CMS Expands List of Hospital Acquired Condtions for Non-Payment
By Mary ann Ciccone

HISTORY
In order to control the federal budget deficit and improve quality of patient care, Congress passed a law prohibiting reimbursement for the treatment of certain hospital acquired conditions. The hospital acquired conditions were identified by the Centers for Medicare and Medicaid Services (CMS). CMS choose conditions that are reasonably preventable, have a high cost and/or volume, and result in a Diagnosis Related Group (DRG) case (which has a higher payment when the condition is a secondary diagnosis). Hospitals absorb the costs of readmission as a result of these acquired conditions. They are also required to submit “present on admission” information on all primary and secondary diagnoses when submitting claims.

Although this ruling currently applies to facilities that are paid under the Medicare Hospital IPPS (Inpatient Prospective Payment System), private insurers such as Aetna, will not pay for some or all of these conditions. Several states such as Massachusetts and New York prohibit payment through their Medicaid systems and more states are following their lead.

CHANGES
Effective October 1, 2008 the following conditions are no longer reimbursed by Medicare as an additional payment (secondary) if present on the patient’s admission:

• Serious Preventable Events – object left in during surgery, air embolism, blood incompatibility
• Catheter-Associated Urinary Tract Infection
• Pressure Ulcers (Stages III and IV)
• Vascular Catheter Associated Infection
• Surgical Site Infection (mediastinitis after coronary artery bypass graft surgery)
• Falls and Trauma (fractures, dislocations, intracranial injuries, crushing injuries, burns).
• Poor Glycemic control involving certain specified diabetic conditions
• Deep Vein Thrombosis or Pulmonary Embolism associated to total knee and hip replacement

The complete list of hospital acquired conditions can be found by clicking: Here

CMS is also analyzing the following conditions for inclusion in future legislation: MRSA, Clostridium Difficile associated disease, and wrong surgery.

As part of the 2009 National Patient Safety Goals and affecting hospital accreditations, JCAHO is requiring evidence based practices for reduction of MRSA, surgical site infections, and catheter related bloodstream infections.

CAPTURING REQUIRED INFORMATION
Hospitals can use an HIT system such as Cerner Millennium™ to provide the required information to CMS to ensure the maximum reimbursement through documentations. This mandate requires that documentation practices be very specific during the patient’s admission, stay, and discharge in order to provide concrete evidence of existence of these conditions. Cerner recommends the following documentation guidelines:

• Do not document by exception. All findings, what was assessed and whether or not it was normal or abnormal must be documented during the assessment process.
• Last charted value functionality should not be used to document data that could be changed during a patient’s stay

CERNER SOLUTIONS
The following Cerner functionality can be used to capture the needed information:

Registration

• ProFile - Present on Admission indicators that identify secondary diagnosis present on admission

Physician Documentation

• Problem and Diagnosis Lists – to identify problems patients present with upon admission
• PowerNotes™ – (ED notes, history and physical notes, progress notes, admission notes) to include problems and diagnosis present on admission

Nursing Documentation

• Powerforms, PowerOrders^®, PowerPlans and Tasks – (with evoking of rules to trigger appropriate protocols) sections in the admission assessment and ongoing assessment forms to document conditions. Discern rules can then be triggered based on documentation to generate appropriate protocol orders and tasks (for example, pressure ulcers).
• Interactive View –can be used similar to Powerforms to chart and trigger rules and trend conditions.

Reporting Solutions/Results Review/Tracking

• PowerInsight – Web-based reporting tool that extracts data from the Cerner system and formats the data for users to review clinical outcomes
• PowerVision – Decision support tool that captures events and generates statistical information
• Flowsheets – create custom flowsheets to view and trend results

Other

• Millennium Lighthouse^®-Evidence-based, data driven process improvement tool. Lighthouse monitors and tracks performance improvements and uses the acquired data to create a clinical care process library. The following Lighthouse quality indicator offerings are currently available:
• VTE Prevention
• Surgical Infection Prevention
• Pressure Ulcer Prevention
• Falls Prevention
• Surgical Anemia Management
• Lipid Management
• Pain Management
• Activity Tolerance
• Medication Adherence
• Cath Lab Throughput
• Heart Failure

BENEFITS
If hospitals ensure proper documentation the benefits include: increased quality of patient care, reduction of preventable medical errors, resulting in increased reimbursement.

SOURCES
Complete final rule: http://edocket.access.gpo.gov/2008/pdf/e8-17914.pdf
ECRI Institue: http://www.ecri.org/Documents/Patient_Safety_Center/CMS_New_Final_Rule.pdf
IDSA - Infectious Disease Society of America: http://www.idsociety.org/newsArticle.aspx?id=6852
CMS - Centers for Medicare and Medicaid Services: http://www.cms.hhs.gov/hospitalacqcond/

For more information, contact us at 610-444-1233 or visit our website at www.getvitalized.com.