Adverse Events, Hospital-Acquired Conditions, and Present on Admission Indicators

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Adverse Events, Hospital-Acquired Conditions, and
Present on Admission Indicators
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Serious reportable adverse events

• Surgery on wrong body part
• Surgery on wrong patient
• Wrong surgery on a patient

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Adverse Events

• Adverse Events are the events that must be
  reported to Medicaid by the hospital. These
  events are clearly identifiable, preventable, and
  serious in their consequences for patients.
• This is a cost containment self reporting
  mechanism that will be required by hospitals
  effective July 1, 2010. It will affect inpatient
  hospital claims only.
• POA issues identified in post payment audit may
  result in a recoupment.

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Hospital-Acquired Conditions (HAC)

• Hospital-Acquired Conditions are conditions that
  are reasonably preventable and were not present
  or identified at the time of admission but are
  either present at discharge or documented after
  admission.

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• Selected HAC

• CC/MCC (ICD-9-CM Codes)

• Foreign Object Retained After Surgery
• Air Embolism
• Blood Incompatibility
• Pressure Ulcer Stages III IV

• 998.4 (CC)
• 998.7 (CC)
• 999.1 (MCC)
• 999.6 (CC)
• 707.23 (MCC)
• 707.24 (MCC)

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• Selected HAC

• CC/MCC (ICD-9-CM Codes)

• Falls and Trauma
• Fracture
•   - Dislocation
•   - Intracranial Injury
•   - Crushing Injury
•   - Burn
•   - Electric Shock

• Codes within these ranges on the CC/MCC list
• 800-829
• 830-839
• 850-854
• 925-929
• 940-949
• 991-994

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• Selected HAC

• CC/MCC (ICD-9-CM Codes)

• Catheter-Associated Urinary Tract Infection (UTI)
• 996.64 (CC)
•  

• Also excludes the following from acting as a
  CC/MCC
• 112.2 (CC)
• 590.10 (CC)
• 590.11 (MCC)
• 590.2 (MCC)
• 590.3 (CC)
• 590.80 (CC)
• 590.81 (CC)
• 595.0 (CC)
• 597.0 (CC)
• 599.0 (CC)

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• Selected HAC

• CC/MCC (ICD-9-CM Codes)

• Vascular Catheter-Associated Infection
• Manifestations of Poor Glycemic Control

• 999.31 (CC)
• 250.10-250.13 (MCC)
• 250.20-250.23 (MCC)
• 251.0 (CC)
• 249.10-249.11 (MCC)
• 249.20-249.21 (MCC)

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• Selected HAC

• CC/MCC (ICD-9-CM Codes)

• Surgical Site Infection, Mediastinitis, Following
  Coronary Artery Bypass Graft (CABG)
• Surgical Site Infection Following Certain
  Orthopedic Procedures

• 519.2 (MCC)
• And one of the following procedure codes
• 36.1036.19
• 996.67 (CC)
• 998.59 (CC)
• And one of the following procedure codes 
  81.01-81.08, 81.23-81.24, 81.31-81.38, 81.83, or
  81.85

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• Selected HAC

• CC/MCC (ICD-9-CM Codes)

• Surgical Site Infection Following Bariatric
  Surgery for Obesity

• Principal Diagnosis  278.01
• 998.59 9 (CC)
• And one of the following procedure codes  44.38,
  44.39, 44.95

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• Selected HAC

• CC/MCC (ICD-9-CM Codes)

• Deep Vein Thrombosis and Pulmonary Embolism
  Following Certain Orthopedic Procedures

• 415.11 (MCC)
• 415.19 (MCC)
• 453.40-453.42 (MCC)
• And one of the following procedure codes
  00.85-00.87, 81.51-81.52, 81.54

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Present on Admission (POA)

• The Present on Admission (POA) Indicator is
  defined as a set of specified conditions that are
  present at the time the order for inpatient
  hospital admission occurs.
• Conditions that develop during an outpatient
  encounter, including the emergency room,
  observation, or outpatient surgery, are
  considered POA.

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POA CONTINUED

• If one of the following DX codes are billed in FL
  67 on the UB 04 claim form then a POA indicator
  must also be in the 8th digit of FL 67 Principal
  Diagnosis and each of the secondary diagnosis
  fields indicated as A through Q.
• Medicaid recognizes all POA indicators for
  reporting purposes.

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 If one of the following diagnosis codes is
billed on the UB 04 claim form then a POA
indicator must also be indicated

• Single Diagnosis Codes and ranges
• 249.10-249.11
• 249.20-249.21
• 250.10-205.13
• 250.20-250.23
• 251.0
• 707.23
• 707.24
• 800-829.1
• 830-839.9

• 850-854.1
• 925-929.9
• 940-949.5
• 991-994.9
• 996.64
• 998.4
• 998.7
• 999.1
• 999.31
• 999.6
•  

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Continued

• A POA indicator is required UNLESS one of the
  following diagnosis codes is also present on the
  claim
• 112.2, 590.10, 590.11, 590.2, 590.3, 590.80,
  590.81, 595.0, 597.0, or 599.0.
• If the claim contains one of these diagnosis
  codes in any diagnosis field, then a POA is not
  required.
•  

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The POA indicator is required for the following
diagnosis codes ONLY when surgical ICD-9 surgical
procedure codes are billed as described below

• 278.01 AND 998.59 and one of the following ICD-9
  surgical procedure codes 44.38, 44.39, or
  44.95,
•  
• 519.2 AND one of the following ICD-9 surgical
  procedure codes 36.10-36.19,
•  

• 996.67 OR
• 998.59 and one of the following ICD-9 surgical
  procedure codes
• 81.01-81.08, 81.23-81.24, 81.31-81.38, 81.83, or
  81.85,
•  
• 415.11 OR
• 415.19 OR
• 453.40-453.42 and one of the following ICD-9
  surgical procedure codes 00.85-00.87,
  81.51-81.52, 81.54

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• The addition of the POA reporting requirement has
  placed even more emphasis on the importance of
  accurate and complete medical documentation. POA
  depends on accurate physician documentation that
  the condition was present on admission.
• The provider should document the POA status or
  the diagnosis at the time of an inpatient
  admission or in a timely fashion so that it is
  evident that the diagnosis is present on
  admission.

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• Therefore, the best source for POA information is
  provider documentation at the time of admission.
• The importance of consistent, complete
  documentation in the medical record cannot be
  overemphasized. Medical record documentation from
  any provider involved in the care and treatment
  of the patient may be used to support the
  determination of whether a condition was present
  on admission.

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• Since these new requirements focus on hospital
  quality improvement and risk management, it is
  important for quality programs to play a role in
  the POA reporting process. It is crucial for
  hospitals to work with their coding departments
  as a joint effort to achieve accurate and
  complete documentation, code assignment, and
  reporting in a timely manner.
• The quality program should also closely monitor
  the coding and documentation processes to ensure
  that both are being handled efficiently, and
  areas where improvement may be needed are
  identified and addressed immediately.

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Questions.....answers
Can you repeat the question?
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for further information

• Please contact
• Jerri Jackson, RN, BSN
• Associate Director, Institutional Services
• Alabama Medicaid Agency
• [phone]
• jerri.jackson_at_medicaid.alabama.gov