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Tag Archives: 2017

2017 IPPS final rule and claims-based measures

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2017 IPPS final rule and claims-based measures

by Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer

The fiscal year (FY) 2017 IPPS final rule was released August 2 and will be published in the Federal Register August 22. The majority of the finalized updates are consistent with those outlined in the proposed rule, but with a few refinements to applicable time periods. The final rule expands and refines the number of claims-based ­outcomes linked to payment under these programs.

Let’s review a few of the key changes to support your CDI program’s strategic focus for the coming year.

 

Risk-standardized readmission rates

Risk-standardized readmission performance for the coronary artery bypass graft (CABG) cohort will be linked to reimbursement in FY 2017. The applicable time period for discharges used to assess performance in FY 2017 has passed, but today’s discharges will impact performance in FY 2018.

This is a great example of why it’s important to focus on new measures adopted in this year’s rule for future program years. CMS utilizes a two- to three-year historical window of data for claims-based measures, so today’s performance impacts us financially two to three years in the future.

 

Risk-adjusted PSI 90 composite

The current Patient Safety Indicator (PSI) 90 measure will continue to be utilized in the Hospital-Acquired Condition Reduction Program (HACRP) and Hospital Value-Based Purchasing Program (HVBP) through FY 2018. At that time:

  • The HACRP will adopt the modified PSI 90 composite in FY 2018
  • The HVBP will discontinue future use of the PSI 90 measure in the FY 2019 rulemaking?CMS notes that the HVBP intends to adopt the modified PSI 90 composite in future rulemaking

 

The modified PSI 90 composite, also called the Patient Safety and Adverse Events Composite, was finalized as proposed. A review of key modifications follows:

  • PSIs in the composite have been revised; one PSI was deleted (PSI 7?CLABSI) and three new PSIs were added, providing a total of 10 PSIs in the modified composite
  • The final rule notes that PSIs 12 and 15 have had specification revisions
  • PSI weighting in the composite has been refined to incorporate the impact of both volume and harm

 

Applicable time periods for the measure were shortened as proposed, although date ranges were revised as noted below in italicized font:

  • HACRP:
    • FY 2018: July 1, 2014?September 30, 2015 (15 months)
    • FY 2019: October 1, 2015?June 30, 2017 (21 months)
  • HVBP:
    • FY 2018: Same as HACRP above (for the performance period; the baseline period will not be revised)

 

Performance scoring for the HACRP will adopt Winsorized z-scores instead of deciles.

  • The z-score method uses a continuous measure score rather than forcing measure results into deciles.
  • Z-scores represent a hospital’s distance from the national mean for a measure in units of standard deviations. A negative z-score reflects values below the national mean, and thus indicates strong performance.
  • To form the total hospital-acquired condition (HAC) score, the z-scores will be used as hospitals’ measure scores. The current scoring approach will then kick in.
    • The domains will be scored as follows:
    • The domain scores will then be multiplied by the domain weight
    • The weighted domain scores will be added together for the total HAC score
    • Hospitals in the top (worst) quartile would be subject to the payment penalty

 

Risk-standardized mortality measures

Risk-adjusted CABG mortality performance will impact financial reimbursement under the HVBP effective with the FY 2022 program. The applicable time periods that will be used to assess performance at that time follow:

  • Baseline period: July 1, 2012?June 30, 2015
  • Performance period: July 1, 2017?June 30, 2020

 

The pneumonia cohort will expand to include patients with a principal diagnosis of aspiration pneumonia and/or patients with a principal diagnosis of sepsis and a secondary present-on-admission diagnosis of pneumonia:

  • This aligns the cohort definition with that for the pneumonia readmission measure adopted with the FY 2021 program year.
  • Applicable timelines will be shortened from the usual three years of data to expedite HVBP adoption. The applicable time period for the cohort follows; italicized font indicates refinements to the dates in the final rule:
    • FY 2021:
    • FY 2022:

 

Cost measures

The previously adopted HVBP payment measure for pneumonia (hospital-level, risk-standardized payment associated with a 30-day episode of care for pneumonia) will expand the pneumonia cohort.

