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How does CMS decide whose fault it is?

Determining attribution is one of the biggest issues that physicians face when using administrative data for capturing complications. Nothing is more frustrating than being blamed for something you didn’t do. Centers for Medicare and Medicaid Services (CMS) attribution can determine financial penalties and public data about physician complications. Their system is designed for administrative ease rather than physician fairness, and uses a hammer for a job that really needs a scalpel.


Surgical attribution

In surgical settings, these issues will often seem - and sometimes will be - more straightforward. A patient who gets a surgical site infection will be assigned to the surgeon who performed the procedure. Even if the cause of the infection is more hospital or system-based, most surgeons accept the “hit”, since they are the person with ultimate responsibility. CMS assigns responsibility for any complication to the operating surgeon.

However, even these seemingly straightforward attributions can be faulty. For example, in many institutions the orthopedic patients are admitted to the medicine service. If the medicine doctor doesn’t order appropriate VTE prophylaxis and the patient gets a pulmonary embolism, that still gets attributed to the orthopedic surgeon.


Inpatient attribution

Attribution can be even more challenging in hospital-based care-team settings. Only rarely now does a hospitalist see a patient through an entire admission unless it’s a short stay. Even in the most straightforward admissions, there are usually at least two physicians providing coverage during the day and night. Some “misses” may be due to the day hospitalist, the night hospitalist, or a combination of the two.


So how does CMS resolve the difficult issue of attribution? With the government’s favorite number - your Tax Identification Number (TIN). CMS looks at all the National Provider Identification numbers that were used when the bill was submitted, and their corresponding TIN. The TINs that bill at least 30% of inpatient E&M codes are assigned responsibility for the complication, and attribution is evenly distributed amongst the NPIs that billed at least one E&M code during that stay.


For example, let’s say a patient was cared for by 7 providers. One was a locums, two were employed by a nocturalist group that contracts with the hospital, and four were employed by the hospital.


So you have:

Dr. A - locums - 10% E&M billing

Dr. B&C - nocturalist group - 20% E&M billing

Drs. D, E, F, G - hospital employed - 70% E&M billing

In this case, any complication would be attributed to Drs. D, E, F, and G. This is true whether the error was actually due to Drs. A, B, or C.


This means that physicians working for large hospital systems are at higher risk for having attribution assigned to them, since there are many more people billing under the same TIN. If you’re at a large hospital and your partner forgets something - or doesn’t document properly - then you both will be equally at fault. This is especially frustrating because physicians in those settings have the least control of hiring or choosing their colleagues compared to private practice physicians.


Questions? Comments? Let us know!


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