“FR Doc. 2013-10755 Filed 05/02/2013 at 4:15 pm; Publication Date: 05/08/2013”

Because the provision of therapy submitted to CMS is generally provided with every intent to meet medical necessity/reasonable and necessary care requirements, it would be paid through the beneficiaries benefit. It is not uncommon practice for an outpatient practice to continue treating in good faith and that the selected interventions and documentation will meet scrutiny and ultimately receive compensation. This is why therapists chose their profession; to be compensated at a job we know can reduce pain and suffering and restore function to the many lives we touch over our careers.

In the past, an ABN (Advanced Beneficiary Notice) was always available. In my personal experience they were rarely used in outpatient practice and generally only when the patient or family felt benefit to the care but the professional felt the care was extending beyond the definition of ‘skilled’ because of a specific plateau or inability to demonstrate significant functional benefit. If continued, an ABN was issued and the patient took the chance at self-pay.

Liability has taken on a new definition with the caps process. Pay special attention and educate your staff accordingly.

Times have changed. This is a new world of healthcare with fiscal responsibility and CMS is guarding the Medicare Trust Fund for good purpose as an aging society will enter the age of well-deserved needed care. With this reality comes education to our staff that an ABN  may be used more often. I say ‘may,’ because most therapists still believe that the treatment they render is medically necessary and that the documentation they provide is sufficient to demonstrate that need.

In order to issue an ABN you are sending a mixed message to the patient that the services ‘may not’ be deemed medically necessary and therefore you are asking the patient to accept responsibility above and beyond their normal benefit payment plan because of this ‘specific fact’. This message seems incongruent, since we wholeheartedly believe treatment is medically necessary, yet we are now in a quandary of wondering whether a hindsight audit might not believe so. Alongside our well intended care we specifically feel is medically necessary we now have to struggle with the ethical dilemma of THE CAP. This arbitrary amount that will now scrutinize if extended payment will in fact be permissible. This ethical struggle, I feel our government knows, will be difficult for therapist to face. Mostly we are bleeding hearts. So without an ABN, your facility will absorb this above and beyond care service charges. Liability is now in the lap of providers without an ABN. Get educated on the use of ABN’s.

Now on goes the business hat… your doors must remain open in order to provide additional care. Bills must be covered, staff are still being paid and resources are being consumed, even though in hindsight that bill may be ‘declined’ by a payment review process whether pre or post, it really is still very conflicting to say the least.

Therapists know that all care, specifically care to those that have the greatest physical demands for recovery are also within the limits of the therapy cap. The proactive extension process has been lost. In fact, without Congressional action before Dec. 31, 2013, beneficiaries needing care above the therapy cap will continue to be forced to forgo care or face paying 100 percent of the cost of additional treatment out-of-pocket when coverage expires. I recommend you continue because that started January 1 whether you acted differently or not. If your Medicare Audit Contractor denies payment to your care above the therapy cap this year and you did not provide an ABN since January 1, you the provider are absorbing those costs. The automatic ‘exceptions process’ has long expired. APTA has even campaigned during Stroke Awareness Month for persons to contact their legislators to take action and at least reapply the exceptions process if the cap cannot be lifted in it’s entirety.

Medicare published the following notification in their e-news bulletin to remind providers – liability for care only falls with the provider for care furnished above and beyond caps when the necessary advanced beneficiary notice was provided.

“Change to Payment Liability for Therapy Cap Denials

Section 603(c) of the American Taxpayer Relief Act of 2012 (ATRA) changed the payment liability for denials resulting from the outpatient therapy caps from beneficiaries to providers effective January 1, 2013. Medicare systems were not updated in time to accurately represent this change on provider remittance advices (RAs). Medicare contractors may have already processed therapy cap denials for services provided in 2013. These denials incorrectly report on RAs beneficiary liability (Group Code “PR”) when liability legally rests with the provider (Group Code “CO”).

Due to differing claims processing system constraints, this inaccurate RA reporting will be corrected beginning on different dates for different claim formats. For institutional claims, the correct liability will be reported beginning on June 24, 2013. For professional claims, the correct liability will be reported beginning on January 1, 2014.

Since Medicare’s payment amount for these claims is correct, Medicare Administrative Contractors will not adjust claims processed before these dates to correct the Group Code. To do so could create disruptions for providers’ accounts receivable. Instead, therapy providers should review any therapy cap denials for dates of service on or after January 1, 2013, to determine whether any payments have been collected from beneficiaries. Providers should refund any beneficiary payments they find for these services. Additionally, providers should cease to collect payments for therapy cap denials unless the beneficiary was appropriately notified via an Advanced Beneficiary Notice of Noncoverage (ABN).”

Have this discussion with your staff. Ethically speaking it’s one you cannot afford to dismiss.

The April 18 release of the CMS Medicare FFS Provider e-News contained  discussions with references to two MedLearn Matter releases pertinent to implementation of claims-based data collection. In that release, Medlearn Matter 8166 provides information on what to expect in the way of alerts when and if you do or do not start practicing transmission of G-codes/modifiers between April 1 and June 30 as a practice run for July 1st; however only non-institutional practices should see those alerts.

They state, “For therapy claims, with dates of service on and after Jan, 1, 2013, processed on and after April 1, 2013, through June 30, 2013, you will receive a Remittance Advice (RA) message to alert you to include the applicable new functional limitation G-codes (from the list of 42) and the appropriate severity/complexity modifier (from the list of 7) on future specified therapy claims”, if in fact you are not yet practicing. Be aware though, these will NOT occur for institutional claims, although institutional providers SHOULD develop workflow to enable this information to populate their uniform bills.    

What are the two new remittance advice messages that will alert you? The Claim Adjustment Reason Codes are;  CARC 246 “this non-payable code is for required reporting only” and RARCN565,  “Alert: This non-payable reporting code requires a modifier. Future claims containing this non-payable reporting code must include an appropriate modifier for the claim to be processed. When nonpayable HCPCS codes G8978 to G8999, G9158 to G9176 or G9186 are submitted without the appropriate modifier (CH – CN).”

Don’t be alarmed, this is still considered a testing phase whereas “Your carrier or B MAC will continue to process and adjudicate your therapy claims without the required G-codes and severity/complexity modifier,” per the MedLearn Matters discussion.

Recall, Claims-Based Outcomes Reporting (MediServe references as CBOR), is just around the corner. Some facilities/individual providers have taken on the task to prepare and start practicing the workflows required to be in place to acknowledge and permit transmittal; unfortunately up until this time those systems may not have been in place to allow the detail to be sent to the receiving contractor database. Now they seem to be prepared and ready to practice their payer alert messaging.

If you need a refresher on the entire claims-based outcomes guidelines; refer to the Revised Medlearn Matters MM8005.

Fair warning!  Beginning July 1, 2013, all Fee for Service Therapy Claims will be rejected using a NEW RA message when the codes are not present with billing transmittal.  No matter what that code version will be, it translates to zero dollars – so don’t wait.  This process takes a little time for a therapist to learn and it is the therapist that must guide and provide the data.

Pick up FREE POCKET guides here if you have not done so already!

Here is what was released in late April:

Posted on April 22, 2013, is the anticipated files and information is now available.

Why a change? Fujitsu NetCOBOL is now required to run the pricer files. “A one-time installation of ‘Fujitsu NetCOBOL’ run time files is required. Instructions for downloading Fujitsu NetCOBOL run time files can be found in section one of the “PC Pricer Download Instructions.”  These instructions may be downloaded through the following link: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PCPricer/Downloads/Updated-PCPricer-Download-Instructions.pdf.

Question:  What are PC Pricer files?

Answer: The PC Pricer is a tool used to estimate Medicare PPS payments. The PC Pricer contains a provider file with records listing all Medicare  providers at the start of the quarter in which the particular version of PC Pricer was released. Facilities that have recently received their Medicare  provider number or had a change of ownership may not be included in the provider  file. If you can’t locate a provider number in PC Pricer it does not mean your  claims aren’t being paid.

Quarterly schedule:

For a given fiscal year, the PRICER release schedule is as follows:

• First quarter release — On or about October 15
• Second quarter release — On or about January 15
• Third quarter release — On or about April 15
• Fourth quarter release — On or about July 15

Questions regarding pricers can be directed to:  PCPricers@cms.hhs.gov.

I would not personally wager on a bet that the g-codes will ONLY affect payment if you do not begin using them at the billing level post July 1. (I’ll provide my rationale in a minute.) As promised, non-coding will immediately affect non-payment if you don’t include the outcomes codes on bills post July 1 for certain. Let’s ask this question however, “what if you later have an additional development request for a record charted after Jan. 1, 2013?” Do you have any concerns if you did not begin charting outcomes codes within that record?

You may be in for a retrospective ‘uh-oh’ if you really didn’t ‘Get Er Done’ as you should have according to change release (CR) 8005 or MM8005. So let’s review this topic in detail because providers are presently struggling with patients in ‘mid stream’ of the July 1 billing deadline. Many are not quite sure how Medicare wants the bill coded if the provider did not begin charting prior to that date and did not begin real testing to the electronic billing document as they were encouraged to do prior to July 1  using the new status code indicator ‘Q’ for reporting purposes only.

I’m now deferring to my logic and logic is not always the enforced process, so for now humor my bulleted points to ponder provided the following ‘facts’ known thus far:  Pay attention to bolded areas.

• Prior to July 1 the information should be in the documentation at the very least but does NOT have to be on the bill (although they are providing a grace period to work it out through the billing department).
•  pg 2 of 11 of MM8005:

Application of New Coding Requirements

“This functional data reporting and collection system is effective for therapy services with dates of service on and after Jan. 1, 2013. However, a testing period will be in effect from Jan. 1, 2013, through June 30, 2013, to allow providers to use the new coding requirements in order to assure that their systems work. During this time period claims without G-codes and modifiers will be processed. “

• “Will be processed”  – I agree, means: will be paid as submitted given all other rules of billing have been followed.
• To me, this states that you should have this information in your notes at the very least after January 1.  But, the payment penalty will not be invoked from Jan – June 30 as a grace to get the billing systems to work appropriately. In essence, the bill will still be paid. 
• On a retrospective actual chart audit if requested for any other purpose, who knows if they will take back money previously paid if outcomes coding is not committed to the charted record per the change request published in December?
• pg 8 of 11 of MM8005:

“Specifically, functional reporting, using the G-codes and modifiers, is required on therapy claims for certain DOS as described below:

• At the outset of a therapy episode of care, i.e., on the DOS for the initial therapy service;

• At least once every 10 treatment days — which is the same as the newly-revised progress reporting period – the functional reporting is required on the claim for services on same DOS that the services related to the progress report are furnished;

• The same DOS that an evaluative procedure, including a re-evaluative one, is submitted on the claim (see below for applicable HCPCS/CPT codes);

• At the time of discharge from the therapy episode of care, if data is available; and,

•On the same DOS the reporting of a particular functional limitation is ended, in cases where the need for further therapy is necessary.

I feel these bullelted items above gives providers ‘hope’ that they can just pick up and begin reporting in the middle of an episode of care if that patient started services PRIOR to July 1. With the guidance above to REPORT the codes when they are required (post July 1 DOS) to the bill;  there are several scenarios that could occur. Until I hear otherwise with additional guidance awaited from CMS, this is what I might do: (Disclaimer:  always consult your compliance department and/or follow all CMS releases should they publish new information following this POST; 05/23/2013. This is for discussion and rationalization given present guidance.)

1.)  Create the very first visit  post July 1 to be a progress reporting period. The present guidance allows you to report progress EARLIER than every 10 days. Essentially any treatment after July 1 would become the first day of my next day 10 episode of care.   You then record the present status and goal for the particular function you are seeing the patient for, even though you may not have already transferred any evaluation information to CMS. Evaluation information should be in my written chart, however if audited; it was due for all services post January 1.  The discipline, G code and impairment modifier are placed to the bill with the appropriate billable CPT code when I make this first visit post July 1st as a ‘progress report’.

2.) I re-evaluate the patient (if they meet conditions of Medicare Re-evaluation) on the first date of service in July. I then state the Initial, and goal G code & modifier along with the appropriate CPT code for that care. 

3.) If it is the last treatment within the episode of care and it occurs on any day after July 1st (only 1 date of service) then I report the previously charted goal  as a G  code & modifier along with the discharge G code and modifier. The chart should have the initial, and any progress up to that point available on the chart for audit if the chart is requested for any ADR (additional development request). 

These are the scenarios I see as far as billing possibilities given the MM8005 change release notice and if I had not practiced sending any billing codes through to my Medicare Audit Contractor. (FI/MAC)  No one should be procrastinating now, we’re in the final lap – “Get ‘Er Done”!

If given the benefit of a doubt you have not covered yourself to follow this first release specifically as written, I fear the Medicare Trust Fund may have gathered anywhere up to another six month buffer of therapy care on audited records. And finally on pg. 2 of MM8005 they promise this in a highlighted note: “A separate CR (and related MLN Matters® Article) will be issued regarding the editing required for claims with therapy services on and after July 1, 2013, at which time Medicare will begin returning and rejecting claims, as applicable, that do not contain the required functional G-code/modifier information.” Sit tight, this has to occur any day now!  I have contacted CMS employees, Pam West and Simone Dennis restating the concerns our clients have voiced, as well as list serve discussions and I am confident this instruction is soon forthcoming.

In 2004 or so  I attended an in-service given by Dr. Regina Herzingler, Faculty of Harvard Business School, on the topic of ‘Consumer Driven Healthcare’ and I was hooked on driving quality improvement and operational performance ever since. TODAY in healthcare are the days she was speaking of long ago in that lecture. I recall her saying there will be a time when persons will be able to measure side by side the cost of hospitals in their area, as well as the outcomes of those facilities and they will be able to determine for themselves how they will spend their ever increasing out-of-pocket expenses. Healthcare reform promised this concept on the horizon and the sun just crested to spotlight the average consumer with data realities. Healthcare compare information can now be complimented with charge to payment data.