The expanded cohort will be consistent with the cohort definition used for the risk-adjusted readmission measure in the Hospital Readmissions Reduction Program (HRRP) and the risk-adjusted mortality measure used in the HVBP:

  • The expanded cohort is anticipated to shift 9.3% of hospitals from the "average payment" category to the "greater than average payment" category

Two new payment measures will be added to the efficiency and cost reduction domain in the HVBP beginning FY 2021:

  • Hospital-level, risk-standardized payment associated with a 30-day episode of care for acute myocardial infarction
  • Hospital-level, risk-standardized payment associated with a 30-day episode of care for heart failure

 

These payment measures are intended to be paired with the 30-day mortality measures, thereby directly linking payment to quality by the alignment of comparable populations and risk adjustment methodologies to facilitate the assessment of efficiency and value of care:

  • The applicable time periods for the measures are as follows:
    • Baseline period: July 1, 2012?June 30, 2015
    • Performance period: July 1, 2017?June 30, 2019
  • The risk adjustment methodologies used for these measures are similar to those used for risk-adjusted mortality

 

Performance for these new measures will be scored using the methodology for the Medicare spending per beneficiary measure.

 

Summary

Effective October 1, 2017, performance for cost and quality measures in the HRRP, HVBP, and HACRP will impact up to 6% of your hospital’s inpatient acute Medicare fee-for-service reimbursement.

So, where to begin? First, become familiar with the measure specifications and risk adjustment methodologies, in addition to existing CMS provided reports on historical performance, to gain insights into your organization’s clinical documentation and coding vulnerabilities.

Measure specifications can be found at: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Measure-Methodology.html.

The final rule is available here: www.federalregister.gov/public-inspection.

 

Editor’s note: Newell is the director of CDI quality initiatives for Enjoin. She has extensive operational and consulting expertise in coding and clinical documentation improvement, performance improvement, case management, and health information management. You can reach Newell at [email protected]. Opinions expressed are that of the author and do not represent HCPro or ACDIS.

HCPro.com – Briefings on Coding Compliance Strategies

2017 IPPS final rule and claims-based measures

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2017 IPPS final rule and claims-based measures

by Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer

The fiscal year (FY) 2017 IPPS final rule was released August 2 and will be published in the Federal Register August 22. The majority of the finalized updates are consistent with those outlined in the proposed rule, but with a few refinements to applicable time periods. The final rule expands and refines the number of claims-based ­outcomes linked to payment under these programs.

Let’s review a few of the key changes to support your CDI program’s strategic focus for the coming year.

 

Risk-standardized readmission rates

Risk-standardized readmission performance for the coronary artery bypass graft (CABG) cohort will be linked to reimbursement in FY 2017. The applicable time period for discharges used to assess performance in FY 2017 has passed, but today’s discharges will impact performance in FY 2018.

This is a great example of why it’s important to focus on new measures adopted in this year’s rule for future program years. CMS utilizes a two- to three-year historical window of data for claims-based measures, so today’s performance impacts us financially two to three years in the future.

 

Risk-adjusted PSI 90 composite

The current Patient Safety Indicator (PSI) 90 measure will continue to be utilized in the Hospital-Acquired Condition Reduction Program (HACRP) and Hospital Value-Based Purchasing Program (HVBP) through FY 2018. At that time:

  • The HACRP will adopt the modified PSI 90 composite in FY 2018
  • The HVBP will discontinue future use of the PSI 90 measure in the FY 2019 rulemaking?CMS notes that the HVBP intends to adopt the modified PSI 90 composite in future rulemaking

 

The modified PSI 90 composite, also called the Patient Safety and Adverse Events Composite, was finalized as proposed. A review of key modifications follows:

