Study guide
21.2 PSI 90 Components and PSIs beyond the Composite
Certified Clinical Documentation Specialist CCDS
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1 Introduction & Exam Overview
1.1 Current Exam Facts 1.2 Eligibility Pathways and the 2,000-Hour Year 1.3 Allowed Resources and Test-Day Rules 1.4 Recertification, Fees, and How This Guide Maps the Eight Domains
2 IPPS Foundations
2.1 How IPPS Works and How CMS Updates It 2.2 MS-DRG Assignment, Relative Weights, and Grouping 2.3 Provider and Clinical Staff Documentation Duties under IPPS
3 Severity, CMI, Medical Necessity, and Oversight
3.1 CC versus MCC Recognition and CC Exclusion Lists 3.2 Case Mix Index and Why CDI Tracks It 3.3 Two-Midnight Rule, Medical Necessity of Setting, and Principal Diagnosis 3.4 MAC, RAC, CERT, OIG, and Denial-Vulnerable Practices
4 Nervous and Respiratory System CDI
4.1 Nervous System Conditions for CDI 4.2 Acute and Chronic Respiratory Failure, ABGs, and Ventilation Support 4.3 Pneumonia, COPD, PE, Pleural Effusion, and Respiratory Infections
5 Circulatory, Digestive, Hepatobiliary, Musculoskeletal, and Skin CDI
5.1 Circulatory Disorders 5.2 Digestive and Hepatobiliary Disorders 5.3 Musculoskeletal and Skin
6 Endocrine, Nutrition, Kidney, and Hematologic CDI
6.1 Diabetes, Dehydration, and Obesity 6.2 Malnutrition Criteria, Severity, and Audit Risk 6.3 AKI, CKD Staging, UTI, and Urinary Stones 6.4 Anemia, Coagulation, Sickle Cell, Lymphoma, and Leukemia
7 Infectious Disease, Other MDCs, and Clinical Indicator Tools
7.1 Sepsis, Severe Sepsis, Postoperative and Other Infections 7.2 Mental, Substance Use, Injuries/Toxicology, and HIV-Related Conditions 7.3 Medications, Diagnostic Tests, and Abbreviations as Clinical Indicators
8 Health Record Elements and Query Triggers
8.1 Which Record Elements Support Diagnosis and Procedure Codes 8.2 Attending versus Radiologist, Pathologist, and Other Providers 8.3 When a Physician Query Is Warranted 8.4 When Queries Are Not Appropriate
9 Query Timing, Verbal Queries, Formats, and Clinical Indicators
9.1 Concurrent, Retrospective, Pre-Bill, and Prospective Timing 9.2 Verbal Queries and Required Documentation 9.3 Open-Ended, Multiple-Choice, and Yes/No 9.4 Clinical Indicators and How to Source Them
10 Compliant Query Practice and Clinical Validation
10.1 Compliant versus Leading and Other Noncompliant Queries 10.2 ACDIS/AHIMA 2026 Guidelines for Achieving a Compliant Query Practice 10.3 Clinical Validation and Diagnoses without Clinical Support
11 CDI Program Metrics
11.1 Productivity, Query Volume, and Provider Response Rates 11.2 CMI, CC/MCC Capture, and High-Frequency DRGs 11.3 SOI/ROM as CDI Program Performance Metrics
12 Physician Metrics, PEPPER, Forecasting, and Public Data
12.1 Measuring Physician Documentation Performance 12.2 PEPPER, Forecasting, Hospital Financial Data, and Public Reporting
13 CDI Roles, Coder Collaboration, and Physician Education
13.1 Roles and Responsibilities of the CDI Specialist 13.2 Coder Roles Working with a CDI Department 13.3 Physician Education Tools, Forms, and Presentations
14 Provider Communication and DRG Reconciliation
14.1 Non-Confrontational Communication and When Verbal Beats Written 14.2 Working DRG versus Final DRG Reconciliation
15 Official Guidelines, Principal Diagnosis, and Secondary Diagnosis
15.1 Official Guidelines, Cooperating Parties, Updates, and AHA Coding Clinic 15.2 Principal Diagnosis Selection 15.3 Secondary Diagnosis Reporting Criteria
16 Sequencing, Coding Conventions, and POA Indicators
