Like tax folks in early April, we healthcare value improvement people, are entering the beginning of our busy season. We survived the first round of the eligible professionals’ appeals to the Centers for Medicare & Medicaid Services (CMS) regarding their 2017 penalty designations. These “informal reviews” aren’t up for second opinions, but through networking with CMS officials, we recognized that there were a number of glitches with the processing of the 2015 data – which greatly influences how we are advising clients for the 2016 data submission cycle. 

Is it too Late to Get Started?

This time of year, we get a ton of calls from frantic business managers in outpatient settings on whether or not they should just throw in the towel when it comes to quality reporting for 2016. It isn’t too late! 

While some quality data vendors may have closed their enrollment for 2016 submissions, that date is unique to each vendor. Vendors have until March 31, 2017 to get data to CMS. So you won’t have until March 31 to enroll, because it takes time to validate each provider and then upload data to CMS; some vendors will be accepting enrollment until early spring 2017. Why not get started now, and find your vendor partner!

Likewise, if you are reporting individually and worry that you don’t have enough data yet, the guidance from CMS is that you must address the quality metrics during the reporting year, which ends Dec. 31. It’s a great time to get your documentation completed and run audits while you may have fewer patients. And remember, double-check if one of the 25 measure groups makes sense for you (20 patients, and 11 or more must be traditional Medicare patients, with reporting done on a defined set of measures based upon the services you provide). Measure groups go away in 2017, so take advantage of them now. 

Stay the Course

For the sake of everyone’s sanity, let’s forget about the recent election and the new president and Congress convening in January. Instead, let’s focus on the fact that the quality reporting programs, electronic medical record mandate, and electronic prescribing requirement have been around for over a decade as either an incentive or penalty for eligible professionals billing Medicare.

And while the Merit-Based Incentive Payment System (MIPS) tweaks and streamlines the existing programs, the fundamental apparatus is still there. Even for those who are betting on Congress dismantling Medicare as we know it and implementing Medicare Advantage for all Americans by Feb. 1, I say if it ain’t broke, don’t change it. I counsel my friends, colleagues, and clients to keep doing what you are doing with quality reporting, electronic prescribing, and electronic medical record use. Let’s go for the gold and not rip up the railroad tracks of workflow that have already been laid, confusing medical assistants and support clinical staff on their roles and job expectations. And honestly, what’s the harm if I am wrong? 

Outsourcing Quality

The most important thing that we in our provider community needed to appreciate this year is that CMS has outsourced its quality evaluation to several contractors. That means we have run into numerous hurdles getting questions answered or problems fixed, because the government agency and contractors weren’t aware of some of the same information or able to access the same data. 

  • QualityNet (Ventech Solutions, Inc.) – This is the helpdesk for the majority of the congressionally mandated “value-based purchasing” quality programs, including the Physician Quality Reporting System (PQRS) and the Value-Based Payment Modifier (VBM). However, they don’t process the data; they just host the helpdesk, also known as the Health Care Quality Information Systems (HCQIS) Infrastructure and Data Center Support (HIDS).

    We have found it best to submit emails (to This email address is being protected from spambots. You need JavaScript enabled to view it.) rather than spending hours waiting for your call to get non-answered. The email process auto-generates a processing number, which is crucial. It also allows for faster transfer of questions to the appropriate subject matter expert. Plus, you get wrong answers from the helpdesk in writing. Be sure to keep copies of these responses, because you may need them in the future. And currently allow a week (seven business days) for processing.

    We are aware of accuracy issues wherein QualityNet isn’t aware of announcements made by other parts of CMS or related subcontractors. For example, QualityNet wasn’t processing requests from organizations to change their Group Practice Reporting Option (GPRO) designation or reporting modalities that were due by Nov. 25, 2016 (there was no formal announcement made other than one directed toward data submission organizations). Likewise, QualityNet can’t answer questions about the 2017 program yet – those are transferred back to CMS for response.
  • PQMM (Signature Consulting Group) – This is the management arm staffed by Signature Consulting Group that oversees and maintains the PQRS measures (soon-to-be-called MIPS measures) through its Physician Quality Measure Management (PQMM). This is the correct group, other than the measure author, to contact for questions about measure specifications. They can be contacted through the QualityNet Help Desk – so be sure to note in your email that your question is a measure specification question and should be routed to PQMM.

    The number of 2016 measure specifications not easily understood by our clients is growing. And several of the measures proposed in 2017 do not reflect MIPS program changes. The 2017 measure specifications are available online at (scroll down halfway to “Learn More About the Merit-Based Incentive Program,” and the measures are under “Measure Specifications Download”) on “preview” with “final measure specifications will be posted by Dec. 31, 2016.” Although a bit late, comments may be directed to this organization for requested changes to troubling and confusing specifications (along with the measure author).
  • PQPMI (Newwave Telecom and Technologies, Inc.) – This is the group processing the PQRS data (with a 2-percent penalty for failure to submit data on Medicare receipts two years after the reporting cycle; 2016 data affects 2018 payment). They process the quality data coming in from Medicare claims, registries, electronic medical record (EMR) vendors, QCDRs, and the CMS Web portal, then create the PQRS feedback reports, publishing them on This contract is called the Physician Quality Programs Management and Implementation (PQPMI).

