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Unless ordered otherwise, most commercial payers will return to business as usual Jan. 1, or sooner. The COVID-19 public health emergency (PHE) continues, but will expanded telehealth coverage and cost sharing waivers? Some health insurers will stop paying for expanded telehealth services as soon as Oct. 1. Patient cost-sharing may resume soon, as well. In […]
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Physicians now may use telehealth to conduct face-to-Face encounters for home health patients. Home care providers may not be getting all the support they want from regulators in the face of the COVID-19 crisis, but the feds are helping home health agencies on one critical point: reimbursement for face-to-face physician encounter visits. What Does the […]
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CMS finalized its proposals regarding the 2-midnight rule, including moving responsibility for rule enforcement and education from Recovery Auditors to Quality Improvement Organizations (QIO). This latter change occurred October 1, 2015.
Ready CDI teams for CMS’ proposed expansion of mandatory ortho episode payment models
by Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer
If your hospital resides in one of the 67 metropolitan statistical areas (MSA) required to participate in the Comprehensive Joint Replacement Model (CJR), you will also be required to participate in a new orthopedic payment model called SHFFT (surgical hip and femur fracture treatment) if an August 2 proposed rule is finalized. The impact? The following assigned MS-DRGs will no longer define hospital reimbursement:
MS-DRGs 469 and 470 are included in the CJR, which we have discussed in prior articles. Let’s take a look at the proposed SHFFT episode payment model (EPM), which involves the other three MS-DRGs, and see what role the CDI program can play as reimbursement shifts to episode-based payments.
Model overview
The episode of care defined for the SHFFT EPM begins with an admission to a participating hospital of a fee-for-service Medicare patient assigned MS-DRGs 480?482. This admission is referred to as the anchor hospitalization. The episode continues 90 days post-discharge from the hospital, and payments for all related Part A and Part B services are included in the episode payment bundle. CMS holds the hospital accountable for defined cost and quality outcomes during the episode and links reimbursement?which may consist of payment penalties and/or financial incentives?to outcome performance.
This is a mandatory EPM for hospitals already impacted by the CJR; the SHFFT model will apply to the same 67 geographic MSAs. The EPM is proposed to begin July 1, 2017, and will last for five years, ending in December 2021.
Cost outcomes
CMS will initially pay the hospital and all providers who bill for services during the episode using the usual fee-for-service models. Thus, the SHFFT EPM will not impact the revenue cycle at first. However, at the end of each performance period, which typically represents 12 months (January through December), CMS will compare or reconcile the actual costs with a preestablished "target price."
CMS will set target prices using an approach that will phase in a blended rate of hospital to regional costs. In recognition of the higher costs associated with discharges in MS-DRGs with an MCC or CC, CMS has developed an algorithm to adjust the target price for this subset of the patient population.
If the reconciliation process indicates that the costs to deliver services for the episode were higher than the target price, CMS will require repayment from the hospital. If, however, the costs to deliver care for the episode were lower than the target price, CMS will provide additional payments to the hospital for the provided services. To receive additional payments, however, performance for defined quality outcomes must meet or exceed established standards.
Quality-adjusted target price
To receive any earned financial incentives, the hospital must meet or exceed performance standards for established quality outcomes. CMS therefore adjusts the target price based on quality performance, referred to as the quality-adjusted target price.
The SHFFT EPM uses the exact same quality outcomes as those defined for the CJR:
Hospital (accountable party), collaborators, and Advanced Payment Models
The hospital is held accountable for episode cost and quality outcomes and all associated financial risks/rewards, even though a variety of providers deliver services and impact performance. As with the CJR, the hospital has been designated as the accountable party because CMS believes the hospital is best positioned to influence coordinated, efficient delivery of services from the patient’s initial hospitalization through recovery.
CMS permits the hospital to enter into collaborative arrangements with physicians and other providers to support and redesign care delivery across the episode and to share financial gains and/or losses. The proposed rule expands the list of collaborators defined in the previous CJR final rule to include other hospitals and Medicare Shared Savings Program accountable care organizations.
The proposed rule also provides an Advanced Payment Model (APM) track for the EPMs, an important step that will further incentivize collaborator participation.
CDI program opportunities
There are five key ways that clinical documentation and reported codes across the continuum impact SHFFT performance:
The costs associated with Part B claims are included in episode costs if the services are related. The primary diagnosis for each visit determines whether the visit is related.
