CMS released its IPPS proposed rule for fiscal year (FY) 2009, and although hospitals will see few changes to Medicare Severity DRG (MS-DRG) refinements and complication/comorbidity (CC) and major CC (MCC) designations, they will see significant expansions to quality measures and hospital-acquired conditions (HAC).
"They didn’t come up with a bunch of big surprises, so that’s what we have to be grateful for,” says DeAnne W. Bloomquist, RHIT, CCS, president and chief consultant for Mid-Continent Coding, Inc. in Overland Park, KS.
CMS proposes to add nine conditions to the list of HAC
Perhaps the greatest change pertains to quality initiatives and HAC. CMS launched its HAC initiative in October 2007. This initiative comes in the wake of Centers for Disease Control and Prevention data that estimated that HAC infections added nearly $5 billion to hospital costs. At the same time, a 2007 survey by the Leapfrog Group found that of 1,200 hospitals, 87% did not follow recommendations to prevent many of the most common HAC.
For FY 2009, CMS proposes to expand the current list of eight HAC to 17 and include the following nine additional conditions (CMS will not yield a higher-paying DRG when the patient acquires one of these conditions during the inpatient stay):
Surgical site infections following certain elective procedures
Legionnaires’ disease
Extreme blood sugar derangement
Iatrogenic pneumothorax
Delirium
Ventilator-associated pneumonia
Deep vein thrombosis/Pulmonary embolism
Staphylococcus aureus associated disease
Clostridium difficile associated disease
Although most of these conditions seem reasonable, several of them are questionable, says James S. Kennedy, MD, CCS, of FTI Healthcare in Brentwood, TN. For example, patients can acquire Legionnaires’ disease both in and out of the hospital setting, particularly through air conditioning units that contain waterborne pathogens. Although there have been definite cases in which patients have contracted the disease from hospital air conditioning units, determining how providers will ascertain whether the condition was present on admission (POA) remains unclear, he says.
Two other conditions, clostridium difficile colitis and delirium, often result from adverse effects from medication. Some patients can experience delirium from just being in the hospital for expanded periods of time (often referred to as sundowning), Bloomquist says. “This may have nothing to do with the hospital. To call it a HAC, there may have been no adverse effect. I’m not sure that it’s fair to say that,” she adds.
CMS won’t reimburse for U indicator
Since POA indicators came on the scene last October, providers have wondered how CMS will treat the “U” indicator (documentation insufficient) and whether it will not yield a higher DRG when it is the only CC or MCC on the claim. CMS has stated that it will treat the U the same as the N (not POA), but with several exceptions. CMS states the following:
Although we are proposing not paying the CC/MCC MS-DRG for HACs coded with the “U” indicator, we do recognize there may be some exceptional circumstances under which payment might be made. Death, elopement (leaving against medical advice), and transfers out of a hospital may preclude making an informed determination of whether an HAC was present on admission.
This should come as no surprise, Bloomquist says. “I think that people should figure it out regardless. You should have the data in the record—not just for HAC, but for all POA conditions,” she says.
Quality measures could expand to 73 total
CMS also proposes to add 43 new quality measures to the existing 30 for FY 2009, bringing the total number of measures to 73. Reporting all of these measures qualifies hospitals to receive a full update to their FY 2009 payment rates. The new measures include the following:
Surgical Care Improvement Project (one new measure)
Hospital readmissions (three new measures)
Nursing care (four new measures)
Patient safety indicators developed by the Agency for Healthcare Research and Quality (AHRQ) (five new measures)
Inpatient quality indicators developed by AHRQ (four new measures)
Venous thromboembolism (six new measures)
Stroke measures (five new measures)
Cardiac surgery measures (15 new measures)
These added measures could equal disaster for smaller hospitals in particular, Bloomquist says. “Your small hospitals will be under a huge administrative burden. There’s one person who does this. How will they do their data reporting? Bigger hospitals may be in the position of hiring additional staff to report on these measures,” she adds.
According to the Deficit Reduction Act of 2005, hospitals that have successfully reported the quality measures in FY 2008 will receive the full update in FY 2009. Hospitals that don’t successfully report these measures will receive an update of 1% which is two percentage points less than the full update.
