Flawed logic

Modern Healthcare - - Opinions Letters -

Ido not blame hos­pi­tals for be­ing an­gry with the CMS and their 2.9% doc­u­men­ta­tion and cod­ing ad­just­ment (“How sick are we?” 100 top hos­pi­tals sup­ple­ment, Aug. 9, p. 8).

The CMS’ method­ol­ogy for its cal­cu­la­tion was flawed for the fol­low­ing rea­sons:

The CMS built in the lack of need for speci­ficity of “acute sys­tolic” or “acute di­as­tolic” heart fail­ure in ver­sion 24 CMS DRGs, given that the term “de­com­pen­sated CHF,” or con­ges­tive heart fail­ure, was suf­fi­cient to serve as a co­mor­bid­ity com­pli­ca­tion, or CC, at that time.

When the CMS re­quired more spe­cific ter­mi­nol­ogy for de­com­pen­sated CHF to serve as a ma­jor CC in MS-DRGs, its im­pact was not cal­cu­lated into the rel­a­tive weights.

The CMS in­tro­duced the term “en­cephalopa­thy” as a ma­jor CC in 2008 which, if doc­u­mented pre­vi­ously, may not have been within the first nine ICD-9-CM di­ag­noses pro­cessed by Medi­care, given that it was not a CC in ver­sion 24 CMS-DRGs.

The Acute Kid­ney In­jury Net­work re­de­fined acute kid­ney in­jury, or AKI, in 2007, amend­ing the change of the cre­a­ti­nine from 0.5 mil­ligrams per de­ciliter to 0.3 mil­ligrams per de­ciliter. For this rea­son, more providers em­braced this new def­i­ni­tion and, as ex­pected, doc­u­mented AKI with greater fre­quency.

The doc­u­men­ta­tion and cod­ing ad­just­ment was ap­plied to all hos­pi­tals equally, not to those with in­or­di­nate in­creases in CC and ma­jor CC rates. Those that were ag­gres­sive in their clin­i­cal doc­u­men­ta­tion im­prove­ment ef­forts were re­warded, given that their rise in the case mix in­dex was likely more than 2.9%; those that had lit­tle need for clin­i­cal doc­u­men­ta­tion im­prove­ment saw their sta­ble rev­enue fall.

Sadly, when the CMS’ method­ol­ogy for cal­cu­lat­ing the doc­u­men­ta­tion and cod­ing ad­just­ment was dis­cussed in 2007 and 2008, the hos­pi­tal in­dus­try did not have a con­vinc­ing al­ter­na­tive. I be­lieve that they can, pro­vided that they uti­lize cur­rent ICD-9-CM data­bases that process more than nine di­ag­noses codes and ad­vo­cate cred­i­ble al­go­rithms that clearly make their point.

James S. Kennedy Man­ag­ing di­rec­tor of cor­po­rate fi­nance FTI Health­care Brent­wood, Tenn.

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