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March 13, 2008

Quality and Accuracy of Hospital Information

Now is the ideal time to review your hospital’s policies and procedures on the accuracy, completeness, and alignment of all patient data being used for billing, performance measurement, public reporting, and patient medical records.

There are several developments converging at one time that require completeness and consistency in reported data. These developments include:

Reporting Data to IDPH
Starting with 1^st Quarter 2008, there are a number of changes that have been announced and become effective with 1^st Quarter 2008 inpatient and outpatient data reported to Illinois Department of Public Health (IDPH) as well as strict enforcement of some existing rules.

Listed below are the areas of concern as we move forward with 1^st Quarter 2008 data that IDPH will be strictly enforcing:

1. 1st Quarter 2008 inpatient discharges, outpatient surgical cases, and other outpatient reported data must be reported in either the new format or the HIPAA 837 4010A1 version. All Illinois hospitals have had staff attend training within the past 9 months and over 60% of all Illinois hospitals have tested and are in production with the new formats for 1^st Quarter 2008 cases and discharges.
    
2. The submission deadlines are strictly adhered to by IDPH. IDPH will not allow hospitals to submit new or corrected patient level data for 1^st quarter 2008 after the deadline of June 4, 2008. Detailed schedules for reporting are available by clicking here at the bottom of the page under deadlines.
    
3. Under the Consumer Guide rules, IDPH is requiring hospitals to report their monthly counts of inpatients and outpatient surgical patients on an ongoing basis. The deadline for 1^st Quarter 2008 inpatient and outpatient monthly count is May 30, 2008.

These monthly counts must be submitted by the deadline date which is about 5 days before the patient level data deadlines. The monthly counts form the denominator for each month and the actual patient level data that meets all edits form the numerator --- and the result is your hospital’s level of reporting compliance.

4. The Consumer Guide Rules require hospitals to achieve a 98% level of inpatient reporting compliance for every month calculated as noted above. Hospitals are provided ongoing feedback reports every time they submit data and both feedback reports - Data Quality Summary Report and Data Submission Verification Report provide your hospital’s level of compliance.
    
5. Hospital CEOs will be required to sign a form each quarter provided by IDPH attesting to the hospital’s accuracy, completeness, and quality of data reported for the quarter. This form will be available in both hard copy and electronic format and will be provided by IDPH after the quarterly submission deadlines.

Hospitals are encouraged to review their current practices and procedures to ensure that the IDPH requirements are met and the deadlines adhered to as IDPH is requiring IHA to strictly enforce the deadline policies. While COMPdata may accept data after the deadlines, IDPH will not accept data after the deadline and the publicly reported data will only include IDPH data received by the deadline.

Merging of Medicare Claims and Quality Data
Medicare started to merge their hospital inpatient claims and quality data together recently and as a result many hospitals have had problems with missing data for the quality reporting and have found themselves struggling to comply and maintain their annual Medicare market basket increase. Additionally, several hospitals are experiencing challenges at validation time when their quality information is different than the information utilized for billing or contained in the medical record.

Some of the most common problems are:

1. Medicare patients that are under Medicare HMO or Medicare Advantage plans should be recorded in the Medicare Hospital Quality Alliance reporting as Medicare Other. It is important to maintain this distinction and report it accurately as Medicare only has in its possession the Medicare only claims for matching purposes and not the Medicare Advantage or HMO claims (as they are handled by the HMO or Advantage plans).
    
2. Incomplete medical record documentation often times results in failing validation and putting the hospital at risk for their Medicare annual payment update (market basket increase). This often times is the result of:

- Lack of authorized physician or clinician signatures
- Diagnostic test results administered but results not in medical record. This is most common in some hospitals that have separate infection control and reporting information systems that are not integrated with billing, medical records, or the EHR. Hospitals should have results documented in medical record and if patient left without knowing results, the attending physician or other clinician should contact patient with any positive test results.

3. The discharge status of a patient can drive the hospital payment, especially when the patient is discharged to a non-acute care setting or home health services. Most hospitals conduct a follow up with Medicare patients that were discharged home to ensure that no additional services were required for the patient within the Medicare prescribed time periods. As often times this falls upon medical records or discharge planning to conduct the follow up, hospitals are encouraged to have alignment of results and for any status changes to be communicated with the financial billing areas for any adjustments to claims.
    
4. Starting 4^th Quarter 2007, the Point of Origin for Admission or Visit element used in billing, Illinois public reporting, and Medicare quality reporting was changed in terms of title and content to mean the place of origin outside the hospital with a few documented exceptions. For example, a patient that is transferred from a nursing home to the emergency room of a hospital, prior to 4^th quarter 2007, had the origin typically reported as emergency room prior to October 1, 2007. The origin now would be correctly reported as nursing home.

By using the revenue codes, health plans and others can identify all of the patients that come through the emergency room and at the same time identify the location of the patient prior to their hospital care. This new code also helps in confirming that a Medicare patient that came from a nursing home and returned to home could also mean that the patient was returning home to their nursing home. Medicare also uses this information to identify transfer cases that may or may not qualify for inclusion in the hospital quality reporting.

As Medicare utilizes this code for both quality and payment purposes, it is important to record accurately and consistently. As the accurate reporting of this element relies heavily on admitting staff and often time emergency room staff to document the source of origin, it is important that they are aware of the changes and requirements for documenting and accurately recording this information.

Recovery Audit Contractors (RACs)
As noted in a prior IHA memo earlier this month, (click here) the RACs have a great deal of leeway in terms of what they can pursue on hospital billing and claims audits. As illustrated in the memo, accurate coding and documentation is essential. Completeness of medical records will be essential and inclusion of all diseases and conditions, such as infections, will be critical as Medicare moves to reducing payments for hospital acquired conditions in federal fiscal year 2009. As Medicare currently reimburses hospitals for participation and completeness of Hospital Quality Alliance measurements and soon will be transitioning to Value Based Purchasing, it is critical that hospitals make sure that their claims and quality performance measurement elements that are common for billing and quality performance reporting are aligned. While Illinois is currently scheduled to begin the RAC program in 1^st Quarter 2009, hospitals are urged to review their processes and procedures for populating billing elements to ensure alignment and to do periodic internal audits of information in preparation for the RAC.

Unlike developments in the past, we are now seeing increasing linkages of administrative and claims data and additional scrutiny and auditing of performance and billing data. Hospitals should take time to ensure their reporting is accurate and complete and their information and reporting systems are aligned.

As additional developments occur or are anticipated in the oversight and review of hospital data for claims and quality performance, IHA will continue to keep you informed so that you may strategically plan ahead. If you have any questions, please contact Pat Merryweather by e-mail at pmerryweather@ihastaff.org. Thank you.