2010 IRF PPS UpdatesClinical Training Call

November 3, 2009Lisa Werner Bazemore, MBA, MS, CCC-SLP

How A CMG is Determined

CMG Determinants

Impairment Group Code

Broad codes that identify the main reason for the rehab stay. 21 main categories.

Motor Score of Functional Independence Measure

Functional assessment based on 12 functional measures – determined upon admission(excludes tub/shower transfers)

Co-morbidities Additional medical condition that has a significant effect on the rehabilitation stay & progress & cost.

Age The age of the patient upon admission

Case Mix Groups

•Discharge-based system Payment is based on discharge information

•Case Mix Groups (CMG) 87 main groups 4 deaths 1 short stay

•Single lump payment for each stay

Case Mix Groups

• All inclusive payment for each patient Off unit surgery, dialysis, and so on.

• 353 payment categories

• The base rate from the government Range of average discharge rates $6,392 - $43,381

with no co-morbidity Range of average discharge rates $9,020 – $53,084

with the highest co-morbidity

Review of Changes

• The final rule introduced changes in these categories:

Relative weights and average length of stay based on the most current Medicare claims and cost report data.

Payment rates based on wage index and labor shares. Update to the outlier threshold. Update to the cost-to-charge ratio ceiling and national

average urban and rural cost-to-charge ratios for purposed of determining outlier payments.

Provider Payment Components

• Federal Base Payment (F) Base rate for October 1, 2007 was $13,451 Change of rate on April 1, 2008 was $13,034 Rate for October 1, 2008 is $12,958 Rate for October 1, 2090 is $13,661 (2.5% increase)

• Labor Share (F) Total is 75.779 of the Medicare payment.

• Wage (V) Maintains budget neutrality.

Provider Payment Components

• Changes to facility adjusters: LIP: 0.4613 versus 0.6229 Rural: 18.4% versus 21.3% Teaching: 0.6876 versus 0.9012

CMG Revisions

• Weight revisions for the CMGs

Resulted in an overall payment increase of $145 million to inpatient rehab facilities.

National impact according to eRehabData looking back over the past fiscal year is $574.03 per case.

CMG Revisions

• Impact of CMG weight revision by RIC:

RIC Variance01 Stroke $474.3002 Traumatic brain injury $638.7403 Nontraumatic brain injury $793.7104 Traumatic spinal cord $2,087.7505 Nontraumatic spinal cord $557.7106 Neurological $647.7007 Fracture of LE $401.0508 Replacement of LE joint $342.9509 Other orthopedic $445.6010 Amputation, lower extremity $598.4011 Amputation, other $1,063.5412 Osteoarthritis -$64.2613 Rheumatoid, other arthritis $712.7114 Cardiac $557.1915 Pulmonary $603.7616 Pain Syndrome $465.9817 Major multiple trauma, no brain injury or spinal cord injury $687.8418 Major multiple trauma, with brain or spinal cord injury $1,088.4419 Guillain Barre $2,093.5420 Miscellaneous $673.3221 Burn $614.83

High Cost Outliers

• Definition: Cases where cost exceeds reimbursement by a significant portion qualifying the facility for additional payment.

PPS Payment plus the adjusted threshold amount compared to estimated cost-to-charge ratio based on Medicare allowables.

GROUPER software detects the high cost and triggers payment if cost is greater than the adjusted outlier threshold.

Medicare pays the provider 80% of the difference between the estimated cost of the case and the outlier threshold.

2010 outlier threshold is $10,652. Expected to occur in 3% of IRF cases.

Exceptions to full CMG Payment

•No change to transfer rule, short stay, or interrupted stay provisions.

•Transfer Rule Discharge to Medicare or Medicaid certified

facility And -

•Has a LOS shorter than the LOS for the CMG they were assigned when discharged

•Per diem payment for the days on the unit plus ½ the per diem for the first day

Transfer Rule Example

• Base Rate $13,661• Weight for CMG 108 Tier 3 = 1.8963• Weight times base rate = $25,905• LOS for CMG 108 Tier 3 is 23• CMG 108 Tier 3 divided by 23 = $1126/day• Times 8 days = $9010• Plus ½ one per diem = $9573

Transfer Process

•Works the same for transfers to:

Skilled Nursing Facilities & Nursing Homes Long Term Acute Care Acute Care Another Rehab Program

Program Interruption

•Program Interruptions include transfers to acute and back to rehab during the stay.