Of note is the fact that CMS is requiring hospitals to report measures related to readmissions, Kennedy says. “Hospitals are under financial pressure to discharge patients more quickly. But physicians want to keep patients longer to make sure that they’re safe. The fact that the readmission rate is a core measure means that hospitals are stuck,” he says.
According to CMS, 18% of Medicare patients are readmitted to the hospital within 30 days of discharge, costing CMS $15 billion annually. Medicare Payment Advisory Commission (MedPAC) data indicates that $12 billion of these costs are potentially preventable.
Hospitals will see few changes to MS-DRG descriptions
CMS proposes two changes to MS-DRG descriptions for MS-DRGs 245, 870, 871, and 872. It proposes to subdivide MS-DRG 245 (AICD lead and generator procedures) to create a new MS-DRG for the implantation and replacement of the AICD leads from the implantation and replacement of AICD pulse generators:
MS-DRG 245 (AICD generator procedures): to include procedure codes 37.96, 37.98, and 00.54
MS-DRG 265 (AICD lead procedures): to include procedure codes 37.95, 37.97, and 00.52
“This is because of the hardware,” says Kennedy. “There are significant costs differences between the leads and the generators. Hospitals are struggling to be profitable with AICDs. People will say that hospitals are still going to lose money on these, though.”
CMS proposes to insert the words “or severe sepsis” after “Septicemia” in the titles of the following MS-DRGs that were effective October 1, 2007:
MS-DRG 870: Septicemia with mechanical ventilation, 96+ hours
MS-DRG 871: Septicemia without mechanical ventilation, 96+ hours with MCC
MS-DRG 872: Septicemia without mechanical ventilation, 96+ hours without MCC
CMS may impose cumulative MS-DRG adjustment
Although there were only minor proposed changes to MS-DRG descriptions, one change that Kennedy says could be significant is that CMS proposes to implement a cumulative documentation and coding adjustment of -1.5%. CMS states the following on p. 691 of the proposed rule:
As required by statute, we are applying a documentation and coding adjustment of -0.9 percent to the FY 2009 IPPS national standardized amounts. The documentation and coding adjustments established in the FY 2008 IPPS final rule with comment period are cumulative. As a result, the -0.9 percent documentation and coding adjustment in FY 2009 is in addition to the -0.6 percent adjustment in FY 2008, yielding a combined effect of -1.5 percent.
Proposed rule outlines several other changes
There are also several other changes of note in the proposed rule, including the following:
MS-DRG relative weights will be 100% cost-based.
The CC/MCC structure remains relatively unchanged with the exception of changes related to proposed new ICD-9 codes, such as those for pressure sores.
CMS proposes to apply its post-acute transfer policy to 273 MS-DRGs. Of these, 24 MS-DRGs qualify as special pay post-acute transfer DRGs.
CMS proposes to implement add-on payments for four new technologies.
Editor’s note: Comments on the proposed rule will be accepted through June 13. CMS will respond to comments in a final rule that it expects to release on or before August 1. To view the rule, visit www.cms.hhs.gov.
The North Philadelphia Health System has unveiled its 91,100 square-foot, $4.5 million emergency department at St. Joseph's Hospital. The new ER is more than double the size of the former emergency room at the North Philadelphia hospital. It can accommodate 22,000 patients annually, while the former ER was about half the size needed to handle the hospital's patient volume for emergency care.
Three more women have died while, or shortly after, giving birth at Northwick Park in London. The hospital was investigated and placed in special measures after 10 deaths between 2002 and 2005.
North West London Hospitals NHS Trust, which runs Northwick Park, has decided to undertake a "broad internal review" to ensure that the improved practices that were put in place while the trust was in special measures, which ended in September 2006, have been maintained.
In 2002, medical tourism to India brought in earnings of $300 million. Every year since then, the number of medical tourists travelling to the country has increased by about 25% every yaer. One report projects that India's earnings through medical tourism would go up to $2 billion by 2012. Some say superior quality of medical service coupled with the low cost of surgeries is responsible for making the country one of the most attractive destinations for medical value travel.
Cuts in Oregon's Medicaid expansion program in 2003 led to a 20% increase in emergency room visits by the uninsured and a nearly 50% increase in hospital admissions of uninsured emergency patients, according to a study. Changes to Oregon's Medicaid expansion program, the Oregon Health Plan, cut the number of enrollees in 2003 by 52,000, swelling the ranks of Oregon's uninsured.
