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Malpractice – Medicare will not pay for “Hospital Acquired Conditions a.k.a “Never Events”

In CMS’ efforts to improve the quality of care, as of October 1, 2008 Medicare will not pay for certain injuries/conditions acquired during inpatient care, these injuries/conditions have been named by CMS as “never events” or “hospital acquired conditions” (HACs). CMS has advised state Medicaid Agencies to amend their statutory language to ensure that payment is not made through Medicaid for those beneficiaries that may have dual eligibility.

On February 8, 2006 President George Bush signed the Deficit Reduction Act (DRA) of 2005. Pursuant to Section 5001(c) of DRA the Secretary must identify the following conditions:“(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.”

If any of the following conditions was not present at the time of admission additional payment will not be made by Medicare. In an attempt to enforce this rule CMS has created POA, which is a coding mechanism used to indicate when a HAC was present to prevent Medicare from being the responsible payer.

For FY 2009 the 10 categories of HACs include:

  1. Foreign Object Retained After Surgery
  2. Air Embolism
  3. Blood Incompatibility
  4. Stage III and IV Pressure Ulcers
  5. Falls and Trauma
    • Fractures
    • Dislocations
    • Intracranial Injuries
    • Crushing Injuries
    • Burns
    • Electric Shock
  6. Manifestations of Poor Glycemic Control
    • Diabetic Ketoacidosis
    • Nonketotic Hyperosmolar Coma
    • Hypoglycemic Coma
    • Secondary Diabetes with Ketoacidosis
    • Secondary Diabetes with Hyperosmolarity
  7. Catheter-Associated Urinary Tract Infection (UTI)
  8. Vascular Catheter-Associated Infection
  9. Surgical Site Infection Following:
    • Coronary Artery Bypass Graft (CABG) – Mediastinitis
    • Bariatric Surgery
      • Laparoscopic Gastric Bypass
      • Gastroenterostomy
      • Laparoscopic Gastric Restrictive Surgery
    • Orthopedic Procedures
      • Spine
      • Neck
      • Shoulder
      • Elbow
  10. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)
    • Total Knee Replacement
    • Hip Replacement

CMS has opted to leave the list of HACs for FY 2010 unchanged. CMS will take this time to evaluate the program in order to assist with future decision making of the program.

Lien Settlement Solutions can assist your firm in understanding the changes in Medicare policies and guidelines. Call us today for more information on Medicare and Compliance at (877)907-5436 or email us at We are the Lawyer’s Complete Solution to Lien Resolution! 

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