Part B Insider (Multispecialty) Coding Alert

Published on Sat Jul 19, 2008 PDF

Expansion of Medicare's list of "never events" worries practices nationwide that treat conditions such as postoperative deep vein thrombosis

Get ready for three new "never events," effective this October.

Last year, CMS issued a list of services that Medicare considers non-payable, including surgeries to retrieve objects that the surgeon accidentally left behind during a procedure, as well as seven additional so-called "never events."

This week, CMS issued its Inpatient Prospective Payment System Final Rule, which goes into effect on Oct. 1. Included in that final rule is a list of three new never events for which CMS will no longer reimburse hospitals, as follows:

• Surgical site infections following "certain elective procedures," including certain orthopedic surgeries, and bariatric surgery for obesity

• Certain manifestations of poor control of blood sugar levels

• Deep vein thrombosis (DVT) or pulmonary embolism (PE) following total knee replacement and hip replacement procedures

CMS will require hospitals to disclose whether the patient had these conditions upon admission. If not, Medicare will not reimburse hospitals for these conditions because they were acquired during the hospital stay. CMS says that the halt in reimbursement will encourage hospitals to make fewer errors.

Groups react: Physician advocacy groups expressed disappointment regarding the decision.

"In the race to improve health care quality, HHS is confusing events that should never happen in a hospital, like wrong-site surgery, with often unavoidable conditions, like surgical site infections," said J. James Rohack, MD, president-elect of the AMA, in a July 31 statement.

"To be reasonably preventable, there should be solid evidence that by following guidelines, the occurrence of an event can be reduced to zero or near zero. This is not the case for many of the now-banned conditions."

CMS' decision not to pay for certain surgical site infections "will be a problem for hospitals because of the fact that they will incur costs associated with diagnosing and treating the infections that will not be recouped through reimbursement from the carriers," says Susan Vogelberger, CPC, CPC-H, CPC-I, CMBS, CCP-P, president of Healthcare Consulting & Coding Education, LLC.

"When an infection is cultured, an epidemiologist can pinpoint where it originated," Vogelberger says. "CMS is targeting the ones that could reasonably have been prevented through the application of evidence-based guidelines. The hospitals must use the POA (Present on Admission) indicators correctly on the claim forms to indicate whether or not the infection was present when the patient came in. Commun-ication between the patient, doctor and coder is more important now than ever before."

Some Conditions Not Preventable

Some experts worry that in the race to add never events to the roster, CMS may have overlooked the fact that some conditions occur despite physicians' best efforts. "Most joint replacement patients, if following instructions, forego any complications," says Annette Grady, CPC, CPC-H, CPC-P, CCS-P, compliance auditor with The Coding Network. "There are those few exceptions where some patients have history of DVT, and no matter what type of precautions are taken with medications, elevation, etc, they may still develop a clot."

To read the IPPS final rule, visit http://federalregister.gov/OFRUpload/OFRData/2008-17914_PI.pdf.