The capture of at least one condition for each of the 28 comorbid categories over the 12-month period will strengthen risk adjustment and RSCR performance. RSCR performance contributes to 50% of the quality composite score, which, in turn, impacts the quality-adjusted target price.
Summary
Together the CJR and SHFFT models cover all surgical treatment options (hip arthroplasty and fixation) for Medicare beneficiaries with hip fractures. These MS-DRGs typically represent one of the largest inpatient surgical volumes for most short-term acute care hospitals.
As hospitals and collaborators assess and refine the management of patients to achieve or exceed the quality-adjusted target price, the data we submit on claims will be used to assess our performance. The CDI program in the inpatient and ambulatory setting must be positioned to promote and support the capture and reporting of impactful documentation.
Additional information on the proposed rule can be located at https://innovation.cms.gov/initiatives/epm.
Editor’s note
Newell is the director of CDI quality initiatives for Enjoin. Her team provides CDI programs with education, infrastructure design, and audits to successfully and sustainably address the transition to value-based payments. She has extensive operational and consulting expertise in coding and clinical documentation improvement, case management, and health information management. You can reach Newell at 704-931-8537 or [email protected].
Ready CDI teams for CMS’ proposed expansion of mandatory ortho episode payment models
by Shannon Newell, RHIA, CCS, an AHIMA-approved ICD-10-CM/PCS trainer
If your hospital resides in one of the 67 metropolitan statistical areas (MSA) required to participate in the Comprehensive Joint Replacement Model (CJR), you will also be required to participate in a new orthopedic payment model called ‘SHFFT’ (surgical hip and femur fracture treatment) if an August 2 proposed rule is finalized. The impact? The following assigned MS-DRGs will no longer define hospital reimbursement:
MS-DRGs 469 and 470 are included in the CJR, which we have discussed in prior articles. Let’s take a look at the proposed SHFFT episode payment model (EPM), which involves the other three MS-DRGs, and see what role the CDI program can play as reimbursement shifts to episode-based payments.
Model overview
The episode of care defined for the SHFFT EPM begins with an admission to a participating hospital of a fee-for-service Medicare patient assigned MS-DRGs 480?482. This admission is referred to as the anchor hospitalization. The episode continues 90 days post-discharge from the hospital, and payments for all related Part A and Part B services are included in the episode payment bundle. CMS holds the hospital accountable for defined cost and quality outcomes during the episode and links reimbursement?which may consist of payment penalties and/or financial incentives?to outcome performance.
This is a mandatory EPM for hospitals already impacted by the CJR; the SHFFT model will apply to the same 67 geographic MSAs. The EPM is proposed to begin July 1, 2017, and will last for five years, ending in December 2021.
Cost outcomes
CMS will initially pay the hospital and all providers who bill for services during the episode using the usual fee-for-service models. Thus, the SHFFT EPM will not impact the revenue cycle at first. However, at the end of each performance period, which typically represents 12 months (January through December), CMS will compare or reconcile the actual costs with a preestablished ‘target price.’
CMS will set target prices using an approach that will phase in a blended rate of hospital to regional costs. In recognition of the higher costs associated with discharges in MS-DRGs with an MCC or CC, CMS has developed an algorithm to adjust the target price for this subset of the patient population.
If the reconciliation process indicates that the costs to deliver services for the episode were higher than the target price, CMS will require repayment from the hospital. If, however, the costs to deliver care for the episode were lower than the target price, CMS will provide additional payments to the hospital for the provided services. To receive additional payments, however, performance for defined quality outcomes must meet or exceed established standards.
Quality-adjusted target price
To receive any earned financial incentives, the hospital must meet or exceed performance standards for established quality outcomes. CMS therefore adjusts the target price based on quality performance, referred to as the quality-adjusted target price.
The SHFFT EPM uses the exact same quality outcomes as those defined for the CJR:
Hospital (accountable party), collaborators, and Advanced Payment Models
The hospital is held accountable for episode cost and quality outcomes and all associated financial risks/rewards, even though a variety of providers deliver services and impact performance. As with the CJR, the hospital has been designated as the accountable party because CMS believes the hospital is best positioned to influence coordinated, efficient delivery of services from the patient’s initial hospitalization through recovery.
CMS permits the hospital to enter into collaborative arrangements with physicians and other providers to support and redesign care delivery across the episode and to share financial gains and/or losses. The proposed rule expands the list of collaborators defined in the previous CJR final rule to include other hospitals and Medicare Shared Savings Program accountable care organizations.
