Hospital Acquired Conditions: Present on Admission

1. Hospital Acquired Conditions: Present on Admission APIC Chapter 26 Carol Jacobson, RN October 1, 2008

2. 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

3. 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.

4. 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.

5. 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

6. CMS Hospital Acquired ConditionsFY 2008 DRIVEN BY PRESENT ON ADMISSION CODES

7. 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

8. 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)

9. 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

10. 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)

11. 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

12. 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.

13. 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. POA Assignment

14. 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

15. 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

16. Impact of Payment Adjustment for Hospital Acquired Condition

17. 2008 HAC Associated Costs

18. Future HAC Associated Costs

19. Future HAC Associated Costs

20. Best Source of Information Provider (Physician) documentation at time of Admission • ED Notes • History and Physical • Progress Notes • Admitting Notes

21. How to improve payments Communicate, Communicate, Communicate! • Build Awareness • Provide guidance • Standardize Procedures • Monitor Implementation • Close the loop

22. 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)

23. 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)

24. New HB 197 measures • Other Measures • Hospital acquired Clostridium difficile • Hospital acquired MSRA + MSSA bacterimia • Handwashing Program • Infection Control staffing

25. Questions? Carol Jacobson carolj@ohanet.org 614-221-7614