    NewWave has several contracts with CMS, including the Chronic Conditions Warehouse and Virtual Resource Data Center contracts. It is also the incumbent contractor for the CMS Enterprise Privacy Policy Engine.

    Two interesting items have come up regarding this. In the informal review process, we learned that the NewWave data processing platform uses the provider specialty off the National Plan and Provider Enumeration System (NPPES) (specialties are called “taxonomy” in this system) to determine the inclusion of that specialty to the PQRS program. Our clients often have differences between the PECOS and NPPES data, and for 2015 we had several instances in which the NPI taxonomy was not updated to reflect subsequent state licensure. Thus, our biggest advice in 2016-2017 for all professionals is to double-check your information in both systems for accuracy and consistency.

    Another concern is that NewWave doesn’t have access to the other reports available on the system. Basically, the two contractors administering the very related programs of PQRS and VBM can’t see each other’s reports. So far, we have had several instances where the PQRS feedback report didn’t match the Quality and Resource Use Report (QRUR) Table 7 Individual Eligible Professional Performance on the 2015 PQRS Measures.
  • Physician Quality Reporting System and Electronic Prescribing Incentive Program Data Assessment, Accuracy, and Improper Payments Identification System Contract – The 2013 award went to Arch Systems, Inc. (among other subcontractors for support of the contracts listed here). Arch is tasked with identifying gaps, data errors, and inconsistencies on how program data is being procured, translated, transmitted, and submitted to the PQRS and eRx incentive programs by registries and GPROs; validating and verifying the accuracy of GPRO and registry data submitted by or on behalf of eligible professionals; and supporting the development and implementation of a process to identify PQRS and eRx improper payments derived from registry and GPRO data.

    These will be the audit watchdogs that we likely will see more from as the program matures in 2016. We look forward to working with them in a more public role.

  • DECC (Computer Science Corporation, ViPS/General Dynamics Information Technology and 2020 – Business Integra) – This large collaboration is the IT backbone for the quality reporting programs. Noted in the contract these contractors (main awardee is Computer Sciences Corporation) under the Development Effort Consolidation Contract (DECC) is to consolidate and innovate four stovepipe applications onto the Oracle platform. The four applications we know and dislike are Hospital Reporting, Physician Quality Reporting System, End-Stage Renal Disease and Quality Improvement Organizations.

    Users already are experiencing some system pinches with these platforms as the consolidation and innovations move forward. A goal in this area is to have more frequent back-and-forth discussions between developers and system users. Personally, I look forward to more API integrations and the movement away from manual uploads of data.
  • Registration and Attestation System (R&A) – This is the meaningful use attestation site used by CMS and states for their Medicaid incentive programs. It’s currently unclear, but this federal contract may have been awarded to Xerox which provided states access to their own systems.

    The already bloated list of contractors is complicated by the integration of this system and its program into MIPS. Maybe the R&A will be added to the DECC?
  • CAHPS for PQRS Data Team (RAND Survey Research Group) – New this year, and buried in my spam folder, is the Rand Corporation taking over the reins and registration site for group practices’ and Accountable Care Organizations’ reporting data on patient satisfaction through the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey-certified vendors.

    Despite the fact that is hosted by QualityNet, the helpdesk this fall, even on the deadline day for specifying the chosen CAHPS vendor (Sept. 20, 2016), they didn’t know about the deadline or to whom to get the information. I was told that a different unit had that information and that the main line couldn’t help me. After separately reaching out to that unit (This email address is being protected from spambots. You need JavaScript enabled to view it.), I learned that an email was sent to the large GPRO organizations giving them information about the new RAND hosted portal Thankfully, the invitation was dug out of the spam and everything was met on deadline. Imagine the number of folks who didn’t follow this route.


With this many actors and hands in the cookie jar can be messy, I can only think of President Eisenhower’s famous quote about the dangers of a military industrial complex. We are in the age of the healthcare industrial complex. We must be aware of the many actors that are outside the government and demand for timely, accurate answers regarding these public programs.

