Influence of Reportable Diagnoses on Quality of Care in Maryland
Accurate and appropriate documentation significantly impacts the quality of care provided to patients. Healthcare quality scores are now publicly reported and used by patients and private payers for decision-making. Organizations like CAPHIS, Health Care For All, HealthGrades, and NAHQ play crucial roles in evaluating and promoting healthcare quality. Various reputable organizations such as Leapfrog Group and NCQA provide resources and information to improve healthcare quality across the US.
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Impact of Reportable Diagnoses on quality of Care Maryland ACDIS CCDS Exam Prep Candace Blankenship, BSN, RN, CCDS cblanke4@jhmi.edu
The most important outcome of accurate and appropriate documentation is its influence on demonstrating the quality of care provided to the patient
Healthcare quality scores are now publically reported Used by patients to make healthcare decisions regarding care Used by private payers when negotiating payments
Quality of Care Organizations Consumer and Patient Health Information Section (CAPHIS) of the MLA The Consumer and Patient Health Information Section (CAPHIS) of the Medical Library Association (MLA) evaluates medical websites based on credibility, sponsorship/authorship, content, audience, currency, disclosure, purpose, links, design, interactivity, and disclaimers. The website serves as a useful directory for specific research and educational needs. Health Care For All s Consumer Health Quality Council The Consumer Health Quality Council is a coalition of Health Care For All, a Massachusetts consumer health advocacy organization. The Consumer Council empowers those impacted by health care quality issues to have a voice in our health care system, to engage fellow consumers to be active partners in their health care, and to advocate for high quality, safe, and accessible health care for all Massachusetts residents. Consumer Council members work on a variety of educational and advocacy initiatives and convene monthly to discuss health care quality issues. Health Grades HealthGrades provides rated profiles for hospitals, nursing homes, physicians, consumers, corporations, and health plans. The website features two distinct search engines for hospitals and physicians. LeapFrog Group The Leapfrog Group is a voluntary program that strives to enforce leaps and improvements in U.S. health care quality. Leapfrog calls attention to and rewards organizations who have exemplified such noteworthy behavior. Their website features specific content for consumers, members, hospitals, and data partners. National Association for Healthcare Quality (NAHQ) The National Association for Healthcare Quality (NAHQ) is an organization for health care professionals. Their website provides information on the Journal of Healthcare Quality as well as affiliated organizations and publications. National Committee for Quality Assurance (NCQA) The National Committee for Quality Assurance (NCQA) provides information on accreditation programs, publications, products, education, and events. The website also features articles on various health care topics. National Quality Forum (NQF) The National Quality Forum (NQF) is private, non-profit organization that measures national health care quality. Their website includes an area to browse healthcare topics, opportunities for members, and publications. Premier Safety Institute, Inc. The Premier Safety Institute, Inc., provides resources for both patients and health care professionals. Their website is designed to provide safety resources and tools to promote a safe health care delivery environment for patients, workers, and their communities. https://www.npsf.org/general/recommended_links.asp?
The ability to measure quality of care and demonstrate facility improvement in providing health care to the community is a requirement that will continue to be mandatory
Extracting data manually for submission (subjective) versus submitting the final coding used for reimbursement (objective) Using APR-DRG grouper to obtain SOI and ROM scoring to identify acuity of illness for their patients versus risk adjusted mortality rated and monitoring case-mix index to identify acuity of illness for their patients Coding for reimbursement versus coding for quality of care Holding the final bill for review versus resubmitting data for quality scoring before the quarter closes
CMS Methodology Tools Hospital Consumer Assessment of Healthcare Providers and Systems Hierarchal Condition Coding (HCC) Hospital Acquired Conditions (HAC) PSI 90 (Patient Safety Indicators)
Hospital Consumer Assessment of Healthcare Providers Survey (HCAHPS) Eligible to participate: 18 yrs or older at time of admission At least one overnight stay as an inpatient Non-psychiatric principle diagnosis at discharge Alive at time of discharge Excluded from participating: Patients discharged to hospice, nursing homes or skilled nursing facilities Court/Law enforcement patients (prisoners) Patients with a foreign home address No publicity patients
Hospital Consumer Assessment of Healthcare Providers Survey (HCAHPS) Communication between patient and nurse Communication between patient and physician How quickly did staff respond to the patient s needs How well was the patient s pain controlled How clean was your room How quiet was your unit at night How well did you understand your discharge instructions How would you rate the overall hospital performance Would you recommend the hospital to your relatives and friends www.hospitalcompare.hhs.gov
Hierarchal Condition Coding (HCC) Hierarchal Condition Coding Prospective model: diagnoses in one year are used to predict cost for the following year HCC follows a calendar year The slate is wiped clean every Jan 1st The coded encounter must be face to face HCC is based on ICD 10 only (no CPT, HCPCS, PCS codes count) MEAT HCCs include patient demographics: age, gender, patient s status related to disability (<65), original reason for entitlement (>65 but Mcare prior to 65) and low income status (Medicaid eligible) A record can have more than one HCC https://www11.empireblue.com/provider/noapplication/f2/s2/t4/pw_g312 847.pdf?refer=ehpprovider https://www.medpartners.com/risk-adjustment-cms-hcc-101/
Hierarchal Condition Coding (HCC) If this is documented: It does not risk adjust It this is documented: It risks adjusts Cardiac dysrhythmia I49.9 Cardiac dysrhythmia, NOS Atrial fibrillation I48.91 Afib, NOS Bronchitis J40 Bronchitis, NOS Chronic obstructive bronchitis Morbid obesity J44.9 COPD, NOS Obesity E66.9 Obesity, NOS E66.01 Morbid obesity Hx of breast cancer Z85.3 Personal hx of breat cancer Breast cancer C50.919 Malignant neoplasm of breast, NOS J13 Pneumonia due to S. pneumoniae Pneumonia J18.9 Pneumonia, NOS Pneumococcal pneumonia
Table 1. HCCs included in the CMS-HCC risk-adjustment model HCC1 = HIV/AIDS HCC2 = Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock HCC6 = Opportunistic Infections HCC8 = Metastatic Cancer and Acute Leukemia HCC9 = Lung and Other Severe Cancers HCC10 = Lymphoma and Other Cancers HCC11 = Colorectal, Bladder, and Other Cancers HCC12 = Breast, Prostate, and Other Cancers and Tumors HCC17 = Diabetes with Acute Complications HCC18 = Diabetes with Chronic Complications HCC19 = Diabetes without Complication HCC21 = Protein-Calorie Malnutrition HCC22 = Morbid Obesity HCC23 = Other Significant Endocrine and Metabolic Disorders
Table 1. HCCs included in the CMS-HCC risk-adjustment model HCC27 = End-Stage Liver Disease HCC28 = Cirrhosis of Liver HCC29 = Chronic Hepatitis HCC33 = Intestinal Obstruction/Perforation HCC34 = Chronic Pancreatitis HCC35 = Inflammatory Bowel Disease HCC39 = Bone/Joint/Muscle Infections/Necrosis HCC40 = Rheumatoid Arthritis and Inflammatory Connective Tissue Disease HCC46 = Severe Hematological Disorders HCC47 = Disorders of Immunity HCC48 = Coagulation Defects and Other Specified Hematological Disorders HCC54 = Drug/Alcohol Psychosis HCC55 = Drug/Alcohol Dependence HCC57 = Schizophrenia HCC58 = Major Depressive, Bipolar, and Paranoid Disorders
Table 1. HCCs included in the CMS-HCC risk-adjustment model HCC70 = Quadriplegia HCC71 = Paraplegia HCC72 = Spinal Cord Disorders/Injuries HCC73 = Amyotrophic Lateral Sclerosis and Other Motor Neuron Disease HCC74 = Cerebral Palsy HCC75 = Myasthenia Gravis/Myoneural Disorders, Inflammatory and Toxic Neuropathy HCC76 = Muscular Dystrophy HCC77 = Multiple Sclerosis HCC78 = Parkinson's and Huntington's Diseases HCC79 = Seizure Disorders and Convulsions HCC80 = Coma, Brain Compression/Anoxic Damage
Table 1. HCCs included in the CMS-HCC risk-adjustment model HCC82 = Respirator Dependence/Tracheostomy Status HCC83 = Respiratory Arrest HCC84 = Cardio-Respiratory Failure and Shock HCC85 = Congestive Heart Failure HCC86 = Acute Myocardial Infarction HCC87 = Unstable Angina and Other Acute Ischemic Heart Disease HCC88 = Angina Pectoris HCC96 = Specified Heart Arrhythmias HCC99 = Cerebral Hemorrhage HCC100 = Ischemic or Unspecified Stroke HCC103 = Hemiplegia/Hemiparesis HCC104 = Monoplegia, Other Paralytic Syndromes HCC106 = Atherosclerosis of the Extremities with Ulceration or Gangrene HCC107 = Vascular Disease with Complications
Table 1. HCCs included in the CMS-HCC risk-adjustment model HCC108 = Vascular Disease HCC110 = Cystic Fibrosis HCC111 = Chronic Obstructive Pulmonary Disease HCC112 = Fibrosis of Lung and Other Chronic Lung Disorders HCC114 = Aspiration and Specified Bacterial Pneumonias HCC115 = Pneumococcal Pneumonia, Empyema, Lung Abscess HCC122 = Proliferative Diabetic Retinopathy and Vitreous Hemorrhage HCC124 = Exudative Macular Degeneration HCC134 = Dialysis Status HCC135 = Acute Renal Failure HCC136 = Chronic Kidney Disease, Stage 5 HCC137 = Chronic Kidney Disease, Severe (Stage 4) HCC157 = Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone HCC158 = Pressure Ulcer of Skin with Full Thickness Skin Loss HCC161 = Chronic Ulcer of Skin, Except Pressure
Table 1. HCCs included in the CMS-HCC risk-adjustment model HCC162 = Severe Skin Burn or Condition HCC166 = Severe Head Injury HCC167 = Major Head Injury HCC169 = Vertebral Fractures without Spinal Cord Injury HCC170 = Hip Fracture/Dislocation HCC173 = Traumatic Amputations and Complications HCC176 = Complications of Specified Implanted Device or Graft HCC186 = Major Organ Transplant or Replacement Status HCC188 = Artificial Openings for Feeding or Elimination HCC189 = Amputation Status, Lower Limb/Amputation Complications https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/PhysicianFeedbackProgram/Downloads/2015-RiskAdj- FactSheet.pdf
2016 Hospital-Acquired Conditions Foreign object retained after surgery Air embolism Blood incompatibility Stage 3 and 4 pressure ulcers Falls and trauma (fxs, dislocations, intracranial injuries, crushing injuries, burn, other injuries) Manifestation of poor glycemic control (DKA, nonketotic hyperosmolar coma, hypoglycemic coma, secondary DM with ketoacidosis, secondary DM with hyperosmolarity) Catheter associated UTI Vascular catheter associated infection Surgical site infection following bariatric surgery Surgical site infection following CABG Surgical site infection for spine, neck, shoulder or elbow ortho procedures Surgical site infections following cardiac implantable electrical device DVT/PE following ortho procedure (TKR/THR) Iatogenic pneumothorax with venous catheterization Surgical site infection for colon and abd hysterectomy procedures
PSI 90 Composite for 2018 Indicator Number Indicator Name PSI-90 Version 5.0.1 Version 5.0.1 Weight PSI-90 Version 6.0.1 Version 6.0.1 Weight PSI #3 Pressure Ulcer Rate Yes 0.0391 Yes 0.0504 Iatrogenic Pneumothorax Rate PSI #6 Yes 0.0905 Yes 0.0531 Central Venous CRBSI Rate PSI #7 Yes 0.0301 No (removed) NA Postoperative Hip Fracture Rate PSI #8 Yes 0.0025 Yes 0.0109 Perioperative Hemorrhage/ Hematoma Rate PSI #9 No NA Yes (added) 0.0691 Physiologic and Metabolic Derangement Rate PSI #10 No NA Yes (added) 0.0575 Postoperative Respiratory Failure Rate Perioperative PE DVT Rate Postoperative Sepsis Rate Postoperative Wound Dehiscence Rate PSI #11 No NA Yes (added) 0.3045 PSI #12 Yes 0.357 Yes (re-specified) 0.1839 PSI #13 Yes 0.0798 Yes 0.2552 PSI #14 Yes 0.0183 Yes 0.0104 Accidental Puncture or Laceration Rate PSI #15 Yes 0.3827 Yes (re-specified) 0.0052
Program for Evaluating Payment Patterns Electronic Report (PEPPER) PEPPER is an electronic data report that contains a single hospital s claims data statistics for Medicare-severity diagnosis related groups (DRGs) and discharges at risk for improper payment due to billing, coding and/or admission necessity issues. Each PEPPER contains statistics for the most recent twelve federal fiscal quarters for each area at risk for improper payments (referred to in the report as target areas ). PEPPER target areas are: Stroke from intracranial hemorrhage, respiratory infections, simple pneumonia, sepsis, unrelated OR procedure, medical DRGS with a CC or MCC, surgical DRGs with CC or MCC, single CC or MCC, excisional debridement, ventilator support, TIA, COPD, percutaneous cardiovascular procedures, syncope, 3 day skilled nursing facility qualifying admissions, spinal fusions, 30 day readmissions, 2 day stays and 1 day stays Reviewed if you fall in the highest quartile or in the lowest quartile https://www.pepperresources.org/
Quality Metrics Used by CMS Based on quality data submitted for Medicare beneficiaries Monitors care in acute care hospitals Excluded: LTC, cancer hospitals, children s hospitals, inpatient rehab facilities, inpatient psych facilities or critical care access hospitals Medicare (original) beneficiary for 12 months prior to admission and 30 days after admission
Quality Metrics Used by CMS Hospital value-based purchasing (HVBP) Hospital-Acquired Condition (HAC) Reduction Program (HACRP) Hospital Readmissions Reduction Program 30-day mortality measures
Hospital value-based purchasing (HVBP) Rewards acute care hospitals with incentive payments when meeting certain quality of care standards These quality of care standards are reviewed and revised every year for appropriateness A percentage of payment is withheld from a participating facility s DRG payment (2%) CMS calculates a facility's quality score based on use of best clinical practices and enhancements to the patient experience Performance is measured against other hospitals (peers) as well as against the previous year s quality performance for the specific facility (improvement) Domains included in the HVBP: Safety (25%), Clinical Care (25%), Efficiency and Cost Reduction (25%) and Patient and Caregiver-Centered Experience of Care/care Coordination* (25%) https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf https://www.stratishealth.org/documents/HAC_fact_sheet.pdf
Hospital value-based purchasing (HVBP Measure ID CAUTI CLABSI CDI MRSA PSI-90 PC-01 SSI Mort-30-AMI Mort-30-HF Mort-30-PN MSPB-1 HCAHP survey Measure Description Cath assoc UTI Central Line Blood Stream Infect Cl Diff Infect Meth Resist Staph Aur bacteremia Pt Safety for Selected Indicators Elect delivery prior to 39 weeks Surg site infect for colon/abd hyst 30 day mortality AMI 30 day mortality HF 30 day mortality PNA Medicare spending per beneficiary Communication, responsiveness, cleanliness, quietness, d/c information, overall hosp rating Domain Safety Safety Safety Safety Safety Safety Safety Clinical Care Clinical Care Clinical Care Efficiency/Cost Reduction Patient Experience
Hospital-Acquired Condition Reduction Program (HACRP) Conditions considered reasonably preventable based on established evidence-based guidelines. The facility will receive no payment for these conditions that occur during the admission (not POA). The case would be paid as if the secondary diagnosis did not exist. A percent of the fee is withheld from the initial payment (1%) When the HAC scores are calculated for the facility at the end of the year, the payment will only be returned if the facility scores do not place it in the worst performing quartile. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC- Reduction-Program.html
2016 Hospital-Acquired Conditions Foreign object retained after surgery Air embolism Blood incompatibility Stage 3 and 4 pressure ulcers Falls and trauma (fxs, dislocations, intracranial injuries, crushing injuries, burn, other injuries) Manifestation of poor glycemic control (DKA, nonketotic hyperosmolar coma, hypoglycemic coma, secondary DM with ketoacidosis, secondary DM with hyperosmolarity) Catheter associated UTI Vascular catheter associated infection Surgical site infection following bariatric surgery Surgical site infection following CABG Surgical site infection for spine, neck, shoulder or elbow ortho procedures Surgical site infections following cardiac implantable electrical device DVT/PE following ortho procedure (TKR/THR) Iatogenic pneumothorax with venous catheterization Surgical site infection for colon and abd hysterectomy procedures
Hospital Readmission Reduction Program (HRRP) HRRP is a pay-for performance program that lowers payments to IPPS hospitals with too many readmissions The HRRP was established under the Affordable Care Act to make Americans health care better by linking payment to the quality of hospital care. It gives hospitals strong financial incentive to: Make their communication and care coordination efforts better Work better with patients and caregivers on post-discharge planning Excess Readmission Ratio (ERR) is used to gauge hospital performance for predicted-to-expected readmissions for AMI, COPD, HF, PNA, CABG and THA/TKA 1.0 is the magic number for 2018. In 2019, it is the median of your peers. https://www.cms.gov/medicare/medicare-fee-for-service- payment/acuteinpatientpps/readmissions-reduction-program.html https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based- Programs/HRRP/Hospital-Readmission-Reduction-Program.html
Hospital Readmission Reduction Program (HRRP) Measure Name Number of Discharges 810 275 617 1053 342 Number or Readmissions 120 38 112 209 20 ERR 30 readm AMI 30 readm CABG 30 readm COPD 30 readm HF 30 readm Hip/Knee 30 readm PNA 0.9875 1.0499 0.9891 0.9506 1.1004 656 120 1.0855 CMS publishes the payment adjustment percentages for all hospitals each year in August. Hospitals with <25 eligible discharges for any measure will not use ERR.
Hospital Readmission Reduction Program (HRRP) The 30 day risk standardized readmission measures include: All-cause unplanned readmissions that happen within 30 days of discharge from the initial (index) admission Patients who are readmitted to the same hospital or another applicable acute care hospital for any reason, no matter what the principle diagnosis was. Exclusions: death, transfer patients, admissions with 0 days to subsequent hospitalization, AMA. Risk adjustment: age, sex, HCC comorbidities and socioeconomic demographic https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/HomeHealthQualityInits/Downloads/PPR_Risk_Adjustment_Method ology_07DEC2016-508-v3.pdf
Hospital Readmission Reduction Program (HRRP) Risk adjustment is driven by secondary diagnoses Acuity of the coded condition Specificity of the coded condition Sequelae of the coded condition Manifestations of the coded condition Accurate capture of secondary diagnoses that impact risk adjustment will impact the readmission ratio Moving the physician from focusing on the consequence of documenting a complication to focusing on accurately describing the patient s severity of illness and risk of mortality that impacted the patient outcome
30 Day Mortality Deaths from any cause within 30 days of a hospital admission for measured conditions Deaths are risk adjusted (POA) (Palliative POA) Facility is compared to national mortality rates (worst quartile gets the penalty) Conditions that are included in the 30 day mortality measure: COPD, AMI, HF, PNA, CVA and CABG* *Sepsis mortality is a separate measure
30 Day Mortality Mortality Scoring Methodologies 1. HSMR2 (Hospital Standardized Mortality Ratio v2) 2. ACA (Acute Care Admission Mortality Ratio) 3. UHC (University Hospital Consortium) 4. APACHE (Acute Physiology, Age and Chronic Health Evaluation Systems) 5. SAPS (Simplified Acute Physiology Score) 6. MPM (Mortality Prediction Models) 7. POSSUM (Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity)
30 Day Mortality 10 most weighted variables for Vizient 1. Ventilator POA (+/-2 days from admission date) 2. Shock 3. DNR (anytime during admission) 4. Malnutrition (secondary diagnosis) 5. CC Metastatic Cancer (secondary diagnosis) 6. Respiratory Failure 7. CC Fluid and Electrolyte disorder 8. Severe brain/spinal disorder 9. Coagulopathy 10. Admission source Transfer from another facility Transfer from a skilled nursing home Transfer from an intermediate care facility* Transfer from critical access hospital (rural hospital) Transfer from Hospice Patient > 85 years of age
Observed/Expected (O/E) Observed mortality. The actual number of patients that died in the hospital each month. Expected mortality. The expected average of hospitalized patient deaths with a particular illness or condition that are beyond the control of the medical center, such as age, gender and other medical problems The meaning of an O/E ratio depends on the score. Equal to 1.5. The hospital's mortality rate is higher than expected. Equal to 1.0. The hospital's mortality rate is equal to what is expected. Equal to 0.75. The hospital's mortality rate is 25 percent lower than expected. Equal to 0.50. The hospital's mortality rate is 50 percent lower than expected.
Observed/Expected (O/E) Inpatient Quality Indicator 12: Coronary Artery Bypass Graft (CABG) Mortality Rate Description: In hospital deaths per 1,000 discharges with coronary artery bypass graft (CABG), ages 40 years and older. Excludes obstetric discharges and transfers to another hospital. Numerator: Number of deaths (DISP=20) among cases meeting the inclusion and exclusion rules. Denominator: Discharges, for patients ages 40 years and older, with any listed ICD 10 PCS procedure code for CABG. Exclusions: Transferring to another short term hospital (DISP=2). MDC 14 (pregnancy, childbirth, and puerperium). With missing discharge disposition (DISP=missing), gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing) or principal diagnosis (DX1=missing).
CDI Impact on Quality Initiatives Accurate and complete documentation Proper reimbursement for services Accurate quality scoring Full return of incentive payments
CDI Impact on Quality Initiatives Physician Education Effective use of queries POA status for documented conditions Full and complete documentation of secondary diagnoses that describe the individual patient s severity of illness and risk of mortality
Practice Question 1 Which of the following is an example of a reportable hospital acquired condition (HAC) to CMS? A. Fat embolism B. IV infiltration C. Pneumonia D. Fractured metatarsal https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/HospitalAcqCond/icd10_hacs.html Look at the Excel spreadsheet. The HAC category populates along the bottom tabs.
Practice Question 2 Which of the following is an example of documentation that would meet the present on admission (POA) criteria for coding? A. A diagnosis that is indicated in the history and physical and ruled out in the discharge summary B. A diagnosis found in a previous medical record C. A diagnosis that is listed as possible in the history and physical D. An acute condition identified on the 3rd day of admission
Practice Question 3 Accurate documentation should 1. Include identification of the patient s SOI 2. Identify conditions that are present on admission (POA) 3. Support medical necessity A. 1 and 2 B. 2 and 3 C. 1 and 3 D. 1, 2, and 3
Practice Question 4 Which of the following indicators is not usually included when reporting physician profiles? A. Individual CMI B. Length of stay C. Risk of mortality (ROM) D. Dollars charged per hour
Practice Question 5 Which of the following postoperative conditions could potentially impact a facility s PSI-90 score as measured by CMS? A. Sepsis B. UTI C. Central line infection D. Pneumonia
Practice Question 6 When performing analysis of PEPPER (Program for Evaluating Payment Patterns Electronic Report) outlier data, which strategy should be considered first for reducing outliers? A. Identify patterns related to the significant outliers B. Perform case reviews to identify opportunities to fix outliers C. Complete coding audit of DRG outliers and educate coding staff D. Conduct case review to identify opportunities for physician education https://www.pepperresources.org/Portals/0/Documents/PEPPER/ST/STPEPPE RUsersGuide_Edition25_508.pdf
Practice Question 7 How is an observed to expected mortality ratio of greater than 1 interpreted? A. Expected death rate is higher than the actual death rate B. No correlation between actual and expected deaths C. Actual death rate is higher than the expected death rate D. Number of expected and actual deaths is equal
Practice Question 8 Which of the following measurements captures the most accurate view of patient outcomes? A. Readmission rates B. CC/MCC capture rates C. SOI/ROM D. PSA-90 score
Practice Question 9 Which of the following external organizations provides publicly reportable data regarding the severity of illness of individual facilities or physicians? A. Healthline B. Heathgrades C. WebMD D. CMS
Practice Question 10 Conditions that are high cost and/or high volume and could have been reasonably prevented through application of evidence-based clinical guidelines are identified as: A. Present on admission diagnoses B. Hospital acquired conditions C. Patient safety indicators D. Hierarchal conditions
