CMS continues emphasis on quality, efficiency
Proposed IPPS strengthens VBP, IQR programs
In the Inpatient Prospective Payment System (IPPS) proposed rule, the Centers for Medicare & Medicaid Services reiterates its intention to shift Medicare reimbursement from a system based on volume to one based on quality of care.
The proposed rule, issued in late April, strengthens the Hospital Inpatient Quality Reporting program and proposes new policies and measures for the Medicare Value-Based Purchasing Program, and adds two new conditions to the list of hospital-acquired conditions. In the proposed rule, CMS reiterated its intention to add new diagnoses to the readmission reduction program in fiscal 2015 but did not mention any specific conditions. There were no coding changes since the U.S. is transitioning between ICD-9 and ICD-10. CMS did not add any new MS-DRGs in the proposed rule.
CMS has announced a 2.3% market basket increase in reimbursement for hospitals that participate in the Inpatient Quality Reporting program, resulting in a net increase of 0.9% after the mandated coding and documentation adjustment.
The move by CMS to reward hospitals for providing efficient and high-quality care makes it more important than ever for case managers to make sure documentation is accurate and complete and clearly reflects patients' severity of illness and services provided, says Susan Wallace, MEd RHIA, CCS, CDIP, CCDS, director of compliance/inpatient consultant for Administrative Consultant Service, LLC, a healthcare consulting firm based in Shawnee, OK.
"Documentation can have a big impact on the hospital's payments under the Value-Based Purchasing initiative and the readmissions reduction program. Case managers should make sure the record clearly documents how sick patients are and appropriately identifies the reason they are admitted as inpatients," she says.
CMS emphasizes in the rule that it intends for hospitals to do a better job of managing care transitions, says Evan Pollack, MD, FACP, senior medical director of Medicare appeals for Executive Health Resources, a Newton Square, PA, healthcare consulting firm.
By identifying patients at risk for readmission, a hospital can be more efficient in its discharge planning, Pollack says. This means that case managers need to identify patients likely to be readmitted early in the stay and take steps to avoid the readmission, he adds. Services to help prevent readmissions can include home health, scheduling a follow-up appointment with a physician, and ensuring that prescribed medications were picked up. "CMS wants hospitals to target patients who are likely to be readmitted based on medical conditions as well as those requiring post-discharge care coordination and focus on providing services so that readmissions do not occur. In some cases, patients are so sick that it is inevitable that they are going to come back, and it may cost the hospital more to try to prevent a readmission than the penalty would be," he says.
The Inpatient Quality Reporting program, the Hospital Acquired Conditions program, and Value-Based Purchasing are all based on inpatient admissions, making it essential that patients are in the appropriate level of care at the appropriate time and that their admission status is clearly documented, Wallace adds.
Hospitals that have excessive readmissions within 30 days for patients with heart failure, pneumonia, and acute myocardial infarction will receive as much as a 1% reduction in reimbursement for all discharges beginning Oct. 1, 2012.
"All measures under the readmission reduction program are risk-adjusted based on the patient's condition. Case managers need to make sure that all conditions are documented so the hospital can get credit for them," Wallace says.
Making sure the physician documentation is clear and complete is essential, she adds. For instance, physicians should clarify the type of pneumonia a patient has. Aspiration pneumonia is not included in the readmission reduction program or the pneumonia mortality measure that is going to be part of Value-Based Purchasing.
Reimbursement based on the Value-Based Purchasing program also begins October 1. (Look for more details on Value-Based Purchasing and how it affects case managers in the next issue of Hospital Case Management.) Under the Value-Based Purchasing program, hospitals' base DRG operating payment is reduced by 1% for each Medicare discharge. Hospitals have the opportunity to receive value-based incentives based on either how well the hospital performs on selected quality measures or how much the hospital's performance improves from its performance during a baseline period. Hospitals that perform well on quality measures or improve their performance on the measures would receive value-based incentive payments.
It's too late to impact payments under Value-Based Purchasing and the readmission reduction program for this year, Wallace points out. In fact, the baseline period for Value-Based Purchasing for fiscal 2014 is already over and the performance period starts either Oct. 1, 2012, or Jan. 1, 2013, depending on the measure. To ensure their hospitals' success in the future, case managers need to make sure that every patient receives evidence-based care and that the quality data submitted to CMS are accurate and timely, she adds.
In the proposed rule, CMS announced its intention to add two conditions to the list of hospital-acquired conditions for which hospitals will not be paid the higher MS-DRG rate if the complication is the sole reason for the higher payment. The conditions are: surgical-site infection following cardiac implantable electronic device and iatrogenic pneumothorax with venous catheterization.
To ensure that hospitals don't lose reimbursement, Pollack advocates using checklists and establishing team rounds that include physicians, case managers, nurses, and pharmacists who double check each other to make sure that nothing gets overlooked. "In addition to the other conditions on the list of hospital-acquired conditions, everybody on the team should understand how long the catheter or the central line has been in so as to avoid hospital-acquired infections," he says.
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For more information contact:
- Susan Wallace, MEd RHIA, CCS, CDIP, CCDS, Director of Compliance/Inpatient Consultant, Administrative Consultant Service, LLC, Shawnee, OK. email:[email protected].
- Evan Pollack, MD, FACP, senior medical director of Medicare appeals for Executive Health Resources, Newton Square, PA. email:[email protected].
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