How your coding, CDI practice impacts U.S. News and World Report rankings (with example)

By Brian Murphy

U.S. News and World Report just released its 2025-26 ranking of the nation’s best hospitals.

As always I’m interested in what you think of these rankings, and secondarily how much your hospital and its CDI and coding programs use the list as a barometer of success. Leave a comment below.

(FYI NYU Langone is crushing it).

I thought this was an interesting bit, a warning not to abandon your local community hospital to get your colonoscopy at Mayo:

“For most illnesses, patients do not need to go to an Honor Roll hospital, which may require traveling away from home and paying expenses for out-of-network care. All rankings and ratings should be seen as just a starting point for patients considering where to seek care with input from their doctors. Individual diagnosis, insurance coverage and priorities are important factors in making a personal best choice.”

Provider clarification impacting O/E ratio

But what I really want to focus on is how the work of a CDI or coding professional can impact your ranking on the list, particularly through observed-to-expected (O/E) ratios for complications.

U.S. News uses risk-adjusted outcome measures in its rankings including specialties like cardiology, GI surgery, and orthopedics. One key metric is the O/E ratio for complications, which compares the actual rate of complications observed at a hospital (numerator) to the rate statistically expected based on patient complexity and risk (denominator).

As I’ve noted (see linked post below) before a great takeaway is to educate your coders and CDI professionals on the Elixhauser methodology, as U.S. News and World Report uses it. This is confirmed again in the published U.S. News and World Report methodology (also see below).

Correctly capturing patient complexity through coding and documentation directly affects the expected portion of this ratio. If documentation is incomplete or vague, the patient may appear less sick than they truly are — reducing the expected rate of complications and making the hospital look worse when complications occur.

Let’s take a look at an example.

Example: Acute Kidney Injury (AKI) and a CDI query

Clinical scenario: A 76-year-old male undergoes major abdominal surgery. Post-op, he experiences a transient rise in creatinine. The physician documents “mild renal dysfunction.”

A CDI specialist notices that the labs meet KDIGO criteria for AKI (e.g., creatinine increase >0.3 mg/dL within 48 hours) and issues a clarification.

Provider response: “Yes, this represents Stage 1 AKI due to hypotension.”

Without this CDI clarification, expected complications are lower, because the patient seems healthier. But the observed complications are higher (AKI is captured anyway via lab data or NSQIP abstraction). And your O/E ratio is worse … it appears your hospital underperformed.

With the clarification expected complications are appropriately higher, due to documented AKI and comorbid hypotension. Observed complications are the same, and the O/E ratio is closer to 1 (or possibly <1). This reflects well-managed complex care … and helps with your U.S. News and World Report rankings.

References

• U.S. News and World Report formal methodology (.PDF): https://health.usnews.com/media/best-hospitals/2025-2026_best_hospitals_specialty_rankings_methodology
• Fierce Healthcare, U.S. News 2025-26 releases Best Hospitals lists, revamps regional rankings: https://www.fiercehealthcare.com/providers/us-news-2025-2026-releases-best-hospitals-lists-revamps-regional-rankings
• Elixhauser: A mouthful to say, but a must know concept in understanding hospital quality and performance (Norwood): https://www.norwood.com/elixhauser-a-mouthful-to-say-but-a-must-know-concept-in-understanding-hospital-quality-and-performance/