CMS continues to shift emphasis to quality of care
CMS continues to shift emphasis to quality of care
Complete documentation is essential
The final rule for the fiscal 2013 Inpatient Prospective Payment System (IPPS), effective Oct. 1, 2012, continues the Centers for Medicare & Medicaid Services' (CMS) move to tie reimbursement to quality, rather than merely quantity, and makes it more important than ever for case managers to ensure that documentation in the medical record is complete and clearly reflects the patient's severity of illness, 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.
In the final rule, CMS announced a 2.3% increase in reimbursement for hospitals that participate in the Inpatient Quality Reporting Program and reiterated its intention to add more risk-adjusted measures to the readmission reduction and value-based purchasing initiatives. In fiscal 2013, CMS begins adjusting hospital reimbursement based on their performance on both initiatives.
Beginning October 1, hospitals with excessive readmissions within 30 days for patients with heart failure, pneumonia, and acute myocardial infarction may have their reimbursement for all discharges reduced by as much as 1%. In addition, beginning October 1, under value-based purchasing, hospitals' base operating DRG payment will be reduced by 1% for each Medicare discharge. Hospitals that perform well on quality measures chosen by CMS or improve their baseline performance on the measures during a performance period will receive value-based incentive payments, beginning in January 2013.
Penalties in the readmission reduction program escalate to 2% in fiscal 2014 and 3% in fiscal 2015. The reductions in base operating DRG payments under value-based purchasing increase by 0.25% annually until reaching 2% in 2017.
The measures on which CMS will base reimbursement in the future are only going to increase, Wallace points out, adding that 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.
The biggest impact that the final rule is likely to have on case managers is the risk-adjusted measures being added to the value-based purchasing and readmission reduction programs in the future, Wallace says.
"Because some of these measures will not be added until 2015, people may think that they don't have to worry about them right now. However, the baseline periods for the new measures closed in 2011 and the performance periods begin as early as Oct. 1, 2012, depending on the measures," she adds.
CMS announced that it is adding four new measures to value-based purchasing in 2014, including post-operative urinary catheter removal on post-operative day one or two, and 30-day mortality for heart failure, pneumonia, and acute myocardial infarction. Additions to the list in 2015 include a composite complication/patient safety measure, central line-associated blood stream infections and Medicare-spending-per-beneficiary which aggregates all Medicare Part A and Part B spending on a patient beginning three days before admissions and continuing until 30 days after discharge.
CMS noted in the final rule that it has the authority to add more measures to the readmission reduction program in fiscal 2015 but did not indicate whether it would add more measures or what measures might be added. People who commented on the proposed rule suggested including atrial fibrillation, chronic obstructive pulmonary disease, coronary artery bypass graft, and percutaneous transluminal coronary angioplasty to the list. CMS merely indicated that it would take the comments into consideration when it addresses expansion of the applicable conditions, Wallace says.
CMS also added two new measures to its list of hospital-acquired conditions. They are surgical-site infections following cardiac implantable electronic device procedures and iatrogenic pneumothorax with venous catheterization.
The Inpatient Quality Reporting Program, the hospital-acquired conditions program, and the Value-based Purchasing Program 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, she adds.
"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.
Source
- Susan Wallace, MEd RHIA, CCS, CDIP, CCDS, Director of Compliance/Inpatient Consultant, Administrative Consultant Service, LLC, Shawnee, OK. email:[email protected].
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