Surgical Diversions

In October, 2007 CMS (Medicare) proposed a list of eight preventable conditions that result in a prolongation and increase in cost of care to the hospitalized patient. These are what CMS terms **never events**. CMS is trying to couch this in terms of patient safety but if you look at the list, there are only a few of these items that are 100% preventable. It’s really less about patient safety and more about how CMS can cut reimbursement. Medicine isn’t an exact science and expecting it to act as one is irrational.

On April, 14 2008 CMS proposed additions to their **never event** list…

The HAC provisions in Medicare regulations required hospitals to begin reporting on their Medicare claims on October 1, 2007, whether certain specified diagnoses were present when the patient was admitted. The first eight conditions, which were selected last year because they greatly complicate the treatment of the illness or injury that caused the hospitalization, resulting in higher payments to the hospital for the patient’s care by both Medicare and the patient, were:

• Object inadvertently left in after surgery
• Air embolism
• Blood incompatibility
• Catheter associated urinary tract infection
• Pressure ulcer (decubitus ulcer)
• Vascular catheter associated infection
• Surgical site infection- Mediastinitis (infection in the chest) after coronary artery bypass graft surgery
• Certain types of falls and trauma

CMS is proposing to expand the list of conditions that need to be reported if present when a patient is first admitted and is seeking public comment on whether they should be added to the list in the final rule to be announced later this year. The list in the proposed rule includes:

• Surgical site infections following certain elective procedures
• Legionnaires’ disease (a type of pneumonia caused by a specific bacterium)
• Extreme blood sugar derangement
• Iatrogenic pneumothorax (collapse of the lung)
• Delirium
• Ventilator-associated pneumonia
• Deep vein thrombosis/Pulmonary Embolism (formation/movement of a blood clot)
• Staphylococcus aureus septicemia (bloodstream infection)
• Clostridium difficile associated disease (a bacterium that causes severe diarrhea and more serious intestinal conditions such as colitis)

Some of the biggest problems in this list are twofold.

1. Who’s to define things like derangement and what constitutes delirium?
2. If these are **never events** can someone please tell me how to avoid them 100% of the time?

All invasive procedures, and I include having a foley and being on a ventilator as invasive, carry risk. The risk is small but it exists and it is not zero. I seems what CMS is seeking to do is to transfer the risk from the receivers of medical care to the providers of medical care.

Personally, I think this list will ever expand and eventually hospitals and physicians will cease to be paid for any care arising out of these **never events**. When that starts happening, watch out. All of a sudden it will not make financial sense for hospitals and doctors to participate with Medicare.

OK, first off this part of my practice is over and I’ve moved on. But let me relay a story of how CMS (that’s Medicare for the uninitiated) works.

I was asked by one of my local breast surgeons if I would see a patient for immediate breast reconstruction with implants. The patient was to undergo bilateral mastectomies. No problem. I see the patient. Surgery scheduled and goes fine.

I submit my claim forms to CMS and I only get paid for the consult. They say the surgery (immediate reconstruction with implants) is only billable as an add-on to a procedure done by me. This is absurd. I didn’t do the mastectomies. It seems that CMS can write their own rules along the way. My coder followed all the proper rules according to the CPT Code books.

It’s now over 6 months later and it looks like I’m going to have to write off the $400 that Medicare is usually willing to pay for this procedure. Yep, you read that correctly. No offense to all those women with breast cancer needing and wanting this combination of procedures but I can tell you now that at this fee schedule and with this ease of reimbursement I surprised that anyone is willing to do immediate breast reconstruction. This clearly has not been worth my time and energy, even to get paid.

Side note: If you think the solution to healthcare is to let the government run it; I wish you luck in getting any doctors to care for you.