DESCRIPTION OF THE HOSPITAL READMISSIONS

REDUCTION PROGRAM (HRRP)

30-DAY READMISSION MEASURES HOSPITAL-
SPECIFIC REPORT
FOR FY 2014 PERFORMANCE PERIOD
JUNE 2013

1
OVERVIEW
The accompanying MicrosoIt Excel Iile contains your Hospital-SpeciIic Report (HSR)
on the 30-day risk-standardized readmission measures (acute myocardial inIarction (AMI), heart
Iailure (HF), and pneumonia (PN)) Ior the perIormance period oI the Federal Fiscal Year (FY)
2014 Hospital Readmissions Reduction Program (HRRP) program (July 2009 June 2012). It
also contains the discharge-level data used to calculate your hospital`s results.
Section I oI this document provides a brieI background oI the Hospital Readmissions
Reduction Program and the FY 2014 30-day readmission measures Review and Corrections
process. Section II provides a detailed description oI the contents oI each worksheet in the HSR
Iile. Section III provides instructions on how to replicate your Excess Readmission Ratio, as part
oI the Review and Corrections process Ior the FY 2014 Hospital HRRP program.
Please see the QualityNet website https.//www.qualitvnet.org/~Hospitals-Inpatient~Hospital
Readmissions Reduction Program Ior more inIormation on the program, the Review and
Corrections process, as well as the methodology used to calculate these measures.
II you have questions about HRRP, your readmission results, or the data in this report,
please submit them to CMSreadmissionsreductionmathematica-mpr.com.
II you have methods questions about the risk-standardized readmission measures in general,
please visit http.//www.qualitvnet.org~Hospitals-Inpatient~Claims-Based Measures~Readmission
Measures or submit them to cmsreadmissionmeasuresyale.edu.
The accompanving file contains discharge-level data that are protected bv the Health
Insurance Portabilitv and Accountabilitv Act of 1996 (HIPAA). It is a violation of HIPAA rules
to share these protected patient-level data with other organi:ations, including the press. E-
mailing protected health information poses a securitv issue, and each HIPAA-covered entitv is
responsible for ensuring compliance with the securitv standards. There are onlv two secure wavs
to send vour patient-level data. (1) encrvpting the data (using a minimum 128-bit encrvption)
and shipping it via a bonded courier with an established chain of custodv (for example the
United States Postal Service or FedEx), and (2) sending it via the government-approved, secure
section of the QualitvNet website (http.//www.qualitvnet.org).
DO NOT EMAIL YOUR HSR. WHEN REFERRING TO THESE DATA, USE ROW
NUMBERS.

2

CONTENTS
OVERVEW ...................................................................................................... 2
BACKGROUND ............................................................................................... 4
FLE CONTENTS AND DESCRPTONS ......................................................... 6
A. Hospital Results Worksheet ....................................................................... 6
B. Discharge-level Worksheets ...................................................................... 7
REPLCATON NSTRUCTONS ................................................................... 11
Step 1: dentify ndex Discharges ................................................................... 12
Step 2: Calculate the Predicted Readmission Rate ........................................ 13
Step 3: Calculate Expected Readmission Rate .............................................. 16
Step 4: Calculate Excess Readmission Ratio ................................................ 17
TABLES
1 Hospital Results Worksheet ........................................................................................ 6
2 Discharge-Level Data Elements .................................................................................. 7
3 Risk Factor Variables ncluded in Discharge-Level Worksheets, by
Measure ...................................................................................................................... 9
FIGURES
1 Replication Step 1 ..................................................................................................... 12
2 Replication Step 2a ................................................................................................... 13
3 Replication Steps 2b & 2c ......................................................................................... 14
4 Replication Step 2d ................................................................................................... 15
5 Replication Step 2e ................................................................................................... 15
6 Replication Steps 3c & 3d ......................................................................................... 16
7 Replication Step 3e ................................................................................................... 17
8 Replication Steps 4 ................................................................................................... 17
3

