Administrative Memos

200107

FROM: Theodore O. Will, Chief Executive Officer
DATE: Jul 06, 2001
SUBJECT: NYPORTS Review Process
IPRO CONTACTS:

Doreen Walz, Assistant Director, Medicaid Psychiatric Review Program, ext 444

IPRO has been authorized by the New York State Department of Health Bureau of Hospital Services (DOH) to validate the reporting of occurrences as defined by Public Health Law and regulation involving Medicaid discharges to the New York Patient Occurrence Reporting and Tracking System (NYPORTS) Tracking System.

The New York Patient Occurrence Reporting and Tracking System (NYPORTS) is an adverse event reporting system implemented pursuant to New York State Public Health Law Section 2805-I, Incident Reporting. For the purpose of NYPORTS reporting, an occurrence is an unintended adverse and undesirable development in an individual patient's condition occurring in a hospital. Most occurrences reported are tracked and trended as groups and are reported on a short form. More serious occurrences such as for example as patient deaths or impairments of bodily functions in circumstances other than those related to the natural course of illness, disease, or proper treatment in accordance with generally accepted medical standards, are investigated individually and require the hospital to conduct a root cause analysis. All adverse events are not medical errors and should not be considered as such. NYPORTS does collect individual case reports on medical errors but the volume of medical errors in NYPORTS is a small percentage compared to the overall volume of reporting.

Discussed below is the sampling process to be utilized and how it will be integrated into the current review process.

I. Sampling Methodology

The NYPORTS validation will be conducted on cases admitted to the hospital on or after June 1, 2000 for cases selected for review beginning July, 2001.
Cases will be identified in the following manner:
A NYPORTS validation will be required on cases flagged for mortality, complications and readmission sets. (Selection criteria for these flags can be found in Medicaid Administrative Memorandum #2001-01)
Any cases selected for review in other categories can potentially be reviewed for NYPORTS if the reviewer identifies a reportable event during the course of another review.

II. Review Process

1. Preliminary Review

All cases selected with the mortality, complication and readmission flags will be reviewed for a NYPORTS occurrence by the nurse reviewers. These cases will also be subject to a full IPRO review that includes utilization, and DRG validation. If all aspects under review are deemed satisfactory, the reviewer will approve the case and the review will end.
Any case with flags other than those identified above that has a potential quality issue identified will have the NYPORTS categories searched as well as the MRAF categories. If a NYPORTS code is not selected the case will follow the regular IPRO quality review process. If a NYPORTS code is selected the case will follow the process listed below. (Quality review criteria can be found in Medicaid Administrative Memorandum 2001-02)
When a possible NYPORTS occurrence is identified the reviewer will select the appropriate NYPORTS code and write a summary of the occurrence as it is documented in the chart.
Identified potential or quality concerns are currently classified using the Medicaid Reviewer Assessment Format (MRAF) which is a method of categorizing decisions made by the reviewer. The NYPORTS codes will be added to the MRAF categories. A reviewer will search the NYPORTS codes first to categorize the identified potential quality issue. If the issue does not fit the NYPORTS categories the reviewer will then proceed to the MRAF categories. If a NYPORTS code is selected a NYPORTS validation will be conducted and the MRAF categories will be ignored.

2. Preliminary Notice of Potential NYPORTS OCCURRENCE

As a result of the review the hospital will receive a preliminary notice of a potential NYPORTS issue that will identify the NYPORTS code and a date(s) indicating where in the chart the issue was identified. The hospital will be asked to either agree or disagree that a NYPORTS issue was identified and indicate if the issue was reported to the NYPORTS tracking system. The hospital will have 45 days to respond to IPRO on the potential NYPORTS concern.
If the hospital agrees with the issue and reported the case to NYPORTS they must respond back to IPRO by indicating agreement and date the case was reported to NYPORTS. If no other issues are identified, i.e., DRG/coding change, no further correspondence on the case will occur.
If the hospital agrees with the issue but has not reported the case to NYPORTS the hospital will have to report the issue to NYPORTS and notify IPRO of the agreement, NYPORTS identified code and NYPORTS System report date. Again, if no further issue(s) is identified, no further correspondence on the case will occur.
If the hospital agrees that a NYPORTS reportable incident occurred, but does not agree with the NYPORTS code selected by IPRO the hospital must respond back to IPRO by indicating agreement, indicate the NYPORTS code they selected and write a rationale for which NYPORTS code selected.
If the hospital disagrees that a NYPORTS reportable incident occurred they must respond back to IPRO with a rationale why and send in a copy of the chart (if not already sent to IPRO) and any additional supporting documentation.

3. Second Level Review (Physician Consultant)

Any response of agreement that a NYPORTS issue occurred but includes a disagreement on the NYPORTS code or a disagreement that a NYPORTS issue occurred will be given to a physician consultant to review. If the physician consultant agrees with the facility the case will be closed. If the physician consultant disagrees with the facility Department of Health (DOH) will be notified and DOH will determine the reportability of the case.
Previously, any case that was determined as a potential immediate concern required a corrective action plan. Now, any immediate concern that has a 900 series NYPORTS code and has been reported by the hospital to the Department of Health with a 900 series code requiring a root cause analysis will no longer require any follow-up to IPRO by the hospital.

Any case that has any other NYPORTS code that does not require root cause analysis will follow the current immediate concern process.

4. Final Decision Notification

The hospital will be notified as to the final decision on every case with a potential NYPORTS occurrence, whether the potential concern is resolved or confirmed. Any case where a chart is requested and the chart is not received will, as standard DOH policy, have a technical denial issued until the case is received.

Should you have any questions or comments in regard to IPRO's NYPORTS review plan, please feel free to contact Patti Weinberg, Vice President, Medicaid/State Health Care Assessment at extension 617 or Kathleen Fox, Senior Director, Medicaid/State Health Care Assessment at extension 361.