Question: I just heard Medicare will no longer pay for care if a patient develops a bedsore during their hospital stay. Is this true?
Dr. Hospitalist responds: Beginning Oct. 1, the Center for Medicare and Medicaid Services (CMS) rolled out the latest change to the Inpatient Prospective Payment System by implementing the following Present on Admission (POA) Indicators:
- Object left in patient after surgery;
- Air embolism;
- Blood incompatibility;
- Catheter-associated urinary tract infections;
- Pressure ulcers (decubitus ulcers);
- Vascular catheter-associated infection;
- Mediastinitis after coronary artery bypass graft;
- Hospital-acquired injuries (fractures, dislocations, intracranial injury); and
- Crushing injury, burn, and other unspecified effects of external causes.
What exactly does this mean? Simply put, if a patient develops any of these conditions during his/her hospital stay, CMS no longer will pay the hospital for additional services associated with treatment of these conditions.
As a healthcare consumer and taxpayer, I believe this measure is long overdue. No patient should ever receive incompatible blood or have an object left in after surgery. Why should we pay for such errors? As hospitalists, our challenge is to develop processes to ensure these events never occur in the hospital. This will require implementing systems as well as educating and training every individual who works in our hospitals.
Coding for these events began Oct. 1 of last year, but payment will not be restricted until Oct. 1 of this year. Coding these events will not only affect hospital payment but will allow for public reporting of hospital performance.
CMS has proposed adding several other conditions for the next fiscal year and is analyzing still more possible conditions.
Proposed for this October:
- DVT and PE;
- Staph aureus septicemia; and
- Ventilator associated pneumonia (VAP).
Conditions under consideration:
- Methicillin-resistant Staphylococcus aureus;
- C. difficile-associated disease; and
- Wrong surgery.
Hospitals are turning to hospitalists not only to help them comply, but to lead the development of systems to improve inpatient care. I encourage you to think about how you can do this at your hospital.
Question: Can you explain why my hospital is asking me to change the way I document heart failure in the chart? They are telling me it is the result of some diagnosis-related group (DRG) rule changes at Medicare that affects how much the hospital gets paid. Is this accurate?
Dr. Hospitalist responds: The changes in physician documentation of inpatients with heart failure are part of a larger change in Medicare’s Inpatient Prospective Payment System. The new changes, called Medicare Severity-Adjusted DRGs (MSDRGs), restructured the DRGs to more fully account for the severity of a patient’s medical condition. The change expanded the number of DRGs from 583 to 745 by splitting the DRGs into three tiers:
- Major complication/co-morbidity (MCC);
- -Complication/co-morbidity (CC); and
- No CC.
Physician documentation that reflects chronic systolic and/or diastolic heart failure represents a CC. Documentation of acute systolic and/or acute diastolic heart failure represents an MCC. Documentation that does not describe the type and acuity of a patient’s heart failure condition will result in no CC.
Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG. A higher DRG weight represents a more medically complex patient and a correspondingly higher payment. These new classifications affect the heart failure DRG weight values as follows: