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CMS Cracking Down on Infection Documentation


 

ARLINGTON, VA. — As hospitals in the United States face the new reality of nonpayment for certain health care-associated infections, ensuring “accurate and appropriate physician documentation on the patient record” is seen by infection control specialists as the area in greatest need of urgent attention.

That finding was among those from a survey of 934 hospital preventionists presented at a conference sponsored by the Association for Professionals in Infection Control and Epidemiology (APIC) and the Premier Healthcare Alliance.

As of Oct. 1, Medicare will no longer pay for care associated with hospital-acquired infections including surgical site infections, catheter-associated urinary tract infections, and vascular catheter-associated infections. Compliance requires documentation of whether the condition was present on admission (POA).

Of the survey respondents, 90% work in infection prevention/control, 2% work in quality/performance improvement, and the rest serve as patient safety experts, as administrators, or in another capacity. A fourth of the respondents (25%) work in facilities with 100 beds or fewer, 31% work in institutions with 101-250 beds, and 16% work in facilities with 500 or more beds. Most (55%) are located in 1 of the 27 states that currently mandate reporting of health care-acquired infections (HAIs).

Asked which listed activity they believe “needs the most attention to optimize your organization's readiness” for the new payment regulations from the Centers for Medicare and Medicaid Services, 52% responded “accurate/appropriate physician documentation on the patient record.” Another 20% listed “accurate coding, including accurate use of new [POA] codes”; 16% checked “interdepartmental collaboration for identification and documentation of health care-acquired conditions”; and 13% selected “physician education on the impact of the CMS rule” on reimbursement for health care-acquired conditions.

“Everybody's worried about the [POA] issue. They view it as intrusive, something that could potentially create new costs and all sorts of other things,” Dr. Daniel Varga, chief medical officer of St. Louis-based SSM Healthcare, said in an interview. But “it's probably going to be more of an issue of doctors' needing to be educated, and for us to build processes to make it easy to document presence or absence of [HAIs].”

In a keynote speech, Dr. Thomas B. Valuck, medical officer and senior adviser at CMS, described the new rule as part of the agency's overall “value-based purchasing” strategy. The idea, he said, is to transform Medicare “from a passive player to an active purchaser of higher-quality, more-efficient health care.”

Until now, “Medicare's fee-for-service schedules and prospective payment systems [were] based on resource consumption and quantity of care, not quality or unnecessary costs avoided,” Dr. Valuck noted. If spending continues at the current rate—projected at $486 billion for 2009—the Part A trust fund will be depleted by 2019, he said.

This is the reason for the focus on hospital-acquired infections, which are estimated to add nearly $5 billion annually to the national health care tab. A 2007 study found that, in 2002, 1.7 million hospital-acquired infections were associated with 99,000 deaths. Yet that survey, conducted by the employer/insurer coalition known as the Leapfrog Group (www.leapfroggroup.org

The three types of infections designated for nonpayment are among a list of 10 health care-acquired conditions that Medicare no longer covers (and for which CMS has mandated reporting for the last year). The list includes “never events” such as foreign objects retained after surgery, blood incompatibility, and other conditions such as manifestations of poor glycemic control and injury after a fall (HOSPITALIST NEWS, August 2008, p. 1).

All 10 health care-acquired conditions are subject to the “present on admission” documentation requirement, which defines as POA any conditions present at inpatient admission, including those that arose during outpatient encounters in the emergency department, observation, or outpatient surgery.

There are four possible POA indicators:

▸ Y, which means that the diagnosis was present at the time of admission.

▸ N, which means that the diagnosis wasn't present.

▸ U, which means that documentation was insufficient to determine if the condition was present at the time of admission.

▸ W, which means that the POA status could not be determined despite a full clinical work-up.

Medicare will pay the additional amount for health care-acquired conditions coded as Y or W, but not for those coded as N or U, Dr. Valuck explained.

The APIC survey also highlighted other challenges that hospitals will face as the new rule goes into effect. Nearly two-thirds (59%) of respondents said that their institution's current surveillance process for detecting problem pathogens and potential HAIs that need investigation was “reasonably timely and efficient” but had “room for improvement,” while 16% said that the process was “not timely and efficient.”

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