepted Patient Safety Indicators, National SID, 1997 PSI Label 12 13 14 16 17 18 19 20 2COMPLICATIONS OF ANESTHESIA 0.107* 0.043 0.157* 0.025 0.124* 0.111* 0.085* 0.065* 0.1DEATH IN LOW MORTALITY DRGS 0.133* 0.004 0.019 0.024 0.006 0.009 0.038 0.020 0.03DECUBITUS ULCER 0.229* 0.219* -0.104* -0.028 0.093* -0.090* -0.039 -0.075* -0.0FAILURE TO RESCUE 0.072* 0.057* -0.047* 0.000 -0.012 -0.086* -0.11* -0.104* -0.1IATROGENIC PNEUMOTHORAX 0.206* -0.007 0.318* 0.026 0.205* 0.093* 0.115* 0.108* 0.13INFECTION DUE TO MEDICAL CARE 0.294* 0.167* 0.306* 0.018 0.290* 0.132* 0.158* 0.101* 0.1POSTOP HIP FRACTURE 0.166* 0.020 -0.093* 0.016 -0.004 0.006 0.032 0.011 -0.0POSTOP HEMORRHAGE OR HEMATOMA 0.102* 0.052* 0.176* 0.149* 0.092* 0.052* 0.045 0.123* 0.15POSTOP PHYSIO METABOL DERANGT 0.065* 0.281* -0.058* 0.025 -0.004 -0.039 -0.008 -0.022 0.0POSTOP RESPIRATORY FAILURE 0.138* 0.322* -0.134* -0.003 0.023 -0.130* -0.048 -0.045 -0.1POSTOP PE OR DVT 1.000 0.122* -0.003 0.056* 0.122* 0.045 0.114* 0.029 0.0POSTOP SEPSIS 1.000 -0.066* 0.000 0.029 -0.094* 0.017 -0.053* -0.0TECH DIFFICULTY W PROCEDURE 1.000 -0.016 0.218* 0.289* 0.229* 0.175* 0.25WOUND DEHISCENCE 1.000 -0.019 -0.03 -0.023 0.029 0.02BIRTH TRAUMA 1.000 0.113* 0.125* 0.116* 0.14OB TRAUMA - VAGINAL W INSTRUMENT 1.000 0.545* 0.233* 0.22OB TRAUMA - VAGINAL WO INSTRUMENT 1.000 0.217* 0.1OB TRAUMA - C-SECTION 1.000 0.2

* Significant at p < 0.05 
324

Table 8A. Factor Loadings, Accepted Patient Safety Indicators, National SID, 1997  Factor 1 PSI PSI Label Loading Var. Exp. PSI PSI Label Loa

7 INFECTION DUE TO MEDICAL CARE 0.6009 0.236 11 POSTOP RESPIRATORY FAILURE 0.4

15 TECH DIFFICULTY W PROCEDURE 0.5194 0.195 3 DECUBITUS ULCER 0.4

6 IATROGENIC PNEUMOTHORAX 0.4834 0.136 14 POSTOPERATIVE SEPSIS 0.4

19 OB TRAUMA - VAGINAL WO INSTRUMENT 0.4552 0.161 12 POSTOPERATIVE PE OR DVT 0.318 OB TRAUMA - VAGINAL W INSTRUMENT 0.4363 0.195 4 FAILURE TO RESCUE 0.317 BIRTH TRAUMA 0.4045 0.093 10 POSTOP PHYSIO METABOL DERANGMNT 0.212 POSTOPERATIVE PE OR DVT 0.3501 0.127 7 INFECTION DUE TO MEDICAL CARE 0.220 OB TRAUMA - C-SECTION 0.2651 0.066 8 POSTOPERATIVE HIP FRACTURE 0.1

9 POSTOP HEMORRHAGE OR HEMATOMA 0.2356 0.032 2 DEATH IN LOW MORTALITY DRGS 0.11 COMPLICATIONS OF ANESTHESIA 0.2350 0.031 6 IATROGENIC PNEUMOTHORAX 0.02 DEATH IN LOW MORTALITY DRGS 0.1592 0.023 17 BIRTH TRAUMA 0.05 FOREIGN BODY LEFT IN DURING PROC 0.1206 0.012 13 POSTOPERATIVE WOUND DEHISCENCE 0.03 DECUBITUS ULCER 0.1033 0.128 9 POSTOP HEMORRHAGE OR HEMATOMA 0.0

14 POSTOPERATIVE SEPSIS 0.0858 0.105 1 COMPLICATIONS OF ANESTHESIA -0.0

8 POSTOPERATIVE HIP FRACTURE 0.0743 0.023 5 FOREIGN BODY LEFT IN DURING PROC -0.04 FAILURE TO RESCUE 0.0472 0.056 16 TRANSFUSION REACTION -0.0

11 POSTOP RESPIRATORY FAILURE 0.0417 0.123 20 OB TRAUMA - C-SECTION -0.213 POSTOPERATIVE WOUND DEHISCENCE 0.0176 0.001 15 TECH DIFFICULTY W PROCEDURE -0.210 POSTOP PHYSIO METABOL DERANGMNT 0.0121 0.043 19 OB TRAUMA - VAGINAL WO INSTRUMENT -0.216 TRANSFUSION REACTION -0.4253 0.108 18 OB TRAUMA - VAGINAL W INSTRUMENT -0.3

 Share of Variance Explained 0.567 Share of Variance Explained 0.3

Black – Highest loading on factor 1; Bold – Highest loading on factor 2 
325

Table 8B. Factor Loadings, Non-OB Accepted Patient Safety Indicators, National SID, 1997  Factor 1 PSI PSI Label Loading Var. Exp. PSI PSI Label Loa

7 INFECTION DUE TO MEDICAL CARE 0.63096 0.272 11 POSTOP RESPIRATORY FAILURE 0.46 IATROGENIC PNEUMOTHORAX 0.47137 0.193 14 POSTOPERATIVE SEPSIS 0.3

12 POSTOPERATIVE PE OR DVT 0.46335 0.149 3 DECUBITUS ULCER 0.3

3 DECUBITUS ULCER 0.31242 0.152 10 POSTOP PHYSIO METABOL DERANGMNT 0.3

15 TECH DIFFICULTY W PROCEDURE 0.30459 0.225 16 TRANSFUSION REACTION 0.214 POSTOPERATIVE SEPSIS 0.27547 0.151 8 POSTOPERATIVE HIP FRACTURE 0.111 POSTOP RESPIRATORY FAILURE 0.26393 0.166 4 FAILURE TO RESCUE 0.1

4 FAILURE TO RESCUE 0.22556 0.047 12 POSTOPERATIVE PE OR DVT 0.19 POSTOP HEMORRHAGE OR HEMATOMA 0.22346 0.040 13 POSTOPERATIVE WOUND DEHISCENCE -0.02 DEATH IN LOW MORTALITY DRGS 0.21816 0.032 2 DEATH IN LOW MORTALITY DRGS -0.01 COMPLICATIONS OF ANESTHESIA 0.1923 0.030 1 COMPLICATIONS OF ANESTHESIA -0.08 POSTOPERATIVE HIP FRACTURE 0.15945 0.032 5 FOREIGN BODY LEFT IN DURING PROC -0.0

10 POSTOP PHYSIO METABOL DERANGMNT 0.13815 0.085 9 POSTOP HEMORRHAGE OR HEMATOMA -0.1

5 FOREIGN BODY LEFT IN DURING PROC 0.06324 0.008 7 INFECTION DUE TO MEDICAL CARE -0.1

13 POSTOPERATIVE WOUND DEHISCENCE 0.04133 0.001 6 IATROGENIC PNEUMOTHORAX -0.216 TRANSFUSION REACTION -0.40846 0.138 15 TECH DIFFICULTY W PROCEDURE -0.4

 Share of Variance Explained 0.661 Share of Variance Explained 0.4

Black – Highest loading on factor 1; Bold – Highest loading on factor 2 
326

Experimental Indicators 

Table 9. Discharge Level Experimental Patient Safety Indicators, Florida and National SID, 1997  Florida National PSI Label Num. Den. Rate Num. Den. Rate ASPIRATION PNEUMONIA 683 170,643 0.00400 3,864 1,331,866 0.00290CABG POST PTCA 792 38,480 0.02058 6,267 281,771 0.02224DECUBITUS ULCER IN HIGH RISK PATIENT 2,190 33,283 0.06580 28,753 421,801 0.06817IN-HOSPITAL FRACTURES RELATED TO FALLS 967 398,488 0.00243 6,310 3,617,435 0.00174INTRA-OPER NERVE COMP INJURY 7 461,526 0.00002 102 4,254,914 0.00002MALIGNANT HYPERTHERMIA 0 478,400 0.00000 0 4,359,259 0.00000POSTOPERATIVE AMI 643 223,770 0.00287 4,264 1,833,269 0.00233POSTOP IATROGENIC COMPL - CARDIAC 9,109 478,400 0.01904 83,502 4,359,259 0.01916POSTOP IATROGENIC COMPL - NERVOUS 1,965 478,400 0.00411 18,121 4,359,259 0.00416REOPENING OF A SURGICAL SITE 3,244 533,311 0.00608 28,850 4,907,182 0.00588SUTURE OF LACERATION 2,344 422,227 0.00555 22,097 3,801,214 0.00581OTHER OBSTERIC COMPLICATION 703 179,018 0.00393 8,213 2,060,609 0.00399OB WOUND COMP - C-SECTION DELIVERY 482 41,642 0.01157 5,517 427,558 0.01290OB WOUND COMPLICATION OF VAGINAL DEL 124 137,376 0.00090 1,506 1,633,038 0.00092POST-PARTUM UTI INFECTION 497 179,017 0.00278 5,296 2,060,547 0.002573RD OR 4TH DEGREE OB LACERATION 7,320 135,771 0.05391 99,383 1,620,823 0.06132UTERINE RUPTURE 127 160,424 0.00079 1,324 1,878,381 0.00070Table 9 shows the total number of adverse events (numerator), the total number of patients at risk (denominator)in Florida and the National SID for each experimental PSI. Florida was the state used for initial testing and deveare shown to compare with the National SID rates. 
327

