Complying with the Centers for Medicare and Medicaid Services (CMS)/Joint Commission mandate to monitor and report core measures is a complex, time-consuming process carrying significant implications for hospitals failing at the task. As the stakes get higher, so too does the level of difficulty involved in maintaining compliant reporting processes. The number of required measures has continued to climb, increasing the level of difficulty involved with abstracting and validating the data. Exacerbating the challenge is a limited supply of internal resources and expertise that can be dedicated to reporting to ensure processes and data definitions are current and protocols are in place to guide appropriate documentation and abstraction. By Brenda Bartkowski
By Brenda Bartkowski
Complying with the Centers for Medicare and Medicaid Services (CMS)/Joint Commission mandate to monitor and report core measures is a complex, time-consuming process carrying significant implications for hospitals failing at the task.
With core measures used as the basis to evaluate clinical processes and care quality for reimbursement under Medicare’s pay-for-performance initiative—and with more payers using core measures during contract negotiations—hospitals need to develop a healthy respect for the financial impact of non-compliance. At minimum, financial penalties translate into a 1.25 percent reduction in reimbursements in fiscal year 2014, increasing annually by .25 percent until it caps out at 2 percent in FY 2017. Further, with CMS publishing core measures data on its public website, non-compliance could also affect a hospital’s reputation among its patient population.
As the stakes get higher, so too does the level of difficulty involved in maintaining compliant reporting processes. The number of required measures has continued to climb, increasing the level of difficulty involved with abstracting and validating the data. Exacerbating the challenge is a limited supply of internal resources and expertise that can be dedicated to reporting to ensure processes and data definitions are current and protocols are in place to guide appropriate documentation and abstraction.
Balancing reporting requirements with the plethora of additional core duties for which Quality Departments are now responsible is a resource balancing act. It is rarely feasible to have abstractors dedicated exclusively—or even primarily—to reporting. As the number of metrics that must be reported under the Hospital Inpatient Quality Reporting (IQR) Program increases with no corresponding change to submission deadlines, though, it has become nearly impossible for hospitals to stay on top of core measures reporting requirements without a dedicated team.
Consider the 2005 “starter set” for the IQR program included just 10 chart-abstracted measures. By 2010, that had expanded to 44 different measures, including 26 chart-abstracted, one survey, 16 claims-based and one structural measure. In 2013, the total had increased to 57. By 2016, hospitals will be required to report on 60 different measures, including 42 chart-abstracted, one survey, 12 claims-based and five structural.
The complexity of reporting is also escalating. Regulatory policies and recommendations from CMS and The Joint Commission tend to change from one reporting period to the next, while protocols and guidelines are revised and expanded annually.
For example, when CMS revised the OP 19 ED Transition Record, it became too complex for many hospitals to manage. Compliant documentation required inclusion of:
Major procedures and tests performed during the ED visit and
Principal diagnosis at discharge or chief complaint and
Patient instructions and
The plan for follow-up care (or a statement that none was required) including designation of the primary physician, other health care professional or site to provide follow-up care and
A list of new medications and changes to continued medications the patient should take post-discharge, with the quantity prescribed and/or dispensed (or intended duration) and instructions for each.
Hospitals had little time to create such a detailed and cumbersome document within their EMR systems. As a result, nearly all failed to comply. CMS did eventually “suspend” the measure until further notice, but not until the damage was done for the majority of facilities.
It is easy to understand how staying compliant within a shifting core measures reporting environment can trip up any hospital. Seeking an extension for just one deadline can create a domino effect nearly impossible to halt. Abstractors who are already struggling to keep up with current reports have little hope of clearing out backlogs once they begin to accumulate.
Avoiding the fallout
To avoid accumulating both the financial penalties and productivity-sapping backlogs, hospitals can no longer view core measures reporting as an occasional responsibility. Proper resources must be dedicated to keeping processes current against the rising tide of regulatory and guideline changes taking place throughout the year.
Consider the fall-out if CMS makes just one change in its Surgical Care Improvement Project (SCIP) documentation requirements between quarterly reporting periods. If the change is missed, the documentation won’t be created and the hospital will fail on that measure—which can directly and negatively impact the bottom line.
Thus, one individual should be tasked with continuously monitoring and communicating any changes to guidelines, metrics or requirements so they can immediately be integrated into the reporting process.
Abstractors must also be properly trained and credentialed to ensure they are up to the task of managing a process with such broad effect on a hospital’s financial and competitive standing. For the validation process, this entails ensuring they are able to achieve appropriate levels of accuracy—a minimum of 75 percent. Adding to this challenge, the growing demand for abstractors with the skills and experience to meet performance standards has created a shortage, but the potential price for failing to do so is simply too high to lower standards.
When evaluating prospective abstractors to manage the core measures reporting process, hospitals look for individuals with health information management (HIM) credentials, such as Registered Health Information Technician (RHIT), Registered Healthcare Documentation Specialist (RHDS), Certified Healthcare Documentation Specialist (CHDS), Certified Medical Abstractor (CMA), Certified Coding Associate (CCA) and Certified Coding Specialist (CCS). This ensures they have the proper background in medical terminology and a comprehensive understanding of the patient medical record.
Clinical credentials are also important, such as Registered Nurse (RN) and Licensed Practical Nurse (LPN). This ensures they have a strong understanding of how the human body works and are prepared for the stronger base of clinical knowledge required for more advanced core measures and as codes transition from ICD-9 to ICD-10.
Testing proficiency is also an important step to ensure skills are where they need to be. The test should comprise both inpatient and outpatient questions from the current core measures set and its corresponding specifications manual. The best abstractors will pass with a score of at least 95 percent, which demonstrates a sufficient understanding of core measures and their impact on the hospital’s performance score.
Finally, it is imperative hospitals continuously evaluate their core measures reporting process. This will reveal any gaps in the process itself. More importantly, it will identify areas of weakness on the front end, for example with clinical documentation, which should be addressed through education or documentation improvement initiatives. This will result not only in compliant reports, but very likely improved core measures performance.
Seek out a partner
A growing number of hospitals are realizing the value of outsourcing core measures reporting to a qualified HIM vendor. As with any relationship, the success or failure of outsourcing core measure reporting rests on the quality of the partner selected.
Look for a partner employing only credentialed abstractors with a minimum of 3-5 years of experience, all of whom should have passed a stringent proficiency test. The firm should be able to deliver an accuracy rate of no less than 95 percent. Finally, the partner should provide services designed to strengthen the hospital’s core measures performance, including weekly and quarterly education sessions, regular evaluations and recommendations for improvement.
Focus on compliance
Whether it is accomplished by enlisting the services of a qualified HIM partner or shoring up its internal resources with appropriately qualified abstractors, what is critical is hospitals realize their core measures reporting processes can no longer be treated as just another item on the responsibility list.
Accurate, streamlined processes will ensure reporting is compliant in terms of content and deadlines, which will ultimately benefit the facility financially and boost its reputations for excellence among its patient population.
About the author
Brenda Bartkowski is the clinical data abstraction manager for Amphion Medical Solutions. She can be reached at Brenda.Bartkowski@amphionmedical.com.