A few key tips to keep in mind:

  • Email your inquires about 2016 quality reporting to This email address is being protected from spambots. You need JavaScript enabled to view it..
  • Keep electronic and paper copies of all correspondence in cases of audits for 5-7 years, based upon your document retention policies.
  • Where possible, help the QualityNet Help Desk route your question to the appropriate contractor by naming the contractor (or acronym) for your question.
  • If you haven’t already, double-check both your NPPES and PECOS files for accuracy, especially on the listed specialty/taxonomy for each of your clinicians. Each specialty/taxonomy listed first is the one that counts for these programs.
  • If you are reporting data to CMS via a vendor (registry, QCDR or EMR), call your vendor and find out more about what data is being submitted and the timeline. While data is required by March 31, the government does allow data to be overwritten if you find errors. Work with your vendor to get data in early, and double-check exactly what they send. We had a caller show us that for their specialty physicians, they submitted data on dental measures because their EMR system collected the data. They were considered poor performers because the measures were reported without their specific knowledge.
  • Stay on top of your deadlines. For inquiries and help, anticipate seven or more business days for response. Plan to get information into the appropriate vendor two weeks ahead of deadline.
  • Comments are due on MIPS by 5 p.m. on Dec. 19. Submit comments through by searching CMS-5517-FC to find the correct regulation. 

About the Author

Jennifer Searfoss is the founder and chief solutions strategist at SCG Health, LLC, a boutique value improvement organization focused on creating value in healthcare through workflow optimization, revenue cycle management, and strategic planning in this post-health reform industry environment.

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 VBPmonitor’s sister monitor, ICD10monitor and HRS recently collaborated to conduct a survey to assess where Talk Ten Tuesday’s listeners are positioned when it comes to Hierarchical Condition Categories (HCCs) in their workplaces. 

In line with the Talk Ten Tuesdays’ audience, the majority of the survey respondents were from the hospital setting. Our initial takeaway from the survey results was that more than half of the respondents indicated they are or will soon be using HCCs; however only 27 percent indicated that they had “above-average” or “expert” knowledge of HCCs. The results are indicative of the accelerating shift from the physician practice setting to the hospital setting, but they also suggest that we may be applying HCCs without the appropriate knowledge – which could potentially impact quality reporting and ultimately, reimbursement.

Over the last few months, ICD10monitor has been reporting how HCCs are becoming more important when coding from both the hospital and physician perspective. Historically, HCCs have been more prevalent on the physician side, but with the continuing shift toward value-based payments, HCCs are becoming essential for hospitals reporting risk adjustment (how sick your patients are) that impacts such payments.

The American Health Information Management Association (AHIMA) defines HCCs as follows: “diagnostic categories assigned based on diagnosis codes on encounter claims or on Medicare Advantage health plans. These categories filter patients into ‘buckets’ that are clinically similar and are expected to have similar cost patterns to predict future healthcare costs.”

Let’s look at the specific demographic results of the survey first.   

Sixty-eight percent of our respondents were from a hospital or health system, with the remaining being from the physician office/practice setting, insurance/billing setting, a government or state agency, or consulting companies. These results support our interest in the hospital setting, since HCCs are fairly new to them. 

Over half of the respondents to the survey, 52 percent, work in a health information management or coding department, followed by 24 percent working in the area of clinical documentation improvement (CDI). Compliance patient accounts, billing, quality, analytics, and “other” made up the remaining fields.

Fifty-seven percent of respondents had job titles in the “specialist” category, which included coders, CDI specialists, nurses, analysts, billers, auditors, and technicians, followed by 32 percent who work in management. The remaining respondents were comprised of vendors, c-suite, payers, and other specialties.   

HCC knowledge was fairly evenly distributed among respondents, with 38 percent having no knowledge or being at a novice level, 35 percent with average knowledge, and 27 percent with above-average or expert knowledge. Fifty-one percent noted that their organization currently performs HCC coding or will be starting soon. As mentioned in the opening paragraph, there is concern here for higher utilization of HCCs when knowledge may not be optimal.

The survey asked what the impetus for each organization’s utilization of HCC coding was, and it instructed respondents to check all that apply. The results revealed the following:

  • Medicare Advantage Plans – 43 percent
  • Medicare Shared Savings ACO – 19 percent
  • Value-Based Purchasing – 26 percent
  • Some Commercial ACOs/Shared Risk Arrangements – 17 percent
  • Health Insurance Exchange Plans – 10 percent
  • States Where Medicare/Medicaid Dual Eligible are Managed Care – 15 percent
  • Population Health/Risk Stratification/Cost Prediction – 18 percent
  • Other – 8 percent
  • N/A – 31 percent

This is a clear indication that risk adjustment programs are becoming more prevalent in organizations, and likely impacting additional areas of the various healthcare settings.

The survey responses indicated that organizations were applying HCC coding across a variety of service types, with respondents identifying the following:

  • Acute Inpatient – 41 percent
  • Outpatient – 34 percent
  • Physician Practice/Clinic – 40 percent
  • Freestanding Service (ASC, IDTF, Imaging Center, Lab, etc.) – 8 percent
  • Post-Acute (Rehab, Behavioral Health, LTAC, Skilled Nursing, Home Health, Hospice) – 14 percent
  • Other – 1 percent

In some instances, respondents were not aware which service types were applying HCCs (20 percent) or the question wasn’t applicable to them (16 percent).