Table 10. Hospital Level Experimental Patient Safety Indicators, Florida and National SID, 1997  Florida NationaPSI Label N Rate SD Skew N Rate SD ASPIRATION PNEUMONIA 178 0.00397 0.00514 4.36419 1,715 0.00256 0.008CABG POST PTCA 69 0.01727 0.01193 0.09464 612 0.02049 0.016DECUBITUS ULCER IN HIGH RISK PATIENT 194 0.07545 0.05976 2.28194 2,288 0.06173 0.065IN-HOSPITAL FRAC RELATED TO FALLS 191 0.00347 0.00790 7.74260 2,269 0.00284 0.023INTRA-OPER NERVE COMP INJURY 191 0.00001 0.00007 7.00068 2,274 0.00001 0.000MALIGNANT HYPERTHERMIA POSTOPERATIVE AMI 179 0.00286 0.00300 2.15227 1,744 0.00199 0.004POSTOP IATROGENIC COMPL - CARDIAC 191 0.01273 0.01497 2.53648 2,272 0.01179 0.013POSTOP IATROGENIC COMPL - NERVOUS 191 0.00255 0.00308 2.02625 2,272 0.00239 0.005REOPENING OF A SURGICAL SITE 191 0.00490 0.00390 0.87565 2,275 0.00399 0.005SUTURE OF LACERATION 191 0.00543 0.00600 5.96016 2,267 0.00585 0.008OB WOUND COMP - C-SECTION DELIVERY 121 0.00987 0.01182 2.49694 1,756 0.01100 0.016OB WOUND COMP OF VAGINAL DELIVERY 126 0.00094 0.00160 2.72679 1,805 0.00097 0.004OTHER OBSTERIC COMPLICATIONS 126 0.00317 0.00367 1.90949 1,812 0.00347 0.005POST-PARTUM UTI INFECTION 126 0.00201 0.00247 1.46515 1,812 0.00349 0.0333RD OR 4TH DEGREE OB LACERATION 129 0.04825 0.02861 0.66478 1,813 0.05827 0.040UTERINE RUPTURE 126 0.00067 0.00104 2.56183 1,807 0.00071 0.003Table 10 shows the hospital level rates for Florida and the National SID, for comparison. 
328

Table 11. Hospital Level Unadjusted and Age-Gender Adjusted Experimental Patient Safety Indicators, Nationa

 Unadjusted Rate Age-Gende

PSI Label N Rate SD Skew Rate SD ASPIRATION PNEUMONIA 1,715 0.00256 0.00803 20.83495 0.00281 0.0076CABG POST PTCA 612 0.02049 0.01683 1.04254 0.02054 0.0168DECUBITUS ULCER IN HIGH RISK PATIENT 2,288 0.06173 0.06517 2.54328 0.05755 0.0658IN-HOSPITAL FRAC RELATED TO FALLS 2,269 0.00284 0.02330 36.57401 0.00286 0.0231INTRA-OPER NERVE COMP INJURY 2,274 0.00001 0.00011 10.74719 MALIGNANT HYPERTHERMIA POSTOPERATIVE AMI 1,744 0.00199 0.00414 9.67318 0.00214 0.0053POSTOP IATROGENIC COMPL - CARDIAC 2,272 0.01179 0.01333 2.07341 0.01189 0.0128POSTOP IATROGENIC COMPL - NERVOUS 2,272 0.00239 0.00533 16.17496 0.00248 0.0041REOPENING OF A SURGICAL SITE 2,275 0.00399 0.00551 8.65050 0.00431 0.0046SUTURE OF LACERATION 2,267 0.00585 0.00840 7.40585 0.00580 0.0087OB WOUND COMP - C-SECTION DELIVERY 1,756 0.01100 0.01677 3.92826 0.01127 0.0179OB WOUND COMP OF VAGINAL DELIVERY 1,805 0.00097 0.00451 28.67962 0.00100 0.0052OTHER OBSTERIC COMPLICATIONS 1,812 0.00347 0.00596 6.30315 0.00359 0.0058POST-PARTUM UTI INFECTION 1,812 0.00349 0.03344 29.26669 0.00351 0.03343RD OR 4TH DEGREE OB LACERATION 1,813 0.05827 0.04083 2.26357 0.05462 0.0407UTERINE RUPTURE 1,807 0.00071 0.00371 24.40042 0.00074 0.0037

Table 11 shows the unadjusted and age-gender adjusted rates for the experimental indicators in the Nation

first column shows the number of hospitals with at least one patient in the at-risk denominator. The second colum

hospital level unadjusted rate, defined as the number of adverse events divided by the number of discharges in th

The third column shows the standard deviation in the hospital level rates, and the fourth column shows the skew defined as the third moment (where the variance is the second moment). The skew statistic is a measure of how hospital level rates are relative to the mean hospital level rate. The more positive the skew statistic is, the longer the distribution. The closer to zero it is, the more symmetrical the distribution. Negative skew statistics indicate 

tail. 
329

Table 12. Hospital Level Risk Adjusted Experimental Patient Safety Indicators, National SID, 1997  DRG Adjusted* Co-morbidity APSI Label N Rate SD Skew Rate SD ASPIRATION PNEUMONIA 1,715 0.00302 0.00746 22.17259 0.00301 0.00739 CABG POST PTCA 612 0.02054 0.01687 1.15669 0.02112 0.01680 DECUBITUS ULCER IN HIGH RISK PATIENT 2,288 0.05368 0.05879 3.16838 0.05101 0.05633 IN-HOSPITAL FRAC RELATED TO FALLS 2,269 0.00288 0.02293 36.80870 0.00288 0.02266 INTRA-OPER NERVE COMP INJURY MALIGNANT HYPERTHERMIA POSTOPERATIVE AMI 1,744 0.00233 0.00525 19.35160 0.00240 0.00524 POSTOP IATROGENIC COMPL - CARDIAC 2,272 0.01607 0.01110 2.10968 0.01593 0.01100 POSTOP IATROGENIC COMPL - NERVOUS 2,272 0.00357 0.00390 14.02002 0.00352 0.00388 REOPENING OF A SURGICAL SITE 2,275 0.00511 0.00426 5.95044 0.00512 0.00419 SUTURE OF LACERATION 2,267 0.00554 0.00851 10.03914 0.00556 0.00849 OB WOUND COMP - C-SECTION DELIVERY 1,756 0.01127 0.01795 4.37917 0.01168 0.01763 OB WOUND COMP OF VAGINAL DELIVERY 1,805 0.00100 0.00521 31.60748 0.00110 0.00520 OTHER OBSTERIC COMPLICATIONS 1,812 0.00359 0.00585 6.70887 0.00369 0.00571 POST-PARTUM UTI INFECTION 1,812 0.00351 0.03344 29.23084 0.00358 0.03334 3RD OR 4TH DEGREE OB LACERATION 1,813 0.05462 0.04070 2.68744 0.05459 0.04006 UTERINE RUPTURE 1,807 0.00074 0.00378 30.60857 0.00081 0.00378 * Age, gender, DRG (except PSI 3, 4, 5, 6, 11); ** Age, gender, DRG, co-morbidity Table 12 shows the mean hospital level risk-adjusted rates, standard deviations and skew statistic for the DRG anadjusted rates. 
330

Table 13. Hospital Level Reliability Adjusted Experimental Patient Safety Indicators, National SID, 1997  Reliability* Adjusted MSX SPSI Label N Rate SD Skew 

