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.
Those who regularly attend the annual AHIMA Convention and Exhibit no doubt have seen the exceptional quilt created each year by AHIMA member Katy Sheehy, MPA, RHIA, and sponsored by the Dames of Distinction to be bid at auction. The quilt is auctioned in support of the Linda Culp Memorial Scholarship fund, which was established in memory of the late Linda Culp, a former HIM professional, hospital chief executive officer, and AHIMA member. If you have seen the quilt, you have probably asked yourself, "Who are these people?"
The new modifier -PO (services, procedures, and/or surgeries furnished at off-campus provider-based outpatient departments [PBD]) and the alternative payment provisions under the Bipartisan Budget Act Section 603 are both related to off-campus PBDs but define "off-campus PBD" slightly differently.
CMS recently published FAQs on modifier -PO, giving providers valuable guidance on how the modifier will apply to hospital services. Last week, CMS also indicated that it will wait until the CY 2017 OPPS proposed rule provides further guidance on Section 603. Nevertheless, some of the guidance related to modifier -PO seems to indicate that CMS is trying to bring the requirements in line with off-campus PBDs covered by Section 603, rather than simply relying on preexisting regulatory definitions of off-campus departments.
Modifier -PO was adopted January 1, 2015, with a required use date of January 1, 2016. It was originally adopted as a modifier to track statistics and information related to hospitals' off-campus PBDs. The modifier nominally applies to all items and services provided in an off-campus PBD, according to the Medicare Claims Processing Manual, but there are some significant exceptions.
The recent FAQs make it clear that modifier -PO does not apply to non-OPPS services. These services include therapy and a few other services still paid on other fee schedules, noted with a status indicator A under the OPPS, as well as dialysis, which is paid under the ESRD PPS. This guidance would dovetail with Section 603, which arguably only applies to services that would otherwise be payable under OPPS, exempting them from OPPS and providing alternative payment. Additionally, because critical access hospital (CAH) services are not paid under the OPPS, the modifier will also not apply to any services at PBDs of a CAH.
Similarly, the FAQs and other guidance indicate modifier -PO is not used for off-campus emergency departments. This guidance is in line with Section 603, which excludes the off-campus alternative payment methodology from items and services furnished at dedicated emergency departments.
CMS' coding modifiers are not always used to report clinical components of a service. Sometimes they can be used in order to provide information about how a service relates to Medicare coverage policies.
