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Don’t let HACs cut into your bottom line

Association of Clinical Documentation Improvement Specialists, September 4, 2008

Learn what is (and isn’t) a hospital acquired condition
 
Editor’s note: This is the first article in a two-part series on hospital acquired conditions (HAC). Part one contains information on the eight HACs finalized in the fiscal year (FY) 2008. Part two will cover the newest three HACs that CMS finalized for FY 2009.
 
The financial impact of HACs will take effect October 1. Is your hospital ready?
 
After that date, when a HAC is not present on admission (POA), and it is the only complication/comorbidity (CC) or major CC (MCC) on the claim, the case will group to a lower-weighted Medicare Severity DRG (MS-DRG)—meaning less reimbursement for your hospital.
 
“It could have a financial impact on the hospital’s bottom line,” said DeAnne W. Bloomquist, RHIT, CCS, a coding and compliance consultant and the president of Mid-Continent Coding, Inc., in Overland Park, KS. “And patient safety is becoming more and more of an issue and folks want to feel safe coming to a hospital. If a hospital can identify and show with evidence-based medicine that they are indeed a safe hospital, they’re going to do well.” 
 
Bloomquist, along with Robert S. Gold, MD, founder of DCBA, Inc., in Atlanta, spoke during the June 12 HCPro, Inc., audio conference, “POA Reporting for Hospital Acquired Conditions: Strategies to Obtain Complete Documentation.”
 
Learn the current conditions to know what counts
 
To ensure accurate reimbursement and proper data capture, coders should first understand the HACs.
 
“Some of [the HACs] you understand, but some of them you may understand incorrectly,” said Gold during the audio conference. So Gold and Bloomquist broke down the eight HACs CMS finalized for FY 2008, which it published in the fall of 2007.
 
The following eight conditions, along with the additional conditions CMS finalized for FY 2009, will take effect October 1:
  • Foreign object retained after surgery. Codes 998.4 (foreign body accidentally left during a procedure) and 998.7 (acute reaction to a foreign substance accidentally left during a procedure) denote this HAC.
Although this HAC may seem fairly straightforward, coders must consider scenarios during which a surgeon intentionally leaves an object in the patient after surgery, said Gold. “When you’re putting hardware in to stabilize a fracture, then you’re doing that on purpose. When you’re putting in a graft for bypass purposes, you’re leaving it there on purpose,” said Gold.
 
These scenarios won’t count against a hospital and negatively affect reimbursement, he said. But consider the following scenario:
A surgeon inserts a plate during surgery. The plate requires multiple screws, but while inserting the screws, one of the screw heads breaks off. The surgeon leaves the screw head in the patient and finishes inserting the plate with an additional screw.
 “Was that a foreign object accidentally left in after surgery because he couldn’t get it back out because the head broke off?” Gold asked. “The surgeon made a specific decision to leave it in, and not to take the entire plate off and remove part of the bone to try to extract this piece of surgical steel that was supposed to have been left in there in the first place,” said Gold.
 
Gold argued that, in this scenario, the screw head is not a foreign object accidentally retained after surgery because it is purposely retained after surgery.
 
Gold also provided another scenario:
A male patient has a hernia repair under spinal anesthesia. While the physicians suture the subcutaneous tissue, the nurses perform a sponge and needle count. They discover that a sponge is missing and locate it via x-ray in the corner of the external oblique. The physicians reopen the external oblique, remove the sponge, finish the procedure, and send the patient to the recovery room.
This scenario also does not describe a foreign object accidentally retained after surgery, Gold said. “That’s what sponge and needle counts are for,” he pointed out. “The patient did not leave the operating room with the sponge in place. He didn’t have to go back to the operating room to have it removed.”
  • Air embolism. Code 999.1 (air embolism to any site, following infusion, perfusion, or transfusion) denotes this HAC that refers to a condition in which air inadvertently passes through an open blood vessel.
This frequently occurs when dry IV lines keep running, and air enters the line of a subsequent IV. This air then becomes embolic to the lungs, said Gold.
 
"Well, you think, air in the lungs; that’s not bad. That’s what we live for. But this is air in the artery to the lungs; it goes to the right atrium, it goes to the right ventricle, gets pumped to the pulmonary artery, gets out into the lungs, and it obstructs blood flow to a portion of the lung,” he explained. “It acts just as any other kind of pulmonary embolism, and it can be rapidly fatal.”

Also be aware of the “excludes” note that pertains to childbirth.  

"When a fetus and the afterbirth separates from the lining of the uterus, the veins in the uterus may not spontaneously close rapidly by themselves,” said Gold. “Once in a while, air will get in and that’s something that’s totally unavoidable.”
  • Blood incompatibility. Code 999.6 (ABO incompatibility reaction) denotes this HAC.