Signal 

SD Share 

ASPIRATION PNEUMONIA CABG POST PTCA 612 0.02319 0.00485 1.04367 0.00544 0.00137 DECUBITUS ULCER IN HIGH RISK PATIENT 2,288 0.05322 0.02164 1.73548 0.02696 0.01203 IN-HOSPITAL FRAC RELATED TO FALLS 2,269 0.00199 0.00151 16.45952 0.00182 0.00192 INTRA-OPER NERVE COMP INJURY MALIGNANT HYPERTHERMIA POSTOPERATIVE AMI POSTOP IATROGENIC COMPL - CARDIAC 2,272 0.01691 0.00878 1.63677 0.01154 0.00752 POSTOP IATROGENIC COMPL - NERVOUS 2,272 0.00389 0.00130 2.62249 0.00193 0.00091 REOPENING OF A SURGICAL SITE 2,275 0.00560 0.00179 2.66912 0.00249 0.00108 SUTURE OF LACERATION 2,267 0.00570 0.00270 6.31452 0.00351 0.00215 OB WOUND COMP - C-SECTION DELIVERY** 1,739 0.01206 0.01094 3.19456 0.01158 0.0105OB WOUND COMP OF VAGINAL DELIVERY 1,805 0.00104 0.00036 1.82693 0.00074 0.00060 OTHER OBSTERIC COMPLICATIONS 1,812 0.00389 0.00385 9.98124 0.00427 0.00462 POST-PARTUM UTI INFECTION** 1,761 0.00253 0.00326 3.92805 0.00328 0.00413RD OR 4TH DEGREE OB LACERATION 1,813 0.05637 0.02551 0.88812 0.02627 0.01206 UTERINE RUPTURE 1,807 0.00080 0.00015 2.28522 0.00038 0.00021 * Age, gender, DRG, co-morbidity and reliability adjusted ** These two indicators were included in the Accepted indicator reliability adjustment, and then later demoted. Treported here reflects that analysis. Table 13 shows the effect of reliability adjustment, and provides statistics on the signal standard deviation, signa

ratio. Hospitals with fewer than three patients in the denominator were not included in the reliability adjustment

smoothing methods were applied to the experimental indicators, because there was less a priori reason to believe or structural characteristics were common to these indicators. 
331

Table 14. Bias Measures*, Experimental Patient Safety Indicators, National SID, 1997 PSI Label N 

Rank 

Corr. Abs. Value 

Top 

10% 

Bot 

10% Two 

ASPIRATION PNEUMONIA CABG POST PTCA 565 0.99201 0.02778 0.89474 0.89474 0DECUBITUS ULCER IN HIGH RISK PATIENT 2194 0.76883 0.23354 0.47273 0.66818 0IN-HOSPITAL FRAC RELATED TO FALLS 2240 0.89556 0.17110 0.62054 0.82143 0INTRA-OPER NERVE COMP INJURY MALIGNANT HYPERTHERMIA POSTOPERATIVE AMI POSTOP IATROGENIC COMPL - CARDIAC 2243 0.75712 0.42083 0.27111 0.73778 0POSTOP IATROGENIC COMPL - NERVOUS 2243 0.84357 0.28434 0.47556 0.75556 0REOPENING OF A SURGICAL SITE 2248 0.81376 0.20992 0.45333 0.76889 0SUTURE OF LACERATION 2240 0.94803 0.08606 0.75446 0.86161 0OB WOUND COMP - C-SECTION DELIVERY 1,756 0.972 0.090 0.828 0.868 OB WOUND COMP OF VAGINAL DELIVERY 1758 0.97279 0.10114 0.85795 0.89205 0OTHER OBSTERIC COMPLICATIONS 1761 0.96006 0.11163 0.68362 0.90960 0POST-PARTUM UTI INFECTION 1,812 0.982 0.093 0.802 0.910 3RD OR 4TH DEGREE OB LACERATION 1758 0.98284 0.07393 0.81818 0.89205 0UTERINE RUPTURE 1760 0.95904 0.13337 0.81818 0.84659 0 * Reliability adjusted to age, gender, DRG, co-morbidity and reliability adjusted Table 14 shows the effect of age, gender, DRG and co-morbidity risk-adjustment on the relative ranking of hospirisk-adjustment, using five measures of impact. Even if risk-adjustment reduces the apparent level of hospital le

relative rank may not be affected if the distribution of the adjusters does not vary systematically across hospitals. 

the relative ranking means that the measures are biased based on the patient characteristics we observe on the admsmall or no impact means that the measures are not biased based on the characteristics we observe (although thercharacteristics that we do not observe that are related to the patients risk of experiencing an adverse event). The frelative rank correlation statistic. The second measure is the average absolute magnitude of the change in actual each hospital. The third and forth measures are the percentage of hospitals that remain in the top (or bottom) 10% 

after adjustment. The last measure is the percentage of hospitals that change more than two deciles in the distribadjustment. 
332

Area Indicators 

Table 15. Unadjusted and Risk-Adjusted Area Patient Safety Indicators, National SID, 1997  Unadjusted Age-Gender AdjustPSI Label N Rate* SD Skew Rate* SD SkeFOREIGN BODY LEFT IN DURING PROCEDURE 714 0.82 2.27 7.03015 0.83 2.41 9.623IATROGENIC PNEUMOTHORAX 714 8.80 16.62 9.73506 8.07 15.43 9.768INFECTION DUE TO MEDICAL CARE 714 12.98 25.24 10.40177 12.71 25.67 9.929TECHNICAL DIFFICULTY WITH PROCEDURE 714 22.03 45.26 14.23158 21.45 44.14 13.08TRANSFUSION REACTION 714 0.07 0.57 16.14953 0.07 0.51 14.95POSTOPERATIVE WOUND DEHISCENCE 673 1.55 3.43 4.64596 1.90 7.20 12.43* Rate per 100,000 (except PSI31, which uses the number of abortions as the denominator) Table 15 shows the unadjusted and age-gender adjusted rates for the area indicators in the National SID in 1997. is the MSA or county (in rural areas), except for the Therapeutic Abortion indicator, where the denominator is thin the state. The other six indicators are accepted patient safety indicators that were modified into area indicatoincidence of the adverse event within geographic areas. The modification generally was to use principal rather thdiagnosis codes, and to use the area population as the denominator. 
333

Supplemental Table 1. Death in Low Mortality DRGs by Category, National SID, 1997 

Category Num. Den. Rate 

Death in Low Mortality DRG – Adult Medical 1,755 1,041,457 0.00169

Death in Low Mortality DRG – Pediatric Medical 318 543,195 0.00059

Death in Low Mortality DRG - Adult Surgical 375 685,286 0.00055

Death in Low Mortality DRG – Pediatric Surgical 30 29,725 0.00101

Death in Low Mortality DRG – Obstetric 201 2,310,440 0.00009

Death in Low Mortality DRG – Neonatal 0 1,928,936 0.00000

Death in Low Mortality DRG – Psychiatric 323 327,706 0.00099
334

Supplemental Table 2. Hospital Level Accepted Patient Safety Indicators, Florida, 1995-97  Risk-adjusted Rate Spearman CorrelatioPSI PSI Label 1995 1996 1997 ’95-‘96 ’96-‘97 ’95-1 COMPLICATIONS OF ANESTHESIA 0.00069 0.00069 0.00081 0.379 0.410 0.32 DEATH IN LOW MORTALITY DRGS 0.00104 0.00111 0.00107 0.290 0.326 0.23 DECUBITUS ULCER 0.01639 0.01715 0.01782 0.702 0.728 0.64 FAILURE TO RESCUE 0.17851 0.17418 0.17144 0.480 0.497 0.45 FOREIGN BODY LEFT IN DURING PROC 0.00010 0.00009 0.00009 0.207 0.206 0.26 IATROGENIC PNEUMOTHORAX 0.00096 0.00099 0.00094 0.515 0.535 0.47 INFECTION DUE TO MEDICAL CARE 0.00147 0.00150 0.00155 0.613 0.614 0.58 IN-HOSPITAL HIP FRACTURE 0.00111 0.00122 0.00123 0.202 0.192 0.19 POSTOP HEMORRHAGE OR HEMATOMA* 0.00016 0.00068 0.00196 0.299 0.224 -0.110 POSTOP PHYSIO METABOL DERANGMNT 0.00098 0.00085 0.00091 0.223 0.272 0.211 POSTOP PULMONARY COMPROMISE 0.00345 0.00293 0.00293 0.423 0.409 0.312 POSTOPERATIVE PE OR DVT 0.00610 0.00732 0.00718 0.407 0.414 0.313 POSTOPERATIVE WOUND DEHISCENCE 0.00262 0.00245 0.00257 0.236 0.226 0.214 SEPTICEMIA 0.00799 0.00896 0.01002 0.308 0.309 0.215 TECH DIFFICULTY W PROCEDURE 0.00293 0.00309 0.00313 0.587 0.596 0.516 TRANSFUSION REACTION . . . 17 BIRTH TRAUMA 0.00896 0.00945 0.00955 0.593 0.583 0.518 OB TRAUMA - VAGINAL W INSTRUMENT 0.20459 0.20691 0.20660 0.654 0.669 0.619 OB TRAUMA - VAGINAL WO INSTRUMENT 0.07452 0.07652 0.07639 0.753 0.756 0.620 OB TRAUMA - C-SECTION 0.00577 0.00623 0.00611 0.285 0.242 0.2*ICD-9 codes 998.11 (Hemorrhage complicating a procedure) and 998.12 (Hematoma complicating a procedure

October, 1996. 
335

Supplemental Table 3. Accepted Indicator Discharge Level Rates by Age Strata 

Age < 1 Age 1-14 Age 15-24 

Label Numer. Denom. Rate Numer. Denom. Rate Numer. Denom. Rate COMPLICATIONS OF ANESTHESIA 28 34,882 0.00080 100 141,690 0.000706 152 313,689 0.00048 DEATH IN LOW MORTALITY DRGS 144 2,136,175 0.00007 214 427,301 0.000501 126 961,976 0.00013 DECUBITUS ULCER 79 59,444 0.00133 308 132,028 0.002333 692 191,976 0.00360 FAILURE TO RESCUE 1,247 16,422 0.07593 657 11,994 0.054777 973 13,007 0.07481 FOREIGN BODY LEFT IN DURING PROC 11 275,937 0.00004 32 702,678 4.55E-05 95 1,394,663 0.00007 IATROGENIC PNEUMOTHORAX 105 259,393 0.00040 274 598,051 0.000458 385 1,245,587 0.00031 INFECTION DUE TO MEDICAL CARE 628 272,806 0.00230 662 654,920 0.001011 965 1,365,335 0.00071 POSTOP HEMORRHAGE OR HEMATOMA 150 34,588 0.00434 207 140,869 0.001469 275 178,186 0.00154 

