Quality of care a factor in hospital reimbursement
Section 5001(c) of the Deficit Reduction Act of 2005 requires hospitals to begin reporting the secondary diagnoses that are present on admission (POA) of patients effective for discharges on or after October 1, 2007. Present on admission is defined as present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.
The following areas have been targeted by the Office of Inspector General for audits in their 2008 work plan. Reviews will be conducted of:
The Centers for Medicare & Medicaid Services (CMS) have selected eight high cost or high volume (or both) diagnosis codes that:
- Represent conditions (including certain hospital acquired infections) that could reasonably have been prevented through the application of evidence-based guidelines; and
- When present on a claim along with other (secondary) diagnoses, have a DRG assignment with a higher payment weight.
According to the final Inpatient Prospective Payment System (IPPS) rule, the eight diagnoses are:
- Catheter-associated urinary tract infections
- Pressure ulcers
- Vascular-associated UTIs
- Three kinds of serious preventable events (object left in during surgery, air embolis, blood incompatibility)
- Falls
- Mediastinitis (a preventable surgical site infection that follows heart surgery)
Then, for acute care inpatient PPS discharges on or after October 1, 2008, while the presence of these diagnosis codes on claims could allow the assignment of a higher paying DRG, when they are present at the time of discharge, but not at the time of admission, the DRG that must be assigned to the claim will be the one that does not result in the higher payment.
The Focus is on Quality of Care
Ensuring the quality of care provided by health care organizations has never been more critical. Both consumers and payers are demanding more accountability in this area and health care quality is emerging as an enforcement priority for health care regulators. The Office of the Inspector General (OIG) in concert with the American Health Lawyers Association has developed a publication to address senior leadership’s responsibility towards quality of care issues within their institution.
The publication is titled “Corporate Responsibility and Health Care Quality: A Resource for Health Care Boards of Directors.” To view that publication, go to: http://www.oig.hhs.gov/fraud/docs/complianceguidance/ CorporateResponsibilityFinal%209-4-07.pdf
As of October 1, 2007 practitioners are required to use tamper-proof prescription pads for Medicaid patients for prescriptions in order for the prescription drugs to receive Medicaid reimbursement. The rule applies to all written prescriptions – even those for over-the-counter drugs – issued to Medicaid patients. There are exemptions for Medicaid managed care patients and emergency prescriptions – though you'd be expected to provide a compliant written prescription in an emergency situation within 72 hours.
CMS has outlined three baseline characteristics of tamper-resistant prescription pads, but each State will define which features it will require to meet those characteristics in order to be considered tamper- resistant. The baseline characteristics must: (1) prevent unauthorized copying of a completed or blank prescription form; (2) prevent the erasure or modification of information written on the prescription by the prescriber; or (3) prevent the use of counterfeit prescription forms. By October 1, 2007, States must require at least one of these baseline requirements. By October 1, 2008, States must require all three characteristics on prescription pads in order to be considered tamper-resistant.
Legislation has been introduced in the House and Senate to delay implementation of the required tamper-proof prescription pads for Medicaid patients, but action has not yet been taken on these bills.
NOTE: President George W. Bush has delayed the implementation date for all Medicaid prescriptions to be written on tamper-resistant paper until April 1, 2008.