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Industry Activities & Emerging Issues
Significant Changes to the FY08 Hospital Inpatient PPS.
[ Back | MS-DRGs | Present on Admission (POA) | Never Events ]
MS-DRGs
The acute care hospital inpatient prospective payment system (IPPS) final rule for fiscal year 2008 was published in the Federal Register on August 22, 2007. This final rule implements the proposed severity adjusted MS-DRG system, which consists of 745 new DRGs that will replace the current 538 CMS DRGs. CMS will adopt the MS-DRGs for the long-term care hospital (LTCH) PPS as well as the IPPS, since both sets of DRGs are based on the same DRG structure.
Though MS-DRGs are based on the current CMS DRGs, MS-DRGs may be split into a maximum of three payment tiers based on severity as determined by the presence of a major complication/comorbidity (MCC); a CC; or no CC. The current CC list was significantly revised in order to better distinguish cases that are likely to result in increased hospital resource use based on secondary diagnoses.
Key DRG tables (6I, MCC list and 6J, CC list) and a crosswalk between CMS DRGs and MS-DRGs are available on the CMS Web site.
AHIMA resources on the MS-DRG system:
Other AHIMA resources on severity adjusted DRG systems:
Present on Admission (POA)
To comply with provisions of the Deficit Reduction Act of 2005, the rule also identifies eight conditions that, starting in fiscal year 2009, would not trigger a higher DRG unless they were present on admission (POA). They are:
- Serious Preventable Event, Object Left in Surgery
- Serious Preventable Event, Air Embolism
- Serious Preventable Event, Blood Incompatibility
- Catheter-Associated UTI
- Pressure Ulcers (Decubitus)
- Vascular Catheter-Associated Infection
- Mediastinitis after CABG-Surgical Site Infection
- Hospital-Acquired Injuries; Fractures, Dislocations, Intracranial Injury, Crushing Injury, Burn, and Other Unspecified Effects of External Causes
The purpose of the POA indicator is to differentiate between conditions present at admission and conditions that develop during an inpatient admission. CMS Transmittal 1240 requires short-term, acute care hospitals to begin reporting the POA code on inpatient claims with discharges beginning on or after October 1, 2007. Thus it is imperative that HIM professionals also become familiar with present on admission guidelines and reporting requirements. The national POA guidelines can be found in the ICD-9-CM Official Guidelines for Coding and Reporting, Appendix I.
AHIMA resources on POA guidelines and reporting:
Never Events
The National Quality Forum (NQF) has endorsed a list of 28 Serious Medical Errors that should never happen, which is known as “never events”. The list includes, but not limited to events such as medication error resulting in death or serious disability, and retention of foreign object after a procedure. According to the NQF the never events are events that are “of concern to both the public, healthcare professionals and providers; clearly identifiable and measurable; and of a nature such that the risk of occurrence is significantly influenced by the policies and procedures of the healthcare organization.” For a complete list of events see NQF’s website: http://www.qualityforum.org/
http://www.qualityforum.org/pdf/news/prSeriousReportableEvents10-15-06.pdf
Centers for Medicare & Medicaid Services (CMS) have joined the effort to help reduce or eliminate payments of never events. According to CMS, they are reviewing their administrative authority regarding reduced payments for never events. CMS does acknowledge that the Deficit Reduction Act requirements regarding hospital-acquired conditions as a first step in payment reduction. However, it is important to remember that while there may be similarities between hospital-acquired conditions and never events, they are two separate lists of conditions.
For more CMS information on never events:
http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1863
Section 5001(c) of Pub. L. 109-171 required the Secretary to select at least two conditions that are (a) high cost or high volume or both, (b) result in the assignment of the case to a higher paying DRG when present as a secondary diagnosis and (c) could reasonably have been prevented through evidence-based guidelines. For 2007 CMS, working in conjunction with public health and infectious disease specialist from the Centers for Disease Control and Prevention, selected eight conditions which are known as hospital-acquired conditions. The present on admission (POA) indicator will be used in the determination of which conditions developed during the hospitalization. Effective October 1, 2008 if one of the conditions is identified by the POA indicator as being acquired in the hospital, the condition will not be considered a complication or comorbid condition (CC) or major complication or comorbid condition (MCC) for MS-DRG payment purposes.
For more CMS information on hospital-acquired conditions:
http://www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acquired%20Conditions.asp#TopOfPage
The Office of Inspector General’s (OIG) 2008 Work Plan will be reviewing the reporting and provider’s response to never events. This review is authorized by the Tax Relief and Health Care Act of 2006. For complete details see the OIG Website:
http://oig.hhs.gov/08/Work_Plan_FY_2008.pdf
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