16.1 Sequencing When Two Diagnoses Equally Meet PD; Working DRG with Multiple Diagnoses 16.2 Integral Signs/Symptoms, the With Convention, and Uncertain Diagnoses 16.3 Present-on-Admission Indicator Assignment and Payment Impact
17 Hospital-Acquired Conditions, Disposition, and ICD-10-PCS Essentials
17.1 CMS Hospital-Acquired Condition Payment Provision 17.2 Discharge Disposition, Transfer Payment, Principal Procedure, and ICD-10-PCS Essentials
18 Ethics, Privacy, and Leading Queries as Compliance Failures
18.1 ACDIS Code of Ethics and CDI Goals beyond Reimbursement 18.2 HIPAA, Minimum Necessary, and Record Confidentiality 18.3 Leading Queries as a Compliance Failure
19 DRG Creep, OIG Oversight, PEPPER, and the False Claims Act
19.1 DRG Compliance, DRG Creep, and the OIG Work Plan 19.2 PEPPER Compliance Risks and the False Claims Act
20 Mortality Index, Observed-to-Expected Ratios, and Quality Data Sources
20.1 Documentation Impact on Mortality Index (SOI/ROM) 20.2 Mortality Reviews and Observed-to-Expected Ratios 20.3 Abstracted versus Claims-Based Quality Data
21 CMS Quality Programs, PSIs, and Infection versus Complication Codes
21.1 HVBP, HAC Reduction Program, HRRP, 30-Day Mortality, and Hospital IQR 21.2 PSI 90 Components and PSIs beyond the Composite 21.3 Healthcare-Associated Infections versus Complication Codes
21.2 PSI 90 Components and PSIs beyond the Composite
Key Takeaways Explain This Topic AI
CMS PSI 90 used in HACRP currently combines PSI 03 Pressure Ulcer; PSI 06 Iatrogenic Pneumothorax; PSI 08 In-Hospital Fall-Associated Fracture; PSI 09 Postoperative Hemorrhage or Hematoma; PSI 10 Postoperative Acute Kidney Injury Requiring Dialysis; PSI 11 Postoperative Respiratory Failure; PSI 12 Perioperative PE/DVT; PSI 13 Postoperative Sepsis; PSI 14 Postoperative Wound Dehiscence; and PSI 15 Abdominopelvic Accidental Puncture or Laceration.
A diagnosis reported as present on admission (POA = Y) is treated as not hospital-acquired and is generally excluded from the PSI numerator; that is a quality-measure rule, not the HAC-POA CC/MCC grouping table.
PSI 08 is in-hospital fall-associated fracture, not the retired “postoperative hip fracture only” definition; PSI 10 is postoperative AKI requiring dialysis, not the older “physiologic and metabolic derangement” label.
Additional AHRQ Patient Safety Indicators exist outside the HACRP composite, and CMS publicly reports some of them separately; do not recite an outdated full inventory or put PSI 07 central-line infection back inside today’s PSI 90.
PSI 90 is claims-based software on coded diagnoses, procedures, and POA values; it is not NHSN chart surveillance and it is not the 14-category HAC-POA list.
Last updated: September 2026
21.2 PSI 90 Components and PSIs beyond the Composite
Quick Answer: The CMS Patient Safety and Adverse Events Composite (CMS PSI 90) used in the Hospital-Acquired Condition Reduction Program (HACRP) currently includes ten Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) : PSI 03 pressure ulcer; PSI 06 iatrogenic pneumothorax; PSI 08 in-hospital fall-associated fracture; PSI 09 postoperative hemorrhage or hematoma; PSI 10 postoperative acute kidney injury (AKI) requiring dialysis; PSI 11 postoperative respiratory failure; PSI 12 perioperative pulmonary embolism (PE) or deep vein thrombosis (DVT) ; PSI 13 postoperative sepsis; PSI 14 postoperative wound dehiscence; and PSI 15 abdominopelvic accidental puncture or laceration. A diagnosis with present on admission (POA) = Y is treated as not hospital-acquired and is generally excluded from the numerator. Other PSIs exist outside this composite; do not invent an outdated full list or restore PSI 07 as if it still sat inside PSI 90.
