CDI and CMS’ pneumonia readmission measure

by Shannon Newell, RHIA, CCS

CMS scours all claims it processes for eligible discharges for the pneumonia readmission measure. Every discharge that meets defined requirements counts regardless of whether the discharge resulted in a readmission. These eligible discharges are then risk-adjusted to assess the patient's burden of illness and the resulting likelihood of readmission.

The principal diagnosis on the claim is one of the key variables which determines whether the discharge will be included as an eligible discharge for the measure. Discharges with a principal diagnosis for unspecified pneumonia (J18.9) and bacterial pneumonias will count. If the principal diagnosis reflects treatment for a viral or aspiration pneumonia, the discharge will not be considered an eligible discharge.

The fiscal year (FY) 2016 IPPS final rule expanded the list of principal diagnosis codes used to identify eligible discharges to also include aspiration pneumonia. The code for sepsis also triggers inclusion when pneumonia is listed as a secondary diagnosis code on the claim. The expanded definition for the pneumonia measure cohort will take effect with discharges beginning October 1, 2016. CMS acknowledged that the cohort revision will have a significant impact on the volume of discharges included in the measure, and on the resulting number of hospitals that will likely receive readmission penalties.

Each claim flagged by CMS as an eligible discharge for the pneumonia readmission measure is then risk-adjusted. The purpose of risk adjustment is to assess the patient's burden of illness and associated likelihood of readmission. As a result of risk adjustment, CMS is able to determine how the hospital's predicted rate of readmission, given its patient complexity, compares to the expected readmission rate if the hospital's patients were treated at the average hospital. This calculation, known as the excess readmission ratio, is used by CMS to evaluate performance and associated readmission payment penalties.

A total of 36 comorbid condition categories impact risk adjustment for the pneumonia ­readmission ­measure. Designated ICD-9-CM codes (CMS has not yet provided ICD-10 codes as of presstime) are assigned to each comorbid condition category. Each category has a coefficient weight that reflects the degree to which its assigned comorbid conditions impact the likelihood of readmission for the patient. The coefficient weights can be positive or negative. The weights are additive, meaning that the more comorbid condition categories represented with at least one documented and coded condition, the greater the impact on risk adjustment.

A subset of comorbid condition categories drives 90% of the positive risk adjustment impact for each discharge in the pneumonia population. Advanced CDI teams, educated on documentation and code assignment impactful to quality measures, can support providers with education and a system to promote appropriate documentation and code capture for conditions. Examples of some of the highly impactful conditions include:

• Malignancies' primary and secondary sites
• Anemias
• Chronic obstructive pulmonary disease
• Congestive heart failure
• Hypoxemia
• Pressure ulcers (any stage)
• Renal dialysis status

Services offered by the inpatient CDI team to promote and support accurate, optimal documentation and code assignment for the pneumonia population benefit both the hospital and the physician for these claims-based admission-related quality measures. Education of the CDI team on these measures--and refinement of existing processes to support the expanded review requirements in both the inpatient and outpatient setting--is a prerequisite to position the CDI team for success.

Editor's note: Newell is the director of CDI quality initiatives for Enjoin. Reach her at 704-931-8537 or shannon.newell@enjoincdi.com. This article originally published in Briefings on Coding Compliance Strategies.