Health Information Management

Understand the impact of HACs and HCACs on your coding practices

JustCoding News: Inpatient, March 14, 2012

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In 2007, CMS began monitoring claims for hospital-acquired conditions (HAC), which are conditions that occur after the physician writes the inpatient admission order and that could have been reasonably prevented through the application of evidence-based guidelines and best practices. Today, Medicare denies approximately $20 million per year under the HAC policy.

Additionally, four HACs comprise 12.2% of total medical professional liability costs:

  • Hospital-acquired infections
  • Hospital-acquired injuries
  • Objects left in surgery
  • Pressure ulcers

“If you have these issues in your facility, then you can very easily understand why they were chosen as some of the ones Medicare looks at closely,” said Shelia Bullock, RN, BSN, MBA, CCM, CCDS, director of clinical documentation services at the University of Mississippi Medical Center in Jackson, MS.

CMS focuses on these HACs due to the abundance of data that supports the assertion that these are preventable conditions, said Bullock, who spoke during the February 14 audio conference “POA, HACs, HCACs for 2012: Solving Common Documentation Challenges.”

Reporting and capturing HACs allow hospital administrators and CMS to measure the facility’s performance, distinguish between pre-existing conditions and those acquired in the hospital, and to increase the validity of hospital report cards related to quality, said Bullock.

Currently, CMS considers the following conditions to be HACs when not present on admission (POA):

  • Stage III & IV pressure ulcers
  • Falls & trauma
  • Vascular catheter-associated infections
  • Deep vein thrombosis/pulmonary embolism after certain orthopedic procedures
  • Certain manifestations of poor control of blood sugar levels
  • Catheter-associated urinary tract infections
  • Foreign object retained after surgery
  • Surgical site infections following coronary artery bypass graft (CABG), certain orthopedic, and bariatric procedures
  • Infection after coronary artery bypass graft
  • Air embolism
  • Blood incompatibility

The impact of the reporting of HACs varies by state. Beverly Cunningham, MS, RN, vice president of clinical performance improvement at Medical City Dallas Hospital in Dallas, TX, who also spoke during the audio conference, indicated that while she has not experienced any financial penalties at her facility yet, the communication from CMS on the subject is abundant.

Bullock’s facility has seen a few financial penalties in addition to increased communication, and she said this may indicate a trickledown effect for neighboring states. Both agree it is only a matter of time before CMS begins imposing greater financial penalties.

Know where to look for HAC documentation

Bullock noted that just because a provider notes a HAC, the coder must look throughout the rest of the chart to ensure documentation clearly indicates the presence of a HAC. Bullock said pressure ulcers are a prime example in which a provider may document a pressure ulcer, indicating a HAC, but the condition may in fact be related to something else entirely. For example, if the condition is a pressure ulcer, the condition may have been POA and therefore needs to be documented and coded accordingly so that the hospital receives full reimbursement. Or the physician may document a pressure ulcer, but the wound care nurses may be treating the ulcer as if it were of a vascular origin.

“We need to look very closely at other documentation, especially [from] our wound care nurses. Could it be a tear? Could it be an ulcer of a vascular origin or other cause? If it’s suspected, that’s an excellent query opportunity to clarify whether this is really pressure-ulcer related or from another source,” said Bullock.

Bullock also cited the example of blood incompatibility and pointed out that CMS considers only an ABO reaction to be a HAC. Coders should double-check lab results to ensure the source of the blood incompatibility and not rely on the documentation of the provider alone. If the blood was given at another facility, coders should make sure the documentation indicates that while the blood incompatibility is on the HAC list, the condition was POA and therefore full reimbursement should be awarded.

Similarly, coders should review urinalysis and culture results taken upon admission to confirm a catheter-associated urinary tract infection was acquired during the hospital stay and was not present at the time of admission. If the results show an infection on admission, the coder should query the physician, as any POA infection will not count against the hospital as a HAC. It’s best to clarify with the physician in these situations because a POA indicator of “N” or “U” triggers Medicare to determine payment reduction and inclusion in publicly reported data. Clarifying these situation ensures that the hospital not only receives the appropriate payment, but that the quality scores for their facility are accurate.

Bullock highlighted three new codes to keep a close eye on, explaining that CMS may add these to the HAC list in the near future:

  • 999.32 (blood stream infection due to central venous catheter)
  • 999.33 (local infection due to central venous catheter)
  • 999.34 (acute infection following transfusion, infusion, or injection of blood and blood products)

Understand the impact of Medicaid on HCACs

Medicaid began monitoring provider preventable conditions statutorily on July 1, 2011 with compliance enforcement to begin July 1, 2012. Medicaid labels these conditions as healthcare-acquired conditions (HCACs) for inpatient facilities and other provider preventable conditions for ambulatory and outpatient facilities.

“Every state must comply. States can have differences, but they must all prohibit payment for specific conditions,” said Bullock. These Medicaid lists must include all those conditions listed under the Medicare HAC rule with the exception of deep vein thrombosis and/or pulmonary embolism following total knee or hip replacement in pediatric and obstetric patients.

Additionally, states may add other conditions to its HCAC list as deemed appropriate. “There’s going to be a flurry of activity at each of our state levels, so it really will behoove us to watch for changes,” said Cunningham.

Bullock discussed the research performed during the development of the rule. Medicaid found that:

  • 29 states did not have any existing HCAC-related nonpayment policies
  • 21 states had existing HCAC-related nonpayment policies that correspond with Medicare’s HAC policy; half of these had requirements exceeding the Medicare policy
  • 7 states were in the process of looking at settings other than inpatient

Bullock highlighted the CMS projections of a total savings of $2 million for fiscal year (FY) 2011, with a total savings of $35 million between FY 2011 and FY 2015. Bullock said these savings will result from a reduction in payments, and as a result coders must scrutinize charts to ensure hospitals receive all the appropriate reimbursement.

Bullock stressed hospitals must bill for HACs and HCACs for both Medicare and Medicaid claims. Hospitals cannot escape liability for these conditions through nonbilling, as this information proves vital in establishing quality indicators for each hospital.

Develop best coding practices to capture HACs and HCACs

Cunningham recommended that coders actively participate as members of hospital HAC committees and assist in the development of best practices.

“Coders are blamed for everything coded on the medical record, when in fact everything is coded according to rules and regulations based on the physicians documentation,” said Cunningham. “Coders are the people who understand the rules and regulations that are going to drive what gets on the universal bill as a code.”

Involving experienced coders in the education of physicians on adequate documentation procedures may help reduce the instances of inaccurate HAC documentation and the resulting coding on the bill.

Cunningham recommended coders work with the clinical documentation specialists within their facility to help with HAC initiatives. “CDI specialists provide the link between medical practice and federal regulations,” said Cunningham.

She noted that many times coding guidelines do not make sense medically to those involved in the clinical practice, and therefore CDI specialists can assist clinicians and coders navigate the divide.

All HACs must be coded and billed, even if no reimbursement is expected, because CMS tracks that information as part of a hospital’s overall quality score. “If we have something that occurs that is our fault, we absolutely want to be transparent,” she said.

But Cunningham advocated that CDI specialists and coders monitor physician documentation to ensure all the closure of all documentation gaps in the medical record.

For example, a physician may document a probable or possible infection, but never actually document a definitive confirmation of this infection. However, coders may sometimes go ahead and report the infection, resulting an inappropriate HAC designation and ultimately cost the hospital money and a reduction in quality scores.

Ultimately, Cunningham stressed that hospitals need to focus on providing quality patient care. Evidence-based guidelines exist to prevent these HACs and HCACs from occurring, and hospitals should implement policies to prevent these when possible.



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