Hospital Outpatient Quality Data Reporting Program
FLORIDA MEDICAL QUALITY ASSURANCE, INC.
Moderator: Bernadette Popovich
August 27, 2008
1:00 pm CT
Question 1:
Yes, I have a question and it’s an issue that we’re coming across on
identifying population and that has to do with the various billing
systems that are on the outpatient side. Many of those are bundling
like they do on the inpatient side, say for like, DRGs so that the CPT
codes are a subset of hick pick codes, so that unless you have a
mechanism to process and deal with and look at hick picks, you never
see this CPT codes across.
And we found that this is affecting multiple hospitals and not just in
isolated case in one or two locations. And it’s really difficult then on the
hospital side to identify their population, by specific CPT codes. And I
didn’t know if this had come up before and there had been any internal
discussions on CMS’ side because the identifications of populations is
still a very significant issue for quite a few hospitals.
Answer 1:
Aren’t the HCPCS codes in addition to the CPT codes documented.
Question 1:
Yes, but depending on how the building vendor set up their system, if
you don’t allow - if you don’t accept the hick pick codes, you’ll never
see a CPT code.
Answer 1:
Are you referring to billing out of the department, I mean...
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Hospital Outpatient Quality Data Reporting Program
Question 1:
Outpatient hospital billing systems. And we’ve come across this in
more than one state, so it’s not just a little isolated that we’re really
finding this as a problem if that in different billing systems, it’s driven by
the hick pick and not the CPT. So, that if there’s not some kind of core
lighting hick pick code that then the master charges under that hick
pick codes are CPT codes.
Answer 1:
(Wanda), this is (Robin), I can appreciate what you’re asking and I’m
not sure any of us are prepared to give a complete answer right now.
So, what I’d like to ask you is if you could send that to us and we will
put that on the grid so that there is an answer that goes out to
everybody. And that will give us a chance to research it and come up
with a consensus among all of us.
Question 1:
Okay, I’ll do that. I do have another question, if I may.
Answer 1:
Sure.
Question 1:
One of the things in the proposal - the proposed rule was that trying to
align definitions for common data elements and like a couple of things
that even have been discussed today are not in alignment with the
inpatient side and from education abstraction perspective that’s very
difficult.
For example, on the inpatient side there has to be a physician
documented link to why the vancomycin was given, it has to be very
explicit. The other thing that - another example is on the inpatient side
it was decided for multiple reasons and issues that vendors could not
chose to default automatically things to UTD, that abstracted
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Hospital Outpatient Quality Data Reporting Program
questions, dates, times, whatever, had to be touched by the abstractor,
i.e. vendors were not allowed to pre-default data elements to UTD.
And those things like for hospitals, they have so much to remember
and try to do correctly, that when the two programs are not aligned, it’s
very difficult. And I know it’s very difficult on your side, but I wondered
how that was moving forward as far as process in place as far as
alignment.
Answer 1:
(Wanda), this is (Wanda), I can tell you for vancomycin on the inpatient
side, we do not require a specific - it does not have to be linked. And
so if you want to submit or do a search on quest, you will find out for
the inpatient side, we do not require specific link to the use of
vancomycin.
Now, there has to be a physician documentation that the patient had
bowel surgery or the patient had - was inpatient in the last year or
whatever that allowable value states, but does not have to be linked to
the use of vancomycin.
Question 1:
And, I was pretty sure we looked this up in the manual, not looking at
quest, but looking at the technical specifications. And maybe it
depends on which version, which timeline you’re looking at.
Answer 1:
As far as I know, we have not for a long time required vancomycin and
the specific region and the order vancomycin to be linked. As far as
your other issue, it was our intension really to make the outpatient
manual a little bit easier to use and hopefully bring the inpatient
manual around to that.
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Hospital Outpatient Quality Data Reporting Program
So, like with a combination of some of the data elements, date and
time, stuff like that. But, yes we understand that the same abstractors
may be looking at the inpatient measures and the outpatient
abstracting both. And that’s presenting some difficulties, we do
understand that.
Question 1:
Okay, thank you.
Question 2:
Hi. Actually, this is (Lori Glover); we’re all in the same room. And we
just had - sort of similar to one of the previous questions, on the
inpatient side when we abstract antibiotic and it’s a 60 minute time roll.
