CMS Releases Final CY 2009 Payment Regulations for Inpatient Hospitals and Initiates Quality Care Incentives

August 14, 2008 – On July 31, 2008, the Centers for Medicare and Medicaid Services (CMS) posted the final acute care inpatient prospective payment rule (IPPS). It will be published in the federal register on August 19, 2008. The final IPPS rule updates payment policies and rates for more than 3,500 hospitals that are paid under Medicare’s diagnosis related group (DRG) payment system. Overall, the final rule is estimated to increase Medicare payments to acute care hospitals by nearly $4.75 billion. With a few exceptions, the rule is effective on October 1, 2008.

Of particular interest to hematologists is the Hospital Acquired Conditions (HAC) initiative. Under the HAC initiative, hospitals are required to report if specific conditions are present upon admission. Beginning October 1, 2008, Medicare will no longer assign an inpatient hospital discharge to a higher paying MS-DRG if a selected secondary diagnosis was not present on admission. Essentially, Medicare will not pay more for conditions that were acquired in the hospital if they were reasonably preventable through the application of evidence-based guidelines.

There is an exception to this policy. Providers will have an option to indicate, through reporting of "W" Present on Admission (POA) indicator, that the presence of the condition on admission cannot be determined based on clinical judgment. Under these circumstances if a "W" indicator was reported for a condition upon admission and that condition was subsequently acquired during the hospital stay CMS will pay for the additional cost of treating the condition.

For CY 2009 CMS has added three conditions to this list including "Deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures." While CMS received a numerous comments from a variety of stakeholders, including ASH, requesting them not to include this condition on the list of hospital acquired conditions, CMS concluded that DVT/PE is reasonably preventable in certain subpopulations, specifically patients undergoing certain hip and knee replacement surgeries. The Agency believes that selecting DVT/PE for these procedures will have the positive effect of encouraging attention to risk assessment prior to surgery.