CMS continues focus on quality measures in 2016 IPPS proposed rule

HCPRO Website, April 20, 2015

By Michelle A. Leppert, CPC

In the fiscal year (FY) 2016 IPPS proposed rule, CMS announces the usual changes to MS-DRGs and their relative weights, the market basket update, and the expansion of its value-based payment quality measures, as it has in previous years.
New to this rule, however, is the integration of ICD-10-CM/PCS—adding more insurance against the delay of the code set’s scheduled October 1 implementation, says James S. Kennedy, MD, CCS, CDIP, president of CDIMD – Physician Champions in Smyrna, Tennessee. CMS made significant improvements to the ICD-10 MS-DRGs for hip revisions and added new MS-DRGs for percutaneous intracardiac procedures.
CMS is also asking for comments regarding its potential implementation of bundled payments for inpatient care, which is required by the Patient Protection and Affordable Care Act to be announced no later than January 1, 2016; however, the agency does not outline how it proposes to implement these payments, Kennedy adds.
“Bundled payments, in my opinion, will be the most dramatic policy implementation since DRG’s introduction in 1984, given that physicians and postacute care providers will now be accountable to DRG-based budgets that they have not been previously held to,” Kennedy says. “If there’s any one portion of this rule that physician and facility providers should read, understand, analyze, and comment on, bundled payments are it.”
Learn more about CMS’ bundled payment demonstration project and a preliminary analysis of its results (particularly in orthopedics).
2-midnight rule
CMS introduced the 2-midnight rule in the FY 2014 IPPS proposed rule. The 2014 final rule established a benchmark that stays expected to last two or more midnights would generally be considered appropriate for inpatient payment, while stays expected to last less than two midnights would generally be considered appropriate for outpatient payment.
Because of provider concern about the rule, CMS and Congress prohibited Recovery Auditors from reviewing patient status on hospital admissions between October 1, 2013, and April 30, 2015. The Medicare Access and CHIP Reauthorization Act of 2015 further extended this prohibition to September 30, 2015.
CMS will continue to review short inpatient hospital stays, long outpatient stays with observation services, and the related -0.2% IPPS payment adjustment. It plans to include information in the calendar year 2016 OPPS proposed rule regarding these services.
Hospital Readmissions Reduction Program
CMS is proposing a refinement to the pneumonia readmission measure to expand the measure cohort and the formal adoption of an extraordinary circumstance exception (ECE) policy.
Most hospitals are familiar with the Yale University mortality and readmission methodologies and cohorts that CMS uses in its Hospital Value-Based Purchasing (HVBP) Program.
In the past, CMS defined the pneumonia cohort for mortality and readmission measurement to include various pneumonia codes as a principal diagnosis, excluding cases where sepsis, aspiration pneumonia, or respiratory failure served as the principal diagnosis, Kennedy says.
CMS proposes in this rule to amend the readmission cohort (and not the mortality cohort) to include these excluded cases, effective with the FY 2017 payment determination.
“It is vital that hospitals comment on this proposal, given that patients with severe sepsis [sepsis with acute organ dysfunction] and septic shock [sepsis with a serum lactate over 4 or resistant hypotension] have poorer outcomes than community-acquired pneumonia and that the facility’s baseline determinations will be adjusted with unforeseen consequences,” Kennedy says.
Provider definition and documentation of patient circumstances and diagnoses using ICD-10-CM administrative language is crucial, given that ICD-10-CM code assignment governing cohort selection is solely dependent upon the integrity and clinical congruence of this documentation, not upon abstraction of the patient’s clinical picture using predefined criteria.
Hospital Value-Based Purchasing Program
The HVBP Program adjusts payments to hospitals for inpatient services based on their performance on an announced set of measures.
CMS proposes removing these two measures:
  • IMM-2, Influenza Immunization
