2015 IPPS final rule: Quality measures can cause coding concerns

Quality measures, such as the Hospital Value-Based Purchasing (VBP) Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition (HAC) Reduction Program, form the basis of the 2015 IPPS final rule, released in early August.

 

Hospital administrators and their staff need to understand the changes finalized in the rule, as well as how the different quality measures interrelate.

 

"The 2015 IPPS rule emphasizes that hospitals, physicians, coders, and clinical documentation integrity staff must understand the risk-adjustment methodologies inherent to value-based purchasing, which are outlined on the Web," says James S. Kennedy, MD, CCS, CDIP, president of CDIMD -- Physician Champions in Smyrna, Tennessee. "These complex documentation requirements must be woven into the hospital's EMR fabric so as to not impede the physician's natural workflow or burden him or her with numerous post-discharge queries."

 

Some of the information and implications are less obvious, says Cheryl Ericson, MS, RN, CCDS, CDI-P, AHIMA-approved ICD-10-CM/PCS trainer, associate director of education for ACDIS and CDI education director for HCPro, a division of BLR, in Danvers, Massachusetts.

 

HACs are a group of "preventable" conditions identified by CMS that patients do not have upon admission to a hospital, but instead develop during the hospital inpatient admission. The Affordable Care Act requires CMS to reduce payment by 1% for hospitals that rank in the lowest-performing 25% for HACs.

 

In the 2014 IPPS final rule, CMS finalized the scoring method for calculating a HAC score for each hospital. The score consists of two domains. The first is based on Patient Safety Indicator (PSI) 90, an administrative claims-based measure. PSI 90 is a composite of eight measures:

The second domain is based on two healthcare-associated infection measures (plus a third measure, surgical site infections, to be added for FY 2016):

A score is calculated for each domain, and the two domains are weighted to determine a total HAC score.

 

The old HAC penalty was not a significant penalty for most organizations because it only excluded the CC or MCC associated with the HAC, Ericson says. Small community hospitals were more at risk for HAC penalties because they usually had only one CC or MCC per record. However, when it comes to the new scoring methodology, small community hospitals may have an edge over larger academic medical centers. The small community hospitals often have more manageable revenue cycle processes, so they look better in comparative measures.

 

VBP is composed of elements of the Hospital Inpatient Quality Reporting (Hospital IQR) Program, which allows CMS to pay hospitals that successfully report designated quality measures a higher annual increase to their payment rates.

 

Hospitals need to be aware of the increased penalty if they are in the bottom quartile, says Ericson. For 2015, the penalty will increase from 1.25% to 1.5%. "Then you have a separate penalty for readmission, a component of HVBP as well as its own measure, which can be in addition to the 1.5% for value-based purchasing and a potential HAC penalty. It really starts to add up."

 

Hospitals may not realize that these measures are comparative to other hospitals, Ericson says. "If you maintain the status quo and everyone around you becomes very aggressive in their efforts, you're going to be on the losing end."

 

CMS is finalizing a total of 63 measures (47 required and 16 voluntary electronic clinical quality measures) in the Hospital IQR Program measure set for the FY 2017 payment determination and subsequent years. It reduced the number of required measures from 57 to 47 and added 11 new measures (one chart-abstracted, four claims-based, and six voluntary electronic clinical quality measures).

 

For FY 2017, CMS will add two new safety measures and one new clinical care-process measure. The two new safety measures are for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and C. difficile.

 

CMS will also readopt the current version of CLABSI and remove these six "topped-out" clinical process measures:

 

When a measure is topped out, CMS does not see enough of a deviation between hospitals to make it worth using the measure any longer. "That should let you know how competitive the process is, when CMS has to drop measures because they have topped out," Ericson says.

 

However, just because a measure has topped out doesn't mean hospitals have resolved all of the problems associated with the measure. For example, discharge instructions for heart failure used to be a problem for hospitals, Ericson says. The measure only required discharge instructions if the patient was admitted for heart failure, but because coding occurs after discharge, there were often discrepancies when it came to heart failure being reported as the principal diagnosis.

