The Data Game. Vicky A. Mahn-DiNicola RN, MS, CPHQ VP Research & Market Insights

Transcription

1 The Data Game Vicky A. Mahn-DiNicola RN, MS, CPHQ VP Research & Market Insights

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3 My Primary Objective Today: Review Upcoming Regulatory Changes

4 Review of Proposed IPPS Rule for FY 2016 CMS-1632-P 45 CFR Part 170 Posted to Federal Registry April 30,

5 Payment/AcuteInpatientPPS/FY2016-IPPS-Proposed-Rule-Home-Page.html

6 Comment Deadline 60 Days after posting to the Federal Registry June 29, PM Eastern Time

7 CMS-1632-P

8 Question #1 What hospital reporting program would you say keeps your leadership team awake at night? A. Hospital Readmission Reduction Program B. Hospital Acquired Conditions Reduction Program C. Value Based Purchasing D. All of the Above E. None of the Above We re on Top of It!

9 A Few Odds and Ends First MS DRG Recoupment MS DRG HAC Payments Bundled Payment Future Cool Stuff

10 MS DRG Recoupment Proposed Recoupment or Repayment Adjustment Authorized by Section 631 of the American Taxpayer Relief Act of 2012 (ATRA) The secretary needs to recoup $11 billion over a 4-year period of FYs 2014, 2015, 2016, and Proposed rule is to establish a 0.8 percent recoupment adjustment to the standardized amount for FY 2016 payments Proposed change would recoup 3 billion dollars in FY 2016 Combined adjustments from FY 2014, 2015 and 2016 will recoup a total of 6 B Still 5 Billion Short!

11 Glucarpidase (Voraxaze ) Zenith AAA Endovascular Graft Kcentra Argus Retinal Prosthesis Zilver Drug eluting Stent CardioMEMS Heart Failure Monitoring System MitraClip System Responsive Neurostimulator System Angel Medical Guardian Ischemia Monitoring Device Blinatumomab (BLINCYTO ) Ceftazidime Avibactam (AVYCAZ) DIAMONDBACK 360 Coronary Arthrectomy System CRESEMBA Idarucizumab LUTONIX Drug Coated PTA Balloon Catheter VERASENSE Knee Balancer System WATCHMAN Left Atrial Appendage Closure Technology Forecast for Future Technologies and Treatments pages

12 Hospital Readmission Reduction Program Review of the IPPS 2016 Proposed Rule Starts on page Hospital Inpatient Quality Program Hospital Readmission Reduction Program Hospital Acquired Conditions Reduction Program Hospital Value Based Purchasing Program - 12

13 The History of the Hospital Readmission Reduction Program Payments for FY 2013 Payments for FY 2014 Payments for FY 2015 Payments for FY 2016 Payments for FY 2017 Max Penalty 1% 2% 3% 3% 3% Acute MI Pneumonia Heart Failure COPD Total Hip/Knee CABG Planned Readmissions Excluded Based on Discharges July 1, 2008 to June 30, 2011 Version 2.1 July 1, 2009 to June 30, 2012 Version 2.1 July 1, 2010 to June 30, 2013 Version 3.0 July 1, 2011 to June 30, 2014 Version 3.0 July 1, 2012 to June 30, 2015

14 Impact on US Hospitals FY 2015 Readmission Penalty for Payment Determination in FY ,610 hospitals fined Increase of 433 in FY 2015 Average penalty.63 Increase from.38 in had full 3% penalty 496 have 1% penalty Retrieved from Kaiser Health News May 1, care-readmissions-penalties-by-state/

15 US Medicare 30-day Hospital Unplanned Readmissions CMS Medicare Quality Chart Book September Instruments/HospitalQualityInits/Downloads/Medicare-Hospital-Quality-Chartbook-2014.pdf

16 US Medicare 30-day Hospital Unplanned Readmissions CMS Medicare Quality Chart Book September Instruments/HospitalQualityInits/Downloads/Medicare-Hospital-Quality-Chartbook-2014.pdf Readmission Rates Declining Even Before They Were Part of The Readmission Reduction Program Coronary Artery Bypass Graph Total Hip and Knee Arthroplasty

17 Trend of ED Visit Rate and Observation Stay Rate Compared to Readmission Rate CMS Medicare Quality Chart Book September Instruments/HospitalQualityInits/Downloads/Medicare-Hospital-Quality-Chartbook-2014.pdf

18 Additional Proposed Changes in FY 2016 IPPS Rule Impacting Payment Determination for FY 2017 Expansion of Pneumonia Cohort (index population) 30-day, All-Cause, Risk-Standardized Readmission Rate following Pneumonia Hospitalization (NQF-0506) Currently including only patients with a principle diagnosis of viral or bacterial pneumonia Proposing to ADD patients with a principle diagnosis (meaning present on admission) of aspiration pneumonia Proposing to ADD patients with a principle diagnosis of sepsis or respiratory failure (meaning present on admission) with a secondary diagnosis of pneumonia Proposing to begin with payment determination FY 2017 (applies to July 1, 2012 discharges forward) Midas+ will be embedding these changes into our CMS Readmission Measures (DataVision) and our Readmission Forecaster in November (after final rule passes in August 2015)

19 Expected Impact of Broader Pneumonia Cohort More hospitals will be eligible (hospitals with less than 25 cases in the three year reporting period are excluded from public reporting) Change in population would add 634,519 patients (representing a 65% increase in national population size) 42 additional hospitals will be eligible for public reporting Overall increase of 0.9 estimated in absolute percentage points Excess readmission ratios expected to change for some hospitals See Additional Details About Impact of this change at Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Measure-Methodology.html

20 NQF Plans to Pilot Risk Adjustment by Sociodemographic Variables 2 year pilot Evaluating multiple SDS methods for conceptual and empirical evidence Evaluating potential for organizations to make incorrect inferences on risk adjusted data Disincentive to provide care to underserved or under privileged populations Evaluating potential data constraints and burden Anticipate that multiple criteria for application of SDS adjustment will evolve Use for Performance Improvement Only Use for P4P Accountability measures 16 readmission measures identified in the initial review

21 Measures Endorsed for NQF 2-year Pilot of Risk Adjustment Using Sociodemographic Data 0505 Hospital 30-day all-cause risk-standardized readmission rate (RSRR) following acute MI 0695 Hospital 30-Day Risk-Standardized Readmission Rates following Percutaneous Coronary Intervention 2375 PointRight OnPoint-30 SNF Rehospitalizations 2380 Rehospitalization During the First 30 Days of Home Health 2393 Pediatric All-Condition Readmission Measure 2414 Pediatric Lower Respiratory Infection Readmission Measure 2502 All-Cause Unplanned Readmission Measure for 30 Days Post Discharge from Inpatient Rehabilitation 2503 Hospitalizations per 1000 Medicare fee-for-service (FFS) Beneficiaries day Rehospitalizations per 1000 Medicare fee-for-service (FFS) Beneficiaries 2505 Emergency Department Use without Hospital Readmission During the First 30 Days of Home Health 2510 Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM) 2512 All-Cause Unplanned Readmission Measure for 30 Days Post Discharge from Long-Term Care Hospitals 2513 Hospital 30-Day All-Cause Risk-Standardized Readmission Rate (RSRR) following Vascular Procedures 2514 Risk-Adjusted Coronary Artery Bypass Graft (CABG) Readmission Rate 2515 Hospital 30-day, all-cause, unplanned, risk-standardized readmission rate (RSRR) following CABG 2539 Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy

22 CMS Clinical Core Variables from EHR Being Considered for Future Risk Adjustment page Core Clinical Data Elements Technical Report Version Core Clinical Variables identified from the EHR to support electronic Hybrid measures, which include risk adjustment for outcome measures such as mortality and readmissions Quality-Initiatives-Patient- Assessment-Instruments/ HospitalQualityInits/Measure- Methodology.html

23 Proposed Disaster Extraordinary Circumstances Waiver for Readmission Reduction Program Proposed rule is for hospitals that experience a natural disaster or other event that prevents them from submitting their claims to CMS to submit a waiver request within 90 days of disaster. Hospital CCN Hospital Name Hospital Address CEO Name Reason for requesting exemption CMS Program Name Measures and submission quarters affected How the extraordinary circumstance negatively impacted performance Evidence of impact CEO Signature Submit a form for each program you are requesting exemption

24 Hospital Value Based Purchasing Program IPPS 2017 Proposed Rule Begins on page Hospital Inpatient Quality Reporting Program Hospital Readmission Reduction Program Hospital Acquired Conditions Reduction Program Hospital Value Based Purchasing Program - 24

25 Hospital Value Based Purchasing FY 2016 Funding pool started in 2012 with 1.00 percent of the base-operating DRG FY 2016 Funding Pool capped at 1.75 with estimated funds at Billion Applies to subsection (d) hospitals Maryland Hospitals no longer exempt because they are no longer paid under section 1814 (b)(3), however they remain Exempt due to new Agreement signed January 1, 2014 to Participate in a 5-year All Payer Model FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 October 1, 2015 to September 30, 2016