In regard to the practice of receiving feedback regarding the results of HCC coding, 40 percent of respondents stated that feedback is shared with staff; 24 percent reported that feedback is not shared; 19 percent said they did not know if feedback was shared; and 17 percent reported that it was not applicable to them. This may indicate that organizations have some more work to do regarding improving their communication to staff as it pertains to key outcomes related to HCCs and risk adjustment. Sharing the feedback can help staff understand the significance of their work and the overall impact to the organization.

It is also important to monitor and report financial impact. HCCs and risk adjustments go beyond MS-DRGs and case mix to impact the potential for penalties or bonuses under the hospital value-based purchasing program, as well as affecting future non-Medicare payers by adjusting capitated payments. Forty percent of respondents stated that they perform or will be performing some form of financial HCC impact reporting, while 13 percent do not perform any, 39 percent don’t know if they do, and 8 percent stated that it was not applicable.

The results of the financial analysis indicated that 10 percent of respondents have seen a positive financial impact, with 1 percent reporting a neutral impact and 3 percent reporting a negative impact. Forty-eight percent reported that they do not know what the financial impact is, and 36 percent stated it was not applicable to them.

As far as who is using HCC coded data, respondents were asked to check all that applied, and they designated the following:

  • Health Information Management (HIM) – 24 percent
  • Quality – 20 percent
  • CDI – 22 percent
  • Business Office/Patient Accounting – 8 percent
  • Finance – 17 percent
  • Contracts – 7 percent
  • Compliance – 9 percent
  • I don’t know – 37 percent
  • N/A – 17 percent
  • Other – 4 percent

We expected to see that most users were from HIM, quality and CDI, but it’s clear to see that other areas of the organization are also utilizing the HCC data, so the impact of the risk adjustment process is gaining in importance – and likely already impacting more of our organizations’ outcomes.

The areas noted as responsible for performing HCC coding in the organization were the following:

  • HIM Coders – 42 percent
  • CDI Staff – 17 percent
  • Physician Office Staff – 13 percent
  • Physicians – 13 percent
  • Billers – 3 percent
  • I don’t know – 27 percent
  • N/A – 20 percent
  • Other – 4 percent

Again, we expect that the HIM and CDI staffs have a major role in the process, since that’s where most code assignment is conducted, but the results show that there are others working outside of these two areas who are also responsible for this assignment and need to have a strong knowledge of HCCs.

The survey concluded with 37 percent responding that staff has either received HCC training or that training is planned, and 39 percent have not yet received training. This result sparked some concern, given the number of responses indicating that HCCs are currently being utilized and applied. Given the impact that HCCs have on both patient severity and financial perspectives, it is critical that all staff working with HCCs understand the application and significance of risk adjustment so that data quality and reimbursement are accurate. The results of this HCC survey reflect the progression toward value-based payments, and even with the recent presidential election outcome and the threatened repeal of the Patient Protection and Affordable Care Act (PPACA), industry experts continue to support and predict a move in this direction. Clearly, risk adjustment plays an important role in this and many other healthcare industry initiatives.

ICD10monitor understands the need to continue to provide additional information, insight, and education to Talk-Ten-Tuesdays’ listeners. We look forward to hearing more from you about your experiences, as well as your specific needs in the area of risk adjustment and HCCs. We will work to help you gain further knowledge relating to this important and timely topic.

About the Authors

Barbara Hinkle-Azzara, RHIA, is the vice president of health information management (HIM) operations for HRS, where she leads client development, coordination, and management efforts. Barbara has more than 25 years of demonstrated HIM experience in planning, organizing, and directing health information management departments and software solution vendor organizations. She has extensive experience with team building, project coordination, workflow analysis, and establishing metrics and accountability for successful outcomes. Barbara has presented at national, state, and local association conventions and is an active member of AHIMA, ACDIS, the New York Health Information Management Association, and the HIM Association of NYC.

Kim Charland is the editor of VBPmonitor and the senior vice president of clinical innovation with Panacea Healthcare Solutions. Kim has 30 years of experience in health information and reimbursement management for hospitals and physician offices. Kim’s primary role with Panacea is publisher of, which is the company’s newest online monitor and is focused on value-based purchasing and quality. She is also co-host of’s Internet news broadcast Talk-Ten-Tuesdays. In addition, she assists with product development for Panacea’s consulting and software divisions, as well as the MedLearn publishing division. Kim is also recognized as a national speaker who has spoken for numerous organizations. Kim is also the president-elect for the New York Health Information Management Association.

