Health Care-Acquired & Provider Preventable Conditions FAQ

HAC: Hospital-Acquired Conditions
HCAC: Health Care-Acquired Conditions
POA: Present On Admission
PPC: Provider Preventable Conditions
OPPC: Other Provider Preventable Conditions

The Deficit Reduction Act of 2005 mandated a quality adjustment in Medicare Diagnosis Related Group (DRG) payments for certain hospital-acquired conditions (HAC) when the condition was not present on admission (POA) to the hospital. In other words, hospitals would no longer receive additional payments for the care required as a result of certain accidents and medical errors that occurred during a hospital stay. CMS entitled the program “Hospital-Acquired Conditions and Present on Admission Indicator Reporting” and it views this initiative as an incentive for hospitals to improve patient care.

As a back-drop to this initiative, CMS published annual HAC rates and estimates of cost savings and deaths averted from 2010 to 2015. The analysis indicated that hospitalized patients experienced > 3 million fewer HACs over the 5-year span (2011–2015) than if the HAC rate had remained at the 2010 level (representing a 21% decline). They estimate that approximately 125,000 fewer patients died due to hospital-acquired conditions, and more than $28 billion in health care costs were saved from 2010 through 2015.

HAC/POA data track the development of nosocomial infections and other adverse effects or iatrogenic complications during the inpatient hospital stay. POA Indicator codes must be assigned to all inpatient principal and secondary diagnosis codes, and most external cause of injury codes (ICD-9-CM “E codes” and ICD-10-CM “W, X, Y codes”). Hospitals began mandatory reporting of POA codes for Medicare inpatient claims on October 1, 2007.

Effective October 1, 2008, CMS reformed payment of inpatient facility services for conditions not identified as POA. Based on these payment reforms, inpatient hospital stays with certain HAC are reimbursed as though the conditions were not present.

Beginning in Fiscal Year (FY) 2015, a HAC Reduction Program began to impose financial penalties on hospitals that performed poorly with regard to certain HACs. By statute, hospital payments are reduced by 1 percent for hospitals that rank among the lowest-performing 25 percent with regard to HACs. HAC reductions are applied after adjustments for the Value-Based Purchasing and the Readmission Reduction Programs.

In FY 2017, 769 of 3,203 hospitals ranked in the worst performing quartile and were subject to payment reduction, as compared to 751 hospitals out of 3,211 hospitals in FY 2016.

Across FY 2015, FY 2016, and FY 2017, the average performance across eligible hospitals improved for the mean Catheter-Associated Urinary Tract Infection (CAUTI) standardized infection ratio (SIR). The mean SIR decreased from 1.12 in FY 2015 and 1.17 in FY 2016 to 0.91 in FY 2017.

Of note, CMS reports on the following HAC Reduction Program scores as of FY 2019:

• Patient Safety Indicator (PSI) 90 Composite measure score (see FAQ 2)
• Central Line-Associated Bloodstream Infection (CLABSI), Catheter-Associated Urinary Tract Infection (CAUTI), Surgical Site Infection (SSI), Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, and Clostridium difficile Infection (CDI) measure.
• Domain 1 and Domain 2 scores
• Total HAC Score
• Payment Reduction Indicator

Publicly-reportable data may be accessed through Hospital Compare within Medicare.gov.  

A helpful fact sheet and an FAQ to better understand the HAC reduction program may be accessed via Quality.net. 

