List of CMS Hospital-Acquired Conditions Expanded under New Final Rule

February 19, 2009 | Healthcare Risk, Quality, & Safety Guidance

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The Centers for Medicare & Medicaid Services (CMS) has expanded its list of hospital-acquired conditions from 8 to 10 in its final rule on the hospital Inpatient Prospective Payment System (IPPS) for fiscal year (FY) 2009. According to CMS, hospital-acquired conditions are conditions it deems to be reasonably preventable with the implementation of evidence-based guidelines. This special advisory presents updated information and recommendations for hospitals to implement in addressing reimbursement implications posed by the new rule. The new rule is available online at http://edocket.access.gpo.gov/2008/pdf/E8-17914.pdf.

In November 2007, ECRI Institute published a special advisory recommending that facilities adopt an enterprise risk management approach in order to address the CMS final rule for the Medicare program that made changes to the hospital IPPS for FY 2008. Facilities were urged to assemble an enterprisewide response team to review the rule, quantify the financial risks and other risk exposures, and create an action plan to mitigate the identified risks associated with the agency’s plan, effective October 2008, to no longer pay for certain hospital-acquired conditions. The November 2007 special advisory also summarized the list of standards and guidelines included in the FY 2008 final rule for preventing the hospital-acquired conditions and provided a list of additional ECRI Institute resources to help hospitals respond to the rule.

In the IPPS FY 2008 final rule, CMS listed eight conditions that it believes are “reasonably preventable” during a Medicare beneficiary’s hospital stay and that will be subject to nonpayment beginning October 1, 2008, if they are sole major complicating conditions (MCCs) or complicating conditions (CCs). Exceptions apply if the claim qualifies for an outlier payment. Under the rule, the presence of a reasonably preventable condition (as the only MCC or CC) would not cause a higher-paying diagnosis-related...

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