Illinois Hospital Association

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April 18, 2008

Proposed Medicare Inpatient Quality Measurements

TO: Chief Executive Officers
  Chief Financial Officers
  Chief Medical Officers
  Chief Nursing Officers
  Chief Information Officers
  Directors of Quality
  Directors of Infection Control and Prevention
  COMPdata Contacts


In a sweeping approach to aggressively address hospital quality issues, Medicare released a number of changes for performance payment and public reporting for federal fiscal year 2009 and beyond for Medicare PPS providers. These changes, along with some hospital specific information, will be discussed at the Illinois Quality Leadership Conference on May 15 and 16.

Expansion of Hospital Acquired Conditions
Medicare is proposing to expand the number of hospital acquired conditions in which a payment reduction will occur from the original 8 to now 17 conditions effective October 1, 2008. The conditions include:

  • Foreign Object Retained After Surgery
  • Air Embolism
  • Blood Incompatibility
  • Stage III and IV Pressure Ulcers
  • Falls and Trauma – Fractures, Dislocations, Intracranial and Injuries such as crushing injuries and burns
  • Catheter Associated Urinary Tract Infection
  • Vascular Catheter Associated Infection
  • Surgical Site Infection – Mediastinitis after Coronary Artery Bypass Graft
  • Proposed – Surgical Site Infections Following Elective Procedures: Total Knee Replacement, Laparoscopic Gastric Bypass and Gastroenterostomy; Litigation and Stripping of Varicose Veins
  • Proposed – Legionnaires Disease
  • Proposed – Glycemic Control – Diabetic; Ketoacidosis – Nonketotic; Hyperosmolar Coma – Diabetic Coma, Hypoglycemic; Coma
  • Proposed – Iatrogenic Pneumothorax
  • Proposed – Delirium
  • Proposed – Ventilator Associated Pneumonia
  • Proposed – Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)
  • Proposed – Staphylococcus Aureus Septicemia
  • Proposed – Clostridium Difficile Associated Disease (CDAD)
  • Proposed – MRSA – Medicare was less supportive of including this condition as Medicare cited that this infection is covered in many of the other conditions and there was limited coding at the time the rules were written (although the ICD-9-CM Maintenance Committee recently recommended additional MRSA codes effective October 1, 2008)
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    Coding of these conditions. Medicare has outlined specific ICD-9CM codes that they will utilize from the claims data to identify the presence of these conditions. To further distinguish those that occurred prior to or during the stay, Medicare will rely upon the Present on Admission (POA) codes. Medicare is proposing to reduce MS-DRG payment for conditions in which a POA code was No (not present on admission) or U (medical record documentation not sufficient to render a decision). Medicare will make the expected full payment for cases in which a POA code was Yes (present on admission) or W (clinically undetermined). Medicare will monitor the types of conditions and the usage of W and establish some expected thresholds for monitoring of hospital reporting.

    When the Present on Admission codes were first under consideration, they did not include a W- Clinically Undetermined code. IHA argued in support of adding this code based upon conversations with our member hospitals and was successful in getting the W code added at the National Uniform Billing Committee meeting. While IHA had strong opposition to the addition of the W code; however, IHA was able to argue favorably to have it included. IHA also served on the POA Work Group of the National Committee on Health Statistics to ensure the code was retained and documented in the guidelines for reporting.

    Quality Measurements for Public Reporting
    For Federal Fiscal Year (FFY) 2009, Medicare is proposing to only add in three measurements for the Hospital Compare public reporting bringing the total measurements for payment purposes to 30. In FFY 2010, Medicare is proposing to expand to 72 measurements for public reporting and payment.

    For FFY 2009, the new measurements include two surgical site infection measurements and a 30-day mortality measurement.

    Starting with FFY 2010, Medicare is proposing that the quality measurements for public reporting also include measurements derived from the administrative claims data from Medicare. As there has been extensive expansion required for clinical quality coding purposes on the administrative claims over the past year and going forward, Medicare is proposing to use their claims data for reporting of public performance measurements in addition to the Hospital Quality Alliance data.

    For 2010, Medicare proposes expanding to 72 measurements including:

  • Hospital Compare – Quality Alliance Measurements
  • Readmission Measurements for Medicare patients for heart attack, heart failure, and pneumonia (based upon claims data)
  • Inpatient Stroke Care
  • Venous Thromboembolic Care
  • Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators including post-op wound dehiscence, accidental puncture or laceration, Iatrogenic pneumothorax, and death among surgical patients with treatable serious complications
  • AHRQ Inpatient Quality Measurement – Abdominal Aortic Aneurysm mortality rate; Hip fracture mortality rate
  • AHRQ Quality Composite Measurements – Mortality for selected surgical procedures, complication/patient safety for select conditions, and mortality for selected medical conditions
  • Nursing Sensitive Measurements – AHRQ Failure to Rescue, Pressure Ulcer Prevalence and Incidence by Severity, Patient Falls Prevalence, and Patient Falls With Injury
  • Cardiac Surgery Measurements
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    Please keep in mind that many of the above measurements will be from the Medicare claims data and will also rely upon the usage of Present on Admission codes for all of the diagnostic conditions reports.

    Documentation
    It is imperative that given the direct linkage to payment of the clinical conditions present on admission or identified during stay, that hospitals ensure that their documentation is accurate and complete. Given that clinical conditions tied to documentation of POA codes will be linked to Medicare payments, it is anticipated that this will also become a focus of the Recovery Audit Contractors.

    Illinois Quality Leadership Conference – "Excelling and Accelerating Quality Care and Outcomes"
    The proposed regulations along with hospital comparative reports from COMPdata will be provided to attendees of the Illinois Quality Leadership Conference on May 15 and 16. The conference is co-sponsored by IHA and the Metropolitan Chicago Healthcare Conference and will cover many topics of importance to hospital executives and clinicians.

    Staff Contact: Pat Merryweather