All Entries in the "CMS" Category
CMS issues IPPS proposed rule for FY 2013
CMS released the 2013 IPPS proposed rule Tuesday night.
Inpatient acute care hospitals could see a 2.3% increase in payment rates under the fiscal year (FY) 2013 Inpatient Prospective Payment System (IPPS) proposed rule, released April 24. The 2.3% is a net update after inflation, due to improvements in productivity, a statutory adjustment factor, and adjustments for hospital documentation and coding changes.
In addition, the IPPS proposed rule contains provisions to strengthen the Hospital Inpatient Quality Reporting (IQR) Program and proposes new policies and measures for the Hospital Value-Based Purchasing (VBP) Program.
“If the goal is to reward excellence, hospitals have to ensure that their coders are up to speed with appropriate identification of complications and with [present on admission] POA indicators as well as the over-documentation issues that could lead to financial penalties,” says Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta.
CMS also proposes a methodology to calculate the readmissions adjustment factor for inpatient hospitals that could result in a 0.3% decrease in overall payments to hospitals.
Coding changes
As expected, there were few changes to the ICD-9-CM code set. CMS previously indicated that it would limit such changes to allow providers time to prepare for ICD-10 implementation previously slated for October of 2013 but now potentially delayed until October of 2014.
“Since we are proposing to use ICD-9-CM until October 1, 2014, it potentially adds another year of limited updates,” says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding for HCPro, Inc, in Danvers, Mass.
For FY 2013, CMS proposes to reassign cases with a principal diagnosis code 487.0 (influenza with pneumonia) and a one of a list of pneumonia codes listed as a secondary diagnosis codes from MS-DRGs 193, 194, and 195 to MS-DRGs 177, 178, and 179. CMS proposes to make three additional codes complications and comorbities (CCs) and change one major CC (MCC) to a CC for FY 2013. It does not plan to add any MCCs or delete any CCs.
CMS proposes adding these diagnoses to the CC list:
- 263.0, Malnutrition of moderate degree
- 263.1, Malnutrition of mild degree
- 440.4, Chronic total occlusion of artery of the extremities
It also is proposing to change the severity level of diagnosis code 584.8 (acute kidney failure with other specified pathological lesion in kidney) from an MCC to a CC.
“While I support many of their CC/MCC changes, such as making mild and moderate malnutrition a CC, I am saddened that CMS still refuses to make heart failure not otherwise specified a CC,” says James S. Kennedy, M.D., C.C.S., C.D.I.P., managing director at FTI Consulting in Brentwood, Tenn.
IQR proposed changes
The IQR program currently includes 72 quality measures. CMS has proposed reducing that number to 59 for the FY 2015 payment determination, and 60 for the FY 2016 payment determination.
Participation in the IQR program is optional, although those who choose not to participate receive a 2% reduction in the annual payment update. CMS proposes adding perinatal care and readmissions, including overall readmissions and readmissions relating to hip and knee replacement procedures to the IQR quality measures for FY 2013. In addition, CMS would also measure how well hospitals use a surgery checklist designed to reduce errors.
VBP proposed changes
Beginning in FY 2013 and continuing annually, CMS will adjust hospital payments based on how hospitals perform or improve their performance on a set of quality measures.
For the FY 2014 VBP Program, the proposed rule includes a new outcome measure that rewards hospitals for avoiding central line-associated bloodstream infections that can develop during inpatient hospital stays.
For the FY 2015 VBP Program, CMS proposes grouping and scoring measures in four domains—clinical process of care, patient experience of care, outcome, and efficiency. CMS also proposes adding a total of four new measures to the list.
Readmissions reduction program methodology
In the FY 2012 IPPS final rule, CMS began implementation of the Readmissions Reduction Program for three conditions:
- acute myocardial infarction (i.e., heart attack)
- heart failure
- pneumonia
CMS also finalized its definition of readmission as:
“occurring when a patient is discharged from the applicable hospital and then is admitted to the same or another acute care hospital within a specified time period [30 days] from the time of discharge from the index hospitalization.”