26 Each Measure Worth 0 to 10 Points Points are dependent upon your hospital s performance against the rest of the nation Achievement Threshold Benchmark National Median (50 th Percentile) during a baseline period with respect to a fiscal year Note: This definition does not apply to the Medicare Spending per Beneficiary Measure; which is the median (50 th percentile) of hospital performance on a measure during the performance period with respect to a fiscal year Arithmetic mean of the top decile (10 th Percentile) during a baseline period with respect to a fiscal year Note: This definition does not apply to the Medicare Spending per Beneficiary Measure; which is the arithmetic mean of the top decile of hospital performance on a measure during the performance period with respect to a fiscal year Definitions were clarified in the FY 2014 IPPS/LTCH Rule

27 Each Measure Worth 10 Points IMM-2 Influenza Immunization 0 Points Performance Period January 1, 2014 to December 31, % % Achievement Threshold Benchmark = Your Hospital s Performance beginning with Discharges January 1, 2014

28 Each Measure Worth 10 Points IMM-2 Influenza Immunization 10 Points Performance Period January 1, 2014 to December 31, % % Achievement Threshold Benchmark = Your Hospital s Performance beginning with Discharges January 1, 2014

29 Achievement Points IMM-2 Influenza Immunization % 97% % Performance Period January 1, 2014 to December 31, 2014 Achievement Threshold Benchmark Achievement Range Points For hospitals that score better than half the hospitals in the US they can Score Achievement Points based on a linear scale between the Achievement threshold and the Benchmark

30 Improvement Points IMM-2 Influenza Immunization Achievement Threshold Benchmark 86% Baseline Period Jan 2012 Dec 2012 Performance Period Jan 2014 Dec % 97% % A unique improvement range for each measure will be established for each hospital that defines the distance between the hospital s baseline period score and the national benchmark score 8 Points Improvement Range The improvement threshold is an individual hospital s performance level on a measure during the baseline period with respect to a fiscal year

31 FY 2015 Value-Based Purchasing Clinical Process of Care Domain (Payment Determination for Discharges from October 1, 2014 to September 30, 2015) Established in the FY 2013 IPPS/LTCH PPS Final Rule 12 Clinical Process of Care Measures Baseline Period January 1, 2011 to December 31, 2011 Performance Period January 1, 2013 to December 31, 2013 Measures Threshold (%) Benchmark (%) AMI 7a Fibrinolytic agent received 30 minutes of hospital arrival AMI 8a PCI received 90 minutes of arrival O0 HF 1 Discharge Instructions Efficiency 20% Outcome 30% Clinical Process of Care 20% Experience of Care 30% SCIP VTE 1 removed from FY 2015 Measures PN 3b Blood culture before 1 st antibiotic received in hospital PN 6 Initial antibiotic selection for CAP immunocompetent patient SCIP 1 Antibiotic 1 hr before incision or 2 hrs if Vancomycin/Quinolone SCIP 2 Received antibiotic consistent with recommendations SCIP 3 Prophylactic Antibiotic Discontinued w/in 24 hrs surgery end time SCIP 4 Controlled 6 AM postop glucose for cardiac surgery SCIP 9 Postop urinary catheter removed postop day 1 or 2 SCIP-Card 2 Pre-admission beta blocker and periop beta blocker SCIP-VTE-2 Received VTE prophylaxis w/in 24 hrs prior to or after surgery

32 FY 2015 Value-Based Purchasing Experience of Care Domain (Payment Determination for Discharges from October 1, 2014 to September 30, 2015) Established in the FY 2013 IPPS/LTCH PPS Final Rule 8 Patient Experience of Care Measures Efficiency 20% Outcome 30% Clinical Process of Care 20% Experience of Care 30% Baseline Period January 1, 2011 to December 31, 2011 HCAHPS Survey Dimensions Communication with Nurses Communication with Doctors Responsiveness of hospital staff Performance Period January 1, 2013 to December 31, 2013 Floor(%) Threshold (%) Benchmark (%) Pain management Communications about medications Cleanliness and quietness Discharge information Overall rating of hospital

33 FY 2015 Value-Based Purchasing Outcome Domain (Payment Determination for Discharges from October 1, 2014 to September 30, 2015) Established in the FY 2013 IPPS/LTCH PPS Final Rule Three Outcome of Care Mortality Measures Baseline Period October 1, 2010 to June 30, 2011 Performance Period October 1, 2012 to June 30, 2013 Measures Threshold (%) Benchmark (%) Efficiency 20% Outcome 30% Clinical Process of Care 20% Experience of Care 30% Acute MI 30-day Mortality Rate Heart Failure 30-day Mortality Rate Pneumonia 30-day Mortality Rate One Complication/Patient Safety Measure Baseline Period October 15, 2010 to June 30, 2011 Performance Period October 15, 2012 to June 30, 2013 Measures Threshold Benchmark (%) AHRQ PSI-90 Composite One Hospital Acquired Infection Measure Baseline Period January 1, 2011 to December 31, 2011 Performance Period February 1, 2013 to December 31, 2013 Measures Threshold Benchmark (%) CLABSI (Standardized infection ratio)

34 FY 2015 Value-Based Purchasing Efficiency Domain (Payment Determination for Discharges from October 1, 2014 to September 30, 2015) Established in the FY 2013 IPPS/LTCH PPS Final Rule New! One Cost of Care Efficiency Measure Efficiency 20% Outcome 30% Clinical Process of Care 20% Experience of Care 30% Baseline Period May 1, 2011 to December 31, 2011 Performance Period May 1, 2013 to December 31, 2013 Measures Threshold (%) Benchmark (%) MSPB-1 Medicare spending per beneficiary Median Medicare spending per beneficiary ratio across all hospitals during performance period Mean of 10 th percentile of Medicare spending per beneficiary ratios across all hospitals during performance period - 34

35 Changing Shifts in Domain Weighting FY 2015 FY 2016 Efficiency 20% Clinical Process of Care 20% Efficiency 25% Clinical Process of Care 10% Patient Experience of Care 25% Outcome 30% Patient Experience of Care 30% Outcome 40% Hospitals must have sufficient data in at least two domains to calculate a total performance score - 35

36 Value Based Purchasing Measures for Program Year 2016 CAUTI 40% Clinical Care Outcome Domain Baseline: Jan-Dec 2012 (** Oct 2010-Jun 2011) Performance: Jan-Dec 2014 (** Oct 2012 Jun 2014) CLABSI 25% Patient Experience Domain Baseline Period: Jan-Dec 2012 Performance Period: Jan-Dec 2014 HCAHPS Catheter-Associated UTI Central Line-Associated BSI Mort-30-AMI AMI 30-day mortality rate ** Mort-30-HF Heart Failure 30-day mortality rate ** Mort-30-PN Pneumonia 30-day mortality rate ** PSI-90 Composite patient safety/complication ** SSI Surgical Site Infection (Colon and Abdominal Hysterectomy) Hospital Consumer Assessment of Healthcare providers & Systems Survey 10% Clinical Care Process Domain Baseline: Jan-Dec 2012 Performance Period: Jan-Dec 2014 AMI 7a IMM-2 PN-6 SCIP- Inf-2 SCIP- Inf-3 SCIP- Inf-9 SCIP- Card-2 SCIP- VTE-2 Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival Influenza Immunization Initial Antibiotic Selection for CAP in Immunocompetent Patient Prophylactic Antibiotic Selection for Surgical Patients Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time Urinary Catheter Removed on Postop Day 1 or Postoperative Day 2 Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Perioperative Period. Surgery Patients Who Received Appropriate VTE Prophylaxis 24 Hours Prior and to 24 Hours After Surgery 36 25% Efficiency Domain Baseline Period: Jan-Dec 2012 Performance Period: Jan-Dec 2014 MSPB-1 Medicare Spending per Beneficiary

37 More Changing in Domain Weighting Efficiency 25% FY 2016 Patient Experience of Care 25% Clinical Process of Care 10% Safety, 20% Efficiency 25% FY 2017 Patient Experience of Care 25% Clinical Process of Care 5% Outcome 40% Outcome 25% Hospitals must have sufficient data in at least three domains to calculate a total performance score for FY

38 Value Based Purchasing Measures for Program Year 2017 Three new measures adopted in FY 2015 IPPS Rule for FY 2017 VBP Program and domain weighting changes 25% Clinical Care Outcome Domain Baseline Period: Oct 1, 2010 June 30, 2012 Performance Period: Oct 1, 2013 June 30, % Previously was 15% Safety Domain Baseline Period: Jan-Dec 2013 (excluding PSI-90) Performance Period: Jan-Dec 2015 (excluding PSI-90) Mort-30-AMI AMI 30-day mortality rate CAUTI Catheter-Associated UTI Mort-30-HF Mort-30-PN 5% Previously was 10% Clinical Care Process Domain Baseline Period: Jan-Dec 2013 Performance Period: Jan-Dec 2015 AMI 7a Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival IMM-2 PC-01 Influenza Immunization Elective Delivery Prior to 39 Completed Weeks Gestation 25% Patient Experience Domain Baseline Period: Jan-Dec 2013 Performance Period: Jan-Dec 2015 HCAHPS Heart Failure 30-day mortality rate Pneumonia 30-day mortality rate Hospital Consumer Assessment of Healthcare providers & Systems Survey CLABSI PSI-90 SSI C. Difficile MRSA 25% Efficiency Domain Baseline Period: Jan-Dec 2013 Performance Period: Jan-Dec 2015 MSPB-1 Central Line-Associated BSI SIR (non reliability adjusted) Composite patient safety/complication Baseline Period Oct 1, 2010 to June 30, 2012 Performance Period Oct 1, 2013 to June 30, 2015 Surgical Site Infection Colon Abdominal Hysterectomy Clostridium difficile Infection SIR Methicillin-Resistant Staphylococcus aureus Bacteremia SIR Medicare Spending per Beneficiary Hospitals must have sufficient data in at least three of four domains to calculate a total performance score

