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April 4, 2008
Update on Key Health Information Reporting Issues
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Chief Executive Officers |
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Chief Financial Officers |
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Chief Medical Officers |
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Chief Nursing Officers |
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Chief Information Officers |
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Directors of Quality |
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Directors of Infection Control and Prevention |
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COMPdata Contacts |
As we have been saying, the overlap and convergence of quality and financial
issues is continuing with direct impact on many areas within a hospital setting.
We continue to encourage hospitals to meet as teams to address these issues and
to work together as consistency of reporting and internal documentation is
critical.
Following are some updates on key developments as they pertain to state and
national reporting:
Illinois
4th Quarter 2007 Reporting – Hospital Report Card and Consumer
Guide Data
Illinois Department of Public Health (IDPH) Hospital CEO Attestation Form
For Hospital Discharge Data
Joint Educational Conference Calls on Data Quality for Hospital Discharge
and Outpatient Data
Federal
NPI Taxonomy Code Problems and Medicare Work Around Solutions
Hospital Outpatient Reporting Started
Illinois Hospital Quality Leadership Conference May 15 and 16
Illinois
4th Quarter 2007 Reporting – Hospital Report Card and Consumer
Guide Data
Hospitals once again came through and honored their commitment and support
to public reporting by all Illinois hospitals reporting their nurse staff
vacancy and SCIP infection data by end of the day on March 31. For additional
upcoming deadlines on Hospital Report Card Act, please refer to IHA’s 2008
schedule (click here).
The hospital inpatient discharge and outpatient surgical data continue also
to be reported on time by Illinois hospitals. 4th Quarter 2007 was
sent to IDPH earlier this week and IHA released applicable 4th
Quarter 2007 inpatient and outpatient data to its COMPdata customers on April 1.
Illinois Department of Public Health (IDPH) Hospital CEO Attestation Form For
Hospital Discharge and Outpatient Data
As reported earlier, hospital CEOs will need to submit an attestation form
to IDPH at the end of each quarter attesting to the completeness and accuracy of
their data. If there are any known problems, the information must be documented
on the form. The submission of this attestation form will begin with 1st
Quarter 2008 information and continue for each quarterly submission of data. To
view the form in PDF, click here and in Word,
click here.
While hospital CEOs can designate someone within their organization to
complete and submit this form, the organization will be accountable for their
information submitted and attestation on the accuracy and completeness of data.
Joint Educational Conference Calls on Data Quality for Hospital Discharge and
Outpatient Data
Given that hospital discharge and outpatient data for 1st Quarter
2008 are utilizing a new reporting format with new data elements for public
reporting, it is essential that hospitals ensure the data are accurately
reported. IHA strongly encourages hospitals teams to meet and review the data
including hospital data coordinators, medical records, information technology,
financial, quality, infection control and prevention, and COMPdata customers. It
is very easy to make an error with any new format conversion as well as with any
internal hospital system changes and often times it is the end user, the
COMPdata on-line customer that discovers the error.
In an effort to help guide and facilitate hospital team reviews, IHA will be
holding educational conference calls that are focused on the data submission
feedback reports provided to each data coordinator with their submission of
hospital data. Specifically, IHA will review and discuss the value of each of
the feedback reports and why it is so critically important during conversions
that several areas within a hospital are reviewing the Data Quality Summary
Report, Data Submission Verification Report, and Edit/Error Reports. The
"Hospital Quality Monitoring of Publicly Disclosed Data" are scheduled for:
- April 9, 2008 - 10:00 to 11:00 Central Time
- April 18, 2008 - 10:00 to 11:00 Central Time
Federal
NPI Taxonomy Code Problems and Medicare Work Around Solutions
On April 3, CMS announced that the usage of NPIs with taxonomy
codes for claims payment was not working and that CMS has abandoned the taxonomy
codes and is now requesting providers to secure multiple NPIs for provider
sub-part units. This is a major change in operations and direction for many
providers and will require substantial changes at many organizations. Yet, as
many of our providers have told us, their claims were failing because of the
inability by health plans and FIs to successfully crosswalk NPIs and taxonomy
codes to the right provider and make payment – as a result, many of our
providers had significant amounts of claims reject. This was occurring
nation-wide.
Hospitals are encouraged to review the message provided by Medicare and to
follow the necessary steps to secure additional NPIs if needed and to make
necessary changes. A copy of the message along with links to the various NPI
informational documents can be found by clicking
here.
As the deadline for usage solely of the NPI for claims transactions is May 23,
IHA is joining with AHA and other state hospital associations asking for a
relaxation of the deadline and for providers that wish to submit both NPIs and
legacy codes to be allowed to continue until a new deadline is available. IHA
will continue to keep you informed on this critical development.
Hospital Outpatient Reporting Started
Just a quick reminder, Hospital Outpatient Quality reporting for the Hospital
Compare CMS initiative began with April 1, 2008 cases. Hospitals that are
reimbursed under the Hospital Outpatient PPS system for Medicare, must
participate in the second quarter reporting in order to secure their full market
outpatient market basket increase for calendar year 2009.
While IHA has conducted educational conference calls on this topic, IHA is
planning to do additional conference calls to assist hospitals. Please remember
that 2nd quarter 2008 reporting for hospital outpatient measurements
is considered by many as a ‘Pilot’ as there will be no public reporting or
validation applied. However, we encourage hospitals to use this opportunity to
improve their internal processes and identify accuracy and completeness issues
prior to the 3rd quarter 2008 data which will be made public and
hospital information will be validated.
Illinois Quality Leadership Conference – May 15 and 16
The Illinois Quality Leadership Conference will be held on May 15
and 16 at the Hilton in Lisle. The focus of the program is the
cross cutting requirements across multi-disciplinary areas within a hospital to
meet performance reporting and excel in quality improvement.
Discussion Topics will include:
Institute for Healthcare Improvement (IHI) 5 Million Lives Campaign –
IHI Faculty will discuss the emerging role of CMOs and CMIOs within
hospitals and successful strategies to reduce patient harm and improve
health outcomes
Quality Improvement Organization 9th Statement of Work
effective August 1, 2008 and hospital requirements and initiatives
presented by the Illinois Foundation for Quality Health Care executive
director
Dartmouth Atlas presentation on hospital specific performance and
discussion about chronic care management and end-of-life care challenges and
opportunities
Illinois Public Reporting Requirements - Hospital Report Card Act nurse
staff reporting and infection measurements; Consumer Guide Reports;
Infection MRSA and C-Diff reports; and Adverse Event reporting
Federal Reporting Requirements on Hospital Compare inpatient and
outpatient public reporting requirements; validation processes; patient
satisfaction; payment information; and physician quality reporting
requirements; and Patient Safety Organization (PSO) rules
Recovery Audit Contractor focus and lessons learned from Florida
demonstration program from Florida Hospital Association executive.
Highlights will include the importance of documentation and alignment and
integration of all hospital information internally
State and local perspectives from leading health care experts and
researchers on PBS Series on "Unnatural Causes" and presentations on
interventions underway to reduce breast cancer mortality among African
American women and reduce and control diabetes in the Hispanic population.
IHA staff will discuss the types of information and reports providers will
be seeing with the state mandated reporting on race and ethnicity that
became effective in Illinois on January 1, 2008.
Registration and Fees
Registration Information will be sent by e-mail and regular mail. The fees
for the program will cover all meeting material, lunches, refreshments, and a
networking reception. Early bird registration fees will be $175
for the first registrant and $160 for each additional registrant.
If you have additional questions, please contact
Pat Merryweather.
IHA will continue to keep you updated and informed on these developing issues.
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