Tuesday, 22 September 2015 21:52

Hospital-Acquired Condition Reduction Program: How can CDI Specialists and Coders Help?

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“Do or do not. There is no ‘try.’” –Yoda

Dear Oct. 1, 2015 – are you trying to kill us? As all of you know, implementation of the ICD-10-CM and PCS coding guidelines is set to take place in the U.S. on this date. What you may not know is that there is another pay-for-performance (P4P) initiative that takes effect Oct. 1 – the Hospital-Acquired Condition (HAC) Reduction Program. Per the Centers for Medicare & Medicaid Services (CMS) website:


“Section 3008 of the 2010 Patient Protection and Affordable Care Act (PPACA) established the HAC Reduction Program to encourage hospitals to reduce HACs. HACs are a group of reasonably preventable conditions that patients did not have upon admission to a hospital, but which developed during the hospital stay. Hospital performance under the HAC Reduction Program is determined based on a hospital’s Total HAC Score, which can range from 1 to 10. The higher a hospital’s Total HAC Score, the worse the hospital performed under the HAC Reduction Program. Hospitals are given an opportunity to review their data and request a recalculation of their scores if they believe an error in the score calculation has occurred. Effective beginning FY 2015, the law requires the Secretary of the Department of Health and Human Services to reduce payments to hospitals that rank in the quartile of hospitals with the highest total HAC Scores by 1 percent.”


The target HACs include claims-based PSI (patient safety indicator) No. 90 weighted at 35 percent and two CDC abstraction measures weighted at 65 percent:

PSI 90:

  • Pressure ulcer – Stage 3 and 4 (or unstageable)
  • Iatrogenic pneumothorax
  • Central venous catheter-related blood stream infection
  • Post-op hip fracture
  • Perioperative pulmonary embolism or DVT
  • Post-op sepsis
  • Post-op wound dehiscence
  • Accidental puncture or laceration

Two CDC Abstraction Measures:

  • CLABSI (central line-associated blood stream infection)
  • CAUTI (catheter-associated UTI)

CMS estimates that 807 hospitals would be subject to the 1-percent reduction in 2016. Why are HACs so difficult to manage? What muddies the waters? Let’s take a look at a typical documentation scenario that may cause a condition to be coded as a HAC.

Typical Situation – Uncharted Territory

The below table contains typical documentation that clinical documentation improvement (CDI) specialists and coders come across. We’ll use catheter-associated UTI (CAUTI) as our HAC example:

6/1/15 History and Physical:

“Acute Renal Failure on CKD stage 3. IV fluid resuscitation started, 1st liter in. Check UA.” –Dr. Smith

6/2/15 MD Progress Note:

“AKI on CKD. Creatinine 2.6—1.8 today. Continue treatment. UTI, started Rocephin. Cultures pending, will adjust accordingly.” –Dr. Jones

6/2/15 RN Progress Note:

“Indwelling Foley cath, per wife has been in 2 weeks. Removed per Dr. Smith, new Foley placed.” –Rachel, RN

6/4/15 Discharge Summary:

“AKI on CKD, creatinine back to baseline. UTI 2/2 to Foley cath, cultures grew Klebsiella, started on Ceftin.” –Dr. Carter

Read the above series of events and documentation carefully. Based on the above documentation, if no query was sent or a query was sent with no response from the provider, the coder would have no choice but to code this as a CAUTI and put “no” for present on admission. This series of events indicates to Medicare that this hospital caused this patient to develop a CAUTI (HAC) due to poor care.

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Last modified on Tuesday, 22 September 2015 22:03

Rachel Mack is a CDI Specialist for SCL Health where she performs current chart reviews and audits. The focus of her work is on identifying missed opportunities to obtain an accurate and complete record for each patient. Rachel has nursing experience in CVICU, ICU, and home health and has worked in Clinical Documentation Improvement as a CDI Specialist, CDI Educator, and CDI Consultant. She has written various articles for the VBPmonitor and ICD-10monitor and has assisted in creating CDI training materials. She was also a presenter at the 2015 ACDIS conference.