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Impact of the Centers for Medicare and Medicaid Services Hospital-Acquired Conditions Policy on Billing Rates for 2 Targeted Healthcare-Associated Infections

  • Alison Tse Kawai (a1), Michael S. Calderwood (a1) (a2), Robert Jin (a1), Stephen B. Soumerai (a1), Louise E. Vaz (a3), Donald Goldmann (a4) (a5) and Grace M. Lee (a1) (a5)...

The 2008 Centers for Medicare & Medicaid Services hospital-acquired conditions policy limited additional payment for conditions deemed reasonably preventable.


To examine whether this policy was associated with decreases in billing rates for 2 targeted conditions, vascular catheter-associated infections (VCAI) and catheter-associated urinary tract infections (CAUTI).


Adult Medicare patients admitted to 569 acute care hospitals in California, Massachusetts, or New York and subject to the policy.


We used an interrupted times series design to assess whether the hospital-acquired conditions policy was associated with changes in billing rates for VCAI and CAUTI.


Before the policy, billing rates for VCAI and CAUTI were increasing (prepolicy odds ratio per quarter for VCAI, 1.17 [95% CI, 1.11–1.23]; for CAUTI, 1.19 [1.16–1.23]). The policy was associated with an immediate drop in billing rates for VCAI and CAUTI (odds ratio for change at policy implementation for VCAI, 0.75 [95% CI, 0.69–0.81]; for CAUTI, 0.87 [0.79–0.96]). In the postpolicy period, we observed a decreasing trend in the billing rate for VCAI and a leveling-off in the billing rate for CAUTI (postpolicy odds ratio per quarter for VCAI, 0.98 [95% CI, 0.97–0.99]; for CAUTI, 0.99 [0.97–1.00]).


The Centers for Medicare & Medicaid Services hospital-acquired conditions policy appears to have been associated with immediate reductions in billing rates for VCAI and CAUTI, followed by a slight decreasing trend or leveling-off in rates. These billing rates, however, may not correlate with changes in clinically meaningful patient outcomes and may reflect changes in coding practices.

