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December 2016

Medicare Bundled Payments: Are AMI and CABG Next?
By Lisa A. Eramo
For The Record
Vol. 28 No. 12 P. 14

How HIM Professionals Can Ensure Success Through Data Quality

Bundled payments have been growing in popularity over the past several years—particularly with the Centers for Medicare & Medicaid Services (CMS). In the beginning, these payment models were voluntary; forward-thinking organizations made the deliberate choice to participate. Now, the agency is taking additional steps to implement and grow mandatory bundled payments that continue to reward hospitals for working with physicians and other providers to avoid unnecessary complications, improve quality outcomes, prevent hospital readmissions, enhance the patient experience, and enable a faster recovery in the appropriate care setting.

"CMS' goal is to improve care for all Medicare beneficiaries—not just those whose clinicians happen to be early adopters of new payment models," according to a CMS spokesperson. "That means the next step is to test whether bundles can deliver better care at a lower cost when implemented at scale and across all types of providers and patients. … This requires a mandatory test where a wide range of hospitals across the country will participate."

In particular, CMS proposes to add acute myocardial infarction (AMI) and coronary artery bypass graft (CABG) surgery to a growing list of conditions and procedures for which bundled payments will be mandatory. A final rule is expected by the end of 2016. If finalized, the cardiac bundle would be implemented in July 2017.

In the 900-plus-page proposed rule released July 25, 2016, the agency announced that it would require hospitals in 98 selected metropolitan statistical areas (MSAs) to participate in this latest cardiac bundle. MSAs are defined as having at least one urbanized area with a population of 50,000 or greater.

Medicare severity diagnosis-related groups (MS-DRGs) subject to the cardiac bundle include the following:

• 231 Coronary Bypass With PTCA [percutaneous transluminal coronary angioplasty] With MCC [major complication/comorbidity];

• 232 Coronary Bypass With PTCA Without MCC;

• 233 Coronary Bypass With Cardiac Catheterization With MCC;

• 234 Coronary Bypass With Cardiac Catheterization Without MCC;

• 235 Coronary Bypass Without Cardiac Catheterization With MCC;

• 236 Coronary Bypass Without Cardiac Catheterization Without MCC;

• 246 Percutaneous Cardiovascular Procedure With Drug-Eluting Stent With MCC or 4+ Vessels/Stents;

• 247 Percutaneous Cardiovascular Procedure With Drug-Eluting Stent Without MCC;

• 248 Percutaneous Cardiovascular Procedure With Non-Drug-Eluting Stent With MCC or 4+ Vessels/Stents;

• 249 Percutaneous Cardiovascular Procedure With Non-Drug-Eluting Stent Without MCC;

• 250 Percutaneous Cardiovascular Procedure Without Coronary Artery Stent or AMI With MCC;

• 251 Percutaneous Cardiovascular Procedure Without Coronary Artery Stent or AMI Without MCC;

• 280 Acute Myocardial Infarction, Discharged Alive With MCC;

• 281 Acute Myocardial Infarction, Discharged Alive With CC [complication/comorbidity]; and

• 282 Acute Myocardial Infarction, Discharged Alive Without CC/MCC.

This isn't CMS' first foray into this type of reimbursement model, and experts say it probably won't be the last.

"What we are hearing from CMS is that bundled payments are not going away," says Tori Manis, senior manager at ECG Management Consultants. "They are growing the number of sites, they are expanding the clinical conditions included, and they are increasing the quality metrics required for reporting and payment."

Setting the Stage for Bundled Payments
The latest cardiac bundle comes in the wake of several other similar payment programs.

In early 2016, the agency announced it would extend the Bundled Payments for Care Improvement (BPCI) initiative through September 30, 2018. BPCI is a voluntary program that links payments for multiple services during an episode of care for 30, 60, or 90 days postdischarge. The program was previously scheduled to end after participants completed a three-year period of performance for each clinical episode selected. Now, participants have the option to extend the program for an additional two years.

In April, CMS implemented its Comprehensive Care for Joint Replacement (CJR) model. Unlike those preceding it, the CJR is a mandatory payment model for nearly 800 hospitals in 67 MSAs. CJR is a five-year program that specifically targets hip and knee replacements (MS-DRGs 469 and 470) and uses a regional pricing methodology.

