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The new CMS payment policy might be more bark than bite with regard to SSIs


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If a patient at your facility contracts a surgical site infection (SSI), your facility might still be paid for treatment, despite the new Centers for Medicare & Medicaid Services (CMS) payment policy that took effect October 1 prohibiting reimbursement for SSIs and other hospital-acquired conditions. 

CMS initially said it would restrict payment only for mediastinitis associated with coronary artery bypass graft surgery October 1. 

But it later added the following SSIs to its list: 

  • Bariatric surgery
  • Laparoscopic gastric bypass
  • Gastroenterostomy
  • Laparoscopic gastric restrictive surgery and orthopedic procedures, including surgeries of the spine, neck, shoulder, and elbow

However, some of these SSIs will present only after a patient is discharged from the hospital, due to the short hospital stay required by the procedure, says Peggy Luebbert, MS, MT(ASCP), CIC, CHSP, owner of Healthcare Interventions, Inc., in Omaha, NE. Typically, a patient will be discharged only to return to the hospital for readmission when an infection becomes apparent. The hospital-acquired infection will then be coded as present on admission. This means that the infection would be eligible for payment, Luebbert says. If it had presented during the patient’s original hospital stay, CMS would deny payment. 

CMS’ clarification

CMS confirmed this scenario in an e-mail to BOIC and offered the following clarification:

Conditions that are (1) present on readmission to the same facility or (2) present on subsequent admission to a different facility do not fall under the statutory scope of the Hospital Acquired Conditions policy. In other words, if a surgical site infection associated with joint replacement or bariatric surgery does not present until after the patient has been discharged, and that patient is either readmitted to the same facility or admitted to a different facility, the infection would be reported as present on admission for the second hospital stay, and Medicare would pay for the [Medicare severity diagnosis-related group] assigned to that stay at discharge.

This means that many of the SSIs on CMS’ list, including some bariatric surgery infections, will be paid for, Luebbert says. When it comes to gastric bypass procedures, it’s very difficult to reduce the infection rate to zero due to the heightened risk of infection present during this type of surgery and because the population is at elevated risk, she says. 

“If you have a rupture or a tear, you’re dealing with some bad bugs, so the patient can become septic pretty quickly,” Luebbert says. 

Nevertheless, the infection rate for bariatric surgery has dropped markedly in recent years, she says. 

No substitute for prevention 

Although payment loopholes such as the one described above can be found in the new CMS policy, the real money saver for most institutions will still be prevention. Make sure you have systems in place to ensure that staff members follow recommended IC guidelines.

Many ICPs are cheering on the new CMS policy because it gives more clout to the IC initiatives they’ve been trying to promote for years, says Lou MacDaid, MT(ASCP), CIC, a quality improvement specialist at UHS Corporate Quality in Greenville, NC.

Most facilities have been striving to institute CMS guidelines related to SSIs and orthopedic procedures. “This really drives home that process because it’s not just the ICP saying it, it’s the government mandating it,” she says. With this in mind, ICPs endeavor to prevent infections and perform monitoring to ensure protocols are followed. 

“Ultimately, if you’re doing all these things to prevent the infection in the first place, you won’t need to worry about reimbursement,” Luebbert says.