Data Collection Support Webinar MetaStar, Inc. August 15, 2007 Pam Clemens Candi Davis

Data Collection Support Data Collection Support WebinarWebinar

MetaStar, Inc.August 15, 2007

Pam ClemensCandi Davis

AnnouncementsAnnouncements

Carol Ferguson ResignationCarol Ferguson Resignation

RHQDAPU Form Due August 15thRHQDAPU Form Due August 15th

Program Management ApplicationsProgram Management Applications

AnnouncementsAnnouncements

Program Management ApplicationProgram Management ApplicationICD Population & SamplingICD Population & Sampling

Measures DesignationMeasures Designation

AnnouncementsAnnouncements Program Management Program Management

ICD Population & SamplingICD Population & SamplingAllows providers or their contracted vendor to Allows providers or their contracted vendor to enter their sampling frequency, total population enter their sampling frequency, total population counts, and sample sizes for each quartercounts, and sample sizes for each quarter

AnnouncementsAnnouncements Program Management Program Management

Measures DesignationMeasures DesignationAllows providers or their contracted vendor to Allows providers or their contracted vendor to designate the measures they will be submitting designate the measures they will be submitting to the QIO Clinical Warehouseto the QIO Clinical Warehouse

Clarifications/UpdatesClarifications/UpdatesQuarter 4 – 2006 ValidationQuarter 4 – 2006 Validation

Week 5Week 5

28 Hospitals Reported28 Hospitals Reported10 PPS10 PPS

18 CAH18 CAH

5 Failures (all CAH)5 Failures (all CAH)# 1 mismatch: PN – Chest X-ray Element# 1 mismatch: PN – Chest X-ray Element

Clarifications/UpdatesClarifications/Updates Validation Rate Graphs Validation Rate Graphs

Validation Rate Graphs Validation Rate Graphs Updated through 3Q06Updated through 3Q06

Will be mailed to public reporting contactWill be mailed to public reporting contact

Review cover letter for next stepsReview cover letter for next steps

Clarifications/UpdatesClarifications/UpdatesMedQIC UpdatesMedQIC Updates

AMI/HF Contraindication Pocket CardAMI/HF Contraindication Pocket Card

Heart Care Discharge Instructions Fact Heart Care Discharge Instructions Fact Sheet Sheet

Heart Care Reperfusion Performance Heart Care Reperfusion Performance Measures for AMI Fact SheetMeasures for AMI Fact Sheet

Clarifications/UpdatesClarifications/UpdatesMedQIC UpdatesMedQIC Updates

FACT SHEETS for Diagnostic Uncertainty, FACT SHEETS for Diagnostic Uncertainty, Identified Pneumonia Pathogen, and Chest Identified Pneumonia Pathogen, and Chest X-ray for Discharges 4/1/07+X-ray for Discharges 4/1/07+

Core Measures Quick Reference Guide – Core Measures Quick Reference Guide – April 1, 2007April 1, 2007

Much more …Much more …

Clarifications/UpdatesClarifications/UpdatesQuest Answers RevisedQuest Answers Revised

CMS has released a list of QUEST answers that CMS has released a list of QUEST answers that have been revised for May and June 2007have been revised for May and June 2007

If it is your practice to utilize printed copies of If it is your practice to utilize printed copies of QUEST FAQs, make sure abstractors are aware of QUEST FAQs, make sure abstractors are aware of these revised answersthese revised answers

The most frequently asked about data element for The most frequently asked about data element for both May and June was PN: Chest X-rayboth May and June was PN: Chest X-ray

Clarifications/UpdatesClarifications/UpdatesSpecification Manual v 2.3 Specification Manual v 2.3

Released in JuneReleased in June

For discharges October 1, 2007+For discharges October 1, 2007+

See Summary of AMI & HF Measure See Summary of AMI & HF Measure ChangesChanges

See Summary of PN & SCIP Measure See Summary of PN & SCIP Measure ChangesChanges

Clarifications/UpdatesClarifications/UpdatesData Abstraction Training Resources Data Abstraction Training Resources

Mock medical records (fictitious charts) have been Mock medical records (fictitious charts) have been developed for use by hospitals and Medicare developed for use by hospitals and Medicare Quality Improvement Organizations (QIOs) in Quality Improvement Organizations (QIOs) in training data abstractors. training data abstractors.

