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In its 2025 Inpatient Prospective Payment System (IPPS) final rule, CMS announced that it was replacing PSI-04 (Death among surgical inpatients with serious treatable complications) with a new one: 30-day Risk-Standardized Death Rate among surgical inpatients with Complications (also known as “Failure-to-Rescue”).

Over a year later, this metric remains an enigma.

First, if you like visuals (and I do) check out this algorithm that summarizes the metric (click the picture to go to direct source):

It is a claims-based metric, meaning it’s monitored (both what is included and excluded) entirely by submitted ICD-10-CM and ICD-10-PCS codes on claims. This contrasts with abstracted metrics where humans (abstractors) search the chart and submit a report to track the metric. Examples of abstracted metrics include NHSN’s Surgical Site Infection Rate and CMS’s Sepsis Bundle (Sep-1).

One thing that surgeons and hospitals should understand is that this measure assesses the percentage of surgical inpatients who experienced a complication and then died within 30-days from the date of their first operating room procedure. It does not track the percentage of complications themselves. Failure-to-rescue (FTR) is defined as the probability of death given a postoperative complication.

Oh, and if you didn’t already know, we’re already in the reporting period (which started July 1, 2023 and goes through June 30, 2025) for the fiscal year 2027 payment determinations.

Which Patients are Included?

It’s not all inpatient surgical patients. It only includes discharges assigned to three groups:

1. General surgery

2. Orthopedic surgeries

3. Cardiovascular procedures

Congrats, y’all!

The procedure that triggers the metric can occur 3 days prior to the admission, all the way through discharge of that admission.

Before we move on, if you want to know specifics, go to this link (automatically downloads a .zip file) and download the excel file. When I refer to “Tables” below, I am referring to the Tables in that excel file.

The metric also includes discharges associated with ECMO (extracorporeal membrane oxygenation) or tracheostomy MS-DRGs, which must also meet ALL the below criteria (They’re confusing. I’ll explain after.):

• Had an eligible MDC.

  • These include:

    • Circulatory system (MDC 5)

    • Digestive system (MDC 6)

    • Hepatobiliary system and pancreas (MDC 7)

    • Musculoskeletal system and connective tissue (MDC 8)

    • Skin, subcutaneous tissue and breast (MDC 9)

    • Endocrine, nutritional, and metabolic diseases (MDC 10)

• O.R. procedure code (Table 1), that in the absence of ECMO or tracheostomy, would assign discharge to an eligible MS-DRG (Table 2)

• Without a procedure code for ECMO

  • ICD-10-PCS codes (Table 5): 5A1522F, 5A1522G, 5A1522H

• Without a procedure for tracheostomy occurring before or on the same day as the first non tracheostomy procedure

  • ICD-10-PCS codes (Table 6): 0B110F4, 0B110Z4, 0B113F4, 0B113Z4, 0B114F4, 0B114Z4

👆️ That bit about the ECMO and tracheostomy exclusions confused me at first. Let me explain. There are two DRGs that they’re referring to:

• DRG 003 ECMO or Tracheostomy with Mechanical Ventilation >96 hours or Principal Diagnosis except face, mouth, and neck with Major O.R. Procedure

• DRG 004 Tracheostomy with Mechanical Ventilation >96 hours or Principal Diagnosis except face, mouth, and neck with Major O.R. Procedure

As you can see, you can fall into that “ECMO DRG” without ECMO being done. So, if ECMO is performed, then you’re excluded from the metric.

Otherwise, if the tracheostomy is done before or during the O.R. procedure that triggered the metric (and that would have fallen into the original 3 surgical groups), then you’re excluded. If the tracheostomy is done after the O.R. procedure, then it’s still included.

There are a few other factors that can exclude a patient from the metric. These include any of the following:

• Patients aged >90 years old.

• DNR status (ICD-10-CM Code Z66) that is present on admission.

• Patients admitted from a hospice facility.

• Discharged against medical advice.

• Being included in an ungroupable MS-DRG

• No qualifying O.R. procedure with reported date

• Contradictory death information such as:

  • Reported date of death before admitting date.

  • Death date before discharge date when patient was reportedly discharged alive.

  • Discharge disposition reported as died but enrollee has subsequent claims.

• With missing discharge disposition, gender, age, quarter, year, or principal diagnosis

Note that otherwise this metric includes patients aged 18 - 89 enrolled in Medicare.

Which Complications Trigger the Metric?

The actual list of ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes can be found in Table 3 and Table 4 in the referenced excel file above. But, in general, complications include:

• Cardiac events

• Congestive heart failure

• Hypotension or shock or hypovolemia

• Pulmonary embolus or deep vein thrombosis or phlebitis

• Cerebrovascular accident (CVA) or transient ischemic attack (TIA)

• Coma

• Seizure

• Psychosis

• Nervous system complications

• Pneumonia or pneumonitis

• Pneumothorax/effusion

• Respiratory compromise or bronchospasm

• Internal organ damage or perforation

• Peritonitis

• Gastrointestinal bleed and blood loss

• Sepsis

• Deep wound infection or wound complication

• Renal dysfunction

• Gangrene/amputation

• Intestinal obstruction or ischemia

• Retained foreign body

• Pressure injury

• Orthopedic complication

• Hepatitis or jaundice

• Pancreatitis

• Necrosis of bone (thermal or aseptic)

• Osteomyelitis

• Disseminated intravascular coagulation (DIC)

• Pyelonephritis

• Or other postsurgical complications

Again, these must not be documented as present on admission.

How Is It Risk-Adjusted?

This is the question that initially led me to explore this new metric further. It’s the one thing that I, as a CDI physician advisor, can impact. However, my research led me to increased confusion, as I’m not a big enough statistical numbers nerd to understand it all.

You can explore their risk adjustment methodology by visiting here, selecting the “Scientific Applicability” Tab, and then navigating to “Risk Adjustment” on the left. The excel file of their methodology can be found here.

Their risk-adjustment methodology for comorbidities uses Elixhauser variables, which (admittedly) make my head spin with a relatively considerable number of variables which seem like they should increase your risk of complications/death but actually decreases it. These negative Elixhauser variables often contradict some of the Vizient variables that our institution tracks. Being unable to reconcile these conflicting methodologies, I came to an important conclusion and reminder: instead of trying to pinpoint this (and other) metrics with particular comorbidities, we should encourage complete and accurate documentation to the highest degree of specificity possible. No more and no less. It’s the central dogma of CDI.

If you want to know more about Elixhauser, I encourage you to watch Penny Jefferson’s wonderful webinar that she recently presented in our online community (which you can access with a 7-day free trial). Dr. James Kennedy also has a lot of great posts and webinars on the topic on LinkedIn.

A Reminder

Lastly, remember that for the sake of our patients, hospitals and health care providers can benefit from knowing not only their institution’s mortality rate, but also their institution’s ability to rescue patients after an adverse occurrence.

We shouldn’t game the system to make quality metrics perfect, as this can lead to missing important opportunities to identify clinical care issues and ultimately improve patient care at the system level.

That’s all for now. Don’t hesitate to ask questions as they help inspire future issues!

Cheers,

Robert

Thanks to Penny Jefferson for co-writing this newsletter with me. Also thank you to Laura Samson, RN BSN CCDS for editing this newsletter!

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