Michael S. Calderwood, MD, MPH, FIDSA Regional Hospital Epidemiologist Assistant Professor of Medicine Infectious Disease & International Health

Coding Changes Limited Penalty Impact From CMS Hospital-Acquired Conditions Policy

MedicalResearch.com Interview with:

Michael S. Calderwood, MD, MPH, FIDSA Regional Hospital Epidemiologist Assistant Professor of Medicine Infectious Disease & International Health

Dr. Calderwood

Michael S. Calderwood, MD, MPH, FIDSA
Regional Hospital Epidemiologist
Assistant Professor of Medicine
Infectious Disease & International Health

MedicalResearch.com: What is the background for this study?  

Response: Prior work by Lee et al. (N Engl J Med 2012;367:1428–1437) found that the 2008 CMS Hospital-Acquired Conditions (HAC) policy did not impact already declining national rates of central line-associated bloodstream infections (CLABSIs) or catheter-associated urinary tract infections (CAUTIs). We studied why this policy did not have its intended impact by looking at coding practices and the impact of the policy on the diagnosis-related group (DRG) assignment for Medicare hospitalizations. The DRG assignment determines reimbursement for inpatient hospitalizations.

MedicalResearch.com: What are the main findings?

Response: There were three main findings of our study:

  1. When focused on coding for conditions not present on admission to the hospital, the billing codes that were targeted to identify CLABIs and CAUTIs were rarely used by hospitals, far less than expected based on national estimates. In the three years following the 2008 CMS HAC policy (2009-2011), an average of 6,800 Medicare discharges per year had a hospital-acquired CLABSI, and an average of 750 Medicare discharges per year had a hospital-acquired CAUTI. To put this in perspective, in the most recent year of data reported on Hospital Compare (7/1/16-6/30/17), hospital infection prevention teams reported 15,306 CLABSIs and 20,008 CAUTIs (https://data.medicare.gov/data/hospital-compare). This is after a 50% reduction in CLABSIs from 2008 through 2014, so it is possible that the actual number of CLABSIs back in 2009-2011 was even higher than the 15,306 listed above.
  2. In addition to the codes billing codes for CLABSI and CAUTI being rarely used, they were commonly listed as present on admission (POA) in the post policy period. Given that CMS only targeted codes for conditions not present on admission, hospitals were more focused on this POA designation. Our data show that 81% of Medicare discharges with a CLABSI code and 91% of Medicare discharges with a CAUTI code designated this code as POA when looking at discharges from 2009-2011, compared to 1% and 0.2%, respectively in 2007. This is a significant rise in the use of the POA designation, which is not to say that some or even a large number of these infections were not POA, but it is worth mentioning that one study looking at CAUTI coding found that at least one-third of infections listed as POA actually met criteria as hospital-acquired infections (Infect Control Hosp Epidemiol 2010;31:627–633). As written in our paper, “This result calls into question the accuracy of the POA designation.”
  3. And finally, even when CLABSI and CAUTI were coded as not POA, there was a financial impact on only 0.4% of hospitalization with a CLABSI code and 5.7% of hospitalization with a CAUTI code. As we wrote in our discussion, “When determining hospital reimbursement based on DRG assignment, other diagnosis codes may be submitted for reimbursement, limiting the magnitude of change due to ICD-9 codes selected to identify CLABSI and CAUTI (Infect Control Hosp Epidemiol2010;31:627–633, Infect Control Hosp Epidemiol 2013;34:238–244).

MedicalResearch.com: What should readers take away from your report?

Response: Our study suggests that the impact of the original 2008 CMS HAC policy was minimal due to coding practices that limited its financial impact on hospitals. 

MedicalResearch.com: What recommendations do you have for future research as a result of this work?

Response: The newer CMS HAC Reduction Program focuses on healthcare-associated infections (HAIs) reported to the CDC’s National Healthcare Safety Network (NHSN) by hospital infection prevention programs. These HAIs are identified using surveillance definitions and not by coding. There is also a larger financial impact on hospitals, with hospitals ranked in the worst quartile based on reported infections being subject to a 1% loss in Medicare revenue through the HAC Reduction Program. As we wrote in our discussion, “While this has definitely attracted the attention of hospital leadership, it will be important to be vigilant about the impact … on patient outcomes.” Future research should focus on ensuring that the tracked quality metrics are linked to improvements in patient outcomes. It is important to be cognizant of the fact that the more metrics that hospitals are required to track, the less time that can be spent away from the computer actually preventing infections. It is also important to monitor for unintended consequences.

Research is needed looking at the impact of these payment policies on adjudication of individual cases to improve numbers without meaningfully impacting patient outcomes.

I have no disclosures.


Calderwood, M., Kawai, A., Jin, R., & Lee, G. (2018). Centers for medicare and medicaid services hospital-acquired conditions policy for central line-associated bloodstream infection (CLABSI) and cather-associated urinary tract infection (CAUTI) shows minimal impact on hospital reimbursement. Infection Control & Hospital Epidemiology, 1-5. doi:10.1017/ice.2018.137

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Last Updated on July 2, 2018 by Marie Benz MD FAAD