Staff can use the gold standard records to practice Staff can use the gold standard records to practice abstracting data for submission to the QIO abstracting data for submission to the QIO Clinical Warehouse. Clinical Warehouse.

Three charts are provided for each clinical topic.Three charts are provided for each clinical topic.

Clarifications/UpdatesClarifications/UpdatesData Abstraction Training Resources Data Abstraction Training Resources

Abstractions of the mock medical records for each Abstractions of the mock medical records for each topic are provided as “answer keys.” topic are provided as “answer keys.” These abstracted cases were created using CART These abstracted cases were created using CART paper tools paper tools The abstracted cases correlate with the CMS and The abstracted cases correlate with the CMS and Joint Commission abstraction guidelines effective Joint Commission abstraction guidelines effective with 04-01-07 discharges. with 04-01-07 discharges.

Hot TopicsHot TopicsInpatient Prospective Payment SystemInpatient Prospective Payment System

Inpatient Prospective Payment System Inpatient Prospective Payment System (IPPS) Final Rule FY 2008 released on (IPPS) Final Rule FY 2008 released on August 2August 2ndnd


New measures added to bring total to 27New measures added to bring total to 27Expanded measure set for FY 2009Expanded measure set for FY 2009

Pneumonia 30-day Mortality (Medicare patients)Pneumonia 30-day Mortality (Medicare patients)SCIP-Inf-4: Cardiac surgery patients with controlled SCIP-Inf-4: Cardiac surgery patients with controlled 6AM postoperative serum glucose6AM postoperative serum glucoseSCIP-Inf-6: Surgery patients with appropriate hair SCIP-Inf-6: Surgery patients with appropriate hair removalremovalSCIP-Cardiovascular 2: Surgical patients on beta SCIP-Cardiovascular 2: Surgical patients on beta blocker therapy prior to admission who received a beta blocker therapy prior to admission who received a beta blocker during the perioperative periodblocker during the perioperative period


Expanded measure set for FY 2009Expanded measure set for FY 2009““These measures have been endorsed, or are currently These measures have been endorsed, or are currently under endorsement review by the NQF and will be under endorsement review by the NQF and will be added to the measure set, contingent on their receiving added to the measure set, contingent on their receiving NQF endorsement by publication of the OPPS CY 2008 NQF endorsement by publication of the OPPS CY 2008 final rule in November 2007.”final rule in November 2007.”

““Data collection for these measures for purposes of Data collection for these measures for purposes of RHQDAPU will begin in CY 2008.”RHQDAPU will begin in CY 2008.”


Data Submission: Data Submission: ““CMS is requiring hospitals to submit CMS is requiring hospitals to submit aggregate population and sample size counts aggregate population and sample size counts for Medicare and non-Medicare discharges for for Medicare and non-Medicare discharges for the four topic areas on a quarterly basis.”the four topic areas on a quarterly basis.”


Hospital-Acquired ConditionsHospital-Acquired ConditionsPresent On Admission (POA)Present On Admission (POA)

Public display identifying hospitals that Public display identifying hospitals that share a common Medicare Provider share a common Medicare Provider Number Number

Value-Based Purchasing FY 2009 Value-Based Purchasing FY 2009

Hot TopicsHot TopicsOutpatient Prospective Payment SystemOutpatient Prospective Payment System

Outpatient Prospective Payment System Outpatient Prospective Payment System (OPPS) Final Rule CY 2008 is due out in (OPPS) Final Rule CY 2008 is due out in November 2007November 2007

Effective with calendar year beginning Effective with calendar year beginning January 1, 2008January 1, 2008


““In this rule, CMS is proposing new In this rule, CMS is proposing new measures that are specific to hospital measures that are specific to hospital outpatient services.”outpatient services.”