In June, CMS announced the Oncology Care Model, a voluntary program that provides financial incentives for physicians and commercial payers when both parties collaborate to improve care coordination and provide high-quality, low-cost care for beneficiaries undergoing chemotherapy. CMS announced a total of 196 organizations would participate in the program.

At this point, Manis says the cardiac bundle has the most in common with the CJR.
Consider the following:

• Both the CJR and cardiac bundle are mandatory. Selected hospitals must participate regardless of their readiness.

• Both the CJR and cardiac bundle hold hospitals accountable for care that extends beyond the inpatient setting. This includes the cost and quality of care provided to Medicare fee-for-service beneficiaries during the inpatient stay and for 90 days postdischarge.

• Participating hospitals are paid a fixed quality-adjusted target price for each episode of care. In the case of the cardiac bundle, payments are made when patients are admitted for a heart attack, bypass surgery, or percutaneous cardiovascular procedure (ie, percutaneous transluminal coronary angioplasty with or without stents).

• At the end of each model performance year, CMS performs a reconciliation. During this process, the agency compares a hospital's actual spending for each episode (eg, total expenditures for related services under Medicare Parts A and B) with its target price. Hospitals that meet this price or fall below are paid the savings achieved—provided they also meet or exceed quality standards. Hospitals have the option to share these savings with one or more collaborators as defined by CMS. If hospitals exceed the target price, they are required to repay the difference to Medicare.

The number of hospitals affected by the cardiac bundle will likely be higher than those impacted by CJR simply because of the additional MSAs that have been announced for the former. However, on a per-hospital basis, the impact in terms of dollars may be similar, says Phillip Dawes, senior vice president of value-based reimbursement at nThrive. Dawes estimates that, on average, 4% of Medicare payments relate to MS-DRGs included in the CJR while 3% are associated with MS-DRGs included in the cardiac bundle.

Cost is another story. For joint replacements, there's generally a 50/50 split in terms of inpatient and postacute care dollars spent, Dawes says. With AMI and CABG, there's a shift toward the acute side with 70% of costs related to inpatient services and only 30% for postacute care.

"What this means is that in terms of interventions, you're focused less on trying to take cost out of the postacute care setting and more on reducing readmissions," Dawes says.

Unfortunately, reducing readmissions is tricky—especially for AMIs. "Joint replacements are elective. You are more able to predict outcomes and where patients will go postdischarge. A heart attack is very unpredictable, and the patient population looks very different," Manis says.

"Care redesign strategies for the proposed episode payment model are likely to require more widespread changes in care pathways and more substantial care coordination than the CJR model given the broad spread of spending across multiple types of services following hospital discharge," according to a CMS spokesperson.

Interestingly, a recent study published in Health Affairs suggests that most readmissions for heart attack, heart failure, and pneumonia after seven days may be explained by community or household factors outside the hospital's control.

In its comments on the proposed rule, the American Hospital Association urges CMS to delay the inclusion of AMI so hospitals can work through the CABG bundle first. It also urges the agency not to implement the cardiac bundles in the same geographic areas as the CJR model among other requests related to risk adjustment, transfer-adjustment methodology, discount factors, and financial arrangements with other providers.

Integrating HIM Expertise
Still, there are ways in which hospitals can improve data quality and coding accuracy, which is reassuring for hospitals required to participate in the cardiac bundle, says Patty Griffin, RHIA, interim coding manager at himagine solutions. In her previous role as corporate director of a large health system in Tennessee, Griffin spearheaded an effort to identify and validate CABG cases that were part of a voluntary bundle. (She says the same methodology can be applied to the mandatory bundle.) She did so by following these steps:

• HIM received an alert from the hospital's CABG coordinator—a physician extender who works closely with the surgeons and the clinical documentation improvement (CDI) team—every time a CABG bundle patient was going to be admitted. The alert came in the form of an e-mail that included the patient's name, account number, surgeon, and expected date of the procedure.

• Griffin flagged these accounts in the hospital's EHR.

• One of two senior coders with an in-depth knowledge of the bundle coded the case postdischarge and forwarded it to an external reviewer for a prebill review.

• During the prebill review, the external reviewer validated severity of illness (SOI), risk of mortality (ROM), and the presence of any CCs or MCCs.