You can go to the link provided, Medicare Provider Charge Data 2011, on the CMS website and download the entire Excel file for yourself.  Then you can do as I did… living in Ohio I made a quick analysis that for the 7,012 procedures listed in Ohio, these represented an average covered charge to average total payment of 56 percent. Are these the results of inflated charge masters? Why can one facility list the same DRG procedure for so much less than another?  It is transparent what the covered charges were for each procedure and exactly how many CMS procedures were provided for the particular DRG (reported when n was greater than 11). Many questions will begin to form with this new release of information. Will a consumer with the ability to choose go to a facility that performed on average so many more procedures than another?

Choice may go beyond loyalty. Informed consumers act different for various reasons. What is the new marketing strategy for hospitals? Price wars could be on the horizon, outcomes certainly should be too!  Is healthcare reform really all that bad? It depends who is asking and if you are a consumer or a provider. One thing is clear: your strategies need alignment quick.

Your mind may be racing with many other ‘what ifs’, such as what will people do with this information? If I am a consumer and I am signing a responsibility of payment or ABN and/or have a particular copay responsibility, anyone knows that a percent of less total charges will become less total dollars out of pocket. I would also be able to download the file and carve out the facilities I would most likely be referred and if a procedure lends itself time to make a decision, I would certainly pair that with outcomes data made available.  Your marketing strategy either just got easier or harder depending on your data, and because this data is from 2011 and we are already forging well into 2013 care; what will future reports do for you?

I say, there is no time to wait. If you haven’t already gotten the message that transparency and pay for performance are soon to lead the way, I just think transparency forged ahead by leaps and bounds! Although this is beginning with inpatient PPS payment information, what other level of service is next to follow?  Every effort here on out must be toward effective, efficient care at the right price – or you just could be pricing your services right off the shelf.

CMS is proposing robust updates and changes to next years IRF PPS Regulations. In short summary, these are the highlights:

1.) Revise the list of diagnosis codes that are used to determine presumptive compliance under the “60 percent rule.”   (pg 64- 88)

2.) Update the IRF facility-level adjustment factors.  (pg 35)

3.) Revise sections of the Inpatient Rehabilitation Facility-Patient Assessment Instrument that relate to the quality reporting section.  (pg 100)

4.) Revise requirements for acute care hospitals that have IRF units. (pg 96)

5.) Clarify the IRF regulation text regarding limitation of review. (pg185)

6.) Update references to previously changed sections in the regulations text. (pg 95)

7.) Revise and update quality measures and reporting requirements under the IRF quality reporting program, as a recent blog alerted you on the indicators they were reviewing for selection.  (pg 107 & pg 124 starts)

8.) Revise sections of the IRF PAI that are not quality related. Look for additions, deletions, changes in selection items, increased number of co-morbid conditions and a signature and date page.   (pg 88 – 95  & 151)

9.) Applying reduction factors for 2014 if failure to report timely on the previous quality indicators. (pg 142)

As we are reviewing the 186 page document right now, stay tuned for further blog updates and a mid-summer Proposed Rule webinar.  Please be aware that these are proposed regulations and CMS is seeking your comments before the final is released. Pay attention to the very beginning portion of the document and the very end which provide information for where and how to submit your comments for both the rule and the updates proposed to the IRF PAI itself.

The further guidance will need additional clarification as well, because the workflow timelines are not fully detailed in this release.

For example new guidance states this, “Medicare Administrative Contractors (MACs) will conduct prepayment review on claims reaching the $3,700 threshold with dates of service Jan. 1, 2013, to March 31, 2013. CMS requested MACs conduct these manual medical reviews within 10 days. At this time, there is no advance request for an exception process.”

Given this instruction, it is not clear as to when 10 days is counted. Recognition must occur in their system that the threshold has been reached by either OT alone or PT and SLP together, and then they must elicit records by an additional development request (ADR) in order to perform a manual review within 10 days. Given the best case scenario, as soon as their system recognizes and sends a requests for ADR documentation, the facility has 45 days to respond to an ADR. If you wait until that last day and then add the 10 days for them to review the documentation, you can easily see that the process will beg much attention at the facility level in order to decrease the waiting time for a pre-payment review and decision of payment. For at least the first three months of the year, regardless of state, you are looking for a delay in payment beyond your previous payment cycle. Be prepared – your reaction makes all the difference in how much delay to expect!

Unfortunately, the newest process still does not allow for you to initiate the review, even after March. Regardless of state you must wait for the limit to be billed to the fiscal intermediary/MAC based on the recognized billing thresholds. After their system recognizes the threshold was met, payment process will unfold in one of two ways for all services on or after April 1, 2013; the caveat – your state will determine whether you get paid first and denied later or paid after review of the completed review. Either way, you must provide the services to the beneficiary in advance of the decision!

Documentation must clearly provide reasonable and necessary care for the condition requiring your skilled interventions and all guidance in the Medicare Benefit Policy Manual; 100-02  Chapter 15; Section 220 must be followed as implemented Jan 7, 2013.

Per guidance:

“Prepayment Review:

• Claims submitted in the Recovery Audit Prepayment Review Demonstration states will be reviewed on a prepayment basis. These states are: Florida, California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina and Missouri.
• In these states, the MAC will send an ADR to the provider requesting the additional documentation be sent to the Recovery Auditor (unless another process is used by the MAC and the Recovery Auditor).
• The Recovery Auditor will conduct prepayment review within 10 business days of receiving the additional documentation and will notify the MAC of the payment decision.

Postpayment Review:

• In the remaining states, the Recovery Auditors will conduct immediate postpayment review.
• In these states, the MAC will flag the claims that meet the criteria, request additional documentation and pay the claim. The MAC will send ADR to the provider requesting the additional documentation be sent to the Recovery Auditor. The Recovery Auditor will conduct postpayment review and will notify the MAC of the payment decision.”

Either way, final payment will always be as a result additional documentation request and review. Whether you obtain and hold on to that payment will depend on your therapist ability to document thoroughly to mandated details and reasonable and necessary care. If you’re not in a prepayment review state, you’ll at least have a smaller days outstanding margin to wait for payment. If clinical documentation has much to be desired, eventually you’ll give away free care whether you were effective or not in reaching that patient’s intended goals.

Both processes mandate in some form: treat now and pay later. Due diligence to chart audits will demand thorough compliance.

While at the 2013 Spring AMRPA conference a few weeks ago, I had the opportunity to listen to Anne Deutsch, RN, Phd, CRRN, Senior Research Public Health Analyst, RTI International; Clinical Research Scientist, Rehabilitation Institute of Chicago. She provided a quick update on the history of quality reporting including: the ‘Three Aims’ of CMS National Stategy, Better Health, Healthy People and Communities and Affordable Care.

In addition, she shared the six priorities specific to the National Quality Strategy and listed them as follows in her slides:

1. Making care safer by reducing harm caused in the delivery of care.
2. Ensuring that each person and family are engaged as partners in their care.
3. Promoting effective communication and coordination of care.
4. Promoting the most effective prevention and treatment practices for the leading causes of mortality (cardiovascular disease).
5. Working with communities to promote wide use of best practices to enable healthy living.
6. Making quality care more affordable for individuals, families, employers and governments by developing and spreading new health care delivery models.

A few of those items should peak your interest as to how that will affect your line of service, but for now, let’s just discuss Quality Measures under consideration for the LTC industry; which by the way includes IRF.

MAP is a public-private partnership created to provide input to the Department of Health and Human Services on the SELECTION of performance measures for public reporting and performance-based payment programs.  Additionally, MAP seeks industry leaders to comment and help guide thought generated to guide policy which may eventually be endorsed by the National Quality Forum (NQF) whose staff reviews, endorses and recommends use of standardized healthcare performance measures.  These steps eventually lead to policy and enforcement for participation in government paid services. At this point I hope your attending fully – eventually this process gets to you – the clinician and leaders of healthcare.

In January 2013,  MAP released a Pre-Rulemaking Draft report and many industry leaders made comments and recommendations.  The final report was recently published and is now available to review.

“The MAP Pre-Rulemaking Report: 2013 Recommendations on Measures Under Consideration by HHS represents MAPs second annual round of input regarding the performance measures currently under consideration for use in federal programs. ”

If you review this report,  pay attention to Section 7: Pre-Rulemaking Input on Post-Acute and Long-Term Care Performance Measurement Programs, as many organizations have voiced support and opposing discussions as to why 10 measures being discussed for inclusion in the Post Acute Care Service areas may or may not be the indicators to adopt, as we add additional quality and performance measurements to IRF Reporting.

Anne listed these additional measures being discussed to add to new or worsened pressure ulcers and CAUTI.

• Influenza vaccination coverage among healthcare personnel
• Percent of residents or patients who were assessed and appropriately given the seasonal influenza vaccine.
• Percent of residents or patients assessed and appropriately given the pneumococcal vaccine.
• Reliability adjusted central line-associated blood stream infection
• Reliability adjusted catheter associated urinary tract infection
• Reliability adjusted Clostridium difficile SIR measure
• 30-day all-cause post IRF discharge hospital readmission measure
• Functional change: change in motor score
• Functional outcome;  change in mobility
• Functional outcome measure; change in self-care

Think of these items in particular to the patient populations served in IRF.  How many come from hospitals already administering flu and pneumococcal vaccines?  Do you have many patients with central lines?  If functional change and outcomes are measured will they be based on functional measurement we all know and have been using for more than 10 years in IRF’s or will they wait until proposed CARE tool standards may be rolled out to the industry for continuum measurement?  These are all questions you too should consider and discuss with your staff. Get on board, and be certain your organizations and physicians are voicing your opinions this won’t be the last time comments will be accepted.

Of course this could not be done without a host of speakers and this year we were privileged to meet the Hon. Willis (Bill) Gradison, MedPAC Commissioner and Scholar in Residence, Duke Fuqua School of Business, who provided us a glimpse of how MedPAC came to be and the importance of reviewing the latest published report.

He stated, “After prospective payment was put into place in the early 1980s, a series of issues arose. We were concerned that we weren’t getting the true professional advice from HCFA (now CMS), at the time. We needed outside object views that were not just concerned with the budget only. The Prospective Payment Advisory Committee was born. At that time there was a Physician Payment Review Commission and the two were combined to create what is now known as MedPAC.”

He jokingly stated, with minor paraphrasing by me, that each year the panel of experts “prepare reports for every level of service and provide insight and recommendations; often gathering dust and at times rule makers take the information off the shelf to incorporate into law.” He then went on to discuss some items that were ‘off the record’ because they were his personal insights and recommendations. What I found most appealing was his sincere message that the information shared through MedPAC is insightful but requires response from the clinicians at large. Willis states they do not often get feedback after the report is released except from large professional organizations. He truly believes that if a larger audience of those that could be affected by the policy recommendations provided input and testimony that it would have more influence on the decisions policy makers made.

He then announced the completed Report to the Congress Medicare Payment Policy, March 2013 had been available since March. He encouraged everyone to visit its pages and to review and share thoughts on the statements and facts gathered. The recommendations made by the commission are at the end of the report and they urge congress to review the report and recommendations, as well as to reach out for additional information needed to make policy decisions.

I believe many of you will want to read the various chapters dedicated to the lines of service you may work under or manage as well as the discussion on solutions to the sustainable growth rate (SGR) fix. Analyze the rationale offered for the various statements made and see if you agree or feel additional considerations or information should be considered and then make known as an individual or as part of a organization or group you affiliate with in your professional career. 

In particular I will discuss, field locator areas of the UB from 42 – 47 and the fact that I have seen various interpretations to the specific billing requirements defined in the Medicare Claims Processing Manual 100-04; Chapter 3, Section 140.3.

Because cost reports are ultimately created from provider statistical & reimbursement reports, the charge detail aggregate data influences Medicare allowable charges. That, in turn, is used to calculate outlier payments and facility specific adjustments (like market basket); it’s never too late to review your own facilities completion of the uniform bill if for nothing else but uniformity so that analysis across facilities is valid.

Type of bill, PPS designated revenue code, type of bed code and display of ‘ancillary’ therapy charges is where this discussion with real examples will concentrate.

For the Part A Medicare beneficiary – an IRF bill is tagged with a 0024 Revenue Code that symbolizes the patient will be paid by the IRF PPS designated Health Insurance Prospective Payment System (HIPPS) value. This is generally a five digit combination of the tier status (A-D) and the CMG derived by the IRF PAI grouper software. In some instances, this may be one of the five special CMGs (short stay or expired patient codes); this line item appears first in the list of detailed revenue codes.

Next in the 42 field locator a room type value is diplayed
:

• Room Type – Revenue Code – third and fourth digits in the room code designates the TYPE of room for the inpatient stay. A single bed is 011x; a double bed room is 012x; these two are used most often. Since 8 describes a rehabilitation accommodation; the last digit should be ’8′. Also note that instructions state the field locators then must display the daily rate times the units. The unit would be the number of days in the patient’s stay. Avoid using general accommodation codes.

Last – although all other charges are to be itemized by revenue code and listed on the bill for cost report purposes, I will discuss the display of therapy services charges only within this post as this is generally the most varied item I see between bills. The claims processing manual describes this criteria for posting therapy services:

Even though a facility is not paid based on itemized charges, the details within the UB are significant to validate specificity of the care provided with the skills uniquely abundant in a rehabilitation level of care.

