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Centers for Medicare & Medicaid - CMS


 

The Centers for Medicare and Medicaid (CMS)

CMS develops Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs.   CoP and CfC are the minimum health and safety standards that providers and suppliers must meet in order to be Medicare and Medicaid certified and receive reimbursement.

CMS Deemed Status and national accreditation organizations

If a national accrediting organization, such as The Joint Commission, has and enforces standards that meet the federal Conditions of Participation, CMS may grant the accrediting organization "deeming" authority and "deem" each accredited health care organization as meeting the Medicare and Medicaid certification requirements. The health care organization would not be subject to routine Medicare survey and certification process. See Premier SafetyShare™ for more on accrediting organizations.

CMS still conducts random validation surveys and complaint investigations of organizations with deemed status. In addition, the organizations are obliged to provide CMS with a listing of, and related documentation for, organizations receiving conditional accreditation, preliminary non-accreditation, and non-accreditation. The organizations also provide CMS with accreditation decision reports for hospitals involved in CMS validation surveys and any other survey report CMS requests.

CMS required explicit incorporation of some CMS CoP standards into accrediting organizations' standards in order for organizations like the Joint Commission (TJC) to maintain deeming authority. See the Crosswalk between CMS and (TJC) Standards effective January 1, 2009. TJC was to enforce by July 1, 2009.

However, on March 26, 2009 TJC removed this overly prescriptive language from its 2009 standards that the Centers for Medicare and Medicaid Services (CMS) had previously required TJC to add, effective January 1, 2009. The changes are a result of TJC's negotiations with CMS over its deeming authority. The January 2009 language had included specific requirements for certain standards such as Infection Prevention and Control, Environment of Care, based on CMS conditions of participation (CoP). The CoP prescriptive language had been absent from TJC standards for 15 years and is now removed from the March 26 document. TJC states that these requirements are already covered in existing elements of performance or addressed in the survey process. A cross-walk provides a side-by-side comparison.

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CMS Conditions of Participation for healthcare settings

As discussed above, CMS provides the conditions of participation (CoP) or standards for each healthcare setting, as well as the "interpretive guidelines" surveyors use to apply each standard in each setting.

An index of the all hospital CoPs is provided below listing each standard. Click on the web address at the top of the page in order to link to any of the standards listed in the index.

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CMS Interpretive guidelines - Conditions of Participation for healthcare settings

The CMS State Operations Manual (SOM) provides the "interpretive guideline" (IG) for each standard within each healthcare setting.

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CMS Infection control interpretive guidelines for healthcare settings

Hospital

Ambulatory Surgical Centers

Long Term Care – including training materials

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CMS Hospital-Acquired Conditions (HAC) and Present on Admission (POA) Indicators

On February 8, 2006 the President signed the Deficit Reduction Act (DRA) of 2005 that required there be an adjustment in Medicare DRG (Diagnosis Related Group) payment for certain hospital-acquired conditions (HACs) with a component that addresses new Present on Admission (POA) coding. CMS has titled their program Hospital-Acquired Condition and Present on Admission Reporting (HAC and POA).

Section 5001(c) of the DRA required the Secretary to identify, by October 1, 2007, at least two conditions for which hospitals under the IPPS (Inpatient Prospective Payment System) would not receive additional payment beginning on October 1, 2008, if the condition was not present on admission. The conditions must be (a) high cost or high volume or both, (b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines.

Payment for hospital-acquired conditions (HAC)

For discharges occurring on or after October 1, 2008, hospitals would not receive additional payment for cases in which one of the selected HACs was not present on admission. That is, the case would be paid as though the secondary diagnosis was not present. Section 5001(c) provides that CMS can revise the list of conditions from time to time, as long as it contains at least two conditions. However, if the patient has another coded complication (that is not a HAC) then the case will still paid at the higher DRG level.

Hospital-acquired conditions for potential reduced payment-effective October 1, 2008: Finalized by CMS August 2008

Healthcare-associated infections

Other Hospital-acquired conditions

All selections are from the National Quality Forum's list of 28 "Serious Reportable Events" frequently referred to as "Never Events."

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Premier Resources – FAQ

Resources from CMS for HAC-POA

Present on Admission (POA) Section 5001(c) also requires hospitals to report present on admission information for both primary and secondary diagnoses when submitting payment information for discharges on or after October 1, 2007.

Implementation of HAC-POA indicators – CMS Web site
Go to: http://www.cms.hhs.gov/HospitalAcqCond/

CMS has developed a special Web site that provides an overview and detailed, current and pertinent information concerning the DRA implementation that CMS has termed: "HAC-POA Indicators" Several sections provide specifics on the following:

Code Reason for Code
Y Dx was present at time of inpatient admission.
N Dx was not present at time of impatient admission. CMS is proposing to not pay the CC/MCC DRG for those selected HACs that are coded as "N" for the POA Indicator
U Documentation insufficient to determine if condition was present at the time of inpatient admission. CMS is proposing to not pay the CC/MCC DRG for those selected HACs that are coded as "U" for the POA Indicator
W Clinically undetermined. Provider unable to clinically determine whether or not the condition was present at the time of inpatient admission or not. CMS is proposing to pay the CC/MCC DRG for those selected HACs that are coded as "W" for the POA Indicator.
1 Unreported/Not used. Exempt from POA reporting. This code is equivalent code of a blank on the UB-04, however, it was determined that blanks are undesirable when submitting this data via the 4010A. All POA indicator options coded as "1" are exempt from the HAC payment provision.

Educational Resources

Two fact sheets address a) HAC in acute inpatient prospective payment system (IPPS) hospitals and b) POA indicator reporting by acute IPPS hospitals. These fact sheets provide information on this initiative such as the list of affected and exempt hospitals, the implementation timeline, a detailed chart on the category of conditions, as well as general reporting requirements and information on coding, documentation, and claims.

CMS in conjunction with the Centers for Disease Control and Prevention (CDC) held a public Listening Session on HAC & December 17, 2007 that describe the background and issues related to successful implementation of the HAC and POA indicators

HAC-POA Indicators Web site should be checked periodically for updates
http://www.cms.hhs.gov/HospitalAcqCond/

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