If it’s given at the same time that the surgery starts or outpatient were
to answer yes. But, I think as for inpatient, we’re answering no.
Answer 2:
That’s not correct, for the inpatient it’s the same, it should be yes.
Question 2:
So, it is aligned for inpatient. And then as the antibiotic gets started
exactly at 60 minutes, is that...
Answer 2:
That’s still yes.
Question 2:
So, they’re both yes. Inpatient and outpatient.
Answer 2:
Correct.
Question 2:
Thank you.
Answer 2:
Sure.
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Hospital Outpatient Quality Data Reporting Program
Question 3:
Yes, I have a question about correcting the time, the antibiotic list
giving such an inpatient, you collect a time and the algorithm decides
which category it goes in. Right, an outpatient, it’s up to the abstractor
to say yes or no, it was within the sixth year, 120 minutes, and that’s
problematic for a lot of abstractors because then we can’t drill down for
which department needs a process improvement.
We don’t know whether its two minutes or two hours, and our vendor
only collects what the specification manual says, which is to collect the
yes or no. So, is there going to be any changes in the future to
collecting the time, that way we can drill down and know which
department the fault was.
Answer 3:
That actually was a question that went across the skip list serve and
we had more respondents stating that they liked the way it was on the
outpatient side that they would rather not collect so much information.
Every administration time of the antibiotics, they would just rather
answer yes, that it was given in the time frame specified.
I can’t give you the specific answers of some of the quality
improvement personnel that said, it’s just fine if we find out it wasn’t
answered correctly or it wasn’t documented, we can figure out who did
it wrong. So, we see both sides of it and we would like to leave it
simple and have antibiotic timing just come out yes or no.
Question 3:
Thank you.
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Hospital Outpatient Quality Data Reporting Program
Question 4:
Yes, I’m sorry; I didn’t know I was going to be the next one. I have a
couple of questions, they’re kind of short and sweet, and so I’d like to
give all of them. I wanted to know what the start date is going to be for
the physical 2010 proposal.
The second question I have is for the proposed rule, is there going to
be specific diagnosis codes or just based on procedures. And I wanted
to know when the validation will start and also there are multiple
selections for that location at the federal register, I wanted to know
which one we’re suppose to select and what page it starts at.
Answer 4:
I think that’s comes to me, but there were a lot of questions there and I
was confused.
Question 4:
Okay.
Answer 4:
Because the first part was is that we aren’t on a fiscal year, we’re on
calendar year.
Question 4:
I’m sorry, the calendar year.
Answer 4:
Okay, help me out here, so that was the first question, we’re in
calendar year. Now, what was exactly the question?
Question 4:
What’s the start dates for the calendar year, in other words, right now
we’re doing the calendar year, 2009 and it’s starting with the second.
Answer 4:
Okay, this has to do with the confusion, I think the confusion is - okay,
the calendar year 2008 rule, which was published last year.
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Question 4:
Right.
Answer 4:
Okay, that’s what we’re doing now and what we do now will be used to
make calendar year 2009, the decision for that whether or not you
make (unintelligible).
Question 4:
So, this would be starting January 1, 2009?
Answer 4:
Okay, so now the calendar year 2009 payment decisions, those that
will affect your calendar 2009 payment is being done right now. Your
April, May, and June services that have to be reported by November,
2008 because we’re good at that. The calendar year 2009, which we’re
under the proposed rule right now will be finalized in November and
will effect what we do in calendar 2009 and calendar year starts
January.
Question 4:
Okay, that’s basically what I was asking. So, it’s basically January,
2009 is what’s 2010.
Answer 4:
What we do there that will be...
Answer 4:2010 payment decisions, yes.
Question 4:
January 2009 data forward is for 2010.
Answer 4:
I have to check the rulebook exactly which data that we are using.
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Hospital Outpatient Quality Data Reporting Program
Question 4:
I guess my simpler answer is if the proposal goes through, the new
measures that are proposed, what would the start date be?
Answer 4:
January 2009.
Question 4:
Okay.
Answer 4:
But, the new measures, remember are all claim spaced and you don’t
have to actually have to do anything.
Question 4:
Okay, so they’re not data abstraction based?
Answer 4:
No, there are no new clinical data abstraction measures proposed. We
are taking forward the ones we have.
Question 4:
Okay, that would have been helpful if they had stated that when they
were going through the overview.
