The FY 2017 IPPS proposed rule released April 27 is replete with modifications and expansions to claims-based quality and cost outcome measures. Although many of these proposed changes are for future fiscal years, ICD-10 codes reported for current discharges will impact the future financial performance for our organizations.

Cost measures

Two new payment measures are proposed as additions to the efficiency and cost reduction domain beginning in FY 2021:

• Hospital Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Acute Myocardial Infarction
• Hospital Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Heart Failure

CMS cites the following site for full measure specifications: www.cms.gov/Medicare/Quality-Initiatives-Patient-assessment-Instruments/HospitalQualityInits/Measure-Methodology.html.

The risk adjustment methodologies used for these measures are similar to those used for risk-adjusted mortality. The payment measure is intended to be paired with the 30-day mortality measures, thereby directly linking payment to quality by the alignment of comparable populations and risk adjustment methodologies to facilitate the assessment of efficiency and value of care.

The baseline period for these measures is July 1, 2012, through June 30, 2015. The performance period for these measures is July 1, 2017, through June 30, 2019. Performance for these new measures will be scored using the methodology used for the Medicare Spending Per Beneficiary measure.

CMS expands on its interest to further integrate quality and cost measures to reflect value, and is seeking public input on potential approaches. Underlying present challenges in reflecting value are noted as follows:

• Currently, the HVBP assesses quality and efficiency separately through distinct performance measures in different domains, which as of FY 2018 are equally weighted to create the overall Total Performance Score. The four domains include:
  • Safety
  • Efficiency and cost reduction
  • Clinical care
  • Personal and community engagement
• The current scoring approach can permit a hospital to earn a higher payment adjustment relative to other hospitals by performing well on quality-related domains without performing well in the efficiency and cost reduction domain, or vice versa.
• Without a measure or score for value that reflects both quality and costs, the ability to assess value is limited.

This column is devoted to restraint and seclusion documentation; it provides support for, and a tool for, 100% review of patients in restraints and/or seclusion.

The Joint Commission and CMS have a common goal of reducing the use of restraints and seclusion in hospitals. Hospitals have come a long way in meeting this goal, and requirements for improvement (RFI) usually are received because of poor documentation in the medical record. Generally, recommendations result from lack of physician orders, physicians not seeing patients on-site, incomplete orders as to the reason for restraints and/or seclusion, and care plans not including the goal to remove patients from restraints and/or seclusion.

Often during surveys, there will be no patients in restraints or seclusion and the surveyors will ask for closed records to review. Once the medical record is closed, little can be done to correct documentation. Therefore, a solid open record review is essential to avoid recommendations.

A process for reviews

Review of open records of patients in restraints and/or seclusion can be performed in several ways. Of utmost importance is the development of a method to identify patients in restraints and seclusion on a daily basis, and to review new and recurring patients until they are discharged. For example:

1.Nurses, clinical documentation specialists, and tracer teams (plus others?) can review medical records each day to ensure documentation compliance

2.If the hospital has an EMR, HIM staff can review open records online to identify discrepancies in documentation and report back to each unit

3.HIM and IT staff can collaborate to develop a method of importing information directly from the EMR to identify documentation errors

Any of these methods should eliminate errors as long as they are corrected as soon as possible before patients are discharged.