CMS, payers agree on set of quality and cost measures to link payment

Clinical documentation and coding has a significant impact on value-based quality outcome performance. Such outcomes include risk-adjusted mortality, readmission, patient safety, complication rates, and cost efficiency measures.

Value-based outcomes linked to payment represent the next wave of opportunity for CDI programs to support their health systems. Clinical documentation and coding across the continuum impact performance for claims-based measures contained within these standard data sets. Claims-based outcome measures use ICD-10 codes submitted on claims both to define the populations (or cohorts) included in the measure, as well as to risk-adjust performance.

Let's look at a few examples to illustrate how clinical documentation and code assignment can impact performance for one of the claims-based measures in the figure, the risk standardized complication rate?THA/TKA (RSCR THA/TKA):

• Assignment of the discharge disposition as "AMA" also excludes the THA/TKA discharge from the measure.
• Documentation and reporting of "morbid obesity" prior to the admission for the THA/TKA procedure strengthens risk adjustment. Note: "Obesity" does not impact risk adjustment.
• Documentation and reporting of "chronic renal insufficiency" prior to the admission for the THA/TKA procedure will further strengthen risk adjustment. Note: "Renal insufficiency" will not count.
• Documentation and reporting of "coronary artery disease" in the THA/TKA inpatient encounter will strengthen the risk adjustment even further.

The alignment of quality measures that will be linked to payment by public and private payers provides a framework upon which future efforts can be based. CMS will go through a public notice and comment rulemaking for implementation of these core sets and looks forward to public input on the measures included in these core measure sets.

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