Question 4:
I thought that was going to be more data abstraction.
Answer 4:
No, no, they’re claim spaced.
Question 4:
Okay, that makes it a lot easier because I was thinking, oh my God, all
of these procedures that are being done there’s no way we could
abstract this, okay.
So, then the last simple question was when was validation starting.
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Answer 4:
Okay, the proposal, remember, this is the pro-scaled rule is that we
would not be getting any validation efforts until January, 2009 services.
Question 4:
Okay. And then if it’s possible that they could send the link for that
federal register because when I went to the sight that you lifted, it just
goes - there’s like six selections, I don’t know which one...
Answer 4:
Do a search...
Question 4:
I did.
Answer 4:
There are a number of documents and they’re the same the document,
if you look you’ll see they have the same name.
Question 4:
They’re slightly different.
Answer 4:
Well, they’re the...
Question 4:
The names are slightly different, let’s put it that way. And then do you
have start page?
Answer 4:
I can play with the date. On the start on the rule is it is actually federal
register. It is volume 73, number 139, and the Hospital Outpatient
Quality Data starts on page 4, 1539.
Question 4:
Okay. Yes, because it’s like searching for a needle in a haystack.
Okay, thank you.
Answer 4:
Okay, next question. Thank you.
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Hospital Outpatient Quality Data Reporting Program
Question 5:
Okay, I have three different questions and one of them I’ve asked one
time before via email and I guess I’m just really, really, really being
dense. Why is it we are reporting discharges to critical access
hospitals, they really aren’t by definition tertiary care facilities or
cardiac care centers?
Answer 5:
(Wanda) can you address that please?
Answer 5:
(Rebecca) is going to have to answer that, (Rebecca)?
Answer 5:
Okay. Well I think they just open it up that, you know, potentially
they’re, you know, the facilities that they looked for were critical access
hospital, federal facilities, and short term acute care. Although, you’re
right, we don’t expect that there are a lot of facilities that are going to
be transferring from, you’re facility to a critical access hospital for PCI.
But, at this time those are the codes that are used.
Question 5:
Okay, on the follow up on that in code 43, the VA facilities, do you
know if at any point and time in the near future, they’re going to be
separating out the VA nursing homes? We are small rural hospital and
sometimes we get the - we have a VA nursing home here in town and
sometimes, you’ll get somebody that comes in through the ER that hits
the right codes.
But the family decides, and no they don’t want anything more done,
they just want to go back to the VA nursing home. Well, that’s a code
43 and we have to answer, when was the EKG, (unintelligible) like if
we were going to be sending them up to a VA hospital.
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Hospital Outpatient Quality Data Reporting Program
Answer 5:
Right and I think that you said that those cases really are only going to
be impacted by the ECG and the chest pain or in the aspirin measure
and whenever they put these measures together; they made the
decision not to include exclusions for patients with comfort measures
only in these outpatient measure sets.
I think that once they get some more data in, if they can see how, you
know, often it’s happened, they may make the decision to try to figure
a way around that. But, at this time, the way that the code is listed out
by the NUBC it does include those VA nursing homes in that 43 code.
Question 5:
You know, I guess I don’t see how they’re going to be able to decide
whether they went to the VA nursing home or the VA hospital.
Answer 5:
Well, at this time until that code is separated out further, which we
don’t know if they have any plans to do so. We wouldn’t be able to
differentiate within that status code 43.
Question 5:
Okay. And then my last question is on question 178, it’s - let me get it
and make sure I’m saying it correctly. It’s talking about in paraenthesis
that this includes the EMS contact with referring from the timing of the
90 minutes with the initial provider contract.
I want to make sure that what you’re - what that is saying is that
(unintelligible) I believed was from my door to their lab, not when the
patient was picked up at their house by the ambulance company. We
have a big rural area and sometimes it may be 15-20 minutes from the
time the EMS actually gets to the house, picks up the patient, and can
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actually get into our facility, so are we counting that time in that 90
minute frame?
Answer 5:
No, this measure just accounts for the time that they arrive at your
facility door to the time that they’re transferred, but the guidelines from
the American College of Cardiology and the American Heart
Association, their recommendation are that someone having an MI that
they receive acute coronary intervention within 90 minutes of the first
provider contact.