I. BACKGROUND
Section 3025 oI the 2010 AIIordable Care Act (P.L. 111-148) requires the Secretary oI the
Department oI Health and Human Services to establish a Hospital Readmissions Reduction
Program whereby the Secretary would reduce Inpatient Prospective Payment System (IPPS)
payments to hospitals Ior excess readmissions beginning on or aIter October 1, 2012 (Federal
Fiscal Year (FY) 2013). The AIIordable Care Act Iurther requires the Secretary to adopt the
three National Quality Forum (NQF) endorsed 30-day Risk-Standardized Readmission measures
Ior acute myocardial inIarction (AMI), heart Iailure (HF), and pneumonia (PN) Ior the Hospital
Readmissions Reduction Program beginning in October 2012. To comply with these
requirements, the Centers Ior Medicare & Medicaid Services (CMS) calculates Excess
Readmission Ratios Ior these three readmission measures based on the NQF-endorsed
methodology, using discharges Irom a prior period.
CMS has been calculating and publicly reporting these three NQF-endorsed readmission
measures Ior the Hospital Inpatient Quality Reporting (IQR) Program since 2009. It is
important to note that the set of hospitals among which these three measures are calculated
for the Hospital Readmissions Reduction Program differs from those used in calculations
for the IQR Program. The Hospital Readmissions Reduction Program includes only
subsection(d) hospitals and hospitals paid under section 1814(b)(3) (i.e. Maryland
hospitals). Consequently, your hospital-specific Excess Readmission Ratios for AMI, HF,
and PN may differ from those calculated for IQR because they are calculated using a
different set of hospitals. See Section III below for details.
The Excess Readmission Ratios are used to determine the payment adjustment Ior each
eligible hospital. The Excess Readmission Ratio is a measure oI relative perIormance. II a
hospital perIorms better than an average hospital that admitted similar patients (that is, patients
with similar risk Iactors Ior readmission such as age and comorbidities), the ratio will be less
than 1.0000. II a hospital perIorms worse than average, the ratio will be greater than 1.0000. As
proposed in the FY 2014 IPPS Proposed Rule, CMS intends to report these ratios in the FY 2014
IPPS Final Rule in August 2013 as well as on the Hospital Compare website
(http.//www.hospitalcompare.hhs.gov/) in October 2013. (For inIormation regarding the
calculation oI the readmission adjustment, visit http.//cms.gov/Medicare/Medicare-Fee-for-
Service-Pavment/AcuteInpatientPPS/Readmissions-Reduction-Program.html.)
This document is intended as a tool to help you understand the data in your HSR. Section II
oI this document describes the data tables provided in the HSR, including the discharge-level
data worksheets. Additionally, Section III oI this document provides explanations oI data used
and step-by-step instructions Ior replicating the Excess Readmission Ratios Irom your discharge
data, using mock data to provide a sample calculation. Hospitals are encouraged to reIer to the
sample steps included below when replicating their measure results. The accompanying
Hospital-SpeciIic Report (HSR) Excel Iile contains your hospital`s measure results and
discharges Ior the FY 2014 perIormance period.
CMS is providing hospitals these detailed data and step-by-step instructions to allow them to
review and submit corrections on inIormation used to calculate the 30-day readmission
measures. The Review and Corrections period will run Irom June 13, 2013 July 12, 2013.
Hospitals that have concerns about their calculation should submit a question using the Iollowing
4

email address: CMSreadmissionsreductionmathematica-mpr.com no later than 11:59 p.m.
PT on July 12, 2013. Please note, however, the Review and Corrections process that CMS has
proposed does not allow hospitals to submit additional corrections related to the underlying
claims data, or to add new claims to the data extract used to calculate the results.