CMS also addresses these areas related to the program:
- Adjustment factor (both the ratio and floor adjustment factor)
- Aggregate payments for excess readmissions and aggregate payments for all discharges
- Applicable hospital
- Limitations on review
- Reporting of hospital-specific information, including the process for hospitals to review and submit corrections
Additions to the HAC list
CMS proposes adding two conditions to the list of hospital acquired conditions (HACs) for 2013:
- surgical site infection following cardiac implantable electronic device (CIED)
- iatrogenic pneumothorax with venous catheterization
Inpatient facilities do not receive higher MS-DRG payments for patients with complications or major complications caused by the conditions on the HAC list. CMS plan to update the existing vascular catheter-associated infection HAC category by adding the following two codes:
- 999.32 (bloodstream infection due to central catheter)
- 999.33 (local infection due to central venous catheter)
CMS proposed adding pneumothorax associated with transbronchial biopsy several years ago, but it was not finalized, McCall says. This condition does seem to meet HAC the criteria of occurring commonly and can cause a significant increase in resource consumption in order to treat this condition, she says. It is also labeled as a complication and comorbidity. However, HACs must also be reasonably preventable, according to evidence-based research, and this has also kept other conditions, such as ventilator-associated pneumonia, off the list in the past.
The addition of the surgical site infections from CIEDs seems to follow along with the inclusion of other site infections already on the HAC list, especially given an increased focus on ensuring sterile environments to avoid contamination of a primary infection at the time of placement of such devices, McCall says.
Coding and documentation adjustment
CMS expects the FY 2013 proposed documentation and coding adjustment (DCA) to net an aggregate increase of 0.2%. The DCA was originally established at the time CMS implemented MS-DRGs. It was thought that due to the increased need for specificity, facilities would focus attention on improvements to documentation. The last two years, the DCA has resulted in a payment offset of -2.0% and -2.9%.
“In good news, the documentation and coding adjustment actually works in the provider’s favor this year, increasing reimbursement by 0.2%,” Kennedy says. “That’s a substantial increase from the previous years.”
Comment on the proposed rule
CMS will accept comments on the proposed rule until June 25 and will respond to all comments in a final rule to be issued by August 1, 2012. Facilities can download a display copy of the proposed rule here.
The proposed rule will appear in the May 11, 2012 Federal Register.
Editor’s Note: This article first appeared as a “Breaking News Alert” and was published on HCPro.com.
Incorporate awareness of transfer DRGs into CDI record review efforts
CMS never met a dollar it didn't want back.
CMS never met a dollar it didn’t try to recoup. So we have RACs and HACs and stacks of regulatory requirements that take many, many healthcare dollars to manage. The post-acute care transfer DRGs are but one example.
(RACs, of course, are Recovery Audit Contractors which the government recently renamed Recovery Auditors or the Recovery Audit Program. And I’m sure you all know that HACs stands for hospital acquired conditions.)
For the uninitiated, post-acute care transfer DRGs exist because CMS doesn’t want to pay the hospital the full freight if the patient receives follow-up care somewhere else, and it ends up having to pay the another facility or healthcare agency (such as home health) as well. When the program began, 10 DRGs were designated as transfer DRGs; that list has since expanded to 273.
You can download the current list here.
Why do you need to know about transfer DRGs?
The CDI specialist is one of the few people who has at least a general idea of where the DRG is going to land before the patient is discharged. As you know, every DRG is attached to both an arithmetic length of stay (A/LOS) and a geometric length of stay (G/LOS). The A/LOS is the average LOS of patients within that DRG, including transfers and long-stay outliers. The G/LOS is the national mean length of stay for that DRG, except for transfers and long-stay outliers. The A/LOS is used for calculating outlier payments, while the G/LOS determines the transfer DRG payments. If you don’t have a good idea of the DRG before you transfer the patient or discharge the patient with services, your facility’s number crunchers could have an unpleasant jolt at reimbursement time.
When a patient is transferred to another facility or home with services after staying fewer days than the transfer DRG’s G/LOS, the post-acute care transfer DRG rule kicks in. Instead of receiving the full DRG reimbursement (relative weight multiplied by the hospital’s blended rate), a per-diem rate applies. The per-diem rate is the DRG reimbursement divided by the G/LOS. The hospital will receive twice the per-diem rate on day one and the per-diem rate every day thereafter up to the full DRG reimbursement.
