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

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Presentation on theme: "CMS HOSPITAL ACQUIRED CONDITIONS Mary Nickel, RN, MSM Director, Medical Staff Support/Clinical Quality Saint Clares Hospital."— Presentation transcript:

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

2 OBJECTIVES Provide background on CMS Hospital Acquired Conditions (HACs) Provide background on CMS Hospital Acquired Conditions (HACs) Present CMS criteria for selecting HACs Present CMS criteria for selecting HACs Explain reporting requirements Explain reporting requirements Emphasize the importance of medical record documentation Emphasize the importance of medical record documentation Discuss the importance of evidence- based practices Discuss the importance of evidence- based practices

3 BACKGROUND Common medical errors total more than $4.5 billion additional health spending/year (Centers for Disease Control) Common medical errors total more than $4.5 billion additional health spending/year (Centers for Disease Control) National Quality Forum (NQF) created a list of 28 Never Events National Quality Forum (NQF) created a list of 28 Never Events NQF defines Never Events as errors in medical care that are: NQF defines Never Events as errors in medical care that are: Concerning to both public and healthcare professionals and providers, Concerning to both public and healthcare professionals and providers, Clearly identifiable and measurable, and Clearly identifiable and measurable, and Significantly influenced by the policies and procedures of the healthcare organization. Significantly influenced by the policies and procedures of the healthcare organization.

4 NQFS 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

5 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 NQFS NEVER EVENTS

6 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 NQFS NEVER EVENTS

7 CMS HACs Criteria Medicares Hospital Acquired Conditions (HACs) somewhat overlap with NQFs 28 Never Events Medicares Hospital Acquired Conditions (HACs) somewhat overlap with NQFs 28 Never Events Not all HACs are included in the NQFs Never Events Not all HACs are included in the NQFs Never Events Medicares HACs are based on the following criteria: Medicares HACs are based on the following criteria: High cost, high volume, or both, High cost, high volume, or both, Identified as an ICD-9-CM coded complicating or major complicating condition resulting in an secondary discharge diagnosis = higher payment (higher MS-DRG), and Identified as an ICD-9-CM coded complicating or major complicating condition resulting in an secondary discharge diagnosis = higher payment (higher MS-DRG), and Reasonably preventable through evidence-based practices. Reasonably preventable through evidence-based practices.

8 REPORTING CMS required reporting on claims for discharges starting 10/1/07 CMS required reporting on claims for discharges starting 10/1/07 Starting 10/1/08, CMS will no longer pay for the extra cost of treating patients with HACs Starting 10/1/08, CMS will no longer pay for the extra cost of treating patients with HACs Insurance companies in alignment with CMS Insurance companies in alignment with CMS

9 CMS HACs Pressure ulcer stages III and IV Falls and trauma Fractures Dislocations Intracranial Injuries Crushing Injuries Burns Electric Shock

10 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 CMS HACs

11 Vascular-catheter associated infection Catheter-associated urinary tract infection Administration of incompatible blood Air embolism Foreign object unintentionally retained after surgery CMS HACs

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

13 Manifestations of Poor Glycemic Control Manifestations of Poor Glycemic Control Diabetic Ketoacidosis Diabetic Ketoacidosis Nonketotic Hyperosmolar Coma Nonketotic Hyperosmolar Coma Hypoglycemic Coma Hypoglycemic Coma Secondary Diabetes with Ketoacidosis Secondary Diabetes with Ketoacidosis Secondary Diabetes with Hyperosmolarity Secondary Diabetes with Hyperosmolarity CMS HACs

14 Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Total Knee Replacement Total Knee Replacement Hip Replacement Hip Replacement CMS HACs

15 CodeReason for Code YDiagnosis 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. NDiagnosis 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. UDocumentation 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. WClinically 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. 1Unreported/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. CMS POA INDICATOR OPTIONS

