CMS HOSPITAL ACQUIRED CONDITIONS Mary Nickel, RN, MSM Director, Medical Staff Support/Clinical Quality Saint Clares Hospital

CMS’ HOSPITAL ACQUIRED CMS’ HOSPITAL ACQUIRED CONDITIONSCONDITIONS

Mary Nickel, RN, MSMDirector, Medical Staff Support/Clinical Quality

Saint Clare’s Hospital

OBJECTIVESOBJECTIVES

Provide background on CMS’ Provide background on CMS’ Hospital Acquired Conditions Hospital Acquired Conditions (HACs)(HACs)

Present CMS’ criteria for Present CMS’ criteria for selecting HACs selecting HACs

Explain reporting requirementsExplain reporting requirements Emphasize the importance of Emphasize the importance of

medical record documentationmedical record documentation Discuss the importance of Discuss the importance of

evidence-based practicesevidence-based practices

BACKGROUNDBACKGROUND

Common medical errors total more Common medical errors total more than $4.5 billion additional health than $4.5 billion additional health spending/year (Centers for Disease spending/year (Centers for Disease Control)Control)

National Quality Forum (NQF) created a National Quality Forum (NQF) created a list of 28 Never Eventslist of 28 Never Events

NQF defines Never Events as errors in NQF defines Never Events as errors in medical care that are:medical care that are: Concerning to both public and healthcare Concerning to both public and healthcare

professionals and providers,professionals and providers, Clearly identifiable and measurable, andClearly identifiable and measurable, and Significantly influenced by the policies and Significantly influenced by the policies and

procedures of the healthcare organization.procedures of the healthcare organization.

NQF’S NEVER EVENTSNQF’S NEVER EVENTS

Surgical 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

Patient Protection 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


Environment 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


CMS’ HACs CriteriaCMS’ HACs Criteria

Medicare’s Hospital Acquired Conditions Medicare’s Hospital Acquired Conditions (HACs) somewhat overlap with NQF’s 28 (HACs) somewhat overlap with NQF’s 28 Never EventsNever Events

Not all HACs are included in the NQF’s Never Not all HACs are included in the NQF’s Never EventsEvents

Medicare’s HACs are based on the following Medicare’s HACs are based on the following criteria:criteria: High cost, high volume, or both,High cost, high volume, or both, Identified as an ICD-9-CM coded complicating or Identified as an ICD-9-CM coded complicating or

major complicating condition resulting in an major complicating condition resulting in an secondary discharge diagnosis = higher payment secondary discharge diagnosis = higher payment (higher MS-DRG), and(higher MS-DRG), and

Reasonably preventable through evidence-based Reasonably preventable through evidence-based practices.practices.

REPORTINGREPORTING

CMS required reporting on claims CMS required reporting on claims for discharges starting 10/1/07for discharges starting 10/1/07

Starting 10/1/08, CMS will no Starting 10/1/08, CMS will no longer pay for the extra cost of longer pay for the extra cost of treating patients with HACs treating patients with HACs

Insurance companies in Insurance companies in alignment with CMSalignment with CMS

CMS’ HACs - 2008CMS’ HACs - 2008

Pressure ulcer stages III and IV Falls and trauma

Fractures Dislocations Intracranial Injuries Crushing Injuries Burns Electric Shock

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


Vascular-catheter associated infection

Catheter-associated urinary tract infection

Administration of incompatible blood

Air embolism Foreign object unintentionally

retained after surgery


Additional categories to be Additional categories to be added under CMS’ HACs policy added under CMS’ HACs policy effective 10/1/08effective 10/1/08


Manifestations of Poor Glycemic Manifestations of Poor Glycemic Control Control Diabetic Ketoacidosis Diabetic Ketoacidosis Nonketotic Hyperosmolar Coma Nonketotic Hyperosmolar Coma Hypoglycemic Coma Hypoglycemic Coma Secondary Diabetes with Secondary Diabetes with

Ketoacidosis Ketoacidosis Secondary Diabetes with Secondary Diabetes with

HyperosmolarityHyperosmolarity


Deep Vein Thrombosis Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)(DVT)/Pulmonary Embolism (PE)

Total Knee Replacement Total Knee Replacement Hip ReplacementHip Replacement


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. http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide08.pdf

CMS’ POA INDICATOR CMS’ POA INDICATOR OPTIONSOPTIONS

POA INDICATOR REPORTINGPOA INDICATOR REPORTING

POA indicator is mandatory for all POA indicator is mandatory for all inpatient hospital claimsinpatient hospital claims

POA is defined as present at the time POA is defined as present at the time the order for inpatient admission the order for inpatient admission occursoccurs