Display of therapy charges has varied interpretation from what I have seen. The leading code for therapy services are 04 with the third digit of ’2′ symbolizing Physical Therapy; a ’3′ Occupational Therapy and a third digit ’4′ Speech Language Pathology. The ‘X’ symbolizes the Type of procedure where the AMA provided procedural codes are indicated. I believe the ‘or’ in the claims manual sentence is what makes the intended definition require additional clarification. Some facilities will leave all descriptions at the service only level while others define the procedure. In a world of cost reporting transparency the values behind the various services charges hold significant detail in what makes a rehabilitation service provider unique and deserving of a rehabilitation level of care. Many bills will not substantiate intensity of resources as a stand alone which begs review of the written chart on audit.

If you wonder why your cost to charge ratio may not symbolize the level of care you provide, you may find the key to improving the accuracy in the detail of this section of your bill. Each procedure code is validated by a ‘weight’ associated with providing that level of care and again, although not paid like outpatient, the charge master driven bill should incorporate the resources required to provide higher skilled services that demand comparable charge structures. Medically necessary interdisciplinary skill sets are portrayed more clearly in the level of service and care provided when the charge master maintains correlation to procedure code values on the detailed bill; this is despite cost reports rolling total charges to the first three characters for therapy services: 042, 043 and 044 for example. Why? Because the detail is available when transferred in cost reporting.

An IRF part A stay has been interpreted different ways although guided by the claims processing manual. Look at your detailed bill and see which example most closely resembles your reporting style. (Note – dollar signs are NOT utilized on real UB’s and are used for clarity only.)

EXAMPLES UB-04 IRF BILLS:

A.)

B.)

C.)

D.)

‘Procedure’ or ‘Service’ holds many different interpretations for display on the UB-04; I personally believe we need clarification and/or picture examples published as a MedLearn Matter to help everyone apply the same expectations on the uniform IRF bill. Before IRF’s are railroaded toward obscurity, providers of inpatient rehabilitation services need to understand the underlying charges that CMS attempts to compare. Most importantly, with value- based purchasing leading future payment reform, all bills should be uniform so that IRF cost to charge ratios do not, for the most part, remain mystery calculations.

How does your bill compare? Should these variances concern us?

Typical to nearly any answer provided in a blog, each scenario will hold its own facts and good cause for rationale. When it is specific to recovery of functional mobility to meet the plan of care, I will default to this rationale and then provide the CMS rationale when it may be for other causes outside of your control as a health provider or despite best effort, no further progress is expected.

The IRF accepts patients with specific barriers to a discharge goal. Those barriers to discharge are owned by the entire interdisciplinary team. It’s inevitable that various  items will be  manageable more quickly than others. Until the team meets the discharge plan, no less than two therapies along with 24 hour rehab nursing managed by the rehabilitation physician should continue the remaining plan to successfully achieve the hopeful promised discharge capabilities. Reinforcing all mobility and self-care to highest potentials.

If any therapist put themselves in the patients shoes, they too would hope for that concentrated effort – that the interdisciplinary team will work together to meet the established discharge goal. The team seeks to meet the discharge plan; whereas no one stops at the minimum when not all goals are met. Some areas you will exceed the least level required to discharge … until every area is met. Efficacy is met when everyone on the team collaborates to tackle those very specific areas to be certain carryover and capability exist for the realistic discharge expectation, as long as that expectation is still reasonable.

Only when the original plan is no longer viable, despite everyone’s best effort, should the team discontinue the rehab level of care – always taking into consideration the value cost of the patients benefit being utilized. Recalling CMS ALOS is just that – averages,  and those are made up of real length of stays to enable the desired discharge location and permanency of stability. But let’s say the rationale falls outside of ‘reasonable and necessary’ criteria, established goals have all been met and or it is unlikely that further progress will occur to enable your intended discharge plan as established. CMS provides this clarification on how to handle the rare circumstances when greater than 3 days without intensity of services are needed and the discharge has been delayed for circumstance beyond your control.

Clarification regarding whether the discharge dates on the IRF patient assessment instrument (IRF-PAI) and the discharge dates on the IRF claim must be the same.

As we stated on the May 31, 2012, IRF Coverage Requirements National Provider Call, we believe that the discharge dates on the IRF-PAI should always match the discharge dates on the IRF claims. Thus, we removed language from the IRF-PAI Training Manual (effective Oct. 1, 2012) that may have led providers to believe that they could put different discharge dates on the IRF-PAI than on the claim.

Although previous guidance in the IRF-PAI Training Manual suggested that patients could be downgraded from a Medicare Part A IRF stay by “discharging” the patient on the IRF-PAI when the patient no longer required an IRF level of care, this guidance is no longer consistent with Medicare regulations. As stated in Chapter 1, Section 110.3 of the Medicare Benefit Policy Manual (Pub. 100-02), “Since discharge planning is an integral part of any rehabilitation program and must begin upon the patient’s admission to the IRF, an extended period of time for discharge from the IRF would not be reasonable and necessary after established goals have been reached or the determination has been made that further progress is unlikely.” We believe that it is in the patient’s best interest for the IRF to begin the discharge planning process early and continue it throughout the IRF stay. Thus, although we allow a brief period for the IRF to find alternative placement for a patient who no longer meets the IRF coverage criteria, an extended stay in the IRF for such patients is not warranted.

In the very rare case in which it may become apparent that the patient’s discharge from the IRF is going to be delayed for an extended period of time, the IRF should provide the patient with an Advance Beneficiary Notice (ABN) informing the patient that he or she may be liable for any remaining charges. The IRF should also use occurrence code 76 on the IRF claim for the remaining days to indicate that those days are not Medicare-covered under the IRF prospective payment system. Otherwise, the IRF claim will continue to be considered a Medicare Part A stay and will continue to be subject to review under the IRF coverage requirements.”

Although occurrence span code 76 is used to report a period of non-covered care “for which the patient is responsible” (generally speaking), and you are issuing an ABN, this opens another entirely different discussion. Are covered days and ‘regular days’ appropriately established in the common working file so that only those days reported as Part A covered are included? Since even one covered day permits payment at a CMG level and accepting the IRF PPS payment rate as the full rate does not permit ‘balance billing’, what exactly is the significance of the occurrence code 76 except to defer possible denial of the entire stay based on the days when ‘intensity/ reasonable and necessary’ care are questioned by the rehab provider with inability to discharge? Perhaps you should be discussing this in your next executive session and asking for those answers from your MAC.

Extrapolation of damages back to 2010 could be devastating to providers. If in preponderance you are not following the regulations for your Medicare population, you too could be at risk. If your physicians believe that timeliness of published guidelines are not really meant to be ‘specific’ but just guidelines; there is nothing further from the truth. The 2010 regulations provide no less than 47 items that need monitored for completion. Not just in the first 4 days of the stay but throughout the entire stay. Not having a hardwired workflow to ensure success in meeting these requirements in preponderance for your population is fool-hardy to say the least.

Use this free IRF Clarifications Tool to be sure you are interpreting guidelines as CMS intends you to apply the regulations. There is a ‘keyword’ look up, or you can select a specific regulation category and that will take you directly to the source document at CMS.

If you don’t already have a checklist available to help with an audit, I can provide a template. Email me at darlene.daltorio-jones@mediware.com and I can share one with you and recommendations for use. In addition, I have created two different rebuttal templates that specifically follow the 2010 mandates. If you use exact federal register requirements when responding to an additional development request (ADR) you will be certain to find, tag and provide all the necessary documentation to demonstrate compliance as instructed.

Let’s pause for one moment and put the title of your own facility in the headlines of that OIG article. It’s very possible that documentation was available but it was unclear, poorly labeled or not in the correct place of the medical record. The regulations presently have 155 specific clarifications to interpret process appropriately. Clarity of interpretation and follow through is paramount. To correlate with the published article, what if any of these scenarios were true? Think about your own process and see if any of these possibilities or others exist…

(1) Documentation that a comprehensive preadmission screening occurred within the 48 hours immediately preceding the admission:

• Because this process is done while the patient is in the acute care side of the facility, the medical record department scanned the documentation to the acute care and not the rehabilitation medical record.
• The persons that registers patients placed approximate times of admission onto the chart for arrival and not the ‘real’ time; not aware of the very important 48 hour window.

(2) Documentation that a rehabilitation physician performed a postadmission evaluation within the first 24 hours of the IRF admission,

• The post admission evaluation and the history and physical are one and the same, however it does not clearly label and or not every question required in the post admission evaluation was evident.
• How many facilities within the post admission evaluation attest within the document;  ’I, the rehab physician…?’

(3) Documentation that a rehabilitation physician developed and documented an individualized overall plan of care within 4 days of the IRF admission,

• Each facility may develop their own procedures to meet this requirement. Are all the elements required answered within the plan of care and is it evident that the physician’s input and final approval to the plan were sealed by the end of the 4th day?
• Some facilities meet the H&P, Post Admission Evaluation and the Plan of Care  in the same note. Although not recommended by clarification it is allowable. Imagine how confusing an audit is to align exact elements when these are a merged document.

(4) documentation that interdisciplinary team meetings met all federal requirements. The hospital’s procedures did not ensure that IRF services were documented according to Medicare requirements.

• There are 16 clarifications for interdisciplinary team conference. Often these conferences are a round table of staff reiterating progress notes as present status and NOT meeting the defined four bulleted purpose of team conference.

As a company we can provide you with the very best tools to help monitor these mandates in advance of them being missed or forgotten. We are here to improve your success and reduce your risk as an IRF attempting to stay on top of this very issue; we have solutions that make monitoring required elements simple.   Come browse our website!

From Oct. 1, 2012 until Dec. 31, 2012, Manual Medical Review required seeking approval from the fiscal intermediary for up to an additional 20 visits once the threshold of $3,700 was reached and after attesting and applying the KX modifer for $1,900 of combined  PT/SLP or the OT benefit alone in the outpatient therapy setting. Going forward, this will now hinge upon your waiting for the Fiscal Intermediary (FI/MAC) to begin the review process. Just how much treatment do you provide past $3,700 to allow their ADR request and pre-payment review process to be elicited?

Why is this significant? It realigns the approval with a process already utilized by FI/MACs – “prepayment review,” and possibly consolidates their work into one rather than two separate review processes. How so?

Recall that previous instruction for 2012  covered each of these questions below in “quotations.”

“Will claims that are pre-approved be guaranteed payment?

Answer: Authorization does not guarantee payment. Retrospective review may still be performed.”

My comment: Past process maintained a two-step process. FI/MACs had to ‘look again.

“Why would a Medicare contractor review therapy that has been pre-approved?

Answer: There are many reasons retrospective review would be needed after a pre-approval: clinically inappropriate modalities; patient’s clinical therapy needs do not match what was reported. For example:

• Patient’s functional level is greater than reported;
• Patient reached functional independence more quickly than predicted;
• Excessive or inappropriate therapy was furnished, e.g.;
• Therapy more often or of longer duration than is medically r/n;
• Therapy provided to clinical treatment area not reasonable and necessary, e.g. therapy to shoulder when knee is the issue.”

My comment: In prepayment review, they see documentation after services have been provided; they can establish if all the above were actually completed, thus reducing CMS payment risk and no further need to review the same claim twice. If you did not meet the conditions, just as before, you still would not be paid. For FI/MACs this is less work to review just once.  The burden/risk is completely upon the documentation of provider ‘in retrospect.’

“What happens if I request pre-approval and gain approval for 20 treatment days and I actually furnish 30 treatments?

Answer:  The claim will be subject to prepayment medical review.”

My comment: Inspection after the fact keeps the FI/MAC from doing this step TWICE. Seeing that previously it was already OPEN to prepayment review even if the approval process and additional sessions were rendered.

So you have to ask, is this ‘interim’ process a good alternative? It depends who is asking the question. Although not exhaustive, what are a list of the present questions/concerns?

• Medicare beneficiaries must wait for the FI to initiate the ADR; when bills are  dropped generally monthly, this will add time for the FI to recognize that the threshold WAS met (previously you could solicit approval upon you  knowingly ready to reach the threshold). This adds additional delay to  access of care.
• Once the ADR is requested, the process may wind its way through the fiscal departments rather than directly to the requesting party as allowable in the manual medical review process.
• Once the ADR has been sent, information copied and returned to begin the 10 day turnaround of approval to occur, will it be for individual service dates or up to 20 days as previously discussed? Not covered in this quick  interim discussion.
• The  interim instruction does not state whether an ABN is recommended for any care provided awaiting the pre-payment review. Since ABNs must be  specific, why would you alert the beneficiary that it ‘may not be paid’ when in fact you are attesting to the medical necessity and supplying the  rationale and documentation that it is necessary?
• It  appears that this process reduces the administrative work required at both the provider and FI for administrative steps. The provider still must keep track of billable care but this eliminates the request processes and the FI adds an additional flag for total paid service to produce an ADR they are  already accustomed to handling – now with a speedier turn around.
• A clinic assured of their documentation and practices may choose to provide services as necessary and take the chance/risk that approval is forthcoming. Does this make administrative review of documentation have tighter controls to gear up for possible denial process reviews?
• I  am certain you are thinking of a few questions/issues yourself. Don’t be  shy and add those to the comment of this blog. We can always forward the list to the provided ‘comments to CMS on caps’ email address.

Was it a dream? No, it was fact! Sens. Benjamin L. Cardin (Maryland) and Susan M. Collins (Maine) indeed did introduce a bill to amend title XVIII of the Social Security Act to the Committee on Finance. Just how far might this go?

