Understanding Risk of Mortality
Risk of mortality reflects the likelihood that a patient will die during the current episode of care, based on the combination of diagnoses, comorbidities, and clinical findings documented in the record. RHIA candidates should understand that risk of mortality is used both in classification systems like APR-DRG and independently in hospital quality reporting programs that measure risk-adjusted mortality rates.
Risk-Adjusted Mortality Reporting
Publicly reported mortality measures, such as those for conditions like heart failure, pneumonia, and acute myocardial infarction, calculate an expected mortality rate for each hospital based on the specific risk profile of its patient population, then compare the observed mortality rate to that expected rate. A hospital with an observed rate higher than its risk-adjusted expected rate may be flagged as a lower performer, even if the raw number of deaths is small, if its documented patient population appeared to be relatively low risk.
The Documentation Connection
- Comorbidities that increase mortality risk must be documented and coded to be captured in risk adjustment models
- Vague or nonspecific documentation, such as "sepsis" without documentation of associated organ dysfunction, can understate a patient's true risk profile
- Present on admission status affects whether a condition is counted toward the risk adjustment calculation for certain measures
Consequences of Undercoding Risk
When comorbidities that elevate mortality risk are not fully documented and coded, a hospital's expected mortality rate is calculated as if the patient population were healthier than it actually was, making the hospital's actual outcomes appear comparatively worse in public reporting, even when the quality of care provided was appropriate.
Balancing Accuracy and Compliance
While accurate capture of risk of mortality diagnoses is important, coding professionals must ensure that all diagnoses are fully supported by clinical documentation and coding guidelines, avoiding any practice that could be construed as upcoding purely to influence quality metrics rather than to reflect genuine clinical findings.
Exam Tip
Understand the connection between comorbidity documentation, risk of mortality calculation, and public quality reporting, since exam scenarios may ask you to explain why incomplete documentation can distort a hospital's reported performance.