 

As a result, hospitals began identifying all patients who had heart failure anywhere in their history and would then provide all of those patients with discharge instructions for heart failure, Ericson says. Just providing discharge instructions as a blanket measure doesn't necessarily meet CMS' intent when it created the measure.

 

"People have figured out work-arounds on some of these metrics, and they have topped out because everyone is doing so well on them," Ericson says. That said, just providing discharge instructions as a blanket measure doesn't necessarily meet CMS' intent for creating the measure.

 

Because CMS is removing the topped out measures, it will revise the domain weighting for FY 2017. In addition, CMS will adopt one new hospital-level risk-standardized complication rate following elective hip and knee arthroplasty measure with a 30-month performance period for FY 2019 and a 36-month performance period for FY 2020.

 

These measures often require organizations to evaluate their revenue cycle processes, Ericson says. Any weak link in the chain can erroneously lead to failures on these quality measures. For example, does the registration staff know how to accurately identify when a hip or knee arthroplasty is elective compared to non-elective i.e., urgent?

 

CMS finalized the third increase in the Hospital Readmissions Reduction Program maximum penalty, raising it from 2% to 3%, as required by the Affordable Care Act.

 

The readmissions reduction program began in 2013 with a 1% maximum reduction in payments for hospitals with excessive readmissions. The maximum penalty increased to 2% for FY 2014 and will be 3% in FY 2015.

CMS will assess hospitals' readmission penalties using these five readmissions measures:

 

As part of the FY 2015 IPPS final rule, CMS finalized an updated method to account for planned readmissions. CMS will add readmissions for coronary artery bypass graft (CABG) surgical procedures to the list for FY 2017.

 

CMS annually reviews and readjusts what is included in various measures. This makes the measures moving targets, and that creates difficulties for hospitals, Ericson says.

 

For many years hospitals followed the same practices and procedures. In the past five to 10 years things have move at a faster pace. "Things are changing so rapidly, hospitals aren't built to respond that quickly," Ericson says. "As more and more penalties apply some organizations are heavily investing in these areas, so even if they don't have quality, they are going to pull themselves out of the bottom quartile because it is comparative and they know how to look comparatively 'good' within the coded data."

 

 

CMS is beginning to link IQR with EHR incentives, which is both good and bad, Ericson says.

 

Consider tobacco dependence with withdrawal. In ICD-10-CM, this condition is a CC. Recording smoking status and delivering tobacco cessation is included in EHR meaningful use stages 1 and 2. However, the way CMS is asking for information about smoking for meaningful use is different from the documentation coders need to accurately report the condition, Ericson says.

 

IQR includes chart-abstraction measures and chart extraction generally happens 60 days or longer after discharge. Hospitals have only recently started assessing quality measures in real-time to be able to identify potential coding and reporting discrepancies, Ericson says.

 

If hospitals perform a chart abstraction 60 days after discharge, the coding manager is often reluctant to rebill the claim with the additional information unless it resulted in overpayment, Ericson says. When hospitals found that the data wasn't what they wanted it to be, they started looking for ways to improve the reporting.

 

The 2015 IPPS final rule focuses on quality measures, such as the Hospital VBP Program, the Hospital Readmissions Reduction Program, and the HAC Reduction Program.

 

CMS introduced no new ICD-9-CM codes for 2015 because a code freeze is in effect until ICD-10 implementation October 1, 2015. However, it did finalize several MS-DRG changes.

 

CMS finalized its proposal to create the following MS-DRGs for endovascular cardiac valve replacements:

 

CMS also will replace MS-DRGs 490 and 491 with the following new MS-DRGs:

 

CMS also finalized removing the following additional diagnosis codes to MS-DRG 794 (neonate with significant problems):