POSTOP HIP FRACTURE 0 31,190 0.00000 1 92,563 1.08E-05 14 236,426 0.00006 POSTOP PHYSIO METABOL DERANGMNT 8 16,432 0.00049 35 63,991 0.000547 63 65,469 0.00096 

POSTOP PE OR DVT 63 34,572 0.00182 138 140,843 0.00098 528 177,749 0.00297 POSTOP RESPIRATORY FAILURE 45 12,762 0.00353 120 55,410 0.002166 86 61,653 0.00139 POSTOP SEPSIS 154 6,294 0.02447 150 17,519 0.008562 93 13,302 0.00699 TECH DIFFICULTY W MED CARE 285 275,640 0.00103 515 696,745 0.000739 841 590,352 0.00142 TRANSFUSION REACTION 2 275,937 0.00001 8 702,678 1.14E-05 8 1,394,663 0.00001 WOUND DEHISCENCE 21 15,564 0.00135 29 44,908 0.000646 38 50,406 0.00075 BIRTH TRAUMA 27,880 2,052,482 0.01358 

OB TRAUMA - VAGINAL W INSTRUMENT 120 518 0.23166 11,563 55,072 0.20996 OB TRAUMA - VAGINAL WO INSTRUMENT 403 3,762 0.107124 48,750 532,041 0.09163 OB TRAUMA - C-SECTION 3 669 0.004484 439 108,850 0.00403 Supplemental Table 3 reports the rate of each indicator by four age strata. This analysis is intended to provide infthe applicability of these indicators to the pediatric population. 
336

Supplemental Table 4. Percentage of Indicator Numerator or Denominator Represented by Age Strata  Age < 1 Age 1-14 Age 15-24 Label Numer. Denom. Numer. Denom. Numer. DenomCOMPLICATIONS OF ANESTHESIA 0.9% 0.7% 3.28% 2.89% 5.0% 6.DEATH IN LOW MORTALITY DRGS 4.8% 31.1% 7.13% 6.22% 4.2% 14.DECUBITUS ULCER 0.1% 1.1% 0.29% 2.48% 0.6% 3.FAILURE TO RESCUE 0.9% 2.2% 0.49% 1.59% 0.7% 1.FOREIGN BODY LEFT IN DURING PROC 0.7% 1.7% 1.99% 4.24% 5.9% 8.IATROGENIC PNEUMOTHORAX 0.6% 1.8% 1.65% 4.07% 2.3% 8.INFECTION DUE TO MEDICAL CARE 2.3% 1.9% 2.45% 4.54% 3.6% 9.POSTOP HEMORRHAGE OR HEMATOMA 1.2% 0.8% 1.72% 3.23% 2.3% 4.POSTOP HIP FRACTURE 0.0% 0.9% 0.03% 2.67% 0.5% 6.POSTOP PHYSIO METABOL DERANGMNT 0.4% 0.7% 1.66% 2.77% 3.0% 2.POSTOP PE OR DVT 0.2% 0.8% 0.40% 3.24% 1.5% 4.POSTOP RESPIRATORY FAILURE 0.8% 0.7% 2.24% 2.94% 1.6% 3.POSTOP SEPSIS 2.3% 0.9% 2.26% 2.54% 1.4% 1.POSTOP WOUND DEHISCENCE 1.0% 1.5% 1.31% 4.21% 1.7% 4.TECH DIFFICULTY WITH PROCEDURE 0.6% 1.9% 1.12% 4.90% 1.8% 4.TRANSFUSION REACTION 1.6% 1.7% 6.20% 4.24% 6.2% 8.BIRTH TRAUMA 100.0% 100.0% OB TRAUMA - VAGINAL W INSTRUMENT 0.33% 0.32% 31.3% 33.OB TRAUMA - VAGINAL WO INSTRUMENT 0.33% 0.26% 40.3% 36.OB TRAUMA - C-SECTION 0.12% 0.16% 16.9% 25.Supplemental Table 4 reports the percentage of the numerator and denominator consisting of patients in four age 

provides further information regarding the applicability of these indicators to the pediatric population. 
337

Figure 1. Distribution of non-zero hospital level Decubitus Ulcer rates in 1997 National SID (10% of the hospita

Y-Axis is the percent of hospitals. X-axis is the hospital’s Decubitus Ulcer rate, unadjusted. The blue line is the superimposed on the actual distribution. Median rate is 1.6%, mean rate is 2.1% and skew statistic is 3.62. 
338

Figure 2. Distribution of non-zero hospital level Birth Trauma rates in 1997 National SID (25% of the hospitals Axis is the percent of hospitals. X-axis is the hospital’s Birth Trauma rate, unadjusted. The blue line is the normsuperimposed on the actual distribution. Median rate is 0.25%, mean rate is 0.88% and skew statistic is 13.00. 
339

Figure 3. Distribution of non-zero hospital level Decubitus Ulcer rates in 1997 National SID (25% of the hospita

Y-Axis is the percent of hospitals. X-axis is the hospital’s Decubitus Ulcer rate, adjusted for risk and reliability. normal distribution superimposed on the actual distribution. Median rate is 1.4%, mean rate is 1.7% and skew sta
340

Figure 4. Distribution of non-zero hospital level Birth Trauma rates in 1997 National SID (25% of the hospitals Axis is the percent of hospitals. X-axis is the hospital’s Birth Trauma rate, adjusted for risk and reliability. The 

normal distribution superimposed on the actual distribution. Median rate is 0.26%, mean rate is 0.91% and skew 
Appendix H 

Comparison of PSIs with CSP Indicators and Miller et al. PSIs 

This appendix lists the differences between the final PSIs and the Complications Screening 

Program indicators and Miller et al. PSIs. These two sets of indicators were used as a starting 

point for this report. Also listed is the acceptance status of each indicator. 

343

APPENDIX H. COMPARISON OF PSIs WITH CSP INDICATORS AND MILLER ET AL. PSIs Table 1. Comparison of Miller et al. PSIs to PSIs evaluated in this report Miller et al. PSIs Relationship to PSI indicators Procedure for suture of laceration Experimental indicator (“Suture of laceration”). PSI adds 043, “suture of cra

3930 “suture of unspecified blood vessel,” 3931, “suture of artery,” 3932, “s

“suture of laceration of cervix.” PSI excludes obstetric admissions, and does 

PSI includes timing restriction of same day or after procedure. 

Perforation diagnosis Rejected pre-panels due to coding input. Postoperative infection Rejected pre-panel. Transfusion reaction Accepted indicator (“Transfusion reaction”). PSI does not include 999.8, “o

PSI does not exclude trauma. 

Foreign body left during procedure 

Accepted indicator (“Foreign body left in during procedure”). PSI includes Ebody during procedure.” PSI does not exclude trauma. 

Infection due to procedure Accepted indicator (“Infection due to medical care”). PSI adds 996.62. Iatrogenic conditions Indicator split prior to panel. “Iatrogenic hypotension” rejected by panel. “Ia

combined in “Postoperative PE or DVT.” “Iatrogenic pneumothorax” retain

specified exclusions. 

Wound disruption Accepted indicator (“Wound dehiscence in abdominopelvic surgical patient

998.3, “Postoperative wound disruption.” PSI limited to abdominoplevic surobstetric admissions. 

Miscellaneous misadventure Indicator split prior to panel. Shock due to anesthesia included in “Complica

by panel. Postoperative shock due to procedure was rejected. Accidental pun

in “Technical difficulty with procedure,” accepted by panel. Air embolism wof “Technical difficulty with procedure.” 

Obstetric misadventure Indicator split prior to panel. Most codes assigned to experimental indicator

complications.” “Wound complication - cesarean section” was accepted. 

Birth trauma Accepted indicator (“Birth trauma – injury to neonate”). PSI does not includ

plexus.” PSI excludes preterm infants with subdural or cerebral hemorrhage

imperfecta. 

E codes E codes split prior to panels and assigned to indicators. 
344

Table 2. Comparison of CSP Indicators to PSIs evaluated in this report CSP Indicator Relationship to PSI indicators 1. Post-operative cerebral infarction 

Rejected pre-panel. 

2. Aspiration pneumonia Experimental (“Aspiration pneumonia”). PSI definition adds two E codes to 

is limited to elective surgery patients. 

3. Post-operative pulmonary compromise 

Accepted (“Postoperative pulmonary compromise”). PSI retains only acute and limits to elective surgery. PSI excludes obstetric patients. 

4. Post-operative gastrointestinal hemmorhage or ulceration following non-GI surgery 

Rejected pre-panel 

5. Post-operative complications relating to urinary tract anatomy 

Rejected pre-panel 

6. Cellulitis or decubitus ulcer Accepted (“Decubitus ulcer”). PSI omits two cellulitis codes. PSI does not e

patients 80 yrs and older. PSI does not limit to dxs after #5. PSI LOS is 4 dadefinition excludes patients admitted from long term care facility. 

