Journal excerpt: Foray into CDI for value-based purchasing

About 41% of CDI programs currently review medical records for quality improvement items, according to an online ACDIS membership poll. Although CMS implemented the Value-Based Purchasing (VBP) reimbursement model as required by the Affordable Care Act (ACA) in 2011, many CDI programs have only recently started investigating how their daily efforts positively affect VBP components.

Historically, CMS did not tie reimbursement to outcomes and quality scores. Hospitals were paid based on the MS-DRG and on volume—the more admissions, the more reimbursement. The ACA has led to a hybrid payment system: The MS-DRG is still an influence, but payment is also affected by outcome measures and quality reporting.

The new payments use the same basic reimbursement calculation with an added variable base rate. While MS-DRGs’ relative weight remains static, the hospital’s reimbursement rate, determined in part by the quality factors, changes using the following calculation—MS-DRG relative weight (RW) multiplied by the hospital base rate (BR) equals reimbursement (RW x BR = $).

Since CMS calculates the base rate once for the entire year, facilities likely won’t notice the effect of improved quality scores for a number of years. For instance, the risk-standardized mortality measures for fiscal year 2022 will be based on data collected from July 1, 2017 to June 30, 2020. So today’s documentation could actually influence hospital reimbursement five years down the road.

Editor’s note: This article was published in full in the March/April issue of the CDI Journal. To download the journal in its entirety, click here. To read the remainder of this article, click here.