Two Rules: IPPS Makes DRG Changes, OPPS Would Relax Supervision

When the 2021 inpatient prospective payment system (IPPS) regulation[1] takes effect in 10 days, there will be a new case mix index (CMI) and geometric mean length of stay (GMLOS) for every MS-DRG, and they will have a ripple effect on hospitals’ benchmarking data for their CMI goals. For example, the CMI for ischemic stroke with major complications and comorbidities (MCC) is going from 2.79 to 2.88, but the GMLOS is dropping from 4.8 to 4.7, which means Medicare will pay more for treating it, but hospitals will need to be a bit more efficient caring for those patients to remain below the mean length of stay. With major small and large bowel procedures with MCC, both the CMI and the GMLOS are going down.

“Every CFO wants to know what their hospital CMI is, and they’re probably budgeted from a CMI goal for the year,” said Ronald Hirsch, M.D., vice president of R1 RCM, at a Sept. 15 webinar sponsored by RACmonitor.com.[2] “Case managers are often held accountable for their numbers, and if the goal is to have a length of stay equal to or less than the GMLOS for their overall admissions, you have to be aware that on Oct. 1, the overall GMLOS goal is going to change.” It’s because CMS moved the target. “Shoot for a new goal,” he said.

That’s one thing worth noting in the 2021 final IPPS rule, which CMS announced Sept. 2. CMS gave hospitals only 30 days from the effective date of the IPPS final rule to incorporate it, a truncated timeline attributed to the COVID-19 pandemic. Hirsch also discussed the proposed OPPS rule,[3] which was published in the Aug. 12 Federal Register.[4] When it’s finalized, hospitals also will have only 30 days to absorb it.

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