Learn What’s Missing in the HAC Reduction Program

CMS is excluding several measures in the 2023 Hospital Acquired Condition (HAC) section of its Hospital Specific Report (HSR).

The Centers for Medicare & Medicaid Services (CMS) is not including the PSI 90 measure result, measure scores, or total Hospital Acquired Condition (HAC) score for any hospital in its Hospital Specific Report (HSR). CMS is also excluding all Health Associated Infections (HAI) that occurred in 2021 from program calculations for the HAC Reduction Program for the 2024 fiscal year. 

The results are based on the performance period of Jan. 1, 2021 to Dec. 31, 2021. 

CMS notifies hospitals of the exact dates of the scoring calculations review and correction period, and will post these dates on the HAC Reduction Quality Net web page. The posted dates for 2023 are Aug. 15, 2022 to Sept. 13, 2022.

As finalized in the Inpatient Prospective Payment System (IPPS) Final Rule for the 2023 fiscal year, no hospital will receive a payment reduction for the HAC Reduction Program. CMS is still reporting hospitals’ HAI and CMS PSI 90 results on the Care Compare website, for the sake of transparency.

The HAC Reduction Program includes six measures:

• One claim-based composite measure of patient safety, the Patient Safety and Adverse Events Composite (PSI 90);
• Five chart-abstracted measures of HAI:
  • Central Line-Associated Bloodstream Infections (CLABSI);
  • Catheter-Associated UTIs (CAUTI);
  • Surgical Site Infections for abdominal hysterectomy and colon procedures;
  • Methicillin-Resistant Staphylococcal Aureus (MRSA) bacteremia; and
  • Clostridium Difficile Infection (CDI).

There are 14 Hospital-Associated Conditions:

1. Foreign Object Retained After Surgery;
2. Air Embolism;
3. Blood Incompatibility;
4. Stage III and IV Pressure Ulcers;
5. Falls and Trauma;
6. Catheter-Associated UTI;
7. Vascular Catheter Associated Infection;
8. Surgical Site Infection – Mediastinitis After Coronary Artery Bypass (CABG);
9. Manifestations of Poor Glycemic Control;
10. Deep Vein Thrombosis/Pulmonary Thrombosis with Total Knee or Hip Replacements;
11. Surgical Site Infection – Bariatric Surgery;
12. Surgical Site Infection – Certain Orthopedic Procedures of Spine, Shoulder, and Elbow;
13. Surgical Site Infection Following Cardiac Implantable Electronic Device Procedures; and
14. Iatrogenic Pneumothorax with Venous Catheterization.

The specific ICD-10-CM/PCS codes are listed in the MS-DRG Definitions Manual v40. The HAC Reduction Program website provides a fact sheet as well as a Frequently Asked Questions section.

Programming note: Listen to Laurie Johnson’s live coding report every Tuesday on Talk Ten Tuesdays at 10 a.m. EST.