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    1. Page 1

    2. Page 2 2009 IPPS Proposed Rule April 24, 2008

    3. Page 3 Table of Contents

    4. Page 4 Section 1

    5. Page 5 MS-DRG Significant cost difference between lead and generator procedures will split MS-DRG 245 (AICD lead and generator procedures) into 2 DRGs MS-DRG 245 (AICD generator procedures), to include procedure codes 37.96, 37.98, and 00.54 MS-DRG 265 (AICD lead procedures), to include procedure codes 37.95, 37.97, and 00.52

    6. Page 6 MS-DRG CMS proposal to include severe-sepsis in titles of the following DRGs: MS-DRG 870: Septicemia with mechanical ventilation, 96+ hours MS-DRG 871: Septicemia without mechanical ventilation, 96+ hours with MCC MS-DRG 872: Septicemia without mechanical ventilation, 96+ hours without MCC

    7. Page 7 MS-DRG CMS proposes to base 100% of the relative weights of Medicare Severity DRGs (MS-DRG version 26) on costs This marks the final step in a three-year transition to cost-based weights from charge-based weights. In fiscal year (FY) 2008, the relative weights consisted of a 50/50 blend of CMS-DRG and MS-DRG rates.

    8. Page 8 MS-DRG For Medicare Dependent Hospitals and Sole Community Hospitals, the coding adjustment was not applied in FY08. CMS may apply it in FY10. It believes that if it finds evidence of coding improvements not consistent with real resource use, the adjustment should be cumulative if it does apply this adjustment: a cumulative 1.5% reduction for FY08 and FY09 in addition to the FY10 adjustment.

    9. Page 9 MS-DRG CMS plans a retrospective review of FY08 and FY09 claims to evaluate the degree of case mix growth attributable to coding and documentation improvement. Based on this evaluation, the agency will propose potential adjustments to rate years 2010, 2011, and 2012 to recover these revenues. The proposed analysis will examine within DRG change versus shifts across DRGs. Data from 1999-2007 from the Medicare Clinical Data Abstraction Center would form a baseline for growth when incentives for coding improvement were not in place. CMS invites comments on this planned analysis.

    10. Page 10 MS-DRG CMS is proposing changes to the cost report to increase the accuracy of both inpatient and outpatient weights. The changes at this time are for the category Medical Supplies and Equipment. The compression of this CCR results from the inclusion of devices with significantly different markups than other medical supplies. To address this issue, CMS will add another cost center for more expensive devices such as pacemakers and other implantable devices. The proposal is do develop a cost center with medical devices, DME sold and DME rented. CMS is also seeking comments on other cost centers for future consideration. CMS is also proposing changes in revenue codes reported in the MedPAR data to allow better matching of revenues and CCRs to compute estimated costs.

    11. Page 11 Section 3

    12. Page 12 QI Measures from the FY08 final rule planned to be added for FY09 PN 30-day mortality (NQF endorsed) SCIP-Infection-4 Cardiac Surgery Patients with Controlled Postoperative Serum Glucose (NQF endorsed) (data required starting Jan 1, 2008) SCIP-Infection-6 Surgery Patients with Appropriate Hair Removal (NQF endorsed) (data required starting Jan 1, 2008) SCIP-Infection-7 Colorectal Patients with Immediate Postoperative Normothermia (will not be part of the FY09 measure set) SCIP-Cardio-1 Surgery Patients on a Beta Blocker Prior to Arrival Who Received a Beta Blocker During the Perioperative Period (will not be part of the FY09 measure set)

    13. Page 13 QI Proposals for FY10 (data changes to begin with January 1, 2009 discharges) Removal of Pneumonia Oxygenation from measure set (topped out) Under AMI measures, PCI time changed to within 90 minutes of arrival Under PN measures, antibiotics changed to within 6 hours of arrival

    14. Page 14 QI CMS proposes to add 43 new quality measures to the existing 30 for FY 2010, bringing the total number of measures to 73. Reporting all of these measures qualifies hospitals to receive a full update to their FY 2010 payment rates. The new measures include the following: Surgical Care Improvement Project (one new measure) Hospital readmissions (three new measures) Nursing care (four new measures) Patient safety indicators developed by the Agency for Healthcare Research and Quality (AHRQ) (five new measures) Inpatient quality indicators developed by AHRQ (four new measures) Venous thromboembolism (six new measures) Stroke measures (five new measures) Cardiac surgery measures (15 new measures)

    15. Page 15 FY 2010 - QI Proposals for new FY10 measures (data changes to begin with January 1, 2009 discharges, unless otherwise listed) *SCIP-CV-2 Surgery Patients on a Beta Blocker Prior to Arrival Who Received a Beta Blocker in the Perioperative Period *Nursing Failure to Rescue (April 1, 2009) *Nursing Pressure Ulcer Prevalence and Incidence by Severity (Joint Commission measure) (April 1, 2009) *Nursing Patient Falls Prevalence (April 1, 2009) *Nursing Patient Falls with Injury (April 1, 2009)

    16. Page 16 FY 2010 QI - continued Readmission PN 30-day Risk Standardized Readmission Medicare patients using claims data Readmission AMI 30-day Risk Standardized Readmission Medicare patients using claims data Readmission HF 30-day Risk Standardized Readmission Medicare patients using claims data Incentives to Decrease Readmissions Direct adjustment to hospital DRG payments for avoidable readmissions Adjustments to hospital DRG payments through a performance-based payment methodology Public reporting of readmission rates

