2011 IRF PPS Updates Clinical Training Call October 5, 2010 Lisa Werner, 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-morbiditiesAdditional medical condition that has a significant effect on the rehabilitation stay & progress & cost. AgeThe 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 last year Range of average discharge rates $6,624 - $40,477 with no co-morbidity Range of average discharge rates $7,810 $50,729 with the highest co-morbidity * Blood transfusion and certain medical education costs excluded 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, 2009 is $13,661 (2.5% increase) Rate for April 1, 2010 is $13,627 Labor Share (F) Total is of the Medicare payment. Wage (V) Maintains budget neutrality. Provider Payment Components Changes to facility adjusters: 2011: Stated as a per facility update 2010: Stated as noted below LIP: versus Rural: 18.4% versus 21.3% Teaching: versus CMG Revisions Weight revisions for the CMGs Increased payment by > 15% - 0% Increased payment between 5% and 15% - 0.7% Changed by < 5% % Decreased payment between 5% and 15% - 0.7% Decreased payment by > 15% - 0% CMG Revisions Impact of CMG weight revision by RIC: CMG Revisions Published CMG differences for 2011 versus actual variances 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. 2011 outlier threshold is $11,410. 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 the per diem for the first day Transfer Rule Example Base Rate$13,587 Weight for CMG 108 Tier 3 = Weight times base rate = $25,073 LOS for CMG 108 Tier 3 is 22 CMG 108 Tier 3 divided by 22 = $1140/day Times 8 days = $9120 Plus one per diem = $9690 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 3 rd 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 3 rd 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 CMG payment weight is.1450 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.5356 5102 expired, orthopedic with a length of stay of 14 days or more 5103 expired, not orthopedic with a length of stay of 15 days or fewer.7312 5104 expired, not orthopedic with a length of stay of 16 days or more Changes to Comorbidities that Tier Tier 1: No changes Tier 2: No changes Changes in Comobidities that Tier Tier 3 Additions: Flu due to identified avian virus with pneumonia (excluded from RIC 15) Flu due to avian with other respiratory issues (excluded from RIC 15) Flu due to avian manifestation not elsewhere classified (excluded from RIC 15) Flu due to H1N1 flu with pneumonia (excluded from RIC 15) Flu due to H1N1 flu with other respiratory issues (excluded from RIC 15) Flu due to H1N1 flu manifestation not elsewhere classified (excluded from RIC 15) Febrile non-hemolytic transfusion reaction (no exclusions) Changes in Comorbidities that Tier Tier 3 Deletions: 488. Flu due to avian flu virus Flu due to identified avian virus Flu due to identified H1N1 virus 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: Hemochromatosis Transfusions due to overload, fluid overload Secondary thrombocytopenia Spinal stenosis, lumbar region, with neurogenic claudication Post traumatic seizures Fecal issues Cognitive and communication deficits Transfusion reactions: ABO, non-ABO, Rh Coding Additions V Code Additions: History of combat and operational stress disorder V11.4 Congenital deformities - V13.6x Do not resuscitate status V49.86 Physical restraint status V49.87 Body Mass Index levels V85.4x Code Deletions Codes discontinued: Disorders of iron