Desarrollo de la propuesta

Service Line Category

MS-DRG

1 = Maternity Care

765-768, 774, 775 (Note: While the Federal Register classifies these codes as

medical or surgical, for HCAHPS they are to be coded as Maternity Care.)

2 = Medical 52-103, 121-125, 146-159, 175-208, 280-282, 286-316, 368-395, 432-446, 533- 566, 592-607, 637-645, 682-700, 722-730, 754-761, 776-782, 808-816, 834- 849, 862-872, 913-923, 933-935, 947-951, 963-965, 974-977 3 = Surgical 1-13, 20-42, 113-117, 129-139, 163-168, 215-265, 326-358, 405-425, 453-517, 573-585, 614-630, 652-675, 707-718, 734-750, 769, 770, 799-804, 820-830, 853-858, 901-909, 927-929, 939-941, 955-959, 969, 970, 981-989 M = Ineligible 283-285, 789-795, 876, 880-887, 894-897, 945, 946, 998, 999

Note: MS-DRGs in the ineligible category include patients with newborn, psychiatric,

rehabilitation, or deceased MS-DRGs, and MS-DRGs with no assigned type. Should a patient with an ineligible MS-DRG be drawn into the sample, please code, Service Line, as “M – Missing,” and then code, Final Survey Status, as “3 - Ineligible: Not in eligible population.” 1

This table of MS-DRG codes was updated on October 1, 2008 and is based on: Federal Register Notice, Vol.73, No.161, August 19, 2008.

M

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Overview

This section describes guidelines for the mail only mode of survey administration.

Data collection for sampled discharged patients must be initiated between 48 hours and six weeks (42 days) after discharge. Hospitals/Survey vendors must wait 48 hours to make the first attempt to contact discharged patients. This will allow enough time to pass for the patient to return home and feel settled after his or her hospital stay. Patients must not be given the survey while they are still in the hospital. Hospitals/Survey vendors will send sampled patients a first questionnaire with a cover letter. A second questionnaire with a follow-up cover letter must be sent to all sampled patients who did not respond to the first questionnaire approximately 21 days after the first questionnaire mailing.

Note: If after the first mailing the hospital/survey vendor learns that a patient is ineligible for HCAHPS, the hospital/survey vendor must not send the patient the second questionnaire. After

the sample has been drawn, any patients who are found to be ineligible must not be removed or replaced in the sample. Instead, these patients are assigned the “Final Survey Status” code of ineligible. An administrative record must be submitted for these patients.

Data collection must be closed out for a particular patient by six weeks (42 days) following the mailing of the first questionnaire. Patients who receive the HCAHPS survey must not be offered incentives of any kind. Patients who do not respond to the survey are assigned a “Final Survey Status” code of non-response.

Hospitals/Survey vendors must make every reasonable effort to ensure optimal survey response rates and to pursue contacts with potential respondents until the data collection protocol is completed.

No proxy respondents are permitted in the administration of the HCAHPS survey, not even for patients who are critically ill, elderly, physically or mentally impaired, or are coming to the hospital from other institutions, such as nursing homes. As stated above, a proxy must not answer the survey questions for the respondent, however, an individual may assist the patient with reading the survey, writing responses, or translation of the survey, but only the patient may provide answers to the survey.

The basic tasks and timing for conducting the HCAHPS survey using the mail only mode of survey administration are summarized below.

Mail Only Survey Administration

Send first questionnaire with initial cover letter to sampled patient(s) between 48 hours and six weeks (42 days) after discharge.

Send second questionnaire with follow-up cover letter to non-respondent(s) approximately 21 days after the first questionnaire mailing.

Complete data collection within six weeks (42 days) after the first questionnaire mailing.

Submit final data files to CMS via My QualityNet by the data submission deadline. No files will be accepted after the submission deadline date.

To reiterate, the initial mail-out of the survey questionnaire must occur between 48 hours and six weeks (42 days) after discharge. Data collection must then be completed no later than six weeks (42 days) after the initial mail-out. To illustrate, examples are provided of two patients who were discharged from a hospital on January 1 (not a leap year).

Patient 1:

¾ The first survey is mailed out on January 4 (three days after discharge)

¾ If the patient has not returned the survey by January 25 (21 days after the initial mailing on January 4), a second survey is mailed out

¾ Data collection must be closed out on February 15for this patient, which is six weeks (42 days) after the January 4 initial mail-out date

¾ If the survey is returned on February 15, which is the last day of the survey administration time period for this patient, then the survey is included in the final survey data file; the Lag Time (See Data Specifications and Coding section) for this patient is calculated as 45 days

¾ If the survey is returned after February 15 (after the survey administration time period for this patient), then the survey is not included in the final survey data file (however, an

administrative record is submitted for this patient) and a “Final Survey Status” code “8 − Non-response: Non-response after maximum attempts” is assigned; the Lag Time for this patient is coded as “888 – Not applicable”

Patient 2:

¾ The first survey is mailed out on February 12 (42 days after discharge)

¾ If the patient has not returned the survey by March 5 (21 days after the initial mailing on February 12), a second survey is mailed out

¾ Data collection must be closed out on March 26 for this patient, which is six weeks (42 days) from the February 12 initial mail-out date

¾ If the survey is received on March 26, which is the last day of the survey administration time period for this patient, then the survey included in the final survey data file and the Lag Time for this patient is calculated as 84 days

¾ If the survey is received after March 26 (or after the survey administration time period for this patient), then the survey is not included in the final survey data file (however, an

administrative record is submitted for this patient) and a “Final Survey Status” code “8 − Non-response: Non-response after maximum attempts” is assigned; the Lag Time for this patient is coded as “888 – Not applicable”