Conditions that develop during an Conditions that develop during an outpatient encounter, i.e. clinic, ED, outpatient encounter, i.e. clinic, ED, outpatient surgery are considered POAoutpatient surgery are considered POA

POA indicator is applied to both POA indicator is applied to both principal and secondary diagnosesprincipal and secondary diagnoses

CASES/CHARGESCASES/CHARGES

MEDICAL RECORD MEDICAL RECORD DOCUMENTATIONDOCUMENTATION

Documentation in the record is Documentation in the record is very importantvery important Must be consistentMust be consistent Must be completeMust be complete Must be timelyMust be timely

Completed by a healthcare Completed by a healthcare provider who is legally provider who is legally accountable for establishing a accountable for establishing a diagnosisdiagnosis

IMPLEMENTING EVIDENCE IMPLEMENTING EVIDENCE BASED PRACTICESBASED PRACTICES

Performing and documenting risk Performing and documenting risk assessmentsassessments ObesityObesity DiabetesDiabetes SmokingSmoking Prior history of PE/VTEPrior history of PE/VTE Prior history of UTIsPrior history of UTIs Other co-morbiditiesOther co-morbidities

Risk assessment criteria established by Risk assessment criteria established by various professional practice organizationsvarious professional practice organizations American College of CardiologyAmerican College of Cardiology Society of Thoracic SurgeonsSociety of Thoracic Surgeons American College of Chest PhysiciansAmerican College of Chest Physicians Centers for Disease Control and PreventionCenters for Disease Control and Prevention

Decreasing risks through Decreasing risks through operational practicesoperational practices MonitoringMonitoring PositioningPositioning TimingTiming MarkingMarking MaintainingMaintaining

Decreasing risks with appropriate Decreasing risks with appropriate antibioticsantibiotics

IMPLEMENTING EVIDENCE IMPLEMENTING EVIDENCE BASED PRACTICESBASED PRACTICES

Pressure ulcer stages III and IV

HOW WOULD YOU HOW WOULD YOU DECREASE RISK TO DECREASE RISK TO

PREVENT…PREVENT…


PREVENT…PREVENT… Falls and trauma

Fractures Dislocations Intracranial Injuries Crushing Injuries Burns Electric Shock


PREVENT…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


PREVENT…PREVENT… Vascular-catheter associated

infection


PREVENT…PREVENT… Catheter-associated urinary tract

infection


PREVENT…PREVENT… Administration of incompatible

blood


PREVENT…PREVENT… Air embolism


PREVENT…PREVENT… Foreign object unintentionally

retained after surgery


PREVENT…PREVENT… Manifestations of Poor Glycemic Manifestations of Poor Glycemic

Control Control Diabetic Ketoacidosis Diabetic Ketoacidosis Nonketotic Hyperosmolar Coma Nonketotic Hyperosmolar Coma Hypoglycemic Coma Hypoglycemic Coma Secondary Diabetes with Secondary Diabetes with

Ketoacidosis Ketoacidosis Secondary Diabetes with Secondary Diabetes with

HyperosmolarityHyperosmolarity


PREVENT…PREVENT… Deep Vein Thrombosis Deep Vein Thrombosis

(DVT)/Pulmonary Embolism (PE)(DVT)/Pulmonary Embolism (PE) Total Knee Replacement Total Knee Replacement Hip ReplacementHip Replacement

WHAT WOULD YOU DO WHAT WOULD YOU DO ONCE A HAC OCCURS…ONCE A HAC OCCURS…

Disclose incident to patient and Disclose incident to patient and apologizeapologize

Conduct a Root Cause Analysis Conduct a Root Cause Analysis (RCA)(RCA) Ask “why” 5 timesAsk “why” 5 times Involve those who provided the Involve those who provided the

care/services; include physicianscare/services; include physicians Create an action plan based on the Create an action plan based on the

root cause(s)root cause(s) Implement and monitor the plan for Implement and monitor the plan for

improvementimprovement

Next stepsNext steps Continue to assess each HAC Continue to assess each HAC

against your hospital’s practicesagainst your hospital’s practices Develop policies and procedures to Develop policies and procedures to

decrease your patients’ risksdecrease your patients’ risks Monitor for HACs and analyze Monitor for HACs and analyze

incidentsincidents Educate your staff and physicians Educate your staff and physicians

on HACs and preventionon HACs and prevention Involve your patients Involve your patients

CMS’ HACsCMS’ HACs

QUESTIONSQUESTIONS

Documents

CMS HOSPITAL ACQUIRED CONDITIONS Mary Nickel, RN, MSM Director, Medical Staff Support/Clinical Quality Saint Clares Hospital