The CDI team’s impact on the CMS pneumonia readmission measure

March 28, 2016
CDI Blog - Volume 9, Issue 18

by Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer

The Hospital Readmissions Reduction Program (HRRP) is a CMS pay-for-performance program that links the amount hospitals are paid to risk-adjusted readmission rates. Measures included in the program are claims based, which simply means that the ICD-10 codes we submit on our claims for payment are also used to assess our performance; our performance then impacts our payment.

Many hospitals are solely focused on the reduction of the observed, or actual, number of readmissions due to a lack of understanding of measure methodology and the impact of comorbid conditions on risk adjustment. In this article, we'll review the HRRP's pneumonia measure to promote an understanding of how documentation and code assignment impacts measure performance.

Discharges included in the pneumonia 30-day all-cause readmission measure
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.

Principal diagnosis selection determines eligible discharge selection
The principal diagnosis on the claim is one of the key variables that 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 impact of the FY 2016 IPPS final rule on the pneumonia cohort
The 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.

Risk adjustment
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.

The risk adjustment algorithm used by CMS:

  • Uses data from Part A and Part B claims
  • Considers claims submitted from the date of discharge for the pneumonia encounter back 12 months
  • Looks for conditions that impact the patient's expected readmission rate
  • Will not count some conditions if they are only documented in the discharge for the pneumonia encounter

Conditions that impact the patient's expected readmission rate
A total of 36 comorbid condition categories impact risk adjustment for the pneumonia readmission measure. Designated ICD-9 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.

Key conditions
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

Engagement of physicians
CMS has rolled out a number of physician quality initiatives that utilize hospital claims-based data to impact physician quality profiles and reimbursement. An awareness of these initiatives can help foster an improved understanding of the increasing alignment of physician and hospital interests in accurate, optimal documentation and code assignment?not to mention a greater appreciation for the services and expertise of the CDI team! Let's provide one example with a high-level review of the physician Value-Based Payment Modifier (VBPM).

Payments to physicians and other eligible providers have traditionally been made using the Medicare Physician Fee Schedule. Under the VBPM, payments are adjusted based on demonstrated performance for defined quality measures and risk-adjusted cost of care. In addition, performance is publically reported on CMS' Physician Compare website (www.medicare.gov/physiciancompare/search.html).

One of the measures in the VBPM is the acute conditions composite, which measures the risk-adjusted admission rate for designated ambulatory sensitive conditions. These include:

  • Bacterial pneumonia (preventable quality indicator [PQI] #11)
  • Urinary tract infection (PQI #12)
  • Dehydration (PQI #10)

CMS adopted PQIs, which were developed by the AHRQ, to assess potentially avoidable hospitalizations.

The capture of the correct principal diagnosis will impact whether a discharge will qualify for inclusion in the physician quality measure. In addition, the capture of secondary diagnosis reflective of an ­immunocompromised state can exclude a discharge from counting in this measure. Examples include chronic kidney disease stage 5, malnutrition, pancytopenia, and status codes for prior organ transplants.

Summary
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.

In our next article, we'll take a look at another CMS quality initiative that aligns hospital and physician interests in documentation and code assignment--the Comprehensive Care Joint Replacement Payment Model.

Editor's note: Newell is the director of CDI quality initiatives for Enjoin.  She has extensive operational and consulting expertise in coding and clinical documentation improvement, performance improvement, case management, and health information management. You can reach her at 704-931-8537 or shannon.newell@enjoincdi.com.