Mortality Measures Optimization: Getting to Know the Data · –Understand publicly reported...

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Mortality Measures Optimization: Getting to Know the Data

Mary Beth Bumbarger, RHIA, CCS, CHDADirector, Health Information & Quality ManagementBrundage GroupSt. Petersburg, FL

Timothy N. Brundage, MD, CCDSMedical DirectorBrundage GroupSt. Petersburg, FL

2019 Copyright, HCPro, a division of Simplify Compliance LLC, and/or session presenter(s). All rights reserved. These materials may not be copied without written permission.

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:– Identify CMS mortality measure definitions, data sets, risk adjustment methodology, and O:E ratio

– Understand publicly reported mortality data and its effect on Medicare reimbursement under the inpatient Value‐Based Purchasing program

– Demonstrate awareness of how CDI can affect the accurate reporting of mortality measures

– Identify best practices for managing mortality measure data


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CMS Hospital Value‐Based Purchasing (HVBP)


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Hospital Value‐Based Purchasing Overview

• CMS effort to link Medicare’s payment system to improve healthcare quality

• Hospitals are no longer paid solely on the quantity of services provided• Inpatient hospital services are based on the quality of care evaluated using a pre‐defined set of quality and cost measures

• Goals:– Eliminate or reduce occurrences of adverse events– Adoption of evidence‐based care standards and protocols– Re‐engineer processes that improve patient care experience– Increase transparency of care for consumers– Recognize hospitals that deliver high‐quality care at a lower cost to Medicare


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• Hospital performance based on approved set of measures grouped into domains• Domains are assigned weights (percentages), which are then used to score each

domain• Hospitals receive 2 scores on each measure—one for achievement and one for

improvement• End result is a single Total Performance Score (TPS)

Measures Used in the HVBP Program


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How Is the HVBP Program Funded?

• Through reducing participating hospitals’ Diagnosis‐Related Group (DRG) payments for the applicable fiscal year (2% since 2017)

• The money withheld is redistributed to hospitals based on their TPS • Actual amount earned depends on the range and distribution of all hospitals’ TPS

• Hospitals can earn back a value‐based incentive payment percentage less than, equal to, or more than the program year reduction rate


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HVBP Payments

• CMS calculates a value‐based incentive payment adjustment factor• The adjustment factor is applied to the base operating DRG payment amount for each discharge in the fiscal year, on a per‐claim basis

• What does this mean?

– Payment adjustment is applied to every discharge in the fiscal year, not just the discharges affected by the measure(s)


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VBP Program Measures – Clinical Care Domain

Measure ID Measure Description FY 2018

FY 2019

FY 2020

FY 2021

FY 2022

FY 2023

FY 2024

MORT‐30‐AMI Acute Myocardial Infarction (AMI) 30‐Day Mortality Rate Yes Yes Yes Yes Yes Yes Yes

MORT‐30‐HF Heart Failure (HF) 30‐Day Mortality Rate Yes Yes Yes Yes Yes Yes Yes

MORT‐30 PN Pneumonia (PN) 30‐Day Mortality Rate Yes Yes Yes No No No No

MORT‐30 PN Pneumonia (PN) 30‐Day Mortality Rate (Updated Cohort) No No No Yes Yes Yes Yes

COMP‐HIP‐KNEE

Total Hip Arthroplasty (THA)/Total Knee Arthroplasty Complication Rate (TKA) No Yes Yes Yes Yes Yes Yes

MORT‐30‐COPD

Chronic Obstructive Pulmonary Disease (COPD) 30‐Day Mortality Rate No No No Yes Yes Yes Yes

MORT‐30‐CABG

Coronary Artery Bypass Grafting (CABG) 30‐Day Mortality Rate No No No No Yes Yes Yes

QualityNet.org: Hospital Value‐Based Purchasing Fiscal Years 2018–2024 Measures


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Publicly Reported Data … What’s the Big Deal?


