Version 25 of AHRQ Patient Safety Indicators (PSI): Review these important updates

By Brian Murphy

The AHRQ updated the Patient Safety Indicators (PSI). But before we get into them, first a reminder of what PSIs are and why they matter.

PSIs provide information on potentially avoidable safety events. Each PSI has inclusion criteria (who/what gets counted; the at-risk population) and exclusion criteria (codes or conditions that exclude a case). PSIs are triggered/captured strictly by diagnosis/procedure codes and present on admission (POA) indicators.

PSIs impact hospital revenues and quality performance.

• Revenue: Many PSIs overlap with CMS’s Hospital-Acquired Condition Reduction Program (HACRP). If a hospital scores in the lowest quartile of HACRP it suffers a 1% Medicare payment penalty. Also, PSI-90 is included in the CMS Hospital Value Based Purchasing Safety Domain; strong performance can earn the hospital a bonus payment, poor performance a penalty.
• Quality: Poor PSI performance/high rates can directly lower a hospital’s reputation and placement in specialty or overall rankings. For example, Healthgrades uses AHRQ PSI methodology directly in its Patient Safety Excellence Award and other star ratings. U.S. News & World Report uses PSI 90 as part of its Patient Safety Index.

CDI specialists can impact PSI reporting by capturing conditions that serve as exclusionary diagnoses or clarifying whether a diagnosis is POA. This is part of clinical validation.

Version 2025 PSI updates

There are some notable 2025 changes; I counted 39 discrete changes, although many are technical edits corresponding with annual code updates. I’m focusing on a few that are part of the PSI-90 composite and directly related to CDI work.

• PSI 03 (Pressure Ulcer Rate): Added five dx codes related to Cardiogenic Shock, Cardiac Arrest, and Anoxic Brain Damage
• PSI 06 (Iatrogenic Pneumothorax Rate): Added 50 codes related to thoracic surgery, including lung or pleural biopsy and diaphragmatic repair.
• PSI 08 (In-Hospital Fall Associated Fracture Rate): Removed 58 codes including osteoporotic pathologic fractures (non-hip) and alveolar ridge fractures. The AHRQ determined these were pathologic fractures of osteoporotic bones, occurred spontaneously, and therefore no fault of the hospital.
• PSI 09 (Postop Hemorrhage and Hematoma Rate): Added 3 codes related to coagulation disorders.
• PSI 10 (Postop AKI requiring dialysis rate): Added 2 codes related to partial or total nephrectomy.
• PSI 11 (Postop Respiratory Failure Rate): 41 codes added, including nine for left ventricular assist devices (LVAD). Per AHRQ, LVADs are now widely used as a bridge to heart transplantation and may be used for extended periods of time due to the limited availability of donor hearts. “Therefore, it is clinically appropriate to include LVAD insertion, by any approach, to the code list identifying lung or heart transplant procedures.” AHRQ also added end stage heart failure (I50.84) to the exclusion list, stating that use of prolonged mechanical vent use is expected in the care of these patients.
• PSI 13 (Postop Sepsis Rate): Removed 124 high-risk immunocompromised state procedure codes; added seven diagnosis codes in this range.

There are more changes than I can list here so be sure to review the table below.

References

• View a summary table of the changes to PSI version 2025: https://qualityindicators.ahrq.gov/Downloads/Modules/PSI/V2025/ChangeLog_PSI_v2025.pdf
• View the PSI list: https://qualityindicators.ahrq.gov/measures/psi_resources
• View the PSI technical specifications here: https://qualityindicators.ahrq.gov/measures/PSI_TechSpec

Sample PSI Decision Flow

1. Surgeon performs surgery → outcome occurs
2. Surgeon documents the event
   • If documented as a complication (e.g., “postoperative hemorrhage”) → coder considers complication code.
   • If documented as expected/normal (e.g., “expected blood loss, not a complication”) → coder avoids complication code.
3. Coding & CDI review
   • CDI specialists query if documentation is ambiguous.
   • Coders assign ICD-10-CM diagnosis codes based strictly on documentation.
4. Present on Admission (POA) flag applied
   • If the diagnosis was present at admission → excluded from PSI.
   • If it arose after admission (postop) → included if coded as a complication.
5. PSI software logic (AHRQ algorithms)
   • Applies inclusion criteria (adult, inpatient, LOS, etc.).
   • Applies exclusion criteria (e.g., trauma cases, immunocompromised).
   • If none apply → case is flagged in the PSI numerator.

Example in Practice

• Case A: Postoperative hemorrhage. Surgeon documents “expected bleeding, not a complication.”
  • Coder uses a “postop diagnosis” code but not a complication code.
  • Not included in PSI.
• Case B: Postoperative hemorrhage. Surgeon documents “complication: postop hemorrhage requiring re-exploration.”
  • Coder assigns “complication” diagnosis code (T81.0).
  • Meets PSI criteria (unless exclusion).
  • Included in PSI.

Bottom line:

PSIs are driven by codes + POA, not by narrative judgment. The key safeguard is how well the documentation supports coding. If “expected outcome” is clearly documented, it should never become a PSI trigger.