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Prepare to track conditions not present on admission
CMS will stop paying for some in FY 2009
In a little more than a year, if a patient develops an additional condition or infection after admission, your hospital may not get paid for treating the condition.
As part of its move toward a value-based purchasing system, the Centers for Medicare & Medicaid Services (CMS) will stop paying for the treatment of select conditions that were not present on admission as of October 2008.
In its proposed rule for fiscal year 2008, CMS requires hospitals to report whether secondary diagnoses coded on the claim were present on admission starting in October 2007, according to Deborah Hale, CSS, president of Administrative Consultant Services Inc., a health care consulting firm based in Shawnee, OK.
Hospitals filing claims on the UB-04 already have to include a "present on admission" code" on their inpatient claims, Hale says. CMS will issue instructions for how hospitals can include the code on electronic claims forms at a later date.
The pay-for-performance provision of the Deficit Reduction Act of 2005 requires CMS to identify two or more DRGs to focus on for payment reductions when the presence of a hospital-acquired infection increases the DRG payment.
The act stipulates that the conditions selected are high cost, high volume, or both; that they are assigned to a higher-paying DRG when they are present as a secondary diagnosis; and that they are reasonably preventable through the application of evidence-based guidelines.
"CMS wants to make sure they are not paying to treat complications that are the result of poor quality. They are identifying diagnoses that could occur while the patient is hospitalized that could have been prevented by evidence-based medicine," Hale says.
CMS to select preventable conditions
CMS has formed a workgroup of physicians and staff from CMS and the Centers for Disease Control and Prevention (CDC) to review a list of potential conditions and set priorities. In the proposed rule, CMS is proposing to select the first six conditions on the list, which include catheter-associated urinary tract infections, pressure ulcers, and Staphylococcus aureus septicemia, as well three serious preventable events ("never events") — objects left in surgery, air embolisms, and blood incompatibility.
CMS is soliciting comments from the public on these and seven other conditions to determine if they are reasonably preventable, currently have unique codes, and would be good candidates for future inclusion on the list.
In fact, the agency already has taken the first steps toward lowering payments for hospital-acquired infections.
In its final rule for fiscal 2007, issued in August 2006, CMS created two new DRGs for infectious or parasitic diseases resulting in an operating room procedure. DRG 579, infectious diseases for which the principal diagnosis is postoperative or post-traumatic infection, will result in approximately $10,000 less reimbursement than DRG 578 (infectious or parasitic diseases), Hale says.
Hale described a possible scenario that could occur in other DRG pairs if CMS singles them out for attention under the "present on admission" rule: An elderly patient comes in with a hip fracture (DRG 211) and develops pneumonia while in the hospital. Under the present CMS regulations, the DRG would change to DRG 210, indicating the presence of a comorbidity or complication.
"This DRG has a higher relative weight, which substantially increases the amount of the payment. If hospital-acquired pneumonia is one of the complications that CMS includes in the rule, the net effect would be that CMS will not reimburse the hospital for treating the pneumonia, which could have been prevented," Hale points out.
The same would be true for a decubitus ulcer or a urinary tract infection caused by a catheter, if those are diagnoses CMS chooses to include, she adds.
It's highly unlikely that a patient would come in for repair for a hip fracture and have pneumonia as well, but it's not impossible, Hale says.
Track when CCs occur
That's why it's important for hospitals to pay attention to complications and comorbidities and track when they occurred, Hale adds.
The "present on admission" reporting will include five options that must be included on all diagnoses:
While recording the "present on admissions" diagnosis is the primary responsibility of the coding staff, case managers who are involved in clinical documentation improvement must make sure that all conditions that are present when the patient is admitted are included in the documentation.
This will enable coders to identify the appropriate sequence of diagnoses as they review the charts and note which conditions were present on admission.
"The only way to determine if a condition is not hospital-acquired is if it was noted in the documentation that it was present on admission," Hale says.
For instance, suppose a patient is admitted with a principal diagnosis of pneumonia. Two days later, the clinical documentation specialist or case manager looks at the chart and points out that the patient also met the criteria for sepsis at the time of admission but it was not documented on the chart. The physician is queried and on the third day, adds the diagnosis of sepsis to the chart. "In this instance, it may be harder for the coder to determine whether the sepsis was present on admission or developed three days later," she points out.
Case managers and/or clinical documentation specialists should get in the habit of asking the physician to clarify whether an additional diagnosis was present on admission, Hale recommends.
Hospitals will need to educate and train their medical records and clinical staff on the new reporting requirements and compliance issues, she adds.
"Ultimately, it will be a good thing for hospitals because it will help provide a better picture of the severity of illness of their patients and the quality of the care they provide," Hale says.
Under the current system, many tertiary care hospitals appear to be providing substandard care because there is no opportunity to include the comorbidities and complications that patients had when they were admitted, Hale points out.
In preparation for the time when they may not be paid for conditions that are not present on admission, hospitals should begin tracking their admission data to determine what additional diagnoses are present on admission and which ones occur most frequently during the hospital stay, Hale suggests.
Identify QI initiatives
Use the information to identify opportunities for quality improvement initiatives, she recommends. Look at ways to avoid complications, such as infections and deep vein thrombosis, that occur during the hospital stay.
Start looking ahead and making sure that the documentation supports all of the conditions a patient had at admission, Hale says.
"When something is being documented as a late determination, the documentation should support that it was present when the patient was admitted," she says.
Pay for performance is an emerging trend in health care and the "present on admission" requirement is only a first step in the total overhaul of the Medicare inpatient prospective payment system, Hale points out.