39 Two Measures Proposed for Removal in FY 2018 page IMM-2 Influenza Immunization Topped out statistically Will continue in HIQR Program because it aligns with National Quality Strategy s Best Practice for Healthy Living Goal AMI-7a Fibrinolytic Therapy Received within 30 minutes of hospital arrival Rarely reported at most hospitals (Most AMI patients get PCI) Proposing to also remove this measure from HIQR Program

40 Proposing to Discontinue the Clinical Process Domain in FY 2018 and Beyond 0% Previously was 5% Clinical Care Process Domain Baseline Period: Jan-Dec 2014 Performance Period: Jan-Dec 2016 AMI 7a Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival IMM-2 PC-01 Influenza Immunization Elective Delivery Prior to 39 Completed Weeks Gestation 25% Previously was 20% CAUTI CLABSI PSI-90 SSI After removal of AMI-7a and IMM-2 only one measure will be left in Clinical Process Domain Proposing to Move PC-1 Elective Delivery to Patient Safety Domain Patient Safety Domain proposed to be reweighted from 20 to 25 percent Safety Domain Baseline Period: Jan-Dec 2014 (excluding PSI-90) Performance Period: Jan-Dec 2016 (excluding PSI-90) Catheter-Associated UTI Central Line-Associated BSI SIR (non reliability adjusted) Composite patient safety/complication Baseline Period Oct 1, 2010 to June 30, 2012 Performance Period Oct 1, 2013 to June 30, 2015 Surgical Site Infection Colon Abdominal Hysterectomy C. Difficile Clostridium difficile Infection SIR MRSA Methicillin-Resistant Staphylococcus aureus Bacteremia SIR

41 More Changing in Domain Weighting Safety, 20% Efficiency 25% FY 2017 FY 2018 Clinical Process Patient Experience of Care 25% Outcome 25% of Care 5% Efficiency 25% Safety 25% Clinical Care 25% Patient Experience of Care 25% - 41

42 New Standard Population Data for Hospital Acquired Infections Used to Calculate Points in VBP Patient Safety Domain NHSN Population Current CDC Standard Population Data New CDC Standard Population Data VBP Program VBP Program CAUTI CY 2009 CLABSI CY SSI - Colon Surgery - Abdominal Hysterectomy CY MRSA CY CDI CY CY 2015 CMS to Use Current CDC Standard Population Data to evaluate baseline and performance periods CMS to Use New CDC Standard Population Data to evaluate baseline and performance periods We will see this again in the HAC Reduction Program Proposed Rules!

43 Adding 3-item Care Transition Measure to HCAPHS Set (applies to FY 2018 Program) First reported on Hospital Care December 2014 Endorsed by CMS and NQF as a hospital level comparison metric but NOT recommended as an internal tool to compare performance across nursing units or providers During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. When I left the hospital, I clearly understood the purpose for taking each of my medications.

44 Value Based Purchasing Measures and Applicable Periods Proposed in FY 2016 IPPS Rule for FY 2018 VBP Program (pages ) 25% Clinical Care Domain Baseline Period: Oct 1, 2009 June 30, 2012 Performance Period: Oct 1, 2013 June 30, 2016 Mort-30- AMI Mort-30- HF Mort-30- PN 25% Patient Experience Domain Baseline Period: Jan-Dec 2014 Performance Period: Jan-Dec 2016 HCAHPS * CTM-3 AMI 30-day mortality rate Heart Failure 30-day mortality rate Pneumonia 30-day mortality rate Hospital Consumer Assessment of Healthcare providers & Systems Survey Care Transition Measures (3) 25% Efficiency Domain Baseline Period: Jan-Dec 2014 Performance Period: Jan-Dec 2016 MSPB-1 Medicare Spending per Beneficiary 25% Safety Domain Baseline Period: Jan-Dec 2014 (excluding PSI-90) Performance Period: Jan-Dec 2016 (excluding PSI-90) CAUTI CLABSI PSI-90 SSI CDI MRSA PC-01 Catheter-Associated UTI Central Line-Associated BSI SIR (non reliability adjusted) Composite patient safety/complication Baseline Period July 1, 2010 to June 30, 2012 Performance Period July 1, 2014 to June 30, 2016 Surgical Site Infection (ICU-only) Colon Abdominal Hysterectomy Clostridium difficile Infection SIR Methicillin-Resistant Staphylococcus aureus Bacteremia SIR Elective Delivery Prior to 39 Completed Weeks Gestation * New measure for FY 2018 added from previous rules

45 Minimum Required Scores for VBP Program Proposed for FY 2018 and Beyond Must report three of four domains Minimum of 25 cases in each mortality measure cohort (must have 2 of 3 cohorts) Minimum of 100 surveys in Patient Experience of Care Measures Minimum of 25 claims in Efficiency Medicare Spending Measure Safety Domain Minimum of three scores in domain Minimum 10 cases in PC-1 Elective Delivery Minimum of 1 predicted infection for NHSN measures Minimum of 3 cases in PSI-90 Composite Efficiency 25% Clinical Care 25% Safety 25% Patient Experience of Care 25%

46 Value Based Purchasing Measures and Applicable Periods Proposed in FY 2016 IPPS Rule for FY 2019 VBP Program (page 24504) 25% Clinical Care Domain Baseline Period: July 1, 2009 to June 30, 2012 Performance Period: July 1, 2014 to June 30, 2017 Mort-30- AMI Mort-30- HF Mort-30- PN *Mort-30- THA/TKA 25% Patient Experience Domain Baseline Period: Jan-Dec 2015 Performance Period: Jan-Dec 2017 HCAHPS CTM-3 AMI 30-day mortality rate Heart Failure 30-day mortality rate Pneumonia 30-day mortality rate Total Hip or Knee Arthroplasty mortality Baseline: July 1, 2010 to June 30, 2013 Performance: July 1, 2015 to June 30, 2017 Hospital Consumer Assessment of Healthcare providers & Systems Survey Care Transition Measures (3) 25% Efficiency Domain Baseline Period: Jan-Dec 2015 Performance Period: Jan-Dec 2017 MSPB-1 Medicare Spending per Beneficiary 25% Safety Domain Baseline Period: Jan-Dec 2015 (excluding PSI-90) Performance Period: Jan-Dec 2017 (excluding PSI-90) CAUTI CLABSI PSI-90 SSI CDI MRSA PC-01 Catheter-Associated UTI Central Line-Associated BSI SIR (non reliability adjusted) Composite patient safety/complication Baseline Period July 1, 2011 to June 30, 2013 Performance Period July 1, 2015 to June 30, 2017 Surgical Site Infection (ICU-only, signaling intent to propose inclusion of non-icu for FY 2019 ) Colon Abdominal Hysterectomy Clostridium difficile Infection SIR Methicillin-Resistant Staphylococcus aureus Bacteremia SIR Elective Delivery Prior to 39 Completed Weeks Gestation * New measure for FY 2018 added from previous rules

47 Value Based Purchasing Measures and Applicable Periods Proposed in FY 2016 IPPS Rule for FY 2020 VBP Program (page 24504) 25% Clinical Care Domain Baseline Period: July 1, 2010 to June 30, 2013 Performance Period: July 1, 2015 to June 30, 2018 Mort-30- AMI Mort-30- HF Mort-30- PN Mort-30- THA/TKA 25% Patient Experience Domain Baseline Period: Jan-Dec 2016 Performance Period: Jan-Dec 2018 HCAHPS CTM-3 AMI 30-day mortality rate Heart Failure 30-day mortality rate Pneumonia 30-day mortality rate Total Hip or Knee Arthroplasty mortality (assumes same timelines as others) Hospital Consumer Assessment of Healthcare providers & Systems Survey Care Transition Measures (3) 25% Efficiency Domain Baseline Period: Jan-Dec 2016 Performance Period: Jan-Dec 2018 MSPB-1 Medicare Spending per Beneficiary 25% Safety Domain Baseline Period: Jan-Dec 2016 (excluding PSI-90) Performance Period: Jan-Dec 2018 (excluding PSI-90) CAUTI CLABSI PSI-90 SSI CDI MRSA PC-01 Catheter-Associated UTI Central Line-Associated BSI SIR (non reliability adjusted) Composite patient safety/complication Baseline Period July 1, 2012 to June 30, 2014 Performance Period July 1, 2016 to June 30, 2018 Surgical Site Infection (ICU and Non-ICU) Colon Abdominal Hysterectomy Clostridium difficile Infection SIR Methicillin-Resistant Staphylococcus aureus Bacteremia SIR Elective Delivery Prior to 39 Completed Weeks Gestation

