IRF PPS FY 2013 Update and Changes: What the CMS Notice ... · drive CMG placement Co-morbidities ... for Federal Fiscal Year 2012; ... What the CMS Notice Says and Means for Rehabilitation

IRF PPS FY 2013 Update and Changes: What the CMS Notice Says and Means for

Rehabilitation Facilities

Carolyn C. Zollar J.D.

AMRPA

Darlene D’Altorio-Jones, PT, MBA-HCM

MediServe


AMRPA

Vice President for Government

Relations and Policy Development

[email protected]

Medical Rehab FY 2013 Notice and OPPS NPRM IRF Quality Reporting

Copyright 2012, AMRPA, Washington, DC

Inpatient Rehabilitation Facilities

Prospective Payment System (IRF PPS)

So You Want To Be Paid?


Today‘s Agenda

• Brief IRF PPS Refresher Course

• FY 2013 Notice Changes

• IRF QRP Proposed Updates

• Financial Analysis and Implications


Review: IRF-PPS Inclusions and Exclusions

• Includes:

• PPS Excluded Rehab Hospitals and Units in US

& Territories

• Capital and Inpatient Operating Costs

• Excludes:

• Hospitals and Units in Demo Programs (MD)

• Costs of Bad Debt, Educational Programs, Blood

Clotting Factor Units

• Physician, PA, NP, Midwife, Qualified

Psychologist & Anesthetists Services


Review: IRF-PPS

• Applies to Traditional FFS Medicare Cases Only

• Physician Billing is Separate - Part B, Physician

Fee Schedule (PFS)

• Incentive is to Have the Patient‘s Costs Stay

Under the Payment

• Most Often Equated to Length of

Stay Management

• Bad, Bad, Bad Idea and CMS Agrees


Review: IRF-PPS Basics

• Data Collection

• Inpatient Rehabilitation

Facility –Patient Assessment

Instrument (IRF-PAI)

• Patient Classification System-

Case Mix Groups (CMGs)

• Per Discharge Payment Adjusted

For Facility Characteristics

• Special Payment Policies, Outlier

Policy


IRF-PPS Basic Components

Step One: Case Mix Groups

• Intended to Reflect Patient Characteristics and Cost of

Service

• Reflect Acuity of the Patient In Terms of:

• Comorbidities in 4 Comorbidity Tiers

• A (none) to B (most complex)

• Functional Independence/Dependence

• Total Score Ranges Up to 84 For Motor and Self

Care and 35 for Cognition

• FY 2013 CMGs, Weights-See Table 1, p. 44623


IRF-PPS Basic Components

Case Mix Group Factors

Impairment Group Codes (Condition) ICD-9-Codes that identify the main

clinical condition

Rehabilitation Impairment Categories

(21) Categories

Groupings of similar IGCs

Functional Independence Measure Functional assessment based on 17

functional measures – determined

upon admission (excludes tub/shower

transfers); motor FIM scores tend to

drive CMG placement

Co-morbidities

(4 Tiers)

A condition secondary to principal

diagnosis; Generally represent san

increase in cost to serve the patient if

the condition is present.

Age


IRF PPS Basic Components

Step Two: Standard Federal Payment Amount

• Determined from Historic Basis/2002

• Updated Through MB

• Subject to Statutory Change

• Case Mix Change

• Wage, Labor Share

• Budget Neutrality

• ACA Amendments

• MB

• Productivity

• P4RCopyright 2012, AMRPA, Washington, DC


Step Three: Why Facility Adjusters?

• To acknowledge variations in costs of care among

IRH/Us not captured by the CMG weights

• Low Income Percentage (LIP)

• Teaching

• Rural 18.4%



Step Four: Special Payment Policies

• Majority of Cases Get One Payment

• IRH/Us Receive PIP

• Short Stay – Three Days or Less CMG 5001

• Death - CMGs 5101 – 5104

• Transfers

– Sent to Another IRH/U, LTCH, Acute, M+M SNF

Before Meeting CMS ALOS

• Formula T = ((CMG Payment/ CMG ALOS) x

LOS + 50 % of Per Diem)


• Interrupted Stays

• Patient Returns to Same Facility On Day of

Discharge or By Midnight of Third Consecutive Day

• Stated Very Curiously Re: Payment (42 C.F.R.