5

II. FILE CONTENTS AND DESCRIPTIONS
Your HSR has been created as a read-only document to prevent unintentional changes. II
you wish to retain changes/edits to the Iile, you will need to use the 'Save As option to save the
document under a diIIerent name.
A. HospitaI ResuIts Worksheet
The Iirst worksheet in the HSR Iile (Table 1 Hospital Results) presents your number oI
eligible discharges and number oI readmissions; your predicted and expected readmission rates;
your Excess Readmission Ratio; and the national crude readmission rate. The data period Ior
calculating the Excess Readmission Ratio Ior the FY 2014 program is discharges Irom July 1,
2009 through June 30, 2012. Table 1 contains the Iollowing elements:
TabIe 1: HospitaI ResuIts Worksheet
COLUMN NAME DESCRIPTION
Measure Readmission measure. AM = acute myocardial infarction; HF= heart failure; PN =
pneumonia.
Number of Eligible
Discharges at Your
Hospital
Number of discharges at your hospital that meet the inclusion criteria for each
readmission measure during the data period of interest.
Note: Results for hospitals with fewer than 25 eligible discharges will not be used to
calculate the score for that measure for the FY 2014 program; results are shown for
your information.
Number of Readmissions
at Your Hospital
Number of eligible discharges that had a readmission within 30 days from the date of
index discharge.
Predicted Readmission
Rate
The 30-day readmission rate predicted on the basis of your hospital's performance
with its observed case mix and your hospital's estimated effect on readmissions
(provided in your hospital discharge-level data).
Expected Readmission
Rate
The 30-day readmission rate expected on the basis of average hospital performance
with your hospital's case mix and the average hospital effect (provided in your hospital
discharge-level data).
Excess Readmission Ratio Ratio of predicted readmission rate to the expected readmission rate.
National Crude
Readmission Rate
The number of readmissions nationally divided by the number of eligible discharges
nationally.
6

B. Discharge-IeveI Worksheets
The last three worksheets in the HSR Iile contain discharge-level inIormation Ior each
measure. DO NOT EMAIL THESE WORKSHEETS OR ANY OF THEIR CONTENTS
BECAUSE THEY CONTAIN PERSONALLY IDENTIFIABLE INFORMATION. WHEN
REFERRING TO THESE DATA, USE ROW NUMBERS. There is one worksheet Ior each
condition:
'Table 2 Discharges AMI Readm
'Table 3 Discharges HF Readm
'Table 4 Discharges PN Readm
These worksheets contain inIormation on discharges Ior patients with AMI, HF, and PN that
were considered Ior inclusion in the 30-day Risk-Standardized Readmission measure
calculations Ior your hospital Ior the FY 2014 Hospital Readmission Reduction Program. These
data are designed to assist you in reviewing the discharges used Ior these calculations and Ior
replicating your Excess Readmission Ratios contained in Table 1 oI the Hospital-SpeciIic Report
(HSR) that you received.
Each worksheet contains discharge-level data Ior all Part A Medicare Fee-Ior-Service (FFS)
patient stays with a principal discharge diagnosis oI AMI, HF, or PN with a discharge date
between July 1, 2009 and June 30, 2012, Ior patients who were aged 65 and above at the time oI
admission.
Each worksheet includes the Iollowing data elements:
TabIe 2: Discharge-LeveI Data EIements
COLUMN VARIABLE NAME DESCRIPTION
CoIumn A HCNO 10-11 digit Medicare health insurance claim account number. Note: This
not the same as the SSN.
CoIumn B Medical Record Number Patient medical record number on claim
CoIumn C Beneficiary DOB Patient date of birth (MM/DD/YYYY)
CoIumn D Admission Date of ndex
Stay
Hospital admission date (MM/DD/YYYY)
CoIumn E Discharge Date of ndex
Stay
Hospital discharge date (MM/DD/YYYY)
CoIumn F Primary Diagnosis Primary diagnosis of the index stay
CoIumn G Discharge Destination
Location to which the patient was discharged
See the ResDAC site for the coding of this variable:
http://www.resdac.org/cms-data/variables/patient-discharge-status-code
CoIumn H ndex Stay
Flag for index stay included in measure calculation
YES: Stay was included in measure calculation
NO: Stay was excluded from measure calculation
7
8