7. Septicemia Accepted (“Septicemia”). PSI doesn't include bacteraemia. PSI limits denom

patients, and does not limit to specified DRGs. PSI excludes obstetric admis

8. Post-or intra-operative shock due to anesthesia. 

Code rejected as part of “Complications of anesthesia” indicator by panel. 

9. Reopening of a Surgical Site Experimental (“Reopening of surgical site”). PSI removed two codes, 5461 

and 3595 (corrective procedure on heart). Other revision of vascular proceduwithing 24 hours of principle procedure. 

10. Mechanical complication due to device, implant or graft, except organ transplant. 

Rejected pre-panel. 

11. Miscellaneous complications Rejected pre-panel, most codes reassigned to toher indicators. 999.1 “air em

“Technical difficulty with procedure.” 999.3, “other infection” accepted as p

medical care.” 999.8, “other transfusion reaction” rejected as part of “Transf

E912, “inhalation and ingestion of food causing obstruction of respiratory trexperimental set as part of “Aspiration pneumonia.” 
345

12. Shock or cardiopulmonary arrest in-hospital 

Rejected pre-panel 

13. Post-operative complications relating to central or peripheral nervous system. 

Rejected pre-panel. Bracial plexus lesions (353.0) included as part of experi“Intaoperative nerve compression injuries.” 

14. Post-operative acute myocardial infarction 

Experimental (“Postoperative AMI”). PSI definition limits denominator to ePSI does not exclude MDC 5. 

15. Post-operative cardiac abnormalities except AMI 

Rejected pre-panel 

16. Post-operative infections except pneumonia and wound 

Rejected pre-panel, infection due to c. difficile included in own indicator. 

17. Procedure related perforation or laceration 

Experimental (“Suture of laceration”). PSI definition does not include perfo“suture of cranial and peripheral nerve,” 3782, “suture of laceration of diaph

unspecified blood vessel,” 3931, “suture of artery,” 3932, “suture of vein,” 4small intestine,” and 6761, “suture of laceration of cervix.” PSI excludes obnot limit to elective surgery. 

18. Post-operative coma or stupor Rejected pre-panel 19. Post-operative pneumonia Rejected by panel 20. Post-operative physiologic, metabolic derangements 

Accepted (“Postoperative physiologic and metabolic derangements”). PSI o

dialysis dependent acute renal failure, and other diabetic comas. PSI limits dsurgical patients, and excludes obstetric admissions. 

21. Complications relating to anesthetic agents and other CNS depressents 

Similar indicator proposed by panel (“Complications of anesthesia,” Accept

22. Venous thrombosis and pulmonary embolism 

Accepted indicator (“Postoperative PE or DVT”). PSI definition adds 453.9 and procedure code 38.7. PSI excludes obstetric patients. 

23. Wound infection Rejected pre-panel 24. Post-procedural hemorrhage or hematoma 

Accepted indicator (“Postoperative hemorrhage or hematoma”). PSI requirecode, adds hematoma codes, and 38.8x. PSI eliminates seroma code. 

25. In-hospital hip fracture Accepted (“In-hospital hip fracture”). PSI ecludes patients with lymphoma o

inflicted injury and principal dx of delirium and other psychoses and anoxic 
346

excludes patients with principal dx of trauma. PSI limits to surgical patients

26. Iatrogenic complications Experimental (nervous system and cardiac). Rejected (all others). PSI defini

indicators. 

27. Technical difficulty with medical care 

Accepted (“Technical difficulty with procedure”). PSI only includes E8700-excludes obstetric admissions. 

28. Complications relating to drugs 

Rejected pre-panel. 

Sentinel events 999.6 and 999.7 are included in accepted indicator, transfusion reaction. E87

part of “Foreign body left in during procedure.” 998.2 accepted as part of “Tprocedure.” 54.92, “removal of foreign body from peritoneal cavity was reje

“disruption of operation wound.” 
Appendix I 

Definitions of Indicators Presented to Panelists 

This appendix presents the definitions of each indicator as presented to panelists during 

the first round of ratings. Panelists then discussed these definitions during the conference 

call and suggested changes to the indicator. Short descriptions of the indicators are 

presented first followed by the ICD-9-CM level details for each indicator. 

349

APPENDIX I. DEFINITIONS OF INDICATORS PRESENTED TO PANELISTS Indicator Numerator Denominator Aspiration pneumonia Discharges with ICD-9-CM codes of 507.0, 

E911, or E912 in any secondary diagnosis field per 100 surgical discharges. 

All surgical discharges. Exclude patients with a principseizure, trauma, drug overdose

CABG following PTCA Discharges with ICD-9-CM codes for CABG 

(see below) in any procedure field per 100 discharges with PTCA (see below) in any procedure field. CABG must occur on the same day or after the PTCA. 

All discharges with ICD-9-CM (see below) in any procedure c

Complications of anesthesia Discharges with ICD-9-CM codes of 995.4 

(Shock due to anesthesia) or E876.3 (ETT misplacement) in any diagnosis field per 100 discharges. 

Medical and surgical dischargeExclude patients with any diag

Death in low mortality DRGs All discharges with disposition of "deceased" per 

100 population at risk. 

Patients in DRGs with less than rate. Exclude patients with any diagtrauma, immunocompromised 

Decubitus ulcer Discharges with ICD-9-CM code of 707.0 in any 

secondary diagnosis field per 100 discharges. 

Medical and surgical dischargeExclude patients greater than oof age. Include only patients with a lenmore than 10 days. Exclude patients in MDC 9 or diagnosis of hemiplegia, parapquadriplegia, or IV drug abuse

Dosage complications Discharges with ICD-9-CM code denoting a 

dosage complication (see below) in any 

Medical and surgical discharge
350

diagnosis field per 100 discharges. 

Foreign body left in during procedure Discharges with ICD-9-CM codes of 998.4, 

998.7, E871.x in any secondary diagnosis field per 100 surgical discharges. 

Medical and surgical discharge

Iatrogenic hypotension Discharges with ICD-9-CM code of 458.2 in any 

diagnosis field per 100 discharges. 

Medical and surgical patients. Exclude patients with any diag

Iatrogenic pneumothorax Discharges with ICD-9-CM code of 512.1 in any 

diagnosis field per 100 discharges. 

Medical and surgical patients. Exclude patients with any diag

Infection due to medical care Discharges with ICD-9-CM code of 999.3 or 

E875.x in any diagnosis field per 100 discharges. 

Medical or surgical patients. Excludes patients with any diatrauma. 

In-hospital hip fracture and fall (Renamed Postoperative hip fracture) 

Discharges with ICD-9-CM code for hip fracture or fall (see below) in any secondary diagnosis field per 100 surgical discharges. 

All surgical discharges. Excludes patients in MDC 8. Excludes patients with principafor seizure, syncope, stroke, coanoxic brain injury or poisonincode of trauma or metastatic ca

Intestinal infection due to C. difficile Discharges with ICD-9-CM code of 008.45 in 

any secondary diagnosis field per 100 discharges. 

Medical and surgical patients. 

Postoperative acute myocardial infarction Discharges with ICD-9-CM codes for AMI (see 

below) in any secondary diagnosis field per 100 non-cardiac surgical discharges. 

Non-cardiac surgical dischargeExclude patients undergoing cabelow). Exclude patients in MDC 5. 

Postoperative hemorrhage or hematoma Discharges with ICD-9-CM codes for 

hemorrhage or hematoma (see below) in any secondary diagnosis or procedure code field per 100 surgical discharges. Procedure code for control of hemorrhage must 

All surgical discharges. 
351

occur on the same day or after the principal procedure. 

Postoperative iatrogenic complications Discharges with ICD-9-CM code for iatrogenic 

complications (see below) in any secondary procedure fields per 100 surgical discharges. 

All surgical discharges. 

Postoperative physiologic and metabolic derangements 

Discharges with ICD-9-CM codes for physiologic and metabolic derangements (see below) in any secondary diagnosis field per 100 surgical discharges. 

All surgical discharges. Exclude patients with a principtrauma. Exclude patients with both a diketoacidosis and a principal diadiabetes. Exclude patients with both a secode for oliguria or anuria or aand a principal diagnosis of AMarrhythmia, cardiac arrest, or hMDC 8. 

Postoperative pneumonia Discharges with ICD-9-CM codes for 

pneumonia (see below) in any secondary diagnosis field per 100 surgical discharges. 

All surgical discharges. Exclude patients in MDC 4. Exclude patients with any diagimmunocompromised state or c

Postoperative pulmonary compromise (Renamed Postoperative respiratory failure) 

Discharges with ICD-9-CM codes for pulmonary compromise (see below) in any secondary diagnosis field per 100 surgical discharges. 

All surgical discharges. Exclude patients in MDC 4 and 

Postoperative pulmonary embolism or deep vein thrombosis 

Discharges with ICD-9-CM codes for pulmonary embolism or deep vein thrombosis (see below) in any secondary diagnosis field per 100 surgical discharges. 

All surgical discharges. Exclude patients with a principdeep vein thrombosis. 

Postoperative septicemia Discharges with ICD-9-CM code for septicemia 

(see below) in any secondary diagnosis field per 100 discharges in the population at risk. 