Could this be a reason CMS is slowly reacting to the fact that we NEED a Manual Medical Review process outlined for 2013?  Is this the reason why a PT in Ohio, who just recently posted to the PTManager list serve, was told that all Medicare payment is being held on Part B’s over the $1,900 cap regardless of modifier or need and that an apparent ‘non-payment’ is being invoked ‘at this time?  Is there hope that even with Sequestration looming ahead of us in just a few short weeks that a total recall of therapy caps can and will occur? Is there hopes that DOPTA may help to alleviate this administrative nightmare? Will it include all therapy caps (all outpatient therapy whether private practice or hospital-based physician fee schedule)? No one knows the answer just yet, but it’s time to begin speaking to your representatives in Congress about the support of the repeal.

Remember though, G-Codes  and outcomes reporting and therapy caps are two entirely different initiatives; don’t get them confused and don’t be lax in preparation for July 1 when mandated outcomes reporting will occur for Medicare part B.

Stay tuned, I am sure more information and discussion on the topic are not far off!

In this ’2013 New Standards Review’ and discussion of most frequently cited standards and how to comply with intent, Christine brought greater than 30 years of dedicated passion to the art of providing rehabilitation with a focus on quality and results – the foundation and reason any of us entered rehab professions no matter how long ago.

When practicing with expectations driven by rehabilitation professionals and their consumers, rehab providers set themselves apart from the med/surg world of standard acute care practice. This is what CARF standards emphasize; the specialty area of practice intended for the population we treat. We have to recognize our differences and behave and manage the plan of care in the specialized way even we would expect if our loved ones were the patient. Accreditation, although not mandatory, is the level of care being sought in a healthcare continuum that also is focusing on quality and results. If you feel your program has lost touch with that reality, maybe it’s time to realign your mission, vision and values specific to the rehabilitation population you treat.

With pay for performance and outcomes driven expectations, it’s hard to imagine the leap to accountable efficient care if providers continue to drop the rigors expected to treat the specialty populations served in an inpatient rehabilitation unit. Whether that unit is small or large it is the population served that deserves the unique care provided by the interdisciplinary team. The workflow and documentation to support that unique level of expertise is often lost or not evident in the standard ‘med/surg’ linear documented care.

I have heard time and again that units within hospitals struggle to maintain their identity, often railroaded to behave and accept staff without the experience and background of rehabilitation expertise. This makes it even more difficult to fulfill the training and education for the patient and care-givers that often absorb 24-hour patient care in lengths of stays shorter than 16 days. Imagine packing everything we know or have practiced for a specific specialty into a learning curve of two weeks or less – keeping patient safety foremost and expecting lasting outcomes without returns to an acute care environment to manage what may have been missed.

Patients are entering rehabilitation units with significantly more ‘burden of care,’ higher acuities and functional impairment that leaves them mostly dependent on the caregiver in greater than half of their ADL functions. The rehab level of care may not have the intensity of a one-0n-one critical care unit but it does have the hands on intensity to provide significant input and practice to the 12 mobility and five cognitive areas significantly impaired in the populations treated.

If the interdisciplinary team is truly not acting in concert with all expectations that create barriers to the anticipated discharge plan, how is that focus providing results and how will your outcomes meet expectations? In revisiting CARF standards, these core concepts and intents emphasize the unique practices and expectations toward our professional standards and intent. Practicing toward those expectations leaves no doubt that the level of care is uniquely special to the profession of rehabilitative medicine – returning the patient to the community as often as possible with less impairment and a plan to manage residual needs with the resources available.

• http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Downloads/IRF_Coverage_Follow_Up.pdf

These clarifications define appropriate interpretation and expectations for the 14 coverage criteria specific to the 2010 Rules. I’ve included an updated graph showing the number of discussions on each topic. It is recommended that each facility review these criteria and set dashboards toward meeting the various expectations. Seeing that many areas can lead to non-payment, it is never too late to adopt best practices in meeting the intent of interpretation. Recall that if ‘in preponderance’ your workflows do not support these very specific rules, it is not unheard of for fiscal intermediaries and RAC auditors to issue denials for non-payment and then pull additional charts to detect patterns of bad practice. Your hard work and even successful outcomes can be thrown away as a hit/miss in reimbursement just because standards for  412.622 – Basis of Payment  are not evident in documentation.

In warped speed, let me refresh the last 17 years and what has been accomplished with the various publications and rules set toward this Administrative Simplification process; as simple as it is not!

HHS published a final Privacy Rule in December 2000, which was later modified in August 2002. Compliance with the Privacy Rule was required as of April 14, 2003 (April 14, 2004 for small health plans). HHS published a final Security Rule in February 2003 with mandates for compliance in April 2005 and 2006 for smaller plans. With all this came final Enforcement Rules in the Federal Register in February of 2006.  More promise of simplification led to National Provider Identification (2005),  Electronic Claims Submission (2003) and a slew of new acronyms we are slowly becoming use to. Recall simplification hatched all these new procedures and workflows.

• NPI – National Provider Identification ( Effective 2005)
• EDI – Electronic Data Interchange (Effective 2003) – Transactional Code Sets
• Claim, encounter information, payment and remittance advice, claims status, eligibility, enrollment, disenrollment, referrals and authorizations
• ICD-9 & ICD-10 (October 2013); largely utilized by now, more highly enforced for reporting, coding, payment
• HCPCS – Anciillary Services – Health Care Procedural Code Sets
• NDC – National Drug Codes
• CDT – Current Dental Terminology
• EIN -Unique Employers Identification Number (IRS)
• NPI – National Provider Identifier (10 position)
• ACA – Affordable Care Act (2010) brought HPID – Health Plan Identifier
• EFF – Electronic Funds Transfer
• RA – Remittance Advice
• HITECH Act – Interim Final Rule (October 2009)

I am just not sure ‘Administrative Simplification’ was a great choice of words; although you can see how trying to communicate all of these very specific ideas across any number of home-brewed methodologies would never equate to any ability to share information toward advances we can only dream of now. I feel Lady Justice is getting a tired arm and the fact that she is blindfolded has most likely kept her sane with healthcare providers wishing they too could look the other way; that hasn’t been our fate at all and you can tell we’ve worked hard and steady as required to get to where we are now.

Reality is, we are 17 years into the master plan of administrative simplification. With every leap of new technology and privacy challenges, our eyes are more wide open then ever to stepping it up and getting it right!  The era of electronic documentation, data retrieval, sharing of information and expedited expectations are right here RIGHT NOW.  If you or your staff are still in denial it’s either time to retire or balance the scales of justice. We seem to be very aware of safety and security mandates but administrative simplification has been resisted for a variety of reasons, whether true or not, and pushed and pushed til the point where we must admit; WE ARE HERE!  Now is the time; 2013 and beyond will continue to fulfill expectations so that eventually, at the end of it all, we can feel this list of acronyms and the work it has held has simplified that half tilted promise toward level.

And if that dream doesn’t keep you up at night, we still have Congress and a looming March and fiscal cliff to climb.

Looking back at the original quarterly goal, we stated that our quota was to write 20 blog posts with a aim high GOAL of 40. Hands on keys (all hands on deck jargon for those of us who type),  I met my quota of 20 and fell far short of the aim high GOAL of 40. I felt the goal needed readjustment for good purpose. I stopped at 20;  40 wasn’t practical. It was a bad goal. (As a therapist I felt this was appropriate to argue – don’t you?)

Our CORE Results Group had a discussion and decided that content over volume was more important and the fact that we had plenty in the ‘queue’ not published would result in stale material sitting on the side with misdirected effort. Here we are a nearly two years later and we finally honed in a reasonable expectation of 10 per quarter;  recall from above, this annual minimum was a quarterly goal when the plan got started two years ago.

Why am I discussing this? Because it relates to expectations, naive projections and goal adherence which are areas we deal with each and every day in the clinic! Measurement and goal setting is being HIGHLY discussed right now as well as the transparency, development and consistent adherence to expectations. This is our future, the future of accountability toward action and reporting and meeting goals as professionals. There is no escape, as it is nearly the end of the first month and to stay on target for this quarter I need to release at least three to four blogs ASAP.

Goals drive performance and initially when we start something new, like reporting quality measures on IRF or preparing for CBOR (Claims-Based Outcomes Reporting) for outpatient fee for service claims, we learn through experience. Realistic performance is a discussion everyone must have as we are projecting and reporting more formally the expectations we place upon ourselves and the ability of patients to meet those expectations within the scope of practice.

Although we may not be too thrilled about additional work to report outcomes, and we certainly may not agree with the very precepts of how the system is developed to a ‘standard of impairment’ percentage no matter the scale we use to measure; we WILL LEARN. We will learn about how we set goals, how we drive performance and how we meet hidden expectations. Of course it will require practice and we may fall far short from our original expectations as a naive writer must have thought 40 blogs per quarter was well within reach given all other duties. (Typed with a smile!)

Professionally, we will utilize the information in aggregate to help expedite performance, realistic expectations and most of all, more efficient and effective outcomes. Why? Because as professionals of every type in the medical business we entered these professions with a sincere desire to make a difference in the lives of those hurting from illness or ailment. When we set goals now (because they are being monitored), I believe it will make a difference that will drive us to be much more accountable to the patients served.  We have all heard before,  ’what is measured is managed,’ and these new outcomes and performance metrics are no different.

(On to my next topic!)

If you are curious as to the savings in your own state or territory, just click on the links above made available through cms.gov.

Despite a vast amount of news coverage on the Affordable Care Act, most specifically in a negative sense and generally throughout the period of campaigning and elections, very little information was given as to how various portions of the act enabled new and different benefits the elderly could rely upon. Two of these benefits, more affordable medications and the ability to treat conditions earlier when they are less expensive, were not the most visible to the public eye.

It’s important for healthcare providers to alert patients to resources available to them. A free ‘New to Medicare’ visit is available for persons initially signed up for Medicare within their first year, after that year the annual wellness visits are available at no cost. Think of the patients you are presently treating in your hospitals. Could knowledge of this access have improved or prevented the major symptoms requiring admission? How can your facilities do a better job in advocating for your patients healthcare? Do you ask this question to your patients: “have you accessed no cost or lower cost options available to you that may have helped prevent or lessen your present health care need?”

The future of medicine lies in preventative care when millions of baby boomers reach an age where healthcare is attempting to stay cost neutral. We are either part of the solution or part of the problem. What percent of the population accessing an annual wellness visit is acceptable and what percent did your particular state achieve? Can we look at statistics to see if persons accessing wellness visits had less costs per year than a similar patient not accessing these services? Are there particular diagnoses your facility can manage in an innovative way to swing health care dollars to prevention rather than over utilization? Most likely there is, but our leadership must understand affordable care today so we can ACT in ways that sustain meaningful healthcare for all in the future.

I often field questions on various professional list serve sites regarding basic Medicare coverage. Each year, this Medicare booklet updates the information and provides other resources for our patient populations. Anyone can download the booklet directly if they have electronic access. If you prefer to have a copy mailed to your home you can complete that section for them or call 1‑800‑633‑4227 to request information or delivery of a copy.

The basic information on what is Part A, Part B, Original Medicare vs. ‘A Health Plan’ option or how are medications covered, etc. are in this booklet. The information provided can even assist professionals that help patients bridge the knowledge gap for home-going services and coverage.  Do you know what a ‘benefit period’ means and the importance of that period to your Medicare patients when it comes to access and or out of pocket expenses? Professionally it is our job to discharge a patient adequately prepared so they do not become a readmission risk. It’s a great place to provide your staff information when you need a few of your Medicare benefit questions answered!

Medicare & You 2013

“Attention Health Professionals:  Information Regarding the 2013 Medicare Physician Fee Schedule”

The negative update of 27 % under current law for the 2013 Medicare Physician Fee Schedule is scheduled to take effect on January 1, 2013.

Medicare Physician Fee Schedule claims for services rendered on or before December 31, 2012, are unaffected by the 2013 payment cut and will be processed and paid under normal procedures and time frames.

The Administration is disappointed that Congress has failed to pass a solution to eliminate the sustainable growth rate (SGR) formula-driven cuts, and has put payments for health care for Medicare beneficiaries at risk. We continue to urge Congress to take action to ensure these cuts do not take effect. Given the current progress with the legislation, CMS must take steps to implement the negative update.

Under current law, clean electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt. CMS will notify you on or before January 11, 2013, with more information about the status of Congressional action to avert the negative update and next steps.”

They encourage all health professionals to share the news and to take action to avert these next steps!

I’ve heard a few of these myths and have blogged on several of these topics; perhaps you want the real answer.  I encourage you to review the list below and start TALKING! Let these facts be part of your conversation this week!

Here are the list of MYTHS I am sure you want the real answers to:

• Myth: RACs deny every claim that they review
• Myth: RACs have a contingency fee between 30 and 50 percent
• Myth: Every RAC denial is overturned on appeal
• Myth: RACs have non-clinicians conduct review of medical records
• Myth: RACs create their own policies and are not bound by CMS regulations, NCDs or LCDs
• Myth: RACs can review as many claims as they want from a provider
• Myth: RACs don’t have physicians on staff
• Myth: RACs are focusing complex reviews on Critical Access Hospital claims
• Myth: RACs do not tell anyone what they are reviewing
• Myth: RACs do not issues detailed result letters
• Myth: RACs do not issue timely denial letters
• Myth: RACs outsource all the medical review to staff in India and the Philippines
• Myth: RACs deny IRF (inpatient rehab facility) claims because the care could have been given in a less intensive setting
• Myth: RACs target providers who are part of CMS demonstrations

The references to support the answers provided to these myths are the Statement of Work for Recovery Audit Programs and the Implementation Document as part of a 2010 Report to Congress.

Then, if on an interdisciplinary team like that in multi-service outpatient care or in an inpatient rehabilitation unit/facility, what specific impairments are considered roadblocks to discharge? And if  given those roadblocks, what level must be achieved to enable that particular patients resources or themselves to handle these impairments successfully and safely? When you have that answer, you have the million dollar solution and the road map to its accomplishment partially ‘in the bag’ so to say.

