The Affordable Care Act of 2010 mandated the development of quality reporting and pay for performance program in all practice settings, including hospitals. These hospital pay for performance programs support CMS’ goal of improving healthcare for Medicare fee for service beneficiaries by linking payment to the quality of hospital care.
The Hospital Acquired Condition (HAC) program is part of CMS’ effort to reduce to the number of hospital acquired infections. Under this program, hospitals are ranked on their total rate of hospital acquired infections, and the 25% of hospitals with the highest rates of these conditions receive a 1% reduction in inpatient Medicare fee-for-service payments.
The program includes six types of hospital acquired infections which are reported to national as well as state databases if they meet specific criteria based on CDC definitions and criteria. These six measures include:
Reporting one of these conditions as a hospital-acquired infection is based on objective information in the medical record independent of physician documentation of the condition. In the case of CAUTI and CLABSI, these conditions are only considered “hospital-acquired” infections when they meet specific CDC definitions and criteria. A CAUTI or CLABSI that is NOT considered “hospital-acquired” is when the infection does not meet CDC criteria. A diagnosis of CAUTI or CLABSI is a codeable condition whether it is hospital-acquired or not.
Let's look at two case scenarios to illustrate the differences:
Case #1. A patient has a urinary tract infection and an indwelling urinary catheter that has been in place for two days, is symptomatic with fever of 101, and has a urine culture > 100,000 E. coli. This meets the CDC criteria for a catheter-associated urinary tract infection (CAUTI) and would be reportable to national and state databases as a hospital-acquired infection.
On the other hand, if the above patient had their urinary catheter in place less than two days, this case would not meet the CDC criteria and excluded from reporting as a hospital-acquired condition.
In both cases, the patient had a CAUTI, and if CAUTI is documented by the physician it would be assigned the ICD-10 code for CAUTI, code T83.511A, Infection and inflammatory reaction due to urinary catheter. Only the first scenario would be reported as a “hospital-acquired” infection as required under the HAC Reduction Program.
Case #2. A patient who has a central line in place for three days also has fever and chills and two positive blood cultures. This would meet CDC criteria and considered a central line associated blood stream infection (CLABSI) and would be reportable as a hospital-acquired infection.
However, if the above patient’s record included documentation that the patient had tampered with their central line, it would be excluded and not reported as a hospital-acquired infection.
In both cases, the patient had a CLABSI, and if CLABSI is documented by the physician it would be assigned the ICD-10 code for CLABSI, code T80.211A, Blood stream infection due to a vascular catheter.
Only the first scenario would be considered a “hospital-acquired infection” and reported as such.
The ICD-10 codes assigned for CAUTI and CLABSI do not imply that improper or inadequate care was provided, i.e., hospital acquired. The intent of the CDC definitions and criteria is to exclude those infections that would not be considered hospital-acquired, such as when there is an alternate source of the bloodstream infection.
Whether a condition is reported as a “hospital-acquired infection” is dependent on meeting CDC criteria and independent of coding. Either way, it is still a clinically valid and codeable diagnosis.
In summary, these six measures are reported as “hospital-acquired” conditions only if they meet CDC definitions and inclusion criteria. Such reporting is not based on provider documentation of the diagnosis. Only those cases identified and reported as “hospital acquired infections” have a potential negative impact on hospital quality rankings and reimbursement under the HAC Reduction program.
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