412.624(g))

Special Payment Policies


• O = 0.80 X ((Cost-Outlier Threshold + CMG

Payment))

• NTE 3% of Total IRF Payments

• FY 2013 Threshold - $10,466 from $10,713 FY 2012


Step Five: Outliers


Late Transmission Penalty

• Penalty Assessed If Actual IRF PAI Assessment

Data Transmission Date > 10 Days from

Transmission Date

• IRF Has 27 Days From (and including) Day of

Discharge to Transmit

• 25% Reduction in CMG Payment

• Some Exceptions

• See 412 CFR 610, 614; CR 3885, 7/29/2005


IRF PPS Payment Formula

P =

1. (Standard Federal Payment Amount) x (CMG

Weight1) x

2. Labor Share = Labor Portion of Federal Payment x

3. (Wage Index) = Wage Adjusted Amount + Non Labor

Amount 2 =

4. Wage Adjusted Federal Payment x

5. Rural Adjustment 3 x LIP Adjustment 4 = Wage,

Rural, LIP Adjusted/FPP1. Calculated from age, motor and cognitive function and comorbidities

2. Non labor amount = Unadjusted Federal Prospective Payment – Labor

3. (1.184) Portion of Federal Payment

4. (1 = DHS ^ (0.4613)

5. (T = FTE/ADC)^(06876))


IRF PPS Payment Formula

P =

6. Wage and Rural Adjusted Payment Only +

7. Teaching Status Adjustment 5 x =

8. Teaching Status Adjustment Amount 6 =

9. Teaching Status Adjustment + Wage, Rural, LIP

Adjusted Rate = Total Payment

10. Outlier (0.80 x (Cost Outlier Threshold + CMG

Payment)

5. (T = FTE/ADC)^(06876))

6. Can be + or -


• Payment Rate for FY 2013 - $14,343 from $14, 076

Effective for Discharges On or After October 1, 2012

• Labor Share is 69.981 Down from 70.199 (FY 2008

Market Basket)

• Average Est. Weight Per Discharge FY 20121 -

1.1425 to FY 2013 -1.1441

• No Change in Facility Adjusters Exponential Values

or Percentage (Rural)

• Appendix C – List of Comorbidities Unchanged

from 8/20/11 List1

FY 2013 Rate Adjustment File

FY 2013 Final IRF PPS Notice: Snapshot


• Outlier Threshold is $10,466 Down from $10,713

• Average Wage Index FY 2013 is 0.9574 v. 09583, FY

2012

• 95% of IRF Cases in CMGs Where Weights Changed by

Less than 5%

• 0.5% Increased by 15%+

• 3.0% Decreased between 5%-15%

• Largest Increase in Weights Affecting Most Cases Is

CMG 0802 No Comorbidity

• CMS Says Reflects Response to 60% Rule

• Largest Decrease in CMG Weight Affecting Most

Cases– 2.3% is CMG D2004 - Misc

FY 2013 Final IRF PPS Notice: Snapshot


Standard Payment Amounts

Year Payment Rate Percentage Change

FY 2004 $12,525 +2.7%

FY 2005 $12,958 +3.5%

FY 2006 $12,762 -1.5%

FY 2007 $12,981 +1.7%

FY 2008 $13,451 +3.62%

FY 2008 Adjusted $13,034 -3.10%

FY 2009 $12,958 -.5830%

Final FY 2010 $13,661 +5.43%

Adjusted FY 2010 per PPACA $13, 627 -0.25

FY 2011 $13,860 +1.70%

FY 2012 $ 14,076 +1.59%

FY 2013 $14,343 +1.89


FY 2012 and FY 2013 Statistics from CMS

FY 2012 FY 2013

Average Wage Index 0.9583 0.9574

Number of Rural Hospitals 195 189

Number of Teaching Programs 116 115

Average DSH 0.1355 0.1385

Average Est. Weight per Discharge 1.14251 1.1441

Average IRF Payment with Outlier $5,881,7601 $5,993,666

1From FY 2013 Rate File

Source: CMS Final Rate Setting Files, Post Correction FY 2012, FY 2013


Pay for Reporting:

Quality Measures for IRH/Us

Starting Soon!


