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.