So, if that means that that patient calls 911 and ambulance arrives at
their house, they’re saying it’s to provide the best care for that patient
from the time the ambulance gets there to the time that they undergo
PCI in the lab should be less than 90 minutes.
Now we’re not nearly a facility accountable for that time that the patient
is out. But we expect that if we want to try to meet those 90 minute
guidelines and windows if they are picked up in the field, brought to
your hospital and you have to transfer them out, it’s just taking almost
90 minutes from the time they reach your door to when they leave.
We know that there’s no way possible there going to meet that 90
minute window. So, you want to try (unintelligible) from arrival to
transfer as close to zero as possible to facilitate that patient getting that
PCI in less than 90 minutes.
Question 5:
Okay, that’s helps a little bit because I was like, we’re doomed if we
have to start counting the EMS time in there. So, okay, thank you.
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Answer 5:
No, that’s just what the guidelines say.
Question 5:
Thank you, I appreciate that.
Question 6:
Hi, my question is reference to number 180 about surgeries that are
cancelled. Now, as far as I’m aware, these guidelines were originally
established for best practices to improve patient outcome and when
you talk about antibiotics being administered prior to an incision, you’re
talking about reducing the risk of infection at the surgical site and the
patient outcome. How can you justify the inclusion of these cases
when you’re never performing an incision on this patient?
Answer 6:
(Wanda) do you have any further information about the rational for
keeping these patients in the...
Answer 6:
We knew about this when we were first developing the measures and
we felt that it happened so rarely that it was not feasible to write an
exclusion for it. We have had a lot of feedback that it is happening as
rarely as we first believed and so therefore we will make this change to
somehow get those out in the population algorithm so that the case
never has to be abstracted. That’s going to be a little bit difficult, but
we’re going to figure out a way to do that. And we will get those cases
out.
Answer 6:
This is (Anita), from (CMSI), I want assure everybody that we
understand this is an issue and that we are working to modify the
technical specifications on this measure so that these cases don’t get
included. And we do thank everyone who did bring it to our attention,
that’s why we need your input at all levels.
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Hospital Outpatient Quality Data Reporting Program
Question 6:
Thank you.
Answer 6:
Thank you.
Question 7:
Hello, I have a couple of questions regarding ECGs. Is there
performance target for ECG timing?
Answer 7:
There’s no specific performance target, although they do kind of
recommend that within 10 minutes. But we made this measure that
expert panel decided to make it an average median time rather than a
10 minute window and obviously the closer once again to zero you are
in getting that ECG, the more quickly providers can make a
determination as to what care needs to take place for the patient.
Question 7:
Okay, when there’s two conflicting times, the data dictionary states to
use the time that the machine prints out we apparently have inaccurate
timing on our machines and it’s a known in the ED and so we consider
our nursing notes to be more accurate. What do you answer to that?
Answer 7:
Well, and in that instance, it’s on one particular ECG. If you have more
than one time documented, the decision was made to go with the ECG
printed report time and when we had hospital pilot test these
measures, they did find that that was a huge problem is that their ECG
machines in the ED, their times were off and all inaccurate.
And what they did is they went out and they developed a quality
improvement program in their ED to address those processes and got
their ECG clock times to match up, you know, with their admitting times
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etc. so that everything would be accurate. So, but at this time the
instructions do instruct that if you have multiple times documented you
go with the ECG printed report time whether that one is earlier or later
than other notes suggest.
Question 7:
Okay, and then one quick question on the proposed quality measures,
are there going to be any specifications or goals just more information
in general on that coming up.
Answer 7:
(Anita)?
Answer 7:
Is that mine, I was wondering if that was mine or not. My
understanding is that these are going to be outlined in the
specifications manual, is that correct? We were going to add those, the
imaging efficiency measures once they’re finalized.
Answer 7:
Right. In the manual, we plan to provide maybe a one page document
that links the abstractor to the measured developer Web site because
in case they update on a different time schedule we want the
abstractor to know what the most up to date specifications are, the
claims measures specifications are. So, we will not have anything in
the data dictionary besides a link out to the Web site that deal with that
claims space measure.
Answer 7:
So, the answer is yes we’re going to tell you how we’re calculating it
and what they mean and we’ll provide a link in the specifications
manual to that site where you can get more details on them.
Question 7:
When will that be?
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Answer 7:
Well, we have to wait until they’re finalized.
END
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