Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Policy & Regulation News

AHA Seeks Changes to Post-Acute Care Medicare Reimbursement

AHA penned two letters to CMS in response to proposed post-acute care Medicare reimbursement models, urging the agency to reconsider issues with coding and quality measures.

By Jacqueline LaPointe

- The American Hospital Association (AHA) has called on the Centers of Medicare and Medicaid Services (CMS) to revise proposed Medicare reimbursement reforms for two post-acute care models. In separate letters, the AHA outlined several issues with potential prospective payment systems for inpatient rehabilitation and skilled nursing facilities, including ICD-10 coding challenges and inappropriate quality measures.

AHA urged CMS to revise proposed rules regarding post-acute care Medicare reimbursement models

According to the AHA letter on proposed changes to the inpatient rehabilitation facilities (IRF) prospective payment system, CMS should address missing ICD-10 codes and inaccurate quality measures.

Under the proposed rule, CMS would require 60 percent of an IRF’s patient cases in a 12-month period to have at least one of 13 qualifying conditions or comorbidities. However, the AHA reported that updated ICD-10-CM codes for certain qualifying conditions are no longer compliant under the 60 percent rule.

“Specifically, we are seeking the inclusion of selected ICD-10-CM codes, which, under ICD-9- CM, qualified toward presumptive compliance,” explained the letter.

The AHA identified four conditions that did not have complaint ICD-10-CM codes, including hip fractures, multiple fractures, traumatic brain injuries, and traumatic injuries. Due to an increase in specificity with ICD-10 codes, many qualifying conditions now have different codes than the approved ICD-9 codes.

READ MORE: AHA Decries Proposed Expansion of Outpatient Site-Neutral Payments

Additionally, CMS has proposed four new quality measures for the 2018 reporting year. These measures are designed to align with the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, which aims to standardize and align quality measures across CMS post-acute care quality reporting programs.

While the AHA commends CMS for fostering coordination across different quality programs, the industry group has asked CMS to assess the measures for validity and reliability.

In particular, the AHA expressed concern regarding the “discharge to community” measure, which evaluates the percentage of Medicare fee-for-service beneficiaries discharged from IRFs to home or home health services with no unexpected hospital readmissions or deaths within 31 days. The quality measure may not accurately portray provider performance because research has shown that patient status discharge codes are unreliable.

Another quality measure that assesses potentially preventable readmissions within 30 days of IRF discharge may cause confusion with the quality reporting program’s existing measure on avoidable readmissions, the letter explained.

“The AHA is concerned by the overlap of the proposed post-discharge PPR [potentially preventable readmissions] measure with the existing IRF QRP [Quality Reporting Program] all-cause readmission measure,” wrote the AHA. “We believe using two distinct readmission measures – with results that are likely to differ – will make it confusing for IRFs to track and improve their performance. We urge the agency to implement a single readmission measure in the IRF QRP.”

READ MORE: AHA Urges Congress to Pass Healthcare Payment Reform Bills

In a letter to CMS regarding proposed changes to the SNF prospective payment system, the AHA suggested that CMS implement the Medicare Payment Advisory Commission’s recommendations. The changes included reimbursing SNFs based on patient clinical characteristics rather than therapy utilization, develop a per-stay and high-cost outlier policy, and create a separate payment for non-therapy ancillary services.

These suggestions would support increases in treating medically complex patients rather than higher-margin rehabilitation patients, especially in hospital-based SNFs that care for a different population than freestanding facilities.

Like the proposed IRF system changes, CMS is also adding three new quality measures to the 2018 SNF quality reporting program, including Medicare spending per beneficiary, discharge to community, and potentially preventable admissions.

The AHA has called on CMS to modify these quality measures, such as including patient functional status as part of the “Medicare spending per beneficiary” measure, reassessing the accuracy of patient discharge status codes, and developing a list of potentially preventable readmissions that is certified and tested by clinical experts.

Included in both letters to CMS, the AHA pinpointed several issues with measuring care quality that would affect the general post-acute care community and their respective Medicare prospective payment systems.

READ MORE: AHA Calls For 25% Rule End for Fair LTCH Medicare Reimbursement

The AHA has urged CMS to include socioeconomic factors in evaluations of quality measures, making appropriate adjustments when necessary. According to research from the National Academy of Medicine earlier this year, social risk factors are linked to patient outcomes of Medicare beneficiaries, especially affecting readmissions and patient experience.

“Indeed, measures that fail to adjust for sociodemographic factors when there is a conceptual and empirical relationship between those factors and the measure outcome lack credibility, unfairly portray the performance of providers caring for more complex and challenging patient populations, and may serve to exacerbate healthcare disparities,” the letter explained.

In addition to socioeconomic determinants, the AHA has called on CMS to perform “dry runs” of the quality reporting programs for both IRFs and SNFs and make the programs more transparent.

“CMS has used dry runs in the past – including in its post-acute care quality reporting programs – for new measures so that providers can become familiar with the methodology, understand the measure results, know how well they are performing, and have an opportunity to give CMS feedback on potential technical issues with the measures,” wrote the AHA.

In light of new quality measures, CMS should also publish more information about measure testing before implementation, stated the letter. The agency may consider field testing new measures with providers.

“Given that the measures will be publicly reported, it is imperative that they provide an accurate portrayal of provider performance,” the letter state. “For this reason, CMS must ensure that each measure is fully tested, and that the results of that testing are fully transparent so that all stakeholders have an opportunity to suggest meaningful improvements to the measure.”

While CMS has asked the healthcare community to comment on its proposed rules for IRF and SNF prospective payment systems, the new Medicare programs are scheduled to launch in 2017.

Dig Deeper:

CMS Payment Reforms Mean Big Bucks for Medicare, Medicaid

How to Reduce Wasteful Spending in the Medicare Program


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