In this episode, Maria Miranda, Director of Emerging Payment Models at BESLER discusses the importance of clinical documentation in the CJR program.
Mike Passanante: Hi, this is Mike Passanante. Welcome back to the Hospital Finance Podcast. Today, I’m joined by Maria Miranda who is the Director of Emerging Payment Models here at Besler. And Maria is going to talk with us today about the importance of clinical documentation in the CJR program.
Maria, welcome back to the program.
Maria Miranda: Thank you, Mike.
Mike: So first, why don’t we just start off, why is clinical documentation so important for CJR?
Maria: Well, clinical documentation can have several important impacts on the CJR program. First of all, it will determine what MSDRG will be assigned, and in part, whether or not the procedure will be part of the CJR program.
Because CJR uses MSDRG assignment as the indicator of whether an episode is included, accurate assignment is crucial.
So, I guess one of the things that you don’t want to do is you don’t want to incorrectly include episodes that do not belong in CJR. So revisions are not included in CJR; only replacements are included in CJR.
Joint revisions are more complex and much more costly than replacements. These procedures are assigned to MSDRG’s 466 through 468 which are not part of the CJR program. CJR only includes MSDRG’s 469 and 470.
In a revision, you have to code for both the removal of the defective or malfunctioning device, as well as the replacement procedure. So the existence of both of those procedures is what allows the MSDRG 466 to 468.
If, however, the coder doesn’t code for the removal, then the case will get misclassified as a 469 or 470, and then it’ll be included in the CJR program. And that’s just going to throw off all of the costs.
Another example where documentation is important, as we’ve discussed on prior podcasts, is whether or not the documentation for major complications and co-morbidities is there. The existence of that documentation is what’s going to allow that episode to be coded at the higher level, the 469, and that, as you know, carries a higher target rate.
There’s also documentation for coding of a fracture. As you know, even though for 469 and 470 are the only two DRG’s, the CJR program does further break that out and includes a higher target rate for fracture. So making sure that the documentation is there will also allow you to get a higher target rate.
Additionally, CMS uses the risk standardized complication rate as one of the measures to calculate your total composite quality score. And the resulting total composite quality score will dictate whether or not you qualify for payment and what level of discounts are going to be applied to your target rate. So making sure that your risk standardized complication rate is truly reflective of your performance is just as important.
Mike: Can you tell us more about the risk standardized complication rate? For instance, what is measured?
Maria: So, the following outcomes are considered complications in the risk standardized complication measure for THA and TJA—acute myocardial infarction (AMI), pneumonia, sepsis, septicemia shock all within seven days from admission, death, surgical site bleeding, pulmonary embolism (if it occurs within 30 days of admission) and mechanical complications of the joint, perioprosthetic joint infection, and wound infections (if they occur within 90 days of admission).
So, even though revisions or complete removal and complete replacement of the knee or hip joint is not included in the CJR program, as I explained in the previous answer, if the procedure is linked to the original replacement surgery, and it occurs within the 90-day window, it will count as complication as part of the risk standardized complication measure for that episode.
Therefore, clarifying whether the revision or complication is linked to any previous replacement surgery is going to be very important.
Mike: So, in layman’s terms, how does the risk standardized complication rate get calculated? And what else can affect the hospital score?
Maria: The measure uses Medicare claims data to identify complications occurring from the date of admission to 90 days post discharge. The risk standardize complication rate is calculated as a ratio of the number of predicted to the number of expected admissions with a complication multiplied by the national unadjusted complication rate.
The denominator of this calculation is the number of admissions with the complication expected on the basis of the nation’s performance with that hospital’s case mix.
The numerator of the ratio is a number of admissions with a complication predicted on the basis of the hospital performance with its observed case mix.
What’s important to note is that CMS uses certain condition categories with their hierarchical condition category methodology to risk adjust at the time of the indexed admission. This information comes from patient claims for the 12-month period prior to the index admission.
So, you see, the documentation comes into play well before the surgery occurs, well before that index at admission.
These prior complications that are captured allow for the limited risks standardization in this measure. Complications are counted in the measure only if they occur during the index admission or during a readmission.
So, making sure that all complications that occur prior to the admission are coded will help you get an accurate risk score and will ensure that only complications that actually occurred during or after the index admission will count towards that risk standardized complication rate.
Mike: And if a hospital already has CDI processes in place to ensure proper coding, is that enough for CJR?
Maria: Well, that’s a great question. And I guess the answer depends on what the focus of their CDI efforts is.
So, the methodologies used are impacted by all of the reported diagnoses, and therefore, requires a more careful review.
Normally, under most CDI efforts, the goal is really to optimize your MSDRG assignment. Most efforts in the past have only concentrated on capturing information that’s actually going to impact that MSDRG. So those efforts are not going to be sufficient.
Only documenting complications and major complications will not tell the whole story of what’s going on with the patient prior to the indexed admission. And that’s really going to be important.
So, you need to make sure that all of the diagnoses codes upon admission are also present, so that you know when the patient is coming in all of the complications. You get the full story, and it doesn’t count against you on the back end.
Mike: And of course, if you’d like to understand more about how you are performing under CJR, your hospital particularly, how you’re coding cases that fall under CJR, we can help you with that. You can reach out to Maria Miranda at mmiranda@Besler.com. She can tell you more about that.
Maria, thanks for coming by the show today and talking to us more about clinical documentation under CJR.
Maria: Great! Thank you, Mike.