Recently, the U.S. Government has been undertaking regulatory activities to drive down healthcare costs and improve patient outcomes. It is crucial to keep an eye on published regulations.

One of the Centers for Medicare and Medicaid Services’ (CMS) key goals is to pay claims right the first time. This means paying the right amount to legitimate providers for covered, reasonable and necessary services, furnished to eligible beneficiaries. The top three reasons for inaccurate claims payment can be attributed to insufficient documentation, medically unnecessary services and incorrect diagnosis coding.

Readmission Reduction Program

A recent activity is the Readmission Reduction Program, where healthcare claims are evaluated for patients who are admitted within 30 days of discharge. The intent is to ensure appropriate care was provided to the patient and identify any extenuating circumstances that required readmission. Documentation and associated codes for the following conditions are being reviewed.

  • Acute myocardial infarction
  • Heart failure
  • Pneumonia
  • Acute exacerbation of chronic obstructive pulmonary disease
  • Elective total hip arthroplasty
  • Total knee arthroplasty

In the year 2017, coronary artery bypass grafts (CABG) will be added to the list.

Patient Safety

Patient safety is a critical concern. Specific documentation supports coding and reporting of Patient Safety Indicators (PSIs). These conditions include:

  • Healthcare-associated infections
  • Surgical complications
  • Falls
  • Other adverse affects of treatment.

The results will allow hospitals to identify areas of opportunity to improve patient care and patient safety.

Value-based Purchasing

The healthcare industry is moving from a volume-based paymet system to a value-based payment system that uses documented and coded patient outcomes to decide whether a patient was provided quality care. This is a CMS initiative that rewards acute care hospitals with incentive payments for the quality of care provided to Medicare beneficiaries. The incentive payments are based on a hospital’s performance on a predetermined set of quality measures and patient survey scores, collected during a baseline period, compared to a performance period.

Hospital-Acquired Condition (HAC) Reduction Program

Another initiative is the Hospital-Acquired Condition (HAC) Reduction Program. This was initiated in Section 3008 of the 2010 Patient Protection and Affordable Care Act. This program modifies payment for a selective number of conditions, if they occur during a hospitalization and were not present on admission. It is believed that these conditions are preventable if appropriate care is provided and documented. Hospitals that rank in the bottom 25 percent of all hospitals will only receive 99 percent of their Medicare Inpatient Prospective Payment System payments.