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Sore Loser?


Sore Loser?

Question: I just heard Medicare will no longer pay for care if a patient develops a bedsore during their hospital stay. Is this true?


Austin, Texas

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.

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Heart Murmurs

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?

Taking Note,

Louisville, Ky.

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:

Old DRG, heart failure/shock: 1.0490.

New MSDRG, heart failure/shock:

  • With MCC: 1.2565;
  • With CC: 1.0134; and
  • Without CC: 0.8765.

I recently spoke with a hospital administrator at a large urban teaching hospital. Nearly a quarter of the hospital’s Medicare inpatients have heart failure. How physicians document heart failure represents a significant opportunity for hospital revenue ($3 million to $5 million a year). Because of this, I expect you are not alone. Hospital administrators all over the country are likely speaking with their hospitalists about their documentation.

Talk Balk

Question: A pharmaceutical company offered an honorarium for me to give a talk. I heard from a colleague that the company is required to report this payment to the government, which makes this information publicly available. Is this true?

Keynote Doc,

Minneapolis, Minn.

Dr. Hospitalist responds: The answer presently depends on where you live. Five states (California, Maine, Minnesota, West Virginia, Vermont) and the District of Columbia have some form of mandatory disclosure of payments made to physicians by pharmaceutical companies.

Minnesota and Vermont make this information publicly available. Other states may not be far behind. In 2006, 11 states considered similar legislation. But according to Ross, et. al., “the Vermont and Minnesota laws requiring full disclosure of payments do not provide easy access to payment information for the public and are of limited quality once accessed.”1

Proposed federal legislation may resolve this issue. Last fall, Sen. Charles Grassley, R-Iowa, introduced a bill called the Physicians Payments Sunshine Act of 2007. This bill would require drug and device manufacturing companies with more than $25 million in annual revenues to report all gifts in excess of $25 in value to physicians and other prescribing clinicians.

Drug/device samples and payment for clinical trials would be exempt. This data would be available in a public, searchable online database. Companies that fail to disclose would face penalties $10,000 to $100,000 for each undisclosed physician payment.

Industry support has been and will continue to be a controversial issue. Many doctors do not believe honoraria influence prescribing. But it is clear financial payments from industry are facing increasing scrutiny. You’ll need to decide whether you’re comfortable accepting this honorarium if your name will be listed on a publicly available database. TH


  1. Ross JS, Lackner JE, Lurie P, et al. Pharmaceutical company payments to physicians: early experiences with disclosure laws in Vermont and Minnesota. JAMA. 2007;297(11):1216-1223.

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