Q&A: Hospital-acquired condition payment provisions

October 10, 2017
Medicare Web

Q:  What is a hospital-acquired condition (HAC), and to whom does the HAC payment provision apply?

A: A hospital-acquired condition (HAC) is an undesirable situation or condition affecting a patient that arose during a stay in a hospital or medical facility. Medicare and Medicaid have used this designation to determine Medicare severity–diagnosis-related group (MS-DRG) reimbursement since 2008.

CMS identified specific conditions, such as those that are high-cost, high-volume, or high-cost and high-volume; those that result in assignment of a case to a DRG with a higher payment when present as a secondary diagnosis; and those that could reasonably have been prevented by applying clinical guidelines.

The HAC payment provision currently applies only to inpatient prospective payment system hospitals. Examples of HACs include pressure ulcers, patient falls resulting in trauma, and catheter-associated urinary tract infections. Hospitals no longer receive additional payment for cases in which one of the selected conditions was not present on admission (POA). When a diagnosis is recorded, it is designated either as POA or not POA. 

For more information, see Case Management Models: Best Practices for Health Systems and ACOs, 2nd edition.

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