IRF-PPS Crash Course

Presented by:Lisa Werner, MBA, MS, CCC-SLP

Director of Consulting Services

Medical Necessity

Medical Necessity Criteria24-hour availability of a rehab physician

• Determines the treatment plan that drives the plan of care

24-hour rehabilitation nursing• Should have medical and rehab

interventionsRelatively intense level of rehabilitation services

• Should address 3-hour, 5-day per week care plan with adjustments to the plan of care as needed

Interdisciplinary team approach• Must have at least 2 (PT/OT/ST)

Coordinated program of care• Should show that some problems

require two or more disciplines to intervene

Significant practical improvement• Long term goals should provide

increased independence or enable the patient to return to the community

Realistic goals• Should be related to the patient’s

prior level of function

Medical Necessity

Medical Necessity Criteria (continued)

Pre-admission screening process• Must have an evaluation process in place to determine the patient’s

need for intense rehabilitation program. Must be approved by a rehab physician.

Team conference• Weekly conferences must be evidenced in the record.

Documentation should indicate the appropriateness for continuing the plan of care or adjusting it as needed.

60% rule compliance

Key Areas

Pre-admission screeningDocument needs to stand alone and justify admissionMust be completed within 48 hours prior to admission

Physician documentation Establishes the justification for admission through H&PMust be completed within 24 hours of the patient’s admission

Nursing documentation The rehab nursing plan of care ties the medical condition established by the physician and the rehabilitation goals set by therapy

Therapy documentationDemonstrates significant progress toward established functional goals

CMS Quality Reporting Program

Initial introduction of required quality measures on the IRF-PAI in October, 2012 Payment reduction (2%) for one of the following:

• Non-compliance with reporting• Failure to meet completion thresholds

Required Quality Measures• New or worsened pressure ulcers (IRF-PAI)• Flu vaccination (IRF-PAI)• Functional Measures(IRF-PAI)• Falls with Injury (IRF-PAI)• CAUTI (NHSN)• MRSA (NHSN)• C-Diff (NHSN)• All Cause Unplanned Readmissions (Claims) Not used to determined compliance with CMS QRP for payment reduction

Reimbursement Basics

Provider Payment Components Federal Base Payment (F)

• base rate for 2019 is $16,021

Labor Portion (F) Wage (V) Rural Factor (F) Low Income Patient (V) Case Mix (V)

Reimbursement Basics

Reimbursement ConsiderationsDischarge-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.

The base rate from the government last year• Range of average discharge rates $8,854 - $44,418

with no comorbidity• Range of average discharge rates $13,193 – $68,360

with the highest comorbidity• Lowest CMG is 0201 – non-traumatic brain injury and

highest is 1903 – Guillain-Barre

CMG Determinants

How a CMG is DeterminedImpairment 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)

Comorbidities Additional medical condition that has a significant effect on the rehabilitation stay, patient progress, and cost.

Age The age of the patient upon admission

Replacement of Lower Extremity Joint

0801 ALOS W/O CM 7Relative Wt. .5754

$ 9,218

0802 ALOS W/O CM 9Relative Wt. .7382

$ 11,826

0803 ALOS W/O CM 11Relative Wt. .9684

$15,514

0804 ALOS W/O CM 10Relative Wt. .8727

$13,981

0805 ALOS W/O CM 12Relative Wt. 1.0401

$ 16,663

0806 ALOS W/O CM 14Relative Wt. 1.2816

$ 20,532

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

Replacementof Lower

Extremity Joint

Weighted Motor Score Index

About Weighted Motor Scores Total Maximum

Motor Score = 84

Total Minimum Motor Score = 12 (“0’s” convert to “1’s” for CMG determination)

If Transfer to Toilet coded “0”– will be converted to a “2”

Item WeightEating .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

Weighted Motor Score Index

Motor Score Index ExampleItem Score Weight ValueEating 5 .6 3.0Grooming 5 .2 1.0Bathing 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

Functional Items Coding Scale

Scores: 6. Independent: Patient completes the activity by

him/herself with no assistance from a helper. 5. Setup or clean-up assistance: Helper sets up or cleans

up; patient completes activity. Helper assists only prior to or following the activity. 4. Supervision or touching assistance- Helper provides

verbal cues or touching/steadying assistance as a patient completes activity. Assistance may be provided throughout the activity or intermittently. 3. Partial/moderate assistance- Helper does less than

half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.

Functional Items Coding Scale

Scores (cont’d): 2. Substantial/maximal assistance- Helper does more than

half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 1. Dependent- Helper does ALL of the effort. Patient does

none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity. 7. Patient refused, if the patient refused to complete the

activity. 9. Not Applicable, if the patient did not perform this activity

prior to the current illness, exacerbation, or injury. 10. Not attempted due to environmental limitations (lack

of equipment, weather) 88. Not attempted due to medical condition or safety

concerns, if the activity was not attempted due to medical condition or safety concerns.