48 Value Based Purchasing Measures and Applicable Periods Proposed in FY 2016 IPPS Rule for FY 2021 VBP Program (page 24505) 25% Clinical Care Domain Baseline Period: July 1, 2011 to June 30, 2014 Performance Period: July 1, 2016 to June 30, 2019 Mort-30- AMI Mort-30- HF Mort-30- PN Mort-30- THA/TKA Mort-30- COPD 25% Patient Experience Domain Baseline Period: Jan-Dec 2017 Performance Period: Jan-Dec 2019 HCAHPS CTM-3 AMI 30-day mortality rate Heart Failure 30-day mortality rate Pneumonia 30-day mortality rate Total Hip or Knee Arthroplasty mortality Baseline: April 1, 2011 June 30, 2014 Performance: July 1, 2016-June 30, 2019 COPD 30-day mortality rate Baseline and Performance same as AMI, HF and PN Hospital Consumer Assessment of Healthcare providers & Systems Survey Care Transition Measures (3) 25% Safety Domain Baseline Period: Jan-Dec 2017 (excluding PSI-90) Performance Period: Jan-Dec 2019 (excluding PSI-90) CAUTI CLABSI PSI-90 SSI CDI MRSA PC-01 25% Efficiency Domain Baseline Period: Jan-Dec 2017 Performance Period: Jan-Dec 2019 MSPB-1 Catheter-Associated UTI Central Line-Associated BSI SIR (non reliability adjusted) Composite patient safety/complication Baseline Period July 1, 2013 to June 30, 2015 Performance Period July 1, 2017 to June 30, 2019 Surgical Site Infection (ICU and Non-ICU) Colon Abdominal Hysterectomy Clostridium difficile Infection SIR Methicillin-Resistant Staphylococcus aureus Bacteremia SIR Elective Delivery Prior to 39 Completed Weeks Gestation Medicare Spending per Beneficiary

49 Performance Standards for FY 2018 (2019) VBP Program (page and subject to change in the final FY 2016 IPPS Rule in August) Performance Measure Achievement Threshold Benchmark CAUTI CLABSI CDI MRSA AHRQ PSI-90 Composite ( FY 19) ( FY 19) SSI Colon Surgery SSI Abdominal Hysterectomy PC-1 Elective Delivery day Acute MI Mortality (Risk Standardized) ( FY 19) ( FY 19) 30-day Heart Failure Mortality (Risk Standardized) ( FY 19) ( FY 19) 30-day Pneumonia Mortality (Risk Standardized) ( FY 19) ( FY 19) 30-day Total Hip Knee Mortality NA ( FY 19) NA ( FY 19) Medicare Spending per Beneficiary Median MSPB ratio across all hospitals during performance period Mean of lowest decile for MSPB ratio across all hospitals during performance period

50 So How Does CMS Spin the Scores for the new 3-item Care Transition Measure in HCAPHS? - 50

51 New Scoring for 3-Care Transition Measures pages to from Final FY 2015 IPPS Rule Increasing from eight to nine dimensions For each of the nine dimensions, Achievement Points (0-10) and Improvement Points (0-9), the larger of the two would be summed to create a prenormalized HCAHPS Base Score (0-90 points) The pre-normalized base score would be multiplied by 8/9 ( ) and rounded up to create the normalized HCAHPS Base score Each of the nine dimensions would be of equal weight so that the normalized HCAHPS Base Score would range from 0 to 80 points HCAHPS Consistency Points would be calculated in the same way as before and would continue to range between 0 and 20 points and will now consider scores across all nine dimensions Final score of points will be the sum of the HCAHPS Base Score and Consistency Points 51

52 Performance Standards for FY 2018 VBP Program (page and subject to change in the final FY 2016 IPPS Rule in August) HCAHPS Measure Floor Achievement Threshold Benchmark Communication with Nurses Communication with Doctors Responsiveness of Hospital Staff Pain Management Communication about Medications Hospital Cleanliness & Quietness Discharge information item Care Transition Overall Hospital Rating Significant opportunities for improvement as a nation!

53 Midas+ Working on Solutions to Improve Hospital Care Transitions Palo Alto Research Center and Midas+ are developing a post-discharge Patient Engagement Information Service that combines realtime patient communication and data analytics to ensure optimal postdischarge patient care.

54 Using the PatientCare App Proactively monitors and instructs patients during their first month after discharge, when a majority of lapses and readmissions occur. Real-time, regular communication is personalized for each patient, promoting adherence to often misunderstood or unheeded discharge instructions. Changes in patient status are tracked and analyzed over time via a care management dashboard, allowing caregivers to stay up-to-date regarding issues such as post-discharge patient compliance, and tailor care recommendations in a timely fashion. Better communication between caregivers and patients helps to ensure nothing falls between the cracks. Midas+ Live Clients: Contact Vicky Mahn- DiNicola or Jim Kirkendall if you would like to be a Pilot Site for this Innovation!

55 Hospital Acquired Conditions Reduction Program Changes in Proposed FY 2016 Rule Starts on page Hospital Inpatient Quality Program Hospital Readmission Reduction Program Hospital Acquired Conditions Reduction Program Hospital Value Based Purchasing Program - 55

56 FY 2015 HAC Reduction Measures Domain 1: AHRQ PSI-90 35% of Total HAC Score Complications/Patient Safety for Selected Conditions Composite (PSI 90) Pressure ulcer rate (PSI 3) Iatrogenic pneumothorax (PSI 6) Central venous catheter-related blood stream infection rate (PSI 7) Postop hip fracture rate (PSI 8) Post op pulmonary embolism or DVT (PSI 12) Postop sepsis rate (PSI 13) Wound dehiscence rate (PSI 14) Accidental puncture and laceration rate (PSI 15) Domain 2: CDC HAIs 65% of Total HAC Score CLABSI SIR(initially only ICU) CAUTI SIR (initially only ICU) - 56

57 Final Scoring Methodology for Domains 1 and 2 for HAC Reduction Program in FY 2016 Domain 1: AHRQ PSI-90 25% of Total HAC Score (Was 35% in FY 2015) Domain 2: CDC HAIs 75% of Total HAC Score (Was 65% in FY 2015) CLABSI SIR(initially only ICU) CAUTI SIR (initially only ICU) SSI (Colon Procedures) SSI (Abdominal Hysterectomy) CMS averages the two SSI SIR scores and establishs a single pooled SSI score The final score for Domain 2 will be the average of the three scores: CLABSI, CAUTI and the pooled SSI score 57

58 HAC Reduction Program in FY 2017 Proposed in FY 2016 IPPS Rule Domain 1: AHRQ PSI-90 15% of Total HAC Score (Was 25% in FY 2016) More measures Chart abstracted data reliable Domain 2: CDC HAIs 85% of Total HAC Score (Was 75% in FY 2016) CLABSI SIR(initially only ICU) CAUTI SIR (initially only ICU) Surgical Site Infections SSI (Colon Procedures) SSI (Abdominal Hysterectomy) MRSA CDI Finalized in FY 2015 Rule 58

59 HAC Reduction Scoring Methodology Percentile Decile Points Min-20 th (zero) 1 1 Min-20 th (not zero) st -30 th st -40 th st -50 th st -60 th st -70 th st -80 th st -90 th st -Max

60 Each Measure Worth 1 to10 Points AHRQ PSI-90 Composite Performance scores for all hospitals will be rank ordered into percentiles. Rates of 0 are assigned one point. Non-zero rates < or = 20 th assigned two points Ten points are assigned to any value > 91 st percentile th Percentile Worst Value 1 st th 3 Points = Your Hospital s Performance Note: Numbers in this illustration are fictitious and do not represent actual distribution

61 Each Measure Worth 1 to10 Points CLABSI Standardized Infection Ratio Performance scores for all hospitals will be rank ordered into percentiles. Rates of 0 are assigned one point. Non-zero rates < or = 20 th assigned two points Ten points are assigned to any value > 91 st percentile th Percentile Worst Value 1 st th = Your Hospital s Performance 8 Points Note: Numbers in this illustration are fictitious and do not represent actual distribution

62 Each Measure Worth 1 to10 Points CAUTI Standardized Infection Ratio Performance scores for all hospitals will be rank ordered into percentiles. Rates of 0 are assigned one point. Non-zero rates < or = 20 th assigned two points Ten points are assigned to any value > 91 st percentile th Percentile Worst Value 1 st th 2 Points = Your Hospital s Performance Note: Numbers in this illustration are fictitious and do not represent actual distribution

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64 Distribution of Total HAC Scores Performance scores for all hospitals will be rank ordered into percentiles. Hospitals that perform less than the 75 th percentile will have NO Penalty Any score < 75 th percentile is in the NO PENALTY zone! 75th Percentile Worst Value 1 st th = Your Hospital s Performance Note: Numbers in this illustration are fictitious and do not represent actual distribution

65 Distribution of Total HAC Scores Performance scores for all hospitals will be rank ordered into percentiles. Hospitals that perform less than the 75 th percentile will have NO Penalty Hospitals that perform at the 75 th percentile or greater will have a 1% Reduction th Percentile $$$ Worst Value 1 st th = Your Hospital s Performance Any score > 75 th percentile is in the 1% Reduction zone! Note: Numbers in this illustration are fictitious and do not represent actual distribution

66 National Performance for CMS FY 2015 HAC Reduction Program 710/3,274 Hospitals Received 1% Penalty District of 71% Columbia Utah 50% Connecticut 45% Nevada 38% New Jersey 37% Rhode Island 36% Washington 35% New Mexico 34% Colorado 33% Delaware 33% Maine 32%

