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.