To prevent VBP financial loss, think like a clinician
Experts say that for facilities to face the financial implications of value-based purchasing they'll have to start thinking like clinicians
Healthcare financial leaders and clinicians have traditionally worked in their own silos, running into each other occasionally but rarely seeing eye-to-eye. Yet they now must work together to achieve the goals set forth in the federal value-based purchasing rule.
Currently, VBP rules hold healthcare organizations accountable for 12 process of care measures and HCAHPS. Next year, however, mortality rates and hospital-acquired-conditions will be added to the mix. To meet both the medical and financial imperatives of VBP, financial leaders will need to go beyond their usual scope. Look through the eyes of the clinicians to improve patient care and prevent reimbursement losses.
“Most CFOs are concerned with the negative consequences of VBP, because if you don’t comply you get a reduction in reimbursements,” says Bruce L. Van Cleave, MD, senior vice president and chief medical officer at Aurora Health Care in Milwaukee. “But, on the medical side we need to concentrate on patient safety and high quality care. If we aren’t careful, when we [each] talk about value-based purchasing we could be having two very different conversations,” says Van Cleave, who is also the former president and CEO for Carondelet Health in Kansas City and a board-certified family practice physician.
Van Cleave’s clinical and administrative background helps him see VBP from both vantages. Taking a broader perspective can help financial leaders prevent VBP reimbursement losses.
“I wish the ongoing conversation we were having [with financial leaders] was, ‘How do we use this to re-look at our strategies around care delivery?’” he says. “And that we’d broaden the discussion away from, ‘How can we maximize our reimbursements?’”
Van Cleave believes that if healthcare leaders concentrate on understanding the intent of the VBP law, they will find the answers to their reimbursement concerns.
“Think about why the government wants us to do this. What outcomes are they really trying to get at? Certainly one outcome is to control cost, but it’s not all of it. … What impact will this have on how healthcare will be practiced in the U.S.? And, how can we link our outcomes and our finances so they are strategically aligned?” he asks.
Van Cleave points to length of stay as an example of how different goals for the financial and clinical staff can influence one another.
“Clinicians need to have enough time to complete the [patient] education cycle, to monitor the illness, and to get the patient tuned up to a higher level before discharge. If it’s rushed, there’s risk. What we need [from CFOs] are the right tools for an efficient process so patients get the right education and care. We need to set standards so when the patient reaches certain milestones we can help them make the transition to home,” he says.
Financial leaders have focused on LOS since 1983. That’s when Medicare introduced the prospective payment system and announced it was going to pay hospitals a flat fee to cover costs based on an expected LOS. CFOs reasoned that if their hospitals could shorten patients’ LOS, the result would be greater margins. They encouraged doctors to discharge patients as soon as they no longer required an acute level of care.
What has been the outcome of this effort? Providers have managed to shorten LOS, but at the cost of 30-day readmission rates. In 2010, Medicare released a study of heart-failure patients showing that between 1993 and 2006, mean LOS decreased from 8.81 days to 6.33 days. In-hospital mortality decreased from 8.5% to 4.3% during the same period, and 30-day mortality decreased from 12.8% to 10.7%. But 30-day readmission rates (which are not part of the VBP measures) increased from 17.2% to 20.1%.
Just as your clinicians’ actions influence patient outcomes and reimbursements, so too do the actions of financial leaders. You may know how VBP will influence your organization’s bottom line, but have you asked clinical leaders how to improve your metrics? By understanding the clinician’s perspective, CFOs may get a clearer picture on how to hit VBP measures and improve HCAHPS scores.
Complying with VBP is going to challenge organizations for the next few years. It puts 1% of Medicare payments for hospitals and health systems at risk in the first year, and that percentage will grow as the measures grow. Nevertheless, it really is possible to win with VBP.
But doing so, Van Cleave observes, requires that “everyone has to pull in the same direction and be very clear about the goal and the numbers to succeed.”
Editor’s Note: This article was written by Karen Minich-Pourshadi, Senior Editor with HealthLeaders Media, and was original posted to its website www.healthleadersmedia.com. She may be reached at kminich-pourshadi@healthleadersmedia.com.