““Hospitals that fail to report data for these Hospitals that fail to report data for these outpatient-specific measures would incur a outpatient-specific measures would incur a reduction in their annual payment update reduction in their annual payment update factor in CY 2009 by 2.0 percentage factor in CY 2009 by 2.0 percentage points.”points.”

Hot TopicsHot Topics Proposed quality measures for CY 2008 Proposed quality measures for CY 2008

ER Transfer (AMI) – Aspirin at ArrivalER Transfer (AMI) – Aspirin at ArrivalER Transfer (AMI) – Median Time to ER Transfer (AMI) – Median Time to FibrinolysisFibrinolysisER Transfer (AMI) – Fibrinolytic Therapy ER Transfer (AMI) – Fibrinolytic Therapy Received Within 30 minutes of ArrivalReceived Within 30 minutes of ArrivalER Transfer (AMI) – Median Time to ECGER Transfer (AMI) – Median Time to ECGER Transfer (AMI) – Median Time to ER Transfer (AMI) – Median Time to Transfer for Primary PCITransfer for Primary PCI

Hot TopicsHot TopicsProposed quality measures for CY 2008 Proposed quality measures for CY 2008 (cont.)(cont.)

HF: ACE-I or ARB Therapy for LVSDHF: ACE-I or ARB Therapy for LVSDPerioperative Care: Timing of Antibiotic Perioperative Care: Timing of Antibiotic prophylaxisprophylaxisPerioperative Care: Selection of Prophylactic Perioperative Care: Selection of Prophylactic AntibioticsAntibioticsEmpiric Antibiotic for Community-Acquired Empiric Antibiotic for Community-Acquired PneumoniaPneumoniaHemoglobin A1c Poor Control in Type 1 or 2 Hemoglobin A1c Poor Control in Type 1 or 2 Diabetes MellitusDiabetes Mellitus


““To receive full OPPS payment rate update in CY To receive full OPPS payment rate update in CY 2009, the hospital must pass our validation 2009, the hospital must pass our validation requirement of a minimum of 80% reliability, requirement of a minimum of 80% reliability, based on our chart-audit validation process, for the based on our chart-audit validation process, for the January 2008 discharges.” January 2008 discharges.” (Reference: CMS-1392-P page (Reference: CMS-1392-P page 671.)671.)

““Our intent is to make this information public in Our intent is to make this information public in CY 2009 by posting it on the CMS Web site.” CY 2009 by posting it on the CMS Web site.” (Reference CMS-1392-P page 674.)(Reference CMS-1392-P page 674.)


““Therefore, we are seeking public comment on the Therefore, we are seeking public comment on the following 30 additional measures, which have following 30 additional measures, which have been identified as hospital outpatient-appropriate been identified as hospital outpatient-appropriate measures and are under consideration for inclusion measures and are under consideration for inclusion in the HOP QDRP measure set, for CY 2010 or in the HOP QDRP measure set, for CY 2010 or subsequent calendar years:” subsequent calendar years:”

See CMS-1392-P pages 660-664 for list of proposed See CMS-1392-P pages 660-664 for list of proposed measures.measures.

Comment period ends 09-14-07.Comment period ends 09-14-07.