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Public Reporting – So What’s the Big Deal?

https://www.medicare.gov/hospitalcompare/search.html


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Hospital Compare – Mortality Data


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What’s the Big Deal … Show Me the Money!

https://www.advisory.com/daily‐briefing/2018/01/02/latest‐hac


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CMS 30‐Day All‐Cause Risk‐Adjusted Mortality Measures


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Background on CMS Mortality Measures Public Reporting

• In 2007 CMS began publicly reporting 30‐day risk‐standardized mortality rates (RSMRs) for AMI and HF

• In 2008 pneumonia mortality measure added• In 2011 mortality measures updated to include AMI, HF, and pneumonia VA

admissions• In 2014 COPD and stroke mortality measures added (doesn’t include VA

admissions) 2019 Measures• Acute myocardial infarction (AMI)• Heart failure (HF)• Pneumonia• COPD• Acute ischemic stroke (new in 2019)• Coronary artery bypass graft (CABG)


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Let’s break it down …• All‐cause mortality … Why All‐Cause?

– A death from any cause is an adverse event– Making inferences about quality of care based solely on the documented cause of death is difficult

• 30‐day time frame … Why 30 Days?– Death within 30 days of the start of the admission can be influenced by hospital care and the early transition to the non‐acute care setting

– In the case where (a) a patient began their index admission with an ED visit, observation stay, or care received in another outpatient location within the same facility, (b) the patient was admitted as an inpatient to that hospital within three days of that outpatient encounter, and (c) the care was combined into one claim

– Older patients are more vulnerable to adverse health outcomes occurring during this time


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• Risk adjustment (RA): A method to account for variation in how sick patients were when they were admitted for their initial hospital stay. Patients’ degree of sickness increases or decreases the probability of observing the measure’s outcome.

• Risk variables typically are age, sex, and comorbidities.


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CMS 30‐Day Risk‐Standardized Mortality MeasuresInclusions (general)

• Index admission is the hospitalization to which the mortality outcome is attributed and includes admissions for patients:– Enrolled in Medicare (FFS) Part A and B for the 12 months prior to the date of the admission, and enrolled in Part A during the index admission, or VA beneficiaries (AMI, HF, and PN measures)

– Age 65 or over – Not transferred from another acute care facility

o When patients are transferred between acute care hospitals, the mortality is attributed to the hospital that admitted the patient for the index hospitalization (transferring facility) TransferTransfer

Hospital A Hospital B


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CMS 30‐Day Risk‐Standardized Mortality Measures Exclusions (general)

• The mortality measures exclude index admissions for patients: – Enrolled in Medicare hospice program or used VA hospice services any time in the 12 months prior to the index admission, including the first day of the index admission

– Discharged against medical advice


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Risk Adjustment


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Risk Adjustment Models


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CMS Mortality Measures Risk Adjustment Variables

• CMS uses the HCC risk adjustment methodology MINUS the “Hierarchical” to create risk factor variables

• Adjust for variables such as age, comorbid diseases, and indicators of patient frailty that are clinically relevant and have relationships with the outcome

• Are obtained from inpatient, outpatient, and physician Medicare administrative claims data extending 12 months prior to the index admission, and all claims for the index admission itself

Physician office coding counts!


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Risk Adjustment Coding Time Frames

• Diagnosis assigned to discharges in the 12 months prior to the index admission are used for risk adjustment– The placement of the diagnosis codes does not matter

• Secondary diagnosis codes assigned to the index admission are used to risk adjust for the HF, COPD, pneumonia, and stroke measures – Complications that arise during the course of the hospitalization are not used in risk adjustment


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30‐Day Risk‐Standardized Mortality Rate FollowingAMI(NQF #0230)


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AMI Cohort

Measure: 30‐Day Risk‐Standardized Mortality Rate Following AMI

Dx Inclusion:

• Principal diagnosis of AMI• Not transferred from another acute care facility• Age 65 or over • Enrolled in Medicare FFS 12 months prior to index admission or VA beneficiary

Exclusions:

• Discharged alive same day/next day, not transferred to another acute care facility• Enrolled in Medicare hospice program or used VA hospice services any time in the 12

months prior to the index admission (including first day of the index admission) • Discharged AMA

Risk Variables:

