By Daniel Land, RHIA, CCS
Coded data has a long and influential life span, and its importance goes beyond that of just today’s revenue cycle. It is important for health information management (HIM) professionals to understand the micro and macro purposes of coded data in relation to key healthcare initiatives such as quality outcomes, risk adjustment, predictive analytics, population health, medical research, fiscal integrity, and institutional longevity. Coded data also has a significant impact on hospital ratings. This article will discuss this impact and HIM’s role in hospital ratings while demystifying the healthcare rating process.
First, consider the impact of coding on the individual patient, upon which healthcare ratings are built. Coded data follows patients throughout their lives and directly influences their safety and well-being. For example, inaccurate coding could result in improper patient care during a future encounter or a denial for a patient seeking life insurance. It is difficult to expunge an incorrect diagnosis code that is attached to a patient. Despite the repetitive nature of coding and auditing, HIM professionals should pause long enough to ask themselves if they would agree with the codes assigned to a claim if they were the patient of record. By doing so, coding moves from the abstract to the tangible. Our national coded data is a vast collection of individual patient stories that help drive the business of healthcare. HIM professionals’ mission is to make certain that patients’ stories are correct for myriad reasons, including their direct impact on healthcare ratings.
Why Healthcare Ratings Matter
Consumerism in healthcare has become the norm as patients have developed into sophisticated comparison shoppers who rely upon a plethora of publically available ratings to make informed decisions about where to seek care and how to best spend their healthcare dollars. Marketplace competition provides hospitals with greater incentive to improve quality, which can lead to fewer complications, lower readmission rates, reduced length of stay, and lower mortality rates.
While many elements factor into health insurance contract negotiations between hospitals and payers, accurate clinical outcomes data (obtained from coding) is foundational to the process. Payers are committed to managing their risk and look to partner with organizations that can objectively quantify their commitment to value-based and high-quality care. Healthcare organizations that fall below benchmarks for certain quality standards, including healthcare ratings, may be subject to financial penalties such as a payer contract becoming null and void.1 Conversely, organizations with excellent outcomes data and ratings have greater leverage in negotiating favorable terms with payers. Bottom line: payers want to do business with organizations that do a good job managing their resources.
Savvy healthcare organizations utilize their ratings as an opportunity to do a deep-dive into the integrity of their institutional data. This multi-factorial analytical process, which involves stakeholders from across the continuum, should provide an objective assessment of institutional data quality. The findings can be used to correct current deficiencies, identify opportunities for improvement, and proactively monitor data quality over time—which should ultimately improve an organization’s ratings. It is important to remember that the accuracy of healthcare ratings is dependent upon the integrity of the supporting data, much of which is derived from coding and clinical documentation.
Specific examples of how coding can negatively impact healthcare ratings include:
- Complication of Care Codes. As stated in the ICD-10-CM Official Guidelines for Coding and Reporting, it is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition and an indication in the documentation that the condition is a complication. When in doubt, query the provider for clarification. Incorrectly assigned complication of care codes can negatively impact healthcare ratings.
- Present on Admission (POA) Indicators. False positives can occur in Patient Safety Indictor (PSI) rates if incorrect POA indicators are assigned. Many PSIs have a coding exception that removes those cases from the PSI algorithm if the condition was present on admission and did not develop subsequent to the admission. It is of particular importance to monitor POA indicators associated with patients who are transferred from outside facilities. The receiving facility does not want to take the hit for a PSI that occurred at the transferring facility.
- Resolved vs. Active Conditions. Although the practice of cloned documentation (copy and paste) of clinical information in electronic health records can be a timesaver for clinicians, it can pose a risk to documentation integrity. Cloned documentation has the potential to blur the distinction between current conditions and resolved (historical) conditions. If documentation of historical (resolved) conditions is misinterpreted as current conditions—and coded as such—artificially inflated PSI rates can occur.
Perceptions of Healthcare Ratings
Although ratings data is typically taken at face value, it is important to remember that healthcare ratings are not always reflective of the quality of care delivered, particularly if the data behind them is flawed.
According to a 2016 article in Boston magazine, Elizabeth Mort, Massachusetts General Hospital’s senior vice president of safety and quality, says ratings have value, but she’s dubious of their simplicity. “Is there really a difference between four and five [stars], three and four, two and three, one and two?” she asks in the piece. “When you artificially slice a distribution curve of measures into categories, you run the risk of misclassifying people.”2 The opinion expressed by Mort of the questionable significance between adjacent star ratings further underscores the importance of accurate data. The accuracy of data legitimizes each star rating and makes the differences among them meaningful. Regardless of varying opinions of their legitimacy, institutions care about their ratings and celebrate when they are classified well.
From the consumer perspective, it is important to utilize data ratings by analyzing the results that are most relevant to a consumer’s particular clinical issue. It is a challenge for consumers to make sense of the competing voices in healthcare ratings because different organizations measure hospitals’ performance and reputation using different criteria. In addition, there is not yet a singular resource that distills ratings information into a single consumer-friendly tool.
Summary of Selected Healthcare Ratings Systems
Some of the most well-known and respected healthcare ratings systems include:
- Hospital Compare: The Centers for Medicare and Medicaid Services (CMS) publishes hospital quality star ratings to help patients select a hospital based on quality performance. CMS uses metrics from the Hospital Inpatient Quality Reporting (IQR) Program and Hospital Outpatient Quality Reporting (OQR) Program to determine star ratings. CMS calculates overall star ratings using a composite of distinct quality metrics. The scores are based on hospital performance in seven different categories: Mortality, Readmission, Safety of Care, Patient Experience, Effectiveness of Care, Timeliness of Care, and Efficient Use of Imaging. Coding examples from the Safety of Care category includes central-line associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI). Healthcare organizations interested in improving their CMS star rating should take a close look at the quality of provider documentation as well as the accuracy and specificity of coding. Documentation and coding are two key methods by which the quality of patient care is judged. Better quality of documentation and coding may directly translate to improved star ratings.
