Hospital Acquired Condition
Encyclopedia
A Hospital Acquired Condition (HAC) is an undesirable situation or condition that affects a patient, that arose during a stay in a hospital or medical facility. It is a designation used by Medicare
/Medicaid
in the United States of America for determining MS-DRG
reimbursement beginning with version 26 (October 1, 2008).
designates some 1000+ ICD-9-CM diagnoses, out of over 14000 (as of 2009), as possible HACs. On February 8, 2006, the President signed the Deficit Reduction Act (DRA) of 2005. Section 5001(c) of DRA requires the Secretary to identify conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. Section 5001(c) provides that CMS can revise the list of conditions from time to time, as long as it contains at least two conditions.On July 31, 2008, in the Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2009 Final Rule, the Centers for Medicare & Medicaid Services (CMS) selected 10 categories of conditions for a HAC payment provision. For discharges occurring on or after October 1, 2008, hospitals no longer receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis were not present.
Conditions selected for implementation
These conditions will have payment implications beginning in October 1, 2008.
Object left in during surgery (998.4 CC)
Air embolism (999.1 MCC)
Blood incompatibility (999.6 CC)
Catheter Associated Urinary Tract Infection,
996.64 CC & one of the following specific infection codes: 112.2, 590.10, 590.11, 590.2, 590.3,
590.80, 590.81, 590.9, 595.0, 595.3, 595.4, 595.81, 590.89, 595.9, 597.0, 597.80, 599.0
Pressure Ulcers (707.00-.01 & 7-7.09 CCs; 707.02-09 MCCs)
Vascular Catheter Associated Infection (999.31 CC)
Surgical Site Infection – Mediastinitis after Coronary Artery Bypass Graft (CABG) Surgery (519.2 MCC & 36.10-.19)
Falls and Trauma – Fractures, Dislocations, Intracranial Injuries, Crushing Injuries, and Burns (Codes will be considered in FY2009 IPPS Proposed Rule)
Almost all of the 1000+ diagnoses that are possible HACs are designated "Falls and trauma."
However, if a diagnosis is not POA, it might be demoted. Most HAC diagnoses are demoted if they are not POA. Some that are not so simple are designated above with the tag "Proc," "Diag," or both. In those situations, a diagnosis must also be accompanied by one of a specific set of diagnoses, procedures, or both to be demoted.
For instance, if a patient falls out of bed while in a hospital, the consequent broken hip was not present on admission, so the "complication" of "broken hip" would be demoted as a "Falls and trauma" HAC. The hospital would not be compensated for treatment of the injury. The intent of this sort of classification is to force hospitals to prevent such problems in the first place.
Medicare (United States)
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...
/Medicaid
Medicaid
Medicaid is the United States health program for certain people and families with low incomes and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states. People served by Medicaid are U.S. citizens or legal permanent...
in the United States of America for determining MS-DRG
Diagnosis-related group
Diagnosis-related group is a system to classify hospital cases into one of originally 467 groups. The 467th was "Ungroupable." The system of classification was developed as a collaborative project by Robert B Fetter, PhD of the Yale School of Management, and John D Thompson, MPH of the Yale...
reimbursement beginning with version 26 (October 1, 2008).
Description
A patient at a hospital can be infected or otherwise degraded by hospital conditions and/or personnel in ways that are sometimes diagnosed as a "complication." MedicareMedicare (United States)
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...
designates some 1000+ ICD-9-CM diagnoses, out of over 14000 (as of 2009), as possible HACs. On February 8, 2006, the President signed the Deficit Reduction Act (DRA) of 2005. Section 5001(c) of DRA requires the Secretary to identify conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. Section 5001(c) provides that CMS can revise the list of conditions from time to time, as long as it contains at least two conditions.On July 31, 2008, in the Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2009 Final Rule, the Centers for Medicare & Medicaid Services (CMS) selected 10 categories of conditions for a HAC payment provision. For discharges occurring on or after October 1, 2008, hospitals no longer receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis were not present.
Categories of Hospital Acquired Condition
The following are the current, as of October 1, 2009 (MS-DRG v27), Hospital-Acquired Conditions:Conditions selected for implementation
These conditions will have payment implications beginning in October 1, 2008.
Object left in during surgery (998.4 CC)
Air embolism (999.1 MCC)
Blood incompatibility (999.6 CC)
Catheter Associated Urinary Tract Infection,
996.64 CC & one of the following specific infection codes: 112.2, 590.10, 590.11, 590.2, 590.3,
590.80, 590.81, 590.9, 595.0, 595.3, 595.4, 595.81, 590.89, 595.9, 597.0, 597.80, 599.0
Pressure Ulcers (707.00-.01 & 7-7.09 CCs; 707.02-09 MCCs)
Vascular Catheter Associated Infection (999.31 CC)
Surgical Site Infection – Mediastinitis after Coronary Artery Bypass Graft (CABG) Surgery (519.2 MCC & 36.10-.19)
Falls and Trauma – Fractures, Dislocations, Intracranial Injuries, Crushing Injuries, and Burns (Codes will be considered in FY2009 IPPS Proposed Rule)
Almost all of the 1000+ diagnoses that are possible HACs are designated "Falls and trauma."
How HAC is determined
When a diagnosis is recorded, it is designated either Present on Admission (POA) or not. If the diagnosis is POA, it is not demoted.However, if a diagnosis is not POA, it might be demoted. Most HAC diagnoses are demoted if they are not POA. Some that are not so simple are designated above with the tag "Proc," "Diag," or both. In those situations, a diagnosis must also be accompanied by one of a specific set of diagnoses, procedures, or both to be demoted.
For instance, if a patient falls out of bed while in a hospital, the consequent broken hip was not present on admission, so the "complication" of "broken hip" would be demoted as a "Falls and trauma" HAC. The hospital would not be compensated for treatment of the injury. The intent of this sort of classification is to force hospitals to prevent such problems in the first place.