AAWC Alert! Changes to Medicare Hospital Payment 2007-2008
Submitted by Peggy Dotson, RN, BS
Member, AAWC Government and Regulatory Affairs Task Force
CMS has introduced a new DRG system that is more specific. It's now known as the Medicare Severity-Diagnosis Related Groups or MS-DRGs. It became effective October of this year.
How MS-DRG Work:
Medicare has converted their Diagnosis Related Groups (DRGs) system to a more specific group set based on the severity of the diagnosis known as Medicare Severity-DRGs (MS-DRGs). This has allowed the Centers for Medicare and Medicaid Services (CMS) to introduce multiple MS-DRGs in place of an existing DRG that was assigned to a diagnosis group with complications. Now Medicare can split a single DGR w/ complications into 2 MS-DRGs; 1) for major complications (MCC) and 2) for regular complications (CC). Payment is then adjusted accordingly.
Rationale:
This change helps shift cost and allows Medicare to pay less for cases that are not major complicated cases. It will take away the payment buffer for many of the DRGs w/ complications resulting in a squeeze for hospital providers. CMS has released the new MS-DRG codes which have gone from 557 to 999.
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This will heighten the need for a review of cases that are complex and the hospital procedures to provide the best care and eliminate complications that increase costs and length of stay (LOS).
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What’s Next
This will be followed by another major change to the way Medicare pays hospitals in 2008. Medicare no longer will reimburse hospitals for the treatment of preventable errors, injuries and certain infections that occur in the facilities. Under the rule, Medicare no longer will reimburse hospitals for the treatment of certain conditions that could reasonably have been prevented, and the facilities cannot bill the beneficiary for any charges associated with the hospital-acquired complication
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The eight conditions included in the proposed rule for which Medicare no longer will reimburse hospitals for treatment include: |
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falls |
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mediastinitis, an infection that can develop after heart surgery |
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urinary tract infections that result from improper use of catheters |
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pressure ulcers (Stage III and IV) |
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vascular infections that result from improper use of catheters |
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three "never events": |
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objects left in the body during surgery |
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air embolisms |
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blood incompatibility |
In addition, the Hospital Length -of -Stay (LOS) data for 2006 has just been released. You can access this data at here. This is a consolidated list of a variety of MS-DRGs and the LOS data for sternal wounds, major open abdominal wounds and other related wounds. This will provide you with insight into what hospitals will be looking at as they estimate which cases make them vulnerable going into next year and beyond.
Timing couldn't be better for Wound Care Experts to work with their providers and institutions to evaluate the variety of complex wounds that occur in the hospital and institute procedures, treatment protocols and newer treatment modalities to prevent and treat wounds that will save money and avoid conditions that may result in no payment from Medicare later in 2008.
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