Impact of Centers for Medicare and Medicaid Services rules on withholding reimbursement

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In 2008, the Centers for Medicare and Medicaid Services (CMS) stopped reimbursing for hospital-acquired conditions (HACs) not present on admission (POA). We sought to understand why this policy did not impact central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) trends” Calderwood et al (2018).

Abstract:

OBJECTIVE: In 2008, the Centers for Medicare and Medicaid Services (CMS) stopped reimbursing for hospital-acquired conditions (HACs) not present on admission (POA). We sought to understand why this policy did not impact central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) trends.

DESIGN: Retrospective cohort study.

SETTING: Acute-care hospitals in the United States.ParticipantsFee-for-service Medicare patients discharged January 1, 2007, through December 31, 2011.

METHODS: Using inpatient Medicare claims data, we analyzed billing practices before and after the HAC policy was implemented, including the use and POA designation of codes for CLABSI or CAUTI. For the 3-year period following policy implementation, we determined the impact on diagnosis-related groups (DRG) determining reimbursement as well as hospital characteristics associated with the reimbursement impact.

RESULTS: During the study period, 65,205,607 Medicare fee-for-service hospitalizations occurred at 3,291 acute-care, nonfederal US hospitals. Based on coding, CLABSI and CAUTI affected 0.23% and 0.06% of these hospitalizations, respectively. In addition, following the HAC policy, 82% of the CLABSI codes and 91% of the CAUTI codes were marked POA, which represented a large increase in the use of this designation. Finally, for the small numbers of CLABSI and CAUTI coded as not POA, financial impacts were detected on only 0.4% of the hospitalizations with a CLABSI code and 5.7% with a CAUTI code.

CONCLUSIONS: Part of the reason the HAC policy did not have its intended impact is that billing codes for CLABSI and CAUTI were rarely used, were commonly listed as POA in the postpolicy period, and infrequently impacted hospital reimbursement.



Reference:

Calderwood, M.S., Kawai, A.T., Jin, R. and Lee, G.M. (2018) Centers for medicare and medicaid services hospital-acquired conditions policy for central line-associated bloodstream infection (CLABSI) and cather-associated urinary tract infection (CAUTI) shows minimal impact on hospital reimbursement. Infection Control and Hospital Epidemiology. June 28th. .

doi: 10.1017/ice.2018.137.

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