67 Special Circumstances New Clarification in FY 2016 Proposed Rule Hospitals without ICUs may request a waiver for Domain 2, in which case their Total HAC score will be based on AHRQ Domain 1 Hospitals may also have other waivers, in which case only Domain 1 scores will be used to calculate the Total HAC score. Beginning with HAC Program FY 2017 Hospitals without a waiver that fail to submit NHSN data will get 10 points for each infection condition not submitted No extraordinary circumstances exemptions provided for in the final rule

68 No Modifications to FY 2016 HAC Program

69 Possible Changes to PSI-90 Composite Measure Changes would require future rule making to include in HAC Program The PSI 90 Composite measure currently consists of PSI 3 Pressure ulcer rate PSI 6 Iatrogenic pneumothorax rate PSI 7 Central venous catheter-related blood stream infections rate PSI 8 Postoperative hip fracture rate PSI 12 Postoperative pulmonary embolism/deep vein thrombosis rate PSI 13 Postoperative sepsis rate PSI 14 Wound dehiscence rate PSI 15 Accidental puncture and laceration rate. PSI 9 Perioperative hemorrhage rate PSI 10 Perioperative physiologic metabolic derangement rate PSI 11 Post-operative respiratory failure rate Currently Under Review by NQF for inclusion

70 Possible Changes to Scoring Infections CAUTI and CLABSI have now completed the NQF maintenance review process, and modified versions of the measures were re-endorsed by NQF on November 10, New measures provide for an optional statistic in addition to the SIR called the Adjusted Ranking Metric (ARM) The ARM accounts for variation in patient risk by vascular access type AND variation in the number of patients a facility treats in a given month The statistic allows for better comparison across facilities CMS will use the SIR value in FY 2016 and consider the potential benefits of using the ARM in future programs

71 Proposed Changes to HAC Reduction Program FY 2018 Add non-icu CAUTI and CLABSI SIR (data collection to begin with Jan 1, 2015 discharges) Pediatric Adult medical Surgical Medical/Surgical Update to CDC NHSN Standard Population Data (using CY 2015 as national baseline similar to the Value Based Purchasing Program)

72 HAC Reduction Program in FY 2018 Proposed in FY 2016 IPPS Rule Domain 1: AHRQ PSI-90? of Total HAC Score (Was 15% in FY 2016) No discussion in proposed rule about scoring changes or domain weightings Domain 2: CDC HAIs? of Total HAC Score (Was 85% in FY 2016) CLABSI SIR(ICU) CAUTI SIR (ICU) CLABSI SIR (medical surgical) CAUTI SIR (medical surgical) Surgical Site Infections SSI (Colon Procedures) SSI (Abdominal Hysterectomy) MRSA CDI 72

73 Time Lines for HAC Reporting for FY Fiscal Year HAC Measures Applicable Discharges Points Domain 1 (25%): AHRQ PSI-90 Composite July 1, 2012 to June 30, Points Domain 2 (75%): CAUTI SIR (ICU only) CLABSI SIR (ICU Only) CDC NHSN SSI SIR (pooled measure for Total Abdominal Hysterectomy and colon surgical procedures) CY 2013 and CY (average) Domain 1: (15%) AHRQ PSI-90 Composite July 1, 2013 to June 30, Points Domain 2: (85%) CAUTI SIR (ICU Only) CLABSI SIR (ICU Only) SSI SIR (pooled Colon and Hysterectomy) CDC NHSN MRSA CDC NHSN SIR C-Difficle SIR CY 2014 and CY (average) Domain 1: (?) AHRQ PSI-90 Composite July 1, 2013 to June 30, Points Domain 2: (?) CAUTI SIR (ICU and Med Surg) CLABSI SIR (ICU and Med Surg) SSI SIR (pooled Colon and Hysterectomy) CDC NHSN MRSA CDC NHSN SIR C-Difficle SIR CY 2015 and CY 2016 (will use CY 2015 national Baseline for calculation of Predicted infection rate in SIRS score 1-10 (average)

74 Reporting Timelines for FY 2016 HAC Scores Hospital-specific reports available late summer 2015 via the QualityNet Secure Portal. Hospitals have a period of 30 days after the information is posted to submit corrections

75 Proposed Disaster Extraordinary Circumstances Waiver for HAC Reduction Program Proposed rule is for hospitals that experience a natural disaster or other event that prevents them from submitting their claims to CMS to submit a waiver request within 90 days of disaster. Hospital CCN Hospital Name Hospital Address CEO Name Reason for requesting exemption CMS Program Name Measures and submission quarters affected How the extraordinary circumstance negatively impacted performance Evidence of impact CEO Signature Submit a form for each program you are requesting exemption

76 Hospital Inpatient Quality Reporting Program pages Inpatient Quality Readmission Reduction Hospital Acquired Conditions Value Based Purchasing Inpatient Psychiatric Quality Resources - 76

77 Hospital Quality Inpatient Reporting Program At A Glance Chart Abstracted Measures NHSN Hospital Acquired Infections CY 2014 for 2016 Payment CY 2015 for 2017 Payment (11 with options for electronic reporting) CY 2016 for 2018 Payment 8 (6 with options for electronic reporting) Complications & Safety Mortality Cost Efficiency Readmission Excess Days Structure of Care HBIPS E-Measures for EHR Incentive 2 (select 16) 28 (select 16) 28 (select 16)

78 Chart Abstracted Measures Proposed for Removal of HIQR Program in FY 2018 Reason Retained as emeasure STK 01: Venous Thromboembolism Prophylaxis Topped out No (no CQM version) STK 06: Discharged on Statin Medication Topped out Yes (Aligns with EHR Incentive Program) STK 08: Stroke Education Topped out NQF endorsement removed Yes (Aligns with EHR Incentive Program) VTE 1: Venous Thromboembolism Prophylaxis Topped out Yes (Aligns with EHR Incentive Program) VTE 2: Intensive Care Unit VT Prophylaxis Topped out Yes (Aligns with EHR Incentive Program) VTE 3: VT Patients with Anticoagulation Overlap Therapy Topped out Yes (Aligns with EHR Incentive Program) IMM 1: Pneumococcal Immunization Not feasible to implement No AMI 7a: Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival SCIP Inf 4: Cardiac Surgery Patients with Controlled Postoperative Blood Glucose (suspended July 1, 2014) Low numbers Does not result in better outcomes Topped Out Potential negative consequences Note: IMM-2 Influenza Immunization has also topped out however it is being retained as it Is the only measure that addresses Best Practices to Enable Healthy Living in the National Quality Strategy Goals Yes No

79 Proposed Changes to Electronic Measure Submission for EHR Certification Must submit 16 of 28 measures (of your choice) for EHR Meaningful Use Program Must submit electronic measures for Q3 and Q Must submit using CEHRT 2014 Edition (version 2016 still in development with ONC) Six measures overlap with EHR Reporting Requirements for HIQR: ED-1, ED-2 STK-4 VTE-5, VTE-6 PC-01 Required for CY 2016 HIQR Data Collection for FY 2018 Payment Determination (either paper or electronic) If submitted electronically, these 6 measures count towards the 16 of the 28 required for EHR Certification If these six measures are reported using paper-based abstraction methods then you still have to submit 16 others electronically to submit the requirements for the EHR Incentive Program No data validation requirements (yet but in development) Public reporting on Hospital Compare for CY 2016 data still deferred for Payment Determination of 2018

80 28 Measures Available for Electronic Data Submission Must submit 16 of 28 for EHR Incentive Program 1. AMI-2 Aspirin Prescribed at Discharge 2. AMI-7a Fibrinolytic Therapy within 30 minutes of arrival 3. AMI-8a PCI within 90 minutes of arrival 4. AMI-10 Statin Prescribed at Discharge 5. CAC-3 Home Management Plan Given to Patient or Caregiver 6. EHDI-1a Hearing Screening Prior to DC 7. ED-1 Mean Time from Arrival to ED Departure for Admitted ED Patients 8. ED-2 Admit Decision Time to ED Departure for Admitted Patients 9. HTN- Health Term Newborn 10. PC-01 Elective Delivery 11. PC-5 and 5a Exclusive Breast Milk Feeding 12. PN-6 Initial Antibiotic Selection for CAP Immunocompetent Patients 13. SCIP-Inf-1a Prophylactic Antibiotics within one hour of incision 14. SCIP-Inf-2a Prophylactic Antibiotic Selection 15. SCIP-Inf-9 Urinary Catheter Removed Post-op Day STK-2 Discharged on Antithrombotic 17. STK-3 Anticoagulation for Atrial Fib/Flutter 18. STK-4 Thrombolytic Therapy 19. STK-05 Antithrombotic Therapy by End of hospital day STK-06 Discharged on Statin Meds 21. STK-8 Stroke Education 22. STK-10 Assessed for Rehabilitation 23. VTE-1 VTE Prophylaxis 24. VTE-2 ICU VT Prophylaxis 25. VTE-3 VT Patients with Anticoagulation Overlap Therapy 26. VTE-4 VT Patients Receiving Unfractionated Heparin with Dosages Platelet Count Monitoring 27. VTE-5 VT Discharge Instructions 28. VTE-6 Incidence of Potentially Preventable Venous Thromboembolism