CMG includes paying for acute stays when:•Patient is discharged to acute and returns to IRF by

midnight of the 3rd calendar day.•All costs associated with the acute stay are

recorded on the rehab cost report.•True for discharges to acute care of your own

facility or acute care of another hospital.

Program Interruption

•Acute stay greater than 3 days are different. If patient goes to acute care and does not return by

midnight of the 3rd calendar day, discharge and re-admit.

Patient will have a new admission and assessment reference period.

New CMG will be assigned based on information gathered at admission.

Short Stays

• Short stays include patients who are admitted and discharged to a community setting before the end of the assessment period.

Revert to short stay CMG 5001. CMG payment weight is .1476 with an average length of stay

of 3 days. Used for lengths of stay 3 days or fewer (day of discharge is

not counted as a day).

Expired on the Unit

• If a patient expires on the rehabilitation unit, CMG weights are as noted:

5101 expired, orthopedic with a length of stay of 13 days or fewer

• .6783 5102 expired, orthopedic with a length of stay of 14 days or

more• 1.5432

5103 expired, not orthopedic with a length of stay of 15 days or fewer

• .7086 5104 expired, not orthopedic with a length of stay of 16 days

or more• 1.9586

Changes to Comorbidities that Tier

•Tier 1: No changes

•Tier 2: No changes

Changes in Cormobidities that Tier

• Tier 3: 285.3 Anemia d/t antineo chemo 

416.2 Chronic pulmonary embolism exclude RIC 15 488.0 Flu due to identified avian virus exclude RIC 15 488.1 Flu due to identified H1N1 virus exclude RIC 15

Coding Additions

• Other coding changes:

Many other coding changes were published. Those mentioned impact payment under the IRF PPS

payment system

Coding Additions

• Other coding changes: Broad overview of coding changes, which you should research

further:• Merkel cell carcinoma• Secondary neuroendocrine tumor• Gouty arthritis• Late effect CVA, dysarthria and fluency• Chronic venous embolism and thrombosis• Acute venous embolism and thrombosis• Hypoxic-ischemic encephalopathy• Speech disturbance codes• Poisoning• Behavioral codes

Coding Additions

• V Code Additions: History codes for personal history of traumatic brain injury –

V15.52 Special screening for traumatic brain injury – V80.01 Special screening for other neurological conditions – V80.09

Coding Deletions

• Codes discontinued: 239.8 - Neoplasm of unspecified nature of other specified sites 274.0 - Gouty arthropathy 279.4 - Autoimmune disease, not elsewhere classified 348.8 - Other conditions of brain 453.8 - Other venous embolism and thrombosis of other specified

veins 488*** - Influenza due to identified avian influenza virus 768.7 - Hypoxic-ischemic encephalopathy (HIE) 784.5 - Other speech disturbance 799.2 - Nervousness 969.0 - Poisoning by antidepressants 969.7 - Poisoning by psychostimulants V10.9 - Unspecified personal history of malignant neoplasm V80.0 - Special screening for neurological conditions

Coding Revisions

• Codes revised: 008.65 - Enteritis due to calicivirus 041.3 - Klebsiella pneumoniae 041.86 - Helicobacter pylori [H. pylori] 453.2* - Other venous embolism and thrombosis of inferior vena cava 453.4x - Acute venous embolism and thrombosis of lower extremity 572.2 - Hepatic encephalopathy 584.x - Acute kidney failure 784.40 - Voice and resonance disorder, unspecified 784.49 - Other voice and resonance disorders 793.x - Nonspecific (abnormal) findings on radiological and other examination 813.45 - Torus fracture of radius (alone) 996.43 - Broken prosthetic joint implant

The Importance of Accuracy

•Three Tiers of Co-morbidities Average eRehabData utilization in the previous 365

days:

•Tier 3 24.34%•Tier 2 8.80%•Tier 1 6.26%

Can be identified up to two days before discharge. Physician identification is mandatory.

Tier 1 Co-morbid Conditions

•Eight Tier 1 Comorbitites:

478.31 VOCAL PARAL UNILAT PART 478.32 VOCAL PARAL UNILAT TOTAL 478.33 VOCAL PARAL BILAT PART 478.34 VOCAL PARAL BILAT TOTAL 478.6 EDEMA OF LARYNX V44.0 TRACHEOSTOMY STATUS V45.1 RENAL DIALYSIS STATUS V55.0 ATTEN TO TRACHEOSTOMY

Tier 2 Comorbidities

• Eleven Tier 2 Comorbidities: 008.42 PSEUDOMONAS ENTERITIS 008.45 INT INF CLSTRDIUM DFCILE 041.7 PSEUDOMONAS INFECT NOS 438.82 LATE EF CV DIS DYSPHAGIA 579.3 INTEST POSTOP NONABSORB 787.20 DYSPHAGIA NOS 787.21 DYSPHAGIA, ORAL PHASE 787.22 DYSPHAGIA, OROPHARYNGEAL 787.23 DYSPHAGIA, PHARYNGEAL PHASE 787.24 DYSPHAGIA, PHARYNGOESOPHAGEAL 787.29 DYSPHAGIA NEC

Top Tier 3 Comorbidities

• Tier 3 (Top 35) 278.01 MORBID OBESITY 357.2 NEUROPATHY IN DIABETES 250.60 DMII NEURO NT ST UNCNTRL 584.9 ACUTE RENAL FAILURE NOS 486. PNEUMONIA, ORGANISM NOS 342.90 UNSP HEMIPLGA UNSPF SIDE 682.6 CELLULITIS OF LEG 998.59 OTHER POSTOP INFECTION 415.19 PULM EMBOL/INFARCT NEC 518.81 ACUTE RESPIRATRY FAILURE 250.40 DMII RENL NT ST UNCNTRLD 250.80 DMII OTH NT ST UNCNTRLD 507.0 FOOD/VOMIT PNEUMONITIS 250.62 DMII NEURO UNCNTRLD 428.30 DIASTOLC HRT FAILURE NOS 995.91 SIRS-INFECT W/O ORG DYSF 250.50 DMII OPHTH NT ST UNCNTRL

• Tier 3 (Top 35) 515. POSTINFLAM PULM FIBROSIS 250.70 DMII CIRC NT ST UNCNTRLD 998.32 DISRUP-EXTERNAL OP WOUND 342.92 UNSP HMIPLGA NONDMNT SDE 284.1 PANCYTOPENIA 342.91 UNSP HEMIPLGA DOMNT SIDE 038.9 SEPTICEMIA NOS 428.20 SYSTOLIC HRT FAILURE NOS 682.2 CELLULITIS OF TRUNK 342.80 OT SP HMIPLGA UNSPF SIDE 682.3 CELLULITIS OF ARM 518.3 PULMONARY EOSINOPHILIA 518.5 POST TRAUM PULM INSUFFIC 250.01 DMI WO CMP NT ST UNCNTRL 780.62 Postprocedural fever 042. HUMAN IMMUNO VIRUS DIS 428.22 CHR SYSTOLIC HEART FAILURE 434.91 CRBL ART OCL NOS W INFRC

Replacement of Lower Extremity Joint

0801 ALOS W/O CM 7Relative Wt. .4714

$ 6391.98

0802 ALOS W/O CM 9Relative Wt. .6317

$ 8614.63

0803 ALOS W/O CM 12 Relative Wt. .9013

$12006.65

0804 ALOS W/O CM 10Relative Wt. .7910

$10790.82

0805 ALOS W/O CM 13Relative Wt. .9874

$ 13438.33

0806 ALOS W/O CM 15Relative Wt. 1.2215

$ 16546.20

Motor >49.55

Motor > 37.05 & < 49.55

Motor > 28.65 & < 37.05& Age > 83.5

Motor > 28.65 & < 37.05& Age < 83.5

Motor > 22.05 & < 28.65

Motor < 22.05

Replacement of Lower

Extremity Joint

Weighted Motor Score Index

Item Weight

Eating .6

Grooming .2

Bathing .9

Dressing – Upper Body .2

Dressing – Lower Body 1.4

Toileting 1.2

Bladder .5

Bowel .2

Transfer Bed, Chair, W/C 2.2

Transfer Toilet 1.4

Transfer Tub, Shower Not included as item for CMG

Locomotion 1.6

Stairs 1.6

Motor Score Index

Item Score Weight Value

Eating 5 .6 3Grooming 5 .2 1Bathing 4 .9 3.6UB Dressing 4 .2 .8LB Dressing 3 1.4 4.2Toileting 4 1.2 4.8Bladder 1 .5 .5Bowel 5 .2 1Transfer Bed, Chair, W/C 3 2.2 6.6Transfer Toilet 4 1.4 5.6Transfer Tub/Shower 4Locomotion 2 1.6 3.2Stairs 2 1.6 3.2

Total 37.5

Questions?

Next call: December 1 @ 1:00 ESTPAS Tool