Once the very specific roadblocks are defined, every person on the team must work toward the solution(s) in a measurable way so that day-to-day you know exactly which areas need more practice, reinforcement and/or additional problem solving to occur. It can’t wait until the next 10 day progress note OR for the weekly conference. These concepts must be engaged on each encounter with the patient so that skillfully, the clinician can concentrate on their expertise and input toward resolving each barrier they have input toward.

If at any point during the patients care you do not have the information that provides you the present status of that patients progress in meeting their roadblock(s), and how you specifically will reinforce progress toward the expected outcome, you are not being a good steward of health care dollars.

Often this type of information is difficult to collate or summarize as a glance, a benchmark or a ‘report card’ of progress. When that is true you may not have the right tools or reports to enable you to be the most effective and efficient that you can be. In today’s healthcare, with shrinking dollar coverage and margins, the only way to successfully dispel barriers more quickly and for teams of professionals to act in unison is through information.

Specifically, state the expected long term goal (LTG) as a measurable term that the patient and their resources can safely manage. You should provide progress toward that LTG as a measured present status statement; this provides comparison to expected outcome and always provides the short term progress toward the expected result. If you can eliminate short term goals and replace with short term progress toward the LTG you are more effective in keeping all focus on the FINAL outcome rather than baby steps that run short on time.

Last but not least, we are in a measurable, outcomes-driven society and the faster we can move staff toward gathering meaningful data that steers specific outcomes focused-care planning, the quicker we can move toward successful outcomes. Being good stewards of health care dollars is in the practice pattern of every professional. Be actionable and utilize clinical intelligence and progress status in real-time to be most effective.

If you need help in getting there perhaps a MediServe  demo or a CORE visit is in your future.

No one person has more investment in a new project than the Chief Medical Information Officer (CMIO) of a facility. That is why when I heard the phrase “Note Bloat”  spoken by Joe Heaton, MD,  CMIO of SCL Health System, I smiled and wholeheartedly agreed; more is not better and sometime less is best!  But in this day and age with so many stakeholders for information and the high probability that some sort of review for quality, quantity and medically necessary care will be waged against our written words, how much is ENOUGH?

Are we truly versed well in our clinical didactic training to include the exact information to paint the clinical expertise and necessity of our care? Are the guidance of SOAP, DAR, DART, SBAR, etc., capable of capturing the most significant information that reflects the time spent at the side of the patient? Are the conditions of participation and quality assurance metrics specific enough to define the constitution of expectations to guide all clinicians appropriately for just the ‘right amount’ of information? And last but not least, are the rules and regulations for billing overestimated so much so that notes have become encyclopedic renditions a search engine couldn’t duplicate so that we receive payment for the care delivered? All the anxiety around all these points is what has fueled the angst of each clinician only wanting to spend time with the patient.  

Are you feeling overwhelmed yet? Most are and this reality has led to NOTE BLOAT –  information so overwhelming that those of us sharing in the care of the individual are having difficulty weeding out the specific information quickly. In addition, as we share in the care of the patient, we waste time finding the truly necessary information to guide our component care effectively and efficiently.  Trending, reports, flags and summative data tactics are tools needed to help guide informatics. Use them, don’t avoid them. We need just enough information to populate guiding data that allows us to quickly assemble and summarize specifically toward the expected end result. Take the time to really understand expectations so that you can trim documentation specifically to meet the ultimate goals.  Define the problem/s, communicate the expected achievable result to lessen the barriers around those issues to successfully discharge and keep the team focused in meeting expectations. Demonstrate how your specific skill sets mitigate harm and manage and stabilize the patient so they are capable of handling their own care given the resources available to them. When barriers are resolved, the patient is discharged.

Most of all follow Dr. Heaton’s advice and avoid NOTE BLOAT.  When stakeholders can’t see expected progression because it’s buried in insignificant and redundant information, your success is diminished and your boat is about to sink.

When I attend national conferences for rehabilitation, I listen for ‘new talk’ on what is happening in the inpatient rehabilitation facility network. More than ever this fall, with the resurgence of chart audits and denials, was the discussion that perhaps the only way to get documentation done correctly is to create ownership of the financial viability for the patient. That when ‘clearly’ (not certain who or how that is defined), the record cannot meet baseline requirements for coverage that not only would the facility have payment rescinded but the responsible physician receives less compensation then a full compliment as outlined by contract. With so much resting on the critical minutia and required elements of charting, the question of who holds financial responsibility is often questioned. Is it all one sided?

How do you make documentation more foolproof? Are templates, checklists and reminders to staff sufficient enough to be sure a medical record holds up to scrutiny? When the final result is often FULL denial and not just portioned lack of payment, any denials are costly. This is particularly true because payment audits often come months after a patient is discharged and all resources have been expended and paid for. The patient could have been wholly successful in meeting the goals outlined by the rehab team and yet payment is never guaranteed and hinges on retrospective review of a detailed record of care.

Did your utilization review process (a process defined in conditions of participation for all inpatient hospitals) provide real-time guidance to be certain all risks were met?

If not, given the new capabilities of a very integrated CMS payment system – if the inpatient bill is declined, will all part B care attending to that denial also be up for recoupment? That too could be a future reality. In the past I have heard talk on this topic but it seems to me the talk is taking on greater proportions and persons are now asking one another how they can get full accountability.

I don’t know why it always has to be a punitive type approach, except that history tells us these types of measures get noticed. Maybe just talk will be enough this time, and the seriousness of non-payment will force us to work together without contract language or regulatory threats so that the obligations of charting specific to the requirements will be done because it’s our professional obligation. If tools are needed to support full compliance, provide the appropriate tools. Shared risk sounds scary because it is. Professionally, it shouldn’t come to threats to understand the importance of protecting the bottom line and resources for all future patients. However, given the conversations around this topic recently, it seems feasible that it may.

Results from this survey will be published in a future blog.

An entire level of very specialized care is being defrauded of importance because a very prescriptive set of expectations of highly stressed contingency may not be taken seriously by the rehabilitation physician. If the rehabilitation physician (even one within the team), is not on board with the expectations set to defend the coverage criteria, you are in for a tumultuous experience when medically necessary audits are performed.

If more than two years later your rehab physician(s) cannot detail each expectation to the rigor of the interpretations themselves, then you may be in jeopardy. These laws hold significant weight in an audit frenzy environment where the payment-neutral healthcare benefit called Medicare Part A is attempting to care for significantly more covered lives at your expense for being foolhardy. Don’t take this wrong, we should be defending the Medicare Trust Fund; that is the RIGHT thing to do and rules help guide right from wrong.

Leadership must audit and guide to appropriate expectations as many facilities operate with higher than 50 percent Medicare populations and they have a lot to lose. If your rehabilitation physician is not detailing the expected documentation and demonstrating they are in charge of the directed care and plan then you are at risk for denial.

Have you determined if your charts defend the 2010 ‘coverage criteria’ seriously? If not, you are headed toward financial reclaim at a level that might sink your ship. No margin, no mission and margins are already tight.  If you don’t believe me, talk to the many facilities now experiencing record level take-backs because rigor and intent can seem gray if documentation isn’t super pristine.

These 2010 requirements take time to master. Defensible documentation must clearly demonstrate that the Inpatient Rehabilitation Facility level of care is truly reasonable and necessary as part of each of the demanded criteria, not just one part. Forget simple check boxes and generic arguments; the pre-admission due diligence must be followed by thorough data and information that aligns with the expectations and risks presented, and the level of detail around individual patient recovery.

ANY physician that calls themselves to serve the special population of IRF patients can not  ‘be ‘rushed’ into doing so. It must be evident in the documentation that the rehabilitation physician is leading, concurring with and guiding the plan of care from the moment a pre-admission candidate is selected, to the 24 hour defense of continued appropriateness. Given input from the team, the baseline plan of care must be confirmed within the first four days and then reassessed for functional and medical management to the discharge barriers no less than 3 times per week. Given all this involvement, they then must physically attend and guide the collaborated plan in a weekly team meeting that focuses on the realistic and achievable outcomes toward expected. That’s a lot of work – the livelihood of  a rehabilitation level of care is in their hands.  It ‘s our future.  The final question will be determined by auditors if not guided by you!  It’s time to be sure your rehabilitation physicians are on board – it’s actually two years too late if they are not!

As post-acute care measurement programs begin to expand per federal guidelines, CMS officials say the timing is right to align measurement across settings, reduce data collection burden and ultimately, facilitate patient-centered coordinated care.  The Department of Health and Human Services contracts with NQF to help provide consensus-based endorsed quality measures that have been reviewed and approved by health care panelists seeking performance and evidenced-based practice standards.

Now that IRF settings have two quality indicators well underway, it is time for IRF leaders to consider the next round and how those measures will be considered and selected. The buzz for continuous quality improvement has never felt stronger; therefore your facility baseline is the next step to defining and developing successful strategies for the next round of re-portable indicators.

It’s a good bet that the next set of indicators will come from the MAP priorities as published in the February 2012 Final Report. Look at these concepts and develop your personal strategy. Care coordination and reduction of re-admissions are being highly discussed in alternative care models of treatment. None of the items included in this list can be ignored. Make the last quarter of 2012 the time to identify your baseline in these areas and make 2013 a time to deliver improved performance – you’ll be one step ahead if you do!

National Quality Forum

The following are good references to have on discussions for how your facility should handle personal convenience items.

• 1.) Convenience items not necessarily provided to all patients as part of a stay
• 2.) Convenience items that may be provided as a courtesy for use during the stay
• 3.) Convenience items that may be needed for home use but not covered under DME simply because they are “convenience” in nature.

Each of these topics are referenced in these two areas of the Medicare online manuals. Pay attention to the examples Medicare provides.

Medicare Claims Processing Manual 100-04; Chapter 1: 40.0 Supplies, Appliances & Equipment

Medicare Claims Processing Manual 100-04; Chapter 3; 40.2.3 – Determining Covered and Noncovered Charges – Pricer and PS&R

There is not a hard and fast rule for ADL items unless they are medically necessary. When medically necessary, they must be supplied as part of a covered part A stay for use while in the facility. Home-going use is entirely different. When items are for home-going use, each facility must make the rule and then apply that rule evenly across all patient types when an item is considered ‘convenience’.

Many of the types of equipment dispensed in IRF/IRUs are considered ‘personal convenience items’ when still needed for home-going. This type of equipment is considered an out of pocket expense (not covered under DME). When you provide uncovered equipment for home-going use you CAN bill the patient. It is important to provide the patient with a courtesy notice so they are aware it will be billed separately.  It also allows the patient to obtain the item in the manner of their choice since it would be out of pocket.   If the item is something that is NEVER covered by Medicare, an Advanced Beneficiary Notification is not technically required but is good practice for courtesy purposes. A simple notification allows the patient to make a choice for who will provide the item when it is not a covered benefit.

If an item is NOT a single use item, meaning it can be sterilized between patient use, it can be loaned to patient. If you want to sell it to the patient for use after discharge, the personal convenience item should be coded as personal convenience and listed in the ‘non-covered’ section of the uniform bill. Personal convenience codes may include 0990, Admitting Kit 0997 (only if not provided to everyone), and ‘other’ 0999 with specific description.

I have seen items available for purchase in a gift shop, through a DME provider store within a hospital and through an equipment closet as a convenience, but billed by an outside business. There are many different ways to permit patients to purchase non-covered items prior to home-going. Creating a fund for ‘hardship’ use when a person qualifies for indigent care is also a good way to provide items for persons who do not have the means to supply their own convenience items.

If you decide not to bill a convenience item that is also used for home-going, it must be provided to all patients free of charge. It is still a wise idea to track those on the UB as a non-covered item with zero charge. Again, applying that rule to all patients equally.

The  manual states (page III-2), you must read the definitions of the 18 functional areas carefully before beginning to use the IRF-PAI scoring instrument; “…committing to memory what each activity includes. Rate the subject only with respect to the specific item.”

The  IRF-PAI manual asks assessing clinicians to commit to memory what each activity includes. It’s not easy when attempting to distinguish subtle differences; key words and the caregiver’s efforts are all important when describing how much assistance the patient requires to complete a task. The patient should always be encouraged to do as much for themselves as possible as a baseline when you are “assessing” the patient. Giving them that opportunity is important so that you do not arbitrarily lower capability. Facility imposed restrictions such as this is a major flaw in these hurried healthcare environments.

If all items in a task must be completed, the series of tasks will be connected in the text of the definition by the word “and.”  If only one must be completed, the series of tasks will be connected by the word “or.” (IRF-PAI Manual III-2)

The number scale rates patients on their performance of an activity taking into account their need for assistance from another person or a device. If help is needed, the scale quantifies that need. The need for assistance (care cost burden) translates to the time/energy that another person must expend to serve the dependent needs of the disabled individual so that the individual can achieve and maintain a certain quality of life.  (IRF-PAI Manual III-1)

When therapist speak of min., mod., max., they are often describing their own effort to help the patient with general therapy descriptors and less often utilizing key words that determine the levels defined for burden of care measurement as defined by the IRF-PAI manual decision trees.

There is no provision to “skip” an assessment of any of the 18 areas. “All FIM instrument items (39A – 39R) must be completed.” (IRF-PAI Manual III-1)

At sometime in the range of mandated observation windows, each item must have a real observation to warrant a score.  If you have to use “Does Not Occur,” staff must be familiar with the only times that designation can be made. If an area “Does Not Occur” for a defined CMS purpose is used, that score is the assessment and there are rules as to which areas this condition applies.

Assessment discussions and the errors I often see when reviewing charts.