81 Hospitals Electing to Submit Electronic Clinical Quality Measures in Lieu of Chart- Abstracted Measures in 2014 for BOTH HIQR and Meaningful Use Requirements In 2014 CMS had 84 hospitals submitting QRDA I files in either the CMS test or production system Of those, 14 have successfully fulfilled the ecqm reporting requirement for the 2014 EHR Incentive Program

82 8 New Measures Proposed for Hospital Inpatient Quality Reporting FY 2018 Structure of Care Measure 1. Hospital Survey on Patient Safety Culture Efficiency Measures (claims based) 1. Kidney/UTI Clinical Episode-Based Payment Measure 2. Cellulitis Clinical Episode-Based Payment Measure 3. Gastrointestinal Hemorrhage Clinical Episode-Based Payment Measure 4. Lumbar Spine Fusion/Re-Fusion Clinical Episode-Based Payment Measure 5. Hospital-Level, Risk-Standardized Payment Associated with an Episode-of-Care for Primary Elective THA/TKA 6. Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction 7. Excess Days in Acute Care after Hospitalization for Heart Failure

83 Acute MI Topic for Hospital Inpatient Quality Reporting Program Measures CY 2015 FY 2017 Payment Determination AMI-7a Fibrinolytic Therapy Within 30 Minutes of Arrival Required for HIQR Abstracted or electronic EHR Program option CY 2016 FY 2018 Payment Determination Proposed for removal with electronic reporting option EHR Program option CY 2015 ORYX Flexible Options Abstracted Electronic AMI-8a Timing of PCI Intervention Voluntary for HIQR Electronic EHR Program option EHR Program option AMI-2 Aspirin prescribed at discharge Voluntary for HIQR Electronic EHR Program option EHR Program option AMI-10 Statin prescribed at discharge Voluntary for HIQR Electronic EHR Program option EHR Program option

84 Pneumonia Topic for Hospital Inpatient Quality Reporting Program Measures CY 2015 FY 2017 Payment Determination PN-6 Initial Antibiotic Selection for Community- Acquired Pneumonia (CAP) in Immunocompetent Patients CY 2016 FY 2018 Payment Determination EHR Program option EHR Program option (with proposed expansion of pneumonia cohort?) CY 2015 ORYX Flexible Options Not available

85 HIQR Program Proposing Expansion of Pneumonia Cohort Initial Reporting on Hospital Compare 2016 Pneumonia 30-Day, All-Cause Risk Standardized Readmission Rate Previously included only patients with a principle diagnosis of viral or bacterial pneumonia Proposing to ADD patients with a principle diagnosis (meaning present on admission) of aspiration pneumonia Proposing to ADD patients with a principle diagnosis of sepsis or respiratory failure (meaning present on admission) with a secondary diagnosis of pneumonia Adds 670,491 patients (total cohort size 1,765,450 patients Adds 67 hospitals who now meet minimum 25 cases Pneumonia 30-Day, All-Cause, Risk-Standardized Mortality Rate Add 686,605 patients (total cohort size of 1,663,195) Add an additional 86 hospitals who now meet minimum 25 cases Dampen the effect of outliers (fewer better than or worse than expected)

86 SCIP Topic for Hospital Inpatient Quality Reporting Program Measures CY 2015 FY 2017 Payment Determination SCIP-Inf-1 Prophylactic Antibiotic Received Within One Hour Prior to Incision SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Patients SCIP-Inf-4 Cardiac Surgery Patients with Controlled Postoperative Blood Glucose SCIP-Inf-9 Urinary Catheter Removed on Postop Day 1 (POD 1) or Postop Day 2 (POD 2) with Day of Surgery Being Day Zero Voluntary for HIQR Electronic EHR Program option Voluntary for HIQR Electronic EHR Program option Decision made in January 2015 to suspend back to 7/1/2014 discharges Voluntary for HIQR Electronic EHR Program option CY 2016 FY 2018 Payment Determination EHR Program option EHR Program option Proposed for removal from HIQR Program EHR Program option CY 2015 ORYX Flexible Options Electronic (1a) Decision made in January 2015 to suspend back to 7/1/2014 discharges

87 Special Note About Submission of ORYX Measures and SCIP If hospitals selected SCIP as one of their six measure sets for CY 2015 they will not have to submit SCIP and will not have to select a new sixth topic. Five will be sufficient to meet ORYX requirements

88 Emergency Department Topic for Hospital Inpatient Quality Reporting Program Measures CY 2015 FY 2017 Payment Determination CY 2016 FY 2018 Payment Determination CY 2015 ORYX Flexible Options ED-1 Median Time from ED Arrival to ED Departure for patients Admitted ED Required for HIQR Abstracted or Electronic EHR Program option Required for HIQR Abstracted or electronic EHR Program option Electronic (1a) Abstracted (1a) ED-2 Admit Decision Time to ED Departure Time for Admitted Patients Required for HIQR Abstracted or electronic EHR Program option Required for HIQR Abstracted or electronic EHR Program option Electronic (2a) Abstracted (2a)

89 VTE Topic for Hospital Inpatient Quality Reporting Program Measures CY 2015 FY 2017 Payment Determination VTE-1 VTE Prophylaxis VTE-2 ICU VTE Prophylaxis VTE-3 VTE Patients with Anticoagulation Overlap Therapy VTE-4 VTE Patients Receiving Heparin Monitor by Protocol or Nomogram VTE-5 VTE Discharge Instructions VTE-6 Incidence of Potentially Preventable VTE Required for HIQR Abstracted or electronic EHR Program option Required for HIQR Abstracted or electronic EHR Program option Required for HIQR Abstracted or electronic EHR Program option CY 2016 FY 2018 Payment Determination Proposed for removal with electronic option EHR Program option Proposed for removal with electronic option EHR Program option Proposed for removal with electronic option EHR Program option CY 2015 ORYX Flexible Options Abstracted Electronic Abstracted Electronic Abstracted Electronic EHR Program option EHR Program option Electronic only Required for HIQR Abstracted electronic EHR Program option Required for HIQR Abstracted or electronic EHR Program option Required for HIQR Abstracted or electronic EHR Program option Required for HIQR Abstracted or electronic EHR Program option Abstracted Electronic Abstracted Electronic

90 Stroke Topic for Hospital Inpatient Quality Reporting Program Measures CY 2015 FY 2017 Payment Determination STK-1 VTE Prophylaxis STK-2 Discharged on Antithrombotic Therapy STK-3 Anticoagulation Tx for Atrial Fib/Flutter STK-4 Thrombolytic Therapy for Acute Ischemic Stroke STK-5 Antithrombotic Therapy End of Hospital Day Two STK-6 Discharged on Statin STK-8 Stroke Education STK-10 Assessed for Rehabilitation Required for HIQR Abstracted CY 2016 FY 2018 Payment Determination Proposed for removal without retention as electronic measure CY 2015 ORYX Flexible Options Abstraction only EHR Program option EHR Program option Abstraction Electronic EHR Program option EHR Program option Abstraction Electronic Required for HIQR Abstracted or electronic EHR Program option Required for HIQR Abstracted or electronic EHR Program option Abstraction Electronic EHR Program option EHR Program option Abstraction Electronic Required for HIQR Abstracted or electronic EHR Program option Required for HIQR Abstracted or electronic EHR Program option Proposed for removal with electronic option EHR Program option Proposed for removal with electronic option EHR Program option Abstraction Electronic Abstraction Electronic EHR Program option EHR Program option Abstraction Electronic

91 Immunization Topic for Hospital Inpatient Quality Reporting Program Measures CY 2015 FY 2017 Payment Determination IMM-1 Pneumococcal Immunization Remains suspended from the Hospital IQR program CY 2016 FY 2018 Payment Determination Proposed for Removal CY 2015 ORYX Flexible Options IMM-2 Influenza Immunization Required for HIQR Abstracted only Required for HIQR Abstracted only Abstraction only Note: IMM-2 Influenza Immunization has also topped out however it is being retained as it Is the only measure that addresses Best Practices to Enable Healthy Living in the National Quality Strategy Goals

92 Proposed Changes in HIQR Data Validation Plan Begins with validation for FY 2018 payment determination Proposal to remove immunization measure validation stratum Influenza Immunization measure to move to the Clinical process of care validation stratum No changes in the total number of charts (8) All 8 would be drawn from the Clinical Process of Care Stratum (previously 5 were from Clinical Process of Care and 3 from Immunization) Modify weights Healthcare-associated infection 66.7% Clinical Process of Care 33.3% No change to validation of HAI Measures Half the hospitals report on: SSI (2 records) MRSA (5 records) C.Difficle (5 records) - The Other half the hospitals report on: SSI (2 records) CLABSI (5 records) CAUTI (5 records)

93 Perinatal Care Topic for Hospital Inpatient Quality Reporting Program Measures CY 2015 FY 2017 Payment Determination PC-01 Elective Delivery Prior to 39 Completed Weeks of Gestation (Collected in aggregate, submitted via Web-based tool or electronic clinical quality measure) Required for HIQR Abstracted or electronic EHR Program option CY 2016 FY 2018 Payment Determination Required for HIQR Abstracted or electronic EHR Program option CY 2015 ORYX Flexible Options Electronic only PC-02 Cesarean Section Abstracted only PC-03 Antenatal Steroids Abstracted only PC-04 Health Care Associated Bloodstream Infection in Newborns PC-05 Exclusive Breast Milk Feeding Subset Measure PC 05a Exclusive Breast Milk Feeding Considering Mother s Choice Abstracted only EHR Program option EHR Program option Abstracted (5a) Electronic (5a) Note: TJC is retiring PC-05a but retaining PC-5 with revisions

