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Title: Documenting, Coding, and Reporting Healthcare-Associated Infections (HAIs) Used in CMS’ Hospital Inpatient Quality Reporting (IQR) Program

Original Presentation Date: Thursday, May 19, 2016

Learning Objectives:

  • Identify pertinent documentation details required to identify, report, and assign specific ICD-10-CM/PCS codes and present on admission (POA) indicators for the following healthcare-associated infections (HAIs):
    • Central line-associated bloodstream infection (CLABSI)
    • Catheter-associated urinary tract infection (CAUTI)
    • Surgical Site Infections (SSIs ) following abdominal hysterectomy or colon surgery
    • Clostridium difficile (C.diff) infection
    • Methicillin-resistant Staphylococcus aureus (MRSA) infection
  • Recognize the difference in how CLABSI, CAUTI, and SSIs are identified as a HAC from the claims data for MS-DRG assignment versus how they are reported and identified for the HAC Reduction Program.
  • Recall the criteria for identifying an HAI, and for including and excluding cases from reporting for each measure in the hospital IQR program.
  • Access the appropriate specification manuals, training materials and tools for reporting HAIs on the CDC’s National Healthcare Safety Network (NHSN) and the CMS QualityNet website.

Presenter: Lynn-Marie Wozniak, MS, RHIT

Lynn is a Content Manager and subject matter expert for the Revenue Cycle, Coding and Compliance segment of Elsevier. She has 35 years of experience in hospital reimbursement consulting, health services research, health policy review, and development. She is a recognized expert in patient classification systems, DRG systems, data quality evaluation, and in the analysis and interpretation of case mix data. Over the years, Lynn has held several elected and appointed positions with AHIMA, NYHIMA, and AdHIMA, including President and member of the Board of Directors of NYHIMA, and member of the AHIMA Council of Accreditation. She is currently Chair of the Commission on Certification for Health Informatics and Information Management (CCHIIM). She is a past recipient of AHIMA’s Professional Achievement Award, and New York Health Information Management Association Distinguished Member.

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