To Score a 7:

Staff usually understands when someone is independent and safe and they apply a score of 7 quite competently. It’s important for them to always know what questions to ask (device/meds) so they can distinguish a 7 from a 6.  From a motor perspective staff often applies a 7 accurately. More often, however, communication and social cognition are not understood in detail. I often see 7′s in communication and social cognition when documentation clearly represents  ”constant cues,” “repetition of instruction,” etc., which is less than perfect for comprehension, memory or both. If staff must consistently take time to apply coaching and cuing, they need to understand when a score of 7 is not appropriate in the social/cognition areas.

To Score a 6:

Generally, use of device/medications, reasonable time or safety needs are considered to apply a level 6. Sometimes staff believe they have to be the one to administer the medications in order to apply the 6 level.  In fact, the care cost burden refers to medications used to manage a problem, this is picked up in the score as long as the patient is still actively taking those medications. Burden rests on whether the medication is currently in use to manage that area, even if on a particular shift  someone did or did not administer it. As a burden measurement tool, if the patient was discharged regardless of shift, that particular area of care would exist and need to be managed. Documentation should cover rationale for applying an assessment score.

To Score a 5:

Cuing, coaxing, set-up or setting-out items is fairly easy to recognize to assign a 5 level of care. When it comes to burden, having to be physically present to continually coach or cue is costly; a helper being present is captured in the score of 5. Any facility that utilizes “sitters,” knows constant attendance is costly. If a patient requires constant attendance, it is rare to see scores above a 5, except if a patient has no bowel/bladder accidents but uses medications to manage these areas. When you see scores, ask yourself if clinically they make sense? Teach and train those that aren’t connecting the dots!

To Score a 3 / 4  or 1 / 2:

I believe what is often mis-interpreted is when should staff apply a rating of a 3 or 4, and when does it move to the left of the decision tree to consider a 1 or 2. For the most part, you look to see if there is occasional or incidental input from the caregiver or just steadying assistance. This is minor physical help and warrants a level of 4. If physical assistance is more than occasional, incidental or steadying and the patient is predominantly performing more than half the activity on their own, then a 3 for moderate assistance can be applied.

The moment the activity requires physical assistance that is greater than 50% such as holding, helping, physically lifting (generally more than one limb), then you must go to the left of the decision tree.  You then decide if you are assisting with all the activities even to some degree or if the patient can perform any independently.  If they can still perform some without assistance than a 2 level may be scored.  If the patient essentially performs no part independently and all areas require physical assistance from a caregiver to complete the task,  than a total assistance or 1 is the answer.

If you provide hand over hand assistance (even “minimally”), often the patient is  ”totally” dependent on you to successfully complete the task.  It is a care-cost-burden model and should appropriately reflect the cost of a caregiver attending throughout the activity. Staff needs to understand that this tool is a reflection of how much care the family will need to absorb when taking the patient home. The measurement tool does exactly what it is intended to do, which is to provide  a reliable measurement of care cost burden but everyone must apply the measurement like a yard stick, or more seriously, like a temperature reading if it is to be reliable.

Somehow, taking away the min., mod. and max. vocabulary can sometimes assist staff to see through the portion of the task that the patient is able to perform. Ask key words like, “Is it occasional, steadying or is it lifting, holding, placing that is occurring?” When you can answer these questions, suddenly min., mod. and max. take on an entirely new understanding.  If you don’t believe me, encourage your staff to review my blog posted on August 26 and to participate in the fun survey.  The results are also posted along with discussions that can help you educate and train your team to more accurately assess patients and to pay attention to the subtle cues we give one another when we talk about how much assistance was provided.

OIG states this is what you can learn from the Work Plan.

What can you learn from our Work Plan?
“The OIG Work Plan outlines our current focus areas and states the primary objectives of each project. The word “New” after a project title indicates the project did not appear in the previous Work Plan. At the end of each project description, we provide the internal identification code for the review (if a number has been assigned), the year in which we expect one or more reports to be issued as a result of the review, and whether the work was in progress at the start of the fiscal year or is planned as a new start. Typically, a review designated as “work in progress” will result in reports issued in FY 2013, but a review designated as “new start,” meaning it is slated to begin in FY 2013, could result in a FY 2013 or  2014 report, depending on the time when the assignments are initiated during the year and the complexity and scope of the examinations.”

The three items listed for IRFs in the 2013 plan are the same as last year’s plan.  

• Late transmission penalty applied by MAC/FI when IRF-PAI submission equaled 27 days or later to CMS
• Appropriateness of the IRF Admission
• Utilization of concurrent and group therapy during an IRF stay

The twist?The expected issue and start dates were updated from the 2012 plan to reflect the new postponed dates to each. See the newest OIG Work Plan 2013 pgs. 1-9 for the updated reference and compare to the snapshot from last year’s plan.

Note that “work in progress” items are items that must be reflected in your present workflows to meet those expectations. Future issue dates and start dates are items you need to analyze now to be sure expectations are trending in a positive manner. Appropriateness for the IRF admission are well documented in the 2010 guidelines and clarification documents. CMS had issued clarifications on their expectation toward individualized therapy at an IRF level of care.  Make sure your practices meet expected reviews by proactive analysis and audits.

CMS provided clarifications in regards to group therapy in IRFs:

Clarification regarding the percentage of one-on-one individualized therapy that would constitute the “bulk” of therapy.

Bed utilization is the foundation of profitability, if and when you know the number you need to remain full, and staff has the ability to work effectively on a turnover rate that meets the patients goals and improves bed capacity. I’m sure you’ve heard the saying, “no margin – no mission.” We all have. How can everyone work together to be certain the turnover rate is effective and efficient from both a patient quality standpoint and a business sense? From restaurants to  the airline industry, they capitalize on seat capacity to manage profitability. Bed utilization in healthcare rivals those analogies.  How do you smartly manage a specific capacity to enable constant workflow (reduce peak and valley chaos), and meet the expectations of the customer, which happens to be the patient, and all the stakeholders of your business?

You can, but it starts with a plan.  Know the patient’s specific barriers to discharge, set the exact targets to meet management of the care that can be provided at discharge and work tightly to that plan; discharging the patient as soon as those goals are met.  Rehab has notoriously shown discharge patterns at 7-day cycles, some suspect because we wait for team conference to act on individual patient readiness.  If this is you, you missed turnover opportunity immensely.  You can analyze this.  Download your admission and discharge dates over the past year and see how close you are to a number divisible by seven. What percentage of your patients are at the peak of the bell curve? Pitch out the return to acute care patients and re-run that number. Now what does it look like?

If your patient population is predominantly rehabilitates on a 7-day cycle, there’s room for improvement in your turnover, bed utilization plan.  I promise!

IRFs have a good system for monitoring functional independence in order to plan needed resources at discharge through functional impairment measurement.  Set the goal for each of the 18 areas and then work diligently toward meeting that level of assistance to enable safe discharge. Engage the caregivers as early as possible to help plan discharge follow through and make that plan happen as quickly as feasible for each individual.

If you do that, you have the ability to affect turnover and to maintain capacity at a rate that is feasible to a well-oiled plan of care focused specifically on meeting the intended needs of the patient so that any wasteful processes are squeezed tight.

Have you analyzed how well your staff creates the discharge plan/goal and how tightly they manage their plan of care to focus specifically on making that plan happen as expeditiously as possible?  Budgets will only get tighter, your best chance to reduce per patient costs and improve revenue is to manage bed utilization, turnover and tightly focused goal attainment.

You can do it! Start your plan today!

Each year, the specialty units that take the highest concentration of patients with both medical and functional impairments are left to operate on budgets very similar to their med/surg counterpart units. Why?  As an exempt unit with highly specialized-needs patients in concentration, the rehabilitation unit can often be perceived as the “step-child” or “second class citizen” to optimal staffing. I did not say that, I have heard that from many others.  A budget is a budget and when you’re squeezing dollars, all beds look the same. Or do they?

There is a mound of information and regulation you can gather to demonstrate your rehabilitation unit is a step above a med/surg unit when staffing, and that by cutting staff, you actually harm future payment.  Your first due diligence is that you have accurate information to base this argument. So here it is. Rehab units classify each patient within the first three days through their IRF-PAI process. The “acuity” derived from that measurement tool is shared with CMS.  Each year, your facility also files cost reports denoting the staffing and costs of that care. The question is, do your patient acuity measures and cost report information make sense? CMS uses this information to guide payment policy. In the 2013 Notice under “Area Wage Adjustment,” it states, “ The Secretary is required to update the IRF PPS wage index on the basis of information available to the Secretary on the wages and wage-related costs to furnish rehabilitation services.”   

The information gathered from cost reports and analyzed by IHS GLOBAL INSIGHT, INC, 2nd QTR, 2012; Historical Data through 1st QTR, 2012, revealed in Table 3, of the 2013 IRF Notice the FY 2013 labor-related share as  69.981 percent for IRF care. Each year, this information is utilized to update reimbursement and is factored back into the facility adjusted payment and labor wage formulas by area.

Now lets’ ask, does the acuity of your patients match the staffing you provide? Are your patient safety and patient satisfaction scores commendable? Are your outcomes in line with where you need to be? If you continue to cut staffing to points that do not allow you to manage well in these areas, will you even be able to provide rehab care to the level your patients deserve?

We are not very smart to plan a realistic budget for the patient types we serve and therefore, we are paid accordingly.We perpetuate this nightmare. You need to analyze all your past numbers, see the patient acuity you manage and then manage staff to that acuity.  If you don’t, your cost reports will provide the “real data” that is then pushed into the formulas that just keeps cutting your reimbursement.   Each year, you are expected to do more with less. Why?  You planned it that way and your cost reports validate what you provided nothing more. It’s a cost neutral system and you keep robbing yourself more neutrally!

At what point do you act responsibly and project payments that are in line with real costs to operate effectively and efficiently? You can start this budget cycle by educating your hospital on why it makes sense to staff to your excluded specialty unit to actually furnish rehabilitation services at a level the Secretary will have enough information to pay you accordingly based on the updated information available to provide that unique, intense interdisciplinary service. Your future and your budget depend on you!

Please ensure your software has been updated for this new version of the data specifications. All questions related to change are available online at the  QIES Technical Support Office  (QTSO) website. If you missed the webinex training, it is still accessible through QTSO in the On Line Training section located in the left task bar menu. From there, you’ll need to select  ”Other,” enter your name and email address. You’ll then be directed to the educational page for viewing. The thorough module provides answers to questions you may have in the change process. Given it’s just one week away from this blog date, I am hoping this is old news for most of you!

Understand this new process translates to the fact that you will need to upload patients discharged at the end of September using the newest XML format in early October whether you choose to report in section 48-50 or not!   

If you have chosen not to participate in pressure ulcer reporting, of course you do not have to complete questions 48 – 50.  All fields will require a dash (-) to  symbolize no assessments will be submitted. Beginning FY 2014, IRFs that do not successfully participate in the program will be subject to a 2.0 percentage point reduction to the market basket used under the IRF PPS for the applicable year.  Expect this “penalty” and live with future impact.

Also, keep in mind that old values for fields 48-50 will not be accepted.  If you plan to submit pressure ulcer data, you do not need to report this section for patients discharged in September; every field must have a character in it to pass the upload process, though. So for these patients, each field will contain a dash to indicate no value and that assessments were not completed.

Although it is best practice to have started collection of data on patients admitted that you knowingly will cross the October discharge date, it is not expected.

The QIES Help Desk (help@qtso.com) provided this reminder to me in a recent email when I inquired about fields 48-50 for patients needing upload after Oct.1.  This is the email response I received from help@qtso.com:

“A dash is allowed for the pressure ulcer items when a skin assessment has not been completed.A patient admitted prior to October 1, 2012 and discharged after October 1, 2012.  In this situation, a “dash” (-) may be used for the admission pressure ulcer items”

With just one week left before Oct. 1, it’s imperative that your workflow and processes are understood and ready to meet the test!

Cahaba Rescinds Proposed LCD  “Surgery: IRF Admission after Single Joint Replacement with CMGs A0801-A0806.”

American Medical Rehabilitation Providers Association (AMRPA), and many other associations, successfully halt an LCD that would further reduce beneficiary access to inpatient rehabilitation (IRF/U),  levels of care after single joint replacement procedures.

The points made by AMRPA, the Missouri Hospital Association and The Coalition to Preserve Rehabilitation (CPR) of the Association of Rehabilitation Nursing along with more than 20 other coalitions, agencies and advocates for rehabilitation signed numerous documents to educate Cahaba on the reasons the LCD  should not be made active.

“Missouri Hospital Association sent a letter to Cahaba last week, urging Cahaba to withdraw a proposed local coverage determination that would deny coverage for admissions with single joint replacements without co-morbidities for case mix groups between A0801 and A0806. Cahaba announced today that they are rescinding the LCD, and it will not be finalized. This is a great outcome to a potential limitation of patient access.”

Each of the letters outlined details discussing the harmful reduced beneficiary access based on diagnosis alone, and inappropriate need for this type of LCD by citing some of these other facts:

• The proposed LCD conflicts with federal regulations.
• Cahaba’s proposal would impermissibly supersede CMS’ regulatory requirements by denying coverage of patients solely based on their case-mix group.
• LCD runs counter to Medicare’s policy and payment standards.
• The proposed LCD, which categorically designates patients in case mix groups A0801 – A0806 as not medically necessary, contradicts both the letter and spirit of the Medicare Benefits Policy Manual and physician-driven medical necessity recommendations.
• LCD effectively would eliminate any role for physician judgment.
• LCD is incongruous with IRF payment standards.
• The Medicare Program Integrity Manual states that “[t]he contractor shall ensure that all LCDs are consistent with all statutes, rulings, regulations, and national coverage, payment and coding policies” in Chapter 12 § 13.1.13.