94 Sepsis Topic for Hospital Inpatient Quality Reporting Program Measures CY 2015 FY 2017 Payment Determination Severe Sepsis and Septic Shock Bundle TO BE COMPLETED WITHIN 3 HOURS: 1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 ml/kg crystalloid for hypotension or lactate 4mmol/L TO BE COMPLETED WITHIN 6 HOURS: 5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) 65 mm Hg 6) In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was 4 mmol/l, re-assess volume status and tissue perfusion and document findings. 7. Re-measure lactate if initial lactate elevated. Required for HIQR Abstracted Only Begins with Discharges CY 2016 FY 2018 Payment Determination Required for HIQR Abstracted Only Sepsis Technical specs (ICD-10 only) available from CMS in June Delivered to CPMS and DataVision Clients in the August CY 2015 ORYX Flexible Options

95 Children s Asthma Care Topic for Hospital Inpatient Quality Reporting Program Measures CY 2015 FY 2017 Payment Determination CAC-3 Home Management Plan of Care Document Given to Patient/Caregiver CY 2016 FY 2018 Payment Determination CY 2015 ORYX Flexible Options EHR Program option EHR Program option Abstracted Electronic

96 Hearing Screening Care Topic for Hospital Inpatient Quality Reporting Program Measures CY 2015 FY 2017 Payment Determination EHDI-1a Hearing Screening Prior to Hospital Discharge CY 2016 FY 2018 Payment Determination EHR Program option EHR Program option CY 2015 ORYX Flexible Options

97 Healthy Term Newborn Care Topic for Hospital Inpatient Quality Reporting Program Measures CY 2015 FY 2017 Payment Determination CY 2016 FY 2018 Payment Determination Healthy Term Newborn EHR Program option EHR Program option CY 2015 ORYX Flexible Options

98 Substance and Tobacco Topic for Hospital Inpatient Quality Reporting Program Measures CY 2015 FY 2017 Payment Determination CY 2016 FY 2018 Payment Determination CY 2015 ORYX Flexible Options TOB-1 Tobacco Use Screening NA NA Abstracted TOB-2 Tobacco Use Treatment Provided or Offered TOBB-2a Tobacco use treatment NA NA Abstracted SUB-1 Alcohol Use Screening NA NA Abstracted SUB-2 Alcohol Use Brief Intervention Provided or Offered SUB-3 Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge NA NA Abstracted NA NA Abstracted

99 Hospital-based Inpatient Psychiatric Topic for Inpatient Psychiatric Facility Reporting Program Measures CY 2015 FY 2017 Payment Determination HBIPS-1 Admission screening for violence risk, substance use, psychological trauma history and patient strengths completed HBIPS-2 Hours of Physical Restraints Use HBIPS-3 Hours of Seclusion Use HBIPS-4 Patients Discharged on Multiple Antipsychotic Meds HBIPS-5 Patients Discharged on Multiple Antipsychotic Meds with Appropriate Justification HBIPS-6 Post Discharge Care Plan Created HBIPS-7 Post Discharge Continuing Care Plan Transmitted to Next Level of Care Upon Discharge Required for IPFQR only Abstracted Required for IPFQR only Abstracted Proposed to be removed for FY 2017 Payment Required for IPFQR only Abstracted Required for IPFQR only Abstracted Required for IPFQR only Abstracted CY 2016 FY 2018 Payment Determination Required for IPFQR only Abstracted Required for IPFQR only Abstracted Required for IPFQR only Abstracted Proposed for Removal for 2018 Payment Proposed for Removal for 2018 Payment CY 2015 ORYX Flexible Options Abstracted Abstracted Abstracted Abstracted Abstracted Abstracted Abstracted

100 Hospital-based Inpatient Psychiatric Topic for Inpatient Psychiatric Facility Reporting Program (continued) Measures CY 2015 FY 2017 Payment Determination FUH-Follow up after Hospitalization APEC Assessment of Patient Experience of Care IMM-2 Influenza Immunization HCP Influenza vaccination coverage among healthcare personnel TOB-1 Tobacco Use Screening TOB-2 Tobacco Use Treatment Provided or Offered TOBB-2a Tobacco use treatment TOB-3 Tobacco Use Treatment Provided or Offered at Discharge TOB-3a Tobacco Use Treatment at DC Use of an Electronic Health Record Required for IPFQR only Claims-based Required for IPFQR only (FY 2016 Payment Determination) Structural web-based Required for IPFQR Abstracted Required for IPFQR NHSN Required for IPFQR Abstracted Required for IPFQR Abstracted Required for IPFQR only (FY 2016 Payment Determination) CY 2016 FY 2018 Payment Determination Required for IPFQR only Claims-based Required for IPFQR only Structural web-based Required for IPFQR Abstracted Required for IPFQR NHSN Required for IPFQR Abstracted Required for IPFQR Abstracted Proposed for 2018 payment determination Abstracted Required for IPFQR only Structural web-based CY 2015 ORYX Flexible Options

101 Hospital-based Inpatient Psychiatric Topic for Inpatient Psychiatric Facility Reporting Program Measures CY 2015 FY 2017 Payment Determination SUB-2 Alcohol Use Brief Intervention Provided or Offered SUB-2a Alcohol Use Brief Intervention Timely Transmission of Transition Record (Discharges From an Inpatient Facility to Home/Self Care or Any Other Site of Care) (NQF #0648) CY 2016 FY 2018 Payment Determination Proposed for 2018 payment determination Abstracted Proposed for 2018 payment determination (replaces HBIPS-7) Abstracted Screening for Metabolic Disorders Proposed for 2018 payment determination Abstracted CY 2015 ORYX Flexible Options Transition Record With Specified Elements Received by Discharged Patients (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care) (NQF #0647) Proposed for 2018 payment determination (replaces HBIPS-6) Abstracted

102 Screening for Metabolic Disorders Denominator includes IPF patients discharged with one or more routinely scheduled antipsychotic medications Numerator is the total number of patients who received a metabolic screening either prior to, or during, the index IPF stay. The screening must contain four tests: (1) BMI (2) blood pressure (3) glucose or HbA1c (4) a lipid panel which includes total cholesterol, triglycerides, high density lipoprotein (HDL), and low density lipoprotein (LDL-C) The screening must have been completed at least once in the 12 months prior to the patient's date of discharge. Screenings can be conducted either at the reporting facility or another facility for which records are available to the reporting facility

103 Transition Record With Specified Elements Received by Discharged Patients (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care) (NQF #0647) Reason for inpatient admission Major procedures and tests performed during inpatient stay and summary of results Principal diagnosis at discharge Current medication list Studies pending at discharge Patient instructions Advance directive or surrogate decision maker documented or reason for not providing advance care plan 24-hour/7-day contact information, including physician for emergencies related to inpatient stay Contact information for obtaining results of studies pending at discharge; Plan for follow-up care Primary physician, other care professional, or site designated for FU care.

104 Question #2 With the exception of Sepsis, how likely is your organization going to continue paper based data abstraction of clinical process measures beyond January 2016? A. Very likely as we do not yet have e-measures in place for all the measures we need or want to track B. Very likely as our e-measure systems are not validated to the point where we trust this data C. Somewhat likely as we have additional reporting requirements to external bodies such as Blue Cross Blue Shield who do not yet have e-measure specifications in place yet D. Not likely at all go Hi Tech or go home! E. Unsure

105 NHSN Topic for Hospital Inpatient Quality Reporting Program Measures CLABSI -Central Line-Associated Bloodstream Infection CAUTI -Catheter-associated Urinary Tract Infection Surgical Site Infections - Colon - Abdominal Hysterectomy MRSA Facility-wide inpatient hospitalonset Methicillin-resistant Staphylococcus aureus CDI- Clostridum difficile Infection HCP- Influenza Vaccination Coverage Among Healthcare Personnel CY 2015 for FY 2017 Payment Determination Required NHSN Tool Required NHSN Tool Required NHSN Tool Required NHSN Tool Required NHSN Tool Required (October 1, 2014 March 31, 2015 flu season (FY2016 PD) due 5/15/2015) CY 2016 for FY 2018 Payment Determination Required NHSN Tool Required NHSN Tool Required NHSN Tool Required NHSN Tool Required NHSN Tool Required (October 1, 2015 March 31, 2016 flu season (FY2017 PD) due 5/15/2016)

106 Mortality Claims-based Measures for Hospital Inpatient Quality Reporting Program Measures MORT-30-AMI Hospital 30-Day, All-Cause, Risk- Standardized Mortality Rate Following Acute Myocardial MORT-30-HF Hospital 30-Day, All-Cause, Risk- Standardized Mortality Rate Following Heart Failure MORT-30-PN Hospital 30-Day, All-Cause, Risk- Standardized Mortality Rate Following Pneumonia MORT-30-COPD Hospital 30-Day, All-Cause, Risk- Standardized Mortality Rate (RSMR) Following COPD FY 2017 Payment Determination Claims Claims Claims Claims FY 2018 Payment Determination Claims Claims Claims Claims STK- Stroke 30-day Mortality Rate Claims Claims CABG- Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Coronary Artery Bypass Graft Surgery Claims Claims