Infect. Control Hosp. Epidemiol. 2015;36(8):871–877

Corresponding author
Address correspondence to Alison Tse Kawai, Department of Population Medicine, Harvard Pilgrim Health Care Institute, 133 Brookline Ave, Boston, MA 02215 (
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1. Hospital-acquired conditions and present on admission indicator reporting provision. Available at:
2. Deficit Reduction Act Sec. 5001. Hospital Quality Improvement. Available at
3. McNair, PD, Luft, HS, Bindman, AB. Medicare’s policy not to pay for treating hospital-acquired conditions: the impact. Health Aff (Millwood) 2009;28:14851493.
4. McHugh, M, Van Dyke, K, Osei-Anto, A, Haque, A. Medicare’s payment policy for hospital-acquired conditions: perspectives of administrators from safety net hospitals. Med Care Res Rev 2011;68:667682.
5. McNutt, R, Johnson, TJ, Odwazny, R, et al. Change in MS-DRG assignment and hospital reimbursement as a result of Centers for Medicare & Medicaid changes in payment for hospital-acquired conditions: is it coding or quality? Qual Manag Health Care 2010;19:1724.
6. Wald, H, Richard, A, Dickson, VV, Capezuti, E. Chief nursing officers’ perspectives on Medicare’s hospital-acquired conditions non-payment policy: implications for policy design and implementation. Implement Sci 2012;7:78.
7. Hartmann, CW, Hoff, T, Palmer, JA, Wroe, P, Dutta-Linn, MM, Lee, G. The Medicare policy of payment adjustment for health care-associated infections: perspectives on potential unintended consequences. Med Care Res Rev 2012;69:4561.
8. Huang, SS, Placzek, H, Livingston, J, et al. Use of Medicare claims to rank hospitals by surgical site infection risk following coronary artery bypass graft surgery. Infect Control Hosp Epidemiol 2011;32:775783.
9. Calderwood, MS, Kleinman, K, Bratzler, DW, et al. Use of Medicare claims to identify US hospitals with a high rate of surgical site infection after hip arthroplasty. Infect Control Hosp Epidemiol 2013;34:3139.
10. Bozic, KJ, Grosso, LM, Lin, Z, et al. Variation in hospital-level risk-standardized complication rates following elective primary total hip and knee arthroplasty. J Bone Joint Surg Am 2014;96:640647.
11. Shahian, DM, Silverstein, T, Lovett, AF, Wolf, RE, Normand, SL. Comparison of clinical and administrative data sources for hospital coronary artery bypass graft surgery report cards. Circulation 2007;115:15181527.
12. Romano, PS, Mull, HJ, Rivard, PE, et al. Validity of selected AHRQ patient safety indicators based on VA National Surgical Quality Improvement Program data. Health Serv Res 2009;44:182204.
13. Kaafarani, HM, Rosen, AK. Using administrative data to identify surgical adverse events: an introduction to the Patient Safety Indicators. Am J Surg 2009;198:S63S68.
14. Hechenbleikner, EM, Makary, MA, Samarov, DV, et al. Hospital readmission by method of data collection. J Am Coll Surg 2013;216:11501158.
15. Zhan, C, Elixhauser, A, Richards, CL Jr, et al. Identification of hospital-acquired catheter-associated urinary tract infections from Medicare claims: sensitivity and positive predictive value. Med Care 2009;47:364369.
16. Meddings, J, Saint, S, McMahon, LF Jr. Hospital-acquired catheter-associated urinary tract infection: documentation and coding issues may reduce financial impact of Medicare’s new payment policy. Infect Control Hosp Epidemiol 2010;31:627633.
17. Meddings, JA, Reichert, H, Rogers, MA, Saint, S, Stephansky, J, McMahon, LF. Effect of nonpayment for hospital-acquired, catheter-associated urinary tract infection: a statewide analysis. Ann Intern Med 2012;157:305312.
18. Meddings, JA, Reichert, H, Hofer, T, McMahon, LF Jr. Hospital report cards for hospital-acquired pressure ulcers: how good are the grades? Ann Intern Med 2013;159:505513.
19. Lee, GM, Kleinman, K, Soumerai, SB, et al. Effect of nonpayment for preventable infections in US hospitals. N Engl J Med 2012;367:14281437.
20. Schuller, K, Probst, J, Hardin, J, Bennett, K, Martin, A. Initial impact of Medicare’s nonpayment policy on catheter-associated urinary tract infections by hospital characteristics. Health Policy 2014;115:165171.
21. Peasah, SK, McKay, NL, Harman, JS, Al-Amin, M, Cook, RL. Medicare non-payment of hospital-acquired infections: infection rates three years post implementation. Medicare Medicaid Res Rev 2013:3.
22. Centers for Medicare and Medicaid Services. Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 2008 rates. Fed Regist 2007;72:4712948175.
23. Healthcare Cost and Utilization Project. Overview of the State Inpatient Databases. Available at:
24. American Hospital Association. American Hospital Association Annual Survey Database Fiscal Year 2009. Chicago: American Hospital Association, 2010.
25. Centers for Medicare & Medicaid Services. Hospital-acquired conditions (present on admission indicator): coding. Available at Accessed August 4, 2014.
26. Waters, TM, Daniels, MJ, Bazzoli, GJ, et al. Effect of Medicare’s nonpayment for hospital-acquired conditions: lessons for future policy. JAMA Intern Med 2015;175:347354.
27. Tehrani, DM, Russell, D, Brown, J, et al. Discord among performance measures for central line–associated bloodstream infection. Infect Control Hosp Epidemiol 2013;34:176183.
28. Cass, AL, Kelly, JW, Probst, JC, Addy, CL, McKeown, RE. Identification of device-associated infections utilizing administrative data. Am J Infect Control 2013;41:11951199.
29. Tukey, MH, Borzecki, AM, Wiener, RS. Validity of ICD-9-CM codes for the identification of complications related to central venous catheterization. Am J Med Qual 2013;30:5257.
30. Stevenson, KB, Khan, Y, Dickman, J, et al. Administrative coding data, compared with CDC/NHSN criteria, are poor indicators of health care-associated infections. Am J Infect Control 2008;36:155164.
31. Tehrani, DM, Cao, C, Kwark, H, Huang, SS. Estimated burden of methicillin-resistant Staphylococcus aureus in California hospitals after changes to administrative codes, 2005-2010. Infect Control Hosp Epidemiol 2013;34:12181221.
32. Centers for Medicare and Medicaid Services. Medicare program;hospital inpatient value-based purchasing program. Final rule. Fed Regist 2011;76:2649026547.
33. Centers for Medicare and Medicaid Services. Medicaid program;payment adjustment for provider-preventable conditions including health care-acquired conditions. Final rule. Fed Regist 2011;76:3281632838.
34. Felt-Lisk, S. Project evaluation activity in support of Partnership for Patients: Task 2 Evaluation Progress Report: Washington, DC, July 7, 2014. Available at: Accessed January 14, 2015.
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