This independent ExamFinch section helps inpatient clinical documentation integrity specialists study how CMS PSI 90 reads the coded Inpatient Prospective Payment System (IPPS) claim. It is not a CMS, AHRQ, or Association of Clinical Documentation Integrity Specialists (ACDIS) reprint. Section 21.1 placed PSI 90 inside HACRP . This section names the components , the POA gate , and the boundary between the composite and the rest of the PSI family.
What PSI 90 is—and what it is not
AHRQ developed PSIs as administrative-data screens for potentially preventable in-hospital complications. CMS calculates CMS PSI 90 from Medicare fee-for-service claims using PSI specifications (CMS’s implementation of the AHRQ software for the HACRP / public-reporting versions in use that year). The composite is a weighted combination of component observed-to-expected ratios. AHRQ publishes harm- and volume-based component weights in its PSI composite documentation; those weights change by software version . Do not memorize a weight table as if it were a CMS unpublished cut score, and do not hand-calculate a hospital’s composite on the exam.
PSI 90 is not :
The 14-category hospital-acquired condition present-on-admission (HAC-POA) list (claim grouping).
National Healthcare Safety Network (NHSN) infection surveillance (chart/laboratory/device protocols).
A license to drop a valid diagnosis from the claim “so PSI does not see it.”
Chart-abstracted severity of illness (SOI) / risk of mortality (ROM) .
It is a claims composite. If the diagnosis is not coded, or is coded without the procedure, exclusion, or POA the specification requires, the software never sees the event. If the diagnosis is coded and matches the numerator with POA = N , the software can see it even when nobody in quality review has opened the chart yet.
The current ten: CMS PSI 90 components
CMS’s live HACRP description and current AHRQ PSI 90 composite documentation (v2025) name the same ten indicators. Learn numbers, names, and the documentation question each one asks . The ACDIS handbook shorthand “PSIs 03, 06, and 08–15” is the same set; it is not “03 through 15 including 04, 05, and 07.”
PSI Current name to study What the component is built to flag High-yield documentation notes
03 Pressure ulcer rate Qualifying secondary pressure-injury codes (specifications focus on Stage III, Stage IV , and related severe codes the software lists) that were not POA Staging and POA against the inpatient order . Emergency-department ulcers before that order are Y . Unstageable and deep-tissue injury are not automatically “PSI 03” unless the current spec includes that code.
06 Iatrogenic pneumothorax rate Iatrogenic pneumothorax as a secondary diagnosis, not POA Procedure context matters clinically (central line, lung biopsy, ventilation). PSI 06 is the iatrogenic pneumothorax code , not every spontaneous pneumothorax. HAC-POA category 14 is narrower (iatrogenic pneumothorax with venous catheterization ).
08 In-hospital fall-associated fracture rate Fracture associated with an in-hospital fall , not POA Not “postoperative hip fracture only.” A hip fracture that occasioned admission is Y and is not this numerator. An inpatient fall with a listed fracture can be.
09 Postoperative hemorrhage or hematoma rate Selected postoperative hemorrhage/hematoma with a procedure the spec includes, not POA Bleeding must meet the measure’s diagnosis/procedure pairing. “Oozing” in a note is not a code. Query for a diagnosed hemorrhage/hematoma and whether it is postoperative, without quality-score language.
10 Postoperative AKI requiring dialysis rate Postoperative acute kidney injury that required dialysis , not POA The old name “postoperative physiologic and metabolic derangement” is retired for this component. Isolated creatinine rise without dialysis is not PSI 10. Dialysis that was POA (end-stage kidney disease already on dialysis) is not a new postoperative dialysis event.
