Coming soon: Better data on hospital-acquired conditions
Document a patient's pre-existing conditions
New requirements from the Centers for Medicare and Medicaid Services for "present on admission" designations will have significant implications for quality professionals.
CMS is requiring hospitals to report secondary diagnoses that patients present with upon admission for Medicare beneficiaries. The new law takes effect Oct. 1, 2007, and illustrates the federal government's increasing focus on linking reimbursement to quality and performance. The goal is to hold providers more accountable for complications that occur after a patient is admitted to the hospital.
In May 2006, CMS announced its intention to work with Congress and health care organizations to reduce payments for care during which a "never" event occurred — a list of 28 serious reportable events identified by the National Quality Forum. Each is considered preventable in the hospital setting, such as surgery performed on the wrong body part or leaving a foreign object inside a patient after surgery. The Leapfrog Group is asking hospitals to refrain from seeking reimbursement for any costs directly related to a "never" event that occurs within their facility.
To comply with the new CMS requirement, quality managers will need to improve their ability to separate the pre-existing conditions a patient has upon arrival from conditions acquired during the hospital stay.
Quality managers should be taking steps now for a smooth transition to the new requirements, says Patti Muller Smith, RN, EdD, CPHQ, a Shawnee, OK-based consultant working with hospitals on performance improvement and regulatory compliance. A key step is reviewing hospital-acquired conditions present in your patient population and determining methods for improvement.
You'll also need to define your organization's "present on admission" indicator — a flag that identifies a diagnosis as present at the time of the inpatient admission. The indicator can include a patient's conditions known at admission, conditions which are present at admission but are not diagnosed until later, and conditions that develop during outpatient encounters at the emergency department, observation or outpatient surgery.
Those additional data are critical components to understanding which conditions were present at admission vs. those that were acquired during the hospital stay, such as infections and other complications from procedures, says Catherine Eikel, director of programs for The Leapfrog Group.
"These data will help identify hospital-acquired infections and other complications that happen within a hospital, so hospitals can hone their quality improvement efforts and prevent future harm," says Eikel.
As a result of the new requirements, your database of information about discharged patients will become a richer source of quality and patient safety data.
"Understanding what a patient entered the hospital with — and what may have developed during her or his stay — helps paint a much clearer picture of hospital quality and safety," says Eikel. "The billing data will become more powerful and accurate tools for identifying errors and adverse events occurring in the hospital."
If the patient's initial admission documentation demonstrates the patient's condition on admission, there is decreased probability that what occurs during the patient's stay in acute care contributed to a longer length of stay or increased use of resources, says Muller-Smith.
"The hospital's quality ratings will also be more accurate, since problems that might arise with the patient during their hospitalization are not a result of the quality of care they received, but due to conditions that were already present and beyond the control of hospital staff," says Muller-Smith.
If documentation is complete and accurate, it will be easier to determine what was a hospital-acquired problem, and reflect more accurately on the quality of care being delivered.
"Quality professionals will be better able to focus their activities on issues that need improvement, rather then dealing with statistical reporting that arises from inadequate documentation of the patient's pre-existing condition," says Muller-Smith.
As for reimbursement, hospitals will benefit from identifying patients who will require more care. Hospitals will receive reasonable compensation for the actual care delivered to patients who, by virtue of their admitting condition, will require more care then the 'average patient' who is in the same DRG category, explains Muller-Smith.
"Overall, it comes down to complete and accurate documentation that paints a true picture of the patient when he or she presents to the hospital," says Muller-Smith.
When reporting additional diagnoses for accurate DRG assignment, the current system does not provide information as to whether the condition was present on admission or developed during the hospital stay, explains Deborah K. Hale, president of Shawnee, OK-based Administrative Consultant Service.
"Interpreters of the data who seek to identify potentially avoidable complications may unfairly attribute a condition to inadequate care in the hospital, when in fact, the condition was present when the patient was admitted," says Hale. Examples of these conditions include decubitus ulcer, dehydration, and congestive heart failure.
The present-on-admission indicator also will identify other providers of care that aren't adequately meeting the needs of the patient. "For example, CMS is particularly interested in home health agencies, which have high hospital admission rates, suggesting inability to adequately manage the patient's care," says Hale.
If coders are carefully trained to identify clinical signs of a condition that was also present on admission, these data will be very valuable to quality measurement and improvement. Since coding will be more precise, data can be used to better identify hospital-acquired conditions and analyze the impact on length of stay, disposition, and other factors, explains Hale.
"It will help them to identify error reduction, without having to do extensive and expensive chart reviews using valuable nursing time," says Eikel.
Unfortunately, physicians do not always list every condition that is present on admission, although they may later document the condition. Therefore, the coder must determine that even though a condition such as a urinary tract infection wasn't mentioned until the third hospital day, the condition was actually present on admission.
CMS is proposing to identify two infections that should not develop during the hospital stay. Paying the hospital for care of these infections will not be allowed because the infection was avoidable if evidence-based medicine had been practiced. "Correct reporting of the present-on-admission indicator would avoid inappropriate payment penalties," says Hale.
[For more information, contact:
Deborah K. Hale, CCS, President, Administrative Consultant Service, P.O. Box 3368, Shawnee, OK 74802. Telephone: (405) 878-0118. E-mail: [email protected]. Web: www.acsteam.net.
Patti Muller-Smith, RN, EdD, CPHQ, Administrative Consulting Service, P.O. Box 3368, Shawnee, OK 74802. Telephone: (405) 878-0118. E-mail: [email protected].]
New requirements from the Centers for Medicare and Medicaid Services for "present on admission" designations will have significant implications for quality professionals.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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