• Anterior myocardial infarction (index admission only)• Other (non‐anterior) location of myocardial infarction (index admission only)• History of CABG surgery• History of PTCA • 25 condition categories


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AMI Top Risk Variables by Frequency

Comorbidity %

Hypertension (CC 95) 82.4Coronary atherosclerosis or angina (CC 88–89) 82.0Diabetes mellitus (DM) or DM complications except proliferative retinopathy (CC 17–19, 123) 47.1

Renal failure (CC 135–140) 41.5

Trauma; other injuries (CC 166–168, 170–174) 32.0

Valvular and rheumatic heart disease (CC 91) 31.7

Chronic obstructive pulmonary disease (COPD) (CC 111) 29.3

Congestive heart failure (CC 85) 28.1Vascular disease and complications (CC 106–108) 27.6Pneumonia (CC 114–116) 20.4

2018 Condition Specific Measures Update Report 30‐Day RSMM‐Frequency of Model Variable 07/2014‐ 06/2017Hierarchical Condition Categories (HCC) version 22


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30‐Day Risk‐Standardized Mortality Rate Following Pneumonia(NQF #0468)


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Pneumonia Cohort

Measure: 30‐Day Risk‐Standardized Mortality Rate Following Pneumonia

Dx Inclusions:

• Principal discharge dx of pneumonia or• Principal discharge dx of sepsis (not incl. severe sepsis) with a secondary dx of

pneumonia POA (and no secondary diagnosis of severe sepsis POA)• Not transferred from another acute care facility• Age 65 or over • Enrolled in Medicare FFS 12 months prior to index admission or VA beneficiary

Exclusions:

• Discharged alive same day/next day, not transferred to another acute care facility• Enrolled in Medicare hospice program or used VA hospice services any time in the 12


Risk Variables:• History of CABG surgery• History of PTCA • 30 condition categories


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Pneumonia Top Risk Variables by FrequencyComorbidity %

Hypertension (CC 95) 82.5Iron deficiency or other/unspecified anemias and blood disease (CC 49) 57.5Coronary atherosclerosis or angina (CC 88–89) 46.2Chronic obstructive pulmonary disease (COPD) (CC 111) 45.0Renal failure (CC 135–140) 42.9Pneumonia; pleural effusion/pneumothorax (CC 114–117) 42.2Disorders of fluid/electrolyte/acid‐base balance (CC 24) 38.7Congestive heart failure (CC 85) 36.4Dementia or other specified brain disorders (CC 51–53) 36.3Vascular disease and complications (CC 106–108) 32.8Respiratory arrest; cardio‐respiratory failure and shock(CC 83–84 plus R09.01 and R09.02)

25.8

Depression (CC 61) 25.0Cerebrovascular disease (CC 101–102, 105) 21.6Protein‐calorie malnutrition (CC 21) 18.5



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30‐Day Risk‐Standardized Mortality Rate FollowingHeart Failure(NQF #0229)


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Heart Failure Cohort

Measure: 30‐Day Risk‐Standardized Mortality Rate Following Heart Failure

Dx Inclusion:• Principal diagnosis of heart failure• Age 65 or over • Not transferred from another acute care facility• Enrolled in Medicare FFS 12 months prior to index admission or VA beneficiary

Exclusions:

• With a procedure code for LVAD implantation or heart transplantation• Discharged alive same day/next day, not transferred to another acute care facility• Enrolled in Medicare hospice program or used VA hospice services any time in the 12


Risk Variables:• History of CABG surgery• History of PTCA • 22 condition categories


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Heart Failure Top Risk Variables by Frequency

Comorbidity %

Hypertension (CC 95) 84.1Congestive heart failure (CC 85) 72.2Coronary atherosclerosis or angina (CC 88–89) 69.7Renal failure (CC 135–140) 65.7Diabetes mellitus (DM) or DM complications except proliferative retinopathy (CC 17–19, 123) 53.4

Valvular and rheumatic heart disease (CC 91) 53.1

Chronic obstructive pulmonary disease (COPD) (CC 111) 48.0Pneumonia (CC 114–116) 42.1

