Date

Fact sheet

CMS PROPOSES ADDITIONS TO LIST OF HOSPITAL-ACQUIRED CONDITIONS FOR FISCAL YEAR 2009

 

CMS PROPOSES ADDITIONS TO LIST OF HOSPITAL-ACQUIRED CONDITIONS FOR FISCAL YEAR 2009

 

OVERVIEW:

 

On April 14, 2008, the Centers for Medicare & Medicaid Services (CMS) announced a proposed rule that would update payment policies and rates under the hospital inpatient prospective payment system (IPPS) for fiscal year (FY) 2009, beginning for discharges on or after October 1, 2008.  CMS is proposing to select nine categories of hospital-acquired conditions (HACs) for FY 2009 in addition to the eight selected one year ago. 

 

In addition to proposing expansion of the HAC list, CMS is proposing 43 new measures for the hospital quality measure reporting program.  More information about the proposed quality measures can be found at: http://www.cms.gov/About-CMS/Public-Affairs/MediaReleaseDatabase/Fact-Sheets/index.html

 

BACKGROUND:

 

Section 5001(c) of the Deficit Reduction Act (DRA) of 2005 required the Secretary of the Department of Health and Human Services to select at least two conditions that are: (1) high cost, high volume, or both; (2) identified through ICD-9-CM coding as a complicating condition (CC) or major complicating condition (MCC) that, when present as a secondary diagnosis at discharge, results in payment at a higher MS-DRG; and (3) reasonably preventable through application of evidence-based guidelines.  The law further required hospitals to begin reporting on claims for discharges, beginning October 1, 2007, whether the selected conditions were present on admission (POA). 

 

Last year, CMS selected eight conditions for the HAC provision (See Table 1).  Beginning October 1, 2008, Medicare will no longer pay at a higher weighted MS-DRG for these conditions or any of the additional nine categories conditions we are proposing to add in this year’s rule.

 

 

COLLABORATING TO IMPROVE QUALITY:

 

CMS experts worked with public health and infectious disease professionals from the Centers for Disease Control and Prevention (CDC) to: 

  1. identify candidate preventable HACs and
  2. develop the process for hospitals to submit a POA indicator for each diagnosis listed on IPPS hospital Medicare claims. 

 

On December 17, 2007, CMS and CDC hosted a jointly-sponsored HAC and POA Listening Session to receive input from hospital associations and other interested individuals.  CMS and CDC received informal comments during the listening session and subsequently received numerous written comments.  The agenda, presentations, audio file, and written transcript of the Listening Session are available at: 

http://www.cms.hhs.gov/HospitalAcqCond/07_EducationalResources.asp

 

CMS is also working with the Agency for Healthcare Research and Quality (AHRQ) and the National Quality Forum (NQF) to identify which of the 28 serious preventable errors (often called “Never Events’) identified by the NQF should be subject to the HACs provisions.  A separate fact sheet comparing the NQF list with the existing and proposed HACs is also being released today.

 

PROPOSED REVISIONS AND ADDITIONS TO THE HAC LIST FOR FY 2009

 

CMS is proposing to add an additional nine categories of conditions that when acquired in the hospital will no longer lead to higher Medicare payment.  CMS proposing to select:  surgical site infections for certain elective procedures, hypoglycemic coma, collapsed lung due to medical care, ventilator-associated pneumonia among other conditions.  In addition, CMS is proposing to create new codes to better identify two conditions that were previously selected:   foreign object retained after surgery; and pressure ulcers. 

 

In addition to the proposed changes above, CMS and CDC have worked with other stakeholders to identify additional conditions that might be candidates that might appropriately be subject to the HAC payment provision (See Table 2).  CMS is seeking comment on the extent to which each of these candidate conditions meets the statutory criteria for selection.

 

Comments on the proposed rule will be accepted through June 13.  CMS will respond to comments in a final rule to be issued on or before August 1, 2008.

