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CMS’ HOSPITAL ACQUIRED CONDITIONS
Mary Nickel, RN, MSM Director, Medical Staff Support/Clinical Quality Saint Clare’s Hospital
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OBJECTIVES Provide background on CMS’ Hospital Acquired Conditions (HACs) Present CMS’ criteria for selecting HACs Explain reporting requirements Emphasize the importance of medical record documentation Discuss the importance of evidence-based practices
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BACKGROUND Common medical errors total more than $4.5 billion additional health spending/year (Centers for Disease Control) National Quality Forum (NQF) created a list of 28 Never Events NQF defines Never Events as errors in medical care that are: Concerning to both public and healthcare professionals and providers, Clearly identifiable and measurable, and Significantly influenced by the policies and procedures of the healthcare organization.
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NQF’S NEVER EVENTS Surgical Events Product or Device Events
Surgery on wrong body part Surgery on wrong patient Wrong surgery on a patient Foreign object left in patient after surgery Post-operative death in normal health patient Implantation of wrong egg Product or Device Events Death/disability associated with use of contaminated drugs Death/disability associated with use of device other than as intended Death/disability associated with intravascular air embolism
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NQF’S NEVER EVENTS Patient Protection Events Care Management Events
Infant discharged to wrong person Death/disability due to patient elopement Patient suicide or attempted suicide resulting in disability Care Management Events Death/disability associated with medication error Death/disability associated with incompatible blood Maternal death/disability with low risk delivery Death/disability associated with hypoglycemia Death/disability associated with hyperbilirubinemia in neonates Stage 3 or 4 pressure ulcers after admission Death/disability due to spinal manipulative therapy
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NQF’S NEVER EVENTS Environment Events Criminal Events
Death/disability associated with electric shock Incident due to wrong oxygen or other gas Death/disability associated with a burn incurred within facility Death/disability associated with a fall within facility Death/disability associated with use of restraints within facility Criminal Events Impersonating a heath care provider (i.e., physician, nurse) Abduction of a patient Sexual assault of a patient within or on facility grounds
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CMS’ HACs Criteria Medicare’s Hospital Acquired Conditions (HACs) somewhat overlap with NQF’s 28 Never Events Not all HACs are included in the NQF’s Never Events Medicare’s HACs are based on the following criteria: High cost, high volume, or both, Identified as an ICD-9-CM coded complicating or major complicating condition resulting in an secondary discharge diagnosis = higher payment (higher MS-DRG), and Reasonably preventable through evidence-based practices.
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REPORTING CMS required reporting on claims for discharges starting 10/1/07 Starting 10/1/08, CMS will no longer pay for the extra cost of treating patients with HACs Insurance companies in alignment with CMS
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CMS’ HACs - 2008 Pressure ulcer stages III and IV Falls and trauma
Fractures Dislocations Intracranial Injuries Crushing Injuries Burns Electric Shock
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CMS’ HACs - 2008 Surgical site infections following:
Coronary Artery Bypass Graft (CABG) - Mediastinitis Bariatric Surgery Laparoscopic Gastric Bypass Gastroenterostomy Laparoscopic Gastric Restrictive Surgery Orthopedic Procedures Spine Neck Shoulder Elbow
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CMS’ HACs - 2008 Vascular-catheter associated infection
Catheter-associated urinary tract infection Administration of incompatible blood Air embolism Foreign object unintentionally retained after surgery
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CMS’ HACs Additional categories to be added under CMS’ HACs policy effective 10/1/08
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CMS’ HACs - 2009 Manifestations of Poor Glycemic Control
Diabetic Ketoacidosis Nonketotic Hyperosmolar Coma Hypoglycemic Coma Secondary Diabetes with Ketoacidosis Secondary Diabetes with Hyperosmolarity
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CMS’ HACs - 2009 Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)
Total Knee Replacement Hip Replacement
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CMS’ POA INDICATOR OPTIONS
Code Reason for Code Y Diagnosis was present at time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as "Y" for the POA Indicator. N Diagnosis was not present at time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as "N" for the POA Indicator. U Documentation insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as "U" for the POA Indicator. W Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as "W" for the POA Indicator. 1 Unreported/Not used. Exempt from POA reporting. This code is equivalent to a blank on the UB-04, however; it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as "1" for the POA Indicator. The "1" POA Indicator should not be applied to any codes on the HACs list. For a complete list of codes on the POA exempt list, see page 110 of the Official Coding Guidelines for ICD-9-CM.
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POA INDICATOR REPORTING
POA indicator is mandatory for all inpatient hospital claims POA is defined as present at the time the order for inpatient admission occurs Conditions that develop during an outpatient encounter, i.e. clinic, ED, outpatient surgery are considered POA POA indicator is applied to both principal and secondary diagnoses
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CASES/CHARGES
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MEDICAL RECORD DOCUMENTATION
Documentation in the record is very important Must be consistent Must be complete Must be timely Completed by a healthcare provider who is legally accountable for establishing a diagnosis
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IMPLEMENTING EVIDENCE BASED PRACTICES
Performing and documenting risk assessments Obesity Diabetes Smoking Prior history of PE/VTE Prior history of UTIs Other co-morbidities Risk assessment criteria established by various professional practice organizations American College of Cardiology Society of Thoracic Surgeons American College of Chest Physicians Centers for Disease Control and Prevention
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IMPLEMENTING EVIDENCE BASED PRACTICES
Decreasing risks through operational practices Monitoring Positioning Timing Marking Maintaining Decreasing risks with appropriate antibiotics
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HOW WOULD YOU DECREASE RISK TO PREVENT…
Pressure ulcer stages III and IV
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HOW WOULD YOU DECREASE RISK TO PREVENT…
Falls and trauma Fractures Dislocations Intracranial Injuries Crushing Injuries Burns Electric Shock
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HOW WOULD YOU DECREASE RISK TO PREVENT…
Surgical site infections following: Coronary Artery Bypass Graft (CABG) - Mediastinitis Bariatric Surgery Laparoscopic Gastric Bypass Gastroenterostomy Laparoscopic Gastric Restrictive Surgery Orthopedic Procedures Spine Neck Shoulder Elbow
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HOW WOULD YOU DECREASE RISK TO PREVENT…
Vascular-catheter associated infection
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HOW WOULD YOU DECREASE RISK TO PREVENT…
Catheter-associated urinary tract infection
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HOW WOULD YOU DECREASE RISK TO PREVENT…
Administration of incompatible blood
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HOW WOULD YOU DECREASE RISK TO PREVENT…
Air embolism
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HOW WOULD YOU DECREASE RISK TO PREVENT…
Foreign object unintentionally retained after surgery
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HOW WOULD YOU DECREASE RISK TO PREVENT…
Manifestations of Poor Glycemic Control Diabetic Ketoacidosis Nonketotic Hyperosmolar Coma Hypoglycemic Coma Secondary Diabetes with Ketoacidosis Secondary Diabetes with Hyperosmolarity
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HOW WOULD YOU DECREASE RISK TO PREVENT…
Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Total Knee Replacement Hip Replacement
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WHAT WOULD YOU DO ONCE A HAC OCCURS…
Disclose incident to patient and apologize Conduct a Root Cause Analysis (RCA) Ask “why” 5 times Involve those who provided the care/services; include physicians Create an action plan based on the root cause(s) Implement and monitor the plan for improvement
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CMS’ HACs Next steps Continue to assess each HAC against your hospital’s practices Develop policies and procedures to decrease your patients’ risks Monitor for HACs and analyze incidents Educate your staff and physicians on HACs and prevention Involve your patients
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QUESTIONS
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