'Present on admission' could have big effect

Eight conditions not reimbursed next year

Beginning Oct. 1, as part of the Centers for Medicare & Medicaid Services (CMS) shift to value-based purchasing, hospitals will have to report the "present on admission" indicator for every diagnosis reported for a patient.

Beginning with admission on and after Oct. 1, 2008, CMS will not assign a higher-paying DRG to patients who have eight secondary diagnoses unless they are documented as being present on admission.

Conditions that will not receive reimbursement beginning in 2008 are: catheter-associated urinary tract infections; decubitus ulcers; vascular catheter-associated infection; mediastinitis (a preventable surgical-site infection that develops after heart surgery); falls; object left in during surgery; air embolism; and blood incompatibility.

"Beginning next year, CMS will not pay to treat these hospital-acquired conditions. The only way to determine if a condition is not hospital-acquired is if it was noted in the documentation that it was present on admission," says Deborah Hale, CSS, president of Administrative Consultant Services Inc., a health care consulting firm in Shawnee, OK.

While recording the "present on admissions" indicators is the primary responsibility of the coding staff, case managers who are involved in clinical documentation improvement must make sure that all conditions that are present when the patient is admitted are included in the documentation.

This will enable coders to identify the appropriate indicators as they review the charts and note which conditions were present on admission.

Here is an example from Hale that illustrates why the "present on admission" documentation is important:

Beginning next year, CMS will not pay for treatment of decubitus ulcers if they develop during the course of a hospital stay. The condition is not always well documented and often doesn't show up in the medical record until the wound care nurse is called in, Hale says.

"This could cause a dilemma for coders because, even though the patient may have had the condition when he or she was admitted, if it's not documented in the beginning, they must assume that is wasn't present on admission and the hospital won't be paid for the cost of treating the condition," she says.

Case managers should make sure that there is a complete assessment of patients at the time of admission so the record accurately reflects what conditions they came in with as opposed to what developed during the course of the hospital stay, Hale suggests.

Track diagnoses that are listed as "not present on admission" and those that develop during the hospital stay and identify areas for quality improvement projects, she adds.