  • PSIs in the composite have been revised; one PSI was deleted (PSI 7?CLABSI) and three new PSIs were added, providing a total of 10 PSIs in the modified composite
  • The final rule notes that PSIs 12 and 15 have had specification revisions
  • PSI weighting in the composite has been refined to incorporate the impact of both volume and harm

 

Applicable time periods for the measure were shortened as proposed, although date ranges were revised as noted below in italicized font:

  • HACRP:
    • FY 2018: July 1, 2014?September 30, 2015 (15 months)
    • FY 2019: October 1, 2015?June 30, 2017 (21 months)
  • HVBP:
    • FY 2018: Same as HACRP above (for the performance period; the baseline period will not be revised)

 

Performance scoring for the HACRP will adopt Winsorized z-scores instead of deciles.

  • The z-score method uses a continuous measure score rather than forcing measure results into deciles.
  • Z-scores represent a hospital’s distance from the national mean for a measure in units of standard deviations. A negative z-score reflects values below the national mean, and thus indicates strong performance.
  • To form the total hospital-acquired condition (HAC) score, the z-scores will be used as hospitals’ measure scores. The current scoring approach will then kick in.
    • The domains will be scored as follows:
    • The domain scores will then be multiplied by the domain weight
    • The weighted domain scores will be added together for the total HAC score
    • Hospitals in the top (worst) quartile would be subject to the payment penalty

 

Risk-standardized mortality measures

Risk-adjusted CABG mortality performance will impact financial reimbursement under the HVBP effective with the FY 2022 program. The applicable time periods that will be used to assess performance at that time follow:

  • Baseline period: July 1, 2012?June 30, 2015
  • Performance period: July 1, 2017?June 30, 2020

 

The pneumonia cohort will expand to include patients with a principal diagnosis of aspiration pneumonia and/or patients with a principal diagnosis of sepsis and a secondary present-on-admission diagnosis of pneumonia:

  • This aligns the cohort definition with that for the pneumonia readmission measure adopted with the FY 2021 program year.
  • Applicable timelines will be shortened from the usual three years of data to expedite HVBP adoption. The applicable time period for the cohort follows; italicized font indicates refinements to the dates in the final rule:
    • FY 2021:
    • FY 2022:

 

Cost measures

The previously adopted HVBP payment measure for pneumonia (hospital-level, risk-standardized payment associated with a 30-day episode of care for pneumonia) will expand the pneumonia cohort.

The expanded cohort will be consistent with the cohort definition used for the risk-adjusted readmission measure in the Hospital Readmissions Reduction Program (HRRP) and the risk-adjusted mortality measure used in the HVBP:

  • The expanded cohort is anticipated to shift 9.3% of hospitals from the "average payment" category to the "greater than average payment" category

Two new payment measures will be added to the efficiency and cost reduction domain in the HVBP beginning FY 2021:

  • Hospital-level, risk-standardized payment associated with a 30-day episode of care for acute myocardial infarction
  • Hospital-level, risk-standardized payment associated with a 30-day episode of care for heart failure

 

These payment measures are intended to be paired with the 30-day mortality measures, thereby directly linking payment to quality by the alignment of comparable populations and risk-adjustment methodologies to facilitate the assessment of efficiency and value of care:

  • The applicable time periods for the measures are as follows:
    • Baseline period: July 1, 2012?June 30, 2015
    • Performance period: July 1, 2017?June 30, 2019
  • The risk-adjustment methodologies used for these measures are similar to those used for risk-adjusted mortality

 

Performance for these new measures will be scored using the methodology for the Medicare spending per beneficiary measure.

 

Summary

Effective October 1, 2017, performance for cost and quality measures in the HRRP, HVBP, and HACRP will impact up to 6% of your hospital’s inpatient acute Medicare fee-for-service reimbursement.

So, where to begin? First, become familiar with the measure specifications and risk-adjustment methodologies, in addition to existing CMS provided reports on historical performance, to gain insights into your organization’s clinical documentation and coding vulnerabilities.

