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