View Entire Collection
By Clinical Topic
Diabetes – Summer 2012
Future of Nursing Initiative
Heart Failure - Fall 2011
Influenza - Winter 2011
Nursing Ethics - Fall 2011
Trauma - Fall 2010
Traumatic Brain Injury - Fall 2010
Fluids & Electrolytes
The Centers for Medicare and Medicaid Services (CMS) recently updated its Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2009 Proposed Rule, which delineates restrictions on Medicare payments to be made to hospitals for preventable conditions listed as secondary diagnoses at the time of patient discharge. The increased cost of care-that is, theextended hospital stay and relatedexpenses resulting from treatment for designated hospital-acquired conditions (HACs) separate from the treatment costs of a principal complaint or diagnosis-is no longer reimbursed if billed. The conditions are deemed costly, common, and reasonably preventable if evidence-based guidelines are followed in providing general care, managing the principal diagnosis, and preventing complications from any comorbid conditions.
Of the eight conditions already included in the IPPS FY 2008 rule and the additional nine proposed for the 2009 rule, the approved list contains all eight from FY 2008 and less than half of those proposed for FY 2009.
Healthcare providers must be diligent and indicate to the hospital all conditions that are present on admission (POA). If there is any question at the time of discharge as to whether or not a condition was POA, or it is either not noted or not identifiable on the basis of data and clinical judgment at admission, it is considered a HAC and not reimbursed. This decision by CMS is to avoid assignment of a case to a diagnosis-related group (DRG) that has a higher payment whenpresent as asecondary diagnosis.
Examples of designated conditions include air embolism, severe pressure ulcers, falls and trauma, catheter-associated urinary tract infections, surgical site infections, complications following certain elective orthopedic and bariatric surgeries, and manifestations of poor glycemic control. The CMS states that this move represents a commitment to improve the quality of care during a hospital stay and to make hospitals safer by adopting payment policies that will encourage hospitals to reduce the likelihood of HACs and preventable medical errors that should never happen, such as performing surgery on the wrong body part.1
There seems to be a loophole, however, in the basic rule; Medicare will pay for physician and other covered items or services needed to treat the HAC, including costs for follow-up care for the HAC. Therefore, the physician is assured of reimbursement for treating the HAC. Doesthis also apply to advanced practice nurses working in acute care who autonomously manage their own panel of patients? Moreover, how does the rule affect Medicaid hospitalpayments? The FY 2009 rule is ineffect until September 30, 2009.
These new designated diagnoses and reimbursement revisions have real-life implications for nursing, as nurses spend more time with patients than any other healthcare professional. We are also usually the ones who first identify when things occur and what is going on with a particular patient. With the nursing shortage and hospital nurse staffing at critically low levels in many places, will this updated rule improve the quality of care? Or will it further jeopardize patient safety by forcing hospitals to make the dollar the bottom line instead of ensuring adequate staffing and improving work conditions for nurses? Only time will tell us the long-term effect of theserevisions on nursing practice.
Jamesetta Newland, RN, PhD, FNP-BC, FAANP, FNAP
1. CMS Office of Public Affairs. Medicare takes new steps to help make your hospital stay safer. Available at: http://www.cms.hhs.gov/apps/media/press/factsheet.asp?Counter=3227&intNumPerPage. Accessed September 4, 2008. [Context Link]
Sign up for our free enewsletters to stay up-to-date in your area of practice - or take a look at an archive of prior issues
Join our CESaver program to earn up to 100 contact hours for only $34.95
Explore a world of online resources
Back to Top