The proposed rule also provides an Advanced Payment Model (APM) track for the EPMs, an important step that will further incentivize collaborator participation.
CDI program opportunities
There are five key ways that clinical documentation and reported codes across the continuum impact SHFFT performance:
The costs associated with Part B claims are included in episode costs if the services are related. The primary diagnosis for each visit determines whether the visit is related.
The capture of at least one condition for each of the 28 comorbid categories over the 12-month period will strengthen risk adjustment and RSCR performance. RSCR performance contributes to 50% of the quality composite score, which, in turn, impacts the quality-adjusted target price.
Summary
Together the CJR and SHFFT models cover all surgical treatment options (hip arthroplasty and fixation) for Medicare beneficiaries with hip fractures. These MS-DRGs typically represent one of the largest inpatient surgical volumes for most short-term acute care hospitals.
As hospitals and collaborators assess and refine the management of patients to achieve or exceed the quality-adjusted target price, the data we submit on claims will be used to assess our performance. The CDI program in the inpatient and ambulatory setting must be positioned to promote and support the capture and reporting of impactful documentation.
Additional information on the proposed rule can be located at https://innovation.cms.gov/initiatives/epm.
Editor’s note
Newell is the director of CDI quality initiatives for Enjoin. Her team provides CDI programs with education, infrastructure design, and audits to successfully and sustainably address the transition to value-based payments. She has extensive operational and consulting expertise in coding and clinical documentation improvement, case management, and health information management. You can reach Newell at 704-931-8537 or [email protected].
Medical centers must grow alongside growing communities and an increasing population. Many general hospitals provide a number of healthcare services, offering patients convenience as they take care of all their needs in one location. Comprehensive medical centers meet the varied needs of patients by providing high quality medical care using advanced technologies.
Home Care
Many general hospitals offer patients specialized services in addition to 24-hour emergency care, in-patient care, and surgical care, including cardiopulmonary rehabilitation, dedicated heart centers, and care in a patient’s home.
Medical centers and clinics know patients feel better and tend to heal faster when they recuperate in the comfort of home. In-home treatment plans are a viable option for homebound patients or for patients who move from a hospital stay to home care.
General hospitals and home care clinics feature trained, licensed professionals in healthcare areas that include nutrition, speech therapy, occupational therapy, physical therapy, and nursing. Home care treatments can consist of many options like disease management, wound care, post-operative care, and rehabilitation.
Heart Clinics
Since the number one cause of death in America is heart disease, many general hospitals have technologically advanced heart clinics that respond to heart attack and stroke victims. These medical centers also assist patients with preventative measures that include accurate diagnoses, regular screenings, and heart and stroke education.
Heart clinics also have dedicated cardiac teams waiting on standby to provide patients bypassing the emergency room with immediate critical care. More advanced medical centers offer innovative ICE programs that involve cooling a patient’s body for 24 to 36 hours after cardiac arrest before slowly raising it to normal. This unique technology increases the survival rate above the national average. In addition, comprehensive medicals use heart clinics to endorse other community outreach programs.
Rehabilitation Programs
Patients suffering from cardiac arrest, stroke, or pulmonary disease recover quicker when participating in a cardiopulmonary rehabilitation program. The patients benefiting the most include those who suffered cardiac arrest and then underwent bypass surgery, coronary stent replacement, or a heart transplant.
Physicians watch and evaluate a patient in a cardiopulmonary rehabilitation program, monitoring the oxygen level, blood pressure, and heart rate of these patients during prescription exercises on therapeutic equipment.
Equally important, cardiopulmonary rehabilitation places emphasis on heart and health education after a patient’s hospital discharge and rehabilitation completion. This helps patients learn new healthy habits that aid in the recovery process and prevent future complications.
Medical centers understand the importance of offering comprehensive healthcare to their varied, growing communities. General hospitals provide patients with the individual care needed from a team of expert healthcare professionals dedicated to caring for the diverse needs of their patients.
Christine O’Kelly writes for the Citrus Memorial Health System, a premier Inverness medical center. Citrus Memorial Health System is a top Florida general hospital.
Despite the inability of republicans in Congress to roll back the Affordable Care Act (ACA), President Trump has promised an executive order to offer relief to healthcare consumers facing rising insurance premiums. He is using “the power of the pen,” according to a tweet, to overhaul healthcare. <INSERT TWEET SCREENSHOT> Under the ACA, new insurance requirements prohibited insurers […]
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