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We have just experienced a heated presidential election featuring uncertainty about what will happen next. Beyond this change in the president and a new Congress, healthcare is in the midst of a decades-long shift from fees for service to payment for value. There are both short-term and long-term unknowns.

In times of uncertainty, focus on basics, make good use of what you have, and prepare for growth in the future. Don’t let the hype and the rapid news cycle distract you from what you and your organization need to succeed.

Regardless of the specific payment model, delivering high value is necessary for success. Value is a combination of quality outcomes and the costs necessary to deliver those outcomes. Used well, healthcare IT can help with both.

This article will focus on three areas where a healthcare provider can take action given the uncertainties:

  • Provide quality care and demonstrate it with quality measures
  • Make small adjustments and build on existing capabilities

Provide Quality Care and Demonstrate It with Quality Measures

There are a large number of quality measures. They are developed by professional associations, researchers, and individual providers, and are the result of a rigorous testing process. Many are National Quality Forum (NQF)-endorsed and used in payment programs (learn more online at

Selecting the quality measures that are right for you and your organization is a process that encompasses two demands: external requirements from other providers, care coordinators, payors, and regulators, plus internal requirements to run your organization and improve care. Know how the outside world assesses your performance and pay heed to what is needed for compliance.

There are many questions to ask in selecting and using quality data. Do the measures offer a full view of the quality provided? Are there areas where you can focus on a few measures that are representative of the larger set you have to collect? How do you measure these outcomes? How do you collect and analyze the data? How do you share it with staff and outside partners? Can you drill into the underlying data? Group it by patient and provider characteristics? Find actionable patterns? How do you act on the measures as part of the care process? Can you use the measures to understand the underlying processes, to learn about the patients and the providers? How can each interaction with a patient lead to better outcomes? What individual risks need to be addressed? What aspects of a care plan need follow-up?

Make Small Adjustments and Build on Existing Capabilities

We are in a period of unprecedented investment in healthcare IT (read more on acute-care hospital adoption at and physician practice adoption at Many providers have implemented systems to meet the Health Information Technology for Economic and Clinical Health (HITECH) Act incentives program. Now it’s time to get real value from that investment.

As with almost all software, getting the system up and running is just the beginning. Once the technology is in place and users have made it through the first year or so of use, it’s time to revisit what was done and look at where small adjustments can make a big difference. Look for the activities that are the most painful, and engage your users. Are some more successful than others? What can they teach the others? There are often multiple ways to accomplish a task. Each approach may have tradeoffs in the workflow, the number of steps, or the ability to reuse information. Assess the tradeoffs in the different approaches. Also look to your vendor for training materials and for system upgrades that might address your pain points.

Before you consider major changes, look for incremental adjustments, as these will often provide the most value. It is not unusual for bad habits to be learned during initial training. With the focus on getting the job done, this is the right place to start. However, when all the systems are up and running, it’s time to revisit the details of how the systems are used. Small adjustments are the least disruptive to workflow, require the least amount of retraining, and can be further refined over time.

Beyond adjustments in using the software, look at capabilities that exist in what you already have, but may not be using properly or using fully. Initial implementation tends to focus on “getting data in” and not how that data can be used effectively by the individual provider or by the organization. The real value from the software will come from building on these unused or underused capabilities. This can range from documenting care and writing orders to how billing is done and how the performance of the organization is reviewed. 

Furthermore, look at how you communicate with other providers and the tools you use to coordinate care. This is an area where the certified electronic health records (EHRs) offer capabilities that may have been implemented to meet the minimum necessary for the meaningful use program. Some small adjustments in what you send, or what others send you, could make a big difference in the usability of the information. Given the difference in timing of when different providers implemented their systems, they may have made choices that should be revisited, given that other providers now have increased capabilities.

In Conclusion

By focusing on basics, you can have a base to build on for the changes that will come. This is a good time to reflect on what’s working, where small changes would make a difference, and to learn how the technology you’ve invested in can deliver more for you. It’s a good way to use a time of uncertainty to be ready for the future.

About the Author

Larry Wolf is Principal at Strategic Health Network, a health policy advisory service. Larry has forty years of experience in health IT with an emphasis on clinical systems across a wide spectrum of care settings. Larry has a strong foundation in the development of clinical systems and a track record of strategic use of data. He is exceptionally able to work across traditional boundaries, bridging the technical, clinical and business worlds; ambulatory care, acute care, postacute care and longterm support services. He builds consensus and shared vision, even among the conflicting positions of members of Federal workgroups.  Larry is a national leader using health IT to improve care coordination. He is a member of the Federal Health IT Standards Committee and chair of the HIMSS Public Policy Committee. He is an organizer of the annual LongTerm/PostAcute Care Health IT Summit and an author of the biannual LTPAC HIT Roadmap. He provides advisory services on strategic direction and information systems architecture.

