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February 8, 2007
Preparing for "Present on Admission"
Implications for Hospital Reimbursement and Public Reporting
As noted in earlier communications for the past year, the Centers for
Medicare and Medicaid Services (CMS) will require hospitals to report on their
inpatient claims a "Present on Admission" code for all principal, secondary, and
e-code diagnoses starting October 1, 2007 with payment adjustments to begin
October 1, 2008. Under the Deficit Reduction Act’s Section 5001 (c), CMS will
implement payment reductions for select complications that occurred during the
patient stay.
At several meetings and briefings over the past week, CMS shared their draft
transmittal that will be sent to all PPS inpatient hospitals within the next
month. For now, critical access hospitals are exempt from reporting a "Present
on Admission" code on their inpatient claims since their payment does not come
under the inpatient PPS changes under the Deficit Reduction Act.
Technical Hurdles Overcome. On February 1, CMS overcame the one
obstacle that could have delayed implementation by receiving approval from the
ANSI X12 Committee to allow a special portion of the HIPAA 837 4010 A1 Claim to
be used for reporting the Present on Admission Code. ANSI has accommodated the
request and the changes will be effective starting October 1, 2007.
Targeted Areas. While providers will not know the areas of focus for
payment reductions starting October 1, 2008; CMS Medical Officer and Senior
Advisor, Tom Valuck, M.D., J.D., did provide some insight at a national meeting
in early December 2006. The areas under consideration currently are surgical
site infection, ventilator associated pneumonia, catheter associated bloodstream
infections, urinary tract infections, pressure ulcers, falls, and deep vein
thrombosis. Criteria for final selection will include those conditions that are
high cost or high volume; assignment to a higher DRG when the condition is
present as a secondary diagnosis; and could reasonably be prevented through the
use of guidelines or evidence based practices.
Hospital Implications. In most hospitals, this will require changes to be
made in several areas, including:
Education and training of all staff on reporting requirements and
compliance issues and technical reporting requirements for medical records and
clinical staff
Health information technology changes will need to be made within any
system that captures clinical information for usage in the inpatient medical
record and billing systems. Hospitals will need to ensure that their medical
records systems and billing systems are aligned and properly recording and
reporting the diagnoses and present on admission codes.
Clinical process and outcome improvement opportunities will need to be
identified (focusing on infections, falls, and deep vein thrombosis that
effect outcomes is a good starting point).
Hospital leadership in all the various areas will need to come
together to identify the pathways for successful implementation
Board engagement to address reporting and quality compliance issues
and any major reimbursement shifts
Audit and compliance controls will need to be put in place as these
will be high profile areas and audits
Expansion. While Medicare is requesting this information, we fully expect
other health plans and employers to require it as well (since they were the
original requestors of the Present on Admission variable over a decade ago).
Also, as noted by Dr. Valuck, once CMS has the data, they will be able to mine
the information quickly to identify unexpected patient outcomes based upon the
information on the patient claim.
Helping IHA Members Get Started. On Friday, February 16 from
1:00 p.m. to 2:00 p.m., IHA will host a one hour conference call providing
additional background information on areas targeted for improvement, linkages to
patient safety and quality measurements of the Agency For Healthcare Research
and Quality, coding details, helpful resources, and technical guidelines. IHA
will be joined by an ANSI X12 member and HIPAA expert to answer some of the
technical issues providers will need to address as they plan their health
information technology changes.
Please contact Dottie Jackson by e-mail at:
djackson@ihastaff.org for February 16
meeting materials and conference call in number.
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