16 POA INDICATOR REPORTING POA indicator is mandatory for all inpatient hospital claims POA indicator is mandatory for all inpatient hospital claims POA is defined as present at the time the order for inpatient admission occurs POA is defined as present at the time the order for inpatient admission occurs Conditions that develop during an outpatient encounter, i.e. clinic, ED, outpatient surgery are considered POA Conditions that develop during an outpatient encounter, i.e. clinic, ED, outpatient surgery are considered POA POA indicator is applied to both principal and secondary diagnoses POA indicator is applied to both principal and secondary diagnoses

17 CASES/CHARGES

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20 MEDICAL RECORD DOCUMENTATION Documentation in the record is very important Documentation in the record is very important Must be consistent Must be consistent Must be complete Must be complete Must be timely Must be timely Completed by a healthcare provider who is legally accountable for establishing a diagnosis Completed by a healthcare provider who is legally accountable for establishing a diagnosis

21 IMPLEMENTING EVIDENCE BASED PRACTICES Performing and documenting risk assessments Performing and documenting risk assessments Obesity Obesity Diabetes Diabetes Smoking Smoking Prior history of PE/VTE Prior history of PE/VTE Prior history of UTIs Prior history of UTIs Other co-morbidities Other co-morbidities Risk assessment criteria established by various professional practice organizations Risk assessment criteria established by various professional practice organizations American College of Cardiology American College of Cardiology Society of Thoracic Surgeons Society of Thoracic Surgeons American College of Chest Physicians American College of Chest Physicians Centers for Disease Control and Prevention Centers for Disease Control and Prevention

22 Decreasing risks through operational practices Decreasing risks through operational practices Monitoring Monitoring Positioning Positioning Timing Timing Marking Marking Maintaining Maintaining Decreasing risks with appropriate antibiotics Decreasing risks with appropriate antibiotics IMPLEMENTING EVIDENCE BASED PRACTICES

23 Pressure ulcer stages III and IV HOW WOULD YOU DECREASE RISK TO PREVENT…

24 Falls and trauma Fractures Dislocations Intracranial Injuries Crushing Injuries Burns Electric Shock

25 HOW WOULD YOU DECREASE RISK TO 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

26 HOW WOULD YOU DECREASE RISK TO PREVENT… Vascular-catheter associated infection

27 HOW WOULD YOU DECREASE RISK TO PREVENT… Catheter-associated urinary tract infection

28 HOW WOULD YOU DECREASE RISK TO PREVENT… Administration of incompatible blood

29 HOW WOULD YOU DECREASE RISK TO PREVENT… Air embolism

30 HOW WOULD YOU DECREASE RISK TO PREVENT… Foreign object unintentionally retained after surgery

31 HOW WOULD YOU DECREASE RISK TO PREVENT… Manifestations of Poor Glycemic Control Manifestations of Poor Glycemic Control Diabetic Ketoacidosis Diabetic Ketoacidosis Nonketotic Hyperosmolar Coma Nonketotic Hyperosmolar Coma Hypoglycemic Coma Hypoglycemic Coma Secondary Diabetes with Ketoacidosis Secondary Diabetes with Ketoacidosis Secondary Diabetes with Hyperosmolarity Secondary Diabetes with Hyperosmolarity

32 HOW WOULD YOU DECREASE RISK TO PREVENT… Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Total Knee Replacement Total Knee Replacement Hip Replacement Hip Replacement

33 WHAT WOULD YOU DO ONCE A HAC OCCURS… Disclose incident to patient and apologize Disclose incident to patient and apologize Conduct a Root Cause Analysis (RCA) Conduct a Root Cause Analysis (RCA) Ask why 5 times Ask why 5 times Involve those who provided the care/services; include physicians Involve those who provided the care/services; include physicians Create an action plan based on the root cause(s) Create an action plan based on the root cause(s) Implement and monitor the plan for improvement Implement and monitor the plan for improvement

34 Next steps Next steps Continue to assess each HAC against your hospitals practices Continue to assess each HAC against your hospitals practices Develop policies and procedures to decrease your patients risks Develop policies and procedures to decrease your patients risks Monitor for HACs and analyze incidents Monitor for HACs and analyze incidents Educate your staff and physicians on HACs and prevention Educate your staff and physicians on HACs and prevention Involve your patients Involve your patients CMS HACs

35 QUESTIONS


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