CDIP Hospital-Acquired Conditions (HAC), Patient Safety Indicators (PSI), and Core Measures Documentation — Questions and Answers
Question 1: Under the CMS HAC Reduction Program, a condition qualifies as a Hospital-Acquired Condition (HAC) when it:
- Is documented as the principal diagnosis on the inpatient claim
- Is a complication that occurred during a prior hospitalization
- 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 (Correct answer)
- Is any secondary diagnosis that extends the patient's length of stay
Correct 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.
Question 2: Patient Safety Indicators (PSIs) are evidence-based quality measures developed and maintained by:
- The Joint Commission (TJC)
- American Hospital Association (AHA)
- Agency for Healthcare Research and Quality (AHRQ) (Correct answer)
- CMS Center for Clinical Standards and Quality
Correct 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.
Question 3: 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?
- Ensure the wound care nurse documents the Braden Scale score in the nursing notes
- 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 (Correct answer)
- Request the coder assign the condition as present on admission to protect the hospital from financial penalty
- Defer documentation of the ulcer to the discharge summary only to allow for complete wound assessment
Correct 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.
Question 4: Core Measures (CMS/Joint Commission hospital quality measures) documentation most directly affects:
- MS-DRG weight assignment and Medicare inpatient reimbursement
- CC/MCC classification of secondary diagnoses for APR-DRG grouping
- Public quality reporting, accreditation compliance, and CMS value-based purchasing performance scores (Correct answer)
- POA indicator assignment for Hospital-Acquired Condition tracking only
Correct 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.
Question 5: Which of the following scenarios represents a Hospital-Acquired Condition (HAC) that would appropriately trigger a CDI query?
- Pneumonia documented by the ED physician as the reason for admission
- Deep vein thrombosis (DVT) noted in the ambulance transfer records from another facility
- Central line-associated bloodstream infection (CLABSI) first identified on hospital day 4 with no prior documentation of infection (Correct answer)
- Acute myocardial infarction documented as present on admission in the ED note
Correct 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.
Question 6: When a CDI specialist issues a query related to a potential Hospital-Acquired Condition, the query must:
- Suggest coding the condition as present on admission to protect the hospital from a HAC penalty
- Be submitted only after patient discharge to avoid influencing active clinical care decisions
- Be compliant, non-leading, and allow the provider to make the accurate clinical determination including the appropriate POA status (Correct answer)
- Receive approval from the hospital's legal department before issuance in all HAC-related cases
Correct 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.
CDIP Hospital-Acquired Conditions (HAC), Patient Safety Indicators (PSI), and Core Measures Documentation
Under the CMS HAC Reduction Program, a condition qualifies as a Hospital-Acquired Condition (HAC) when it: