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

This webinar will describe the documentation details required to identify, report and assign specific ICD-10-CM/PCS codes and present on admission (POA) indicators for the health-associated infections (HAIs) CLABSI, CAUTI, SSIs, MRSA, and C.diff– used in Centers for Medicare and Medicaid Services (CMS) Hospital Inpatient Quality Reporting (IQR) and Hospital-Acquired Conditions (HAC) Reduction Programs. How the measures are defined and reported to the CDC and CMS will be explained along with the criteria for which cases to report. Information will be provided on where and how to access the specification manuals, training materials and reporting tools.

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Original presentation date

May 19, 2016

Viewing the recording does not constitute eligibility to receive a CE. Only attendees of the live event are eligible to receive a CE Certificate.

Learning objectives

By the end of this webinar participants will be able to:

  • 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.


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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