CMS (Center for Medicare & Medicaid Services) has been working to decrease a number of conditions they feel should not happen while patients are in the hospital = HAC (Hospital Acquired Condition). The ACA (Affordable Care Act) created the HAC Reduction Plan, which placed a financial amount that organizations can lose due to a high incidence of HACs.

Although the intent is to move to a pay-for-performance program model of reimbursement as well as improve patient outcomes by reducing the number of HACs, many times it is the documentation or lack of it that is causing the increased reporting of HACs (and not the reality of increasing HACs). The calculation of the incidence of a HAC is defined on the ICD-9 coded bill when a coding professional sets the POA (present on admission) flag for each code. If the provider does not make it clear in the beginning of the stay or documents “POA” later in the medical record, the coding professional sets the flag to “No” or “Unknown”. Both the “no” and “unknown” flags cause the organization to be charged with a HAC.

The Electronic Health Record (EHR) could be an issue as well when defaults are set and/or when a HAC or PSI (Patient Safety Indicator) is not retrospectively reviewed to see if improved documentation or missed documentation would change the outcome. The article “Coding and Documentation Flaws May Contribute to Penalties in HAC Program” talks about the 5 questions that a hospital should ask itself:

• How are HACs reviewed and documented?
• Is there a check and balance to ensure HACs are documented or is there a hard stop in the EHR system?
• Are coders aware documentation is there and can they code it and put it on the claims?
• Do billers check to ensure HACs are reported on the UB or 837 forms?
• How did we get there? Are we abiding by quality measures to determine if there is substance, and not just coding and documenting weaknesses?

These points and the article are reminders that a robust CDI program is essential for healthcare organizations today, not only for reimbursement issues but for quality issues.