Guest Post: Your CDI team’s role in pneumonia value-based outcomes, part 1

by Shannon Newell, RHIA, CCS

The selection of a principal diagnosis, secondary diagnosis, present on admission (POA) status, and discharge status on each claim determines whether a pneumonia discharge will be included in Hospital Value-Based Purchasing Program and Hospital Readmissions Reduction Program measures. And effective CDI reviews can capture this documentation.

Pneumonia as a principal diagnosis

CMS includes any discharges with the principal diagnosis of pneumonia (including aspiration pneumonia) in the mortality and readmission outcome measures. Some of these discharges are excluded for various reasons, for example, discharges with a reported discharge status of “against medical advice” are excluded from both measures. The final group of included discharges is referred to as the “cohort.”

Consider the following case studies.

Case study 1: A patient is admitted with pneumonia and acute respiratory failure requiring BiPAP with admission to the ICU along with IV antibiotics for treatment of the underlying pneumonia. Two principal diagnosis options exist–acute respiratory failure or pneumonia. Coding guidelines permit the selection of either option as the principal diagnosis. Today’s CDI teams typically select the option that results in the highest MS-DRG relative weight. Based on current MS-DRG relative weights, the pneumonia would result in the MS-DRG with the highest relative weight, and if it is selected, the discharge would be included in the readmission and mortality outcome cohorts.

Case study 2: A 65-year-old white male with known AIDS is admitted with pneumonia related to his underlying AIDS. Only the pneumonia is addressed during the hospital stay. Based on ICD-10-CM Official Guidelines for Coding and Reporting, AIDS/HIV infection (B20) would be reported as the principal diagnosis, and the HIV-related condition, pneumonia, would be reported as an additional diagnosis. The reporting of AIDS (B20) as principal diagnosis would remove the patient from the pneumonia readmission/mortality cohorts.

Summary

Performance on the CMS 30-day pneumonia readmission and mortality measures adjusts payments received for the Medicare and commercial patient population. By promoting and adopting evidence-based definitions; associated documentation requirements; accurate selection, sequencing, and assignment of POA status; and accurate reporting of discharge status, the CDI team plays a vital role in data integrity for claims-based quality measures.

Editor’s note: This article was previously published in the Revenue Cycle Advisor. Come back to the ACDIS Blog next week for the second part of the article. Newell was previously the director of CDI quality initiatives for Enjoin, but is now retired. Should you have any questions regarding this article, please email ACDIS Editor Linnea Archibald at larchibald@acdis.org. Opinions expressed are that of the author and do not represent HCPro or ACDIS.