Trauma; other injuries (CC 166–168, 170–174) 42.1

Vascular disease and complications (CC 106–108) 39.9



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30‐Day Risk‐Standardized Mortality Rate Following COPD(NQF #1893)


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COPD Cohort

Measure: 30‐Day Risk‐Standardized Mortality Rate Following COPD

Dx Inclusion:

• Principal diagnosis of COPD or acute respiratory failure with a secondary diagnosis of COPD with exacerbation

• Age 65 or over • Not transferred from another acute care facility• Enrolled in Medicare FFS 12 months prior to index admission or VA beneficiary

Exclusions:• Enrolled in Medicare hospice program any time in the 12 months prior to the

index admission (including first day of the index admission) • Discharged AMA

Risk Variables: • History of mechanical ventilation (ICD‐10‐PCS procedure code)• 28 condition categories

Rationale: COPD is the condition targeted for measurement. Acute respiratory failure admissions with a secondary diagnosis of COPD are also included in order to capture the full spectrum of severity among patients hospitalized with exacerbations of COPD.


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COPD Top Risk Variables by Frequency

Comorbidity %

Hypertension and hypertensive disease (CC 94–95) 84.1Morbid obesity; other endocrine/metabolic/nutritional disorders (CC 22, 25–26) 83.4Other musculoskeletal and connective tissue disorders (CC 45) 70.5Other gastrointestinal disorders (CC 38) 66.2Iron deficiency or other/unspecified anemias and blood disease (CC 49) 50.8Coronary atherosclerosis or angina (CC 88–89) 50.7Vascular or circulatory disease (CC 106–109) 43.0Congestive heart failure (CC 85) 41.8Specified arrhythmias and other heart rhythm disorders (CC 96–97) 41.0Diabetes mellitus (DM) or DM complications (CC 17–19, 122–123) 40.8



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30‐Day Risk‐Standardized Mortality Rate Following Ischemic Stroke


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Ischemic Stroke Cohort

Measure: 30‐Day Risk‐Standardized Mortality Rate Following Ischemic Stroke

Dx Inclusion:• Principal discharge diagnosis of ischemic stroke • Not transferred from another acute care facility• Age 65 or over • Enrolled in Medicare FFS 12 months prior to index admission

Exclusions:• Enrolled in Medicare hospice program any time in the 12 months prior to the

index admission (including first day of the index admission) • Discharged AMA

Risk Variables: • 28 condition categories• Discharge AMA


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Ischemic Stroke Top Risk Variables by Frequency

Comorbidity %

Hypertension (CC 95) 88.6Disorders of fluid/electrolyte/acid‐base; other endocrine/metabolic/nutritional disorders (CC 22–26) 87.9

Other musculoskeletal and connective tissue disorders (CC 45) 65.3Other gastrointestinal disorders (CC 38) 52.3Iron deficiency or other/unspecified anemias and blood disease (CC 49) 36.2Dementia or other specified brain disorders (CC 51–53) 31.4Specified heart arrhythmias (CC 96) 29.6Severe infection; other infectious diseases (CC 1, 3–7) 26.9Valvular and rheumatic heart disease (CC 91) 25.2Vascular disease and complications (CC 106–108) 25.0



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CDI Tips for Supporting Mortality Measures andHCC Risk Adjustment


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Heart Failure

• Acute or chronic– Acute or chronic– Exacerbation– Decompensated

• Systolic (EF < 40%) – HFrEF codes to systolic

• Diastolic (normal EF)– HFpEF codes to diastolic

• Heart failure– Not dysfunction


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Malnutrition – HCC Risk Adjustment

E40 KwashiorkorE41 Nutritional marasmusE42 Marasmic kwashiorkorE43 Unspecified severe protein‐calorie malnutritionE44.0 Moderate protein‐calorie malnutritionE44.1 Mild protein‐calorie malnutritionE45 Retarded development following protein‐calorie malnutrition

E46 Unspecified protein‐calorie malnutritionE64.0 Sequelae of protein‐calorie malnutritionR64 Cachexia

