Ensure quality indicators are documented

Hospital reimbursement will hinge on accuracy

Now that the Centers for Medicare & Medicaid Services (CMS) is requiring hospitals to submit data on 10 quality measures to get the full 3.7% inflation-adjusted payment increase, it is more important than ever for case managers to ensure accurate documentation.

"It is essential that all case managers understand their hospital could suffer financially in the future if they don’t look good on the measures. They should be involved with other clinicians at the point of care in encouraging appropriate patient care and documentation that will support the data collection efforts," says Patrice L. Spath, BA, RHIT, a health care quality specialist with Brown-Spath & Associates in Forest Grove, OR.

Under the Inpatient Prospective Payment System final rule, which goes into effect Oct. 1, hospitals that do not report the quality measure data and those with data that do not pass a validation audit will receive a marketbasket reimbursement increase of 3.3%, or 0.4% less than hospitals that submit valid data.

Many hospitals have been reporting clinical data on 10 quality measures related to the treatment of heart attack, heart failure, and pneumonia cases on a voluntary basis since 2003. Many now are reporting data on 17 quality measures.

According to CMS, preliminary results show that more than 98% of eligible hospitals have submitted quality data. Quality improvement organizations still are in the process of validating the data to certify that the hospitals are eligible to receive the full update for 2006.

In addition to requiring the data submission, the final rule mandates that to receive the full payment, hospitals must correctly abstract the data for two consecutive quarters.

CMS estimates that approximately 2% of hospitals will fail the validation test, resulting in reduced payments of approximately $8 million.

"We have taken steps to improve care through quality measures because it is important, not only to the health of our beneficiaries, but for avoiding unnecessary health care spending," according to Mark B. McClellan, MD, PhD, CMS administrator.

The requirement that hospitals report performance data to get the full reimbursement increase is the next step toward a pay-for-performance system and makes it imperative that hospitals collect the data and do so correctly, Spath says.

Case managers should be careful to make sure the services measured by the quality indicators not only get done, but also are correctly documented in the patient record, she adds. "The problem is that if the care is not documented, it isn’t considered done. The information has to be available in the patient record before the quality department can gather the data for reporting purposes. The role of case managers at a minimum is to be aware of what the core measures are."

For instance, if the physician doesn’t order an ACE inhibitor at discharge for a heart failure patient, in some hospitals, the case manager calls him or her and asks for it to be ordered, if it’s appropriate for that patient.

If the record doesn’t indicate the patient received smoking cessation counseling, the case manager should ask the nurse to ensure it is happening and it is documented.

"Case managers can be a monitoring agent for making sure that the right things are done. This works well only in hospitals where every patient is seen by the case manager, and not everybody has that model," Spath explains.

In those cases, she suggests the nursing staff own the responsibility for reminding the physician of the things that need to be done and documented and that the case managers act as backup.

"The challenge is defining a point person with accountability for the core measures. Sometimes, it’s easier to make the case manager the point person because there are fewer of them," she adds.

Case managers need to have a general awareness of the public reporting of data, the measures used to gather the data, how the data are being used, and the impact information can have on their facility, Spath explains.

Each facility needs to analyze how the work of the case managers can assist in meeting the public reporting challenges. How the case managers can be involved will vary from facility to facility, according to the model of the case management program, she adds.

"There are a lot of challenges in collecting data. For instance, the admitting diagnosis is not always correct. It may not be determined that the patient had an MI until he had been in the hospital three days, and by then, it’s too late to ensure the right things are documented in the patient’s record," Spath says.

Some of the tools that hospitals have developed to assist with care coordination and managing patient care can include reminders of the quality measures, she notes. For instance, many hospitals have created standing order sets or clinical pathways that incorporate the required patient care interventions.

"These are a more efficient way to remind the physician of what needs to be done for patients. Hospitals can’t expect a case manager who works five days a week to be responsible for monitoring compliance with patient management recommendations," Spath says.

Under the final rule for 2006, the CMS Clinical Data Abstraction Centers will identify a random sample of five charts per hospital each quarter and will request the paper medical records, which will be tested for valid data.

The data must pass the CMS validation requirements of a minimum of 80% reliability based on the chart audit, beginning with data submitted for the third quarter of calendar year 2004.

Hospitals will receive educational feedback, including an overall reliability rate and case details on each abstraction and will have 10 business days in which to appeal if they don’t meet validation requirements.

Any reduction in payment will apply only to the year involved.