Reducing Acute Inpatient Readmissions for Pneumonia

Published 10/15/2020

This Electronic Comparative Billing Report (eCBR) focuses on providers who submit claims for pneumonia and experience unplanned hospital readmissions. eCBR information is one of the many tools used by Palmetto GBA to assist individual providers in identifying variation and improving performance. Palmetto GBA is collaborating with MCG, a subsidiary of the Hearst Health Network, to focus on improving the interactions of providers and payers and to facilitate the implementation of evidence-based medicine.

The collaboration will promote the use of information contained in Palmetto GBA’s eCBRs and the MCG Care Guidelines to help hospitals and physicians in A/B MAC Jurisdiction M improve their readmission rates using evidence-based medicine. Palmetto GBA currently uses Comparative Billing Reports (CBRs) as educational tools for providers to give them insights into their billing patterns and utilization of services in comparison to their peers. eCBRs are available to Palmetto GBA providers via the eServices provider portal where they have the ability to view and download their individual eCBRs. The eCBR displayed includes links to additional education material, in this case MCG Care Guidelines.

Providers are encouraged to conduct a self-audit to compare their historical performance in comparison to others in their respective states and A/B MAC Jurisdictions. The collaboration with MCG will enhance the availability of educational information to both hospitals and physicians and establish a common language via the eCBR platform. Based on Palmetto GBA’s experience working with both physicians and institutional providers, this level of communication among physicians, hospitals and payers will be required to sustainably improve the performance of our healthcare system. Palmetto GBA has partnered with MCG to proactively communicate care guidelines alongside data analysis to increase efficiency and lessen the need for readmission for same and/or similar diagnoses.

MCG’s Inpatient and Surgical Care guidelines provide evidence-based criteria and other tools for efficient review of utilization and documentation of medical necessity, making it a valuable resource for proactive care management and assessment of patients facing hospitalization or surgery. The guidelines are designed to be used in conjunction with a provider’s clinical judgment. Please visit MCG’s website for additional information at http://www.mcg.com.

For your personalized Pneumonia MCG results Logon to eServices.

Pneumonia MCG category code (M 282–284) Defined

MCG Code
Guideline Title
MCG Service Category
MCG Guideline Category
Goal Length of Stay
M-282
Pneumonia, Community Acquired
MEDICAL
THOR
Ambulatory or 2 Days
M-283
Pneumonia Due to Aspiration
MEDICAL
THOR
3 Days
M-284
Pneumonia Due to Pneumocystis
MEDICAL
THOR
4 Days

Webinar: Pneumonia DRG 193-195 with MCG Health Webinar

Methods
The metrics reviewed in this CBR are the readmission rates under any diagnoses and the readmission rates under pneumonia diagnoses. A provider is considered to have an all-inclusive readmission when a beneficiary has been admitted to a hospital under any diagnoses within 30 days after discharge for pneumonia. Meanwhile, a provider is considered to have a pneumonia-specific readmission when a beneficiary has been admitted to a hospital under pneumonia diagnoses within 30 days after discharge for pneumonia. The readmission rate for all-inclusive diagnoses or pneumonia-specific diagnoses is calculated as number of readmissions for all-inclusive diagnoses or pneumonia-specific diagnoses over the number of all admissions during the past six (6) months, respectively. For the purpose of this CBR, “peer group” is defined as other providers in the state you are in or Jurisdiction M (JM) that have billed the grouping of MCG category of pneumonia.

Below is an example of eCBR Results that can be viewed using the eServices portal:

Example of eCBR Results that can be viewed using eServices porta.