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CMS continues shift to value over volume in 2016 IPPS final rule

HCPRO Website, August 3, 2015

by Michelle A. Leppert, CPC

CMS finalized changes to multiple quality measures in the fiscal year 2016 IPPS final rule, released July 31.

“The final rule includes policies that advance the vision and commitment to increasingly shift Medicare payments from volume to value,” says Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM trainer, director of CDI Quality Initiative for Huff DRG Review in Eads, Tennessee.

CMS finalized the addition of seven new measures to the Hospital Inpatient Quality Reporting (IQR) Program. In addition, the agency finalized changes to the pneumonia readmission measure as part of the Hospital Value-Based Purchasing (HVBP) Program and the Hospital Readmissions Reduction Program (HRRP).

CMS is not adding or removing any Hospital-Acquired Condition (HAC) categories for FY 2016. It estimates that 19.4% of all hospitals will be penalized with a 1% reduction in MS-DRG payments for all traditional Medicare discharges in FY 2016 due to Hospital-Acquired Condition Reduction Program (HACRP) performance.

CMS also addressed provider comments on its plan to expand the Bundled Payments for Care Improvement (BRCI) Initiative.

The BPCI Initiative is composed of four related payment models that link payments for multiple services received by Medicare beneficiaries during an episode of care into a bundled payment.

More than 75 stakeholders responded to CMS’ request for comments on the BPCI Initiative. While CMS stated it would consider these comments if it does expand the initiative, it provided only general topics addressed by the commenters.

CMS included a small discussion on short stays and the 2-midnight rule. CMS did not propose any changes to the 2-midnight rule in the 2016 IPPS proposed rule, but reminded stakeholders that it did address short stays in the 2016 OPPS proposed rule. Stakeholders have until August 31 to submit comments on the short stay proposals.

The IPPS final rule did not include an extension of the partial enforcement delay of the 2-midnight policy. The partial delay expires September 30.

Hospital Inpatient Quality Reporting Program

CMS added three new claims-based measures and one structural measure for the FY 2018 payment determination and subsequent years; it also added three new claims-based measures for the FY 2019 payment determination.

The seven new measures are:

  • Hospital Survey on Patient Safety Culture
  • Kidney/UTI Clinical Episode-Based Payment
  • Cellulitis Clinical Episode-Based Payment
  • Gastrointestinal Hemorrhage Clinical Episode-Based Payment
  • Hospital-Level, Risk-Standardized Payment Associated with an Episode-of-Care for Primary Elective Total Hip Arthroplasty (THA)/Total Knee Arthroplasty (TKA)
  • Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction
  • Excess Days in Acute Care after Hospitalization for Heart Failure

All of the new measures are claims based except for Hospital Survey on Patient Safety Culture.

Three of the new clinical episode-based measures, kidney/UTI, cellulitis, and GI hemorrhage, will impact payment in FY 2019, Newell says.

CMS finalized removal of six topped-out measures:

  • 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

CMS will retain measures STK-06, STK-08, VTE-1, VTE-2, and VTE-3 as electronic clinical quality measures for the FY 2018 payment determination and subsequent years.

The agency did acknowledge that “the intent of a measure is the same whether it is reported via chart-abstraction or electronically, the submission modes are not the same and measure rates may be different.”

It also removed measures:

  • IMM-1, Pneumococcal Immunization
  • SCIP-Inf-4, Cardiac Surgery Patients with Controlled Postoperative Blood Glucose

Hospital Readmissions Reduction Program

CMS finalized refinements to the pneumonia readmission measure to expand the measure cohort.

Most hospitals are familiar with the Yale University mortality and readmission methodologies and cohorts that CMS uses in its 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.

CMS amended the readmission cohort (and not the mortality cohort) to include patients with a principal discharge diagnosis of:

  • Pneumonia
  • Aspiration pneumonia
  • Sepsis with a secondary diagnosis of pneumonia present on admission

However, CMS chose not to include patients with a principal discharge diagnosis of respiratory failure or sepsis if they are coded as having severe sepsis.