 

 

TABLE 1:  HOSPITAL-ACQUIRED CONDITIONS SELECTED IN IPPS FY 2008 FINAL RULE

 

 

 

Selected HAC

Medicare Data[1]

(FY 2007)

CC/MCC

(ICD-9-CM Codes)

Selected Evidence-Based Guidelines

 

Foreign Object Retained After Surgery

●  750 cases[2]

●  $63,631/hospital stay[3]

998.4 (CC)

998.7 (CC)

NQF Serious Reportable Adverse Event

 

NQF’s Safe Practices for Better Healthcare available at:

http://www.ahrq.gov/qual/nqfpract.htm

Air Embolism

 

●  57 cases

●  $71,636/hospital stay

999.1 (MCC)

NQF Serious Reportable Adverse Event

 

NQF’s Safe Practices for Better Healthcare available at:

http://www.ahrq.gov/qual/nqfpract.htm

Blood Incompatibility

 

●  24 cases

●  $50,455/hospital stay

999.6 (CC)

NQF Serious Reportable Adverse Event

 

NQF’s Safe Practices for Better Healthcare available at:

http://www.ahrq.gov/qual/nqfpract.htm

 

 

 

 

 

 

Stage III & IV Pressure Ulcers

 

●  257,412 cases[4]

●  $43,180/hospital stay

New codes

 (to replace

707.00–707.09)

707.23 (MCC)

707.24 (MCC)

All other pressure ulcer codes will not be a CC.

NQF Serious Reportable Adverse Event

 

Available at:

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.4409

Falls and Trauma:

  - Fractures

  - Dislocations

  - Intracranial Injuries

  - Crushing Injuries

  - Burns

  - Electric Shock

 

●  193,566 cases[5]

●  $33,894/hospital stay

Codes within these ranges on the

CC/MCC list:

800-829

830-839

850-854

925-929

940-949

991-994

NQF Serious Reportable Adverse Events address falls, electric shock, and burns

 

NQF’s Safe Practices for Better Healthcare available at:

http://www.ahrq.gov/qual/nqfpract.htm

Catheter-Associated Urinary Tract Infection (UTI)

●  12,185 cases

●  $44,043/hospital stay

996.64 (CC)

 

Also excludes the following from acting as a CC/MCC:

112.2 (CC)

590.10 (CC)

590.11 (MCC)

590.2 (MCC)

590.3 (CC)

590.80 (CC)

590.81 (CC)

595.0 (CC)

597.0 (CC)

599.0 (CC)

Available at:

http://www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html

 

 

 

 

 

Vascular Catheter-Associated Infection

●  29,536 cases

●  $103,027/hospital stay 

999.31 (CC)

Available at:

http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html

Surgical Site Infection-Mediastinitis after Coronary Artery Bypass Graft (CABG)

●  69 cases

●  $299,237/hospital stay

519.2 (MCC)

And one of the following procedure codes:

36.10–36.19

Available at:

http://www.cdc.gov/ncidod/dhqp/gl_surgicalsite.html

 

 

 

 

TABLE 2:  CANDIDATE HOSPITAL-ACQUIRED CONDITIONS INCLUDED IN IPPS FY 2009 PROPOSED RULE

 

 

HAC Candidate

Medicare Data

(FY 2007)

CC/MCC

(ICD-9-CM Codes)

Selected Evidence-Based Guidelines

 

Surgical Site Infections Following Elective Procedures:

  - Total Knee Replacement

  - Laparoscopic Gastric Bypass and Gastroenterostomy

  - Ligation and Stripping of Varicose Veins

Total Knee Replacement:  

  • 539 cases
  • $63,135/hospital stay

Laparoscopic Gastric Bypass and Gastroenterostomy:   

  • 208 cases
  • $180,142/hospital stay

Ligation and Stripping of Varicose Veins: 

  • 3 cases
  • $66,355/hospital stay

Total Knee Replacement (81.54):   996.66 (CC)

 and 998.59 (CC)

 

Laparoscopic Gastric Bypass (44.38)

and Gastroenterostomy (44.39):  998.59 (CC)

 

Varicose Veins

(38.59):  998.59 (CC)

 

Available at:

http://www.cdc.gov/ncidod/dhqp/gl_surgicalsite.html

 

Available at:

http://www.cdc.gov/ncidod/dhqp/gl_isolation.html

 

Legionnaires’ Disease

·        351 cases

·        $86,014/hospital stay

482.84 (MCC)

Available at:

http://www.cdc.gov/ncidod/dbmd/diseaseinfo/legionellosis_g.htm

 

Available at:

http://www.legionella.org/

 

 

 

 

Glycemic Control:

  - Diabetic Ketoacidosis

  - Nonketotic Hyperosmolar Coma

  - Diabetic Coma

  - Hypoglycemic Coma

Diabetic Ketoacidosis

  • 11,469 cases
  • $42,974/hospital stay

Nonketotic Hyperosmolar Coma

  • 3,248 cases
  • $35,215/hospital stay

Diabetic Coma

  • 1,131 cases
  • $45,989/hospital stay

Hypoglycemic Coma

  • 212 cases
  • $36,581/hospital stay

Diabetic Ketoacidosis:

 250.10 – 250.13 (CC)

 

Nonketotic Hyperosmolar Coma:

  250.20 – 250.23 (CC)

 

Diabetic Coma:  250.30 – 250.33 (CC)

 

Hypoglycemic Coma:

  251.0 (CC)

NQF Serious Reportable Adverse Events address hypoglycemia

 

Available at:

http://www.diabetes.org/uedocuments/InpatientDMGlycemicControlPositionStmt02.01.06.REV.pdf

Iatrogenic Pneumothorax

  • 22,665 cases
  • $75,089/hospital stay

512.1 (CC)

Available at:

http://www.ncbi.nlm.nih.gov/pubmed/1485006

Delirium

  • 480 cases
  • $23,290/hospital stay

293.1 (CC)

Available at:

http://www.ahrq.gov/clinic/ptsafety/chap28.htm

 

 

 

Ventilator-Associated Pneumonia (VAP)

●  30,867 cases[6]

● $135,795/hospital stay

 

The new code for VAP is 997.31.

 

To identify cases in current Medicare data, use a ventilator code (96.70 – 96.72), plus one of the following:

073.0 (MCC)

112.4 (MCC)

136.3 (MCC)

480.0-480.4 (MCCs)

480.8-480.9 (MCCs)

481 (MCC)

482.0-482.2 (MCC)

482.39-482.41 (MCCs)

482.49 (MCC)

482.81-482.84 (MCCs)

482.89 (MCC)

482.9 (MCC)

483.0 (MCC)

Available at:

http://www.rcjournal.com/cpgs/09.03.0869.html

 

Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)

  • 140,010 cases
  • $50,937/hospital stay

453.40 – 453.42

415.11

415.19

Available at:

http://www.chestjournal.org/cgi/reprint/126/3_suppl/172S

 

Available at:

http://orthoinfo.aaos.org/topic.cfm?topic=A00219

 

 

 

 

Staphylococcus aureus Septicemia

●  27,737 cases

●  $84,976/hospital stay

038.11 (MCC)

995.91 (MCC)

995.92 (MCC)

998.59 (CC)

999.3 (CC)

Available at:

http://www.cdc.gov/ncidod/dhqp/gl_isolation.html

 

Available at:

http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html (Intravascular catheter-associated Staphylococcus aureus septicemia only)

Clostridium difficile-Associated Disease (CDAD)

●  96,336 cases

●  $59,153/hospital stay

008.45 (CC)

Available at:

http://www.cdc.gov/ncidod/dhqp/gl_isolation.html

 

Available at:

http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html#9

 

 

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[1] For the IPPS FY 2009 proposed rule, the DRG analysis is based on data from the September 2007 update of the FY 2007 MedPAR file, which contains hospital bills received through September 30, 2007 for discharges through September 30, 2007.

[2] A case represents a patient discharge identified from the MedPAR database that met the associated HAC diagnosis/procedure criteria (a secondary diagnosis on the HAC list and, where appropriate, a procedure code described in conjunction with a specific HAC).

[3] Standardized charge is the total charge for a patient discharge record based on the CMS standardization file.  The average standardized charge for the HAC is the average charge for all patient discharge records that met the associated HAC criteria.

 

[4] The number of cases of pressure ulcers reflects CC/MCC assignments for codes 707.00-707.07, 707.09, which are currently being reported.  New proposed MCC codes 707.23-707.24 will be implemented on October 1, 2008. 

[5] Note:  The number of cases for the falls and trauma HAC is significantly higher for IPPS FY 2009 proposed rule than for IPPS FY 2008 final rule.  The IPPS FY 2008 final rule included cases in which patients fell out of bed only.  The  IPPS FY 2009 proposed rule includes all cases within the CC/MCC code range listed above.

[6] Note:  The number of cases for VAP is significantly lower for the IPPS FY 2009 proposed rule than the IPPS FY 2008 final rule.  The IPPS FY 2008 final rule included all pneumonia cases.  The  IPPS FY 2009 proposed rule includes only cases with a diagnosis of VAP and where a ventilator code was also included.