ARE YOU READY? For HAC’s – October 1, 2008 Kathy Whitmire September 2008

Where did HAC’s Come From? Section 5001(c) of the DRA required the Secretary to identify, by October 1, 2007, at least two conditions that: (a) Are 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.

WHAT IS A HAC? Hospital Acquired Conditions For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis were not present. An example of how the HAC provision may effect an MS-DRG payment, beginning October 1, 2008, is presented below.

HAC - Example  An example of how the HAC provision may effect an MS-DRG payment, beginning October 1, 2008, is presented below: Principal Diagnosis Intracranial hemorrhage or cerebral infarction (stroke) with MCC - MS-DRG 064 Secondary Diagnosis Stage III pressure ulcer (code (MCC)) Present on Admission – Y - PAYMENT = $8, Same Principal Diagnosis Intracranial hemorrhage or cerebral infarction (stroke) with MCC - MS-DRG 064 Secondary Diagnosis Stage III pressure ulcer (code (MCC)) Present on Admission – N PAYMENT = $5,347.98

Confusion at CMS The 8 original selected conditions go to 11 and then back to 10 WHO KNOWS?

8 HAC’s + 3 More = Foreign Object Retained After Surgery 2. Air Embolism 3. Blood Incompatibility 4. Stage III and IV Pressure Ulcers

8 HAC’s + 3 More = Falls and Trauma Fractures Dislocations Intracranial Injuries Crushing Injuries Burns Electric Shock

8 HAC’s + 3 More = Manifestations of Poor Glycemic Control (NEW) Diabetic Ketoacidosis Nonketotic Hyperosmolar Coma Hypoglycemic Coma Secondary Diabetes with Ketoacidosis Secondary Diabetes with Hyperosmolarity

8 HAC’s + 3 More = Catheter-Associated Urinary Tract Infection (UTI) 8. Vascular Catheter-Associated Infection

8 HAC’s + 3 More = Surgical Site Infection Following: Coronary Artery Bypass Graft (CABG) - Mediastinitis 10. Surgical Site Infection Following: Bariatric Surgery (NEW)  Laparoscopic Gastric Bypass  Gastroenterostomy  Laparoscopic Gastric Restrictive Surgery Orthopedic Procedures (NEW)  Spine  Neck  Shoulder  Elbow

8 HAC’s + 3 More = Deep Vein Thrombosis (DVT) /Pulmonary Embolism (PE) (NEW) Total Knee Replacement Hip Replacement

Medicare Bottom Line Medicare expects to save about $20 million a year from the new reimbursement policy, according to acting CMS Administrator Kerry Weems. The agency has been working with hospitals over the past year to prepare their coding procedures for the policy changes coming in October. Weems added that CMS is encouraging state Medicaid programs to adopt similar reimbursement policies.

SO - Where do you start? FIRST FIVE STEPS TO SUCCESS - STEP ONE Make administration & board aware of the new HAC program and the potential loss of income. STEP TWO Measure your hospital’s risk Determine current status through analysis of data Validate accuracy of reporting Establish action steps

SO - Where do you start? STEP THREE Implement new Policy & Procedure for identifying conditions POA’s (present on admission conditions) and then reporting HAC’s to PI. STEP FOUR Develop Strategies for accurate reporting Educate and empower the healthcare team Establish or expand the clinical documentation improvement role Educate hospital staff and medical staff

SO - Where do you start? STEP FIVE  Establish a review committee or POA Team of the following: CFO Nursing Business Office Medical Records UR – Case Mgmt Physician

What Next? The Team approach is KEY! Clinical Staff & Physicians must understand the importance of POA Indicators! Case management and Medical Records need to be experts about POA reporting –

Know the POA Requirements General Reporting Requirements All claims involving inpatient admissions to general acute care hospitals or other facilities that are subject to a law or regulation mandating collection of present on admission information. Present on admission is defined as: present at the time the order for inpatient admission occurs -- conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission. POA indicator is assigned to principal and secondary diagnoses (as defined in Section II of the Official Guidelines for Coding and Reporting) and the external cause of injury codes.

Know the POA Requirements POA Reporting Definitions Y = Yes - Present at the time of inpatient admission N = No - Not present at the time of inpatient admission U = Unknown - Documentation is insufficient to determine if condition is present on admission W = Clinically undetermined - Provider is unable to clinically determine whether condition was present on admission or not The last digit, the 8th, is for the Present on Admission (POA) indicator. These codes are used in the 8th digit

POA Policy Development SAMPLE POLICY LANGUAGE: The POA guidelines outlined in this policy are not intended to provide guidance on when a condition should be coded, but rather, how to apply the POA indicator to the final set of diagnosis codes that have been assigned in accordance with Sections I, II, and III of the official coding guidelines (ICD- 9-CM Official Guidelines for Coding and Reporting.) Subsequent to the assignment of the ICD-9-CM codes, the POA indicator should then be assigned to those conditions that have been coded.

POA Education / Resources REFER TO THE ICD-9-CM Official Guidelines for Coding and Reporting ENSURE THAT STAFF UNDERSTANDS THE USE OF V- CODES ICD-9-CM provides codes to deal with encounters for circumstances other than a disease or injury. The Supplementary Classification of Factors Influencing Health Status and Contact with Health Services (V V84.8) is provided to deal with occasions when circumstances other than a disease or injury (codes ) are recorded as a diagnosis or problem.  V Codes indicate a reason for an encounter They are not procedure codes. A corresponding procedure code must accompany a V code to describe the procedure performed.

To Be Prepared on OCT 1  Have Policy & Procedure in place and implemented  Educate staff on POA and HAC’s  Report to Administration & PI Director on all HAC’s  Talk to FI regarding their denial codes & process  Become familiar with the appeal process.  Make sure medical staff is involved. If hospital looses claim the RAC then comes after the Physician. Get ready now!