Update on PEPPER, Discharge Planning Guidelines, and Coding AMA Discharges

Let’s start with some updates. We have all been Program for Evaluating Payment Patterns Electronic Report (PEPPER)-free for quite a while now, but I can report that there is finally new information.

First, there is a new contractor, Index Analytics, LLC. They appear to do a lot of data work with the federal government, so we will see how they do with PEPPER. From a link that I am not sure is supposed to be live, I can see that the first iteration of the new PEPPER, whenever it appears, will only be mildly seasoned, with just five topics: Stroke Intracranial Hemorrhage, Respiratory Infections, Simple Pneumonia, Septicemia, and Unrelated OR Procedures.

We don’t have a release date for this limited edition of the PEPPER (or the whole rollout).  

Now, call me a skeptic, but I know all of you count on me to approach things with a critical eye – and I already have concerns. The perhaps accidentally posted version of the PEPPER user guide, with release dates of both July and August 2025, indicates that data from claims submitted to Medicare Health Maintenance Organizations (HMOs) will be excluded from inclusion. Why in the world would they not use the proper terminology, Medicare Advantage (MA), in 2025?

While the Centers for Medicare & Medicaid Services (CMS) does refer to HMOs in their publications aimed at patients who may be more familiar with that term, and the PEPPER user guide in 2012 called them HMOs, providers all know (or should know) that these are MA plans. Poor document quality may portend bad product quality.

We shall see.

The other update is that I have it on good authority that we will soon be seeing the interpretive guidelines for the updated discharge planning Conditions of Participation. As you may recall, this update was released in 2019 and added several significant requirements, including providing data on quality and resource use when choice of providers is provided.

These interpretive guidelines are important, because that is what guides the survey organizations when they show up and start asking questions about your discharge planning processes (but of course, only after they check every nursing station for the presence of prohibited cups of coffee or water bottles).

Now, on the “still not updated” side, if you look at the CMS web pages for information on the Recovery Audit Contractor (RAC) program, you will see that they still have four audit targets listed as proposed, with three indicated as pending for nine months and the other pending approval for 14 months.

But the interesting part of that is that two of those four topics are listed on both the Cotiviti and Performant web pages as approved, as of January of this year, a mere 60 days after they were proposed. Why CMS would not update their site is not clear.

Finally, a follow-up on something I have discussed in the past – patients leaving against medical advice (AMA). And I have indicated that I think it is appropriate to code a discharge AMA when the patient insists on discharging to a destination that the medical team feels is not optimal, such as home when skilled nursing facility (SNF) care is recommended because the home situation is not safe for the patient. This allows the hospital to avoid the readmission penalty when things inevitably don’t work out.

Some objected to this broad use of AMA. Well, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) just released a report on AMA discharges, and they agree with me, noting that “CMS could not offer any clinical, regulatory, or professional standards to guide hospitals on when to designate that a patient is leaving AMA, other than citing the use of clinical judgment.” I’ll chalk that up as a win.