Clarification regarding Coding Clinic publication
The AHA will begin to collect and respond to limited questions regarding the ICD-10 code set.
The American Hospital Association (AHA) has not made any formal decisions regarding when it will begin publishing a separate Coding Clinic for ICD-10, contrary to what was reported in December 1 edition of CDI Strategies, according to Nelly Leon-Chisen, RHIA, director of coding and classification for the AHA.
Those with questions pertaining to ICD-10 can submit them to the AHA now. Those who submit inquiries must have working knowledge of the new code set and questions must pertain to the application of the codes and the interpretation of the medical record.
The AHA is beginning to collect questions regarding the new code set and will include some of those questions starting with its 4th Quarter 2012 edition of Coding Clinic for ICD-9-CM, Leon-Chisen told ACDIS.
“This service is for coding advice only not for advice about ICD-10 implementation,” Leon-Chisen said during CMS’ “ICD-10 Implementation Strategies and Planning National Provider Call” on November 17.
The AHA has no plans to translate guidance from previous volumes of Coding Clinic for ICD-9-CM, as the increased specificity of the new code set is expected to make much of the guidance obsolete. However, it has not made a decision just yet about when it will stop publishing Coding Clinic for ICD-9-CM, or when it might begin publishing a specific Coding Clinic for the new code set.
News: 2012 ICD-10-CM code updates available
CMS announced Medicaid HCACs
CMS posted the 2012 ICD-10-CM code updates to the CMS website, including the 2012 ICD-10-CM index and tabular, code titles, addendum, General Equivalence Mappings (GEMs), and reimbursement mappings files.
The 2012 ICD-10-CM files contain information on the new diagnosis coding system, ICD-10-CM, that is being developed as a replacement for ICD-9-CM, Volumes 1 and 2. These files are available on the 2012 ICD-10-CM and GEMs webpage at http://www.cms.gov/ICD10/11b14_2012_ICD10CM_and_GEMs.asp. To access the files, scroll to the bottom of the page to the “Downloads” section.
The 2012 ICD-10-PCS (procedure) files were posted in June on the 2012 ICD-10-PCS and GEMs webpage at http://www.cms.gov/ICD10/11b15_2012_ICD10PCS.asp
VBP discussion offers new initiatives for CDI programs
Join us next week for a discussion of the implications of Value Based Purchasing.
Most facilities are already familiar with the Value-Based Purchasing (VBP) measures since CMS has collected data on them for some time. The Hospital Inpatient Quality Reporting Program is now known as QualityNet, but some know it better as the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU). Many CDI programs incorporate RHQDAPU items on physician documentation improvement tip sheets. (See the Physician Documentation Improvement Pocket Guide, by Pamela P. Bensen, MD, MS, FACEP.)
Until now CMS hadn’t tied payment to a facility’s performance. Instead, hospitals were paid to participate in the program and simply reported the requested conditions. Since 2005, CMS has published each RHQDAPU participating hospital’s measure rates on the Hospital Compare website. Starting October 2012, Medicare will begin paying hospitals for quality measures, according to a CMS fact sheet released April 29.
Editor’s Note: This article is an excerpt from the July edition of the CDI Journal. Join Deborah K. Hale, CCS, CCDS, and Susan Wallace, MEd, RHIA, CCS, CCDS, of Administrative Consultant Service, LLC, in Shawnee, OK, on Tuesday, November 8, for an audio conference discussion regarding the implications of VBP for documentation and coding accuracy.
CDI Week: Time to revisit our scope of practice
Opportunities abound to expand CDI efforts.
The growth in the profession of CDI has been nothing more than phenomenal over the course of the few years. ACDIS membership now stands at more than 2, 500 members. Fueling this tremendous growth in CDI is the increased need for accurate, concise, and effective medical record documentation to support data reporting processes; processes such as ICD-9 (and the 2013 transition to ICD-10), MS-DRG assignment, and quality outcomes. Our healthcare data is coming under intense scrutiny from MAC, CERT, and RAC auditors as Medicare intensifies efforts save money and improve healthcare quality before 2017 when the Medicare Trust Fund is projected to run out of money.