COLUMN VARIABLE NAME DESCRIPTION
CoIumn I Exclusion Reason Each number represents one of six possible reasons below for exclusion
from measure calculation. A value of '0' indicates that no exclusions
were applicable for that admission and it was included in the measure
calculations; any value of '1' through '6' indicates that this exclusion
applied to that admission, thus excluding it from the readmission
measure. Note that any admission may have multiple reasons for being
excluded.*
0 Admission is included in measure calculation
1 Patient not enrolled in FFS Parts A and B during the 12 consecutive
months prior to the index admission, or in the 30 days after discharge
(incomplete administrative data) (Medicare patients only)
2 Patient died during index hospitalization
3 Patient left against medical advice (AMA)
4 Patient was transferred to another acute care facility
5 Patient was admitted and discharged on same day (AM only)
6 Additional admission within 30 days of discharge from an index
admission (an admission cannot be considered both an index
admission and a readmission; therefore, admissions within 30 days of
discharge are considered potential readmissions)
CoIumn J Unplanned Readmission
Within 30 days
Unplanned readmission within 30 days
YES: Patient readmitted within 30 days of index stay discharge date
NO: Patient not readmitted within 30 days of index stay discharge date
CoIumn K Planned Readmission
Planned readmission within 30 days
YES: Patient readmitted within 30 days of index stay discharge date for
planned procedure
NO: Patient not readmitted within 30 days of index stay discharge date
for planned procedure
CoIumn L Readmission Date
Date of readmission (MM/DD/YYYY) (only reported if patient is
readmitted within 30 days of index discharge date)
CoIumn M Readmission to Same
Hospital
Readmission to same hospital (only reported if patient is readmitted
within 30 days of index discharge date)
YES: Readmission was to your hospital
NO: Readmission was to a hospital other than yours
CoIumn N Provider D of Readmitting
Hospital
CCN (6-digit provider D) of the hospital to which the patient was first
readmitted within 30 days of the index discharge
1

CoIumn O Primary Diagnosis of
Readmission
Primary discharge diagnosis for first readmission stay
CoIumn P Discharge Date of
Readmission
Date of discharge from readmission (MM/DD/YYYY) (only reported if
patient is readmitted within 30 days of index discharge)
1
An interactive listing oI hospital provider IDs and name and location can be Iound at the Iollowing link:
https://data.medicare.gov/dataset/Hospital-General-InIormation/v287-28n3.


COLUMN VARIABLE NAME DESCRIPTION
CoIumns
AMI: Q-AU
HF: Q-BA
PN: Q-BD
Risk Factor Variables**
These columns contain model risk factors, and will vary by measure.
Table 3 below indicates which variables are included in each of the three
worksheets.
Row 7 in the HSR contains the model coefficients for each risk factor,
estimated over data for all hospitals.
Beginning in row 8 of the HSR, the file contains a '1' if that patient was
identified as having that risk factor (and equals the years above 65 for
the AGE_65 variable); '0' otherwise. See Table 3 below for a comparison
of the risk factors across the three measures.
CoIumn
AMI: AV
HF: BB
PN: BE
HOSP_EFFECT Hospital-specific effect*
This is the same across all discharges for your hospital, and is only
provided in row 7.
CoIumn
AMI: AW
HF: BC
PN: BF
AVG_EFFECT Average hospital effect*
This is the same across all discharges, and is only provided in row 7.
* For more information on the 30-day readmission model exclusion criteria and the calculation of the hospital specific
and average effect, see https://www.qualitynet.org>Hospitals-npatient>Claims-Based Measures>Readmission
Measures.
** These variables are provided only for discharges that were included in the measure calculation.


TabIe 3: Risk Factor VariabIes IncIuded in Discharge-LeveI Worksheets, by Measure
VARIABLE NAME DESCRIPTION AMI HF PN
MaIe Male Gender Yes Yes Yes
ACS Acute coronary syndrome Yes Yes Yes
AMI_ANT Anterior myocardial infarction Yes No No
AMI_OTH Other location myocardial infarction Yes No No
ANGINA_MI Angina pectoris/old myocardial infarction Yes No No
ARRHYTHMIAS Arrhythmias Yes Yes Yes
ASTHMA Asthma Yes Yes Yes
CAD Chronic atherosclerosis Yes No No
CAD_ANGINA Coronary atherosclerosis or angina No Yes Yes
CANCER Cancer Yes Yes No
CARDIO_RESPIRATORY Cardio-respiratory failure or shock No Yes Yes
CHF History of congestive heart failure Yes Yes Yes
COPD Chronic obstructive pulmonary disease Yes Yes Yes
CVD Cerebrovascular disease Yes No No
DEMENTIA Dementia or other specified brain disorders Yes Yes Yes
DEPRESSION Depression No Yes No
DIABETES Diabetes or DM complications Yes Yes Yes
DECUBITUS_ULCER Decubitrus ulcer or chronic skin ulcer Yes Yes Yes
DIS_FLUID Disorders of fluid/electrolyte/acid-base Yes Yes Yes
DRUG_ALCOHOL Drug/alcohol abuse/dependence/psychosis No Yes Yes
ESLD End-stage liver disease No Yes No
ESRD_DIALYSIS End-stage renal disease or dialysis Yes Yes Yes
HEMATOLOGICAL Severe hematological disorders No Yes Yes
HXCABG History of coronary artery bypass graft (CABG) surgery Yes Yes Yes
9