Patients in DRG 5, 106, 107, 1MDC 11, 12, 13. Exclude patients with a principinfection, or any diagnosis of A
352

immunocompromised state, or Include only patients with a lenmore than three days. 

Postoperative wound dehiscence Discharges with ICD-9-CM codes of 998.3 

(postoperative wound disruption) in any diagnosis or 54.61or 11.52 in any procedure field per 100 discharges. 

Medical or surgical dischargesExclude patients with any diagtrauma, cancer, AIDs, transplanimmunocompromised state. 

Reopening of a surgical site Discharges with ICD-9-CM codes for reopening 

of a surgical site (see below) in any secondary procedure field per 100 surgical discharges. Reopening of surgical site must occur at least one day after the principal procedure. 

All surgical discharges. 

Suture of laceration Discharges with ICD-9-CM codes for suture of 

laceration (see below) in any secondary procedure field per 100 surgical discharges. Suture of laceration must occur on the same day or after the principal procedure. 

All surgical discharges. Exclude patients with any diagforeign body or trauma. 

Technical difficulty with procedure Discharges with ICD-9-CM code denoting a 

condition arising from technical difficulty (see below) in any diagnosis field per 100 discharges. 

Medical and surgical patients. 

Transfusion reaction Discharges with ICD-9-CM codes for 

transfusion reaction (see below) in any diagnosis field per 100 discharges. 

Medical and surgical patients. Exclude patients with any diag

Obstetric indicators Birth trauma Discharges with ICD-9-CM codes for birth 

trauma (see below) in any diagnosis field per 100 liveborn births. 

All liveborn infants. 

Obstetric complication of delivery - trauma Discharges with ICD-9-CM codes for obstetric 

trauma (see below) in any diagnosis or procedure field per 100 deliveries. 

All deliveries. 

Obstetric thrombosis or embolism. Discharges with ICD-9-CM codes for obstetric 

thrombosis or embolism (see below) in any diagnosis field per 100 deliveries. 

All deliveries. 
353

Obstetric complication of delivery - wound complications 

Discharges with ICD-9-CM codes for obstetric wound complications (see below) in any diagnosis field per 100 deliveries. 

All deliveries. 

Obstetric complication of delivery - other Discharges with ICD-9-CM codes for other 

obstetrical complications (see below) in any diagnosis field per 100 deliveries. 

All deliveries. 

Puerperal infection Discharges with ICD-9-CM codes for major 

puerperal infection (see below) in any diagnosis field per 100 deliveries. 

All deliveries. Exclude patients with a diagnoantepartum infection of amniot1, 3] 
354

Acute myocardial infarction .........................................................................................................................................................................Birth trauma..................................................................................................................................................................................................CABG...........................................................................................................................................................................................................Cardiac surgery.............................................................................................................................................................................................Deep vein thrombosis ...................................................................................................................................................................................Dosage Complications..................................................................................................................................................................................Hemorrhage or hematoma ............................................................................................................................................................................Hip fracture or fall ........................................................................................................................................................................................Iatrogenic complications...............................................................................................................................................................................Obstetric thrombosis or embolism................................................................................................................................................................Obstetric trauma ...........................................................................................................................................................................................Obstetric wound complications ....................................................................................................................................................................Other obstetrical complications ....................................................................................................................................................................Physiologic and metabolic derangements.....................................................................................................................................................Pneumonia ....................................................................................................................................................................................................Puerperal infection........................................................................................................................................................................................PTCA............................................................................................................................................................................................................Pulmonary Compromise ...............................................................................................................................................................................Pulmonary embolism....................................................................................................................................................................................Reopening of a surgical site..........................................................................................................................................................................Septicemia ....................................................................................................................................................................................................Suture of laceration.......................................................................................................................................................................................Technical difficulty with medical care (procedure)......................................................................................................................................Transfusion reaction .....................................................................................................................................................................................Acute myocardial infarction ICD-9-CM diagnosis codes: 41000 AMI OF ANTEROLATERAL WALL – 

EPISODE OF CARE UNSPECIFIED 

41001 AMI OF ANTEROLATERAL WALL - 

INITIAL EPISODE OF CARE 

41010 AMI OF OTHER ANTERIOR WALL – 

EPISODE OF CARE UNSPECIFIED 

41011 AMI OF OTHER ANTERIOR WALL – 

INITIAL EPISODE OF CARE 

41020 AMI OF INFEROLATERAL WALL – 

EPISODE OF CARE UNSPECIFIED 

41021 AMI OF INFEROLATERAL WALL – 

INITIAL EPISODE OF CARE 

41030 AMI OF INFEROPOSTERIOR WALL – 

EPISODE OF CARE UNSPECIFIED 

41031 AMI OF INFEROPOSTERIOR WALL –– 

INITIAL EPISODE OF CARE 

41040 AMI OF INFER

CARE UNSPE

41041 AMI OF INFER

EPISODE OF C

41050 AMI OF OTHE

EPISODE OF C

41051 AMI OF OTH

INITIAL EPISO

41060 AMI TRUE PO

INFARCTION UNSPECIFIED 
355

41061 AMI TRUE POSTERIOR WALL 

INFARCTION - INITIAL EPISODE OF CARE 

41070 AMI SUBENDOCARDIAL INFARCTION - 

EPISODE OF CARE UNSPECIFIED 

41071 AMI SUBENDOCARDIAL INFARCTION - 

INITIAL EPISODE OF CARE 

41080 AMI OF OTHER SPECIFIED SITES - 

EPISODE OF CARE UNSPECIFIED 

41081 AMI OF OTHER SPECIFIED SITES - - 

INITIAL EPISODE OF CARE 

41090 AMI UNSPECIFIED SITE - EPISODE OF 

CARE UNSPECIFIED 

41091 AMI UNSPECIFIED SITE - INITIAL 

EPISODE OF CARE 

Birth trauma ICD-9-CM diagnosis codes: 7670 SUBDURAL AND CEREBRAL 

HEMORRHAGE (DUE TO TRAUMA OR TO INTRAPARTUM ANOXIA OR HYPOXIA) 

7673 INJURIES TO SKELETON 7674 INJURY TO SPINE AND SPINAL CORD 7676 INJURY TO BRACHIAL PLEXUS 7677 OTHER CRANIAL AND PERIPHERAL 

NERVE INJURIES 

7678 OTHER SPECIFIED BIRTH TRAUMA 7679 BIRTH TRAUMA, UNSPECIFIED CABG ICD-9-CM procedure code:s 3610 BYPASS ANASTOMOSIS FOR HEART 

REVASCULARIZATION 

3611 OPEN HEART VALVULOPLASTY 

WITHOUT REPLACEMENT 

3612 AORTOCORONARY BYPASS OF TWO 

CORONARY ARTERIES 

3613 AORTOCORONARY BYPASS OF THREE 

CORONARY ARTERIES 

3614 AORTOCORONARY BYPASS OF FOUR OR 

MORE CORONARY ARTERIES 

3615 SINGLE INTERNAL MAMMARYCORONARY ARTERY BYPASS 3616 BYPASS ANASTOMOSIS FOR HEART 

REVASCULARIZATION, DOUBLE INTERNAL MAMMARY-CORONARY ARTERY BYPASS 

3617 ABDOMINAL-CORONARY ARTERY 

BYPASS 

3619 OTHER BYPASS ANASTOMOSIS FOR 

HEART REVASCULARIZATION 

Cardiac surgery Diagnostic Related Groups (DRGs): 103 HEART TRANSPLANT 104 CARDIAC VALVE AND OTHER MAJOR 

CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION 

105 CARDIAC VALVE AND OTHER MAJOR 

CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION 

106 CORONARY BYPASS WITH PTCA 107 CORONARY BYPASS WITH CARDIAC 

CATHETERIZATION 

108 OTHER CARDIOTHORACIC PROCEDURES 110 MAJOR CARDIOVASCULAR 

PROCEDURES WITH CC 

111 MAJOR CARDIOVASCULAR 

PROCEDURES WITHOUT CC 

112 PERCUTANEOUS CARDIOVASCULAR 

PROCEDURES 

Deep vein thrombosis ICD-9-CM diagnosis codes: 45111 PHLEBITIS AND THROMBOSIS OF 

FEMORAL VEIN (DEEP) (SUPERFICIAL) 

45119 PHLEBITIS AND THROMBOPHLEBITIS - 

OF DEEP VESSEL OF LOWER EXTREMITIES - OTHER 

4512 PHLEBITIS AND THROMBOPHLEBITIS OF 

LOWER EXTREMITIES UNSPECIFIED 

45181 PHLEBITIS AND THROMBOPHLEBITIS OF 

ILIAC VEIN 

4519 PHLEBITIS AN

OTHER SITES 

4532 OTHER VENO

THROMBOSIS 

4538 OTHER VENO

THROMBOSIS VEINS 

4539 OTHER VENO

THROMBOSIS 

Dosage Complications ICD-9-CM diagnosis codeE8730 EXCESSIVE A

OTHER FLUID INFUSION. 