Expanding scope
The first annual CDI Week slated for September 18-24 is fast approaching. While the traditional focus of CDI has been the inpatient arena, now is an excellent time to consider expanding into the outpatient arena, a high volume service line for most hospitals with the potential for large revenue losses. In several previous blog posts, I stressed the virtue of CDI specialists playing an active role in the establishment of medical necessity through clinical documentation. Now, I would like to take a moment to outline how our profession can affect outpatient efforts as a logical, natural progression of the CDI scope of practice.
From my experience as an outpatient clinical documentation facilitator (as I assist various programs capture documentation improvement opportunities in my role as an independent CDI consultant), I see the chance for CDI to become an integral part of the revenue cycle denials management process the volume of the denials in outpatient setting is higher than those facilities experience on inpatient side.
Let’s take a look at one example, that of pillow endoscopy. This is an endoscopy carried out by using a wireless video capsule which the patient swallows and which ultimately passes through the digestive system. For this procedure, two capsules are available, one designed for the small bowel and one for the esophagus. Indications for the procedure include: GI bleeding, small bowel neoplasm, Crohn’s disease, and evaluation prior to surgery, according to National Government Services, a CMS MAC contractor for the Midwest. (The LCD for Endoscopy by Capsule can be accessed here.)
In order for the facility and physician to receive reimbursement for these procedures the patient’s record must contain documentation which fully supports the medical necessity for this service. This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. It also requires that photographic copies of the video images, with the beneficiary’s name and the date of service included in the picture, must be available for review. Furthermore, the medical record must document the need for capsule endoscopy and contain reports or reference to the previous appropriate negative endoscopies performed prior to endoscopy by capsule. There are a number of other documentation considerations included in the Local Coverage Determination as well.
Let me emphasize the statement that the documentation must contain reference to the previous appropriate negative endoscopies since this lack of documentation leads to numerous avoidable denials. The lack of this documentation in the pre-operative history and physical (H&P) and/or operative note precludes the necessary reporting of ICD-9 code V45.89-Other Postsurgical Status, a code that needs to be on the claim in conjunction with another covered diagnosis as spelled out in the LCD in order for the claim to be considered a covered benefit and reimbursable to the provider.
I found that physicians often document anemia (285.9) as the indication for the pill endoscopy of the small intestine. However, this is not considered a covered indication for the procedure, resulting in unnecessary write offs of a Medicare allowed payment amount of $701.55. Notice that iron deficiency anemia secondary to blood loss (280.0)(chronic) is considered a covered benefit. When I provide this information to physicians in a medical staff meeting as part of an education session, I receive many hard stares and comments from the audience.
Getting started
To convince hospital administration of the relevance CDI in the outpatient setting, highlight denial reduction and loss of revenue due to ineffective patterns of clinical documentation. The amount of avoidable revenue lost to Medicare and other third-party payer denials is mind boggling. Equally mind boggling is the volume of self-inflicted denials hospitals subject themselves to due basically to poor clinical documentation, something our profession can capitalize on as CDI programs continue to expand their influence.
I personally find the role of CDI to be rewarding, challenging, and most importantly varied. Each day is unique, I am rarely in the same location every day, and no longer preoccupied with searching for CCs and MCCs and solidifying principal diagnoses. More on the role of CDI in the outpatient setting will be introduced in an upcoming white paper. Stay tuned.
Readmission reduction pilot program saves hospital thousands
A recent article in The Miami Herald describes a readmission reduction pilot program at Jackson Memorial Hospital that saved it
Hospital readmissions can seem like a revolving door. CMS has a number of new initiatives aimed at resolving this problem.
an estimated $400,000 in readmission charges.
Jackson nurses visit recently discharged heart patients at their homes to ensure that they’ve filled their prescriptions and understand medication instructions. The nurses also leave frozen healthy meals and check in with patients regularly to monitor their conditions and provide more meals.
The article describes Jackson’s pilot program as a predecessor to accountable care organizations (ACO). The ACO model is widely praised, but this article explains the need to address several challenges. Antitrust and anti-kickback healthcare laws require revisions that will allow healthcare providers to refer patients to entities with which they have a financial relationship. However, some groups warn that relaxing antitrust laws could allow healthcare providers to create the monopolies that these laws were enacted to prevent.