Consider how hard it is in the healthcare industry to implement the seemingly simple and sensible. Case in point, the superbugs MRSA and C. difficile have had their way in hospitals around the globe, from the smallest clinics in the developing world to some of the finest state-of-the-art academic medical centers. Despite widespread acknowledgement of the problem--from policymakers, hospital executives, and clinicians--agreement and compliance with basic protocols are often hard to come by.
My colleague, Kathryn Mackenzie noted in this month's HealthLeaders magazine that Britain has recently imposed a dress code for physicians and other clinicians. They no longer can wear sleeves below the elbows, neckties, jewelry, and fake fingernails.
"We are not unique in facing the perils of [hospital-acquired infections]: Every country in the world is grappling with something that has always been a factor in healthcare. We are, however, the only country which has a mandatory universal surveillance system," said Alan Johnson, MP, secretary of state for health for Britain, in a speech last year discussing steps the country has taken to reduce hospital-acquired infection.
Johnson's administration admits that the ban is not supported by hard scientific evidence, but is part of a common sense approach to improve hand hygiene. His policy, however, was not commonly embraced; rather, some charged Johnson with pandering to the media and, in fact, shifting the health system's focus away from proven methods to combat superbugs.
Indeed, some physicians took issue with the health secretary because they felt the new dress code made them appear unprofessional. One doctor quoted in a London newspaper called banning neckties ridiculous: "We wear neckties because patients expect us to look smart, but bow ties will make us look like circus clowns."
Two other physicians, in a letter to the British Medical Journal, said that banning wristwatches could actually harm patients, because a study showed that many doctors are unable to accurately estimate pulse and respiration rates without their wristwatches.
Despite Britain's tribulations with its new dress code, many hospitals are seeing incremental improvements in their quest to shrink patient infection rates. In fact, my colleague, Maureen Larkin pointed out in her Web exclusive column last week that at the organizational level common sense approaches to fighting the spread of dangerous infections can succeed.
But healthcare hygiene efforts need to be carried out with military-like precision and zeal. That means continual reminders and buy-in throughout the ranks of the organization. Like many aspects of clinical care, we are talking about the perils of human decision-making. It takes only a few forgetful employees to deviate from your protocol to greatly increase exposure.
If nothing else, perhaps Britain's well-reported ban will have a psychological effect on caregivers. True, the dress code might not have a direct impact on limiting hospital-acquired infections, but maybe it will remind physicians to pay careful attention to hand hygiene. So the ban might have a kind of transfer effect that delivers real value.
With so much emphasis on the importance of communicating hand-washing protocols, I thought I'd share this short video I spotted on YouTube by Elspeth Connatty, RN, RGN (UK), RM (UK), with the Department of Infection Control for University of San Francisco Medical Center.
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The owner of a Boca Raton, FL-based chain of medical imaging centers has agreed to pay $7 million to settle a federal healthcare fraud lawsuit. Government lawyers accused board certified radiologist Fred Steinberg, MD, of overcharging Medicare for CT scans and billing the federal program for some tests that were not medically necessary. The settlement also resolves allegations that Steinberg illegally paid as many as two dozen doctors to send him patients for imaging tests that cost up to $2,500 apiece.
Cerner Corp. will market a full suite of blood management software from Wyndgate Technologies along with its Millennium laboratory information system. Wyndgate is owned by Denver-based Global Med Technologies Inc., which offers several blood management products for hospitals and blood centers.
Joe D'Iorio, manager of healthcare services at Tandberg—a global provider of high-definition videoconferencing and mobile video—received the American Telemedicine Association Industry Council Award for Leadership in the Advancement of Telemedicine at the 13th Annual ATA Meeting & Exposition, held in Seattle, WA. The annual award recognized D'Iorio for his leadership in promoting telemedicine and e-health.
The Nuclear Regulatory Commission has issued a $6,500 fine to radiology equipment maker Digirad Imaging Solutions for violations at the company's nuclear medicine centers. Digirad's first violation was for licensing an unauthorized doctor to operate nuclear imaging equipment, and the second violation was for failing to monitor radioactive materials while they were in storage.