• Griffin subsequently validated SOI and ROM herself before returning the claim to the nurse practitioner, who shared the information with the surgeon so he or she also could validate the data.

"Most of the time, we were getting the higher-paying DRG because these were very sick patients," Griffin says. "But many times, I saw that the ROM and SOI was not at least a 3/3. I would make note of this in my e-mail, asking, 'Are we missing some diagnosis that's not documented?'"

Griffin says surgeons were on board with this process because they had a vested interest in benefiting from the shared savings. Hospital executives also liked the fact that the facility could usually continue to maintain a 24-hour turnaround time for dropping claims despite the added layers of review.

CABG bundle patients accounted for less than 1% of the hospital's total weekly patient population, enabling coders and auditors to review these cases in detail without having to carve out a significant amount of time to do so. "When your daily charges are $13 million, [an extra review for 1%] just doesn't have an effect on AR [accounts receivable]. Even if it did cause an increase in AR, we felt that we were sending out a superior product. We knew that it would be correct," Griffin says.

HIM's Role in Bundled Payments: Six Strategies
Experts say data quality is one of the areas where HIM professionals can have the biggest impact on bundled payments. They also can serve as project managers, helping to increase communication between IT, case managers, CDI specialists, and physician advisors.

Consider the following ways in which HIM professionals can ensure accurate bundled payments.

Strive for coding accuracy at all times. This includes coding diagnoses that may not affect the MS-DRG assignment but could impact SOI and ROM.

Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS, managing director of advisory services at nThrive, says to be on the lookout for the following cardiac secondary diagnoses that affect a level 3 SOI:

• acute nephritic syndrome;
• acute kidney injury;
• anaphylactic shock due to blood or serum;
• aneurysm without rupture;
• aplastic anemia;
• arteriosclerosis of extremities with gangrene;
• coagulopathy, most types;
• deep-vein thrombosis, acute;
• embolism, arterial;
• endocarditis;
• gangrene alone;
• heart block, second or third degree (complete);
• heart failure/congestive heart failure (acute [systolic or diastolic] or rheumatic);
• hydronephrosis;
• hypernatremia;
• hypertensive heart disease with heart failure and chronic kidney disease stage 5;
• malnutrition, moderate, protein calorie (unspecified);
• metabolic acidosis;
• neutropenia;
• nonischemic, nonalcoholic cardiomyopathy;
• pancytopenia;
• paroxysmal ventricular tachycardia;
• phlebitis (deep vein upper extremity or lower extremity; femoral vein+/- deep; nonexternally);
• pulmonary valve atresia;
• syndrome of inappropriate antidiuretic hormone secretion;
• sickle cell disease/crisis;
• subaortic stenosis;
• tricuspid atresia;
• vascular insufficiency, intestine (unspecified or chronic);
• Von Willebrand disease; and
• ventricular tachycardia.

The following secondary diagnoses trigger a level 4 SOI:
• acute cor pulmonale;
• AMI;
• acute tubular necrosis;
• aneurysm ruptured;
• cardiac arrest;
• cardiogenic shock;
• disseminated intravascular coagulation;
• endocarditis, acute/bacterial;
• extremity arteriosclerosis with gas gangrene;
• gas gangrene alone;
• hemolytic uremic syndrome;
• kwashiorkor;
• malnutrition, protein calorie, severe (unspecified);
• marasmus;
• pulmonary embolism;
• vascular insufficiency, intestine (acute);
• ventricular fibrillation; and
• ventricular flutter (present on admission).

Hospitals that don't focus on SOI and ROM could end up with an artificially low target price despite higher-acuity DRGs, says Dawes, who's aware of several organizations participating in the BPCI that had this very issue.

"You have to make sure that those codes tell the story of what's going on with that patient both at the DRG level and the code level," says Donna Smith, RHIA, senior consultant and project manager at 3M Health Information Systems. "That's something you need to look at. Coded data is used to evaluate both risk and quality outcomes. It's all about coded data."

She says many hospitals perform in-depth reviews on all mortality cases—particularly those related to AMI and CABG—to ensure that SOI and ROM are documented and coded correctly. As proposed, the cardiac bundle takes the following quality metrics into consideration:

• Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following AMI Hospitalization; and

• Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following CABG Surgery.

