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OIG Final Rule Determines Penalties for Information Blocking

Offenders may soon pay a hefty price. On June 27, 2023, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) posted its final rule implementing penalties for information blocking. The final rule establishes the statutory penalties created by the 2016 21st Century Cures Act, which made sharing electronic health information the […]

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AAPC Knowledge Center

2022 OPPS/ASC Final Rule Finalizes 2% Boost in Payment Rates

CMS dramatically increases financial penalties for noncompliance with hospital price transparency rules. On Nov. 2, 2021, the Centers for Medicare & Medicaid Services (CMS) released the calendar year (CY) 2022 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule, finalizing payment rates and policy changes affecting Medicare services furnished […]

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AAPC Knowledge Center

CMS Releases 2022 Physician Fee Schedule Final Rule

The 2022 MPFS final rule promotes greater telehealth utilization and boosts payment rates for vaccine administration. The Centers for Medicare & Medicaid Services (CMS) has finalized 2022 payments and policies under the Medicare Physician Fee Schedule (MPFS). The rule includes updates to payment rates for physicians and other healthcare professionals for calendar year (CY) 2022; […]

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AAPC Knowledge Center

Next Interim Final Rule for Surprise Billing Ban Released

Second interim final rule implements additional protections and addresses the independent dispute resolution process. On Sept. 30, 2021, the Department of Health and Human Services (HHS), the Department of Labor, and the Department of the Treasury (the Departments), along with the Office of Personnel Management (OPM), released an interim final rule (IFR) with comment period, […]

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AAPC Knowledge Center

2022 IPPS Final Rule Boosts Hospital Reimbursement

CMS estimates a $ 2.3 billion increase in hospital payments next year due, in part, to a 2.5 percent bump in reimbursement rates under Medicare’s IPPS. On Aug. 2, 2021, the Centers for Medicare and Medicaid Services (CMS) posted the fiscal year (FY) 2022 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) Prospective Payment […]

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AAPC Knowledge Center

Final Rule Updates MIPS for 2021 and beyond

CMS continues to phase in the Quality Payment Program while MACRA mandates loom. The long-awaited Physician Fee Schedule (PFS) final rule, now pending publication in the Federal Register, finalizes proposed updates to the Quality Payment Program (QPP) and its two tracks — the Merit-Based Incentive Payment System (MIPS) and Advanced Alternate Payment Models (APMs) — […]

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2017 IPPS final rule and claims-based measures

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

Final Rule Encourages Home Dialysis and Living Donor Kidney Transplants

Mandatory model aims to reduce Medicare expenditures for ESRD patients while improving their quality of care.

The post Final Rule Encourages Home Dialysis and Living Donor Kidney Transplants appeared first on AAPC Knowledge Center.

AAPC Knowledge Center

2017 IPPS final rule and claims-based measures

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