- Healthgrades: Healthgrades publishes patient safety ratings and patient safety excellence awards annually. Healthgrades uses Medicare Provider Analysis and Review (MedPAR) data to identify the number of preventable complications occurring at all eligible short-term acute care hospitals. Healthgrades focuses on potentially preventable events derived from the Agency for Healthcare Research and Quality’s (AHRQ’s) PSIs. Coding examples of PSIs include in-hospital fall with hip fracture, post-operative respiratory failure, and post-operative sepsis.
- US News & World Report Best Hospital Rankings: The Best Hospitals specialty rankings assess hospital performance in 16 specialties including cancer, cardiology and heart surgery, and orthopedics. A hospital’s overall score reflects performance in structure, process, and outcomes. Structure refers to hospital resources directly related to patient care. Process refers to delivery of care which encompasses diagnosis, treatment, prevention, and patient education. Outcomes are typically measured by risk-adjusted mortality. Coding considerations include correct abstracting of a patient’s discharge disposition and accurate coding of PSIs as defined by AHRQ.
A Different Perspective on HIM Audits
Despite the fact that healthcare ratings are an imperfect science, they matter greatly to providers. Consumers’ perception is their reality and if a healthcare organization’s rankings are unfavorable, consumers may take their business elsewhere—despite the fact that the rankings may not reflect the true level of quality provided by the organization. In order to ensure rankings accurately portray an organization’s quality mission, it is beneficial to create a comprehensive audit plan that evaluates the data elements that factor into healthcare rankings.
A sample audit plan may include:
- C-suite awareness of the advantages of HIM’s role in elevating or maintaining their organization’s rankings.
- A designated HIM professional within the organization to serve as the subject matter expert on the specific coding-related elements that factor into healthcare rankings. Since each rating system uses slightly different elements for their calculations, creating a database of the data elements would be a valuable planning tool which would need to be updated over time.
- Incorporation of a designated HIM professional on the quality team.
- Inclusion of quality scores in the executive and leadership dashboards.
- Dedicated health data analyst to abstract and report on quality-related internal and external data.
- A focused quarterly audit plan that assesses documentation quality and coding integrity through the lens of healthcare ratings.
- A joint effort between clinical documentation improvement teams and HIM to objectively analyze audit findings and craft education tailored to address gaps identified by the audit.
- Follow-up audits to proactively identify documentation gaps and coding errors that could lead to negative rankings if not corrected.
- Transparent communication with all team members on the link between ratings and their organization’s fiscal health and longevity, both of which are essential to job security.
HIM Should Use Skills for Ratings Improvement
HIM professionals bring the voice of data quality expertise to the healthcare ratings conversation. According to AHIMA’s HIM Reimagined (HIMR) white paper, “HIMR is, by design, future focused and likely does not reflect what many are currently observing in their workplace settings. The recommendations in this document are bold and ambitious and hold promise for future advancement for the HIM profession.”3
In order to grow beyond the bounds of traditional HIM roles, professionals must position themselves strategically to demonstrate their ability to positively influence healthcare organizations on a broad scale. Locking arms with their organization to achieve desired rankings is a perfect example of the importance of continually scanning the healthcare landscape for ways in which HIM professionals can use their skills in new and different ways. HIM professionals’ unique training makes them indispensable to many different areas of healthcare—a fact that sometimes needs to be spotlighted with greater effectiveness. Work on improving healthcare quality ratings provides that spotlight.
- Lund, Kenneth. “10 Points for Negotiating Hospital Contracts.” American HealthTech. May 2013. www.healthtech.net/hs-fs/hub/116853/file-67112828-pdf/docs/10_points_for_negotiating_hospital_contracts_final_5-13-13.pdf.
- Ducharme, Jamie. “Do Hospital Rankings Really Matter?” Boston. August 4, 2016. www.bostonmagazine.com/health/2016/08/04/hospital-rankings/.
- AHIMA. “HIM Reimagined – Transformation Starts With You.” White paper. 2017. www.ahima.org/about/him-reimagined/himr?tabid=whitepaper.
Deloitte. “Understanding Medicare’s 5-star rating hospital program.” Modern Healthcare. www.modernhealthcare.com/article/20170828/SPONSORED/170829897.
Gruessner, Vera. “How Quality Metrics Affect Value-Based Care Reimbursement.” HealthPayer Intelligence. June 29, 2016. https://healthpayerintelligence.com/news/how-quality-metrics-affect-value-based-care-reimbursement.
Medicare.gov. “Hospital Compare – Data sources.” www.medicare.gov/hospitalcompare/Data/Data-Sources.html.
Seth, Sanjay. “The advantage of data analytics when negotiating value-based contract terms with payers.” Becker’s Health IT and CEO Report. June 20, 2018. www.beckershospitalreview.com/healthcare-information-technology/the-advantage-of-data-analytics-when-negotiating-value-based-contract-terms-with-payers.html.
Daniel Land (firstname.lastname@example.org) is director of revenue integrity and compliance review services at MedPartners.
Land, Daniel. “HIM’s Vital Role in Healthcare Ratings.” Journal of AHIMA 89, no. 9 (October 2018): 20-23.