11 Postoperative respiratory failure rate Postoperative respiratory failure meeting diagnosis and/or ventilation criteria in the spec Acute respiratory failure POA (the reason for emergency surgery) is not a postoperative PSI 11 event. Duration of mechanical ventilation is ICD-10-PCS , but PSI 11 is still a quality spec , not a DRG lesson.
12 Perioperative PE/DVT rate Perioperative PE or DVT, not POA HAC-POA DVT/PE is limited to hip or knee replacement . PSI 12 is broader perioperative venous thromboembolism. Do not import the 14-category limit into PSI 12, and do not call every PE after colectomy a HAC-POA.
13 Postoperative sepsis rate Sepsis after an included operation, not POA Sepsis POA that continues after surgery is not a postoperative PSI 13 by timing alone. Linkage, organ dysfunction, and Sepsis-3 documentation rules still apply clinically; the software reads codes and POA , not SOFA arithmetic.
14 Postoperative wound dehiscence rate Disruption of a surgical wound after an included abdominopelvic operation Dehiscence is not “the dressing was damp.” It is a diagnosed disruption. Superficial vs fascial documentation changes coding and whether the spec’s codes match.
15 Abdominopelvic accidental puncture or laceration rate Accidental puncture/laceration during an abdominopelvic procedure Accidental intraoperative injury documented as such can flag. A planned enterotomy is not accidental puncture. Query for accidental versus expected when the operative note is ambiguous—still nonleading .
PSI 08 name change is a trap. Older materials said postoperative hip fracture . Current AHRQ/CMS language is in-hospital fall-associated fracture . The event is no longer limited to a postoperative hip. A medical patient who falls on day 4 and fractures a femur can belong to PSI 08. A patient admitted with a hip fracture cannot.
PSI 10 name change is a trap. If a stem still says “physiologic and metabolic derangement,” translate it to postoperative AKI requiring dialysis for today’s composite, or recognize the stem as stale.
POA = Y means not hospital-acquired for PSI
PSI software is hunting in-hospital events. The POA indicator is the usual gate:
POA = Y : the condition was present at the inpatient admission order . For PSI 90, that diagnosis is generally excluded from the numerator as not hospital-acquired . Conditions that arise in the emergency department, observation, or outpatient surgery before the inpatient order remain Y —the same clock Domain VI taught.
POA = N : not present at the inpatient order. If the diagnosis/procedure pair matches a component, the stay can enter that numerator.
Do not copy the HAC-POA payment table onto PSI software. Under the Deficit Reduction Act provision, N and U generally block complication or comorbidity (CC) / major CC (MCC) grouping from a selected HAC , and W still pays like Y . That table answers MS-DRG money on this claim . PSI 90 answers whether a quality composite counted a hospital-acquired safety event . If an item asks only about PSI exclusion, the high-yield answer is POA = Y excludes as not hospital-acquired . If it asks about HAC-POA payment , use N/U versus Y/W . Mixing those two sentences is how people miss both items.
U (documentation insufficient) is still a documentation failure . It is a reason to query for timing, not a reason to invent how every vendor treats U inside every PSI version. W (clinically undetermined) is the provider’s inability to determine timing. Neither letter is a quality workaround.
Worked PSI encounters
Community Stage IV ulcer. Sacral full-thickness ulcer photographed in the emergency department before the inpatient order; attending later writes Stage IV. POA = Y . This is not a PSI 03 hospital-acquired numerator. It may still be an MCC. It may still be clinically severe. PSI 03 does not “take community ulcers.”
Hospital-acquired Stage IV. Admission skin exam intact; day 12 heel ulcer documented Stage IV. POA = N . This can enter PSI 03 if the code is in the spec. Separately, HAC-POA may ignore it for CC/MCC grouping . Two ledgers, one ulcer.
Admission hip fracture versus inpatient fall. Patient admitted for femoral-neck fracture after a fall at home: principal fracture, POA = Y , not PSI 08 . Patient admitted for pneumonia, falls on day 3, new humeral fracture documented: POA = N , PSI 08 candidate under the fall-associated fracture definition.
Iatrogenic pneumothorax. New pneumothorax after subclavian central-line attempt, POA = N : PSI 06 candidate, and it may also be HAC-POA category 14 if the codes pair. New pneumothorax after lung biopsy: still PSI 06 if coded as iatrogenic and not POA; not automatically HAC-POA category 14.
Postoperative dialysis. Elective colectomy, creatinine 0.9 on admission, anuric on day 2, new hemodialysis for AKI. PSI 10 candidate. Patient already on chronic dialysis for end-stage kidney disease , creatinine unchanged: that is not new postoperative dialysis for AKI.
Sepsis timing. Sepsis with organ dysfunction present in the emergency department , then emergency laparotomy: postoperative PSI 13 is the wrong reflex. Sepsis first documented on postoperative day 4 after an elective case, POA = N : now you are in PSI 13 territory if codes and exclusions match—still query for clinical validation, not for “please prevent a PSI.”
PSIs beyond the composite—without a fake master list
AHRQ’s PSI module is larger than the ten indicators inside PSI 90 . CMS has also publicly reported selected PSIs that are not in the HACRP composite—most notably PSI 04 , death rate among surgical inpatients with serious treatable complications (often taught as failure to rescue ). Other module indicators have included death in low-mortality DRGs, retained surgical item counts , and obstetric trauma indicators. Those tools matter to quality departments. They are not this guide’s invitation to freeze a historical inventory and call it 2026 HACRP.
Do not restore PSI 07 (central-line-associated bloodstream infection on claims) to the composite. CMS removed that claims infection indicator from PSI 90; HACRP now uses NHSN CLABSI instead of asking PSI 90 to double-count line infections. An item that lists PSI 07 among “today’s PSI 90 components” is using an outdated composite.
Do not equate PSI 05 (retained surgical item) with HACRP PSI 90 just because retained object is also a HAC-POA category. Different engines.
When a stem asks “which PSIs are in the CMS composite used for HACRP,” answer 03, 06, and 08–15 with the current names . When it asks whether other PSIs exist , the correct idea is yes, outside the composite and in some public reports , not a recitation of every retired label.
What documentation work changes PSI 90
Code the clinically valid diagnosis when Uniform Hospital Discharge Data Set (UHDDS) additional-diagnosis rules are met. Omitting a Stage IV ulcer to “protect PSI 03” is a compliance problem.
Assign POA against the inpatient order , including pre-admission hospital time.
Query staging , acuity , postoperative relationship , and accidental versus expected injury when the record is unclear— without reimbursement or quality-outcome language (2026 query brief).
Know spec limits : PSI 12 ≠ HAC-POA hip/knee DVT only; PSI 06 ≠ HAC-POA venous-catheter pneumothorax only; PSI 08 ≠ postoperative hip only.
Leave NHSN case-finding to infection prevention’s protocol. A PSI 13 code path is not an automatic NHSN SSI , and the reverse is also true (next section).
Traps this section is built to catch
Treating PSI 90 as the 14 HAC categories or as NHSN .
Using POA = Y as if it still counted as hospital-acquired for PSI.
Importing HAC-POA N/U payment blocking as the PSI software rule.
Calling PSI 08 postoperative hip fracture only.
Calling PSI 10 any postoperative electrolyte disorder.
Listing PSI 04, 05, and 07 inside today’s HACRP composite .
Inventing a complete outdated PSI catalog and presenting it as current CMS policy.
Querying “please document that this was POA so we do not get a PSI.”
The composite sentence is short: CMS PSI 90 for HACRP is 03, 06, and 08–15. POA = Y excludes the diagnosis as not hospital-acquired. Other PSIs exist outside that composite; do not fake the rest of the list.