CMS continued its focus on improving the quality of patient care in the fiscal year (FY) 2016 IPPS final rule.
"The final rule includes policies that advance the vision and commitment to increasingly shift Medicare payments from volume to value," says Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM trainer, director of CDI Quality Initiative for Huff DRG Review in Eads, Tennessee.
Most of the changes included in the final rule fall under CMS' various quality improvement measures. The agency did finalize some coding and MS-DRG changes for 2016. However, the changes are minor because of the ongoing code freeze prior to ICD-10 implementation.
CMS finalized the addition of seven new measures to the Hospital Inpatient Quality Reporting (IQR) Program. In addition, the agency finalized changes to the pneumonia readmission measure as part of the Hospital Value-Based Purchasing (HVBP) Program and the Hospital Readmissions Reduction Program (HRRP).
CMS is not adding or removing any Hospital-Acquired Condition (HAC) categories for FY 2016. It estimates that 19.4% of all hospitals will be penalized with a 1% reduction in MS-DRG payments for all traditional Medicare discharges in FY 2016 due to HAC Reduction Program (HACRP) performance.
CMS also addressed provider comments on its plan to expand the Bundled Payments for Care Improvement (BPCI) Initiative.
The BPCI Initiative is composed of four related payment models that link payments for multiple services received by Medicare beneficiaries during an episode of care into a bundled payment.
More than 75 stakeholders responded to CMS' request for comments on the BPCI Initiative. While CMS stated it would consider these comments if it does expand the initiative, it provided only general topics addressed by the commenters.
CMS included a small discussion on short stays and the 2-midnight rule. CMS did not propose any changes to the 2-midnight rule in the 2016 IPPS proposed rule, but reminded stakeholders that it did address short stays in the 2016 OPPS proposed rule.
In the CY 2016 OPPS proposed rule, CMS states that it will look at short inpatient stays that do not cross two midnights. CMS will approve these short admissions on a case-by-case basis, based on the physician's judgment and the documentation justifying the stay.
CMS expects short stays for minor surgical procedures or hospital care to be rare and will monitor these types of admissions to prioritize them for medical review.
Beginning October 1, Quality Improvement Organizations (QIO) will conduct initial patient status reviews to determine the appropriateness of Part A payment for short-stay inpatient hospital claims. Recovery Auditors had been scheduled to conduct these reviews.
QIOs will base their reviews from October 1 through December 31, 2015, on Medicare's current 2-midnight policy. Beginning January 1, 2016, QIOs will incorporate any changes to the 2-midnight rule finalized in the OPPS rule to conduct the patient status reviews.
The IPPS final rule did not include an extension of the partial enforcement delay of the 2-midnight policy. However, CMS did extend the delay until December 31 after the rule was released.
Hospital Readmissions Reduction Program
CMS finalized refinements to the pneumonia readmission measure to expand the measure cohort as part of the HRRP.
Many hospitals are familiar with the Yale University mortality and readmission methodologies and cohorts that CMS uses in its HVBP Program.
In the past, CMS defined the pneumonia cohort for mortality and readmission measurement to include various pneumonia codes as a principal diagnosis, excluding cases where sepsis, aspiration pneumonia, or respiratory failure served as the principal diagnosis.
CMS amended the cohorts to include patients with a principal discharge diagnosis of:
- Pneumonia
- Aspiration pneumonia
- Sepsis with a secondary diagnosis of pneumonia present on admission
"CMS listened to provider comments referable to their proposal to change the pneumonia readmissions measure and scaled it back significantly to a more reasonable cohort," says James S. Kennedy, MD, CCS, CDIP, president of CDIMD - Physician Champions in Smyrna, Tennessee.
CMS proposed to add patients with a principal diagnosis of sepsis, severe sepsis, or acute respiratory failure with pneumonia as a secondary diagnosis and to add all cases with aspiration pneumonia as a principal diagnosis to the cohort, Kennedy says. CMS opted not to add cases with acute respiratory failure as the principal diagnosis and excluded sepsis cases if there is a secondary diagnosis of severe sepsis.
"As such, hospitals must be diligent to identify pneumonia patients who had sepsis on admission to determine if they meet ICD-10-CM's administrative definition of severe sepsis (acute organ dysfunction, not failure, due to sepsis) which may differ from those of the Surviving Sepsis campaign," Kennedy says.
However, CMS chose not to include patients with a principal discharge diagnosis of respiratory failure or sepsis if they are coded as having severe sepsis.
"It is interesting to note that the reason CMS did not include these other populations is because, on further analysis, they found that the populations coded with respiratory failure and sepsis actually had lower risk-adjusted mortality, which was an unexpected finding attributed to 'coding patterns,' " Newell says.
The resulting change in the pneumonia cohort also impacts seven of the risk-adjustment variables used in the risk-adjustment algorithm. "These are important to capture to accurately reflect risk-adjusted mortality performance," Newell says.
The revised pneumonia cohort is expected to increase the number of discharges included in the measure by 50%, and to increase the number of hospitals (which will now meet the minimum case threshold of 25 eligible discharges). CMS expects the revised definition to impact the excess readmission rates for some hospitals.
Analyze and address performance improvement opportunities for all populations included in the HRRP, Newell says.
"The actual number of observed readmissions does not impact payment under the HRRP; it is the predicted and expected performance which determines if the hospital has excess readmissions," she adds.
The quality of documentation and coded data has a direct impact on measure performance and associated financial penalties.
Given modifications to the pneumonia cohort, revisit the definitions used to capture "severe sepsis," which disqualifies discharges from inclusion in the measure, Newell advises.
Proactive hospitals are encouraged to study and address data quality opportunities for the coronary artery bypass graft measure. Performance for today's discharges will determine the financial impact for this measure beginning in FY 2017.
Editor’s note: This article was originally published in the August issue of Briefings on Coding Compliance Strategies. Email your questions to editor Steven Andrews at sandrews@hcpro.com.