All Entries Tagged With: "POA"

OIG report highlights need for HAC/POA review

Editor’s Note: This blog was originally posted by Melissa Varnavas, CPC, the associate director of the Association for Clinical Documentation Improvement Specialists, for the ACDIS Blog.

In light of the Office of Inspector General (OIG) report Adverse Events in Hospitals: Methods for Identifying Events. I thought I’d take the opportunity to offer some simple present on admission (POA) and hospital acquired condition (HAC) reminders.

The report reviewed a sample of nearly 300 Medicare hospitalizations in order to analyze current methods of identifying adverse events in hospitals. The OIG found vulnerabilities in both accuracy and completeness of two critical sources of information about events and recommended a “thorough review of medical records by nurses and/or physicians” as “an effective way to identify [adverse] events…”

The two “critical sources” cited by the OIG are billing data and internal hospital incident reports. The OIG found that diagnosis codes “were inaccurate or absent for seven of the 11 Medicare hospital acquired conditions [HAC] identified by the study.” Such problems, according to the report, could cause inappropriate Medicare payments, and inappropriate collection of HAC/quality data.

The report also states that “hospitals participating in the case study apparently did not have any internal incident reports for 112 of the 120 events (93%), including some of the most serious events involving death or permanent disability to the patients.”

CMS stopped paying for conditions caused, even inadvertently, by the care the facility provided. In 2007, CMS implemented this policy by directing hospitals to have coders identify which conditions were POA versus those that occurred or were diagnosed during the patient’s hospital stay, identified as HACs.

A condition is considered POA if:

• The physician includes “present on admission” in the documentation
• The condition is included in the Past Medical History list
• The condition was diagnosed during the admission, but was clearly present on admission (e.g., chronic conditions and cancers)
• The diagnosis was “possible,” “probable,” “rule out,” “suspected,” or “differential on admission,” and was confirmed at discharge
• The condition developed during an outpatient encounter, such as in the emergency room, physician’s office, outpatient surgery, or observation
• The signs and symptoms of the condition were clearly present on admission, listed later in the record as a diagnosis with a POA

Okay, so let’s review the criteria for HACs. HACs include many diagnoses. Medicare has selected a few diagnoses that are eligible for financial penalty if they are the only complication or comorbidity or major CC and meet certain conditions.

For Medicare to decide that a condition is a HAC it must be:

• high cost, high volume, or both
• assigned to a higher-paying DRG when present as a secondary diagnosis
• reasonably preventable through the application of evidence-based guidelines

AHA offers comments on Congress healthcare reform bills

Editor’s Note: This post was excerpted from an article featured in the HIM Connection e-newsletter.

The American Hospital Association (AHA) offered comments and suggestions on the Senate and House healthcare reform bills in a January 7 letter to Congress.

The AHA commented on:

• Hospital-acquired conditions (HAC): The AHA is critical of the Senate bill provision to add a 1% penalty to hospitals in the upper quartile of rates of HACs. “The combination of the current Senate provisions could put some hospitals at risk for three separate payment reductions for the same infections/HACs—once through the current policy, once through value-based purchasing, and once through the new 1% penalty for hospitals with the highest HAC rates. It is unfair for hospitals to be subjected to triple jeopardy if their performance falls short of their goals,” according to the AHA.
• Readmissions: The AHA strongly disagrees with both the House and Senate bills, which impose financial penalties for “excess” (as opposed to “expected”) readmissions. The AHA believes that efforts to reduce readmissions should address “only avoidable and unplanned hospital readmissions related to the original admission.”
• RACs: The AHA urges the removal of the Medicaid RAC provision currently included in the Senate bill, which extends RACs to Medicare Parts C and D, as well as the Medicaid program. The AHA says the addition is “unnecessary for maintaining or improving program integrity.”
• Payment bundling: According to the letter, the AHA supports the testing of different models of bundling payments to improve coordination of care, noting that an appropriate evaluation is essential to determine what works and what does not before broad adoption. The AHA also offers support of the House bill language that supports “a wide array of models, including bundling payment for inpatient and physician services, inpatient and post-acute services, inpatient, physician, and post-acute services, and post-acute services only.”

AHA also comments on rural provisions, long-term care hospital concerns, offers support to health information exchange creation, and the Senate’s approach to a public plan option (i.e., creating state-based, non-public, nongovernmental healthcare co-operatives and non-public, multi-state health plans), and discusses a wide variety of other topics.

To read the letter, visit www.aha.org/aha/letter/2010/100107-let-aha-conferees.pdf.

