Prevent costly healthcare-associated infections (HAIs) with robust CDI, coding practice

By Brian Murphy

 

In 2015, 1 in 31 hospital inpatients developed a healthcare-associated infection (HAI) according to a recently released AHRQ report. These include but are not limited to:

 

• Central line-associated bloodstream infections (CLABSI)
• Catheter associated urinary tract infections (CAUTI)
• Ventilator-associated pneumonia (VAP)
• Non-ventilator hospital-acquired pneumonia (NVHAP)
• Surgical site infections (SSI)
• MRSA and C. difficile infections

 

To improve mortality scores, quality rankings, and payment, you’ve got to prevent HAIs. Here’s two startling reminders why, again from AHRQ:

 

• Inpatient stays with any examined HAI from 2019 had an in-hospital mortality rate that was up to six times higher than those without an HAI.

 

• Inpatient stays with CLABSI had a median hospital cost that was up to twelve times higher than those without CLABSI, with the largest difference ($99,900 vs. $8,500) for those hospitalized for respiratory disorders (MDC 4).

 

CMS is trying to incentive HAI reduction by hitting hospitals in the pocketbook. Its hospital-acquired conditions (HAC) program reduces Medicare payments for hospitals that rank in the worst-performing quartile of reported HACs by one percent, on all Medicare fee-for-service discharges for the applicable fiscal program year. The HAC program includes five HAIs—all included in the above list.

 

Where does prevention start? Through identification. You need to know your baseline and your data. Which of course starts with good CDI and coding practices.

 

You can find a great source of applicable coding guidelines and CDI critical thinking tips for HAIs in the ACDIS Pocket Guide. Let’s look at how that publication covers C. difficile and a couple pneumonia types (note these are excerpts, get the book for the full treatment):

 

C. difficile

 

Per the ACDIS Pocket Guide C. difficile infections usually occur among hospitalized patients, those in long term care, patients 65 and over prescribed antibiotic therapy, have weakened immune systems, or have a previous history of C. difficile.

 

C. difficile can lead to clostridioides difficile colitis (CDI), which should be considered in patients who present with diarrhea and have received antibiotics within the previous three days, or have recently been hospitalized and develop diarrhea 48 hours or more after hospitalization. CDI (A04.7-) is a CC as well as a HAC, but has no weight in V28 of CMS-HCCs.

 

Pneumonia

 

Per the ACDIS Pocket Guide, an easy rule of thumb for identifying hospital-acquired pneumonia (HAP) from community acquired is that HAP presents clinically two or more days after admission. Ventilator-associated pneumonia (VAP) often develops 48 hours or longer after mechanical ventilation is initiated by means of an endotracheal tube or tracheostomy. Typical causative organisms include Pseudomonas species, MRSA, and other Gram-negative bacteria.

 

VAP is a CC and groups to HCC 211 under V28.

 

The Pocket Guide recommends CDI professionals “always review the specific antibiotic ordered and consider the patient’s recent history of exposure,” as both can be good sources of query for etiology.

 

Interestingly HAP and VAP are not included in the HAC Reduction Program. It should be and the National Institutes of Health (NIH) seems to agree.

 

References

 

• AHRQ, Prevalence and Burden of Healthcare Associated Infections (HAIs), 2016–202: https://hcup-us.ahrq.gov/reports/statbriefs/sb313-prevalence-burden-HAIs-2016-2021.pdf

 

• ACDIS, 2025 Pocket Guide

 

• CMS, HAC Reduction Program: https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/hospital-acquired-condition-reduction-program-hacrp