2012 IRF PPS UpdatesClinical Training Call

October 4, 2011Lisa Werner, MBA, MS, CCC-SLP

How A CMG is Determined

CMG DeterminantsImpairment 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 last year Range of average discharge rates $6,880 - $40,964

with no co-morbidity Range of average discharge rates $8,086 – $61,648

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.

Facility adjusters in a budget neutral manner. PPS rates per the recommended market basket

increase. 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.

Implement the quality reporting program provisions.

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 Rate for October 1, 2010 is $14,076

• Labor Share (F) Total is 70.119 of the Medicare payment. Down from 75.271 last year.

• Wage (V) Maintains budget neutrality.

Provider Payment Components

• Changes to facility adjusters: 2012:

• LIP: .1897• Rural: 18.7%• Teaching: .4888 using a formula of (1+FTE interns and

residents/ADC) 2011: Stated as a per facility update (No changes) 2010: Stated as noted below

• LIP: 0.4613 versus 0.6229 • Rural: 18.4% versus 21.3%• Teaching: 0.6876 versus 0.9012

CMG Revisions

• Impact of CMG weight revision by RIC:01 Stroke 214.59$ 02 Traumatic brain injury 373.49$ 03 Nontraumatic brain injury 345.19$ 04 Traumatic spinal cord 2,984.77$ 05 Nontraumatic spinal cord 558.05$ 06 Neurological 216.89$ 07 Fracture of LE 426.03$ 08 Replacement of LE joint 347.26$ 09 Other orthopedic 204.88$ 10 Amputation, lower extremity 693.93$ 11 Amputation, other 842.51$ 12 Osteoarthritis 427.93$ 13 Rheumatoid, other arthritis 264.66$ 14 Cardiac 411.40$ 15 Pulmonary 302.64$ 16 Pain Syndrome 116.94$ 17 Major multiple trauma, no brain injury or spinal cord injury 288.06$ 18 Major multiple trauma, with brain or spinal cord injury (967.30)$ 19 Guillain Barre 874.48$ 20 Miscellaneous 346.41$ 21 Burn (4,619.34)$

CMG Revisions

• Published CMG differences for 2011 versus actual variances

1

CMG Variance101 Stroke M>51.05 $166.93102 Stroke M>44.45 and M<51.05 and C>18.5 $277.55103 Stroke M>44.45 and M<51.05 and C<18.5 $775.37104 Stroke M>38.85 and M<44.45 $202.51105 Stroke M>34.25 and M<38.85 $26.62106 Stroke M>30.05 and M<34.25 $188.50107 Stroke M>26.15 and M<30.05 $164.92108 Stroke M<26.15 and A>84.5 $467.59109 Stroke M>22.35 and M<26.15 and A<84.5 -$109.35110 Stroke M<22.35 and A<84.5 $299.67

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 $10,660. 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 $14,076• Weight for CMG 108 Tier 3 = 1.8639• Weight times base rate = $26,236• LOS for CMG 108 Tier 3 is 23• CMG 108 Tier 3 divided by 23 = $1140/day• Times 8 days = $9120• Plus ½ 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 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 .1475 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

• .5856 5102 expired, orthopedic with a length of stay of 14 days or

more• 1.4718

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

• .6970 5104 expired, not orthopedic with a length of stay of 16 days

or more• 1.8779

Changes to Comorbidities that Tier

•Tier 1: No changes

•Tier 2: No changes

Changes in Comobidities that Tier

• Tier 3 Additions: 284.11 Chemo induced pancytopenia 284.12 Other drug induced pancytopenia 284.19 Other pancytopenia

• Deleted 294.1 Pancytopenia 415.13 Saddle embolic pulmonary artery 488.81 Flu due to NVL A virus with pneumonia 516.31 Idiopathic pulmonary fibrosis 516.32 Idiopathic non-specific inter pneumonia 516.33 Acute interstitial pneumonia 516.34 Resp bronchial interstitial lung