Smith encourages HIM professionals to promote coding specificity at all times. "Severity and risk are based on reporting the most specific diagnoses," she notes. For example, for the cardiac bundle, both initial and subsequent AMIs are included, but the specificity can impact severity and risk of the coded data. Specificity elements to consider include the following:

• ST elevation myocardial infarction (STEMI) vs non-STEMI myocardial infarction;

• initial vs subsequent myocardial infarction;

• anatomic location (ie, anterior wall, inferior wall, or other sites); and

• specific artery (ie, left main coronary artery, left anterior descending coronary artery, other coronary artery, right coronary artery, or left circumflex coronary artery).

Encourage physicians to document greater or lesser saphenous vein when performing CABG procedures, Griffin says. If they always use the greater saphenous vein, consider incorporating this information into the facility's internal coding guidelines so coders don't query for clarification unnecessarily. This information doesn't affect the MS-DRG, but it certainly adds valuable specificity, Griffin says.

Work with IT to develop systems that use symptoms, lab values, and other clinical indicators to identify patients with an AMI as early as possible. Create separate work queues to examine these patients more closely and work collaboratively with CDI specialists to perform concurrent risk stratification, Dawes says.

HIM can also use the data to keep discharge planners in the loop. "Being able to identify these patients early allows you to trigger the right set of care plans that account for what happens after discharge," Dawes says.

For the AMI bundle, CMS proposes to evaluate hospitals on the number of excess days in acute care after hospitalization—yet another reason why collaboration between HIM and discharge planners is necessary, Griffin says. For example, if home health can't perform an intake until days later, it could affect the hospital's bundled payment. HIM needs to explain this to discharge planners so they understand the importance of timely discharges to the right setting, Griffin says.

Review exclusions. Both the AMI and CABG bundles include a list of excluded readmissions as well as excluded Part B services. For example, a patient has an AMI and is readmitted within 90 days with a concussion (MS-DRG 088, 089, or 090). According to Smith, per CMS' proposal, the readmission isn't included in the costs related to the patient's care. Likewise, if a patient undergoes a CABG and is readmitted within 90 days due to a nervous system neoplasm (MS-DRG 054 or 055), the readmission isn't included in the total costs.

Address potential quality problems. Consider postoperative atrial fibrillation. In her previous position, Griffin worked with surgeons to clarify whether atrial fibrillation was a complication of surgery or an expected outcome. If it was the latter, she encouraged surgeons to document the following: "Patient had an episode of atrial fibrillation corrected by [insert medication or procedure] before they left the operating room." Without this documentation, it appeared as though atrial fibrillation had been a preventable condition.

Work collaboratively with physician practices. As hospitals purchase physician practices, HIM departments increasingly absorb the coding and billing function, Smith says. However, just how accurate is the coding that physicians report? Does it include all of the chronic conditions necessary to establish SOI and ROM? The goal is to enable coding that spans the continuum of care, not only the office-based encounter, Smith says.

Educate hospital executives. Early on in the voluntary CABG bundle, Griffin says she had to explain that MS-DRGs 233 and 234 were triggered only when a patient undergoes a CABG and cardiac catheterization at the same facility. Executives incorrectly assumed that the flagship hospital performing the CABG would get credit for a cardiac catheterization that occurs in another facility with a separate NPI (National Provider Identifier) number—even when that facility was part of the same system. For example, this occurred frequently when a smaller hospital performed the less-invasive catheterization procedure and then transferred patients to the larger flagship facility for the CABG surgery.

When MS-DRGs 235 and 236 were triggered, executives incorrectly assumed that HIM professionals weren't capturing costs correctly, Griffin says.

Act Now
Manis says even hospitals that aren't officially mandated to participate should prepare for cardiac bundled payments. "Even if you are not chosen for the cardiac bundle, it will just be a matter of time before everyone is included in the mandate," she says. "A wait-and-see approach is not recommended. Don't wait to see if you're chosen and then plan. There is a lot of planning that you can do now in terms of data analysis, benchmarking, quality reviews, and care coordination evaluation."

— Lisa A. Eramo is a freelance writer and editor in Cranston, Rhode Island, who specializes in HIM, medical coding, and health care regulatory topics.