898


Methods Study population


To examine billing trends for CLABSI and CAUTI among Medicare fee-for-service enrollees, we used Medicare Provider and Analysis Review (MedPAR) inpatient (Part A) claims data from January 1, 2007, through December 31, 2011. We included data from acute-care, nonfederal US hospitals, excluding critical access hospitals, long-term care hospitals, Maryland waiver hos- pitals, cancer hospitals, and children’s inpatient facilities not subject to the IPPS rule.1 We identified diagnosis codes indicative of either a CLABSI (International Classification of Disease, Ninth Revision [ICD-9] code 999.31 from 2007 to 2010 and 999.31, 999.32, and 999.33 for 2011) or a CAUTI (ICD-9 code 996.64) and examined whether these codes were submitted with a POA designator. CMS required hospitals to submit POA information on all coded diagnoses for inpatient discharges occurring on or after October 1, 2007.8 Under the HAC policy rules, coded diagnoses listed as POA=“Yes” were not counted against a hos- pital as preventable complications, but those listed as POA=“No” could not be used to qualify for additional payment because they were preventable complications. For CAUTIs, the ICD-9 HAC code 996.64 also excluded the following codes from being used to qualify for additional payment: 112.2, 590.10, 590.11, 590.2, 590.3, 590.80, 590.81, 595.0, 597.0, and 599.0. These additional codes were excluded due to their association with CAUTIs.


Billing trends


For each year from 2007 through 2011, we determined the number and percentage of Medicare discharges with an HAC code for CLABSI or CAUTI, as well as the number and percen- tage by POA status. This was done to determine the frequency of use for these codes, as well as the POA designators. If hospitals rarely used these codes or commonly designated these codes as POA, this might explain the lack of impact of the CMS HAC policy shown in prior work.4


Michael S. Calderwood et al Impact on diagnosis related group assignment


To evaluate the impact of the CMS HAC policy on payment, we focused on payments during the 3-year period following policy implementation. The policy went into effect on October 1, 2008, and we analyzed discharges from January 1, 2009, through December 31, 2011. For discharges that had an ICD-9 code for either CLABSI or CAUTI that were listed as not POA, we esti- mated the proportion of admissions for which inclusion of the ICD-9 code for these conditions would have resulted in a higher DRG assignment. This analysis was conducted using MS-DRG Grouper software.9 We then compared the characteristics of hospitals with DRG


changes based on HAC coding to the characteristics of hospitals with no DRG changes based on HAC coding by linking to the 2011 America Hospital Association (AHA) annual survey.10 Using the χ2 test, we compared the following hospital char- acteristics: region, city size, hospital bed size, type of ownership, and teaching status.


Results Study population and trends


We analyzed data from 65,205,607 Medicare fee-for-service dis- charge records across 3,291 acute-care, nonfederal US hospitals from January 1, 2007, through December 31, 2011. Table 1 shows the Medicare fee-for-service discharges with CLABSI and CAUTI HAC diagnosis coding by year and by POA status. Over these 5 years, the CLABSI HAC code was used in only 0.23% of Medicare discharges, and the CAUTI HAC code was used in only 0.06% of Medicare discharges. When comparing data from 2007 to 2008 with data from 2009 to 2011, a marked increase in the classifi- cation of these 2 HAC codes as POA=Yes (ie, present on admission) was observed. This finding is important because only those diagnoses that were designated POA could be used by a hospital to qualify for additional payment.


Table 1. Medicare Fee-for-Service Discharges with CLABSI and CAUTI HAC Diagnosis Coding by Year and by Present on Admission Status


HAC Year CLABSI 2007 2008 2009 2010 2011


CAUTI 2007 2008 2009 2010 2011


Total Medicare Fee-for- Service Discharges, No.


10,639,236 13,290,281 13,741,204 13,796,697 13,738,189 10,639,236 13,290,281 13,741,204 13,796,697 13,738,189


Discharges with HAC Diagnosis Coding, No. (%)a


6,600 (0.06) 27,272 (0.21) 36,332 (0.26) 37,708 (0.27) 43,206 (0.31) 6,172 (0.06) 7,450 (0.06) 8,940 (0.07) 10,228 (0.07) 6,448 (0.05)


HAC Code Designated as Present on Admission, No. (%)b


59 (0.9)


9,805 (36.0) 30,673 (84.4) 30,754 (81.6) 33,221 (76.9) 14 (0.02)


3,395 (45.6) 8,147 (91.1) 9,341 (91.3) 5,716 (88.6)


HAC Code Designated as Not Present on Admission, No. (%)b


6,541 (99.1) 17,379 (63.7) 4,906 (13.5) 6,280 (16.7) 9,290 (21.5) 6158 (99.8) 4,050 (54.4) 738 (8.3) 824 (8.1) 693 (10.7)


HAC Code Missing POA Designation, No. (%)b


0 (0)


88 (0.3) 753 (2.1) 674 (1.8) 695 (1.6) 0 (0)


5 (<0.1)


55 (0.6) 63 (0.6) 39 (0.6)


NOTE. CLABSI, central line–associated bloodstream infection; CAUTI, catheter-associated urinary tract infection; HAC, hospital-acquired condition; POA, present on admission. aPercentage of total Medicare fee-for-service discharges. bPercentage of discharges with HAC diagnosis coding.


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68  |  Page 69  |  Page 70  |  Page 71  |  Page 72  |  Page 73  |  Page 74  |  Page 75  |  Page 76  |  Page 77  |  Page 78  |  Page 79  |  Page 80  |  Page 81  |  Page 82  |  Page 83  |  Page 84  |  Page 85  |  Page 86  |  Page 87  |  Page 88  |  Page 89  |  Page 90  |  Page 91  |  Page 92  |  Page 93  |  Page 94  |  Page 95  |  Page 96  |  Page 97  |  Page 98  |  Page 99  |  Page 100  |  Page 101  |  Page 102  |  Page 103  |  Page 104  |  Page 105  |  Page 106  |  Page 107  |  Page 108  |  Page 109  |  Page 110  |  Page 111  |  Page 112  |  Page 113  |  Page 114  |  Page 115  |  Page 116  |  Page 117  |  Page 118  |  Page 119  |  Page 120  |  Page 121  |  Page 122  |  Page 123  |  Page 124  |  Page 125  |  Page 126  |  Page 127  |  Page 128  |  Page 129  |  Page 130  |  Page 131  |  Page 132  |  Page 133  |  Page 134  |  Page 135  |  Page 136  |  Page 137  |  Page 138  |  Page 139  |  Page 140