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CMS Hospital-Acquired Conditions (HAC) and Present on Admission (POA) Indicators

Centers for Medicare & Medicaid Serives (CMS) - On February 8, 2006 the President signed the Deficit Reduction Act (DRA) of 2005 that required there be an adjustment in Medicare DRG (Diagnosis Related Group) payment for certain hospital-acquired conditions (HACs) with a component that addresses new Present on Admission (POA) coding. CMS has titled their program Hospital-Acquired Condition and Present on Admission Reporting (HAC and POA).

Section 5001(c) of the DRA required the Secretary to identify, by October 1, 2007, at least two conditions for which hospitals under the IPPS (Inpatient Prospective Payment System) would not receive additional payment beginning on October 1, 2008, if the condition was not present on admission. The conditions must be (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) could reasonably have been prevented through the application of evidence-based guidelines.

Payment for hospital-acquired conditions (HAC)

For discharges occurring on or after October 1, 2008, hospitals would not receive additional payment for cases in which one of the selected HACs was not present on admission. That is, the case would be paid as though the secondary diagnosis was not present. Section 5001(c) provides that CMS can revise the list of conditions from time to time, as long as it contains at least two conditions. However, if the patient has another coded complication (that is not a HAC) then the case will still paid at the higher DRG level.

  • FY 2008 IPPS In the final FY 2008 IPPS rule, CMS identified an initial eight HACs including three healthcare-associated infections (HAI).
  • FY 2009 IPPS In the final FY 2009 IPPS rule that takes effect October 1, 2008, CMS added two additional HACs to the original list of eight, bringing the final list to ten HAC. The ten includes two new conditions (poor glycemic control and venous thromboembolism following certain orthopedic surgeries) and an expansion of one the original eight, i.e., surgical site infection (SSI), mediastinitis, to also include bariatric and certain orthopedic surgeries. The final list of ten HACs includes three that are healthcare-associated infections.

Hospital-acquired conditions for potential reduced payment-effective October 1, 2008: Finalized by CMS August 2008

Healthcare-associated infections

  • Catheter-associated urinary tract infections. The ICD-9 code does not distinguish between catheter-associated infection and inflammation.
  • Vascular catheter-associated blood stream infection (BSI). CMS now has a specific code for central-line vascular catheters (CVC). CVC-BSIs are not limited to the ICU.
  • Surgical site infection. Two more SSIs have been to mediastinitis:
    • Mediastinitis after CABG surgery. This infection has a specific complication code.
    • Selected orthopedic surgeries – Spinal fusion and other surgeries of the shoulder and elbow.
    • Bariatric surgery for morbid obesity - laparoscopic gastric bypass and gastroenterostomy.

Other Hospital-acquired conditions

All selections are from the National Quality Forum's list of 28 "Serious Reportable Events" frequently referred to as "Never Events."

  • Object left in surgery (Refinement - reaction to foreign substance accidentally left during a procedure)
  • Air embolism.
  • Blood incompatibility.
  • Pressure ulcers (Category III and IV only).
  • Falls- Codes are not actually for "falls" but for potential adverse events or injuries occurring as the result of falls; injuries that should not occur during a patient’s hospitalization. The generic categories of coded injuries include: Fractures, dislocations, intracranial injury, crushing injury, burns, and other and unspecified effects of external causes.
  • Venous thromboembolism (VTE) after hip and knee replacement. Although VTE includes deep vein thrombosis (DVT) and pulmonary embolism (PE), CMS has only selected PE codes to which this payment policy applies at this time.
  • Poor glycemic control - Ketoacidosis and Coma (hypoglycemic and hypoosmolar).