Measure specifications can be found at: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Measure-Methodology.html.

The final rule is available here: www.federalregister.gov/public-inspection.

 

Editor’s note

Newell is the director of CDI quality initiatives for Enjoin. She has extensive operational and consulting expertise in coding and clinical documentation improvement, performance improvement, case management, and health information management. You can reach Newell at [email protected]. Opinions expressed are that of the author and do not represent HCPro or ACDIS.

HCPro.com – HIM Briefings

MIPS 2017: The Results Are In!

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Of the 1,057,824 clinicians eligible to participate in the Merit-based Incentive Payment System (MIPS) in the inaugural year, 1,006,319 (95 percent) participated in MIPS and avoided a negative payment adjustment, according to the Centers for Medicare & Medicaid Services’ (CMS) 2017 Quality Payment Program (QPP) Experience Report. The report, which CMS released March 21, provides […]

The post MIPS 2017: The Results Are In! appeared first on AAPC Knowledge Center.

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Implications of the Joint Commission’s 2016 deletions for staff education and training requirements for 2017

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This article was written by Marlene K. Strader, RN, PhD, and Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, a healthcare consultant in Trabuco Canyon, California, and a former Joint Commission surveyor.
 
In the first quarter of 2016, there were 46 topics that were required for education and training of hospital staff, including physicians, nurses, and other allied healthcare personnel. In May 2016, The Joint Commission deleted many standards and elements of performance (EP), reducing the number to around 40. A few of those deletions impact the Human Resources (HR) chapter as well as other chapters.

HCPro.com – Briefings on Accreditation and Quality

Key attributes for coders moving forward amidst the 2017 coding guideline changes

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Key attributes for coders moving forward amidst the 2017 coding guideline changes

by Laura Legg, RHIT, CCS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer

Resiliency is the ability to spring back or rebound. In sports, it’s one of the mental attributes a player must have. Coders are resilient: bouncing back from one change after another, deciding to code smarter and faster, and having the patience to do whatever is expected?even amid closing grace periods and guideline controversies.

The change to ICD-10 in October 2015, was a solid transition, and no one in healthcare was affected by it more than coders. The changes didn’t stop there. The coming months will again prove to be challenging for coders because of the new ICD-10 codes for both CM and PCS beginning October 1, 2016. Along with that, we’ll see the end of the CMS grace period on code specificity for Part B, and updated ICD-10-CM Official Coding Guidelines. Coders have a lot to learn this fall.

The Centers for Disease Control and Prevention published guidelines for discharges effective October 1, 2016, that have been approved by the four organizations that make up the Cooperating Parties for ICD-10-CM: the American Hospital Association, the American Health Information Management Association, CMS, and the National Center for Health Statistics.

The guidelines are available at www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf. In the linked document, the changes are indicated in bold type for easy identification. Below are some of the highlighted changes.

 

Excludes1

This guideline supports the interim advice published last fall. Here, the Cooperating Parties have given instructions that two conditions unrelated to each other represents an exception to the Excludes1 definition. If it is not clear whether the two conditions are related, coders must query the provider.

 

With

Under Section I.B.7 of the guidelines, "multiple coding for a single condition" clarification has been added for interpretation of the word "with."

The word "with" should be interpreted to mean "associated with" or "due to" when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms.

These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by this term in the classification, provider documentation must link the conditions in order to code them as related.

 

Code assignment and clinical criteria

Also under Section I, the Official Guidelines for Coding and Reporting tell us that the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

Coders are instructed to assign a diagnosis or procedure code according to physician documentation. Coders have been told in the past not to question the physician’s clinical judgment. This appears to be pretty simple until audits from outside the organization place more emphasis on the use of clinical criteria. This use of clinical criteria to assign reported codes is known as "clinical validation." When coders follow the official coding guideline instructing them that a code assignment is not based on clinical criteria used by the provider to establish the diagnosis, they will be caught between following the guideline as instructed and being presented with a claim denial based on the absence of clinical validation.

