Provide Background and Overview of Present on Admission (POA) Indicator

1. Overview of the POA Indicator and MS-DRGsSeptember 2007Alan L. Wang, MDChief Medical OfficerEmory Johns Creek Hospital Regulatory Compliance Support

2. Presentation Objectives • Provide Background and Overview of Present on Admission (POA) Indicator • Documentation, Capture & Transmission of POA • How POA Will Be Used? • What are MS-DRGs? • How will MS-DRGs Impact the Physician? Regulatory Compliance Support

3. What is the Purpose of the Present on Admission (POA) Indicator? • Pre-Existing? or • Hospital Acquired? Regulatory Compliance Support

4. Deficit Reduction Act of 2005 (DRA) October 1, 2007 Requirements: 1. All acute-care facilities reimbursed under the DRG model must identify secondary diagnoses that are present at the time a patient is admitted. 2. The Secretary of Department of Health & Human Services must identify at least two conditions that meet the following criteria: • High cost or high volume, or both • Assigned to a higher paying DRG when present as a secondary diagnosis, and • Reasonably preventable through application of evidence based guidelines Regulatory Compliance Support

5. Deficit Reduction Act of 2005 (DRA) By October 1, 2008, there will be a payment impact based on the presence of identified conditions not present at the time of admission Regulatory Compliance Support

6. FY 2008 IPPS CMS identifies eight conditions – • Object left in surgery • Air embolism • Blood incompatibility • Catheter-associated urinary tract infections • Pressure ulcers (decubitus) • Vascular catheter-associated infections • Mediastinitis after coronary artery bypass graft (CABG) surgery • Hospital-acquired injuries - falls Regulatory Compliance Support

7. Defining POA • Condition / Diagnosis is Present at the Time the Order for Inpatient Admission is Written • Principal and Secondary Diagnoses Regulatory Compliance Support

8. POA • Indicator Values • Y = Yes • N = No • U = Unknown • W = Clinically undetermined Unreported/Not Used = Exempt codes • Based on Physician Documentation Regulatory Compliance Support

9. How Will the POA Indicator Be Used? • Hospital-acquired Conditions, Including Infections • To Improve Hospital Quality Assurance Activities • To Identify and Measure Patient Safety Efforts Regulatory Compliance Support

10. How is the POA Indicator Used? • For Mortality/Complication Rate Studies • In Risk Adjustment Comparisons • State Reporting Requirements • In other Federal Agendas • For Example: • Pay-for-Performance • Values Based Purchasing Regulatory Compliance Support

11. How Will POA Impact Physicians? • If diagnoses are not clearly documented as to whether they were present at the time of admission, the physician will be queried • Increase validity of hospital report cards regarding quality of care • Information available on consumer web sites Regulatory Compliance Support

12. Documentation Considerations • Condition(s) present and diagnosed prior to admission • Condition(s) diagnosed existing during the admission process • Condition(s) suspected, possible, probable, or to be ruled out • Condition(s) requiring investigation • Differential diagnosis • Underlying causes of signs and symptoms • Acute and/or chronic status of condition(s) • External causes of any injury or poisoning Regulatory Compliance Support

13. Benefits of POA • Distinguishing between pre-existing conditions and complications in administrative/billing data • Improved accuracy of safety and quality-of-care measures. • More efficient quality assurance activities Regulatory Compliance Support

14. Medicare Severity Diagnosis Related Group (MS DRG) Regulatory Compliance Support

15. MS-DRGs • CMS is adopting a 745 new Medicare-Severity DRGs (MS-DRGs) system to replace the current 538 CMS DRGs • Based on current CMS DRG • Greatly improves CMS’ ability to identify groups of patients with varying levels of severity using secondary diagnoses • Does a better job of identifying technology Regulatory Compliance Support

16. Current DRG numbers will be reused in the MS-DRG system. October 1st the DRG numbers will represent totally new definitions. Created up to three tiers of payment for each DRG based on the presence of: a major complication or co morbidity (MCC), a complication or co morbidity, or no complication or co morbidity Physician documentation is essential to capture patient co morbid/complications Creating MS-DRG Regulatory Compliance Support 3

17. Current Complications and Comorbidities Definition • Definition: • Intensive monitoring • Expensive and technically complex services • Extensive care requiring a greater number of caregivers Regulatory Compliance Support 9

18. Physicians document in clinical terms Documentation for coding and reporting are assigned based on diagnostic terms Documentation Challenge Not always the same language Regulatory Compliance Support

19. How Will MS-DRGs Implementation Impact Physicians • Clinical documentation is key • Specificity is critical for correct classification • Potential for queries if documentation is unclear. Regulatory Compliance Support

20. Documentation Opportunities • Angina • unstable, stable, progressive, crescendo • Malnutrition • moderate, severe protein-calorie, kwashiorkor, marasmus Regulatory Compliance Support

21. Documentation Opportunities • CHF • systolic or diastolic, hypertensive heart, kidney, heart, acute, chronic, acute on chronic, etc. • COPD • bronchitis, emphysema, acute exacerbation, chronic obstructive asthma with or without exacerbation, chronic obstructive bronchitis with or without exacerbation Regulatory Compliance Support

22. Summary • Differentiation between conditions present on admission and conditions that developed during the inpatient admission • Primary responsibility lies with Medical Staff for complete and accurate documentation • Incomplete documentation will require physician clarification Regulatory Compliance Support

23. Questions? Regulatory Compliance Support