Bloomquist noted that this HAC only applies to ABO incompatibility and incompatible blood transfusion. It does not apply to rhesus factor incompatibility (code 999.7), serum reactions (code 999.5) or other transfusion reactions (code 999.8).  

  • Stages III and IV (decubitus) pressure ulcers. Code 707.23 indicates a stage III decubitus ulcer, and code 707.24 indicates a stage IV decubitus ulcer.
When a pressure ulcer exists and a physician cannot prove that it was POA, coders must assume it is an HAC.
 
“The issue is that physicians are very good at examining patients from the front, and physicians are not that good at taking off everything in the world and examining the patient’s extremities and examining the patient from the back,” said Gold.
 
Physicians should specify the type of ulcer because only a pressure ulcer is tracked as a HAC. For example, a venous ulcer is not an HAC.
 
Gold provided the following scenario:
An 86-year-old woman with altered mental status presents with high temperature and pulse, normal blood pressure, and high white count, with urine showing the woman is a typical “urosepsis patient.” As nurses prepared the patient for a bed bath the next morning, they needed to call in the wound team to take care of a shaggy skin wound in the right pretibial area. 
Gold pointed out that the ulcer is in the pretibial area and that if the patient was lying on her back, the ulcer is most likely not a pressure ulcer. “If the patient were contracted and had the left leg constantly in apposition to the right leg, it could be a pressure ulcer,” he said. “But it’s in the pretibial area and therefore likely a venous ulcer.”
 
In this scenario, a coder should encourage the physician to provide a diagnosis and recommend treatment so the coder can determine whether the condition is a HAC. 
 
Remember that as of October 1, CMS will implement new ICD-9-CM codes that require coders to specify the stage of the ulcer, and physician documentation should reflect this specificity.
 
“The MCCs and CCs are going to change, so we’ll have 707.23, which is stage III decubitus ulcer, which is defined as a full thickness tissue loss without involvement of bone, tendon, or muscle; and 707.24, which is a stage IV decubitus ulcer, which is full thickness tissue loss with involvement of exposed bone, tendon, or muscle. [Codes] 707.20, 707.21, and 707.22 are unspecified, stage I, and stage II codes. Those will no longer be CC or MCC conditions at all,” said Bloomquist.
  • Falls and trauma, including fractures, dislocations, intracranial injuries, crushing injuries, and burns. The following codes denote this HAC:
    • Codes 800–829: Fractures
    • Codes 830–839: Dislocations
    • Codes 850-854: Intracranial injuries
    • Codes 925–929: Crushing injuries
    • Codes 940–949: Burns
    • Codes 991–994: External causes (i.e., heat, air pressure, light, frostbite)
“Remember, it only counts if they’re a CC or an MCC,” said Bloomquist. “If it’s a minor injury, like a fractured finger, it’s not going to affect your payment.”
  • Catheter-associated urinary tract infections (UTI). Code 996.64 (infection due to indwelling urinary catheter) denotes this HAC.
When capturing this HAC, be on the lookout for clues in the medical record, said Gold. For example, a neurogenic bladder or quadriplegic patient may tip coders off to the fact that the patient may have a catheter-associated UTI.
 
A patient doesn’t necessarily need to have an indwelling catheter to be at high risk for contamination; even someone who is catheterized periodically may be at risk for having a UTI that is POA, said Gold.
  • Vascular catheter-associated infections. Code 999.31 (infection due to central venous catheter—catheter-related bloodstream infection, not otherwise specified) denotes this HAC.
The code for vascular catheter-associated infections, also known as “line sepsis,” is new. This code includes infections due to peripherally inserted central catheters (PICC), said Bloomquist.
  • Mediastinitis after coronary artery bypass graft (CABG). Code 519.2 (mediastinitis) and a CABG procedure code from the 36.10–36.19 range denote this HAC.
If a patient presents to the hospital having had a CABG in the past, and now with an infection, make sure you get a definition of what the infection is, said Gold. Even if you don’t find out its type until later, it is still POA. 
 
Editor’s note: For more information on HACs, visit www.cms.hhs.gov/HospitalAcqCond/01_Overview.asp#TopOfPage.
 
To listen to the HCPro, Inc., audio conference “POA Reporting for Hospital Acquired Conditions: Strategies to Obtain Complete Documentation,” visit www.hcmarketplace.com/prod-6461.html.
 
DeAnne W. Bloomquist, RHIT, CCS, is the president and chief consultant for Mid-Continent Coding, Inc., in Overland Park, KS. E-mail her at dee@mccoding.com.
 
Robert S. Gold, MD founded DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician programs in clinical documentation improvement. The goals are data accuracy, profile management, and compliance, and a strong process to support the needs of the medical staff. You can reach him by phone at 770/216-9691 or by e-mail at DCBAInc@cs.com.

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