CMS releases 2009 IPPS final rule

CMS did not publish Tables 6G and 6H (Additions to and Deletions from the CC Exclusion List, respectively) in the final rule because of the length of the two tables. Instead, CMS is making them available at the CMS Web site at www.cms.hhs.gov/AcuteInpatientPPS.

Clinical documentation improvement
CMS finalized a documentation and coding "adjustment" of -0.9% to the FY 2009 IPPS national standardized amount. But note that the IPPS payment reduction for FY 2009 is in reality a more painful -1.5%. This is because the -0.6% documentation and coding adjustments established in the FY 2008 IPPS final rule is cumulative with FY 2009.

This combined effect of a -1.5% reduction in total IPPS reimbursement can be countered with a strong clinical documentation improvement (CDI) program. In fact, CMS in the rule says that there is nothing wrong with such programs:

As we stated in the FY 2008 IPPS final rule with comment period, we do not believe there is anything inappropriate, unethical, or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment as long as the coding is fully and properly supported by documentation in the medical record.

The documentation and coding adjustment was developed based on the recognition that the MS-DRGs, by better accounting for severity of illness in Medicare payment rates, would encourage hospitals to ensure they had fully and accurately documented and coded all patient diagnoses and procedures consistent with the medical record in order to garner the maximum IPPS payment available under the MS-DRG system.

Note, however, that hospitals need to be careful of such statements, even from CMS, says Gloryanne Bryant, RHIA, CCS, senior director of corporate coding/HIM compliance for CHW in San Francisco.

"You have to read carefully these statements in the regulations, because it could be seen as an open door for the RACs [Recovery Audit Contractors)]," Bryant says. "Don't misinterpret this statement and code to optimize—you have to have clinical documentation along with checks and balances in place, and I strongly encourage everyone to have compliance oversight of their documentation improvement program and query/clarification forms being used"

"1.5% is a pretty large decrease. So you're starting in the hole 1.5% for coding and documentation adjustment on your case mix before you even get started," says Krauss. "So, if you don't have a documentation improvement program, now is a good time to consider implementing one."

Changing quality measures
The 2009 final rule also brings some changes to the Reporting Hospital Quality Data for Annual Payment Update Program. Currently hospitals must report 30 quality measures to qualify for a full update to their FY 2009 payment rate. However, CMS has decided to add 13 new quality measures to the list, as well as retiring one of the existing measures. Hospitals are no longer required to report the pneumonia oxygenation assessment measure as of January 1, 2009.

The 13 new measures include the following:

• Surgical Care Improvement Project (SCIP)
  1. SCIP Cardiovascular 2 Surgery Patients on a Beta-Blocker prior to arrival who received beta blocker during the perioperative period
• Nursing Sensitive Measures
  1. Failure to Rescue
• Readmission measures
  1. Heart Failure readmission (Medicare only)
• AHRQ Quality Indicators: Inpatient Quality Indicators and Patient Safety Indicators
  1. Death among surgical patients with treatable serious complications
  2. Iatrogenic pneumothorax, adult
  3. Postoperative wound dehiscence
  4. Accidental puncture or laceration
  5. Abdominal aortic aneurysm (AAA) mortality rate (with or without volume)
  6. Hip fracture mortality rate
  7. Mortality for selected medical conditions (composite)
  8. Mortality for selected surgical procedures (composite)
  9. Complication/patient safety for selected indicators (composite)
• Cardiac Surgery Measures
  1. Participation in a systematic database for cardiac surgery

CMS had originally proposed the addition of 43 new quality measures, but after the comment period, it decided to finalize only 13. "That's going to help hospitals a lot, because adding [43] was going to be a lot of extra work. Having to add only 13 is a big help," says Bloomquist. With the deletion of the oxygenation assessment measure, the total number of measures hospitals must report in 2009 will be 42, which is up from the current 30 measures. "That's an increase of 12—an extremely manageable level for the hospitals," says Bloomquist.

By law CMS must reduce payments to hospitals that do not successfully report quality measures by 2% from the percentage increase that would otherwise apply.

CMS also finalized two additional healthcare-acquired conditions for which it will no longer pay a higher DRG rate beginning in FY 2009 if not present on admission. They include:

• Certain manifestations of poor control of blood sugar levels
• Deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures

The federal agency also expanded its surgical site infection measure and will no longer pay for surgical site infections following certain elective procedures, including certain orthopedic surgeries, and bariatric surgery for obesity.

"While it may be some time before we can begin to assess the real impact of these steps on patient care, we are hearing from hospitals around the country about efforts they have undertaken in the past year to improve staff training and other measures to reduce the incidence of these preventable conditions," CMS Acting Administrator Kerry Weems said in the press release. "And other payers, both public and private, are beginning to adopt similar policies in their payment systems. This is a win-win situation: better outcomes at less overall cost."

Editor's note: To view the final rule on the CMS Web site, visit www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1390-F.pdf. To read the CMS press release, click here. The final rule will also appear in the August 19 Federal Register.

For more information on hospital reporting of quality measures visit the Hospital Compare Web site at www.cms.hhs.gov/HospitalQualityInits/25_HospitalCompare.asp.

This article is brought to you by Briefings on Coding Compliance Strategies, a monthly newsletter by HCPro, Inc.