HACs and the HAC Reduction Program (HACRP)

HACRP is designed to reduce rates of healthcare-associated infections

Most clinical documentation improvement (CDI) professionals are aware of hospital-acquired conditions (HACs). In fact, reviewing a record and looking for potential HACs may be part of their standard workflow. What many who perform these reviews or manage the CDI process may not realize is that the concept of HACs, and along with it a focus on patient safety, was expanded with the Hospital-Acquired Conditions Reduction Program (HACRP). Yes, HACs are still around, but their potential financial impact at an individual healthcare organizational level is far less than a penalty incurred under the HACRP. 

HACs were one of the Centers for Medicare & Medicaid Services’ (CMS’s) first ventures into aligning payment and quality of care. They were developed as part of the Deficit Reduction Act (DRA) of 2005, which required the Secretary of the U.S. Department of Health and Human Services (HHS) (which oversees CMS) to “identify conditions that are: a) high-cost, high-volume, or both; b) result in the assignment of a 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.” However, HACs were not implemented until the Inpatient Prospective Payment System (IPPS) Final Rule for the 2009 fiscal year (FY). Part of the reason for this delay was that implementation of HACs was dependent upon implementation of the present-on-admission indicator (POA). Prior to implementation of the POA indicator, CMS did not have an objective way of differentiating co-morbidities (e.g., those conditions that existed prior to the admission) from complications (those conditions that arose during the admission). In this context, complications do not imply wrongdoing on the part of the healthcare organization; it is merely the terminology CMS used.

There were initially 10 categories of HACs, but it subsequently grew to 14 categories, and has remained at 14 since the IPPS for FY 2013 was introduced. Basically, few changes have occurred with HACs, except for the conversion to the ICD-10-CM/PCS code set (which occurred in FY 2016), since the FY 2013 update. The current categories of HACs are:  

• Foreign Object Retained After Surgery
• Air Embolism
• Blood Incompatibility
• Stage III and IV Pressure Ulcers
• Falls and Trauma (e.g., Fractures, Dislocations, Intracranial Injuries, Crushing Injuries, Burn, Other Injuries)
• Manifestations of Poor Glycemic Control (e.g., Diabetic Ketoacidosis, Nonketotic Hyperosmolar Coma, Hypoglycemic Coma, Secondary Diabetes with Ketoacidosis, Secondary Diabetes with Hyperosmolarity)
• Catheter-Associated Urinary Tract Infection (UTI)
• Vascular Catheter-Associated Infection
• Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG):
• Surgical Site Infection Following Bariatric Surgery for Obesity
  • Laparoscopic Gastric Bypass
  • Gastroenterostomy
  • Laparoscopic Gastric Restrictive Surgery
• Surgical Site Infection Following Certain Orthopedic Procedures
  • Spine
  • Neck
  • Shoulder
  • Elbow
• Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED)
• Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Certain Orthopedic Procedures:
  • Total Knee Replacement
  • Hip Replacement
• Iatrogenic Pneumothorax with Venous Catheterization

You can find a listing of HACs for FY 2022 and the associated ICD-10-CM/PCS codes online at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/icd10_hacs.  

So, what is the possible impact of HACs, and why do some CDI departments include identification of potential HACs in their review process? According to a 2020 FAQ published by CMS, “hospitals no longer receive additional payment for cases in which one of the identified HACs occurred but was not POA. Instead, the case is paid as though the HAC was not present. This payment provision applies only to secondary diagnosis codes, given that the identified HACs are designated as a complication or comorbidity (CC) or a major complication or comorbidity (MCC) when reported as a secondary diagnosis. Payments will be adjusted only if no other CC/MCC conditions are reported on the claim.” In other words, if a HAC is identified on the claim, that condition can no longer impact the MS-DRG assignment as a CC or MCC, which could negatively impact reimbursement for that particular claim if there is not another CC or MCC to replace the impact of the HAC. The impact is limited to one claim, and only if it was the only secondary diagnosis that impacted the MS-DRG assignment. 

Due to efforts by CDI departments to have multiple CCs and MCCs on every claim, when possible, HACs have little if any financial impact on most healthcare organizations. CMS does, however, publicly report HACs for Foreign Object Retained After Surgery; Blood Incompatibility; Air Embolism; and Falls and Trauma because these measures are not covered by any other CMS quality program. However, CMS does not risk-adjust HAC measures based on patient case mix, because these are considered by CMS “to be serious, reportable events that should not occur, regardless of the patient’s condition.” All other HACs have been “absorbed” into other CMS quality measures, such as CMS PSI 90, which is included in the HACRP. Although they both include the concept of hospital-acquired conditions, the HAC (POA) program and HACRP are two distinctly different quality programs.

According to CMS, “the Hospital-Acquired Condition (HAC) Reduction Program is a Medicare value-based purchasing program that reduces payments to hospitals based on how they perform on measures of hospital-acquired conditions.” It was established by the Patient Protection and Affordable Care Act of 2010 and implemented with the IPPS for FY 2015. The HACRP is designed to encourage use of best practices by healthcare organizations to reduce rates of healthcare-associated infections (HAIs) and improve patient safety. Unlike the HAC program, which only impacts CMS reimbursement on a per-claim basis, the HACRP “adjusts payments to hospitals that rank in the worst-performing quartile (above the 75th percentile) … with respect to measures of hospital-acquired conditions. On an annual basis, CMS evaluates overall hospital performance by calculating a Total HAC Score for each hospital as the equally weighted average of their scores on measures included in the program. Hospitals with a Total HAC Score greater than the 75th percentile of all Total HAC Scores … receive a payment reduction of 1 percent on overall Medicare fee-for-service (FFS) payments.”

Additionally, data collected for the HACRP is publicly reported. The HACRP is updated annually as part of the IPPS. Currently, The HAC Reduction Program includes the following six quality measures:

• One claims-based composite measure of patient safety:
  • CMS Patient Safety and Adverse Events Composite (CMS PSI 90)
• Five chart-abstracted measures of HAIs submitted to the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network:
  • Central Line-Associated Bloodstream Infection (CLABSI)
  • Catheter-Associated Urinary Tract Infection (CAUTI)
  • Surgical Site Infection (SSI) for abdominal hysterectomy and colon procedures
  • Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia
  • Clostridium difficile Infection (CDI)

It is important to note that data related to HAIs is not based on claims data; this data is routinely collected as surveillance data by infection control teams and submitted directly to the CDC. Another key difference between the HAC program and HACRP is that the HAC program occurs in real time. The penalty is assessed when the claim is submitted because it is built into claims payment logic. Conversely, data used to determine payment penalties for the HACRP is collected several years prior to the application of the penalty. The FY 2022 HACRP performance period for CMS PSI 90 is based on data collected from July 1, 2018 to Dec. 31, 2019, and the data for the HIA measures was collected from the 2019 calendar year (CY). If organizations only improve patient safety once they receive a HACRP penalty, it could take several years before they are able to right the ship to avoid additional penalties. The good news about HACRP from the CDI perspective is that monitoring performance aligns with efforts to monitor patient safety indicators (PSIs) due to the composite measure of CMS PSI 90, so many CDI departments already have processes in place that could be expanded to include the HACRP.

Programming Note: Listen to Cheryl Ericson report this story live today on Talk Ten Tuesdays, 10 Eastern.