Hospital Acquired Conditions: Present on Admission

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Hospital Acquired Conditions Present on Admission

• APIC Chapter 26
• Carol Jacobson, RN
• October 1, 2008

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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

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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.

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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.

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EXEMPT For POA/HAC

• Critical Access Hospitals (CAHs)
• Long-term Care Hospitals (LTCHs)
• Maryland Waiver Hospitals
• Cancer Hospitals
• Children's Inpatient Facilities
• Inpatient Rehabilitation Facilities (IRF)
• Psychiatric Hospitals

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CMS Hospital Acquired ConditionsFY 2008
DRIVEN BY PRESENT ON ADMISSION CODES
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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

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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)

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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

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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)

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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

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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.

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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.

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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

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POA Indicator Timeline

• Effective October 1, 2007
• CMS 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

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Impact of Payment Adjustment for Hospital
Acquired Condition
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2008 HAC Associated Costs
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Future HAC Associated Costs
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Future HAC Associated Costs
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Best Source of Information

• Provider (Physician) documentation at time of
  Admission
• ED Notes
• History and Physical
• Progress Notes
• Admitting Notes

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How to improve payments

• Communicate, Communicate, Communicate!
• Build Awareness
• Provide guidance
• Standardize Procedures
• Monitor Implementation
• Close the loop

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New HB 197 measures

• Core Measures
• PN-2 Pneumococcal vaccine
• PN-7 Influenza vaccine
• SCIP-inf-1 Prophylaxis Atx 1 hr pre-incision
• SCIP-inf-2 Proph. Atx selection
• SCIP-inf-3 Proph. Atx discontinuation
• SCIP-inf-1 (Pediatric population)

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Proposed HB 197 measures

• CDC Measures
• Surgical site infection
• CABGw/both surgical site donor site incision)
• Caesarian Section
• Knee prosthesis
• Influenza vaccine for HC workers
• Catheter Associated Bloodstream infection in ICU
  pts (pediatrics)
• Surgical Site infections (pediatrics)

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New HB 197 measures

• Other Measures
• Hospital acquired Clostridium difficile
• Hospital acquired MSRA MSSA bacterimia
• Handwashing Program
• Infection Control staffing

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Questions?

• Carol Jacobson
• carolj_at_ohanet.org
• 614-221-7614