The Need to Screen Grows Urgent


In a few months, Medicare will begin denying reimbursement for certain conditions if they’re acquired in the hospital. Hospitalist groups are working against the clock to refine their screening methods to better document when those conditions exist on admission.

Hospitalist groups are also implementing more vigilant checks on admitted patients to make sure those complications—such as bed sores and line infections—are less likely to develop.

The new rules for the In-patient Prospective Payment System (IPPS) name eight conditions, from injuries during a fall to an object left in a surgical patient, that Medicare no longer will pay for. More conditions will be added the following year. The changes also establish 745 new Medicare severity-adjusted diagnosis-related groups (MSDRGs), replacing the current 538.

The changes, ordered by the Centers for Medicare and Medicaid Services (CMS), won’t restrict payment until Oct. 1; coding changes went into effect in October 2007. Coding not only affects payment but also allows for public reporting of hospital performance.

What They’re Doing

“Hospitalists are in an extraordinarily crucial position to help their facilities prepare and manage the new MSDRGs and pay-for-performance models that are being rolled out,” says James S. Kennedy, MD. He is a director with FTI Healthcare in Atlanta and author of the book Severity DRGs and Reimbursement: An MS-DRG Primer, published by the American Health Information Management Association.

Hospitalists “have a tremendous amount of in-patient hospital volume and they can better standardize their approaches,” clearing the way for other medical workers, he says.

He suggests designating one hospitalist per group to develop a working knowledge of ICD-9-CM codes and DRGs and serve as a physician adviser to the coding department.

“It has to be clear to the coder whether or not every condition that was documented by a physician was present on admission or not,” Dr. Kennedy points out.

It makes sense that CMS would order these changes in reimbursement, says Patrick Torcson, MD, chairman of SHM’s Performance and Standards Committee, and medical director for the hospitalist program St. Tammany Parish Hospital in Covington, La.

“With preventable conditions acquired in the hospital, there’s this perverse incentive that hospitals can get more money when complications occur,” Dr. Torcson says.

How are hospitalist groups preparing for these changes? At St. Tammany, there’s a new emphasis on educating hospitalists on documentation to note those present-on-admission indicators (POAIs). Dictation templates now include reminders to note that data. Also, multidisciplinary rounding that’s been effective in the intensive-care unit is being extended to general medical floors.

“There might be the tendency to just order more tests at the time of hospital admission,” Dr. Torcson points out. “Our group is going to avoid going down the track of ordering a urinalysis on every patient admitted, for example, just to rule out a urinary tract infection. We’re going to emphasize clinical judgment on a case-by-case basis.”

For hospital groups with high-risk populations, more testing may be exactly what’s needed. Randy Ferrance, DC, MD, a hospitalist at Riverside Tappahannock Hospital in Virginia, says the average age of his patients is about 70.

“We are doing a lot more screening and urinalysis than we used to do,” Dr. Ferrance says. “Nearly everyone is getting urinalysis, if they have any risk factors at all.”

The group of about four full-time hospitalists also relies more on nurses to note in patients’ charts any skin abnormalities so they can be prevented from developing into sores. The nurses are also “developing criteria for who we consider to be a high risk for decubitus ulcers,” Dr. Ferrance says. “We’re lowering the threshold for what we consider to be high risk.”

The group just revised its history-and-physical template to include more prompts, reminding the admitting physician to check for these POAIs.

Reminders like that coupled with the right technology can make it easier for hospitalists to capture all this information, says Brian Harte, MD, acting chairman of the Department of Hospital Medicine at the Cleveland Clinic, and a member of SHM’s Hospital Quality and Patient Safety Committee.

“What we will be doing is looking at ways to include this primarily into our electronic documentation,” Dr. Harte says. “[We’re] finding a way to cue people so that the default is to think about them, to answer ‘yes’ or ‘no’ to these conditions.”

He recommends giving physicians and nurses plenty of opportunities to note conditions—and not just by adding “pop-up” reminders in electronic records, which, he points out, can start looking like a Web site without ad blockers.

About two years ago, Beth Israel Deaconess Medical Center in Boston was trying to determine how central lines were becoming infected. It was discovered the facility didn’t have a system to record who had placed the lines.

“We wanted a smaller group of providers doing a higher volume of lines, with the belief that if we trained these people and helped them understand, we could minimize the variation of putting in the lines, and we could change the outcome,” says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess.

The hospital now has a nurse dedicated to checking the lines every day. It also designates skin-care nurses who regularly check for pressure ulcers.

Understanding the motivations behind the changes in IPPS will go a long way toward helping hospitalists adapt to them and provide better care, asserts Dr. Li, a member of the SHM Board of Directors.