Every IRF can celebrate and be thankful for that victory!   Thank you to each of the different professional organizations that went to bat on this particular issue!

The purpose of this exercise is to assist staff in paying attention to the subtle key words used in the IRF-PAI manual decision trees when scoring functional assessment. Given the information provided, staff may answer the questions in one of several ways and should be able to discuss why they made one choice over another. By sharing with you the prevalence of how others read and scored the exercise, it provides some insight to the fact that scores can be “all over the place” if specific decision elements are not provided and if staff does not pay attention to the greatest burden elements when there is a combination of descriptions provided by a helper. Ask staff to choose the best answer given the information available when taking this survey. If you haven’t had a chance to take the survey, you can still access the survey through the blog entitled, “Testing Staff’s Ability to Recognize Key Words in Functional Scoring.” Also, I am considering hosting a webinar in the near future to discuss results, if enough people show interest!  Future blogs on the topic are also coming shortly. Getting this correct is the foundation of cost-care-burden resource alignment and measuring improvement accurately in your patient populations.

The results discussion include responses from Aug. 26, 2012 through Sept. 7, 2012 and references the IRF-PAI manual pages for each question along with some discussion as to what the best answer might be for each question.  Because we made a short and long version of this exercise available, whenever the same question was asked to the full set of respondents, you can look at the larger total of respondents because questions were duplicates between the survey and enabled us to get a larger sample number.   Respondents were not asked to describe anything about their background or experience.

We hope you find this information to be another helpful way for you to educate and provide clinical discussion around the importance of scoring. Several points can make huge differences in baseline resource allocation as it relates to the CMI and payment for your Medicare populations. Because outcomes are driven by pre/post answer changes, you want to be certain that your staff thinks critically before applying measurement scores. Pay attention to the subtle word clues that are overshadowed if you speak min., mod., max. language for the most part!

Based on the outcomes shared in the links below, we recommend discussion based on the % Agreement for each question asked.

Blog Discussion Meter

Here are the results:  Click on the link

LONG VERSION (40 Questions)

SHORT VERSION (20 Questions)

Let me know if you are interested in a webinar to discuss the outcomes of this survey.     YES /  NO

Did you ever think it meant anything for you as an inpatient provider of rehabilitation care? Transmittal 2537 just released Aug. 31, 2012 describes in detail the necessary billing procedures for Therapy Caps. Tucked away in the detail is an alarming fact that it can also impact inpatient care on rare occasion. How? Suppose you have an inpatient that has exhausted their Part A benefits, or has only Medicare Part B benefits, and you are utilizing that benefit to pay for their inpatient therapy care. A type of bill (TOB) for a patient with Medicare Part A days left is 11X; paid under HIPPS. If they only have Medicare Part B coverage, the type of bill (TOB) is 12X – or Hospital Inpatient Part B. The transmittal states all 12X bill types must follow the Caps process as though they are an “outpatient provider” of care.

The Transmittal 2537:

7881.4.1
“Medicare contractors shall add a ‘legislation effective’ indictor of A to line items that meet the following conditions: Type of bill 12X(excluding Critical Access Hospital CCNs in the range 1300-1399) or 13X Revenue code 042X, 043X or 044X Modifier GN, GO or GP and Dates of service that fall within the effective dates set on the user-controlled ‘legislation effective’ screen.”

7881.4.1 exempts Critical Access Hospitals but says nothing about specialty exempt Rehabilitation hospital providers. A person without part A benefits will not have a locator field 42 code of 0024 showing they are paid by a HIPPS.


Initial inquiry to CMS confirms that IRFs are not exempt and that if they are billing a Medicare part B patient benefit, the Caps regulation must be followed. Rehab hospitals provide a minimum of three hours of therapy no less than five times per week for each beneficiary in a rehab bed by standard. The KX modifier is not difficult, but as soon as they exceed $3,700 they cannot wait 10 days to decide if the 20 days will be approved. The advanced exception request may be mail driven or an electronic process dependent on your fiscal intermediary. There are more than 1,100 rehab hospitals that may be affected by this transmittal in more than just the traditional outpatient services area. You need to at least consider if your facility falls into this predicament and how often it might happen?

Are you ready to oblige with the uniform billing instructions when the sole purpose of admission to a rehab facility is to receive concentrated therapies? We recognize this may impact a very small percent of the population that access rehabilitation level of care with only a Medicare Part B benefit. We recommend your facility runs a report to see just how much therapy care has been billed as 12X bill type for inpatients in your hospital. When you have that answer, you should work accordingly to abide by the same process as you would for your hospital-based outpatient services when completing your universal bill.

Sign up to attend our upcoming webinar to learn about how it could affect your facility.

Imagine you’re the patient. Whose time matters?  It’s a simple exercise of placing yourself, or a loved one, in thought as the recipient of everything we do as clinicians.  Time becomes just a little more important and less constrictive.  We constantly look at the cost of  materials, software and machinery, but rarely do we look at the expense of  work we do that has little value because we are not acting on fact and knowledge of a particular status.  Wasteful process is costly to clinicians who need fact and measures to guide work in real-time.

When you are ”Lean trained,” you learn about “Muda,” the Japanese word for waste.  In healthcare, we are surrounded by processes that were built on previous workflow, even when new or changing information is provided.  We are resistant to change and hold on to wasteful yet familiar practice.  Rarely do we challenge the fact that if we are wasting time, then we are fueling excuses to add cost and harm to patients. It is time to examine the cost of working without facts so that we can model care to continuous changes in conditions, based on information available through documentation of care process and those outcomes.  If you are still abstracting information manually, and only at a limited percent, you can  never be close to 100 percent effective.  Being effective supports “do no harm.”   Being effective requires you to know the current status and eliminate work processes without value.

Examine the value of clinical intelligence.  Learn to examine process and to adopt information as the leader in true healthcare reform. When Toyota executive, Taiichi Ohno, defined seven causes of waste (Muda), he called them “The Seven Deadly Types of Waste.”   Mind you, he meant deadly in a business sense, but in healthcare we can relate to those words more inherently.  The cost and time associated with how and why we do things needs to be challenged.  When we don’t do the right things because there is not enough time, it’s time to reconsider why healthcare needs reform in the first place.  Reform that begins internally with mindset and has nothing to do with regulatory mandates.   Why do we do everything that we do and what is the value of the information in the process of effective, efficient care?

Going through wasteful processes so they can be eliminated and replaced with useful efficient practices is vital. From the bottom up and the top down we must question workflow and process to meet expectations and to provide time to do the right things; treat, teach, train and educate the patient to manage the impairment they have acquired.  Know just how much has been done and how successful (within charting), so that every clinician interacting with the patient can spend their time meaningfully by building on past accomplishments and not starting over.

By adopting these concepts we can reduce waste, do no harm and manage toward expected outcomes.  It’s all about continuous quality improvement; not working harder, but more effectively in the time we have to do more good and less harm.

How do we know coding must be completed in the IRF PAI during the admission assessment reference dates (ARD)? If you’re paid under the IRF PPS, you’re considered an excluded unit and the conditions of participation as a fee for service Medicare Part A (IRF/U) provider are unique and special.  You must follow the coverage criteria and conditions of participation to be paid.  If you’re speaking on deaf ears, because after all, you’re just a few beds in a monstrous facility you couldn’t possibly know what you’re talking about, here are the areas you need to reference so that you can pull yourself into compliance.

Admission assessments are not an option, they are required for all part A and part C Medicare beneficiaries. These conditions of participation are covered in  Title 42 Volume 2, Chapter IV, Section 412 Subpart P; Prospective Payment for Rehabilitation Hospitals and Units. This section covers the payment and assessment requirements for rehabilitation patients.

Who wants to argue?  Not only is it regulatory, the co-morbid conditions coded on the IRF PAI are the conditions that make the stay “reasonable and necessary” to manage a patient at a rehabilitation level of intensity.  You are required to “complete” all sections of the IRF PAI on admission by day four, unless it’s labeled as a “discharge”  area.

“The federal regulations require that data must be collected and entered into the data collection software (i.e., encoded) by specified time periods. An inpatient rehabilitation facility may change the IRF PAI data at any time before transmitting the data, but only if the data were entered incorrectly,” page II-1  IRF PAI Manual 2012.

Admission co-morbidities determine the tier level portion of the HIPPS payment code. The etiologic diagnosis and impairment group code determine the CMG level of a particular rehabilitation impairment code (RIC).  Data inputs lead to a case mix index amount that identifies resource intensity and payment for the patient conditions you have assessed in total.

It is true that on discharge, you may add to the co-morbid listings all diagnoses that were managed prior to the final two days of the patient’s stay. In addition, you should add complications that expended resources for all care conditions recognized and treated after admission, in addition to those identified in the co-morbidity section item 24 of the IRF PAI that were present on admission.

Initial encoding is the basis for identifying the resources that will be required to care and pay for the stay.  The earlier these are identified, the earlier staff can work in unison to collaborate and care for the listed conditions along with the patients functional rehabilitation; all leading to improving the coordination of effort in achieving discharge barriers and managing the clinical conditions that must be considered to successfully rehabilitate the patient’s recovery.

If you practice the correct way, the patient has the benefit of all staff working as a team to manage these areas and your chart audits will fare better because it will be much more clear that the entire team is working to mitigate risks for these conditions and teach the patient how to manage them more independently for home going, and possibly reducing returns to acute care as well.

Min, mod, max is often what leads staff to incorrectly assign functional measurement scores on the IRF PAI. Why? Because clinicians have not made the subtle connection of key words used in the IRF PAI manual decision trees that lead toward appropriate burden of care measurement.

OK, it might not be “fun” to assess staff’s ability; it may actually be painful, but at least you will begin to help staff capture the thought process required to follow the PAI manual decision trees. Number systems can hold varied interpretation, but when staff are truly cognizant of how the words incidental, cuing, coaxing, steadying, contact, holding, prompted, hand-over-hand and occasional are interpreted, you are halfway toward getting to the correct side of the decision tree.  If  clinicians thought more about the patient’s effort, and which of the words above could describe the assistance provided to accomplish the entire activity, this would help discern just how much effort leads to the correct definition.

Moderate Assistance (level 3) still assumes the patient does more than half of the task independently. It’s the hardest half measurement I know, but it does not have to be that way when using a few key words to help guide which measurement level to select. Moderate is applied for physical assistance one step above “incidental” or “occasional” Minimal (level 4) caregiver help, and the patient is still performing better than half the activity on their own.

The functional “scale rates patients on their performance of an activity taking into account their need for assistance from another person or a device. If help is needed, the scale quantifies that need. The need for assistance (burden of care) translates to the time/energy that another person must expend to serve the dependent needs of the disabled individual so that the individual can achieve and maintain a certain quality of life.” (III-1   2012 IRF PAI Manual)   If your staff generally records a number without use of tools that prompt or assist in scoring accuracy, then the use of key word recognition in writing and describing these activities helps others to apply appropriate assistance going forward.

The General Description for levels of function and scoring found on page III-10 of the 2012 IRF PAI Manual is a good start; however, the specific key words used for each functional area are even more vital. Of importance is how much physical assistance the staff or caregiver is utilizing when they are assessing the patient. Very often I see levels placed on the chart that differ from the patient’s ability to complete a task because too often clinicians do for the patient without assessing what the patient can do for themselves.  They then apply a score and that score is not reflective of the true burden of care.  Truly therapeutic interdisciplinary care rests on the fact that a patient must be encouraged to do for themselves prior to our taking over and doing a task for them.  This is the absolute basis of functional recovery training and with that knowledge each caregiver thereafter builds on the patients ability, continuously challenging improved independent performance.

The manual provides clear examples of walking a shorter distance to the bathroom on a later shift when the patient is capable of walking further.  This example reflects a facility imposed restriction and tasks performed in this manner should not be considered as an assessment or score. Staff should not record measurement scores in an instance like this when the patient can and could walk further, it just so happened it was not challenged as an assessment if the intended goal was to only walk a short distance bed to bathroom in a patient’s room.

To score based on restricted distance is not fair to the patient, it would not reflect a patients real capability. Imagine taking a measurement such as temperature, and removing the thermometer just short of an actual reading. Would you say the patient’s temperature is 88 degrees? Never! Functional assessment is the same. It requires specific details to be followed and challenged before a real determination is made.  Tools are applied to obtain standard information and therefore each time an assessment occurs the same opportunities to perform must be allowed.  If not, the patients consistent ability cannot be measured.  The scores are ‘labels’ of needed resource for an individual to achieve each of the functions and should be closely repeatable between staff members.

Anytime clinicians are unable to assess real details of the patient’s performance, just because they assisted the patient in a task does not mean it can be scored.  If you as a caregiver did not allow the patient to demonstrate their full potential to meet the various levels of measurement,then it should not be considered an assessment.  This can be particularly true when float staff and untrained aides communicate what they did for the patient. Often it appears the patient has regressed when in reality, that individual may not have the detailed training of a rehabilitation professional that prompts, coaches and guides first and then slowly applies graded assistance. Although you would hope that every time we interact with a patient on every functional area that an assessment can occur; it is not always feasible and staff should clearly know when and why they can apply a meaningful score.  Scoring must be meaningful for staff to appreciate its value.

Staff must be aware that recorded assessments act as a label of resource need. When these scores are placed into the legal medical record, they can be confusing and misleading when not applied as a real assessment. As a label of care burden,  the purpose for functional measurement allows us to record patient care resource needs for discharge caregiver carryover.   Beneath the scene is the fact that Medicare fee-for-service Part A  patients are reimbursed based on functional assessment in total along with other IRF PAI factors.  Therefore, the greatest amount of accuracy provides not only the baseline for payment, but where the interdisciplinary team should focus training to effectively assist the individual in learning to care for themselves to the best of their ability. When done correctly, IRF PPS payment is applied for resources actually required to care for the patient and the patient’s capabilities are understood so the staff can improve their independent function through training and guidance.  It’s a win-win!

