Revenue Cycle

CMS, payers agree on set of quality and cost measures to link payment

HIM Briefings, June 1, 2016

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Clinical documentation and coding has a significant impact on value-based quality outcome performance. Such outcomes include risk-adjusted mortality, readmission, patient safety, complication rates, and cost efficiency measures.

Value-based outcomes linked to payment represent the next wave of opportunity for CDI programs to support their health systems. Clinical documentation and coding across the continuum impact performance for claims-based measures contained within these standard data sets. Claims-based outcome measures use ICD-10 codes submitted on claims both to define the populations (or cohorts) included in the measure, as well as to risk-adjust performance.

Let's look at a few examples to illustrate how clinical documentation and code assignment can impact performance for one of the claims-based measures in the figure, the risk standardized complication rate?THA/TKA (RSCR THA/TKA):

  • Assignment of the discharge disposition as "AMA" also excludes the THA/TKA discharge from the measure.
  • Documentation and reporting of "morbid obesity" prior to the admission for the THA/TKA procedure strengthens risk adjustment. Note: "Obesity" does not impact risk adjustment.
  • Documentation and reporting of "chronic renal insufficiency" prior to the admission for the THA/TKA procedure will further strengthen risk adjustment. Note: "Renal insufficiency" will not count.
  • Documentation and reporting of "coronary artery disease" in the THA/TKA inpatient encounter will strengthen the risk adjustment even further.

 

The alignment of quality measures that will be linked to payment by public and private payers provides a framework upon which future efforts can be based. CMS will go through a public notice and comment rulemaking for implementation of these core sets and looks forward to public input on the measures included in these core measure sets.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to HIM Briefings.

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