“Why on earth are you sending me this query? Why do I need to show if that little stage 1 pressure ulcer was present on admit? Is it an HAC or a POA?”
As a clinical documentation specialist, these are just a few of the questions I get from physicians under the Hospital-Acquired Conditions/Present on Admission program. The program began in 2010 under the Affordable Healthcare Act and administered by the Centers for Medicare and Medicaid (CMS).
Through random audits, conditions that do not show documentation of a clear POA status are monitored. CMS may no longer pay hospitals for certain conditions that were not shown to be present at the time of admission or conditions that occurred in the hospital but could have reasonably been prevented.
Auditors often find codes for conditions that had been assigned without supporting documentation to validate the diagnosis. In that case, the hospital payment may be reduced or denied. That’s where we come in!
Clinical documentation specialists review the chart from admission through discharge to find conditions that are not clearly defined or documented as being present on admission — or if they occurred during the stay. We also look for treatments without a diagnosis, ambiguous documentation, conditions with very clear indicators but no diagnosis, or diagnosis with no clinical indicators.
When we send a query
We also look for clinical indicators and will query the provider if the documentation is not clear.
Remember… if it wasn’t documented, it wasn’t addressed or it didn’t exist.
Currently there are 14 CMS-defined HACs. (MRSA and C-diff will be added in 2017). When these conditions are not identified with a POA status or documented as “undetermined” they are presumed to be HAC. Therefore, a query will be sent to the provider to clarify. Below are few of the identified HACs.
Falls and Trauma
Iatrogenic Pneumothorax with Venous Catheterization
CLABSI
CAUTI
Pressure ulcer stage 3, 4
Manifestations for poor glycemic control
Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) following certain orthopedic procedures such as total hip and knee replacements. The full list is at cms.gov.
Hospitals get penalized
In 2012, one out of every eight patients suffered a HAC during a hospital stay. Hospitals in the lowest performing quartile for HACs lose 1% of their total Medicare payments.
Last year the focused conditions for HACS were CLABSI’s, CAUTIs and Surgical Site Infection (SSI). This year, 758 out of 3,308 hospitals subject to the HAC Reduction Program are in the worst performing quartile and face the 1% penalty.
The CDS team and coders are here to help — so if we have questions to verify illness severity and care provided, or POA, we’ll send you a query.
Interesting data, from 2010 to 2013:
So the next time you get that annoying little query from us, know that your reply really matters. You’ll help prevent a future mistake, maybe save a life, avoid lost revenue for the hospital, possibly prevent a penalty— and provide a higher standard of care by identifying those conditions that were present on admission.