CMS Says First Months Are For

Training


CMS‘s Final Quality Measures for FY 2014 Reporting

• National Health Safety Network (NHSN) Catheter Associated

Urinary Tract Infection (CAUTI) Outcome Measure

• Collected For All Patients Without Regard to Payer

• Percent of Residents Who Have New or Worsened Pressure

Ulcers NQF# 0678

• Using Data from Pressure Ulcer, Section M, MDS 3.0

• CMS Revised the IRF PAI

• Medicare FFS and Medicare Advantage Patients

• Data Collected from 10/1/2012 to 12/31/2012

• Information on Data Submission Posted 1/31/2012

• CMS Holding Training Sessions – Open Door Forums


• Address When and How a Measure May Be

Amended, Retired

• NPRM Will Be Issued Unless The Data Collection

Process Reveals a Safety Issue

• Addresses When NQF Changes a Measure How CMS

Will Determine Whether to Issue NPRM or ―Sub

Regulatory Guidance‖ Like a Transmittal

• Determinant: Does The Change Substantially

Change the Nature of the Measure

Outpatient Prospective Payment System

Proposed Rule: IRF QRP Proposals


Outpatient Prospective Payment System

Proposed Rule: IRF QRP Proposals

• Pressure Ulcer Measure Potential Changes

• Expand to Include IRH/Us and Others

• Add ―Patients‖ to Title of Data Collection List

• CAUTI Changes

• Change Title to the Above

• Change Calculation Eventually to Standardized

Infection Ratio (SIR)

• Requires At Least 12 Months of Data Collection

ListCopyright 2012, AMRPA, Washington, DC

CONTACT INFORMATION


V.P. for Government Relations & Policy Development

American Medical Rehabilitation Providers Association

1710 N Street N.W.

Washington, D. C. 20036-2907

Toll-free: 888-346-4624

Phone: 202-223-1920

Fax: 202-223-1925

E-mail: [email protected]


APPENDIX


IRF Regulations

Regulation No. Title Year

CMS-1433-NMedicare Program; Inpatient Rehabilitation Facility Prospective Payment System

for Federal Fiscal Year 20132013

CMS-1349-P

Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System

for Federal Fiscal Year 2012; Changes in Size and Square Footage of Inpatient

Rehabilitation Units and Inpatient Psychiatric Units

2012

CMS-1349-CN

Medicare Program: Inpatient Rehabilitation Facility Prospective Payment System


Rehabilitation Units and Inpatient Psychiatric Units; Correction

2012

CMS-1349-F

Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System


Rehabilitation Units and Inpatient Psychiatric Units

2012

Website: http://www.cms.gov/InpatientRehabFacPPS/LIRFF/list.asp#TopOfPage


http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/List-of-IRF-Federal-Regulations-Items/CMS1246992.html


