metabolism Fluid overload Secondary thrombocytopenia 488.0* Influenza due to identified avian influenza virus 488.1* Influenza due to identified novel H1N1 influenza virus Other anomalies of uterus Hemoptysis Incontinence of feces Poisoning by other specified central nervous system stimulants ABO incompatibility reaction Rh incompatibility reaction V25.1 Encounter for insertion of intrauterine contraceptive device V85.4 Body Mass Index 40 and over, adult Code Revisions Codes revised: 307.0* Adult onset fluency disorder Spinal stenosis, lumbar region, without neurogenic claudication Neurologic neglect syndrome V07.8* Other specified prophylactic or treatment measure V07.9* Unspecified prophylactic or treatment measure V13.61 Personal history of (corrected) hypospadias V13.69 Personal history of other (corrected) congenital malformations V26.35 Encounter for testing of male partner of female with recurrent pregnancy loss The Importance of Accuracy Three Tiers of Co-morbidities Average eRehabData utilization in the previous 365 days: Tier % Tier % Tier % Can be identified up to two days before discharge. Physician identification is mandatory. Tier 1 Co-morbid Conditions Eight Tier 1 Comorbitites: VOCAL PARAL UNILAT PART VOCAL PARAL UNILAT TOTAL VOCAL PARAL BILAT PART VOCAL PARAL BILAT TOTAL EDEMA OF LARYNX V44.0 TRACHEOSTOMY STATUS V45.1 RENAL DIALYSIS STATUS V55.0 ATTEN TO TRACHEOSTOMY Tier 2 Comorbidities Eleven Tier 2 Comorbidities: PSEUDOMONAS ENTERITIS INT INF CLSTRDIUM DFCILE PSEUDOMONAS INFECT NOS LATE EF CV DIS DYSPHAGIA INTEST POSTOP NONABSORB DYSPHAGIA NOS DYSPHAGIA, ORAL PHASE DYSPHAGIA, OROPHARYNGEAL DYSPHAGIA, PHARYNGEAL PHASE DYSPHAGIA, PHARYNGOESOPHAGEAL DYSPHAGIA NEC Top Tier 3 Comorbidities Tier 3 (Top 35) MORBID OBESITY ACUTE KIDNEY FAILURE NOS NEUROPATHY IN DIABETES DMII NEURO NT ST UNCNTRL 486. PNEUMONIA, ORGANISM NOS UNSP HEMIPLGA UNSPF SIDE CELLULITIS OF LEG OTHER POSTOP INFECTION PULM EMBOL/INFARCT NEC ACUTE RESPIRATRY FAILURE DMII OTH NT ST UNCNTRLD DMII RENL NT ST UNCNTRLD DIASTOLC HRT FAILURE NOS FOOD/VOMIT PNEUMONITIS DMII NEURO UNCNTRLD SIRS-INFECT W/O ORG DYSF DMII CIRC NT ST UNCNTRLD Tier 3 (Top 35) 515. POSTINFLAM PULM FIBROSIS DMII OPHTH NT ST UNCNTRL UNSP HEMIPLGA DOMNT SIDE PANCYTOPENIA DISRUP-EXTERNAL OP WOUND Postprocedural fever UNSP HMIPLGA NONDMNT SDE SEPTICEMIA NOS SYSTOLIC HRT FAILURE NOS CHR SYSTOLIC HEART FAILURE CHR DIASTOLIC HRT FAILURE DMI WO CMP NT ST UNCNTRL 042. HUMAN IMMUNO VIRUS DIS CRBL ART OCL NOS W INFRC ANOXIC BRAIN DAMAGE ACT KIDNEY FAILURE w/ LESION DMII UNSPF UNCNTRLD GANGRENE Replacement of Lower Extremity Joint 0801 ALOS W/O CM 7 Relative Wt $ ALOS W/O CM 9 Relative Wt $ ALOS W/O CM 12 Relative Wt $ ALOS W/O CM 10 Relative Wt $ ALOS W/O CM 13 Relative Wt $ ALOS W/O CM 15 Relative Wt $ Motor >49.55 Motor > & < Motor > & < & Age > 83.5 Motor > & < & Age < 83.5 Motor > & < Motor < Replacement of Lower Extremity Joint Weighted Motor Score Index ItemWeight Eating.6 Grooming.2 Bathing.9 Dressing Upper Body.2 Dressing Lower Body1.4 Toileting1.2 Bladder.5 Bowel.2 Transfer Bed, Chair, W/C2.2 Transfer Toilet1.4 Transfer Tub, Shower Not included as item for CMG Locomotion1.6 Stairs1.6 Motor Score Index Item ScoreWeight Value Eating Grooming Bathing UB Dressing LB Dressing Toileting Bladder Bowel Transfer Bed, Chair, W/C Transfer Toilet Transfer Tub/Shower 4 Locomotion Stairs Total 37.5 Questions? Next call: November 1:00 EST How Are We Doing with the Final Rule Changes?