Make the new CMS quality measure Thirty-Day Risk Standardized Death Rate a major priority in your CDI, coding efforts

By Brian Murphy 

 

Among the many ethical challenges CDI professionals face is pressure to make their organizations and/or providers look better on paper, through elimination of diagnoses that might trigger a patient safety indicator (PSI) or other quality measure.  

 

In some organizations the pressure to improve quality scores is stronger than CC/MCC/HCC capture. 

 

But there is a compliant way to do the work of improving organizational quality. 

 

Review your denominator exclusions, query when appropriate, and get them documented. Doing so removes these patients appropriately from the measure. 

 

This work is critical for the new CMS quality measure, Thirty-day Risk-Standardized Death Rate among Surgical Inpatients with Complications (Failure-to-Rescue), recently introduced in the FY 2025 IPPS final rule. 

 

The Failure to Rescue measure is defined as the percentage of surgical inpatients who experienced a complication and then died within 30-days from the date of their first OR procedure. Failure-to-rescue is defined as the probability of death given a postoperative complication. 

 

This measure is publicly reported, meaning that anyone with access to a computer will see how many surgical inpatients with complications passed away within 30 days of their procedure at a given hospital. 

 

Weighty stuff, and not a good look if you’re performing poorly. But the good news is, all the reporting details are freely accessible, down to the very ICD-10-CM codes that move patients out of the denominator.  

 

Which also means CDI and coding professionals can impact this measure. 

 

The numerator represents the number of adverse events or safety incidents that actually occurred (i.e., surgical complications or infections, or in this case deaths). The denominator represents the population at risk, typically defined as all patients eligible for the measure based on specific clinical or procedural criteria.  

 

Denominator exclusions refer to specific conditions, circumstances, or patient groups that are intentionally removed from the denominator to ensure accurate and fair performance measurement. These exclusions are applied when including certain patients might distort the results due to factors beyond the control of healthcare providers or due to clinical appropriateness. 

 

Following are the broad category exclusions for this new measure. 

 

• Cardiac Event  

• Congestive Heart Failure 

• Hypotension/Shock/Hypovolemia 

• Pulmonary Embolus/Deep Vein Thrombosis/Phlebitis 

• Cerebrovascular Accident (CVA)/TIA 

• Coma 

• Seizure 

• Delirium/Psychosis 

• Nervous System Complications 

• Pneumonia/Pneumonitis  

• Pneumothorax/Effusion 

• Respiratory Compromise/Bronchospasm  

• Internal Organ Damage/Perforation  

• Peritonitis 

• GI bleed and blood loss 

• Sepsis 

• Deep wound infection or wound complication 

• Renal dysfunction 

• Gangrene/amputation 

• Intestinal obstruction/ischemia 

• Retained foreign body 

• Pressure injury 

• Orthopedic complication 

• Hepatitis or jaundice 

• Pancreatitis 

• Necrosis of bone (thermal or aseptic) 

• Osteomyelitis 

• Disseminated intravascular coagulation (DIC) 

• Pyelonephritis 

• Postprocedural/Transfusion Complication  

 

These must be reported as present on admission and match the listed ICD-10-CM exclusion codes. See link below for complete details. Other examples of ICD-10-CM codes resulting in exclusion from the measure include Z66: Do Not Resuscitate (DNR) status, and Z51.5: Encounter for palliative care. 

 

This measure is risk adjusted. Risk factors for failure to rescue can be categorized into three groups: 

1. patient risk factors for mortality within 30 days of surgery, such as age, comorbidities, or preoperative ‘do not resuscitate’ orders;  

1. social risk factors that can influence patient risk, such as patient functional status, race/ethnicity, or socioeconomic status, and;  

1. hospital factors, such as nurse and resident staffing, staff skill mix, hospital volume and technological resources.  

 

In general, the accuracy of a patient’s comorbidities with supporting documentation allows appropriate coding of the patient’s complexities. It ensures that patients are appropriately included or excluded from quality measures, which helps maintain accurate performance metrics for the healthcare system.   

 

 

Reference

 

• Review the full measure definition, including inclusions/exclusions and risk adjusters, here: https://p4qm.org/measures/4125