Never Events and Present on Never Events and Present on Admission/Hospital Acquired ConditionsAdmission/Hospital Acquired Conditions

What You Need to Know and DoWhat You Need to Know and Do

Never Events - BackgroundNever Events - Background

The National Quality Forum (NQF) has identified a The National Quality Forum (NQF) has identified a total of 28 events total of 28 events (the NQF is a not-for-profit organization (the NQF is a not-for-profit organization whose mission is to develop and implement national strategies for whose mission is to develop and implement national strategies for health care quality measurement and public reporting)health care quality measurement and public reporting)

These events are defined as:These events are defined as:

– Clearly identifiableClearly identifiable– AdverseAdverse– PreventablePreventable– Indicative of a problem in an organization’s safety Indicative of a problem in an organization’s safety

systemssystems– Important for public credibility or accountabilityImportant for public credibility or accountability

Never Event CategoriesNever Event Categories

Surgical:Surgical:

– Surgery on wrong body part *Surgery on wrong body part *– Surgery on wrong patient *Surgery on wrong patient *– Wrong surgical procedure *Wrong surgical procedure *– Retained foreign objectRetained foreign object– Intraoperative or immediate post op death in ASA Class Intraoperative or immediate post op death in ASA Class

1 patient1 patient

* * Also identified by the Texas Hospital Association (THA)Also identified by the Texas Hospital Association (THA)

Never Event Categories, cont’dNever Event Categories, cont’d Product or DeviceProduct or Device::

– Death or disability with contaminated drugs or devicesDeath or disability with contaminated drugs or devices– Death or disability with device used as other than intendedDeath or disability with device used as other than intended– Intravascular air embolism *Intravascular air embolism *

Patient Protection:Patient Protection:

– Infant discharged to wrong person *Infant discharged to wrong person *– Death or disability with patient elopementDeath or disability with patient elopement– Suicide or attempted suicide in a health care facilitySuicide or attempted suicide in a health care facility

* * Also identified by the Texas Hospital Association (THA)Also identified by the Texas Hospital Association (THA)

Never Event Categories, con’tNever Event Categories, con’t

Care Management:Care Management:

– Death or disability with medication errorsDeath or disability with medication errors– Death or disability with blood incompatibility *Death or disability with blood incompatibility *– Maternal death or disability with low risk pregnancyMaternal death or disability with low risk pregnancy– Death or disability with hypoglycemiaDeath or disability with hypoglycemia– Death or disability with hyperbilirubinemia Death or disability with hyperbilirubinemia * * ((neonates during neonates during

the first 28 days of life)the first 28 days of life)

– Stage 3 or 4 pressure ulcers occurring in a health care Stage 3 or 4 pressure ulcers occurring in a health care facilityfacility

– Death or disability with spinal manipulative therapyDeath or disability with spinal manipulative therapy– Artificial insemination with wrong sperm or egg*Artificial insemination with wrong sperm or egg*

* Also identified by the Texas Hospital Association (THA)* Also identified by the Texas Hospital Association (THA)

Never Event Categories, con’tNever Event Categories, con’t

Environment Events:Environment Events:

– Death or disability with electric shockDeath or disability with electric shock– Line with gas for patient contains wrong gas or is Line with gas for patient contains wrong gas or is

contaminatedcontaminated– Death or disability with a burn occurring in a facility *Death or disability with a burn occurring in a facility *– Death or disability from a fallDeath or disability from a fall– Death or disability with restraintsDeath or disability with restraints

* Also identified by the Texas Hospital Association (THA)* Also identified by the Texas Hospital Association (THA)

Never Event Categories, con’tNever Event Categories, con’t

Criminal EventsCriminal Events::

– Impersonating a physicianImpersonating a physician– Abduction of a patientAbduction of a patient– Sexual assault on a patientSexual assault on a patient– Death or disability from an assault on hospital Death or disability from an assault on hospital

campuscampus

Never Events vs. Present on AdmissionNever Events vs. Present on Admission

Adverse health care events, such as never events, Adverse health care events, such as never events, are the leading cause of death and injury in the are the leading cause of death and injury in the United StatesUnited States– These events will be reviewed on a case by case basis These events will be reviewed on a case by case basis

and charges waived if warrantedand charges waived if warranted

On the other hand, present on admission On the other hand, present on admission conditions are reimbursable, but at a lower DRG conditions are reimbursable, but at a lower DRG payment ratepayment rate

Present on Admission (POA) Present on Admission (POA) Hospital Acquired Conditions (HAC) - BackgroundHospital Acquired Conditions (HAC) - Background

The Deficit Reduction Act required the The Deficit Reduction Act required the Secretary of Health and Human Services to Secretary of Health and Human Services to select two conditions that are:select two conditions that are:

– High cost/high volumeHigh cost/high volume– Result in a DRG that has a higher payment Result in a DRG that has a higher payment

when presented as a secondary diagnosiswhen presented as a secondary diagnosis– Reasonably preventable through application of Reasonably preventable through application of

evidence-based guidelinesevidence-based guidelines

Present on Admission/Hospital Acquired ConditionsPresent on Admission/Hospital Acquired Conditions

In the FY 2008 inpatient prospective payment In the FY 2008 inpatient prospective payment system (IPPS) final rule, CMS adopted eight system (IPPS) final rule, CMS adopted eight conditions for which it would no longer pay conditions for which it would no longer pay hospitals a hospitals a higherhigher DRG if the conditions were not DRG if the conditions were not present on admission (POA)present on admission (POA)

Hospital acquired conditions (HAC) are those Hospital acquired conditions (HAC) are those conditions that were not documented as being conditions that were not documented as being present at the time of admission and could be present at the time of admission and could be assumed to have occurred during the patient’s assumed to have occurred during the patient’s hospital stayhospital stay