VARIABLE NAME DESCRIPTION AMI HF PN
HXPCI History of percutaneous transluminal coronary angioplasty
(PTCA)
Yes No No
INFECTION History of infection Yes No Yes
IRON DEFICIENCY ron deficiency or other unspecified anemias and blood disease Yes Yes Yes
MAJOR_PSYCH Major psychiatric disorders No Yes Yes
MALNUTRITION Protein-calorie malnutrition Yes Yes Yes
MCANCER Metastatic cancer or acute leukemia Yes Yes Yes
LUNGCANCER Lung or other severe cancers No No Yes
LUNG_FIBROSIS Lung fibrosis or other chronic lung disorders No Yes Yes
VAL_RHE_HEART Valvular or rheumatic heart disease Yes Yes Yes
NEPHRITIS Nephritis No Yes No
OTHERCANCER Other major cancers No No Yes
OTHERLUNG Other lung disorders No No Yes
OTHER_GI Other gastrointestinal disorders No Yes Yes
OTHER_HEART Other heart disorders No Yes No
OTHER_INJURIES Other injuries No No Yes
OTHER_PSYCH Other psychiatric disorders No Yes Yes
OTHER_UTD Other urinary tract infection Yes Yes Yes
PARALYSIS_FUNCTDIS Hemiplegia, paraplegia, paralysis, functional disability Yes Yes Yes
PEPTIC_ULCER Peptic ulcer, hemorrhage, other specified gastrointestinal
disorders
No Yes No
PLEURALEFFUSION Pleural effusion/pneumothorax No No Yes
PNEUMONIA History of pneumonia Yes Yes Yes
RENAL_FAILURE Renal Failure Yes Yes Yes
SEPTICEMIA Septicemia/shock No No Yes
STROKE Stroke Yes Yes Yes
UTI Urinary tract infection No No Yes
VASDIS_WCOMP Vascular or circulatory disease Yes Yes Yes
VERTEBRAL_FRACTURES Vertebral fractures No No Yes
AGE_65 Age above 65 Yes Yes Yes
* Please note that the risk factor order in the discharge-level worksheets varies by condition.
10
11

III. REPLICATION INSTRUCTIONS
This section provides a step-by-step guide, using mock data Ior the 30-day AMI measure Ior
replicating the Excess Readmission Ration Iound in your Hospital-SpeciIic Report (HSR).
Hospitals are reminded that this section is intended to serve as a guide in understanding the
calculation steps, but except Ior the national rate and risk Iactor coeIIicients, contains mock data.
Following these steps with your own hospital`s data will allow you to veriIy your results
presented in Table 1 oI your HSR Excel Iile.
2

Presented below is an example oI a hospital with nine qualiIying cases Ior the AMI 30-day
risk-standardized AMI readmission measure.
3
Each step is Iollowed by an image oI the process
in Excel. An Excel Iile combining the steps (and showing Iormulas) is also available upon
request, by contacting CMSreadmissionsreductionmathematica-mpr.com with the subject
line: HRRP Example.

2
Note: Hospitals cannot replicate every step in the measure calculation process because it requires national
data. The data elements provided in the discharge-level data sheets, such as model coeIIicients and intercept terms,
will allow you to replicate how these were applied to your hospital`s data to get the resulting excess readmission
ratio used in the program.
3
Results Irom a measure with less than 25 eligible discharges would not be used Ior calculating the payment
adjustment Ior the program; case size is limited here Ior presentation ease.


