Hospital-Acquired Conditions (HAC), Patient Safety Indicators (PSI), and Core Measures Documentation Flashcards

Under the CMS HAC Reduction Program, a condition qualifies as a Hospital-Acquired Condition (HAC) when it:

Answer: Was not present on admission (POA indicator 'N'), is high-cost or high-volume, and results in higher payment when coded as a secondary diagnosis

CMS defines HACs as conditions that (1) are high-cost or high-volume, (2) result in the assignment of a higher-paying DRG when coded as a secondary diagnosis, and (3) could reasonably have been prevented with evidence-based guidelines. Critically, the condition must have a POA indicator of 'N' (not present on admission). If POA='Y', the HAC payment adjustment does not apply.

Patient Safety Indicators (PSIs) are evidence-based quality measures developed and maintained by:

Answer: Agency for Healthcare Research and Quality (AHRQ)

Patient Safety Indicators (PSIs) are developed by the Agency for Healthcare Research and Quality (AHRQ) to identify potential adverse events that patients experience as a result of exposure to the healthcare system. PSI data is used in CMS quality reporting programs including the Hospital Value-Based Purchasing and HAC Reduction programs.

A patient is admitted without any skin breakdown and develops a Stage 3 pressure ulcer during the hospitalization. What is the CDI specialist's primary documentation responsibility?

Answer: Query the physician to document the pressure ulcer's stage and confirm it was not present on admission, as accurate documentation affects both HAC reporting and DRG reimbursement

Stage 3 and Stage 4 pressure ulcers are CMS-designated HACs. The physician must document the stage (Stage 1–4, unstageable, or deep tissue injury) because the stage determines the ICD-10-CM code and the resulting MS-DRG. The POA indicator must accurately reflect when the condition developed. A leading query designed to avoid a HAC flag would be a compliance violation.

Core Measures (CMS/Joint Commission hospital quality measures) documentation most directly affects:

Answer: Public quality reporting, accreditation compliance, and CMS value-based purchasing performance scores

Core Measures (such as those for heart failure, pneumonia, sepsis, and surgical care) are reported publicly on the Hospital Compare website and factor into CMS Value-Based Purchasing (VBP) scores, which directly affect a hospital's Medicare payment adjustment. Incomplete Core Measures documentation can lower VBP scores even when clinical care was appropriate.

Which of the following scenarios represents a Hospital-Acquired Condition (HAC) that would appropriately trigger a CDI query?

Answer: Central line-associated bloodstream infection (CLABSI) first identified on hospital day 4 with no prior documentation of infection

CLABSI is a CMS-designated HAC. A bloodstream infection first identified on hospital day 4 with no documentation of infection at admission (POA='N') meets HAC criteria and warrants a CDI query to the physician to confirm the timing of onset and clarify the relationship to the central line. The other scenarios describe conditions documented as present on admission.

When a CDI specialist issues a query related to a potential Hospital-Acquired Condition, the query must:

Answer: Be compliant, non-leading, and allow the provider to make the accurate clinical determination including the appropriate POA status

HAC-related queries carry heightened compliance risk because there is a financial incentive to influence POA status. AHIMA and ACDIS guidelines require that all queries — including those related to HACs — be non-leading, present all clinically reasonable options, and allow the physician to make an independent clinical judgment. A query designed to steer the physician toward a 'present on admission' answer to avoid a HAC flag would constitute a fraudulent query.