IRF Regulations


CMS-1344-N

Prospective Payment System for Inpatient Rehabilitation

Facilities for FY 2011 2011

CMS 1538-P

Inpatient Rehabilitation Facility Prospective Payment System for

Federal Fiscal Year 2010; Proposed Rule 2010

CMS-1538-CN

Medicare Program; Inpatient Rehabilitation Facility Prospective

Payment System for Federal Fiscal Year 2010; Correction 2010

CMS-1538-F

Medicare Program; Inpatient Rehabilitation Facility Prospective

Payment System for Federal Fiscal Year 2010 2010

CMS-1554-CN IRF PPS for Fiscal Year 2009; Correction Notice 2009

CMS-1554-F IRF PPS for Fiscal Year 2009; Final Rule 2009

CMS-1554-P IRF PPS for Fiscal Year 2009; Proposed Rule 2009

CMS-1551-F


Federal Fiscal Year 2008; Final Rule (72 FR 44283) 2008

CMS-1551-P


Federal Fiscal Year 2008; Proposed Rule (72 FR 26230) 2008



CMS-1540-F

Inpatient Rehabilitation Facility Prospective Payment System

for Federal FY 2007; Provisions Concerning Competitive

Acquisition for Durable Medical Equipment, Prosthetics,

Orthotics, and Supplies (DMEPOS); Accreditation of

DMEPOS Suppliers; Final Rule (71 FR 48354) 2007

CMS-1540-CN


for Federal Fiscal Year 2007; Certain Provisions Concerning

Competitive Acquisition for Durable Medical Equipment,

Prosthetics, Orthotics, and Supplies (DMEPOS); Accreditation

of DMEPOS Suppliers; Correction (71 FR 57447) 2007

CMS-1290-F


for FY 2006; Final Rule (70 FR 47880) 2006

CMS-1290-CN


for FY 2006; Correction (70 FR 57166) 2006

CMS-1480-N

Inpatient Rehabilitation Facility Compliance Criteria; Notice

(70 FR 36640) 2005

IRF Regulations


IRF Regulations


CMS-1360-CN


for FY 2005; Correction Notice (69 FR 60157) 2005

CMS-1360-N


for Fiscal Year 2005 (69 FR 45721) 2005

CMS-1474-P


for FY 2004; Proposed Rule (68 FR 26786) 2004

CMS-1262-P

Changes to the Criteria for Being Classified as an Inpatient

Rehabilitation Facility; Proposed Rule (68 FR 53266) 2004

CMS-1262-F

Changes to the Criteria for Being Classified as an Inpatient

Rehabilitation Facility; Final Rule (69 FR 25752) 2004

CMS-1205-N


for FY 2003; Notice (67 FR 49928) 2003

CMS-1069-P


Facilities; Proposed Rule (65 FR 66304) 2002

CMS-1069-F


Facilities; Final Rule (66 FR 41316) 2002

CMS-1069-F2


Facilities; Correcting Amendment (67 FR 44073) 2002


http://www.cms.hhs.gov/InpatientRehabFacPPS/LIRFF/itemdetail.asp?filterType=none&filterByDID=0&sortByDID=3&sortOrder=descending&itemID=CMS1216198&intNumPerPage=2000






























IRF Program Transmittals

File Date Title

7760 2012-07-18Systematic Validation of Payment Group Codes for Prospective

Payment Systems (PPS) Based on Patient Assessment

7760 2012-04-27Systematic Validation of Payment Group Codes for Prospective

Payment Systems(PPS) Based on Patient Assessments

7674 2012-01-25Inpatient Rehabilitation Facility (IRF) No-Pay Billing for Medicare

Advantage (MA) Patients Update

7609 10/26/2011

Inpatient Rehabilitation Facility (IRF) and Inpatient Psychiatric Facility (IPF) Cost-to-

Charge Ratios (CCRs)

7510 09/13/2011

Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System

(PPS) Pricer Changes for FY 2012

7464 06/17/2011

Revision to Formula to Compute the Time Value of Money under the Inpatient

Prospective Payment System (IPPS), Outpatient Prospective Payment System (OPPS),

Inpatient Rehabilitation Facility (IRF PPS), Inpatient Psychiatric Facility (IPF PPS) and

Long Term Care Hospital (LTCH PPS)

Website: http://www.cms.gov/InpatientRehabFacPPS/LSIRF/list.asp#TopOfPage


http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/IRF-Program-Transmittals-Items/IRF-CR7760-R2495CP.html




http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/IRF-Program-Transmittals-Items/CMS1256343.html

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/IRF-Program-Transmittals-Items/CMS1256343.html

http://www.cms.gov/InpatientRehabFacPPS/LSIRF/itemdetail.asp?filterType=none&filterByDID=0&sortByDID=2&sortOrder=descending&itemID=CMS1253984&intNumPerPage=10






http://www.cms.gov/InpatientRehabFacPPS/LSIRF/list.asp

File Date Title

7151 05/13/2011

Processing Claims Spanning More than Ten Years with Unlimited Occurrence Span

Codes (OSCs): Final Completion

7150 01/21/2011

Processing Claims Spanning More than Ten Years with Unlimited Occurrence Span

Codes (OSCs): Phase III

6699 1/15/2010 Coverage of Inpatient Rehabilitation Services

7019 7/30/2010

Revised Instructions for Reporting Assessment Dates under the

Inpatient Rehabilitation Facility (IRF), Skilled Nursing Facility

(SNF), and Swing Bed (SB) Prospective Payment Systems (PPS)

6699 1/15/2010 Coverage of Inpatient Rehabilitation Services

7019 7/30/2010

Revised Instructions for Reporting Assessment Dates under the

Inpatient Rehabilitation Facility (IRF), Skilled Nursing Facility

(SNF), and Swing Bed (SB) Prospective Payment Systems (PPS)

7029 7/15/2010

Updates to the Inpatient Prospective Payment System (IPPS), Long

Term Care Hospital (LTCH) PPS, Outpatient Prospective Payment

System (OPPS), and Inpatient Rehabilitation Facility (IRF) PPS

Changes due to the Affordable Care Act (ACA)







http://www.cms.hhs.gov/InpatientRehabFacPPS/LSIRF/itemdetail.asp?filterType=none&filterByDID=0&sortByDID=1&sortOrder=ascending&itemID=CMS1237705&intNumPerPage=2000










File Date Subject

7029 7/15/2010

Updates to the Inpatient Prospective Payment System (IPPS), Long Term

Care Hospital (LTCH) PPS, Outpatient Prospective Payment System

(OPPS), and Inpatient Rehabilitation Facility (IRF) PPS Changes due to

the Affordable Care Act (ACA)

7076 8/13/2010

Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective

Payment System (PPS) Pricer Changes for FY 2011

7088 8/13/2010

Processing Claims Spanning More than Ten Years with Unlimited

Occurrence Span Codes (OSCs)

