The focus of Medicare's Inpatient Prospective Payment System proposed rules is squarely on achieving reductions in hospital-acquired conditions and hospital readmissions, and on value-based purchasing.
CMS' 2015 IPPS proposed rule, released April 30, focuses on quality measures, such as the hospital-acquired condition (HAC) reduction, readmissions reduction, and hospital value-based purchasing (VBP) programs.
CMS also suggested that it intends to implement ICD-10 implementation on October 1, 2015. On page 648 of the rule, CMS states, "The ICD-10-CM/PCS transition is scheduled to take place on October 1, 2015. After that date, we will collect nonelectronic health record-based quality measure data coded only in ICD-10-CM/PCS."
"This is not unexpected," states James S. Kennedy, MD, CCS, president of CDIMD in Smyrna, Tennessee. "Even so, ICD-10 advocates, such as the ICD-10 Coalition, and CMS have their work cut out for them to make ICD-10 more palatable for physicians and their advocacy groups, such as the AMA and the MGMA, as to not have it delayed again by Congress."
CMS seems to acknowledge this uncertainty by stating on page 128, "As of now, the Secretary has not implemented this provision under HIPPA (sic)."
In two additional places (p. 1065 and p. 1074), CMS states, "ICD-10 will officially be implemented on October 1, 2015."
The proposed rule does not contain any changes to the two-midnight rule. However, CMS is asking for input on an alternative payment methodology for short stay inpatient cases that also may be treated on an outpatient basis, including how to define short stay.
"The continued expansion of CMS quality initiatives (value-based purchasing, readmission reduction, and HACs), puts even greater emphasis on the need for comprehensive documentation adequacy and coding accuracy," says Susan Wallace, MEd, RHIA, CCS, CDIP, CCDS, director of compliance/inpatient consultant for Administrative Consultant Service, LLC, in Shawnee, Oklahoma.
"Coders and CDI specialists need a solid understanding of the patient safety indicators, PSI-90 in particular, including knowledge of the impact of coded data and present on admission accuracy to PSI applicability. We should also all understand by now that this isn't about MS-DRG accuracy, it goes well beyond that to ensure appropriate credit in the CMS risk adjustment models, as they are integral to these new quality initiatives."
Because there were no proposed new, revised, or deleted diagnosis or procedure codes for FY 2015, CMS did not need to include tables 6A-6F in the proposed rule, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding for HCPro, Inc. a division of BLR, in Danvers, Massachusetts.
Hospital-acquired Conditions
CMS is proposing to reduce payments for hospitals with the highest rate of HACs by 1% to comply with the Patient Protection and Affordable Care Act. The reduction will apply to the bottom 25% of hospitals (i.e., those with the worst HAC rates).
CMS is not planning to add or remove any HAC categories from the current list, but did ask for continued public comments.
Readmissions Reduction
In addition, CMS proposes increasing the maximum payment reduction for hospital readmissions from 2% to 3%, also to comply with the ACA. CMS proposes to assess hospitals' readmissions penalties using five readmissions measures endorsed by the National Quality Forum.
Under that program, CMS defines a "readmission" as an admission to a subsection (d) hospital within 30 days of a discharge from the same or another subsection (d) hospital.
Value-based Purchasing
The ACA created VSP, which adjusts payments to hospitals under the IPPS based on the quality of care they deliver to patients, in 2013. VBP incentives are funded by a reduction in base-operating DRG payments. The base-operating DRG includes the wage-adjusted DRG operating payment as well as any new technology add-on payments.
CMS will increase the applicable percent reduction, the portion of Medicare payments available to fund the value-based incentive payments under the program, to 1.5% of the base operating DRG payment amounts as mandated by the ACA.
"CMS continues to add financial incentives for patient outcomes, it's our job to make sure coded data correctly reflects the appropriate outcome," Wallace says.
MS-DRGs
CMS is proposing to create the following MS-DRGs for endovascular cardiac valve replacements:
Proposed new MS-DRG 266 (endovascular cardiac valve replacement with MCC)
Proposed new MS-DRG 267 (endovascular cardiac valve replacement without MCC)
"These patients are a different population since they are not amenable to traditional open valve replacement due to co-existing medical conditions presenting different peri-operative and postoperative morbidity," McCall says. "Although this is done in the cath lab, the patients are considered high risk."
CMS is also proposing to collapse MS-DRGs 483 (major joint/limb reattachment procedure of upper extremity with CC/MCC) and 484 (major joint/limb reattachment procedure of upper extremity without CC/MCC) into a single MS-DRG. CMS would delete MS-DRG 484 and revise the title of MS-DRG 483 to "major joint/limb reattachment procedure of upper extremities".
CMS is also proposing to delete MS-DRG 490 and 491 and replaced them with the following MS-DRGs:
- Proposed new MS-DRG 518 (back & neck procedures except spinal fusion with MCC or disc device/neurostimulator)
- Proposed new MS-DRG 519 (back & neck procedures except spinal fusion with CC)
- Proposed new MS-DRG 520 (back & neck procedures except spinal fusion without CC/MCC)
CMS also proposes removing the following additional diagnosis codes to MS-DRG 794 (neonate with significant problems):
- V17.0, family history of psychiatric condition
- V17.2, family history of other neurological diseases
- V17.49, family history of other cardiovascular diseases
- V18.0, family history of diabetes mellitus
- V18.19, family history of other endocrine and metabolic diseases
- V18.8, family history of infectious and parasitic diseases
- V50.3, ear piercing
"These diagnoses really don't impact the newborn but cause a normal newborn DRG 795 to move to the higher paying DRG 794 when assigned as an additional diagnosis," McCall says.
Additional changes
CMS also proposes changes to the Hospital Inpatient Quality Reporting Program.
The proposed rule would increase IPPS operating payment rates by 1.3% after reductions, including a 0.8% coding and documentation reduction. CMS estimates Medicare payments to inpatient facilities will decrease by $241 million in Fiscal Year 2015.
A display copy of the proposed rule is available on the Federal Register website.