MedPartners Horizons Insider

Editor’s Note

The recent announcement of MACRA has health professionals digging for direction on how it will shape the landscape of quality care and revenue cycle. The opinion in this blog is one of many that will begin to stir as a result of the proposed rule.

This MedPartners piece represents the personal opinion, view or experience of the authors, and cannot reflect MedPartners as a whole. If you disagree with an Op-Ed or opinion, or feel you have more to share to the discussion, we’re happy to continue the dialogue in this open forum.

If you are offering a rebuttal, or would like to comment, please do so at the bottom of this page. MedPartners takes its role as a professional forum as a privilege, and not as the ultimate authority.

Brandi L. Fowler, MS, RHIA
VP Education & Compliance

Quality over Quantity

There have been many champions over the years regarding the concept of quality over quantity in Clinical Documentation Improvement (CDI). One can view quantity as a financial measure, and the champions of quality feel that quality should be at the core.  It has been said that money follows quality; quality does not follow money.

On April 27, 2016, the proposed rule of Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was issued by CMS. The CMS website calls a component of MACRA, Medicare Payment Reform, and this might be a fitting title as it outlines a more streamlined payment model tied to quality patient outcomes and moves this paradise along in a timelier manner.

The more I read about MACRA, the more intrigued I become. I had the pleasure of hearing a CMS official speak recently and I better understand the background. If you haven’t heard about MACRA, I urge you to do some research, because this might be the best start toward better patient quality outcomes and a true ‘pay for performance’ that has been seen to date. While refinement and adjustment will likely continue, it’s encouraging to witness the streamlined movement of attaching payment to outcomes towards a laudable goal.

In short, this is some information that is on the CMS website:

“MACRA makes three changes to Medicare payments:
  • Ending the Sustainable Growth Rate (SGR) formula for determining Medicare payments for health care providers’ services.
  • Making a new framework for rewarding health care providers for giving better care not more just more care.
  • Combining our existing quality reporting programs into one new system.

These changes are named the Quality Payment Program (QPP), and replaces what CMS calls, ‘a patchwork system of Medicare reporting programs’ with a flexible system that allows providers, called EP, or Eligible Professionals, to choose from two paths that link quality to payments: Merit-Based Incentive Payment System (MIPS) and Alternate Payment Models (APMs).

MIPS is a new program that combines parts of the Physician Quality Reporting System (PQRS), the Value Modifier (VM or Value-based Payment Modifier), and the Medicare Electronic Health Record (EHR) incentive program into one single program in which Eligible Professionals (EPs) will be measured on: quality, resource use, clinical practice improvement, and meaningful use of certified EHR technology.

APMs give CMS new ways to pay health care providers for the care they give Medicare beneficiaries, and includes: a lump-sum incentive payment to some participating health care providers from 2019-2024, increased transparency, and offering some participating health care providers higher annual payments beginning in 2026. Examples of APMs include Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models.”

The coming times will possibly spark anxiety in some physicians when they begin to receive payment based on the quality reporting of patient care they deliver.

You may be wondering what role the Clinical Documentation Specialist (CDS) carries in this?  I see that role as integral.

For years, the CDS has been accustomed to certain metrics that reflect the severity of the patient, such as CC, MCC, SOI and ROM. With the expanding focus on quality, there appears to be an increasing emphasis on complete and precise documentation and less on a particular metric.

The CDS can be viewed as the caretaker of the patient’s medical record – the patient’s story.  For years, there have been many who have understood that a complete and precise medical record didn’t stop with a CC, an MCC, an SOI or an ROM. While the value and the importance of having that direction is realized, the goal of complete and precise documentation that extended beyond those metrics is equally actualized.

The goal has been to ensure the documentation precisely reflects the individual patient, for if that is accomplished, then everything else will fall into place the way that it should. It appears to be finally falling into place, yet on a grander scale.

What is this grander scale, you may ask? Risk adjustment. As this concept matures and grows, there will likely be more refined risk adjusted methodologies, but at this time there are only a few higher level risk adjustment reimbursement models, the most well-known being HCCs (Hierarchical Condition Categories). HCCs focus on precise documentation of all of the patient’s conditions that are now affecting, or have the potential to affect, his/her health status. The grander scale comes into play not only with the depth of the documentation, but with the breadth, for with the HCC’s focus on the patient, not the setting, it encompasses the patient’s continuum of care.

With the CDS’s established relationship with the physician in the inpatient setting, the CDS is the one who can assist the physician in the outpatient setting if they experience anxiety when they begin to grasp the specificity of documentation that is required to be successful not only with HCCs, but with the Quality Payment Program along the continuum of care.

This is where the Clinical Documentation Specialist will shine… this is what they have been training for. They are primed to partner with the physician to ensure that their documentation across the continuum of care in this new era will be with the precision that is expected.

The QPP is about ensuring that quality care continues to be delivered to the patient and paying the physician accordingly for that care.

HCCs are all about the continuum of care documentation of clinical specificity and MEAT (akin to medical necessity) for all of the patient’s pertinent conditions.

Does this sound familiar?  It should because that’s what the CDS does.

It is quality over quantity.  It is value over volume.

It is the patient.


Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP