Postoperative respiratory failure’s introduction into the CMS value-based reimbursement model

By Robert Stein, MD, CCDS, and Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer

The accurate capture of acute respiratory failure has been a long-standing challenge for CDI programs. The accurate reporting of this condition as a post-procedural event can be even more difficult.

The importance of data quality for post-procedural acute respiratory failure will impact quality outcomes linked to reimbursement under the Hospital-Acquired Condition Reduction Program (HACRP), as well as the Hospital Value-Based Purchasing Program (HVBP), if language in the fiscal year (FY) 2017 IPPS proposed rule is finalized.

In this article we’ll provide insights into how clinical documentation and reported codes may impact payments, and guidance on some common CDI challenges to strengthen data quality.

Performance may impact reimbursement in FY 2018

A quality measure named Patient Safety Indicator (PSI) 11 has existed since 1998, when it was developed by the Agency for Health Care Research and Quality (AHRQ). The measure has been adopted for use by CMS and other comparative databases, such as the University HealthSystem Consortium and Healthgrades, to compare performance across hospitals.

If the proposed rule is finalized as written, how well your hospital performs on this measure will begin to impact hospital reimbursement under the two hospital pay-for-performance programs noted above. Reimbursement impact will begin in:

• FY 2018 for the HACRP
• FY 2019 for the HVBP

Performance for this measure will be assessed and scored, and the score will then be rolled into a weighted patient safety composite measure. Performance for the overall composite measure will then determine reimbursement impact. The name of this composite measure is the Patient Safety and Adverse Events Composite, previously known as the PSI 90 composite measure.

The Patient Safety and Adverse Events Composite measure was reviewed in last month’s column. What is important to note for PSI 11 is that performance for this measure will impact approximately 22% of the composite weight:

Data quality and PSI 11 performance

PSI 11 performance is determined by the diagnosis (ICD-10-CM) codes we submit on claims. This is a risk-adjusted measure evaluated using an observed over an expected ratio.

Discharges included in the measure:

• All elective surgical discharges treated at the hospital are evaluated for comorbidities which impact the complexity of the patient mix and the associated expected rate of postoperative respiratory failure events

Identification of postoperative respiratory events:

• Any discharge included in the measure which has one of the following ICD-10-CM codes on the claim triggers a reportable actual?or observed? postoperative respiratory failure event:

Additional details for key measure drivers can be found on review of PSI 11 specifications located on the AHRQ website at www.qualityindicators.ahrq.gov/Modules/psi_resources.aspx.

PSI 11 CDI vulnerabilities

In our review of thousands of medical records for hospitals across the country, we see common challenges which impact PSI 11 data quality. We discuss a few of the common questions we encounter below to assist your internal data quality efforts.

How do I recognize acute respiratory failure?

• Acute respiratory failure is at the end of a continuum initiated by respiratory dysfunction resulting in abnormalities of oxygenation and/or carbon dioxide elimination
• Acute on chronic respiratory failure is an exacerbation or decompensation of chronic respiratory failure

Clinical criteria to identify if not documented and/or to validate a documented diagnosis include:

• The use of supplemental oxygen or non-invasive/invasive mechanical ventilation
• Signs and symptoms indicative of increased work of breathing (e.g., dyspnea, tachypnea [respiratory rate greater than 28], respiratory distress, labored breathing, use of accessory muscles)
• Impaired gas exchange, which may be identified by the following clinical indicators:

What is the definition of "prolonged" postoperative mechanical ventilation?

• A code for mechanical ventilation (and intubation) should not be assigned postoperatively for mechanical ventilation when it is considered a normal part of surgery.
• Prolonged mechanical ventilation should be reported for an extended period postoperatively. A general rule of thumb for extended is 48 hours with the start time as the time of intubation for the procedure. Provider documentation should support what appears to be an extended time, but is in fact unexpected given the procedure and/or patient complexity.

If the patient is extubated postoperatively, but continues to be treated with supplemental oxygen, when is a query for acute respiratory failure appropriate?

• To determine if this represents acute respiratory failure the values for impaired oxygen exchange can be utilized, along with the amount of oxygen being administered to the patient.
• The P/F ratio can be a helpful tool to identify respiratory failure criteria above for a patient receiving supplemental oxygen:
• If an ABG test is not available, an estimated P/F ratio can be calculated:
• An illustration of the calculation follows:
• The P/F ratio is a useful tool to validate the presence of acute hypoxemic respiratory failure when patients are receiving supplemental oxygen.

When respiratory failure exists in a post-procedural patient, how do I determine if this is, and/or is not, related to the procedure?

• Physician education to promote clear documentation which relates the respiratory failure to an underlying condition (e.g., COPD) and/or to a procedure, and/or to the anesthesia, is essential.
• When such documentation is not clear, a documentation query or clarification is required.

In addition to the above, other record review findings which negatively impact PSI 11 data quality include:

• Accurate reporting of mechanical ventilation duration:
• Accurate selection of post-procedural respiratory failure as the principal diagnosis:

Summary

Value-based care will increasingly utilize claims-based measures to assess quality and cost outcomes linked to payment. To strengthen organizational performance for PSI 11, the following steps are suggested:

• Establish synergy between the CDI program and quality department to support:
• Promote point-of-care capture of risk-adjustment variables pertinent to PSI 11 performance:
• Actively engage your CDI physician advisor with medical staff education and CDI record reviews to facilitate and promote accurate capture of documentation relevant to accurate cohort identification and risk adjustment

Editor’s note

Stein is associate director of the MS-DRG Assurance program for Enjoin, providing clinical insight and education as part of the pre-bill review process. He earned his CCDS credential in June 2013 and completed AHIMA’s ICD-10-CM/PCS coder workforce training in August 2013. Newell is the director of CDI quality initiatives for Enjoin. Her team provides health systems with physician-led education and infrastructure design to sustainably address documentation and coding challenges essential to optimal performance under value-based payments across the continuum. 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 (704) 931-8537 or [email protected]. Opinions expressed are that of the authors and do not represent HCPro or ACDIS.

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