Aligning Payment with Quality: OPPS and the Hospital Outpatient Quality Reporting (OQR) Program

The Hospital OQR program is a pay-for-reporting quality data program for hospital outpatient services.

As a coding professional with 20-plus years of coding and documentation integrity experience under my belt, I humbly recognize that I don’t know everything, and must stay curious and open to learning the ever-changing world of coding, documentation, and reimbursement methodologies. This allows me to remain relevant as a professional and continue to add value to the organization I work for; I hope and trust all of you feel the same way.

As I was preparing a presentation late last year on the American Medical Association (AMA) CPT® Coding updates and the Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule for the 2021 calendar year, I stumbled upon the requirements for the Hospital Outpatient Quality Reporting (OQR) Program.

For many years my interest in CPT and OPPS updates has centered around the CPT changes, the OPPS Ambulatory Payment Classification (APC) and payment status indicator updates, the inpatient-only list, and the OPPS pass-through payments for devices, drugs, biologicals, and radiopharmaceuticals, etc. I must admit, I have not really focused too much on the OQR Program.

Although OPPS began in August 2000, the Hospital OQR program was mandated by the Tax Relief and Health Care Act of 2006, and became effective for payment beginning in the 2009 calendar year. The Hospital OQR program is a pay-for-reporting quality data program for hospital outpatient services, and requires hospitals to meet quality reporting requirements or get a 2-percentage point reduction in their annual payment update. Hospitals qualify for the full OPPS update factor by submitting required quality data for specific quality-of-care measures. Measures of quality may be of various types, including those of process, structure, outcome, and efficiency. In addition to providing hospitals with a financial incentive to report their quality-of-care measure data, the Hospital OQR Program provides the Centers for Medicare & Medicaid Services (CMS) with data to help Medicare beneficiaries make more informed decisions about their healthcare. Hospital quality-of-care information gathered through the Hospital OQR Program is available on the CMS.gov Hospital Compare website.

The table below shows the quality measures for 2021. Currently there are 15 quality measures, including two outcomes-based measures added in 2020. For some of the measures, the data is abstracted from the medical record; for some of the measures, the data is captured via CART, the web-based CMS Abstraction and Reporting Tool; and the outcomes data is captured from hospital outpatient claims. The measures focus on high-impact services and support national priorities for improved quality and efficiency of care for Medicare beneficiaries. For 2021, CMS did not make any changes to the measures used for payment determination. They did, however, finalize a review and corrections period for web-based measures. This review and correction period would run concurrently with the submission period. This would allow hospitals to enter, review, and correct data submitted directly to CMS prior to the submission deadline.

The patient is at the center of everything we do. The accuracy of documentation and the accuracy of coded data impacts healthcare organization and patient care. As coding and documentation integrity professionals, we should know what is being measured and why, and how we can help. Can an outpatient clinical documentation improvement (CDI) program incorporate some of these measures that require abstracting into their work responsibilities? Can an outpatient CDI program bring awareness of the measures and the data collected, and provide it to the impacted clinical areas? Can an outpatient CDI program collaborate with the quality department to strengthen the data collected and reported? Quality reporting, in some capacity, is certainly something to consider for your outpatient CDI program.

Programming Note: Listen to Colleen Deighan report this story live today during Talk Ten Tuesdays, 10-10:30 a.m. Eastern.