E8731 INCORRECT D

DURING INFU

E8732 OVERDOSE OE8733 INADVERTEN

TO RADIATIO

E8734 FAILURE IN D

OR INSULIN-

E8735 INAPPROPRIA

COLD) TEMPEAPPLICATION 

E8736 NON-ADMINS

DRUG OR ME

E8738 OTHER SPECIE8739 UNSPECIFIED E8761 WRONG FLUIHemorrhage or hematomICD-9-CM diagnosis code99811 HEMORRHAG

PROCEDURE 

99812 HEMATOMA 

PROCEDURE 

99813 SEROMA COMICD-9-CM procedure cod
356

287 CONTROL OF HEMORRHAGE AFTER 

TONSILLECTOMY AND ADENOIDECTOMY 

3941 CONTROL OF HEMORRHAGE AFTER 

TONSILLECTOMY AND ADENOIDECTOMY 

3998 CONTROL OF HEMORRHAGE NOS 4995 CONTROL OF (POSTOPERATIVE) 

HEMORRHAGE OF ANUS 

5793 CONTROL OF (POSTOPERATIVE) 

HEMORRHAGE OF BLADDER 

Hip fracture or fall ICD-9-CM diagnosis codes: (includes all 5th digits) 

8200 FRACTURE OF NECK OF FEMURTRANSCERVICAL FRACTURE, CLOSED 8201 FRACTURE OF NECK OF FEMURTRANSCERVICAL FRACTURE, OPEN 8202 FRACTURE OF NECK OF FEMURPERTROCHANTERIC FRACTURE, CLOSED 

8203 FRACTURE OF NECK OF FEMURPERTROCHANTERIC FRACTURE, OPEN 8208 UNSPECIFIED PART OF NECK OF FEMUR, 

CLOSED 

8209 UNSPECIFIED PART OF NECK OF FEMUR, 

OPEN 

E8842 FALL FROM CHAIR OR BED E8849 FALL FROM ONE LEVEL TO ANOTHER E885 FALL ON SAME LEVEL FROM SLIPPING, 

TRIPPING OR STUMBLING 

E887 FRACTURE, CAUSE UNSPECIFIED E888 OTHER AND UNSPECIFIED FALL Iatrogenic complications 

ICD-9-CM diagnosis codes: 9970X NERVOUS SYSTEM COMPLICATIONS 9971 CARDIAC COMPLICATIONS 9972 PERIPHERAL VASCULAR 

COMPLICATIONS 

9973 RESPIRATORY COMPLICATIONS 9974 DIGESTIVE SYSTEM COMPLICATIONS 

9975 URINARY COMPLICATIONSObstetric thrombosis or embolism 

ICD-9-CM diagnosis codes: 671.40 DEEP VEIN THROMBOSIS – POSTPARTUM 

UNSPECIFIED 

671.42 DEEP VEIN THROMBOSIS – DELIVERED 

WITH MENTION OF POSTPARTUM COMPLICATION 

671.44 DEEP VEIN THROMBOSIS – POSTPARTUM 

CONDITION OR COMPLICATION 

673.20-4 OBSTETRIC PULMONARY EMBOLISM Obstetric trauma ICD-9-CM diagnosis codes: 66420, 1,4 THRID-DEGREE PERINEAL LACERATION 66430, 1,4 FOURTH-DEGREE PERINEAL 

LACERATION 

66530, 1, 4 LACERATION OF CERVIX 66540, 1, 4 HIGH VAGINAL LACERATIONS 66550, 1, 4 OTHER INJURY TO PELVIC ORGANS ICD-9-CM procedure codes: 7550 REPAIR OF CURRENT OBSTETRIC 

LACERATIONS UTERUS 

7551 REPAIR OF CURRENT OBSTETRIC 

LACERATIONS OF CERVIX 

7552 REPAIR OF CURRENT OBSTETRIC 

LACERATIONS OF CORPUS UTERI 

7561 REPAIR OF CURRENT OBSTETRIC 

LACERATION OF BLADDER AND URETHRA 

7562 REPAIR OF CURRENT OBSTETRIC 

LACERATION OF RECTUM AND SPHINCTER ANI 

Obstetric wound complications ICD-9-CM diagnosis codes: 

67410,2,4 DISRUPTION 67420,2,4 DISRUPTION 67430 OTHER COMP

OBSTETRICA

Other obstetrical complicICD-9-CM diagnosis code(includes 5th digits): 6651 RUPTURE OF 

LABOR 

6680 PULMONARY 6681 CARDIAC CO6682 CENTRAL NE

COMPLICATI

6688 OTHER COMP

ANESTHESIA LABOR AND 

6689 UNSPECIFIED 

ANESTHESIA 

6691 SHOCK DURI

AND DELIVE

6694 OTHER COMP

OBSTETRICAPROCEDURES 

66930, 2, 4 ACUTE REN

LABOR AND 

Physiologic and metaboliICD-9-CM diagnosis codeDIABETES WITH KETO25010 TYPE 2, OR U

STATED AS U

25011 TYPE 1 NOT S

UNCONTROL

25012 TYPE 2 OR UN

UNCONTROL

25013 TYPE 1 UNCOACUTE RENAL FAILUR5845 WITH LESION 
357

5846 WITH LESION OF RENAL CORTICAL 

NECROSIS 

5847 WITH LESION OF RENAL MEDULLARY 

[PAPILLARY] NECROSIS 

5848 WITH OTHER SPECIFIED PATHOLOGICAL 

LESION IN KIDNEY 

5849 ACUTE RENAL FAILURE, UNSPECIFIED DIABETES WITH HYPEROSMOLARITY: 25020 TYPE 2, OR UNSPECIFIED TYPE, NOT 

STATED AS UNCONTROLLED 

25021 TYPE 1 NOT STATED AS 

UNCONTROLLED 

25022 TYPE 2 OR UNSPECIFIED TYPE, 

UNCONTROLLED 

25023 TYPE 1 UNCONTROLLED DIABETES WITH OTHER COMA: 25030 TYPE 2, OR UNSPECIFIED TYPE, NOT 

STATED AS UNCONTROLLED 

25031 TYPE 1 NOT STATED AS 

UNCONTROLLED 

25032 TYPE 2 OR UNSPECIFIED TYPE, 

UNCONTROLLED 

25033 TYPE 1 UNCONTROLLED Pneumonia ICD-9-CM diagnosis codes:481 PNEUMOCOCCAL PNEUMONIA 4821 KLEBSIELLA PNEUMONIAE 4822 PNEUMONIA DUE TO PSEUDOMONAS 4823 HEMOPHILIS PNEUMONIAE 4824 PNEUMONIA DUE TO STREPTOCOCCUS 4825 PNEUMONIA DUE TO STAPHYLOCOCCUS 4826 PNEUMONIA DUE TO ANAEROBES 4827 PNEUMONIA DUE TO E. COLI 4828 PNEUMONIA DUE TO OTHER GRAM 

NEGATIVE 

4829 PNEUMONIA DUE TO LEGIONNAIRES 

DISEASE 

4830-8 PNEUMONIA DUE TO OTHER SPECIFIED 

ORGANISM (MYCOPLASMA PNEUMONIA, CHLAMYDIA, OTHER SPECIFIED) 

485 BRONCHOPNEUMONIA, ORGANISM 

UNSPECIFIED 

486 PNEUMONIA, ORGANISM UNSPECIFIED 

(EXCLUDES HYPOSTATIC OR PASSIVE PNUEMONIA, ASPIRATION PNEUMONIA)

Puerperal infection ICD-9-CM diagnosis code: 67000 MAJOR PUERPERAL INFECTION, 

UNSPECIFIED AS TO EPISODE OF CARE 

67002 MAJOR PUERPERAL INFECTION, 

DELIVERED WITH MENTION OF POSTPARTUM COMPLICATION 

67004 MAJOR PUERPERAL INFECTION, POSTPARTUM CONDITION OR COMPLICATION PTCA ICD-9-CM procedure codes: 3601 SINGLE VESSEL PERCUTANEOUS 

TRANSLUMINAL CORONARY ANGIOPLASTY [PTCA] OR CORONARY ATHERECTOMY WITHOUT MENTION OF THROMBOLYTIC AGENT 

3602 SINGLE VESSEL PERCUTANEOUS 

TRANSLUMINAL CORONARY ANGIOPLASTY [PTCA] OR CORONARY ATHERECTOMY WITH MENTION OF THROMBOLYTIC AGENT 

3605 MULTIPLE VESSEL PERCUTANEOUS 

TRANSLUMINAL CORONARY ANGIOPLSTY [PTCA] OR CORONARY ATHERECTOMY PERFORMED DURING THE SAME OPERATION, WITH OR WITHOUT MENTION OF THROMBOLYTIC AGENT 

3606 INSERTION OF CORONARY ARTERY 

STENTS 

Pulmonary compromise ICD-9-CM diagnosis codes: 

51881 ACUTE RESPI51882 OTHER PULM

NOT ELSEWH

514 PULMONARY 

HYPOSTASIS 

518.5 PULMONARY 

FOLLOWING 

518.4 ACUTE EDEMPulmonary embolism ICD-9-CM diagnosis code41511 IAGTROGENI

AND INFARC

41519 OTHER 

Reopening of a surgical sICD-9-CM procedure cod123 REOPENING O302 REOPENING O602 REOPENING O

