CMS Target Areas for HPMP

CMS has selected target areas for the Hospital Payment Monitoring Program (HPMP) based on historical knowledge and experience as well as analysis of payment errors related to medically unnecessary admissions, inappropriate readmissions, and diagnosis related group (DRG) incorrect coding.

The topic areas are as follows (Note: These topic areas have been changed since program inception. The topic areas below represent current CMS target areas as reported in your most recent PEPPER User Guide. Hospitals should not focus on these areas alone but should integrate educational efforts towards these areas in addition to their own identified payment error areas).

CMS Target Areas in PEPPER version 16 (released October 2006).

Note: These target areas may change based on current payment error trends.

One-day stays excluding transfers

Numerator: count of discharges with length of stay less than or equal to one day excluding patient status of 20 (expired), 07 (left against medical advice), or 02 (discharged/transferred to a short-term general hospital for inpatient care)

Denominator: count of all discharges excluding patient status 02

DRG 127 one-day stays

Numerator: count of discharges with DRG equal to 127 (heart failure and shock) with length of stay less than or equal to one day excluding patient status of 20 (expired), 07 (left against medical advice), or 02 (discharged/transferred to a short-term general hospital for inpatient care)

Denominator: count of all DRG 127 discharges

DRG 143 one-day stays

Numerator: count of discharges with DRG equal to 143 (chest pain) with length of stay less than or equal to one day excluding patient status of 20 (expired), 07 (left against medical advice), or 02 (discharged/transferred to a short-term general hospital for inpatient care)

Denominator: count of all DRG 143 discharges

DRGs 182 and 183 one-day stays

Numerator: count of discharges with DRG equal to 182 (esophagitis, gastroenteritis and miscellaneous digestive disorders age > 17 with complication or comorbidity) or 183 (esophagitis, gastroenteritis and miscellaneous digestive disorders age > 17 without complication or comorbidity) with length of stay less than or equal to one day excluding patient status of 20 (expired), 07 (left against medical advice), or 02 (discharged/transferred to a short-term general hospital for inpatient care)

Denominator: count of discharges with DRG equal to 182 or 183

DRGs 296 and 297 one-day stays

Numerator: count of discharges with DRG equal to 296 (nutritional and miscellaneous metabolic disorders age > 17 with complication or comorbidity) or 297 (nutritional and miscellaneous metabolic disorders age > 17 without complication or comorbidity) with length of stay less than or equal to one day excluding patient status of 20 (expired), 07 (left against medical advice), or 02 (discharged/transferred to a short-term general hospital for inpatient care)

Denominator: count of discharges with DRG equal to 296 or 297

DRG 014 and 559

Numerator: count of discharges with DRG equal to 014 (intracranial hemorrhage and stroke with infarct)

Denominator: count of discharges with DRG equal to 014, 015 (nonspecific CVA and precerebral occlusion without infarct), or 524 (transient ischemia)

IMPORTANT: DRGs 014 and 015 were redefined and DRG 524 was added effective with discharges starting October 1, 2002. This impacts the comparability of the proportions reported for these DRGs. Trending cannot be conducted for these DRGs using fiscal year 2003 data. Hospitals are recommended to evaluate the fiscal year 2003 data as a stand-alone time period.

DRG 079

Numerator: count of discharges with DRG equal to 079 (respiratory infections and inflammations age > 17 with complication or comorbidity)

Denominator: count of discharges with DRG equal to 079, 080 (respiratory infections and inflammations age > 17 without complication or comorbidity), 089 (simple pneumonia and pleurisy age > 17 with complication or comorbidity), or 090 (simple pneumonia and pleurisy age > 17 without complication or comorbidity)

DRG 243

Numerator: count of discharges with DRG equal to 243 (medical back problems).

Denominator: count of all discharges

DRG 416

Numerator: count of discharges with DRG equal to 416 (septicemia age > 17)

Denominator: count of discharges with DRG equal to 416, 320 (kidney and urinary tract infections age > 17 with complication or comorbidity), or 321 (kidney and urinary tract infections age > 17 without complication or comorbidity)

Seven-day readmit to same facility or elsewhere

Numerator: count of index (first) admissions for which a readmission occurred within seven days to the same hospital or to another short-term acute care PPS hospital for the same beneficiary (identified using the Health Insurance Claim number); patient status of the index admission is not equal to 02 (discharged/transferred to a short-term general hospital for inpatient care)

Denominator: count of all discharges

DRG 089

Numerator: count of discharges with DRG equal to 089 (Simple Pneumonia and Pleurisy, age > 17 with complication or comorbidity).

Denominator: count of discharges with DRG equal to DRGs 089, 090 (Simple Pneumonia and Pleurisy, age > 17 without complication or comorbidity), or 088 (Chronic Obstructive Pulmonary Disease)

Complication/comorbidity (CC) pairs

Numerator: count of discharges for medical DRGs with a CC, excluding DRGs 079/089

Denominator: count of discharges for all medical DRG pairs, excluding DRGs 079/080/089/090

3-Day skilled nursing facility (SNF)-qualifying admissions

Numerator: count of discharges to a SNF with a three-day length of stay

Denominator: count of all discharges to a SNF (identified by patient status code of 03 (discharged or transferred to a SNF) or 61 (discharged or transferred to a swing bed))

Based on ongoing analysis, CMS may choose other target areas in the future. Therefore, be sure to also focus on hospital-specific payment error areas.

IPRO disseminates quarterly Program for Evaluating Payment Patterns Electronic Report (PEPPER) data for these target areas to facilitate auditing and monitoring activities for your particular hospital. Look for these data in Quality Net Exchange -- register now if your hospital has not already done so.