Editor’s Note: Read the article at http://www.miamiherald.com/2011/08/03/2344316/will-acos-create-a-revolution.html. This blog post was originally published on the Case Management Mentor Blog
Will readmission reduction hurt your hospital’s bottom line?
The Hospital Readmission Reduction Program (HRRP) will reduce reimbursement to hospitals with high readmission rates to encourage them to prevent patients from returning after discharge. However, a new study suggests that hospitals will see an even bigger reduction in reimbursement if they experience fewer readmissions.
The issue is simple math. The current system pays hospitals for episodes of care. If hospitals reduce their readmissions they will have fewer episodes to bill. Fewer bills mean less reimbursement.
Brett Stauffer, MD, and colleagues, is the author of an Archives of Internal Medicine report, which examines the financial impact of reducing heart failure readmissions at a community hospital in Garland, TX. Although the hospital reduced preventable heart failure readmissions by 48%, it also lost an average of $751 for each heart failure patient. The authors estimated that the HRRP will reduce the hospital’s negative financial impact, but by only 10%.
The study raises an interesting question. Although reducing hospital readmissions will save money for Medicare and other payers, what does it mean for hospitals?
“While we are not-for-profit entities, at the end of the day we still have to make payroll,” Stauffer told HealthLeaders Media. “We have bills to pay and have to maintain enough margin to pay for capital expenses, build new facilities and keep them updated, and that’s got to be paid for by somebody,” he said.
The hospital, which does not admit a large number of CHF patients, will continue its efforts to reduce readmissions because it is the right thing to do, said Stauffer. Other hospitals may share this perspective. The report seems to suggest that providing hospitals an incentive might require moving away from a pay-per-episode model and rewarding hospitals for positive outcomes. The Value-Based Purchasing program final rule may prove to be a step in that direction.
Editor’s note: This post was originally published on the Case Management Mentor blog.
CMS releases FY 2012 IPPS final rule
CMS released its final rule for the FY 2012 Inpatient Prospective Payment System integral to inpatient Medicare reimbursement at short-term and long-term acute care hospitals as announced in an August 1 press release.
In a major surprise, CMS finalized a documentation and coding adjustment (DCA) of -2.0% instead of the proposed -3.15% for fiscal year (FY) 2012, according to the 2012 inpatient prospective payment system (IPPS) final rule released August 1.
CMS originally proposed a year-over-year reduction of 0.5% in payments to acute care hospitals under the FY 2012 IPPS, including a DCA of -3.15%. However, CMS finalized a cut of 2.0%, a decrease from 2.9% in FY 2011, which translates to $1.13 billion more in hospital payments in FY 2012 than they had received in the previous year. “We’re very pleased to see that CMS has scaled back their proposed coding cuts,” says Joanna Kim, senior associate director for policy for the American Hospital Association (AHA) in Washington, DC. “We are quite disappointed that CMS did not change their methodology of analyzing documentation and coding, but are glad they recognized that the proposed 3.15% cut would be very difficult for hospitals to absorb all in one year.”
Kim suggests that hospitals look closely at the new payment rates and make sure they can budget appropriately.
James S. Kennedy, MD, CCS, managing director for FTI Healthcare in Atlanta, agrees that the temporary reprieve is a positive for hospitals. “The DCA is what it is. At least for next year, it’s good that we got a break,” he says. “But CMS will maintain its current methodology of calculating it and will continue to assess it to hospitals until they have recouped what they believe they have overpaid.”
“We recognize the concerns regarding possible financial disruption that may be caused by the proposed documentation and coding improvement payment adjustment,” CMS states in the rule. “We note, however, that these payment adjustments are necessary to correct past overpayments due solely to documentation and coding improvements. We have already delayed implementation of the required prospective adjustment amount, and we proposed only a portion of the remaining required adjustment to allow hospitals time to adjust to future payment differences and to moderate the effect of this adjustment in any given year.
Editor’s Note: This article was initially send to ACDIS members on Tuesday, Aug. 2. Read the complete analysis online at www.hcpro.com