Present on Admission/Hospital Acquired ConditionsPresent on Admission/Hospital Acquired Conditions

CMS has identified the following POA and CMS has identified the following POA and HAC conditions for FY 2008:HAC conditions for FY 2008:

– Object left in during surgery Object left in during surgery (ICD-9 998.4 & 998.7)(ICD-9 998.4 & 998.7)

– Air embolism Air embolism (ICD-9 999.1)(ICD-9 999.1)

– Blood incompatibility Blood incompatibility (ICD-9 999.6)(ICD-9 999.6)

– Pressure ulcers Pressure ulcers (Stage III & Stage IV) (Stage III & Stage IV) (ICD-9 707.23 & 707.24)(ICD-9 707.23 & 707.24)

– Catheter-associated urinary tract infections Catheter-associated urinary tract infections (ICD-9 996.64)(ICD-9 996.64)– Vascular catheter-associated infections Vascular catheter-associated infections (ICD-9 999.31)(ICD-9 999.31)

– Surgical site infection – mediastinitis after CABGSurgical site infection – mediastinitis after CABG (ICD-9 519.2)(ICD-9 519.2)

Evidence of these conditions must be documented in your Evidence of these conditions must be documented in your H&P or progress notes beginning October 1, 2008H&P or progress notes beginning October 1, 2008

Present on Admission/Hospital Acquired ConditionsPresent on Admission/Hospital Acquired Conditions CMS has added the following POA and HAC conditions for CMS has added the following POA and HAC conditions for

FY 2009 for which Medicare will deny a higher DRG FY 2009 for which Medicare will deny a higher DRG payment:payment:

– Falls and TraumaFalls and Trauma Fracture Fracture (ICD-9 800-829)(ICD-9 800-829) Dislocation Dislocation (ICD-9 830-839)(ICD-9 830-839) Intracranial injury Intracranial injury (ICD-9 850-854)(ICD-9 850-854) Crushing injury Crushing injury (ICD-9 925-929)(ICD-9 925-929) Burn Burn (ICD-9 940-949)(ICD-9 940-949) Electric shock Electric shock (ICD-9 991-994)(ICD-9 991-994)

– Manifestations of poor glycemic control Manifestations of poor glycemic control (diabetes ketoacidosis and (diabetes ketoacidosis and hypoglycemic coma; numerous codes) hypoglycemic coma; numerous codes)

– Surgical site infection following certain orthopedic procedures Surgical site infection following certain orthopedic procedures (ICD-9 (ICD-9 996.67 & 998.59)996.67 & 998.59)

– Surgical site infection following bariatric surgery (Surgical site infection following bariatric surgery (ICD-9 278.01 & 998.59)ICD-9 278.01 & 998.59)– Deep vein thrombosis/pulmonary embolism following certain orthopedic Deep vein thrombosis/pulmonary embolism following certain orthopedic

procedures procedures (total knee and hip replacement; numerous codes)(total knee and hip replacement; numerous codes)

Present on Admission/Hospital Acquired ConditionsPresent on Admission/Hospital Acquired Conditions

Why is the POA issue confusing?Why is the POA issue confusing?

Many third party payors are using the term never Many third party payors are using the term never event for POA conditionsevent for POA conditions

Some managed care payors overlap but do not Some managed care payors overlap but do not mirror CMS on chosen events with respect to mirror CMS on chosen events with respect to making payment decisionsmaking payment decisions

The University Hospitals will follow the guidelines The University Hospitals will follow the guidelines set forth by CMS when identifying POA conditionsset forth by CMS when identifying POA conditions

Never EventsNever EventsPresent on Admission/Hospital Acquired ConditionsPresent on Admission/Hospital Acquired Conditions

The University Hospital’s have been identifying never The University Hospital’s have been identifying never events via the rL Solutions event reporting system. events via the rL Solutions event reporting system. Therefore, this will not be a change in our practiceTherefore, this will not be a change in our practice

It is vitally important that our provider’s work collaboratively It is vitally important that our provider’s work collaboratively with the Case Management and HIM departments, since with the Case Management and HIM departments, since these departments will continue to query about POA these departments will continue to query about POA conditions at time of admissionconditions at time of admission

Failure to document POA conditions in the medical record Failure to document POA conditions in the medical record will decrease the DRG reimbursement to the University will decrease the DRG reimbursement to the University HospitalsHospitals

Present on Admission/Hospital Acquired ConditionsPresent on Admission/Hospital Acquired Conditions

Documentation is Documentation is keykey to being successful with to being successful with identifying POA conditionsidentifying POA conditions

– Document POA conditions if they exist and are either Document POA conditions if they exist and are either primary or secondary diagnosesprimary or secondary diagnoses Hospitals will receive the full DRG payment with appropriate Hospitals will receive the full DRG payment with appropriate

documentationdocumentation

– Failure to document POA conditions results in CMS Failure to document POA conditions results in CMS reimbursing hospitals at a lower DRGreimbursing hospitals at a lower DRG CMS views these conditions as hospital-acquiredCMS views these conditions as hospital-acquired

Never EventsNever EventsPresent on Admission/Hospital Acquired ConditionsPresent on Admission/Hospital Acquired Conditions

Questions? Please contact:Questions? Please contact:

Sue Elke, Director of Compliance, University Sue Elke, Director of Compliance, University Hospitals - Hospitals - 214-645-1494214-645-1494

Doug Arrington, Director of Billing Compliance, UT Doug Arrington, Director of Billing Compliance, UT Southwestern - Southwestern - 214-648-6034214-648-6034

Alex Mullin, Director of Reimbursement, Health Alex Mullin, Director of Reimbursement, Health System Affairs - System Affairs - 214-648-9047214-648-9047