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While there has been and will be a great deal of focus on the movement from volume-based to value-based payments in healthcare, less publicized is the work of an advisory committee with an important role in this journey. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) created the Physician-Focused Payment Model Technical Advisory Committee (PTAC) with a charter directing that the group comment and make recommendations to the Secretary of the U.S. Department of Health and Human Services  (HHS) on physician-focused payment model (PFPM) proposals submitted.  PTAC is an 11-member committee assembled via appointment.

While PTAC recommends on proposals, the Secretary of HHS decides on whether and when to implement PFPMs. PTAC approximates that the review and recommendation process will take 16 weeks. PTAC began accepting letters of intent as of Oct. 1, and proposals as of Dec. 1.

PTAC anticipates that recommendations on initial proposals submitted will occur in spring of 2017. Options that PTAC could consider for PFPMs include: a) not recommending a model to move forward to the Secretary of HHS for consideration; b) limited-scale testing of a proposed model; c) implementation of a proposed model; and d) implementation of a proposed model as a high priority. Each proposal will be assessed on criteria for PFPMs established by the Secretary of HHS, as required by MACRA. There are 10 criteria for model consideration, three of which are considered a high priority for each proposal to meet. The criteria are noted below, with high-priority items bolded:

  • Scope of proposed PFPM: Does the model broaden or expand the Centers for Medicare & Medicaid Services (CMS) alternative payment model (APM) portfolio by addressing a payment policy issue in a new way, or does the model include entities that have had limited opportunities to participate in APMs?
  • Quality and cost for model: Does the model improve healthcare quality at no additional cost, maintain healthcare quality while decreasing cost, or both improve healthcare quality while decreasing cost?
  • Payment methodology: Does the model pay APM entities with a methodology that would achieve goals overall as it pertains to PFPM criteria? Questions to be answered would include how the PFPM payment methodology is different than current methodologies available for payment and why the model cannot be tested under current payment methods.
  • Value over volume
  • Flexibility
  • Ability to be evaluated
  • Integration and care coordination
  • Patient choice
  • Patient safety
  • Health information technology

PTAC uses a public comment process for review of documents released, as well as meetings open to the public on a quarterly basis. PTAC’s next public meeting is scheduled for Dec. 16. Additional information on PTAC, including its charter, FAQs, biographical information for members, guideline documents for submission of PFPMs, archives of past meetings, etc. can be found online at:

About the Author

Kim Charland is the editor of VBPmonitor and the senior vice president of clinical innovation with Panacea Healthcare Solutions. Kim has 30 years of experience in health information and reimbursement management for hospitals and physician offices. Kim’s primary role with Panacea is publisher of, which is the company’s newest online monitor and is focused on value-based purchasing and quality. She is also co-host of’s Internet news broadcast Talk-Ten-Tuesdays. In addition, she assists with product development for Panacea’s consulting and software divisions, as well as the MedLearn publishing division. Kim is also recognized as a national speaker who has spoken for numerous organizations. Kim is also the president-elect for the New York Health Information Management Association.

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E RemerEDITOR’S NOTE: This is the final installment in a two-part series on the enigma of sepsis. You can read Part I here.

As I thought about writing this article, I was at first going to propose that we figure out a way to marry the old sepsis definition and coding schema with the new sepsis definition, but I came to realize that I agree with Sepsis-3. I realized that the factors that made me identify a patient as SICK was organ dysfunction. You can be sick from a pneumonia or a UTI, but when you start getting encephalopathic or experiencing acute kidney or liver dysfunction/failure or have a Type 2 MI with elevated troponin, that is when the provider can recognize you have crossed the threshold to SICK and septic. Your providers probably are like me – their gut is also telling them that the underlying infection has caused a systemic cascade, manifesting in organ dysfunction, which might not have risen to the level of “failure.”

In 2016, the Third International Consensus Definitions for Sepsis and Septic Shock, Sepsis-3, in JAMA defined sepsis as a “life-threatening organ dysfunction caused by a dysregulated host response to infection.” They proffered an increase in the Sequential Organ Failure Assessment (SOFA) score of ≥ 2 as the grounds to make the diagnosis of organ dysfunction. Since several of the variables are dependent on laboratory tests, which may not be immediately available (e.g., platelet count, serum bilirubin, and serum creatinine), a new measure with predictive validity was sought. The qSOFA (“q” for quick) score was derived to allow application at the non-ICU bedside, with the intent to identify patients at risk of dying. The variables are altered mentation, systolic BP ≤ 100 mm Hg, and RR ≥ 22/min; demonstrating two out of three variables is positive.

(Sidebar: When I teach this to residents, I always point out that the first derangement is elevation of respiratory rate. Respiratory rates as recorded are notoriously inaccurate unless they are machine-derived. I would strongly suggest counting the respirations yourself.)

Sepsis-3 goes on to define septic shock as a subset of sepsis in which “profound circulatory, cellular, and metabolic abnormalities increase mortality risk.” The authors then conclude with recommendations for ICD coding. Those of us reading this subsection who are familiar with coding guidelines found ourselves scratching our heads in utter amazement. Their recommendation is to code R65.20, Severe sepsis without septic shock for the terminology of “sepsis,” and R65.21, Severe sepsis with septic shock for the diagnosis of “septic shock.” This is not compliant. Documentation must match the ICD-10-CM code, or at least be able to index to it. “Sepsis” cannot be capriciously coded as “severe sepsis,” although sepsis with sepsis-related organ dysfunction can compliantly be coded as severe sepsis. Semantically, Sepsis-3 abolished “severe sepsis,” but practically speaking, it eliminated recognition of cases of early sepsis prior to onset of organ dysfunction. This has set up our collective clinician discomfort at diagnosing, documenting, and coding sepsis in the Sepsis-3 world. We feel like the sepsis continuum isn’t continuous or complete anymore.


The addition of a comorbid condition or complication (CC) or major CC (MCC) does not change DRGs 871 and 870, there being no “with CC” or “with MCC” variants. As far as I can tell, if sepsis establishes your DRG, the addition of severe sepsis alone (without accompanying organ failure codes) does not change the relative weight or severity of illness/risk of mortality (SOI/ROM). However, if the sepsis is not present on admission, and the underlying infection is establishing the DRG, the addition of severe sepsis on top of sepsis may change the SOI/ROM, which could be significant. This is another reason why the elimination of the diagnosis of “severe sepsis” (that is, only having sepsis and septic shock as diagnostic options) is unacceptable unless they change the coding implications to reflect the clinical reality.

The last piece of this puzzle is the SEP-1 Centers for Medicare & Medicaid Services (CMS) core measure. They still define sepsis as 2/4 SIRS plus suspected infection, and severe sepsis as having an elevated lactate or (sepsis-related) organ dysfunction. There are specific, time-dependent actions one must take for a patient with severe sepsis or septic shock, but the included population is inpatients age 18 and over with an ICD-10-CM principal or secondary diagnosis of sepsis, severe sepsis, or septic shock. The intent is “to facilitate the efficient, effective, and timely delivery of high-quality sepsis care,” thereby reducing use of resources and decreasing mortality. Most facilities have implemented some type of sepsis order set or bundle to ensure compliance with the core measure, and the outcome has been absolute mortality reduction. It is odd to have the definitions for the core measure not correlate with the definitions in the most current guidelines.

The criteria as put forth by the Third International Consensus have not been universally embraced by the medical community yet. Here is the apparent dilemma:

  • If we continue to use Sepsis-2, we will have three categories: sepsis, severe sepsis, and septic shock. The auditors will have a field day with denials.
  • If we transition to Sepsis-3, as it stands, we will compliantly only be able to code two choices if they are documented purely as sepsis or septic shock. This will fundamentally change the composition of the sepsis spectrum pie chart and wreak havoc with SEP-1.

Factors include the following:

  • Auditors will use whatever criteria fit their narrative. It is likely they will jump on the Sepsis-3 bandwagon and find opportunities to downgrade the sepsis DRGs, MS-DRGs 871/870, to the underlying infection if there is no R65.20 or R65.21 or organ dysfunction as a secondary diagnosis.

Any denials stemming from an admission prior to Feb. 23, 2016 referencing Sepsis-3 should be forcefully rejected on the grounds that Sepsis-2 criteria were all we had available to use at the time. Providers are expected to be omniscient, not prescient.

  • Providers are not reliably documenting organ dysfunction currently. In clinical documentation improvement (CDI), we work hard to transition folks from “altered mentation” to “encephalopathy” to capture the severity of illness the provider was trying to convey. When you notice the creatinine has bumped, or the INR is high, what you are thinking is that there is acute renal or liver dysfunction. No one ever diagnoses critical illness polyneuropathy or myopathy, and no one thinks of ileus as an organ dysfunction.

So what should we do? The issues are what constitutes sepsis and how to diagnose it, how to document it, and then how to compliantly code it.

  1. Your facility/organization/system should have a discussion about sepsis and set up internal practice guidelines. The goal should be to recognize sepsis as early as possible, but truthfully. The objective is to save lives, not to maximize revenue.
    1. Convene your infectious disease physicians, critical care specialists, hospitalists, emergency physicians, and any other providers who might want to participate in hashing out the internal practice guidelines.
    2. If your medical staff does not buy into the Sepsis-3 criteria, have a written guideline indicating what they believe constitutes sepsis (especially without organ dysfunction) and how to diagnose it. Your providers may state that they believe the criteria from Sepsis-2 are still valid. I advise the guidelines to specify that the patient should be sick – just meeting SIRS criteria is not sufficient. However, if at some point the Sepsis-3 criteria become the prevailing definition for a reasonable, prudent clinician in your locale, you will have to revisit this policy.
    3. Be sure that they understand that no matter how they choose to define sepsis, they will still be held to any core measures set by CMS.
    4. Your providers must understand that the coding guidelines state that “a provider’s statement that a patient has a condition is sufficient.” If they think a patient is septic, they should document it and supply their clinical evidence to support their diagnosis.
    5. It is better to consider sepsis early and rule it out than to miss it initially and have unwelcomed outcomes. You can make an uncertain diagnosis (rule-out, possible, probable, suspected) and then figure it out. If it gets ruled out, it isn’t coded. Diagnose, evolve, resolve, recap.

If the diagnosis was sepsis, the record should be consistent (i.e., not one provider only documenting the diagnosis of UTI and another documenting sepsis due to UTI), and the diagnosis should appear in the discharge summary. It is quite suspect to have a principal diagnosis that is missing from the discharge summary.

  1. Empower clinical documentation integrity specialists to query for clinical validity if they do not find support for a sepsis diagnosis. It is easier to get it right on the front end than to appeal a denial on the back end.
  2. The qSOFA is meant to provide simple bedside criteria to identify infected patients with the potential for poor outcomes. This is done to prognosticate and direct transfer to the intensive care setting.
    1. R41.82, Altered mental status, unspecified or R40.4, Transient alteration of awareness are suboptimal ICD-10-CM codes, even if they support qSOFA. Try to educate your physicians to recognize, document, and code encephalopathy.
    2. A blood pressure of less than 100 mm Hg may be relative or actual hypotension, depending on the patient’s baseline and the absolute number. Precision of language gets you the most specific codes.
    3. There are many ways to express elevated lactic acid as a consequence of tissue hypoperfusion (“hyperlactatemia” is the term found in Sepsis-3). Your providers either need to document “lactic acidosis” or “excessive lacticemia” to index to E87.2, Acidosis. This latter term is definitely not doctor-friendly. You are not going to be able to train your docs to spew that verbiage. One option is to figure out a way to make an acronym expansion to get there.
    4. If you are using Sepsis-3, I posit that it is possible to have “organ dysfunction” without frank organ failure. This may result in some “other specified diseases of (insert organ here)” instead of the organ failure code. If an auditor claims there is no sepsis because there is no organ failure code, but your physician documented “organ dysfunction,” fight it.
    5. Leverage your electronic medical record (EMR).
      1. If your providers insist on uniting Sepsis-2 and Sepsis-3, you could have three check-off boxes available to them:

□      Sepsis (per Sepsis-2 criteria, no organ dysfunction noted),

□      Sepsis (per Sepsis-3 criteria, with organ dysfunction consistent with severe sepsis by Sepsis-2 criteria), and

□      Septic shock.

Let them tick off the one that describes the patient’s condition.

  1. Give them a list of organ dysfunctions to choose from to support their diagnosis. They will find more often than not that the patient did meet Sepsis-3 criteria.
  2. Make sure your sepsis bundle is helpful and guides them to  the necessary SEP-1 measures and to get the mandatory data points.
  3. Be aware of exclusion criteria for SEP-1. If it is in the patient’s best interest to be transitioned to comfort care, it is in the provider’s best interest to do it within three hours of presentation of severe sepsis, and within six hours of presentation of septic shock.

My advice is to have your providers go with their gut. When a patient is SICK from a presumed or confirmed infection, recognize sepsis and document: Sepsis with organ dysfunction. This provides clarity for anyone reading it – the patient meets Sepsis-3 criteria, and the coder can compliantly code R65.20, demonstrating severity. List and support the organ dysfunction, and don’t forget encephalopathy, acute kidney injury, lactic acidosis from tissue hypoperfusion, hyperbilirubinemia or coagulopathy indicating acute liver dysfunction or failure, Type 2 myocardial infarction, hypoxemia or acute respiratory failure, and critical illness polyneuropathy or myopathy.

Sepsis is a very serious condition, and it is vital that we diagnose it and treat it in a timely fashion. In terms of coding to get credit for having taken care of it, my expectation is that we will not be left in limbo forever. I have it on good authority (Jim Kennedy, MD, CCS, CCDS, CDIP) that Coding Clinic will eventually render an official opinion on how to handle sepsis and Sepsis-3. Until then, my final recommendation is the same as it is for any topic:

Do the right thing for the patient, document so you make the patient appear as sick in the EMR as he or she looks in real life, and let the quality metrics and reimbursement fall where they may. 

About the Author

Erica Remer, MD, FACEP, CCDS is the founder and president of Erica Remer, MD, Incorporated. Dr. Remer has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016.

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