“It is interesting to note that the reason CMS did not include these other populations is because, on further analysis, they found that the populations coded with respiratory failure and sepsis actually had lower risk-adjusted mortality, which was an unexpected finding attributed to ‘coding patterns,’ ” Newell says.

The resulting change in the pneumonia cohort also impacts seven of the risk adjustment variables used in the risk adjustment algorithm. “These are important to capture to accurately reflect risk-adjusted mortality performance,” Newell says.

The revised pneumonia cohort is expected to increase the number of discharges included in the measure by 50%, and to increase the number of hospitals (which will now meet the minimum case threshold of 25 eligible discharges). CMS expects the revised definition to impact the excess readmission rates for some hospitals.

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 finalized removal of IMM-2 (Influenza Immunization) because it determined the measure was topped out.

CMS is also removing AMI-7a (Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival) because few hospitals have the minimum number of cases necessary to report the measure.

Because CMS finalized the removal of these two measures from the Clinical Care-Process subdomain, the agency finalized its proposal to move PC-01 (Elective Delivery) from Clinical Care-Process to the Safety domain. CMS will eliminate the Critical Care-Process subdomain and rename the Clinical Care-Outcomes subdomain as simply the Clinical Care domain.

The agency also adopted a new measure for FY 2018 reporting: 3-Item Care Transition Measure (CTM-3).

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 defines selected ward (non-ICU) locations as adult or pediatric medical, surgical, and medical/surgical wards.

CMS also finalized the addition of Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Chronic Obstructive Pulmonary Disease Hospitalization beginning in FY 2021.

Hospital-Acquired Conditions Reduction Program

CMS finalized the 24-month period from July 1, 2013, through June 30, 2015, as the time frame for Domain 1 measure (AHRQ PSI-90 Composite measure).

CMS decreased the Domain 1 weight from 25% to 15% and increased the Domain 2 weight from 75% to 85% for FY 2017.

CMS also finalized an expansion of data for CLABSI and CAUTI measures. The agency will include data from pediatric and adult medical ward, surgical ward, and medical/surgical ward locations, in addition to data from adult and pediatric ICU locations for the CLABSI and CAUTI measures, beginning in FY 2018.

As part of the discussion of the HAC Reduction Program, CMS acknowledged comments about quality measures included in both the HVBP Program and the HAC Reduction Program.

CMS noted that the overlapping measures “cover topics of critical importance to quality improvement in the inpatient hospital setting and to patient safety.”

The agency also stated that the two programs have different purposes and policy goals.

CMS noted that the National Quality Forum (NQF) has not yet completed maintenance review of the Patient Safety Indicator (PSI) 90 measure.

“CMS clarified in the final rule that PSI 90 has not lost NQF endorsement, which is in fact not required for measure adoption into the HVBP,” Newell says.

The NQF is considering expanding this measure from eight PSIs to 11 PSIs. The prior version of PSI 90 remains adopted. CMS will provide notification of any future refinements to this measure upon completion of NQF maintenance review.

MS-DRG changes

CMS eliminated MS-DRGs 237 (major cardiovascular procedures with MCC or thoracic aortic aneurysm repair) and 238 (major cardiovascular procedures with MCC or thoracic aortic aneurysm repair). The agency created five new MS-DRGs to replace them:

  • MS-DRG 268, aortic and heart assist procedures except pulsation balloon with MCC
  • MS-DRG 269, aortic and heart assist procedures except pulsation balloon without MCC
  • MS-DRG 270, other major cardiovascular procedures with MCC
  • MS-DRG 271, other major cardiovascular procedures with CC
  • MS-DRG 272, other major cardiovascular procedures without CC/MCC

CMS also modified the titles for three spinal fusion MS-DRGs:

  • MS-DRG 456, spinal fusion except cervical with spinal curvature/malignancy/infection or extensive fusion with MCC
  • MS-DRG 457, spinal fusion except cervical with spinal curvature/malignancy/infection or extensive fusion with CC
  • MS-DRG 458, spinal fusion except cervical with spinal curvature/malignancy/infection or extensive fusion without CC/MCC

CMS finalized the designation of eight ICD-10-PCS codes as non-OR.

An inspection copy of the final rule is available, and it will be published in the Federal Register August 17.