Comments to CMS CMS-1533-P

June 4, 2007

Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
Attention: CMS-1533-P
P.O. Box 8011
Baltimore, MD 21244-1850

RE: CMS-1533-P, Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems; DRGs: Hospital-Acquired Conditions

Dear Sir/Madam:

The Texas Hospital Association, on behalf of its more than 500 member hospitals, is pleased to submit comments on the hospital inpatient prospective payment systems rules published in the May 3, 2007, Federal Register. In the proposed rule, the Centers for Medicare & Medicaid Services seeks comments on how many and which hospital-acquired conditions should be selected for implementation in FY 2009. CMS outlines 13 conditions it is considering, but it recommends only six conditions for implementation at this time, including three serious preventable events. The six conditions are:

• catheter-associated urinary tract infections;
• pressure ulcers;
• object left in during surgery;
• air embolism;
• blood incompatibility; and
• Staphylococcus aureus septicemia.

The conditions must meet three criteria as required by section 5001(c) of Pub.L. 109-171: (a) high cost or high volume or both; (b) result in the assignment of the case to a DRG that has a higher payment when present as a secondary diagnosis; and (c) could reasonably have been prevented through the application of evidence-based guidelines. In addition, the Present on Admission indicator is required in order to determine which of the selected conditions developed during a hospital stay.

There are significant challenges enabling the correct identification of relevant cases:

• Correctly identifying cases that meet the criteria using only the documentation of physicians or qualified health care practitioners as prescribed in the ICD-9-CM Official Guidelines for Coding and Reporting is a challenge that has not been fully resolved since implementation of the DRG system. Frequently, the necessary information is documented by other members of the health care team.
• Additional complexity arises for hospital coding personnel to accurately capture the present on admission status enabling the correct identification of the conditions that are present on admission.

While the use of POA will bring increased accuracy to administrative data, the experience of California and New York in collecting POA data indicates that it may be several years before the use of the indicator accurately reflects whether a condition is a complication or a comorbidity. CMS carefully should consider not only the criteria for selection set forth in the Deficit Reduction Act, but the ability of hospitals to identify and code the present on admission status accurately.

THA supports the initial selection of the three serious preventable event conditions: leaving an object in during surgery, air embolism as a result of surgery, and providing incompatible blood or blood products. The three events meet the selection criteria and should never occur during an inpatient stay. All are high cost, are preventable through prevention guidelines and are classified as CCs under the current CMS DRGs. In addition, the three conditions are not as dependent upon use of POA as the other proposed conditions.

The other conditions proposed for selection have potential challenges as outlined below.

Catheter-Associated Urinary Tract Infections: Many clinicians believe that urinary tract infections may not be preventable after several days of catheter placement, and prevention guidelines still are debated by clinicians. Trying to accurately code for urinary tract infections that are present on admission may lead to excessive urinalysis testing for patients entering the hospital.

Pressure Ulcers: Some patients, especially those with vascular insufficiency, may develop pressure ulcers regardless of preventive measures. Identifying which patients fall into this category remains a challenge. Hospitals may stop accepting patients at risk for pressure ulcers if they believe patients are entering their hospitals with undetected early-stage pressure ulcers.

Staphylococcus aureus bloodstream infection/septicemia: Accurately diagnosing Staphylococcus aureus septicemia on admission will be a challenge. Patients may be admitted to the hospital with a Staphylococcus aureus infection of a limited location, such as pneumonia or a urinary tract infection. Subsequent development of Staphylococcus aureus septicemia may be the result of the localized infection and not a hospital-acquired condition. Additionally, the changes in coding guidelines for sepsis in recent years presents further challenges to hospital coding personnel to accurately capture present on admission status.

THA recommends that CMS proceed cautiously, starting with the three serious preventable event conditions. Other conditions should be adopted as hospitals have time to develop and implement processes to accurately capture POA, and for consensus to build regarding prevention guidelines. Time is needed to determine whether unintentional consequences will arise as a result of implementing the hospital-acquired conditions policy at the same time that dramatic changes are being made to the CMS DRG system.

THA appreciates the opportunity to make comments on the proposed changes to the hospital inpatient prospective payment systems rules.

Sincerely,