No, Medicaid patients are also subject to certain payment reductions. On June 1, 2011, CMS released the final rule wherein the Patient Protection and Affordable Care Act prohibits Medicaid payments for two categories of Provider Preventable Conditions (PPC). The rule prohibits Medicaid payments under section 1903 of the Social Security Act expended for medical assistance related to PPC, provided that the regulation does not result in loss of access to care or services for Medicaid beneficiaries. Additionally, the rule applies to individuals dually eligible for both Medicare and Medicaid programs. PPC is an umbrella term defined by two categories: 1) Health Care-Acquired Conditions (HCAC) and 2) Other Provider-Preventable Conditions (OPPC). Currently, the minimum Medicaid HCAC list correlates to the HAC Medicare outline established for inpatient hospital settings. OPPC can occur in an outpatient hospital, nursing facility, ambulatory care setting, and other healthcare settings. The Affordable Care Act provides individual states broad flexibility in defining their HCAC and OPPC policies and programs. In August 2012, CMS published the Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2013 Final Rule. The Final Rule discussed the addition of two new HACs, one of which was a new Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED) and the other was Iatrogenic Pneumothorax with Venous Catheterization. Two additional ICD-9-CM codes were added to the Vascular Catheter-Associated Infection HAC Category. For the FY 2014 Final Rule, no additional HACs were added.

Finally, as finalized in the FY 2015 Hospital Inpatient Prospective Payment System/Long Term-Care Hospital Prospective Payment System (IPPS/LTCH PPS) Final Rule (Long-Term Care Hospital PPS), CMS adopted the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator (PSI) 90 Composite and the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) Central Line-Associated Bloodstream Infection (CLABSI), Catheter-Associated Urinary Tract Infection (CAUTI), Surgical Site Infection (SSI), Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, and Clostridium difficile (CDI) measures for the FY 2017 HAC Reduction Program. The Recalibrated PSI 90 Composite (updated for FY 2018) includes the following 10 PSIs:

1. PSI 03 - Pressure Ulcer Rate
2. PSI 06 - Iatrogenic Pneumothorax Rate
3. PSI 08 - In-Hospital Fall with Hip Fracture Rate
4. PSI 09 – Perioperative Hemorrhage or Hematoma Rate
5. PSI 10 – Postoperative Acute Kidney Injury Requiring Dialysis Rate
6. PSI 11 – Postoperative Respiratory Failure Rate
7. PSI 12 - Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate
8. PSI 13 - Postoperative Sepsis Rate
9. PSI 14 - Postoperative Wound Dehiscence Rate
10. PSI 15 – Unrecognized Abdominopelvic Accidental Puncture/Laceration Rate

Of note, the Recalibrated PSI 90 Composite is a weighted average of the risk- and reliability-adjusted versions (or smoothed versions) of these 10 PSIs.  In 2019, CMS will use 21 months of data (instead of the 15 months of data used in 2018 and 24 months of data used in 2017) to calculate a hospital’s Recalibrated PSI 90 composite performance.

In FY 2018, CMS transitioned to a new scoring methodology (Winsorized z-score). It is a continuous scoring method that relies on the actual measured value, ranking hospitals with the best performance to the worst performance, and directly comparing each hospital’s measured result with the mean score (in standard deviations). Because of this change in reporting, a hospital cannot compare scores from FY 2018 with previous years’ scores. Changes in this calculation method does not affect how CMS determines domain scores, Total HAC scores, or the worst-performing quartile.

The total HAC score for each hospital is calculated using two defined domains: Domain 1 (weighted at 15% in FY 2017) and Domain 2 (weighted at 85% in FY 2017). Domain 1 is the PSI 90 Composite. Domain 2 is composed of CLABSI, CAUTI, SSI, MRSA bacteremia, and CDI measure scores. If a hospital only has a score for one of the domains, then a weight of 100 percent will be applied to the domain for which the hospital has a score.

For more information on the scoring methodology used for FY 2019 HAC Reduction Program, please see the Hospital-Specific Report (HSR) User Guide.