FIELD 

3403 REOPENING O

SITE 

3595 REVISION OF 

ON HEART 

3949 OTHER REVIS

PROCEDURE 

5412 REOPENING O

SITE 

Septicemia ICD-9-CM diagnosis code0380 STREPTOCOC03810 STAPHYLOCO

UNSPECIFIED 

03811 STAPHYLOCO

SEPTICEMIA 

03819 OTHER STAP
358

0382 PNEUMOCOCCAL SEPTICEMIA 

(STREPTOCOCCUS PNEUMONIAE SEPTICEMIA) 

0383 SEPTICEMIA DUE TO ANAEROBES SEPTICEMIA DUE TO 03840 GRAM-NEGATIVE ORGANISM, 

UNSPECIFIED 

03841 HEMOPHILUS INFLUENZAE 03842 ESCHERICHIA COLI 03843 PSEUDOMONAS 03844 SERRATIA 03849 SEPTICEMIA DUE TO OTHER GRAMNEGATIVE ORGANISMS 0388 OTHER SPECIFIED SEPTICEMIAS 0389 UNSPECIFIED SEPTICEMIA Suture of laceration ICD-9-CM procedure codes: 2951 SUTURE OF LACERATION OF PHARYNX 3161 SUTURE OF LACERATION OF LARYNX 3341 SUTURE OF LACERATION OF BRONCHUS 3343 CLOSURE OF LACERATION OF LUNG 3482 SUTURE OF LACERATION OF 

DIAPHRAGM 

3930 SUTURE OF UNSPECIFIED BLOOD 

VESSEL 

3931 SUTURE OF ARTERY 3932 SUTURE OF VEIN 4282 SUTURE OF LACERATION OF 

ESOPHAGUS 

4461 SUTURE OF LACERATION OF STOMACH 4671 SUTURE OF LACERATION OF 

DUODENUM 

4673 SUTURE OF LACERATION OF SMALL 

INTESTINE, EXCEPT DUODENUM 

4675 SUTURE OF LACERATION OF LARGE 

INTESTINE 

4871 SUTURE OF LACERATION OF RECTUM 4971 SUTURE OF LACERATION OF ANUS 5581 SUTURE OF LACERATION OF KIDNEY 5682 SUTURE OF LACERATION OF URETER 5781 SUTURE OF LACERATION OF BLADDER 5841 SUTURE OF LACERATION OF URETHRA 5061 CLOSURE OF LACERATION OF LIVER 5191 REPAIR OF LACERATION OF 

GALLBLADDER 

6941 SUTURE OF LACERATION OF UTERUS Technical difficulty with medical care (procedure) ICD-9-CM Diagnosis Codes E870X ACCIDENTAL CUT, PUNCTURE, 

PERFORATION, OR HEMORRHAGE DURING MEDICAL CARE 

E872X FAILURE OF S

DURING PRO

E8765 PERFORMANC

OPERATION 

9982 ACCIDENTAL 

LACERATION 

99881 EMPHYSEMA 

(SURGICAL) RPROCEDURE 

99882 CATARACT FR

FOLLOWING 

99889 OTHER SPECI

PROCEDURESCLASSIFIED 

9991 AIR EMBOLIS

Transfusion reaction ICD-9-CM diagnosis code9996 ABO INCOMP9997 RH INCOMPA9998 OTHER TRANE8760 MISMATCHE
Appendix J 

Peer Reviewers 

This appendix lists the peer reviewers who who provided comments on the report draft. 

361

APPENDIX J. PEER REVIEWERS 

The EPC acknowledges the contribution of the following individuals, who provided 

comments on the report draft. This review was used to improve the final report. 

Dan Berlowitz, MD, MPh 

Associate Director, 

Center for Health Quality, Outcomes and 

Economic Research (CHQOER) 

Bedford VA Hospital 

Bedford, MA 

Andrew Brown, MD, MPH 

Associate Professor of Medicine and 

Director 

The University of Mississippi Medical 

Center 

Jackson, MS 

Timothy Dresselhaus, MD, MPH

Associate Professor, UCSD Department 

of Medicine 

Associate Chief, VA Medical Service 

San Diego Center for Patient Safety 

San Diego, California 

William Claiborne Dunagan, MD 

Vice President, Quality 

BJC HealthCare 

St. Louis, MO 

Victoria Fraser, MD 

Associate Professor of Medicine 

Washington University School of 

Medicine 

St. Louis, MO 

David Gaba, MD 

Professor, Department of Anesthesia at 

Stanford University 

Director, Patient Safety Center of 

Inquiry 

Palo Alto Veterans Administration 

(VAPAHCS) 

Palo Alto, CA 

Lein Fang Han, PhD 

Health Service Researcher 

Quality Measurement and Health 

Assessment Group 

Centers for Medicare & Medicaid 

Services 

Baltimore, MD 

John Hickner, MD, MS 

Professor of Family Practice 

Michigan State University College of 

Human Medicine 

East Lansing, MI 

Lisa I. Iezzoni, MD, MSc 

Professor of Medicine, Harvard Medical 

School 

Division of General Medicine and 

Primary Care 

Beth Israel Deaconess Medical Center 

Boston, MA 

Harold Kaplan, MD 

Professor and Director of Clinical 

Laboratories 

New York Presbyterian Hospital and 

Columbia Presbyterian Medical 

Center 

New York, NY 

Ed Kelley, PhD 

Senior Service Fellow, National 

Healthcare Quality Report 

Center for Quality Improvement and 

Patient Safety 

Agency for Healthcare Research and 

Quality (AHRQ) 

Rockville, MD 
362

Christine Kovner, RN, PhD, FAAN 

Professor, Division of Nursing 

Steinhardt School of Education, New 

York University 

New York, NY 

Peter Layde, MD, MSc 

Professor and Director Division of 

Research 

Department of Family and Community 

Medicine 

Medical College of Wisconsin 

Milwaukee, WI 

Jared Loeb, PhD 

Vice President, Research and 

Performance Measurement 

JCAHO 

Oakbrook Terrace, IL 

Stephen Luther, PhD 

Evaluation Methodologist 

VISN 8 Patient Safety Center of Inquiry 

James A. Haley, Veterans 

Administration Hospital 

Tampa, FL

Colin Mackenzie, MD 

Profesor & Director 

National Study Center for Trauma & 

EMS 

Baltimore MD 

Steven Meuer, MHS, MBA

Director, Patient Safety 

BJC HealthCare 

St. Louis, MO 

Jack Needleman, PhD

Assistant Professor 

Harvard School of Public Health 

Boston, MA 

Peter Pronovost, MD,PhD 

Associate Professor 

Dept of Anesthesiology and Critical 

Care Medicine 

Johns Hopkins University School of 

Medicine 

Baltimore, MD 

Amy Rosen, PhD 

Senior Research Scientist and Associate 

Professor, Health Services

Center for Health Quality, Outcomes and 

Economic Research (CHQOER) 

Boston University School of Public 

Health 

Bedford, MA 

Loel Solomon, PhD 

Deputy Director Health Care Quality 

and Analysis Division 

Office of Statewide Health Planning and 

Development 

Sacramento, CA 

Dionyssios Tsilimingras, MD, MPh 

Health Science Specialist 

Center for Health Quality, Outcomes, & 

Economic Research- VA Medical 

Center 

Bedford, MA 

Wu Xu, PhD 

Director for Office of Health Care 

Statistics 

Utah Department of Health 

Salt Lake City, Utah 

Coding Consultant 

Rita A. Scichilone, MHSA, RHIA, 

CCS, CCS-P, CHC 

Director, Coding Products and Services 

American Health Information 

Management Association (AHIMA) 

Chicago, IL 
 363

Acronyms Used in This Report 

AHIMA American Health Information Management Association 

AHRQ Agency for Healthcare Research and Quality 

AIDS Acquired Immune Deficiency Syndrome 

AMI Acute Myocardial Infarction 

APR-DRG All-Patient Refined-Diagnostic Related Group 

CABG Coronary Artery Bypass Graft 

CC Comorbidities or complications 

CHF Congestive Heart Failure 

CMA California Medical Association 

CMS Centers for Medicare and Medicaid Services 

CNS Central Nervous System 

COPD Chronic Obstruction Pulmonary Disease 

CSP Complications Screening Program 

DNR Do Not Resuscitate 

DRG Diagnostic Related Groups 

DVT Deep Vein Thrombosis 

E-Codes External cause-of-injury codes 

EPC Evidence-based Practice Center 

HCUP Healthcare Cost and Utilization Project 

HIV Human Immunodeficiency Virus 

ICD-9-CM International Classification of Diseases 9th Revision Clinical Modification 

IV Intravenous (catheter) 

IVC Intra Vena Cava 

JCAHO Joint Commission for the Accreditation of Healthcare Organizations 

MDC Major Diagnostic Categories 

MSA Metropolitan Statistical Area 

MSX Multivariate Signal Extraction 

NCHS National Center for Health Statistics 

NIS Nationwide Inpatient Sample 

NQF National Quality Forum 

NQR National Quality Report 

NSQIP National Surgical Quality Improvement Program (VA) 

OB Obstetric 

OR Operating Room 

PE Pulmonary Embolism 

PO Postoperative 

PICC Peripherally Inserted Central Catheter 

PSI Patient Safety Indicator 

PTCA Percutaneous Transluminal Coronary Angioplasty 

QI Quality Indicator 

SID State Inpatient Databases 

VA (Department of) Veterans Affairs 

VBAC Vaginal Birth After Cesarean 

UCSF University of California at San Francisco 

UTI Urinary Tract Infection