    17. Page 17 FY 2010 QI - continued VTE-1 VTE Prophylaxis VTE-2 VTE Prophylaxis in the ICU VTE-4 Patients with overlap in anticoagulation therapy VTE-5/6 Patients with UFH dosages who have platelet count monitoring and adjustment of medication per protocol or nomogram VTE-7 Discharge instructions to address: follow-up monitoring, compliance, dietary restrictions and adverse drug reactions/interactions VTE-8 Incidence of preventable VTE

    18. Page 18 FY 2010 QI - continued Stroke-1 DVT Prophylaxis (July 1, 2009) Stroke-2 Discharged on Antithrombotic Therapy (July 1, 2009) Stroke-3 Patients with Atrial Fibrillation Receiving Anticoagulation Therapy (July 1, 2009) Stroke-5 Antithrombotic Medication by end of Hospital Day Two (July 1, 2009) Stroke-7 Dysphagia Screening (July 1, 2009)

    19. Page 19 FY 2010 QI - continued *AHRQ-PSI 4 Death among surgical patients with treatable serious complications (October 1, 2009) *AHRQ-PSI 6 Iatrogenic pneumothorax, adult (October 1, 2009) *AHRQ-PSI 14 Postoperative wound dehiscence (October 1, 2009) *AHRQ-PSI 15 Accidental puncture or laceration (October 1, 2009) *AHRQ-IQI 4 and 11 Abdominal aortic aneurysm (AAA) mortality rate (with or without volume) (October 1, 2009) *AHRQ-IQI 19 Hip fracture mortality rate (October 1, 2009) *AHRQ-IQI Mortality for selected medical conditions (composite) (October 1, 2009) *AHRQ-IQI Mortality for selected surgical procedures (composite) (October 1, 2009) *AHRQ-IQI Complication/patient safety for selected indicators (composite) (October 1, 2009)

    20. Page 20 FY 2010 QI - continued Cardiac Surgery Participation in a Systematic Database for Cardiac Surgery Cardiac Surgery Pre-operative Beta Blockade Cardiac Surgery Prolonged Intubation Cardiac Surgery Deep Sternal Wound Infection Rate Cardiac Surgery Stroke/CVA Cardiac Surgery Post-operative Renal Insufficiency Cardiac Surgery Surgical Re-exploration Cardiac Surgery Anti-platelet Medication at Discharge Cardiac Surgery Beta Blockade Therapy at Discharge Cardiac Surgery Anti-Lipid Treatment at Discharge Cardiac Surgery Risk-adjusted Operative Mortality for CABG Cardiac Surgery - Risk-adjusted Operative Mortality for Mitral Valve Replacement/ Repair Cardiac Surgery - Risk-adjusted Operative Mortality for Aortic Valve Replacement Cardiac Surgery - Risk-adjusted Mortality for Mitral Valve Replacement and CABG Surgery Cardiac Surgery - Risk-adjusted Mortality for Aortic Valve Replacement and CABG Surgery

    21. Page 21 Section 4

    22. Page 22 POA Criteria Criteria for Selection of POA Conditions Cost or Volume CC or MCC Evidence-Based Guidelines Reasonably Preventable

    23. Page 23 POA - Hospital Acquired Conditions (HAC) Centers for Disease Control and Prevention data estimating that HAC infections added nearly $5 billion to hospital costs Survey by the Leapfrog Group found that out of 1,200 hospitals, 87% did not follow recommendations to prevent many of the most common HACs CMS proposal to expand 8 HAC conditions to 17 HAC conditions

    24. Page 24 POA Conditions under consideration to be added for FY09 Surgical site infections following certain elective procedures Total Knee Replacement Laparoscopic Gastric Bypass and Gastroenterostomy Ligation and Stripping of Varicose Veins Legionnaires disease Extreme blood sugar derangement/ glycemic control Diabetic Ketoacidosis Nonketotic Hyperosmolar Coma Diabetic Coma Hypoglycemic Coma Iatrogenic pneumothorax Delirium Ventilator-associated pneumonia Deep-vein thrombosis/pulmonary embolism Staphylococcus aureusassociated disease Clostridium difficileassociated disease

    25. Page 25 POA Changes to existing POA conditions Foreign Object Retained After Surgery Currently only counts code 998.4 Proposed to also include code 998.7 acute reaction to foreign substance accidentally left during a procedure Pressure ulcers Major changes to the ICD-9 codes - New codes include staging of the ulcer. Proposal: Stage III and IV are MCCs Non-staged and Stage I and II are non-CCs

    26. Page 26 POA U conditions U / unknown - Documentation is insufficient to determine if condition is POA CMS has proposed that it will treat the U the same as the N (not POA), but with several exceptions: Death AMA / elopement Transfers out of a hospital may preclude making an informed determination of whether a HAC was present on admission

    27. Page 27 Section 5

    28. Page 28 Section 6

    29. Page 29 Thank you! Bonnie Peters, BS, CCS-P, CPC, CPC-H Bonnie.peters@navigantconsulting.com 505-918-7551

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