Changes to Comorbidities that Tier

• Tier 3 Additions: 518.51 Acute resp failure following trauma/surgery 518.52 Other pulmonary insufficiency following

trauma/surgery 518.53 Acute on chronic acute respiratory failure following

trauma/surgery• Deleted 518.5

793.19 Other nonspecific abnormal findings of the lung fields 998.00 Postoperative shock, NOS 998.01 Postoperative shock, cardiogenic 998.02 Postoperative shock, septic 998.09 Postoperative shock, other

• Deleted 998.0 999.32 Blood infection due to central venous catheter 999.33 LCL infection due to central venous catheter

Changes in Comorbidities that Tier

• Tier 3 Deletions: 284.1 Pancytopenia 518.5 Post-traumatic pulmonary insufficieny 998.0 Postoperative shock

Coding Additions

• Other coding changes:

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

payment system

The Importance of Accuracy

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

days:

•Tier 3 27.16%•Tier 2 8.55%•Tier 1 5.81%

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 584.9 ACUTE KIDNEY FAILURE NOS 357.2 NEUROPATHY IN DIABETES 250.60 DMII NEURO NT ST UNCNTRL 486. PNEUMONIA, ORGANISM NOS 342.90 UNSP HEMIPLGA UNSPF SIDE 682.6 CELLULITIS OF LEG 998.59 OTHER POSTOP INFECTION 518.81 ACUTE RESPIRATRY FAILURE 428.30 DIASTOLC HRT FAILURE NOS 415.19 PULM EMBOL/INFARCT NEC 250.40 DMII RENL NT ST UNCNTRLD 250.62 DMII NEURO UNCNTRLD 995.91 SIRS-INFECT W/O ORG DYSF 250.80 DMII OTH NT ST UNCNTRLD 507.0 FOOD/VOMIT PNEUMONITIS 428.32 CHR DIASTOLIC HRT FAILURE 250.70 DMII CIRC NT ST UNCNTRLD

• Tier 3 (Top 35) 428.22 CHR SYSTOLIC HEART FAILURE 515. POSTINFLAM PULM FIBROSIS 428.20 SYSTOLIC HRT FAILURE NOS 250.50 DMII OPHTH NT ST UNCNTRL 284.1 PANCYTOPENIA 998.32 DISRUP-EXTERNAL OP WOUND 780.62 Postprocedural fever 038.9 SEPTICEMIA NOS 342.91 UNSP HEMIPLGA DOMNT SIDE 998.32 Disruption of an external op

(surgical) wound 342.92 UNSP HMIPLGA NONDMNT SDE 682.2 CELLULITIS OF TRUNK 518.5 POST TRAUMATIC PULM

INSUFFIC 584.5 ACT KIDNEY FAILURE w/ LESION 250.01 DMI WO COMP NT ST UNCONT 682.3 CELLULITIS OF ARM

Replacement of Lower Extremity Joint

0801 ALOS W/O CM 7Relative Wt. .4888

$ 6880.35

0802 ALOS W/O CM 9Relative Wt. .6573

$ 9252.15

0803 ALOS W/O CM 12 Relative Wt. .9062

$12755.67

0804 ALOS W/O CM 10Relative Wt. .8004

$11266.43

0805 ALOS W/O CM 13Relative Wt. .9856

$ 13873.31

0806 ALOS W/O CM 15Relative Wt. 1.2034

$ 16939.06

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 WeightEating .6Grooming .2Bathing .9Dressing – Upper Body .2Dressing – Lower Body 1.4Toileting 1.2Bladder .5Bowel .2Transfer Bed, Chair, W/C 2.2Transfer Toilet 1.4Transfer Tub, Shower Not included as item

for CMG

Locomotion 1.6Stairs 1.6

Motor Score Index

Item Score Weight ValueEating 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 3.2Total 37.5

Quality Measures

• Three measures: Percent of Patient with New or Worsened Pressure Ulcers, NQF #0678 Catheter associated urinary tract infections will be reported to the

CDC National Health Safety Network (NHSN) The third item under consideration is “30–day comprehensive All-

Cause Risk-Standardized Readmission Measure.” CMS will publish the electronic specifications related to reporting the

pressure ulcer measure on the CMS website no later than January 31, 2012.

Questions?

Next call: November 1 @ 1:00 EST