SAMPLE INPATIENT PPS COMMENT LETTER ON THE CODING AND DOCUMENTATION ADJUSTMENT
Highlighted areas require that you insert information specific to your hospital.
DATE
Marilyn Tavenner
Acting Administrator
Centers for Medicare & Medicaid Services
Hubert H. Humphrey Building
200 Independence Avenue, S.W., Room 445-G
Washington, DC 20201
RE: CMS-1498-P, Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Proposed Fiscal Year 2011 Rates; Effective Date of Provider Agreements and Supplier Approvals; and Hospital Conditions of Participation for Rehabilitation and Respiratory Care Services Medicaid Program: Accreditation Requirements for Providers of Inpatient Psychiatric Services for Individuals Under Age 21; Proposed Rule (Vol. 75, No. 85), May 4, 2010
Dear Ms. Tavenner:
The INSERT YOURHOSPITAL OR HEALTH SYSTEM’S NAME appreciates the opportunity to comment on the Centers for Medicare & Medicaid Services’ (CMS) hospital inpatient prospective payment system (PPS) proposed rule for fiscal year (FY) 2011.
The rule issued April 19 includes a large proposed cut to adjust for increased payments due to alleged changes in documentation and coding that occurred when CMS changed to the Medicare-Severity Diagnosis-Related Group (MS-DRG) grouper to determine inpatient PPS payment amounts. CMS proposes a 2.9 percent cut – $3.7 billion – to recoup half of the payments made in FYs 2008 and 2009 that CMS claims were due to documentation and coding changes that did not reflect real changes in case mix. GENERALLY DESCRIBE THE IMPACT THIS CUT WILL HAVE ON YOUR HOSPITAL’S MEDICARE PAYMENTS IN FY 2011 COMPARED TO FY 2010, AND THE EFFECT THIS WILL HAVE ON YOUR ABILITY TO PROVIDE HIGH-QUALITY CARE.
The INSERT YOURHOSPITAL OR HEALTH SYSTEM’S NAMEbelieves there is a fundamental flaw in CMS’ methodology for determining the effect of documentation and coding change on FY 2008 and FY 2009 payments. We urge you to modify your methodology to account for the historical trend in case mix growth.
CMS states that the increase in payments it found could not be due to “real” case-mix change because its analysis looks at only one set of patient claims, and was run through the old and new groupers. However, we believe that an increase,as calculated in this manner, cannot be deemed a change in documentation and coding because, again, the analysis only looks at one set of patient claims, which by definition are coded identically. Analyzing a single year of claims is not the correct methodology for determining whether there was a change in documentation and coding practices relative to prior years.
The increase CMS found actually reflects differences in how the two DRG systems are designed to measure case-mix. It should come as no surprise that the same set of claims results in different case-mix indices (CMIs) when grouped under the CMS-DRGs compared to the MS-DRGs because, as CMS stated when it implemented the MS-DRGs, they were designed “to better recognize severity of illness among patients” (72 Federal Register 47130). In fact, it is possible that hospitals have maintained an absolutely consistent level of documentation and coding all along, but that the MS-DRGs simply recognize the consistent level of documentation and coding differently.
To properly evaluate whether and to what extent the introduction of the MS-DRGs changed hospitals’ coding practices, CMS must consider historical trends by analyzing multiple years of patient claims. Specifically, CMS should apply the FY 2009 MS-DRG grouper to past claims in order to evaluate the trend in CMI across those years. Through FY 2007, these results would represent real case-mix growth and hospitals’ pre-MS-DRG documentation and coding practices. For FYs 2008 and 2009, these results would represent real case-mix growth and hospitals’ post-MS-DRG documentation and coding practices. The extent to which the FY 2008 and 2009 results deviate from the FY 2000 through FY 2007 trend can be attributed to changes in coding practices due to the implementation of MS-DRGs.
In order to estimate this effect, CMS should use the FY 2000 through FY 2007 CMI values obtained in the previous step to create “predicted” CMI values for all years, including FYs 2008 and 2009. These predicted values would represent what CMI would have been in FYs 2008 and 2009 had hospitalcase mix continued its historical trend.
Finally, CMS should compare the predicted to the actual growth rate in CMI from FY 2007 to FY 2009. If the actual rate is less than or equal to the predicted rate, then it indicates that hospitals did not change their documentation and coding practices when MS-DRGs were implemented. If the actual rate is higher than the predicted, it indicates that hospitals did change their documentation and coding practices when MS-DRGs were implemented. If this is the case, to determine the amount by which changes in documentation and coding affected CMI, CMS should subtract the predicted growth rate from the actual growth rate.
To determine the documentation and coding-related increase in FY 2008, CMS should conduct the above analysis using the FY 2008 grouper, which was a 50/50 blend of the MS-DRGs and CMS-DRGs, since this is what was used for payment purposes in FY 2008.
We believe that if CMS conducts this analysis, it will demonstrate that a significant portion of the change CMS found and attributed to documentation and coding is actually the continuation of the historical trend in case mix growth, rather than the effect of documentation and coding changes due solely to MS-DRG implementation.
Accordingly, the HOSPITAL OR HEALTH SYSTEM NAMEstrongly urges CMS not to implement its proposed cut of 2.9 percent to recoup half the alleged overpayments made in FYs 2008 and 2009. This proposed cut is based on a flawed analysis and is drastically overstated. Further, it would significantly and negatively impact our ability to provide high-quality patient care while meeting new demands for health information technology and delivery system reform.
Thank you for the opportunity to share our concerns and recommendations.
Sincerely,
NAME OF HOSPITAL CEO OR OTHER REPRESENTATIVE
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