04/17/2008
My August 13, 2007 blog discussed CMS’ then-groundbreaking move to deny reimbursement
for seven hospital-acquired conditions including pressure ulcers, hospital falls,
certain catheter-associated infections, air embolism as a result of surgery, leaving
an object in during surgery, providing incompatible blood or blood products and
mediastinitis following coronary bypass surgery. CMS has now
announced that it proposes expanding
the list to include the following nine conditions:
-
Surgical site infections following certain elective procedures
-
Legionnaires’ disease
-
Extreme blood sugar derangement
-
Lung collapse (Iatrogenic pneumothorax)
-
Delirium
-
Ventilator-associated pneumonia
-
Formation/movement of a blood clot (Deep vein thrombosis/Pulmonary Embolism)
-
Bloodstream infection (Staphylococcus aureus septicemia )
-
Bacterial infection that causes severe diarrhea and serious intestinal conditions
such as colitis (Clostridium difficile associated disease)
CMS has explained that the underlying rationale for denying reimbursement is “to
strengthen the tie between the quality of care provided to Medicare beneficiaries
and payment for the services provided when they are in the hospital.” This
goal is consistent with - and, in fact, mandated by - the Deficit Reduction Act
of 2005 (Pub. L. 109-171), which requires the Secretary to identify certain high
cost and/or high volume preventable conditions that result from inadequate hospital
care and are identifiable by unique ICD-9-CM codes.
There are two final things you should know about CMS’ latest move. First,
these new reimbursement rules will not have a direct or immediate impact on individual
physicians. Second, if you manage hospital A/R, you are prohibited from billing patients for these claims, even though they will be denied by Medicare.
Labels :
CMS,
Coding,
Reimbursement,
Medicare/Medicaid,
Quality of Care
Comments:
I presently work on an Acute Care of the Elderly unit
in a hospital. We have worked so hard teaching health care professionals the difference
between dementia/delirium. We strive to detect early onset of delirium and/or prevent
it all together. Often times, delirium is unpreventable especially in the older
adult that is post-op after hip surgery. I am wondering what is the rationalle for
denying delirium reimbursement and what are the guidelines/criteria? This worries
me.
Thanks.
Comment by Jessica (Geriatric
CNS) – May 20, 2008
You are certainly
not alone in your concern regarding the reimbursement implications for Hospital
Acquired Conditions (“HAC”). Many experts have questioned the underlying presuppositions
and methodologies for selecting particular conditions. As to delirium, while
CMS has acknowledged that “[t]he literature for delirium
prevention studies is small, and the methodologic quality of many studies is poor,”
it has nevertheless taken the position that delirium is “reasonably preventable”
and needlessly costs Medicare an average of $23,290 per incident.
See Prevention of Delirium in Older Hospitalized Patients.
As such, Medicare will no longer provide hospitals additional
reimbursement for the increased cost associated with delirium (or any of the other
conditions designated as “hospital acquired conditions”), unless the patient is
documented to have had the condition upon admission. However, it
is important to note that the impact of this hospital reimbursement penalty will
be limited to the approximate 3,500 acute care hospitals that receive reimbursement
under the Inpatient Prospective Payment System (IPPS); this rule will not have a
direct impact upon individual providers.
Note: You can
Click here to listen to recent public listening sessions regarding HAC.
Also, if you want to contribute to CMS’ discussion, you can
submit your
comments prior to the end of the comment period and your comments will be
reviewed by CMS and incorporated into the public rulemaking record.
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