7122 10/28/2010

Processing Claims Spanning More than Ten Years with Unlimited

Occurrences Span Codes (OSCs): Phase II

7163 11/12/2010 Update to the Frequency Billing Requirements

7192 12/3/2010

Outlier Reconciliation and other Outlier Manual Updates for the

Inpatient Prospective Payment System (IPPS), Outpatient Prospective

Payment System (OPPS), Inpatient Rehabilitation Facility (IRF) PPS,

Inpatient Psychiatric Facility (IPF) PPS and Long Term Care Hospital

(LTCH) PPS
















File Date Subject

6607 8/28/2009

Inpatient Rehabilitation Facility Annual Update: Prospective Payment

system Pricer Changes for FY2010

1479 3/14/2008

April 2008 Inpatient Rehabilitation Facility (IRF) Prospective Payment

System (PPS) Pricer Changes

5965 3/14/2008

April 2008 Inpatient Rehabilitation Facility (IRF) Prospective Payment

System (PPS) Pricer Changes

6002 7/25/2008

Clarification on the Correct Condition Code to Report on Provider

Adjustment Requests to Indicate a Health Insurance Prospective

Payment System (HIPPS) Code Change

6166 9/5/2008

Inpatient Rehabilitation Facility Annual Update: Prospective Payment

System Pricer Changes for FY 2009













File Date Subject

5597 7/13/2007

IOM Pub. 100-09, Chapters 3- Provider Inquiries and Chapter 6-

Provider Customer Service Program Updates

5694 8/24/2007

Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective

Payment System (PPS) Pricer Changes for FY 2008

5597 6/29/2007

IOM Pub 100-09, Chapters 3, Provider Inquiries and Chapter 6 -

Provider Customer Service Program Updates

5846 12/14/2007

The Supplemental Security Income (SSI)/Medicare Beneficiary

Data for Fiscal Year (FY) 2006 for Inpatient Prospective Payment

System (IPPS) Hospitals, Inpatient Rehabilitation Facilities (IRFs),

and Long Term Care Hospitals (LTCHs)

1137 12/22/2006

CR 5325 - Inpatient Rehabilitation Facility (IRF) Teaching Status

Adjustment

938 5/5/2006

CR 5016 - Inpatient Rehabilitation Facility Prospective Payment

System (IRF PPS)

619 1/3/2006

CR 3885 - Late IRF-PAI Data Submission Penalty Protocol Within

the Inpatient Rehabilitation Facility Prospective Payment System

















File Date Subject

478 2/18/2005

CR 3704 - Clarification of the Verification Process to be Used to

Determine if the IRF Meets...

680 9/16/2005

CR 4037 - Inpatient Rehabilitation Facility Annual Update: PPS

Pricer Changes for FY 2006

207 6/18/2004

CR 3309 - Expansion of Policy Where Patient is a Member of a

Medicare Advantage (MA) Organization For Only a Portion of the

Billing Period to Include Inpatient Rehabilitation Facilities (IRF) and

Long Term Care Hospitals (LTCH)

221 6/25/2004 CR 3334 - Medicare IRF Classification Requirements

263 7/30/2004

CR 3378 - Inpatient Rehabilitation Facility (IRF) Annual Update:

Prospective Payment System (PPS) Pricer Changes for FY 2005

347 10/29/2004

CR 3503 - Inpatient Rehabilitation Facility (IRF) Classification

Requirements

392 12/10/2004

CR 3567 - The Supplemental Security Income (SSI) Medicare

Beneficiary Data for Fiscal Year 2003 for Inpatient Rehabilitation

Facility Prospective Payment System (IRF PPS)

















File Date Subject

39 12/8/2003

CR 2978 - Updated data for determining additional payment

amounts for the low-income patient adjustment applicable for

facilities subject to the IRF PPS

A-01-110 9/14/2001

CR 1851 - Instructions for Implementing the IRF PPS: Revision

and Modification of Transmittal A-01-92

A-01-131 11/1/2001 CR 1921 -Additional instructions for implementing the IRF PPS

A-01-146 12/21/2001 CR 2003 - IRF PPS Revenue Code File Update

A-01-92 7/31/2001 CR 1657 - Instructions for Implementing the IRF PPS

A-00-91 11/30/2000

CR 1343 - This PM is informational only. Specific contractor

claims processing instructions will follow

A-02-058 N/A

CR 2250 - IRF Annual Update: Prospective Payment System

Pricer Changes for FY 2003








































Additional Resources

• Billing

Pub 100-4, Chapter 3, Section 140

• CMS IRF Home Page

• http://www.cms.hhs.gov/ImpatientRehabFacPPS

/

• CMG for FY 2013

• FY 2013 IRF PPS Notice, July XX, 2012

• IRVEN V.2.4 (9/8/10)


http://www.cms.hhs.gov/ImpatientRehabFacPPS/



Items For Your Toolkit

• IRF PPS Documents

• Be Familiar With:

1. FY 2002 Final Rule, August 7, 2001 (The

Original Payment System)

2. FY 2006 Final Rule, August 12, 2005 (FY 2006

Refinements)

3. Final Rule FY 2007, August 18, 2006 Federal

Register

4. Final Rule FY 2007 Correction Notice,

September 29, 2006 Federal Register

5. Final Rule for FY 2008, August 7, 2007 Federal

RegisterCopyright 2012, AMRPA, Washington, DC

Items For Your Tool Kit

• IRF PPS Documents

• Section 1886 (j) Social Security Act

• 42 CFR Subpart P, 412.600 et. seq.

• New, Revised IRF PAI Training Manual, 2012

• Annual SSI , Comorbidity etc., Updates on CMS

Website

• UB Billing Form

• New Inpatient Rehabilitation Facility Patient

Assessment Instrument (IRF-PAI), 2012

• CMS IRF PPS website –

www.cms.gov/inpatientrehabfacpps/


http://www.cms.gov/inpatientrehabfacpps/

http://www.cms.gov/inpatientrehabfacpps/

Items For Your Toolkit

• IRF PPS Documents cont’d

• Be Familiar With:


Register


Register

8. FY 2011 Notice, July 22, 2010 Federal Register


Register

10. FY 2012 Correction Notice, September 26, 2011

Federal Register

11. FY 2013 Notice, July XX, 2012 Federal RegisterCopyright 2012, AMRPA, Washington, DC

FY 2006: First Refinements

• Now 92 Total CMGs, 353 Payment Groups

• Changed Comorbidities

• Revised Tier Structure

• Moved to Weighted Motor FIM

• Added Teaching Adjustment

• Adjusted Outlier Policy

• Took a 1.9 % Reduction for Coding

• Move To Core Based Statistical Areas (CBSAs)


Key Concepts

• Be Familiar with Rehab Impairment Categories

and Impairment Group Codes

• Be Familiar with Comorbidity Tiers

• A = None − B = Most Severe

• Tier 1 = Most Severe − Tier 3 = Least

Severe


Key Concepts

• Be Familiar with ICD-9-CMG

• Provide Complete Verbal, Written, Dictated

Description of Patient On Admission, in H+P and Post

Admission Evaluation So Coders Can Properly Assign

IGC, RIC, then CMG, Comorbidities and Tiers


Facility Adjusters:Low Income Percentage

• ((1+DSH)^(0.4613))

• DSH Patient Percent = (Medicare SSI Days/Total

Medicare Days) + (Medicaid, Non-Medicare

Days/Total Patient Days)

• SSI Ratio Important, Published Annually by CMS

• Used by IRFs to Estimate the LIP Adjustment

• See CMS IRF PPS Website for SSI Ratio Annual

Updates

• If DSH Phased Out What Happens?


TABLE 6: Example of Computing the IRF FY 2013 Federal Prospective Payment

Steps Rural Facility A

(Spencer Co.,

IN)

Urban Facility B

(Harrison Co., IN)

1 Unadjusted Federal Prospective

Payment

$30,513.30 $30,513.30

2 Labor Share X 0.69981 X 0.69981

3 Labor Portion of Federal

Payment

= $21,353.51 = $21,353.51

4 CBSA Based Wage Index

(shown in the Addendum ,

Tables 1 and 2)

X 0.8551 X 0.8900

5 Wage-Adjusted Amount = $18,259.39 = $19,004.63

6 Nonlabor Amount + $9,159.79 + $9,159.79

7 Wage-Adjusted Federal

Payment

= $27,419.18 = $28,164.41




(Spencer Co.,

IN)

Urban Facility B

(Harrison Co., IN)

8 Rural Adjustment X 1.184 X 1.000

9 Wage- and Rural- Adjusted

Federal Payment

= $32,464.30 = $28,164.41

10 LIP Adjustment X 1.0228 X 1.0666

11 FY 2013 Wage-, Rural- and

LIP- Adjusted Federal

Prospective Payment Rate

= $33,204.49 = $30,040.16

12 FY 2013 Wage- and Rural-

Adjusted Federal Prospective

Payment

$32,464.30 $28,164.41

13 Teaching Status Adjustment X 0 X 0.0610




(Spencer Co.,

IN)

Urban Facility B

(Harrison Co., IN)

14 Teaching Status Adjustment

Amount

= $0.00 = $1,718.03

15 FY 2013 Wage-, Rural-, and

LIP-Adjusted Federal

Prospective Payment Rate

+ $33,204.49 + $30,040.16

16 Total FY 2013 Adjusted Federal

Prospective Payment

= $33,204.49 = $31,758.19


Facility Adjusters: Teaching Adjustment

• (( 1+FTE Residents Training in the IRF/ADC)^

(0.6876))

• ADC=Average Daily Census

• Subject to a Cap on the FTE Count

• FY 2012 Rule Provides Temporary Cap Adjustment

Due To IRH/U Closure or Residency Program

Closure


Payment Example

• Medical Record Shows

• CVA – Left Sided Hemi Paresis

Renal Dialysis, Prostate Cancer, Severe Malnutrition, Dehydration

• Weighted Motor FIM 24

• Age 78

• IRF-PAI Shows

• Motor FIM 26


Payment Example Unadjusted

• RIC = Stroke

• Scores = CMG 0109

• Comorbidities = V45.11 = Tier 1

• Unadjusted Payment = $30,444.45 for FY 2013


Table 13—Possible Future Measures And Topics For The IRF

Quality Reporting Program

Overarching Goal: Safety and Prevention

• VTE Prophylaxis.

• Patient Immunization for Influenza.

• Patient Immunization for Pneumonia.

• Staff Immunization.

Overarching Goal: Safety and Healthcare Acquired Conditions—

HAIs

• Surgical site infections.

• Multidrug resistant organism infection.


Overarching Goal: Better, Person Centered-Care: Care

Coordination/Care Outcome

• Functional Change: Change in Motor Score.

• Change in Cognitive Function: Change in Cognitive Score.

• Communication.

• Percent of patients whose individually stated goals were met.

• Care Transitions Measure–3 (CTM–3).

• Discharge Outcome/Discharge disposition:

• Home.

• Assisted Living.

• Nursing Home.

• LTCH.

• Hospital.

• Hospice.




• Patient Preferences for care, treatment and management of

symptoms by healthcare providers.

Overarching Goal: Better, Person Centered-Care: Symptom

Management

• Percent of patients on a scheduled pain management regime

on admission who report a decrease in pain intensity or

frequency.

• Percent of patients with pain assessment conducted and

documented prior to therapy.

• Percent of patients who self-report moderate to severe pain.

• Percent of patients with dyspnea improved within one day of

assessment.




Overarching Goal: Better, Person Centered-Care: Experience of

Care

• Patient Survey, for example, Hospital Consumer

Assessment of Healthcare Providers & Systems.

• Percent of patients for whom care delivered was consistent

with patient stated care preferences.

* Consistent with NQF Serious Reportable Events.

** Consistent with Healthcare Acquired Conditions (HAC)

Prevalence Measure.




IRF PPS FY 2013 Update and Changes: What the CMS Notice Says and Means for Rehabilitation Hospitals and Units Starting October 1, 2012

Darlene L. D‘Altorio-Jones, PT., MBA HCM

Strategist, Rehabilitation Management; MediServe

HOW MIGHT THIS

IMPACT YOU?

Overall Impact – Facility Adjusters

59

Standard Payment Conversion (formally known as Budget Neutral

Conversion Factor)

Weighting & LOS factors

• Standard Base Payment Rate $14,076 to $14,343

• Outlier Payment Rate:

• 2012 payments expected 2.8% to be outlier payments.

• Estimated 2013 aggregate IRF payments @

approximately 3% provides a $10,466 outlier 2013 rate

• (Compared to $10,713 from the 2012 Correction Notice

payment amount.)

• CMG Weights & ALOS Table Updates – Let‘s

Review

Updates to Budget Neutrality

60

• CMG Weights & ALOS Table

• Relative Weights for 353 CMG‘s

• 199 or 56 % of cases weighted more or equal to 2012

• 154 or 44 % of cases weighted less

• Affect of Standard Payment @ $14,343 rate:

• 272 or 77 % of cases paid more or equal to 2012

• 81 or 23 % of cases paid less

• ALOS

• 51 or 14 % have Greater ALOS Published days

• 148 or 42 % have Less ALOS Published days

• 154 or 44 % have no change in the ALOS Published days

CMG Relative Weights - 1433 Notice

61

2013 Table Comparison

62

56%

44%

CMG Affects 2013 to 2012

CMG Weighted More or Equal

14%

42%44%

ALOS Affects 2013 to 2012

ALOS Greater

ALOS Less

ALOS Equal

Affects By RIC /CMG Breakdown

63

• 377,040 Cases in 2012 with distributional effects given the

CMG relative weight changes

• Total estimated aggregate payments to IRFs for FY 2013 will

not be affected as a result of the CMG relative weight

revisions. However, the revisions will affect the distribution

of payments within CMGs per a rule statement.

and tiers

Cases - Distributional Change Effect

64

• Timely IRF PAI assessment is critical to confirm

appropriate Case Mix Index (CMG) being applied.

• Validation and completion of functional measurement

and admit PAI items guide expectations towards

clinical resource needs and utilization.

• Staff must understand the importance of accurate

measurement as it leads to appropriate payment to

match the intensity/care cost burden required at the

individual patient level.

Scoring Accuracy Paramount

65

Rule Example:

Rule Payment Example A0110

66

• Using the same Indiana Facilities A & B used in the

previous example. How does this translate for other

common case types?

• MediServe offers a free tool that enables you to

review facility payment with YOUR facility

adjusters.

• This html link is provided upon request and adjusts

payment based on your unique payment criteria.

Snapshot Variances Rural/Urban

67

How Inpatient Rehab Providers Are Paid

68

http://mediserve.com/resources

Wage Index

Disproportionate Share

Rural or Urban

Teaching Status

Outlier Payments

Short Stays

Expired Patients

http://mediserve.com/resources

69

• Given 1.28 as an average CMI payment for all facilities,

MediServe applied the facility adjustment formulas to each

facility (CMS data file) and compared a 2013 to 2012 value for

a net change in reimbursement . (Positive vs. Negative effects in dollars)

• Positive > $1

• 44% -

• 483 facilities

• Positive >$500

• 49%

• 543 facilities

• Negative 7%

• 77 facilities

1,108 Facilities - Facility Adjusters Applied

70

Negative Change

7%

Positive > $144%

Positive > $50049%

Average Change in Reimbursement - After FacilityLevel Adjusters

Standard Payment Base Rates: ( Note* 3,2,1 – None Order)

Stroke Base Rate Change 2013 to 2012

71

2013 to 2012 Standard Rate Change Compare

72


73


Fracture LE Base Rate Change 2013 to 2012

74


75

• Stroke

• Fx. LE

ALOS Variance Snapshots 2013 to 2012

76


Replacement LE Base Rate Change 2013 to 2012

77

LE Jt. Replacement Base Rate Change 2013 to 2012

78


Miscellaneous Base Rate Change 2013 to 2012

79

80


• Replacement LE – ALOS Changes

• Miscellaneous – ALOS Changes

ALOS Variance Snapshots 2013 to 2012

81

• Without focus and interdisciplinary communication it will be

nearly impossible to drive expectations expeditiously.

• Keep focus on impending barriers and the teams ability to

eradicate any that stand in the way of the discharge plan.

• Focus at this level always meets the individuals needed

LOS rather than predetermined averages.

• Review facility ability to meet discharge expectations against

YOUR own outcomes.

• Are the published ALOS significantly different than yours?

• Manage to individual patient expectations/abilities.

• Coverage Criteria (2010 Rules) will not go away!

• Getting paid and keeping payment requires leadership

vigilance.

Challenges

82

• Keeping Medicare payment is contingent on

following the Coverage Criteria ‗specifically‘ as

detailed.

Expectations & Reality

83

14 Criteria = 145 Clarifications *

84

www.mediserve.com/irf-clarification/

85

www.mediserve.com/irf-clarification/

http://www.mediserve.com/irf-clarification/



• Keep your hard earned cash!

• Know your numbers and continually audit for

coverage criteria compliance.

• Margins can only be managed well when

communication and expectations are clearly

defined from front to end in the patients‘

experience.

Monitor & Correct

86

Questions?

MediServe

www.MediServe.com

1-800-279-8456

Email: [email protected]

AMRPA

www.amrpa.org

1- 888-346-4624

Email: [email protected]

*CEU forms provided in follow-up email

Thank You!

http://www.mediserve.com/

http://www.mediserve.com/

mailto:[email protected]

mailto:[email protected]

ACA Section 3004: Quality Reporting Program

for IRFs

August 16, 1-2:30 p.m.

Call: 1-800-837-1935

Conference ID: 20492286.

CMS Special Open Door Forum

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