Hospital Acquired conditions (HAC) CATAGORIES AND billing guidelines

Overview
Hospital Acquired Conditions (HAC) are serious conditions that patients get during an inpatient hospital stay. If hospitals follow proper procedures, patients are less likely to get these conditions. UnitedHealthcare Medicare Advantage doesn't pay for any of these conditions, and patients can't be billed for them, if acquired while in the hospital. UnitedHealthcare Medicare Advantage will only pay for these conditions if they were present on admission to the hospital.

Effective October 1, 2015, the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Version 33 Hospital Acquired Condition (HAC) list replaced the ICD-9-CM Version 32 HAC list.

HAC Categories:

01- Foreign Object Retained Following Surgery
02- Air Embolism
03- Blood Incompatibility
04- Stage III and IV Pressure Ulcers
05- Falls and Trauma
06- Catheter-Associated Urinary Tract Infection (UTI)
07- Vascular Catheter-Associated Infection
08- Surgical Site Infection (SSI) –Mediastinitis Following Coronary Artery Bypass Graft (CABG)
09- Manifestations of Poor Glycemic Control
10- Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) With Total Knee or Hip Replacement
11- Surgical Site Infection (SSI) Following Bariatric Surgery for Obesity
12- Surgical Site Infection (SSI) Following Certain Orthopedic Procedures of Spine, Neck, Shoulder or Elbow
13- Surgical Site Infection (SSI) Following Cardiac Implantable Electronic Device (CIED) Procedures
14- Iatrogenic Pneumothorax w/ Venous Catheterization

Present on Admission Guidelines

To group diagnoses into the proper Diagnosis-related group (DRG), CMS needs to capture a Present on Admission (POA) Indicator for all claims involving inpatient admissions to general acute care hospitals. Collection of POA indicator data is necessary to identify which conditions were acquired during hospitalization for the HAC payment provision as well as for broader public health uses of Medicare data. Use the UB-04 Data Specifications Manual and the ICD-10-CM Official Guidelines for Coding and Reporting to facilitate the assignment of the POA indicator for each "principal" diagnosis and "other" diagnoses codes reported on claim forms UB-04 and 837 Institutional.


The POA Indicator guidelines are not intended to provide guidance on when a condition should be coded, rather to provide guidance on how to apply the POA Indicator to the final set of diagnosis codes that have been assigned in accordance with Sections I, II, and III of the official coding guidelines. Subsequent to the assignment of the ICD-10-CM codes, the POA Indicator should be assigned to all diagnoses that have been coded.

A joint effort between the health care provider and the coder is essential to achieve accurate and complete documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Medical record documentation from any qualified health care practitioner who is legally accountable for establishing the patient's diagnosis.

The provider, a provider's billing office, third party billing agents and anyone else involved in the transmission of this data shall insure that any re-sequencing of diagnosis codes prior to transmission to CMS also includes a re-sequencing of the POA Indicators


General POA Reporting Requirements

** POA indicator reporting is mandatory for all claims involving inpatient admissions to general acute care hospitals or other facilities.

** POA is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA.

** A POA Indicator must be assigned to principal and secondary diagnoses (as defined in Section II of the Official Guidelines for Coding and Reporting) and the external cause of injury codes. CMS does not require a POA Indicator for an external cause of injury code unless it is being reported as an "other diagnosis."

** Issues related to inconsistent, missing, conflicting, or unclear documentation must be resolved by the provider.

** If a condition would not be coded and reported based on Uniform Hospital Discharge Data Set definitions and current official coding guidelines, then the POA Indicator would not be reported.

 CMS POA Indicator Reporting Options, Description, and Payment Indicator Description Medicare Payment
Y Diagnosis was present at time of inpatient admission. Payment is made for condition when an HAC is present
N Diagnosis was not present at time of inpatient admission. No payment is made for condition when an HAC is present
U Documentation insufficient to determine if condition was present at the time of inpatient admission. No payment is made for condition when an HAC is present
W Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission. Payment is made for condition when an HAC is present
1 Unreported/Not used. Exempt from POA reporting. This code is the equivalent of a blank on the UB-04, it was determined that blanks were undesirable when submitting this data via the 4010A.

NOTE: The number “1” POA Indicator should not be applied to any codes on the HAC list.  Exempt from POA reporting


Paper Claims

On the UB-04, the POA indicator is the eighth digit of Field Locator (FL) 67, Principal Diagnosis, and the eighth digit of each of the Secondary Diagnosis fields, FL 67 A-Q. In other words, report the applicable POA indicator (Y, N, U, or W) for the principal and any secondary diagnoses and include this as the eighth digit; leave this field blank if the diagnosis is exempt from POA reporting.

Electronic Claims

Submit the POA indicator on the 837I in the appropriate Health Care Information Codes segment as directed by the “UB04 Data Specifications Manual.


Reimbursement Guidelines

For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis were not present.

The Present on Admission Indicator Reporting provision applies only to IPPS hospitals. CMS also required hospitals to report POA information for both primary and secondary diagnoses when submitting claims for discharges on or after October 1, 2007.


Q: Do the POA and HAC programs apply to outpatient or ambulatory surgery services?
A: No, this program is only for inpatient acute care admissions.

Q: If the POA indicator is not on the claim, will the claim be returned?
A: Beginning with claims with discharges on or after October 1, 2008, if hospitals do not report a valid POA code for each diagnosis on the claim, the claim will be returned to the hospital for correct submission of POA information