In today’s healthcare environment, it is essential that organizations face this issue head on and provide coders with guidance on how to solve the dilemma of a record that contains physician documentation but does not contain clinical validation. Clinical documentation improvement efforts to improve upon complex clinical condition documentation must continue to bring the coding and medical records together to allow coders to code correctly and avoid payer denials.

CMS must clarify the reason the Recovery Auditors are allowed to deny claims, whether auditors will bypass this official coding guideline, and how organizations can reconcile the discrepancy.

 

Laterality coding

This update clarifies that when a patient with a bilateral condition has surgical correction on both sides, the first side corrected is coded with the bilateral code. The second site is not coded using the bilateral code because the condition no longer exists on the corrected side. If the treatment on the first side did not completely resolve the condition, then the bilateral code is used.

Documentation for BMI, non-pressure ulcers, and pressure ulcer stages

Section I.B.14 says for body mass index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and NIH Stroke Scale (NIHSS) codes, code assignment may be based on medical record documentation from clinicians who are not the patient’s provider. Dietitians often document the BMI, nurses often document pressure ulcer stages, and an emergency medical technician often documents the coma scale. Keep in mind the associated diagnosis must be documented by the patient’s provider. A query should be used to clarify any conflicting medical record documentation.

This guideline shows the addition of the coma scale and NIHSS to conditions where code assignment can be determined from clinicians who are not the patient’s provider. Many coders may not be familiar with the ­NIHSS?it is a 15-item neurologic examination used to evaluate the effect of acute cerebral infarction. The NIHSS evaluates:

  • Levels of consciousness
  • Language
  • Neglect
  • Visual field loss
  • Extraocular movement
  • Motor strength
  • Ataxia
  • Dysarthria
  • Sensory loss

 

The NIHSS evaluation is often done by nursing staff and can help physicians quantify the severity of a stroke in the acute setting.

 

Zika virus infection

The official guidelines instruct coders to code only confirmed cases of the Zika virus with code A92.5 as documented by the provider. Note that this is an exception to the hospital inpatient guidelines. "Confirmation" does not require documentation of the type of test performed; the physician’s diagnostic statement that the condition is confirmed is sufficient. Documentation of "suspected," "possible," or "probable" Zika is not assigned to code A92.5.

 

Hypertensive crisis

A coding guideline has been added to instruct coders to assign a code from category I16 for hypertensive urgency, hypertensive emergency, or unspecified hypertensive crisis. This may call for some physician documentation education to make physicians aware that these more specific codes are available and can be used instead of documentation of hypertension without any further description.

 

Coma scale

In addition to using the coma scale codes (R40.2-) for traumatic brain injury codes, acute cerebrovascular disease codes, or sequelae of cerebrovascular disease codes, the coma scale may be used to assess the status of the central nervous system for other non-trauma conditions. Examples include monitoring patients in the ICU regardless of their medical condition.

 

Observation

One observation Z code category has been added for use when a newborn patient is being observed for a suspected condition that is ruled out. The new code category is Z05: encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out.

 

Newly added ICD-10 codes

CMS will implement an unprecedented number of new code changes October 1. A partial code freeze prevented regular updates for the last five years, resulting in the release of over 5,000 ICD-10 revisions on that date. The newest coding updates can be found at https://www.cms.gov/Medicare/Coding/ICD10/Latest_News.html.

The new ICD-10 codes come as we thaw out from the code freeze that has been in effect since October 1, 2011. Since that time, we have received only limited code updates to both the ICD-9 and ICD-10-CM/PCS code sets. Now, the long delay is over. ICD-10-CM changes include 1,928 diagnosis code changes with expanded code choices for atrial fibrillation, heart failure, diabetes mellitus Type 2, disorders of the breast, and pulmonary hypertension.