Overall, there are 14 infections and events for Medicare HAC and baseline Medicaid Category 1 HCAC negatively affecting CMS reimbursement for inpatient hospitals: 

1. Foreign Object Retained After Surgery
2. Air Embolism
3. Blood Incompatibility
4. Stage III and IV Pressure Ulcers
5. Falls and Trauma – Including fractures, dislocations, intracranial injuries, burns, frostbite
6. Catheter-associated Urinary tract infection (UTI)
7. Vascular Catheter-Associated Infection
8. Surgical Site Infection-Mediastinitis after Coronary Artery Bypass (CABG)
9. Manifestations of Poor Glycemic Control
10. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)
11. Surgical Site Infection following Bariatric Surgery
12. Surgical Site Infection following certain Orthopedic Procedures 
13. Surgical Site Infection following Cardiac Implantable Electronic Device (CIED)
14. Iatrogenic Pneumothorax with Venous Catheterization

In addition to HCAC, Medicaid established a second category of non-payment policies for provider preventable conditions (PPC), applicable to any health care setting:  

Category 2 Other Provider Preventable Conditions (OPPC):

1. Wrong Surgical or other invasive procedure performed on a patient
2. Surgical or other invasive procedure performed on the wrong body part
3. Surgical or other invasive procedure performed on the wrong patient
4. OPPCs identified in the state's plan and according to the requirements of the final regulation

As discussed, the initial HAC program (for Medicare and Medicaid) includes the list of 14 conditions that, if acquired during a hospital stay, would lower the diagnosis-related group (DRG) payment as if the condition were not present. Without the payment reduction program, these conditions would generally increase the DRG payment. That program continues to this day, but has had very little effect on payment reductions overall.

The HAC penalty, on the other hand, has had a substantial effect on payment reduction. It comprises the 1% penalty for the (roughly) lowest performing quartile.

Emergency physician documentation is often crucial in supporting whether a condition was present at the point of hospital admission. If documentation is insufficient to determine whether a condition was POA, CMS will deny reimbursement as a presumed "hospital-acquired" condition.

POA is defined as present at the time the order for inpatient admission occurs. Thus, conditions occurring during an emergency department visit are considered POA. Medical record documentation from any qualified provider involved in the care and treatment of the patient may be used to support the determination of whether a condition was present on admission.

The 2011 Affordable Care Act stipulates that no reduction in payment for a provider preventable condition will be imposed on a provider when the condition defined as a PPC for a particular patient existed prior to the initiation of treatment by that provider.

Emergency physicians must thoroughly evaluate and document the patient's clinical conditions. This will include documentation of all relevant diagnoses and comorbidities:

• Infections or complications of urinary catheters, dialysis ports and PICC lines;
• Infections of integumentary, genitourinary, respiratory systems;
• Sepsis;
• Staged decubitus ulcers;
• Context of injuries (e.g. falls and other trauma);
• Adverse drug effects and reactions;
• Interpretation of abnormal lab values (e.g. blood glucose, PTT and electrolytes).

While "rule out, suspected and probable" diagnoses and conditions cannot be coded for the professional component, these differential diagnoses are valuable for the medical record. Your HPI, ROS, PMH, exam and clinical impression documentation are more important than ever to support reimbursement.

There are currently some exclusions for inpatient Medicare and Medicaid patients in the following settings:

1. Critical Access Hospitals
2. Long Term Care Hospitals
3. Maryland Waiver Hospitals*
4. Cancer Hospitals
5. Children's Inpatient Facilities
6. Religious Non-Medical Health Care Institutions
7. Inpatient Psychiatric Hospitals 
8. Inpatient Rehabilitation Facilities
9. Veterans Administration/Department of Defense Hospitals

*Maryland Waiver Hospitals must report the POA indicator on all claims.

It is advisable to periodically check with your state Medicaid administrator to determine current provider-preventable conditions and reporting requirements, as well as the appeals process for improperly identified PPC.

Third party payers beyond Medicare and Medicaid are closely monitoring the realized savings potential via nonpayment for preventable conditions. In summary, documentation of all relevant diagnoses and comorbidities for any patient, irrespective of disposition or payer, is a best clinical practice.

The HAC Reduction Program scores for hospitals can be found on the Hospital Compare website. 

Hospital-Acquired Condition Reduction Program  

Hospital-Acquired Conditions (Present on Admission Indicator)

HAC and Present on Admission Fact Sheet (updated October 2017)

For CMS resource (zip files) for 2015 ICD-9 and ICD-10 POA exempt codes