A hospital-acquired condition (HAC) refers to a condition that affects a patient during a stay in a hospital or medical facility. Healthcare-acquired conditions (HCAC) should be reported only if they occur in an inpatient acute care hospital. Healthcare-acquired conditions include air embolism, catheter-associated urinary tract infection, falls/trauma due to fracture, dislocation, intracranial injury, burns or even electric shock, surgical site infection and vascular catheter-associated infection. Documenting these conditions with the help of medical billing companies allows hospital administrators as well as CMS to measure the practice’s performance. These reports can distinguish between pre-existing conditions and those acquired in the hospital. Not only hospital-acquired infections but also conditions such as pressure ulcers, blood type mismatch, or iatrogenic injury can be an HAC.

Under the CMS policy, if an HAC occurs during a patient’s stay, that condition is not included in the Medicare Severity Diagnosis-Related Group (MS-DRG) assignment. To group diagnoses into the proper DRG, CMS needs to capture a Present on Admission (POA) Indicator for all claims involving inpatient admissions to general acute care hospitals. The reporting of the HAC conditions along with the associated present-on-admission (POA) indicator is what determines if the condition is a hospital-acquired one.

CMS POA Indicator options include:

  • Y – Diagnosis was present at the time of inpatient admission
  • N – Diagnosis was not present at the time of inpatient admission
  • U – Documentation insufficient to determine if the condition was present at the time of inpatient admission
  • W – Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission

In the year 2008, the Centers for Medicare & Medicaid Services’ (CMS) Hospital Inpatient Prospective Payment (IPPS) policy stopped providing reimbursement for hospitals and providers for HAC not present at admission. Based on this policy, the provider was responsible for the cost of infections acquired during the patient’s stay.

However, a 2018 report published in Infection Control & Hospital Epidemiology shows that the policy has had only minimal impact on hospital reimbursement. The report found that associated billing codes were “rarely used” by hospitals for HAC. Even when used, these codes had only minimal impact on hospital reimbursement.

In 2011, the CMS finalized a rule that bans Medicaid payments for the additional cost of services that result from certain preventable healthcare acquired injuries, which is known as provider-preventable conditions (PPCs).

HACs will have effect on reimbursement, only if it is in the second position and patients have minor severity of illness.

ICD-10 Codes for HAC

HAC 01: FOREIGN OBJECT RETAINED AFTER SURGERY SECONDARY DIAGNOSIS

  • T81500A Unspecified complication of foreign body accidentally left in body following surgical operation, initial encounter
  • T81510A Adhesions due to foreign body accidentally left in body following surgical operation, initial encounter
  • T81520A Obstruction due to foreign body accidentally left in body following surgical operation, initial encounter
  • T81530A Perforation due to foreign body accidentally left in body following surgical operation, initial encounter
  • T81590A Other complications of foreign body accidentally left in body following surgical operation, initial encounter
  • T8160XA Unspecified acute reaction to foreign substance accidentally left during a procedure, initial encounter

HAC 02: AIR EMBOLISM SECONDARY DIAGNOSIS

  • T800XXA Air embolism following infusion, transfusion and therapeutic injection, initial encounter

HAC 03: BLOOD INCOMPATIBILITY SECONDARY DIAGNOSIS

  • T8030XA ABO incompatibility reaction due to transfusion of blood or blood products, unspecified, initial encounter
  • T80310A ABO incompatibility with acute hemolytic transfusion reaction, initial encounter

HAC 04: STAGE III and IV PRESSURE ULCERS SECONDARY DIAGNOSIS

  • L89003 Pressure ulcer of unspecified elbow, stage 3
  • L89103 Pressure ulcer of unspecified part of back, stage 3
  • L89143 Pressure ulcer of left lower back, stage 3
  • L89504 Pressure ulcer of unspecified ankle, stage 4
  • L89614 Pressure ulcer of right heel, stage 4
  • L89893 Pressure ulcer of other site, stage 3

HAC 05: FALLS AND TRAUMA SECONDARY DIAGNOSIS

  • M9910 Subluxation complex (vertebral) of head region
  • S020XXB Fracture of vault of skull, initial encounter for open fracture
  • S02111A Type II occipital condyle fracture, initial encounter for closed fracture
  • S060X1A Concussion with loss of consciousness of 30 minutes or less, initial encounter
  • S12111A Posterior displaced Type II dens fracture, initial encounter for closed fracture
  • S12150A Other traumatic displaced spondylolisthesis of second cervical vertebra, initial encounter for closed fracture

An article in ICD 10 monitor recommends Health information management (HIM) coders to discuss with the physician or facility’s staff to determine if a condition is present on admission. Accurate ICD-10 medical coding services provided by reliable companies can help practices improve their performance with better documentation.