Section H: Bladder and Bowel

H0350 Bladder Continence Code 0, Always continent, if throughout the 3-day assessment period the

patient has been continent of urine, without any episodes of incontinence. Code 1, Stress incontinence only, if during the 3-day assessment period the

patient has episodes of incontinence only associated with physical movement or activity such as coughing, sneezing, laughing, lifting heavy objects, or exercise.

Code 2, Incontinent less than daily, if during the 3-day assessment period the patient was incontinent of urine once or twice.

Code 3, Incontinent daily, if during the 3-day assessment period the patient was incontinent of urine at least once a day.

Code 4, Always incontinent, if during the 3-day assessment period the patient had no continent voids.

Code 5, No urine output, if during the 3-day assessment period, the patient had no urine output (e.g., renal failure, on chronic dialysis with no urine output) for the entire 3 days.

Code 9, Not applicable, if during the 3-day assessment period the patient had an indwelling bladder catheter, condom catheter, or ostomy for the entire 3 days.

Section H: Bladder and Bowel

H0400 Bowel Continence Code 0, Always continent, if during the 3-day assessment period the

patient has been continent for all bowel movements, without any episodes of incontinence. Code 1, Occasionally incontinent, if during the 3-day assessment

period the patient was incontinent for bowel movement once. This includes incontinence of any amount of stool at any time. Code 2, Frequently incontinent, if during the 3-day assessment period

the patient was incontinent for bowel movement at least twice, but also had at least one continent bowel movement. This includes incontinence of any amount of stool at any time. Code 3, Always incontinent, if during the 3-day assessment period the

patient was incontinent for all bowel movements (i.e., had no continent bowel movements). Code 9, Not rated, if during the 3-day assessment period the patient

had an ostomy or other device, or the patient did not have a bowel movement during the entire 3 days. Note that patients who have not had a bowel movement for 3 days should be evaluated for constipation.

The Importance of Accuracy

Three Tiers of ComorbiditiesAverage eRehabData use in the previous 365 days:

•Tier 3 42.6%•Tier 2 10.6%•Tier 1 6.8%

Comorbidities can be identified up to two days before discharge, but physician identification is mandatory.

Comorbidities — Impact

Impact of Comorbidities

Comorbidities — Stroke 0110 Reimbursement

None $33,765.86Tier 3 – e.g. Diabetes 1 Uncontrolled $35,311.87Tier 2 – e.g. Pseudomonas Infection $38,546.53Tier 1 – e.g. Vocal Cord Paralysis $44,306.08

Operational Process to the CMG

Pre-admission screening (screener/physician) Gather apparent Impairment

Group Code Gather co-morbid conditions Complete a functional

assessment Payer status

(Medicare vs. other payer)

Admission Physician assessment is

done and H&P/PAA is written IRF-PAI is started once

Impairment Group Code and co-morbid conditions are confirmed with physician documentation Therapy and nursing

assessment are completed and plan of care is written Functional independence

measure motor subscale scores are obtained

Operational Process to the CMG

Assessment Coders review charts at the

end of the assessment to assign admission codes Beginning CMG is established Discharge plan identified

Concurrent Coding Additional comorbidities and

complications are added to the IRF-PAI as per physician documentation

Discharge Discharge destination

selected Length of stay set Patient is discharged Final coding is completed IRF-PAI is locked and

transmitted UB-04 is sent to MAC for

payment

How it Works 80%+ of the Time

SUN MON TUE WED THU FRI SAT

Discharge Home

Facility receives the full CMG payment.

1 2 3

Patient stays at least to the fourth day and discharged home.

4

Simple Payment Determination

Simple Payment Determination

Base Rate x CMG/Tier pay weight Example: CMG 0204 for TBI/Tier 3

Base Payment Rate $15,835CMG/Tier Pay Weight x 0.9348

= $14,8022% sequestration - 296Payment = $14,506

Exceptions to full CMG Payment

Transfer RuleDischarge to Medicare- or Medicaid-certified facility And -

• Has a length of stay shorter than the length of stay 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 Process

Transfer Rule Example Base Rate = $15,835Weight for CMG 0108 Tier 3 = 1.8754Weight times base rate = $29,696 LOS for CMG 0108 Tier 3 = 21 days CMG 0108 Tier 3 divided by 21 = $1,414/day Times 8 days = $11,313 Plus ½ one per diem ($707) = $12,020

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 stays 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.

Correct Coding

Why Correct Coding is Important Assignment of appropriate case mix group (CMG) Correct payment tier for co-morbidities Prevention of issues with potential Medicare compliance audits Compliance with the “60%” rule

Accurately coding of documented diagnoses allows for appropriate reimbursement and permits us to capture all possible resources for our patients’ care.

Questions?