Several Patient Safety Indicators (PSIs) of the Agency for Healthcare Research and Quality (AHRQ) are designed to detect postoperative complications.1 Because these PSIs are based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes, they are dependent on medical record documentation and coding practices, which are governed by Official Coding Guidelines and payment-related regulations from the US Centers for Medicare and Medicaid Services (CMS) but nonetheless vary among hospitals. Physicians play a critical role in this process because coders are instructed to select codes primarily from what physicians document.
Utter GH, Vermoch KL, Rogers S. Clinical Documentation Improvement and the Agency for Healthcare Research and Quality Accidental Puncture or Laceration Patient Safety Indicator. JAMA Surg. 2015;150(5):388-389. doi:10.1001/jamasurg.2014.2385