Hot TopicsHot TopicsIPPS and OPPS IPPS and OPPS

See QNet home page for link to final IPPS See QNet home page for link to final IPPS ruleruleWatch for final OPPS rule due out in Watch for final OPPS rule due out in NovemberNovemberSee IPPS and OPPS Fact Sheets on CMS See IPPS and OPPS Fact Sheets on CMS website for details website for details

http://www.cms.hhs.gov/apps/media/http://www.cms.hhs.gov/apps/media/fact_sheets.aspfact_sheets.asp

Topic of the DayTopic of the Day PN: Chest X-ray Element PN: Chest X-ray Element

Many validation mismatches have occurredMany validation mismatches have occurredDue to abstractor error Due to abstractor error

Recommend review abstraction guidelinesRecommend review abstraction guidelines

Pay attention to ANY x-ray interpretation Pay attention to ANY x-ray interpretation found in narrative documentation such as found in narrative documentation such as discharge summarydischarge summary

Topic of the Day Topic of the Day PN: Identified Pathogens PN: Identified Pathogens

Need NOT be a final report if you have a Need NOT be a final report if you have a specified organismspecified organism

Gram positive cocci on a gram stain is NOT an Gram positive cocci on a gram stain is NOT an identified/ specified organismidentified/ specified organism

Most often you will NOT have an identified Most often you will NOT have an identified pathogen within 24 hours of arrivalpathogen within 24 hours of arrival

See table for further guidance and Quest See table for further guidance and Quest referencesreferences

Submitted QuestionsSubmitted QuestionsIV Beta BlockersIV Beta Blockers

Quest # 89815Quest # 89815Question: “For 4/1/07 discharges, please Question: “For 4/1/07 discharges, please explain rationale of why within the explain rationale of why within the ‘contraindication to beta blocker on arrival’ the ‘contraindication to beta blocker on arrival’ the statement ‘physician documentation of statement ‘physician documentation of hold/discontinuation of IV beta blocker’ is hold/discontinuation of IV beta blocker’ is included among the exception for clearly included among the exception for clearly implied reasons for prescribing beta blocker on implied reasons for prescribing beta blocker on arrival.” arrival.”

Submitted QuestionsSubmitted QuestionsIV Beta BlockersIV Beta Blockers

Quest # 89815Quest # 89815Answer: “For 4/1/07+ discharges: This change Answer: “For 4/1/07+ discharges: This change is intended to reduce the number of false is intended to reduce the number of false exclusions that result due to an order to hold or exclusions that result due to an order to hold or discontinue IV beta blockers. Orders for IV discontinue IV beta blockers. Orders for IV beta blockers are commonplace, and a patient is beta blockers are commonplace, and a patient is not expected to continue on chronic IV beta not expected to continue on chronic IV beta blockers – They will eventually need to be blockers – They will eventually need to be discontinued as the patient is transitioned to discontinued as the patient is transitioned to oral beta blockers.”oral beta blockers.”

Submitted QuestionsSubmitted QuestionsReadmissionsReadmissions

Quest # 55302 April 2006Quest # 55302 April 2006Question: “…for hospital quality measure Question: “…for hospital quality measure reporting purposes, should the clinically related reporting purposes, should the clinically related same day readmissions be reported as one same day readmissions be reported as one encounter (i.e. admit date of first admission and encounter (i.e. admit date of first admission and discharge date of second admission) as required discharge date of second admission) as required by CMS for claims submission?”by CMS for claims submission?”

Submitted QuestionsSubmitted QuestionsReadmissionsReadmissions

Quest # 55302Quest # 55302Answer: “CMS is aware of this issue and at Answer: “CMS is aware of this issue and at this time, for abstraction purposes, we have this time, for abstraction purposes, we have been given the direction that these readmissions been given the direction that these readmissions should be treated as two different episodes of should be treated as two different episodes of care, even though for billing it is one episode of care, even though for billing it is one episode of care. If one of the records is pulled for care. If one of the records is pulled for validation, the provider should only send the validation, the provider should only send the documentation for the dates of the record that documentation for the dates of the record that was pulled.”was pulled.”

Questions/Feedback

Contact InformationContact Information:

MetaStar, Inc.2909 Landmark PlaceMadison, WI 53713

(608) 274-1940 or (800) 362-2320

www.metastar.com

This material was prepared by MetaStar under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 8SOW-WI-INP-07-104.

Documents

Data Collection Support Webinar MetaStar, Inc. August 15, 2007 Pam Clemens Candi Davis