Being an outlier is not an admission of guilt

The PEPPER reports data on the hospital’s performance in each measure compared to all other hospitals in your state, your Medicare administrative contractor’s jurisdiction, and the nation. In no way does it tell you if you are doing things improperly. A hospital that provides complex specialty services such as transplant, surgical oncology, and interventional cardiology will inherently have more complex patients than a small community hospital without such services and should have a higher percentage of patients with CCs and MCCs. Each measure, therefore, needs to be evaluated based on that hospital’s patient population. In addition, the PEPPER uses the outlier range of 20% at the high and low ends. If you ask a statistician what percent should be used for an outlier range, they will likely tell you 2.1%.

As the data is interpreted, instead of asking what the hospital is doing wrong, they should ask if the data accurately represents their patient population.

Know where to look

For the compliance officer with more tasks than time, reviewing all 26 measures and 56 tabs in depth is unlikely, so where should the precious time be spent? Start with the “compare” tab, where every measure is listed with the hospital’s total number of discharges in that target area, along with the hospital’s percentile ranking. It also conveniently labels high and low outliers with red or green, respectively.

A glance at each “graph” tab can also provide a quick view of the hospital’s performance along with presenting three years of past data. If the hospital’s performance was always below the outlier limit but one quarter is above, it may warrant less attention than the measure where the hospital is consistently above the 80th percentile.

For each high outlier that warrants review, assess the number of cases and the percentile. If an outlier area has 11 admissions and is at the 82nd percentile, it has a lower priority than an area with 120 admissions at the 94th percentile. Read the definition to understand what is being measured and determine who can assist in performing a review. For instance, an outlier in “DRGs (diagnosis related groups) with CC or MCC” should be referred to the clinical documentation staff to review a random selection of cases to ensure all coded CCs and MCCs are clinically supported, and the “Perc CV Px” should be referred to the cath lab manager to ensure that physicians performing elective cardiac stents are not admitting their patients as inpatient. Many of the measures refer to specific DRGs, so make use of your clinical documentation and coding colleagues liberally to understand the difference, for instance, between DRG 064 (intracranial hemorrhage or cerebral infarction with MCC) and DRG 067 (nonspecific cerebrovascular accident and precerebral occlusion without infarction with MCC).

Enlist the help of your physician advisor

A high percentage of “spinal fusion” should be referred to the physician advisor to review documentation to support the medical necessity of a spinal fusion was present. Spinal fusion is a more complex surgery with a higher reimbursement, so ensuring that a spinal fusion was necessary as opposed to a less complicated, lower reimbursed surgery is warranted.

Likewise, a high percentage of one- and two-day inpatient admissions should be referred to the physician advisor to ensure the physician chooses the correct admission status. At first glance, one might question why a two-day inpatient admission is potentially noncompliant, as the Two-Midnight rule specifies that a patient who passes two midnights in the hospital should be admitted as inpatient. But the caveat is that these two midnights must each be medically necessary. A large number of two-day inpatient admissions may suggest that patients who could safely be treated as outpatients with observation services are being admitted as inpatients due to delays in care, convenience issues, or simply the desire of the physician to “stretch out” the care to qualify the patient for inpatient admission. None of these would be compliant.

Physician advisors should also be asked to review “total knee replacement” cases if the percentage performed as inpatient is high. This surgery was removed from the Medicare Inpatient Only list in 2018 and, as a result, can be performed as inpatient only if inpatient admission is clinically justified and well documented. If that justification is not present, processes should be undertaken to improve the status determinations in this surgery.

Valuable readmission data available

While compliance may not be directly involved with readmissions, the data on the PEPPER can provide some valuable insights. The report not only includes the number of readmissions in the quarter, but it also breaks down the readmissions into any hospital and the same hospital. This allows a hospital to determine what percentage of patients who had their index admission at their hospital were readmitted to another hospital or returned to them. However, there are many other explanations; a high percentage of patients whose readmission was at another facility might suggest that they were unhappy with their care during the index admission and chose to go elsewhere when they once again required hospital care.