  • AMI-7a, Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
If CMS does remove these two measures, it plans to move PC-01 (Elective Delivery) to the Patient Safety domain and to remove the Clinical Care—Process subdomain for FY 2018 and beyond. The Patient Safety domain will have an increased weight in the HVBP scoring methodology in FY 2018 (from 20% to 25%).
CMS is proposing to adopt:
  • 3-Item Care Transition Measure for FY 2018
  • Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Chronic Obstructive Pulmonary Disease Hospitalization beginning in FY 2021
“The policy changes reflect a continued shift from process measures to outcome measures,” says Shannon Newell, RHIA, CCS, AHIMA-Approved ICD-10-CM/PCS Trainer, a director with CCDI-DQ in Charlotte, North Carolina.
CMS continues to emphasize patient safety measures, she adds. The Hospital-Associated Infection measures will expand the population in FY 2019. The Central Line–Associated Bloodstream Infection (CLABSI) and Catheter-Associated Urinary Tract Infection (CAUTI) measures will include selected ward (non-ICU) locations.
CMS is also continuing its emphasis on patient satisfaction measures, Newell says.
Further, the rule provides ongoing signals of CMS’ intent to keep expanding the Efficiency Domain to include condition- and/or treatment-specific episode measures, she notes.
Hospital-acquired conditions
The proposed rule indicates that 19.4% of hospitals are anticipated to be penalized with a 1% reduction in MS-DRG payments for all traditional Medicare discharges in FY 2016 due to Hospital-Acquired Condition (HAC) Reduction Program (HACRP) performance.
CMS is proposing three changes to the HACRP:
Expanding the population covered by CLABSI and CAUTI measures from ICU locations to select medical and surgical wards in FY 2018
Adjusting the relative contribution of each domain to the total HAC score
Adding an ECE policy
CMS is not proposing to add or remove any categories in the rule.
The agency is placing an increased emphasis on performance for hospital-associated infections (HAI), Newell says—specifically, the weight for the HAI domain will increase from 75% to 85%. This increase is due to stakeholder requests and the expanded number of measures finalized in prior rules, which increased from four to six.
PSI 90 continues to undergo National Quality Forum (NQF) maintenance review. CMS is considering adding three new measures:
  • PSI 9, peri-operative hemorrhage rate
  • PSI 10, peri-operative physiologic metabolic derangement rate
  • PSI 11, postoperative respiratory failure
“This expansion, if approved, would be considered a significant change to the measure, and if it occurs CMS will engage in notice and comment rulemaking prior to adoption,” Newell says.
Hospital Inpatient Quality Reporting Program
CMS proposes removing nine measures from the Hospital Inpatient Quality Reporting (IQR) Program, including six “topped out” measures. Those topped out measures are:
  • STK-01, Venous Thromboembolism (VTE) Prophylaxis for Patients with Ischemic or Hemorrhagic Stroke
  • STK-06, Discharged on Statin Medication
  • STK-08, Stroke Education
  • VTE-1, Venous Thromboembolism Prophylaxis
  • VTE-2, Intensive Care Unit Venous Thromboembolism Prophylaxis
  • VTE-3, Venous Thromboembolism Patients with Anticoagulation Overlap Therapy
However, CMS plans to retain all but STK-01 as electronic clinical quality measures for the FY 2018 payment determination and beyond.
CMS is proposing to remove SCIP-Inf-4 (Cardiac Surgery Patients with Controlled Postoperative Blood Glucose). In January, CMS formally suspended the collection of data for SCIP-Inf-4 beginning with July 1, 2014, discharges.
In addition, CMS plans to require hospitals to report 16 of the 28 electronic clinical quality measures under the Hospital IQR Program that align with the Medicare EHR Incentive Program for FY 2018 payment determination.
CMS also plans to align the reporting and submission timelines for the clinical quality measures under the Medicare EHR Incentive Program for eligible hospitals and critical access hospitals with the reporting and submission timelines for the Hospital IQR Program.
Throughout the proposed rule, CMS asks for input from the hospital community. Comments are due by June 16, 2015, to the addresses outlined in the rule. They may be submitted electronically or in hard copy.