CMS Proposes Doubling the Number of Non-reimbursable Hospital-Acquired Conditions

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.

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