Respond to the following peer discussion:

The two conditions that I chose were pressure ulcers and deep vein thrombosis. The environmental setting will be an emergency room in a nonprofit hospital. The discussion will consider regulatory changes regarding reimbursement with these conditions. CMS reduced and refused payment for specific hospital-acquired conditions. These included both pressure ulcers and pulmonary embolisms. Quality outcomes and reimbursement are intermingled.

Pressure ulcers are wounds that occur due to prolonged pressure on an area. This pressure decreases circulation and causes tissue damage. Reviewing the CMS guidelines, one will find significant reimbursement reductions for stage 3 and stage 4 pressure ulcers. The Centers for Medicare and Medicaid Services (CMS) designated /spital-Acquired Pressure Injuries, stage 3 and stage 4, as a Hospital-Acquired Condition (HAC) which are not identified upon admission are not reimbursable at the MS-DRG rate(CMS, 2019). This has a significant impact on and revenue reimbursement. According to Padulla & Delarmente  (2019), the cost would be more than $26.8 billion, with about 59% of that cost directly related to only a small stage 3 and stage ulceration rate. The advanced practitioner should ensure a thorough initial assessment to ensure all conditions are identified upon admission including documentation. Reimbursement is contingent upon treatment plans, diagnosis, and coding practices. 

A pulmonary embolism is a blood clot or foreign body that gets lodged in an artery that blocks the blood flow. According to  Gidwani & Bhattacharya (2015), the CMS payment reform resulted in a 35% reduction in pulmonary embolism post hip and knee patients aged 65-69 years old. Quality goals and reimbursement are interlinked. 

Both conditions are associated with higher treatment cost, reduced reimbursement, higher mortality, hospital readmissions, and pain. How the conditions of pressure ulcers and pulmonary embolisms affect the advanced practitioner will vary. These conditions are complications from treatment received complications, or lack of quality of care. The advanced practitioner should focus on treatment protocols that follow evidence-based practices. All elements of documentation of examinations and treatments should be compliant to maximize reimbursement and ensure quality and continuity of care. Reimbursement is tied to the products and service provided to receive payment for those services. Advocate for improved practices within the organization you practice and promote quality practices. Don make assumptions and treat the underlying reason the complication. 

References

CMS. (n.d.). Hospital-acquired conditions (present on admission indicator). Center for Medicare and Medicaid Services. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond

Gidwani, R., & Bhattacharya, J. (2015, May 1). CMS reimbursement reform and the incidence of hospital-acquired pulmonary embolism or deep vein thrombosis. Journal of general internal medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4395609/

Padulla, W. & Delarmente, B. (2019) The national cost of hospital-acquired pressure injuries in the United States. National Library of Science. https://pubmed.ncbi.nlm.nih.gov/30693644/