Step 1: Identify Index Discharges
Limit your replication calculations to rows where "Exclusion Reason" (column I) equals 0`.
In this example, this is true Ior the discharges in rows 8 - 16.
Figure 1: RepIication Step 1

*Important Step ClariIications:
Exclusion Reason: Discharges that were excluded Irom the model, i.e. those Ior
which the exclusion reason is not equal to zero, do not show risk Iactors starting in
column Q and should not be included in the replication steps.
12

Step 2: CaIcuIate the Predicted Readmission Rate
2a. For each eligible discharge, multiply each risk Iactor Ilag by the relevant coeIIicient. In the
mock HSR below, cells Q8-Q16 (MALE) are each multiplied by cell Q7. This is repeated
Ior all risk Iactor columns.
Figure 2: RepIication Step 2a

*Important Step ClariIications:
When multiplying the risk Iactor Ilags by the coeIIicients in your discharge data, be
sure to use all the decimal places in the coeIIicient cell value (some may be cut oII
due to Iormatting.) Using an Excel Iormula that reIerences the cell will ensure that
the Iull data value is used.
Only do this step Ior the risk-Iactor columns beginning with column Q (MALE) and
ending with the 'AGE65 variable Ior each measure.
The coeIIicients in row 7 Ior each risk Iactor will vary by measure, but are the same
across all hospitals.
2b. Sum all the products (risk Iactor Ilags * coeIIicient) Irom Step 2a Ior each discharge.
2c. Add your HOSPITALEFFECT to the sum oI risk Iactor Ilags * coeIIicients (Irom step 2b).
13

Figure 3: RepIication Steps 2b & 2c

*Important Step ClariIication:
The coeIIicients used in this example Ior HOSPEFFECT are mock and should not
be used in your actual calculation Ior replication. In this example, the value Irom cell
AV7 is added to each oI the sum oI products in cells AX22 through AX30.
2d. In Excel, insert the results Irom Step 2c using the Iormula below, where exp( ) is the
exponential Iunction in Excel and the variable STEP2C is the cell reIerence to the result
Irom Step 2c. This is the predicted probability oI readmission Ior each discharge.
Equation (1) Predicted probability Ior each discharge

1 1 exp 1 2 STEP C
14

Figure 4: RepIication Step 2d

2e. Sum the results Irom Step 2d Ior all qualiIying discharges (rows), and divide by the number
oI qualiIying discharges (all rows Ior which Index Stay equals YES`), and multiply this
result by 100. Do not round. This is the predicted rate oI readmission Ior your hospital and
rounded to one decimal place it should match the number in Column D oI Table 1 in your
HSR.
Figure 5: RepIication Step 2e

15

Step 3: CaIcuIate Expected Readmission Rate
3a. Same as Step 2a. You can use the results Irom step 2a.
3b. Same as Step 2b. You can use the results Irom step 2b.
3c. Add the AVGEFFECT to the sum oI risk Iactor Ilags*coeIIicients (Irom Step 3b).
3d. In Excel, insert the results Irom Step 3c using the Iormula below, where exp( ) is the
exponential Iunction in Excel and STEP3C is the cell reIerence to the result Irom Step 3c.
This is the expected probability oI a 30-day readmission Ior the stay.
Equation (2) Expected Probability

1 1 exp 1 3 STEP C
Figure 6: RepIication Steps 3c & 3d

3e. Sum the results Irom Step 3d Ior all qualiIying discharges (rows), and divide by the number
oI qualiIying discharges (all rows Ior which the Exclusion Reason equals 0`), and multiply
this result by 100. Do not round. This is the expected rate oI readmission Ior your hospital
and rounded to one decimal place it should match the number in Column E oI Table 1 in
your HSR.
16

Figure 7: RepIication Step 3e


Step 4: CaIcuIate Excess Readmission Ratio
Divide the (unrounded) Predicted Readmission Rate (Irom Step 2e) by the (unrounded)
Expected Readmission Rate (Irom Step 3e) to calculate the Excess Readmission Ratio, and round
to the Iourth decimal point. This number should match the Excess Readmission Ratio in column
F oI Table 1 in your HSR.
Figure 8: RepIication Steps 4

17