Extensive PCS updates are also being implemented. There are 3,651 new PCS codes, revised code titles, and a grand total of 75,625 valid codes with this update. It is important to note that 87% of the PCS code updates are in the cardiovascular system.

Following adoption of the new codes, review of coding accuracy will be needed. Any misconceptions or incorrect rationale should be recognized and communicated early to prevent ongoing or costly patterns from developing. Remember to ensure software updates are also in place and scheduled on time.

The new cardiovascular PCS codes include:

  • Unique codes for unicondylar knee replacement
  • Codes involving placement of an intravascular neurostimulator
  • Expanded body part detail for the root operations Removal and Revision
  • New codes in lower joint body system
  • New codes for intracranial administration of substances such as Gliadel chemotherapy wafer using an open approach
  • Addition of bifurcation qualifier to multiple root operation tables for all artery body part values
  • Specific body part values for the thoracic aorta
  • Specific table values to capture congenital cardiac procedures
  • Unique device values for multiple intraluminal devices

 

Other PCS changes include:

  • Donor organ perfusion
  • Face transplant
  • Hand transplant

 

The impact of the new codes will depend on what you do, so it’s important for hospitals to assess how the changes will affect them specifically. If you don’t deal with the areas where the codes have changed, the updates will be much easier than if your facility uses all the affected codes. Make sure the applicable codes are integrated into your internal applications and processes, while verifying that vendor products support the new codes. You don’t want to have claims rejected because not all of the new codes were incorporated.

Overall, there are moderate changes to the Official Guidelines for Coding and Reporting. The 2017 coding updates, however, are extensive and may seem overwhelming to some coders. The addition of over 10,000 codes after only one year of using ICD-10 will require coder resiliency to learn them all and understand how to apply them.

 

Editor’s note

Legg is director of HIM optimization at Healthcare Resource Group in Spokane Valley, Washington. For questions, please contact Associate Editor Amanda ­Tyler at [email protected]. Opinions expressed are those of the author and do not represent HCPro or ACDIS.

HCPro.com – Briefings on Coding Compliance Strategies

False Claims Act 2017 Recoveries May Surprise You

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The DOJ has been busy reclaiming billions of federal healthcare dollars. It’s impressive that the U.S. Department of Justice (DOJ) Office of Public Affairs can send out a press release with the headline Justice Department Recovers Over $ 3.7 Billion From False Claims Act Cases in Fiscal Year 2017. It shows that, last year, the government […]
AAPC Knowledge Center

Report from the Department of Justice Fraud & Abuse Control for 2017 sheds light upon the importance of compliance

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In April, the Government released last year’s accomplishments for their work in Healthcare Fraud and Abuse. In 2017 $ 2.6 billion was returned to the Federal Government or paid to private persons. Specifically; $ 1.4 billion was returned to the Medicare Trust Funds and $ 406.7 million was returned to Medicaid programs. Yes, that means that over $ 1 million dollars was paid to Qui Tam relators or put into resources to continue to fight fraud and abuse.

A staggering 967 investigations were opened in 2017 resulting in criminal charges filed for 439 cases involving 720 defendants. This resulted in 639 convictions which is an impressive 88.7% conviction rate. In addition 818 civil actions were filed.

Another interesting statistic was the high number of healthcare exclusions that were published. There were a total of 1,281 healthcare exclusions. They stated that 309 of those exclusions were related to patient abuse or neglect and 972 were a result of licensure revocations.

The post Report from the Department of Justice Fraud & Abuse Control for 2017 sheds light upon the importance of compliance appeared first on The Coding Network.

The Coding Network

Top 20 Principal Hospice Diagnoses for 2017

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Since the implementation of the hospice benefit in 1983, the number of Medicare beneficiaries receiving hospice services has grown from 513,000 in 2000 to nearly 1.5 million in 2017. Over the years, there have been changes in the diagnosis patterns among Medicare hospice enrollees — largely due to changes in coverage. In 2002, lung cancer […]
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