Hospital Acquired Condition 14 (HAC 14)

Kristin Wallick, MD, FCCP

Case: A 72 year old male with tracheobronchomalacia underwent a fiberoptic bronchoscopy, right thoracotomy, and tracheal bronchoplasty. Prior to surgery, he had a PICC line placed by intervention radiology due to poor venous access without complication. Postoperatively he developed a right pneumothorax requiring chest tube placement. A Hospital-Acquired Condition (HAC) 14, iatrogenic pneumothorax with venous catheterization was attributed to this patient.

The HAC Reduction Program (HACRP) is a Medicare Value-Based-Purchasing (VBP) program that supports the Centers for Medicare and Medicaid Services’ (CMS’) effort to link Medicare payments to healthcare quality in the inpatient hospital setting. Under the program, CMS reduces overall Medicare payments for hospitals that rank in the worst-performing quartile of all hospitals on measures of Hospital-Acquired Conditions (HACs). On an annual basis, CMS evaluates overall hospital performance by calculating total HAC Scores based on the equally weighted average of scores of program measures. Hospitals with a total HAC score greater than the 75th percentile of all total HAC scores will receive a 1-percent payment reduction. This payment adjustment applies to all Medicare discharges for the applicable fiscal program year when CMS pays hospital claims. CMS uses the Total HAC Score to determine the worst-performing quartile of hospitals based on data for six quality measures. (1)

Over the past three years, data analysis at our institution has demonstrated a lack of a temporal relationship and correlation between central venous catheterization and pneumothorax for HAC-14. Currently, HAC-14 only requires the presence of a diagnosis code of postoperative pneumothorax (J9.5811), not present on admission, with any of the central line procedure codes. There are no exclusions and no options to link or unlink the diagnosis code to the procedure code regardless of the temporal correlation of the procedure or etiology of the pneumothorax. If both codes are listed on the coding summary, the HAC will be triggered, even if no temporal or causal relationship exists. The intention of the HAC 14 is to track the incidence of iatrogenic pneumothorax from central line placement. The goal is to provide data to institutions to determine quality improvement opportunities associated with central line placements. There is no opportunity for any intervention to decrease the incidence of the HAC 14 in our patient as the etiology of the pneumothorax is not the central line. For complication metrics to be impactful and accurate, the coding of this HAC-14 must have a clear association and etiology.

The use of central venous catheters has become the standard practice for the administration of chemotherapy, vasopressors, intravenous fluid or blood products, and parenteral nutrition. Central venous catheters are common among critically ill patients. More than five million central venous catheters are inserted in the United States each year. (2). In the United States in 2014, over 15 million catheter-days/year were recorded in the intensive care unit alone. (3). The incidence of pneumothorax with central line placement ranges from 1-3% in the medical literature. (4,5).

If an ICD 10 -CM code set does not exist, requests can be made through the ICD-10-CM Classification Team at the National Center for Health Statistics (NCHS) Centers for Disease Control and Prevention (CDC). We have requested new ICD 10 diagnosis codes under the J95.811 postprocedural pneumothorax with the intent to add a revision to the HAC 14 inclusion criteria with these diagnosis codes. These new codes would specify if the pneumothorax was due to a central line or vascular line placement. This approach would also require NCHS to update their inclusion codes to require one of these two new codes and remove the code J95.811 from the HAC 14 inclusion list. Currently an internal review and consideration are underway.