One year later: How are you handling HAC and POA

Last October, CMS began paying hospitals less for certain hospital-acquired conditions (HAC) that occur in specific situations and are not present on admission (POA). CMS designed the program to save money by ceasing to pay hospitals for conditions that could have been avoided. However, a new study published in the September 9 issue of Health Affairs, estimates that the program has saved $1.1 million to $2.7 million annually.

Before the HACs took effect, many experts warned that the HACs could affect the hospital’s bottom line, but this study suggests that may not be the case. Have they affected your hospital’s bottom line?

The following HAC conditions took effect October 1, 2008:

1. Foreign Object Retained After Surgery
2. Air Embolism
3. Blood Incompatibility
4. Stage III and IV Pressure Ulcers
5. Falls and Trauma

• Fractures
• Dislocations
• Intracranial Injuries
• Crushing Injuries
• Burns
• Electric Shock

6. Manifestations of Poor Glycemic Control

• Diabetic Ketoacidosis
• Nonketotic Hyperosmolar Coma
• Hypoglycemic Coma
• Secondary Diabetes with Ketoacidosis
• Secondary Diabetes with Hyperosmolarity

7. Catheter-Associated Urinary Tract Infection          (UTI)
8. Vascular Catheter-Associated Infection
9. Surgical Site Infection Following:

• Coronary Artery Bypass Graft (CABG) – Mediastinitis
• Bariatric Surgery
  • Laparoscopic Gastric Bypass
  • Gastroenterostomy
  • Laparoscopic Gastric Restrictive Surgery
• Orthopedic Procedures
  • Spine
  • Neck
  • Shoulder
  • Elbow

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

• Total Knee Replacement
• Hip Replacement

If you are finding HAC and POA is an issue at your facility, check out these tips. Garri Garrison, RN, CPUR, CPC, CMC, director of consulting services at 3M Health Information Services in Atlanta, offered the following tips for keeping staff up to speed on HACs and POA in the September 2008 issue of Case Management Monthly:

• Educate case managers on what POA status is and partner with your health information management department to determine where POA codes apply.
• Be aware of new HACs when they’re announced by CMS. “This is just the beginning. It’s likely these conditions will continually evolve,” Garrison says.
• Look at your facility’s current documentation selection tools to see whether they lend themselves to capturing these data on admission. If they don’t, improve them.
• Do a self-audit. Randomly pull 30 charts to see whether they accurately note POA conditions. If you think there are gaps, chances are an auditor will as well.

“If you fail your own audit, you’re going to fail others, such as the recovery audit contractors’,” says Garrison, who describes case managers as “quality of care managers” and points to POA guidelines as “quality indicators.”

For more information on HACs, visit www.cms.hhs.gov

To listen to the HCPro, Inc., audio conference “POA Reporting for Hospital Acquired Conditions: Strategies to Obtain Complete Documentation,” visit www.hcmarketplace.com.

To read the complete article ” Don’t let HACs cut into your bottom line“, visit the ACDIS Web site’s Helpful Resources section.

In the wake of the RAC, don’t forget about Present on Admission (POA)

I’m sure everyone is aware of the Hospital-Acquired Conditions (HAC) the Centers for Medicare & Medicaid Services (CMS) announced would not be paid for beginning October 1, 2008. The 10 categories of HACs are:

(1) Foreign objects retained after surgery
(2) Air embolism
(3) Blood incompatibility
(4) Stage III & IV pressure ulcers
(5) Falls & trauma
(6) Manifestations of poor glycemic control
(7) Catheter-associated urinary tract infections
(8) Vascular catheter-associated infection
(9) Surgical site infection following: Coronary Artery Bypass Graft (CABG)—Mediastinitis, Bariatric surgery, and some orthopedic surgeries
(10) Deep vein thrombosis (DVT)/Pulmonary embolism (PE) following some ortho procedures.

When looking through this list of conditions, as healthcare professionals we realize there are steps that can take place to reduce and/or eliminate the possibility of these conditions, and then there are conditions that no matter what we do may unfortunately happen.

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CMS, RACs, POA, LOS–but what about the patient?

Boy is healthcare ever on a fast track and getting more complex and confusing. There are new and revised regulations coming from the Centers of Medicare and Medicaid Services (CMS), and the Recovery Audit Contractor (RAC) implementation has us going to more meetings than we know what to do with. Let’s not forget about Present on Admission (POA) and we need to be monitoring those lengths of stay (LOS). Don’t get me wrong, these are all very important, high priority issues, but what about the patient?
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