CMS rule raises bar on quality

Pay more attention to readmissions and HAIs

In August, the Centers for Medicare & Medicaid Services (CMS) released the final rule regarding Medicare payment policies and rates for next year. The rule will affect Medicare payments to general acute care hospitals and long-term care hospitals for inpatient stays, but strengthens the Hospital Inpatient Quality Reporting (IQR) Program by placing greater emphasis on preventing health care-associated infections (HAIs) such as central line-associated bloodstream infections. It also outlines a Hospital Readmissions Reduction Program (HRRP) that will cut payments to facilities that have "excess" readmissions for patients with myocardial infarction, heart failure, and pneumonia. The methodology used for determining excess readmissions is based on National Quality Forum methodologies: numbers 330 for heart failure, 505 for myocardial infarction, and 506 for pneumonia. (For sample methodology see box, below.)

Sample Excess Readmission Measurement

Source: National Quality Forum

•Methodology for Heart Failure
Number 0330

Outcome: 30-day all-cause readmissions for patients discharged from the hospital with a principal diagnosis of heart failure, as measured from the date of discharge of the index heart failure admission

Included population: Index admissions for Medicare fee-for-service beneficiaries age 65 or over admitted to the hospital with a principal ICD-9-CM discharge diagnosis of heart failure and discharged alive

Age <65

In-hospital deaths
Incomplete data (without FFS Part A, without 12-mo enrollment prior to discharge, without 1 month enrollment post discharge)

Transfers out
Additional HF admissions within 30 days

• Complete methodology, including risk adjustment variables, is available at

For the most part, the rule will emphasize areas of import that quality professionals at the best facilities are already working on, says Susan Wallace, MEd, RHIA, CCS, CCDS, director of compliance and inpatient consultant for Administrative Consultant Service, LLC, of Shawnee, OK. But it still requires notice. "With continued expansion of the inpatient quality reporting, value-based purchasing, Medicare spending per beneficiary ratio and the Readmission Reduction Program, we see more and more emphasis on risk adjustment," she says. "While age is certainly a risk-adjustment factor, so are the patient's comorbid conditions. When CMS evaluates claims data for risk adjustment of these measures, it is important to remember that there are very specific guidelines for what can and cannot be reported, and everything has to originate with the physician's documentation."

The way to ensure the kind of accurate documentation that will legitimize severity of illness is to have a clinical documentation improvement (CDI) program. Wallace says a fair number of hospitals have yet to create one. It entails having clinical professionals review patient records while they are still in the hospital to see if they need to query a physician for clarification so that the record reflects the real severity of the patient's condition.

Wallace says some hospitals are doing this facilitywide, but for many, that would require too much financial and staff resources. "It would be great if they could do this for every patient, but the reality is that it is hard to find the resources to do that." She adds that such hospitals can use audits to determine the type of patient who might need extra attention to his or her documentation.

Even hospitals that have CDI programs should be evaluating their scope, she says. "In the beginning, many of them focused on accuracy of the MS-DRGs. But in today's environment, it is important to recognize that MS-DRG accuracy is only part of the picture. Many conditions that impact severity of illness may not necessarily impact the MS-DRG." As an example, Wallace cites a patient who has a secondary diagnosis of diabetes. That is not as precise as documenting that the patient has specific diabetic manifestations such as diabetic neuropathy or diabetic nephropathy.

"Official coding guidelines prevent a coder from assuming a relationship between those conditions; it must be documented by the physician. If you do not have a solid CDI program, or are inadequately staffed for comprehensive CDI review, then you are probably underreporting diagnoses and may not get appropriate credit for severity of illness," Wallace says.

At the very least, hospitals should be monitoring what is going on at the NQF, since measures it endorses are on the CMS radar for future inclusion in the IQR program, Wallace notes. "We also see an increasing correlation between CMS measures, HAIs and the CDC's National Healthcare Safety Network initiatives." That means being aware of issues like CLABSI, catheter-associated urinary tract infections, ventilator-associated pneumonia — not just the infection control staff, but all physicians, coders, and anyone working on CDI, too.

Wallace adds that at the start of next year, CAUTI becomes an abstracted measure for the IQR, and hospitals will have to provide more detailed information on cases. "The HAI measures are risk-adjusted, so even when they occur, hospitals should assure that the patient's risk of developing the condition was appropriately recognized with physician documentation of the patient's comorbid conditions."

For the readmissions portion of the final rule, Wallace says that it is "important for hospitals to evaluate physician documentation and reporting practices to assure these conditions are being appropriately sequenced as the principal diagnosis. CDI programs can help by identifying those conditions early in the patient's stay and querying the physician for clarification if there is any ambiguity regarding the correct principal diagnosis. If heart failure was not truly the reason for the patient's admission, the case should not be included in the heart failure measure."

One other item of note from the final rule: Hospitals will have a $1.13 billion, 1.1% increase in payments for 2012 compared to 2011.

The full rule is available on line at

For more information on this topic, contact Susan Wallace, MEd, RHIA, CCS, CCDS, Director of Compliance and Inpatient Consultant, Administrative Consultant Service, LLC, Shawnee OK. Telephone: (405) 878-0118.