Tip: CDI efforts can help to reduce AMI mortality outcome risks

by Shannon Newell, RHIA, CCS

The 30-day all cause acute myocardial infarction (AMI) mortality outcome measure has been linked to hospital payments since the inception of the Hospital Value-Based Purchasing Program (HVBP). In February 2016, CMS announced that 70% of commercial payers also agreed to use this measure as one of the cardiology outcomes linked to payment. The Medicare Episode Payment Bundle for AMIs, proposed to begin in July 2017, will further link reimbursement to measure performance. Yet, traditional CDI efforts in the name of risk of mortality may fall short under the CMS mortality risk adjustment methodology.

One reason is that principal diagnosis selection drives inclusion of a discharge--CMS includes any discharges with the principal diagnosis of an AMI--in the mortality outcome measure. Some of these discharges could (and should) be excluded for various reasons, outlined in CMS' methodology. For example, patients who discharge against medical advice are excluded from the AMI mortality measure. The final group of included discharges is referred to as the “cohort.” Consider the following case studies:

Case Study 1: The patient was admitted with severe unstable angina and diaphoresis with the finding of ST elevation in the anterior leads on an EKG with the initial set of cardiac enzymes being negative. Because of the suspicion of acute transmural myocardial infarction (MI), receives TPA infusion. Subsequent cardiac enzymes are negative, and at the time of discharge, the physician documents an aborted transmural MI. In this situation the principal diagnosis would be unstable angina because the AMI was aborted. However, if coronary artery disease was documented, coding guidelines would require selection of this condition as the principal diagnosis. This discharge would be excluded from the AMI mortality cohort with the correct application of coding guidelines for principal diagnosis selection.

Case Study 2: The patient was admitted with subendocardial MI with acute systolic heart failure and cardiogenic pulmonary edema and treated with supplemental oxygen and IV Lasix therapy. Due to the patient’s age, the MI is treated conservatively. Two principal diagnosis options exist: Acute systolic heart failure and subendocardial MI. Coding guidelines permit the selection of either option as the principal diagnosis but today’s CDI teams typically select the option which results in the highest MS-DRG relative weight, and, perhaps inadvertantly, also result in attribution of the discharge to the AMI mortality cohort in this case.

Once the hospital submits a claim with the principal diagnosis of AMI, CMS analyzes its databases to determine if that Medicare beneficiary died within 30 days of discharge (for any reason). If a mortality is identified, CMS attributes the death to the hospital that reported a claim with AMI as the principal diagnosis within 30 days preceding the death.

Each discharge included in the AMI mortality cohort is then risk adjusted to determine the expected rate of mortality. The CMS methodology uses comorbid categories (CC), not hierarchical condition categories, to determine the likelihood of death for each discharge.

• Each CC comprises related ICD-10 codes
• There are a variety of CCs which impact AMI mortality risk adjustment
  • These categories are weighted; some have a more significant impact on risk adjustment than others
  • 12 categories drive 90% of strengthened risk adjustment opportunity
  • Only about 25% of these conditions serve as MS-DRG major comorbid categories or CCs
  • CMS looks for the presence of these conditions in the AMI admission as well as all Part A and (face to face) Part B claims for the 12 months prior to that admission
    • Some of the conditions must be documented prior to the patient’s admission for AMI management or there is no “credit” for risk adjustment

Performance for the CMS 30-day AMI mortality measure adjusts payments received for the Medicare and commercial patient population. Although this is a hospital centric measure, meaning the measure assesses the hospital’s management quality for the AMI population, documentation and reported codes across the continuum affect the patient's expected risk of mortality, and in turn effect measure performance for a wide variety of providers.

A few questions for CDI and quality programs to consider as they evolve their clinical documentation initiatives to support value-based payments:

• Does your principal diagnosis selection process consider attribution of discharges to quality measures in addition to MS-DRG relative weights?
• Does your record review process to support the capture of comorbidities impactful to mortality focus only on actual deaths, instead of the entire denominator included in the measure?
• Are you focused on the capture of comorbidities impactful to the CMS mortality methodology?
  • The comorbidities in this algorithm differ from those used in other mortality risk adjustment methodologies commonly used in CDI programs today
  • The broad number of comorbidity categories requires that the CDI and quality team focus on point of care capture
• Do the clinical documentation and reported codes in your system’s outpatient settings support the capture of comorbid conditions impactful to risk adjustment?

Editor’s Note: Newell is an independent consultant who has extensive operational and consulting expertise in coding and clinical documentation improvement, performance improvement, case management, and health information management. Reach her at Sknewell1010@gmail.com. This article originally published in HIM Briefings.