Protein Calorie Malnutrition HCC 21 Wt. 0.545

Risk adjusts at twice the value as morbid obesity 0.273


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Renal Disorders – HCC Risk Adjustment

Acute Renal Failure HCC 135 Wt. 0.422 N17.0 Acute kidney failure with tubular necrosisN17.1 Acute kidney failure with acute cortical necrosisN17.2 Acute kidney failure with medullary necrosisN17.8 Other acute kidney failureN17.9 Acute kidney failure, unspecified

Chronic Kidney Disease, Stage 5 HCC 136 Wt. 0.237

Chronic Kidney Disease, Stage 4 HCC 137 Wt. 0.237

Dialysis Status HCC 134 Wt. 0.422


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Best Practices


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Team Approach

Quality

HIM/Coding

CDI

Mortality Measures Data Integrity


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CDI• Documentation tips to support quality measures:

– Diagnoses need to be documented present on admission (POA) to be included in the risk calculation

– Capture diagnoses in the ER and on the H&P– Highest degree of specificity – Ensure documentation captures all conditions being monitored, evaluated, assessed, or treated

– Capture hospice and palliative care documentation – Ensure documentation provides linkage language, causal relationships, etc. – Query providers to obtain accurate, complete, and succinct documentation throughout the record


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Coding/HIM

• Evaluate annual updates to ICD‐10 Official Guidelines for Coding and Reporting for quality impact

• Review AMA Coding Clinic for updates/clarifications of coding and reporting guidelines for quality impact

• Ensure strong query process/procedures for obtaining supporting documentation of diagnosis/POA status

• Monitor accuracy, completeness, and timeliness of documentation– Copy/paste – Problem list

• Verify accuracy of admission source and discharge disposition


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Quality Management

• Monitor your QualityNet.org Hospital‐Specific Report (HSR)– Provide hospitals with their detailed measure results, discharge‐level data, and state and national results

– Review and correction period (about 30 days)• Doesn’t allow hospitals to submit additional corrections related to the claims data or add new claims used to calculate the results

• HSRs are designed to allow hospitals the opportunity to review results and the discharge data used in the calculation and to replicate their results

• Discrepancies or concerns regarding the claims or calculations must be reported during the review and correction period in order to be considered by CMS– Submit to the QualityNet Help Desk


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Hospital Specific Report (HSR)

• Provides hospitals with their detailed measure results, discharge‐level data, and state and national results

CMS FY2019 HVBP Mortality Mock RSMR Report


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Optimize the Observed to Expected (O:E) Ratio

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Observed rate: ‐ Useful if wanting to identify cases for follow‐up and performance improvement‐ Not appropriate for comparing across hospitals (doesn’t consider case mix)

Risk‐adjusted rate: Should be used for making comparisons across hospitals or within your own hospital over time; it adjusts for differences in case mix


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Team Approach to O:E Optimization

Help providers understand the impact documentation has on the hospital and their quality metrics

Document for (Comorbid Conditions)


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New in 2019 – Preparing for Revised Stroke Mortality Measure

• When will the NIH Stroke Scale be used in the stroke mortality measure? – The refined Stroke 30‐day mortality measure is proposed to be publicly reported in FY 2022. The

refined measure will be based on discharges that occurred between July 1, 2018 and June 30, 2021.

• What data does my hospital need to collect/report to prepare for the use of the NIH Stroke Scale? – The measure will obtain NIH Stroke Severity scores from Medicare administrative claims data.

Hospitals are encouraged to use the appropriate NIH ICD‐10 Stroke Severity codes. In the future, the measure may utilize electronic health record (EHR) data.

• What resources will CMS provide to help hospitals prepare for the use of the NIH Stroke Scale? o To help hospitals prepare for the use of the NIH Stroke Scale, CMS has made the “Hospital 30‐day,

all‐cause risk‐standardized mortality rate (RSMR) following acute ischemic stroke hospital with claims‐based risk adjustment for stroke severity” technical report publicly available on QualityNet.

Qualitynet.org: Frequently Asked Questions for the Risk Standardized Outcome and Payment Measures


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Thank you. Questions?

[email protected]@BrundageGroup.com

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section of the program guide.


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