“Of course we never want to leave something by accident inside a patient,” Dr. Li says. But less dramatic complications, like bedsores, can start to seem routine. “I think what happens over time is people get dulled to it,” he says. “They begin to believe it’s OK to have pressure ulcers, and it’s never OK.”

Conditions on CMS’ Radar

The Centers for Medicare and Medicaid Services will stop reimbursing for these conditions if they exist upon a patient’s admission to the hospital:

  • Object left in surgery;
  • Air embolism;
  • Blood incompatibility;
  • Catheter-associated urinary tract infection;
  • -Pressure ulcers;
  • Vascular catheter-associated infection;
  • Surgical site infection—mediastinitis after coronary artery bypass graft surgery; and
  • Injuries from falls (specific trauma codes).


For all the good intentions behind CMS’s changes, it might be problematic for hospitalists to screen for the conditions CMS selected, says Heidi Wald, MD, MSPH, assistant professor of medicine at the University of Colorado, Denver, School of Medicine. Dr. Wald co-wrote a commentary called “Nonpayment for Harms Resulting from Medical Care” in the December 2007 Journal of the American Medical Association (JAMA).

A diagnosis can be coded as present on admission, not present on admission, unable to determine because the documentation was lacking, or unable to clinically say, Dr. Wald notes. She wants more information from CMS’s pilot studies, and says it remains to be seen how efficient the changes will be in practice.

For an example of how things can get complicated, Dr. Wald suggests a hypothetical situation: A patient comes to the emergency department with chest pain, is admitted to the hospital, receives a catheter, develops a fever, and is found in a subsequent urinalysis to have a urinary tract infection (UTI).

“Did the ED doc screen for a UTI on admission?” Dr. Wald asks. “Probably not. It would be ‘clinically unable to determine,’ from the way I’m reading it, because they didn’t have testing on admission. So in this case, it would behoove you not to screen.”

Dr. Wald praises CMS for giving hospitals a financial reason to focus on complications. She’s happy to see an increase in awareness of nosocomial infections.

“This is the right thing for hospitals to be doing, to find out ways to improve practice and to decrease infectious complications,” she notes. “I think the financial incentive is a way to push the cultural change along.”

Temple University in Philadelphia, which has about 25 hospitalists in its group, hopes to roll out formal changes in its policies in late spring or early summer, says William Ford, MD, program medical director of Cogent Healthcare and chief of the section of hospital medicine at Temple.

His hospitalists’ monthly meeting will include a regular, five-minute presentation on a topic in emergency medicine that pertains to the CMS changes, Dr. Ford says. It also will be part of their monthly journal meetings.

The goal is to make three of the conditions—UTIs, blood infections, and ulcers—part of physicians’ daily assessment, keeping it uppermost in their minds to continually evaluate the need for treatments such as Foley catheters or central lines.

Sometimes “three days go by and the doctor doesn’t think, because he or she is treating other parts of their illness, ‘Do they still need that Foley catheter, do they still need that IV?’ ” Dr. Ford notes. “If the patient does not need those two modalities, discontinue them … because those are two big causes for infection.”

Tips to Help Screen

Include a list of conditions in electronic documents and paperwork to cue doctors to check for them on admission and create documentation;

  • Standardize admission processes and documentation;
  • Assess how hospitals prevent these conditions and improve your system;
  • Create more opportunities to observe conditions with redundant checks; and
  • Designate healthcare providers to make regular inspections of catheters and look for pressure ulcers.—LT

Early Reaction

While the changes are incentive to be more attentive to detail, Dr. Ferrance wonders whether there could be a down side.

“I’ll be honest and admit I didn’t catch every single Stage 1 decubitus ulcer on every patient I admitted,” he says. “Now I’m much more vigilant.” Still, he adds: “It increases the paperwork burden, and it adds to the nonpatient part of our day. I have to wonder if the increased burden of paperwork pays off in that much benefit to the patient.”

And pressure is building. Insurers Aetna Inc. and WellPoint Inc. are following Medicare’s example, moving to end payment for some of the most serious hospital errors. Other major insurers are investigating changing their policies.

The public also cares quite a bit about the issue, Dr. Wald notes. When a New York Times blog mentioned Dr. Wald’s JAMA article, readers left scores of comments. Some were stunned to hear hospitals can be paid extra when complications occur.

Professional societies and organizations can help medical centers adjust to these changes by providing guidance and leadership, suggests Dr. Li. Hospitals will benefit by educating all providers about the system changes and the reasons behind them, he says.

“This is about a lot more than the doctor and the patient,” he argues. “This is about changing the culture and institution.” TH

Liz Tascio is a medical journalist based in New York.

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