New CMS specialty code and more on Sepsis-3

This column discusses the new CMS specialty code for hospital medicine and developments in sepsis criteria.

The Centers for Medicare and Medicaid Services (CMS) has finally agreed to assign a unique specialty code for hospital medicine, 20 years after the first use of the term “hospitalist.”

Photo by Thinkstock
Photo by Thinkstock

This change has been long overdue, giving recognition to the growing number of clinicians in the U.S. who identify themselves as hospitalists. However, the code number and implementation date have not yet been announced and may have to await a final regulatory ruling by CMS later this year.

The 2-digit specialty codes are self-selected by clinicians and are submitted on the Medicare Enrollment Application (Form CMS-855). They are intended to identify the type of practice and services provided to patients. A clinician may submit up to 2 codes to designate a primary and a secondary specialty. CMS believes that these codes improve the quality of data about utilization, appropriateness of care, and other measures of performance.

Before this decision, hospitalists typically had to submit a primary specialty code for internal medicine, family practice, general practice, or pediatrics, lumping them in with predominately outpatient care providers. Thus, data on hospitalists' practice patterns, quality and costs of care, and other performance characteristics have been compared with others in the selected specialty, putting hospitalists at a distinct disadvantage on certain measures.

Performance has always been an important clinical consideration, but its impact on reimbursement and public reporting of quality of care is rapidly growing. Medicare uses physician specialty data to look at individual quality, costs, and utilization. CMS’ Value Modifier adjustment to the Physician Fee Schedule and other emerging programs utilize such data.

The new hospital medicine specialty code will permit hospitalists to be compared with their own colleagues, allowing a clear picture of practice and performance characteristics to emerge and demonstrate hospital medicine's value.

Questions about the new specialty code remain. Pediatric hospitalists may have a tough choice about whether to be compared primarily with pediatricians or with all hospitalists in general. How about hospitalists who do both inpatient and outpatient work? Perhaps their choice depends on the predominant focus of their clinical practice. If hospitalists in a group billing under a single tax ID number use different specialty codes, might they then be classified as a multispecialty group subject to different performance benchmarks than single-specialty groups?

Clinicians are allowed to choose which primary specialty code best describes their medical practice, typically the one that constitutes a predominance of their professional services. Medicare expects physicians to select the specialty code that most accurately reflects their clinical practice. Hospitalists and hospital medicine as a whole are likely to benefit by using the new hospital medicine specialty code. Hospitalists in single or multispecialty groups should probably use the new code for clarity and consistency.

Brian Harte, MD, FACP, president-elect of the Society of Hospital Medicine, which lobbied CMS to create the code, sums it up nicely. “The hospitalist provider code will provide Medicare and other players in the health care system an important new tool to better understand and acknowledge the critical role we play in the care of hospitalized patients nationwide,” he told The Hospitalist in February.

Sepsis-3 update

There have been important developments since the new Sepsis-3 definition and criteria were discussed in the April ACP Hospitalist.

The April Coding Corner noted that Sepsis-3 recommendations are inconsistent with the criteria utilized by the Surviving Sepsis Campaign (SSC) guidelines. SSC promptly published a response to Sepsis-3 on its Web site stating the Campaign's intent to “facilitate the continued successes of sepsis screening, early identification and treatment that have been the hallmark of SSC's quality improvement efforts associated with improved survival during the preceding decade.”

SSC further stated that “screening should continue essentially as has been previously recommended by SSC [using Sepsis-2 criteria]...Patients with sepsis (formerly called severe sepsis) should still be identified by the same organ dysfunction criteria [from Sepsis-2 and SSC 2012]....Hospitals should prepare for major changes...[and] educate their physician and nursing staff and their coding departments.”

This could be interpreted as an expression of concern that screening, early identification, and treatment of sepsis could be hampered by Sepsis-3. It indicates that Sepsis-2 and SSC 2012 guidelines should still be followed for diagnosis and that SSC does not exclusively adopt the Sepsis-3 organ dysfunction criteria. Nevertheless, it calls for education and preparation for an eventual transition.

CMS criteria for sepsis, severe sepsis, and septic shock are currently derived from Sepsis-2 and SSC 2012 definitions and are used for the Hospital Inpatient Quality Reporting Program, which grades hospitals on quality performance. The agency has not announced any planned changes based on Sepsis-3.

It seems unlikely that the committee responsible for ICD-10 and Official Coding Guidelines will change its content, which is based on Sepsis-2 criteria, for at least another year and a half.

Meanwhile, Medicare recovery audit contractors may adopt Sepsis-3 criteria for the clinical validation of sepsis. This could prompt many denials of claims for sepsis diagnoses based on Sepsis-2 criteria, resulting in a large number of unfavorable audit decisions. Aggressive appeals by hospitals may be necessary to avoid substantial revenue losses. Stay tuned for more updates as the responses to Sepsis-3 evolve.