107 Readmissions Claims-based Measures for Hospital Inpatient Quality Reporting Program Measures FY 2017 Payment Determination READM-30-AMI Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate Following Acute Myocardial Infarction READM-30-HF Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate Following Heart Failure READM-30-PN Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate Following Pneumonia READM-30-THA/TKA - Hospital-Level 30-Day, All-Cause Risk-Standardized Readmission Rate Following Elective Total Hip or Knee Arthroplasty Claims Claims Claims Claims FY 2018 Payment Determination Claims Claims Claims Claims READM-30-HWR Hospital-Wide All-Cause Unplanned Readmission Claims Claims COPD READMIT Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate Following COPD STK READMIT - 30-Day Risk Standardized Readmission Rate Following Stroke CABG READMIT- Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate Following CABG AMI Excess Days in Acute Care after hospitalization HF Excess Days in Acute Care after hospitalization Claims Claims Claims Claims Claims Claims Claims Claims

108 Case Managers.. Please Maintain Your Sense of Humor This Next Part..

109 Excess Days in Acute Care After Hospitalization for Acute MI Proposed for FY 2018 Payment Determination page th most common principal discharge diagnosis with Medicare in th most expensive condition billed to Medicare in percent of patients return to the ED within 30 days of discharge 12 percent are discharged from the ED and are not captured by Acute MI 30-day readmission measure Observation status admits are increasing and variable across US Hospitals This measure assesses all cause acute care utilization 30 days post discharge from Acute MI and includes Hospital readmissions Observation stays ED visits ED treat and release counted as one half day Observation stays calculated in hours and rounded up to nearest half days

110 Excess Days in Acute Care After Hospitalization for Acute MI Proposed for FY 2018 Payment Determination page Planned readmissions excluded Same clinical cohort as 30-day Unplanned Acute MI Readmissions except VA admissions are excluded Risk adjusted similar to readmission model CMS to request evaluation by NQF for possible adjustment by SDS variables Excess Acute Care Days (EACD) value is established for each provider Excess Acute Care Day (EACD) are calculated as the difference between the average of the predicted number of days spent in acute care for patients discharged from the average number of days that would have been expected if those patients had been cared for at an average hospital The difference is multiplied by 100 so that EACD represents EACD per 100 discharges.

111 Excess Days in Acute Care After Hospitalization for Heart Failure Proposed for FY 2018 Payment Determination page nd most common principal discharge diagnosis with Medicare in rd most expensive condition billed to Medicare in percent of patients return to the ED within 30 days of discharge 12 percent are discharged from the ED and are not captured by Heart Failure 30-day readmission measure Observation status admits have risen three fold for Heart Failure Same clinical cohort as 30-day Heart Failure Readmission except VA admissions excluded Uses same methodology as previously described for Acute MI EACD calculation

112 Complications Measures for Hospital Inpatient Quality Reporting Program Measures FY 2017 Payment Determination Hip/knee complications - Hospital-Level Risk-Standardized Complication Rate following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty PSI 4 (PSI/NSI) - Death among Surgical Inpatients with Serious, Treatable Complications Claims Claims FY 2018 Payment Determination Claims Claims PSI 90 - Patient Safety for Selected Indicators (Composite Measure) Claims Claims

113 Experience of Care Measures for Hospital Inpatient Quality Reporting Program Measures FY 2017 Payment Determination HCAHPS - HCAHPS + 3-Item Care Transition Measure (CTM 3) Required Survey FY 2018 Payment Determination Required Survey

114 Registry and Structure of Care Measures for Hospital Inpatient Quality Reporting Program Measures FY 2017 Payment Determination Participation in a Systematic Clinical Database Registry for Nursing Sensitive Care Systematic Clinical Database Registry for General Surgery Safe Surgery Checklist Patient Safety Culture Required QNET Required QNET Required QNET FY 2018 Payment Determination Required QNET Required QNET Required QNET Proposed QNET

115 Hospital Survey on Patient Safety Culture page Patient safety culture surveys can be used to: Raise staff awareness about patient safety Assess the current status of patient safety culture Identify strengths and areas for improvement Examine trends in patient safety culture over time Multiple Patient Safety Culture Survey s Pascal Metrics Safety Attitudes Questionnaire (SAQ) The Patient Safety Climate in Healthcare Organizations (PSCHO) The Manchester Patient Safety Framework AHRQ Hospital Survey on Patient Safety Culture (HSOPSC)

116 5 Questions in the AHRQ Hospital Survey on Patient Safety Culture (HSOPSC) 1. Does your facility administer a detailed assessment of patient safety culture using a standardized collection protocol and structured instrument? 2. What is the name of the survey that is administered? 3. How frequently is the survey administered? 4. Does your facility report survey results to a centralized location? a) National data repository; b) State-based data repository; health c) system repository; other; and do not d) report the data outside the facility 5. During the most recent assessment: a) How many staff members were requested to complete the survey? (b) How many completed surveys were received?

117 AHRQ Hospital Survey on Patient Safety Culture (HSOPSC) Collected each calendar year Web tool available on Quality Net No cost to complete Required for FY 2018 Initial time period for survey response January-December 2016

118 Question #3 Which type of patient safety survey does your organization use today? A. AHRQ Hospital Survey on Patient Safety Culture B. Other standardized survey other than AHRQ C. Safety survey developed by our organization D. We are not currently deploying a patient safety survey E. Not applicable to my organization or unsure

119 Claims-based Efficiency Measures for Hospital Inpatient Quality Reporting Program Measures FY 2017 Payment Determination FY 2018 Payment Determination MSPB- Payment-Standardized Medicare Spending Per Beneficiary Claims Claims AMI - Hospital-Level, Risk-Standardized Payment Associated with a 30- Day Episode-of-Care for AMI HF - Hospital-Level, Risk-Standardized Payment Associated with a 30- Day Episode-of-Care for HF PN - Hospital-Level, Risk-Standardized Payment Associated with a 30- day Episode-of-Care for Pneumonia THA/TKA Hospital-Level, Risk-Standardized Payment Associated with an Episode-of-Care for Elective Total Hip or Knee Arthroplasty Kidney/UTI Payment Kidney/UTI Clinical Episode-based payment measure Spine Fusion/Refusion Clinical Episode-based payment measure Cellulitis Clinical Episode-based payment measure GI Payment Gastrointestinal Hemorrhage Clinical Episode Payment measure Claims Claims Claims Claims Claims Claims Claims Claims Claims Claims Claims

120 4 Clinical Episode-Based Payment Measures page Evaluate the difference between observed and expected episode cost at the episode level before comparing at the provider level Kidney/UTI Cellulitis Gastrointestinal Hemorrhage Lumbar Spine Fusion/Re-Fusion Similar to Medicare Spending per Beneficiary Measure Medicare Part A and Part B services 3 days prior to a hospitalization through 30 days following discharge Risk adjusted using patient variables clinically related to the triggering diagnosis or procedure Pending NQF endorsement Exemptions from Measure Inclusion: Lack of continuous enrollment in Medicare Parts A and B from 90 days prior to index admission through the end of the episode with Medicare as the primary payer. Death date during episode window. Enrollment in Medicare Advantage during the episode window Claims with missing date of birth Death dates preceding the date of the trigger event Claims with payment 0. Acute inpatient stays that involved a transfer Claims from a non-ipps or nonsubsection (d) hospital

121 Methodology for Proposed Clinical Episode-Based Payment Measures Average of ratios for each episode observed cost Expected Costs National average observed Episode Cost Episode-weighted Median of all US Providers Episode Amount Measure Methodology available at: Hospital-Inpatient> Claims-Based Measures > Proposed episodic payment measures (located in call out box on top right)> Measure Methodology Note that measure methods paper suggest these will also be part of the Hospital Value Based Purchasing Program!

122 Hospital-Level, Risk-Standardized Payment Associated With a 90-Day Episode-of-Care for Elective Primary Total Hip and/or Total Knee Arthroplasty Similar to Medicare Spending per Medicare Beneficiary Measure Medicare Part A and B data Includes patient copayments as well as payments from coinsurance Captures payments for Medicare patients across multiple care settings, services, and supplies (inpatient, outpatient, skilled nursing facility, home health, hospice, physician, laboratory, ambulance services, durable medical equipment, prosthetics, orthotics, and supplies

123 Transition to ICD-10 Y93.D1 Activity, knitting and crocheting End-to-end testing in January 2015 competed 661 volunteers submitted 14,929 test claims CMS accepted 81% 13% rejected due to: Incorrect National Provider Number Dates of Service Outside of Service Invalid HCPCS codes Invalid Place of Service 3% of claims contained invalid ICD-10 codes leading to rejection Final round of testing to occur July 20-24, 2015

124 Question #4 Name the ICD-10 Diagnosis Code that will best help your organization manage risk and improve quality in the future! A. V97.33XD: Sucked into jet engine, subsequent encounter. B. W220.2XD: Walked into lamppost, subsequent encounter. C. Z63.1: Problems in relationship with in-laws D. R46.1: Bizarre personal appearance E. All of the above this is progress! How did we ever manage without these?

125 Midas+ Clients are All Winners!