hospital acquired conditions: present on admission apic chapter 26 carol jacobson, rn october 1,...

Hospital Acquired Conditions: Present on Admission

APIC Chapter 26Carol Jacobson, RN

October 1, 2008

OHA Role

Federal Communicate and provide comments to the

American Hospital Association (AHA) State – Rely on input from hospitals

Quality Institute Collaboratives OPSI HAI Committee for HB197 Chasing Zero CDI – OSU and CDC OHICU – CLBSI

Section 5001(c) of Deficit Reduction Act of 2005

Requires CMS to identify at least two conditions by October 1, 2007, that are

(a) high cost or high volume or both,

(b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and

(c) Reasonably prevented through the application of evidence‑based guidelines.

Affected Hospitals

The Present on Admission (POA) Indicator requirement and Hospital-Acquired Conditions (HAC) payment provision only apply to:

Inpatient Prospective Payment Systems (IPPS) Hospitals.

EXEMPT For POA/HAC

1. Critical Access Hospitals (CAHs)

2. Long-term Care Hospitals (LTCHs)

3. Maryland Waiver Hospitals

4. Cancer Hospitals

5. Children's Inpatient Facilities

6. Inpatient Rehabilitation Facilities (IRF)

7. Psychiatric Hospitals

CMS Hospital Acquired ConditionsFY 2008

DENIALSof

HIGHER PAID DRG

CatheterAssociated

UrinaryTract

Infections

PressureUlcers

VascularCatheter-assoc

Infection

Object LeftIn

Surgery

AirEmbolism

BloodTransfusion

Incompatibility

Hosp. Acquired Injuries

(i.e. falls/burns/fractures . . .

(19)

MediastinitisCABG

DRIVEN BY PRESENT ON ADMISSION CODES

Conditions Selected FY 2008

Serious Preventable Events Object left in during surgery (998.4 CC and 998.7) Air embolism (999.1 MCC)

Blood incompatibility (999.6 CC)

Pressure Ulcers (707.00-.01 & 7-7.09 CCs; 707.02-09 MCCs)

Falls and Trauma – Fractures, Crushing Injuries, Dislocations, Intracranial Injuries, Electric Shock, and Burns

Conditions Selected FY 2008

Catheter Associated Urinary Tract Infection, (996.64 CC & one of the following specific infection codes:

112.2, 590.10, 590.11, 590.2, 590.3, 590.80, 590.81, 590.9, 595.0, 595.3, 595.4, 595.81, 590.89, 595.9, 597.0, 597.80, 599.0)

Vascular Catheter Associated Infection (999.31 CC)

Surgical Site Infection – Mediastinitis after Coronary Artery Bypass Graft (CABG) Surgery (519.2 MCC & 36.10-.19)

Additional Conditions for FY2009

Poor Glycemic control Deep Vein Thrombosis (DVT)/ Pulmonary

Embolism (PE) (DVT: 453.40-.42 CCs; PE: 415.10 & 415.19 MCCs)

Expansion of SSI to include Bariatric & certain orthopedic surgeries

Conditions needing further analysis

Methicillin Resistant Staphylococcus Aureus (MRSA) (

Clostridium difficile-Associated Disease (CDAD) (008.45 CC)

Wrong Surgery (wrong body part, wrong patient, wrong surgery

performed on a patient)

Other Payers

CMS sent letter to state Medicaid offices providing information about how states can adopt the same HAC

To date Ohio Medicaid has not announced concurrence

Third party payers – many have already adopted similar non-payment policies

POA Reporting Requirements

POA indicator is based not only on the conditions known at the time of admission, but also include those conditions that were clearly present but not diagnosed, until after the admission took place.

POA is defined as present at the time the order for inpatient admission occurs.

POA Assignment

POA indicator applies to principal diagnosis, secondary diagnoses, external cause of injury codes.

Inconsistent, missing, conflicting or unclear documentation must be resolved by the provider.

Reporting options and definitions:

“Y” - condition Present on Admission“N” - condition not explicitly documented

on admission“U” - insufficient/no information in the

record“W” - clinically undetermined“1” - unreported/not used – exempt from

POA reporting

POA Indicator Timeline

Effective October 1, 2007CMS will collect POA Oct– Dec 2007 Voluntary – no link to payment

January 1, 2008 hospitals required to collect POA

April 1, 2008 CMS will reject entire claim if POA coding is not present

Oct. 1, 2008 CMS cannot assign a case to higher DRG if hospital acquired

Impact of Payment Adjustment for Hospital Acquired Condition

Inpatient PPS Columbus Wage Adjusted Rate $5320.41

DRG 195 Simple pneumonia w/out CC

Weight

0.8398

Payment

$ 4468.08

DRG 194 Simple pneumonia w/CC

707.01 Pressure Ulcer - Elbow

1.0235 $ 5445.44

Potential Loss $ (977.36)

2008 HAC Associated Costs

Hospital Acquired Condition

# Cases/cost hospital stay (FY 2007)

Catheter-associated UTI

12,185 cases/$44,043

Vascular Catheter-associated Infection

29,536 cases/$103,027

Surg Site Infection – Mediastinitis

69 cases/$299,237

Future HAC Associated Costs

Hospital Acquired Condition

# Cases/cost hospital stay (FY 2007)

SSI – Total Knee Replacement

539 cases/$63,135

SSI – Lap Gastric Bypass & Gastoenterostomy

208 cases/$180,142

SSI – Varicose Vein Ligation/Stripping

3 cases/$66,355

Future HAC Associated Costs

Hospital Acquired Condition

# Cases/cost hospital stay (FY 2007)

Ventilator Associated Pneumonia (VAP)

30,867 cases/$135,795

Staph aureus Septicemia

27,737 cases/$84,976

C. difficile-associated Disease (CDAD)

96,336 cases/$59,153

Legionnaire's Disease 351 cases/$86,355

Best Source of Information

Provider (Physician) documentation at time of AdmissionED NotesHistory and PhysicalProgress NotesAdmitting Notes

How to improve payments

Communicate, Communicate, Communicate!

Build AwarenessProvide guidanceStandardize ProceduresMonitor ImplementationClose the loop

New HB 197 measures

Core MeasuresPN-2 Pneumococcal vaccinePN-7 Influenza vaccineSCIP-inf-1 Prophylaxis Atx 1 hr pre-incisionSCIP-inf-2 Proph. Atx selectionSCIP-inf-3 Proph. Atx discontinuation

SCIP-inf-1 (Pediatric population)

Proposed HB 197 measures

CDC MeasuresSurgical site infection

CABGw/both surgical site + donor site incision)Caesarian SectionKnee prosthesis

Influenza vaccine for HC workersCatheter Associated Bloodstream infection

in ICU pts (pediatrics)Surgical Site infections (pediatrics)

New HB 197 measures

Other MeasuresHospital acquired Clostridium difficileHospital acquired MSRA + MSSA

bacterimiaHandwashing Program Infection Control staffing

Questions?

Carol Jacobson

carolj@ohanet.org

614-221-7614