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Rachel V. Rose, JD, MBA, advises clients on compliance and transactions in healthcare, cybersecurity, corporate and securities law, while representing plaintiffs in False Claims Act and Dodd-Frank whistleblower cases. She also teaches bioethics at Baylor College of Medicine in Houston. Rachel can be reached through her website, www.rvrose.com.
Winter weather often leads to an increase in hospitalizations. Make sure you document all preexisting conditions prior to hospitalization.
Winter weather often leads to an increase in hospitalizations - especially for the elderly. When preexisting conditions are not documented upon admission, they could be counted as hospital acquired conditions. A healthcare-acquired condition (HCAC) falls under the broad category of provider-preventable conditions (PPC), which includes both HCACs and other provider-preventable conditions (OPPC). So, what is the difference?
According to the final regulations issued in the Federal Register, HCACs apply to inpatient hospital settings, while OPPCs apply to both inpatient and outpatient settings. OPPCs also minimally include Medicare National Coverage Determinations including: "Surgery on the wrong patient, wrong surgery on a patient, and wrong site surgery." Overall, HCACs are narrower, but the impacts are the same. The most significant adverse outcomes from these types of events are (1) adverse patient outcomes, and (2) no reimbursement for the care provided in response to the identified conditions. But, what are the conditions that need to be highlighted?
Section 2702 of the Patient Protection and Affordable Care Act of 2010 expanded the Social Security Act to prohibit federal payments for certain types of acquired conditions. This applies equally to Medicare and Medicaid. According to the U.S. Government's website, the two categories of nonpayment follow:
Category 1 – Healthcare-acquired conditions (for any inpatient hospitals settings in Medicaid)
• Foreign object retained after surgery
• Air embolism
• Blood incompatibility
• Stage III and IV pressure ulcers
• Falls and trauma (including fractures, dislocations, intracranial injuries, crushing injuries, burns, electric shock)
• Catheter-associated urinary tract infection (UTI)
• Vascular catheter-associated infection
• Manifestations of poor glycemic control (including diabetic ketoacidosis, nonketotic hyperosmolar coma, hypoglycemic coma, secondary diabetes with ketoacidosis, secondary diabetes with hyperosmolarity)
• Surgical site infection following coronary artery bypass graft (CABG), mediastinitis, bariatric surgery (including laparoscopic gastric bypass, gastroenterostomy, laparoscopic gastric restrictive surgery), orthopedic procedures (including spine, neck, shoulder, elbow)
• Deep vein thrombosis (DVT)/pulmonary embolism (PE) following total knee replacement or hip replacement with pediatric and obstetric exceptions
Category 2 – Other provider preventable conditions (for any healthcare setting)
• Wrong surgical or other invasive procedure performed on a patient
• Surgical or other invasive procedure performed on the wrong body part
• Surgical or other invasive procedure performed on the wrong patient
OPPCs are identified in the state's plan and according to the requirements of the final regulation. The best way to avoid nonpayment and adverse patient outcomes is to do a comprehensive evaluation of the patient and document everything both in and out of the hospital.