Below is a link so that you and your staff can take a baseline “test” of key performance words and how they apply to min., mod., max. as a measurement of care burden.

If you follow the link, a future blog will provide you details on how well people grasp key words that guide assessment scores. This is not an official inter-rater reliability test.  This is an exercise that may help you guide staff on their awareness of “key words” that translate to burden of care assistance as those words are used in the IRF PAI Manual to describe level of assistance.  It will also be a way for us to review answers of all those taking the assessment to see what particular questions may pose interpretation inconsistencies even when guiding words are used from the PAI Manual.

Long Version 40 Questions: Test your knowledge

Short Version 20 Questions:  Test your knowledge

It’s all for the fun of learning and improving accuracy of the applied assessment.  The more who participate, the better our ability to learn from each other.  Answers and rationale will be provided in a later blog.

As you can imagine, this made me scurry to as many references as possible to see how this could possibly be true.  I didn’t have to look very far before I figured out why there was confusion.  When reviewing the discharge and transmission timelines, the instructions are found in several places (CFR Title 42, Section 412.610 & 412.614, the Medicare Claims Processing Manual Chapter 3, Section 140.3.4 and where most of the clinical staff review the schedule, in the IRF PAI Manual itself.  Unfortunately, the description language, when comparing the various references side-by- -side may lead you to believe there was a change, or  that is does not list the same schedule.   It’s the description that might be hard to follow.   In fact, there is no change advised Susanne Seagrave, Ph.D., Inpatient Rehab Team Lead, Centers for Medicare & Medicaid Services.  She provided a clear example in an email to me dated 08/06/2012.

These CFR sections specifically detail the requirements for coverage and section (4) of the law specifically highlights the documentation requirements specific to payment allowance.  If you print this section and create a checklist from the requirements, it will be very difficult to fail an audit.

In fact, I recommend that a rebuttal form specific to these areas is crafted so that these sections of a chart can be tagged in defense during chart review.  By using the exact sections of law and demonstrating that the information is in fact in the medical record, it would be impossible to argue that the Basis of Payment is not covered specifically.

If you find upon audit that these areas are in question, it provides your facility with very specific performance  improvement as an action plan toward compliance in meeting the detailed regulations.

After returning home and alerting their quality department, one participant from the in-service with a small unit certified as an inpatient rehabilitation facility was told by their quality department they did not have to register their unit any differently than their acute hospital. I suppose they already share their rehab unit CAUTI data. The quality staff informed the in-service participant that unless they were a “free standing” unit, they did not have to register differently or report differently.

Specifically if you are a unit within a larger hospital system, I implore you now to talk and discuss your unit registration and expectations with your quality representative.  The National Health Safety Network (NHSN) has an informative 14-page handout called,”Updates to NHSN for IRF Locations within Acute Care & Critical Access Facilities” that I recommend you read.

If the CMS Certification number does not have an “R” or “T” in the third position, but instead has the last four digits between 3025-3099, the IRF must be enrolled as a separate facility and not as a location within the acute care facility.  This does not mean that units do not have to reallocate these specific beds to the certified IRF unit.

Be proactive. NHSN says, “The updated functionality within NHSN will allow users to designate specific rehab locations within the facility as separately licensed CMS units. In addition, users will be able to enter the rehab specific CCN, thus allowing the data to be appropriately sent to CMS to satisfy IRF PPS reporting requirements.” If you do not want to experience the 2.0% reduction to your annual payment update formula, follow-up and make sure your quality department is well aware that reclassifying your beds is key to getting the correct information to CMS. Stand firm! Educate and protect your ability to receive appropriate payments.  Specifically, when in fact, you are submitting data on the beds designated for IRF PPS rate payment.

Good Luck!

No policy changes were proposed in this notice, but that does not mean there is not a significant impact to ongoing IRF management and financial success.  Value changes have been published and are in alignment with 2012 implemented changes.    In essence, “methods described in the FY 2012 IRF PPS final rule (76 FR 47836) to update the Federal prospective payment rates for FY 2013 using updated FY 2011 IRF claims and the most recent available IRF cost report data,”  is how CMS described these updates.     The standard payment conversion factor per 1.0 case mix has moved from $14,076 to $14,343 before applying facility specific adjustment values.

Resulting impact changes for 2013 Notice are:

- Case-Mix Group (CMG) Relative Weights and Average Length-of-Stay Values for FY 2013 updates – create resultant changes in payment values and average stays

- Updates to the Facility-Level Adjustment Factors

- Market Basket Increase Factor, Productivity Adjustment, “Other”Adjustment discussions

- Labor-Related Share for FY 2013

- Area Wage Adjustment

- Description of the IRF Standard Conversion Factor and Payment Rates for FY 2013

- Update to Payments for High-Cost Outliers under the IRF PPS

- Update to the Outlier Threshold Amount for FY 2013

- Update to the IRF Cost-to-Charge Ratio Ceilings

Quality Indicators for Pressure Ulcer & CAUTI, as previously advised, without change in this notice.  Addendum’s will remain on the CMS website, rather than inclusion in the Federal Register when published.   The wage index appears as a separate addendum this year.

A quality information proposed-rule-type notice was also released earlier this month in an unsuspecting place.  The proposed rule discusses more of the how and why quality indicator changes can be made in the future without any impact to previously published quality guidelines.

AMRPA and MediServe will share the details of this notice release in a few short weeks.  The information and tools can be utilized for impact analysis specific to your book of business.  Register for this free webinar today.

“Results of one of the following four measurement instruments are recommended, but not required:

- National Outcomes Measurement System (NOMS) by the American Speech-Language Hearing Association

- Patient Inquiry by Focus On Therapeutic Outcomes, Inc. (FOTO)

- Activity Measure – Post Acute Care (AM-PAC)

- OPTIMAL by Cedaron through the American Physical Therapy Association

If results of one of the four instruments above is not recorded, the record shall instead contain the following information indicated by asterisks (*), and should contain, but is not required to contain, all of the following, as applicable. Since published research supports its impact on the need for treatment, information in the following indented bullets may also be included with the results of the above four instruments in the evaluation report at the clinician’s discretion. This information may be incorporated into a test instrument or separately reported within the required documentation. If it changes, update this information in the re-evaluation, and/or Treatment Notes, and/or Progress Reports, and/or in a separate record. When it is provided, contractors shall take this documented information into account to determine whether services are reasonable and necessary.”

*Documentation required to indicate objective, measurable beneficiary physical function including, e.g.,:

- Functional assessment individual item and summary scores (and comparisons to prior assessment scores) from commercially available therapy outcomes instruments other than those listed above; or
- Functional assessment scores (and comparisons to prior assessment scores) from tests and measurements validated in the professional literature that are appropriate for the condition/function being measured; or
- Other measurable progress towards identified goals for functioning in the home environment at the conclusion of this therapy episode of care.”

For at least the last three years, Medicare has guided every plan to contain measurement criteria relevant to the functional loss. How often has this measurement been completed? Does your facility monitor those outcomes? Do you have data on the success of meeting the required objectives?

As previously covered in my colleague, Bob Habasevich’s, post on July 20, “ If all goes as proposed, therapists in outpatient settings will begin adding new codes to a Medicare patient’s bill or payment claim form on Jan. 1, 2013.  These new codes will be related to and describe the patient’s functional impairment for which treatment is requested; the status of that impairment at beginning, during and the end of care, and the goal to be achieved in treating the impairment.” “Specific codes to be known as G Codes will be assigned for each of these steps in the process.”If you have not taken the inclusion of functional outcomes into consideration, it will be increasingly more important as post acute care effectiveness and costs are being weighed. When completing the discharge summary, is the success of the measured outcome made prominent?  Has the treatment rendered provided the desired results?

Take a look at documentation provided in your clinic. If outcomes have lagged behind, or have been missing, now is the time to correct and emphasize their importance. The future of pay for performance and effective and efficient care practices will become the center of attention. Be prepared; provide staff the expectations for which measurements are most effective for the various functional impairments.Gather your results and share effectiveness. Better yet, determine the baseline that all should strive to achieve. Working toward improved outcomes is a winning goal for all stakeholders.

Connect with Darlene on LinkedIn

Only July 6, 2012, CMS released the 2013 OPPS/ASC proposed rule (CMS-1589-P). This proposal included comments for the IRF Quality Reporting Program in the event you don’t scan rules that normally do not pertain to your book of business.

Not to be alarmed, nothing significantly changes from what we have prepared to begin this October, but it’s worth mentioning should you want to contribute your thoughts during the comment period that ends at 5:00 p.m. EST on September 4, 2012.  Comments can be made at:  http://www.regulations.gov, under the “submit a comment” section.

Staring on page 519 of this released proposed rule, you will see section XVII. This section covers the IRF Quality Reporting Program updates. CMS provides rationale and discussion for why this released proposal has commented on IRF regulations in an unsuspecting place.

“XVII: Proposed Inpatient Rehabilitation Facility (IRF) Quality Reporting Program Updates

A. Overview
In accordance with section 1886(j)(7) of the Act, as added by section 3004 of the
Affordable Care Act, the Secretary established a quality reporting program (QRP) for
Inpatient Rehabilitation Facilities (IRFs). The IRF Quality Reporting Program
(IRF QRP) was implemented in the FY 2012 IRF PPS final rule (76 FR 47836). We refer
readers to the FY 2012 IRF PPS final rule (76 FR 47873 through 47883) for a detailed
discussion on the background and statutory authority for the IRF QRP.
In this proposed rule, we are proposing to:

• (1) adopt updates on a previously adopted measure for the IRF QRP that will affect annual prospective payment amounts in FY 2014;
• (2) adopt a policy that would provide that any measure that has been adopted for use in the IRF QRP will remain in effect until the measure is actively removed,suspended, or replaced; and
• (3) adopt policies regarding when notice-and-comment rule-making will be used to update existing IRF QRP measures.

While we generally would expect to publish IRF QRP proposals in the annual IRF
Prospective Payment System (PPS) rule, there are no proposals for substantive changes to
the IRF PPS this year, so we are only publishing an update notice. Because full noticeand-
comment rulemaking is required for what we are proposing for the IRF QRP, we
needed to identify an appropriate rulemaking process in which we could insert our IRF
QRP proposals. As this proposed rule was already scheduled to include additional
pay-for-reporting proposals for the Hospital OQR Program and quality reporting
requirements for the ASCQR Program, it offered an opportunity to allow the public to
review all three quality programs’ proposals in concert with one another in a timeframe
that would be appropriate for implementing these IRF QRP proposals in time for the FY
2014 IRF PPS payment cycle. Therefore, we elected to include the IRF QRP proposals
in this CY 2013 OPPS/ASC proposed rule.”

I propose you read this proposal today! As we await a late July or early August release of notice for 2013, join me for our webinar on August 16 as I discuss IRF PPS FY 2013 Updates and Changes with AMRPA’s Ms. Carolyn Zollar, J.D., Vice President for Government Relations and Policy Development.

We now have 145 clarification statements in the form of questions and answers on the IRF Coverage Criteria page from CMS that define appropriate interpretation and expectations for IRF PPS paid facilities. These five training documents called,  ”Follow-Up Coverage Requirements” specify exact definitions in meeting the 14 coverage criteria.  Getting it right is crucial because in totality they express reasonable and necessary in the eyes of an auditor monitoring if the coverage criteria are being met in the documentation within your medical records.

When one topic spawns more than 30 distinct elements of interpretation, it’s difficult to pull it all together to be certain you understand the expectations.  MediServe is committed to helping you get it right and find the right interpretations more easily.

To make it easier to locate all the items around the specific topics, we have loaded them into an online  searchable  file for easy reference by placing all like topics together, displaying the question and answers in one place and providing the link back to the resource document at it’s primary source at CMS.gov. You can even search by keyword.

These are the topics and the number of items found in total for those areas within the five published documents through 6/30 /2012.   If an additional clarification document is posted, we’ll update the file and re-link you to those possibilities.  You will want to bookmark the CMS Clarifications on IRF  as a favorite in your browser. It will save you lots of time looking for that exact interpretation and how it is being applied toward compliance.

Utilize the link to discuss interpretation and validation that your facility is following each of the areas appropriately. You may also want to cut and paste information into a rebuttal document specific to a challenged regulation topic. These items are pulled together and list the CMS interpretation resource(s) in one place, should you be asked to defend rationale in meeting coverage criteria.  This tool will help you close the gap on compliance toward IRF 2010 regulations now being audited for medical necessity at the FI/MAC and RAC levels.

Be prepared! Perform self-audits and educate expectations so that after earning reimbursement for your resources and care, you may also keep that hard earned cash.  If in preponderance you’re not following these criteria, it’s more than just cash at stake. IRF PPS Excluded status rests on meeting these criteria. One answer toward not providing therapy on weekends made this clear when stating, “failure to comply with all of the IRF coverage requirements may result in the IRF being out of compliance with governing regulations, which could potentially subject the IRF to declassification.”

MediServe provides the resource tool to help you monitor your success!

In this day of health care reform, with greater emphasis on measurement and management of outcomes, the first step to knowing how you are doing is to first get a glimpse of exactly what your hospital collects.  The who, what, where, when and why of data collected in your organization must be understood.  What is the goal and purpose of the data? Do you know exactly what is duplicated and shared to various outcomes agencies or insurers? Most important, what is the internal process of acting on the data and putting a process in place that provides appropriate feedback and adhesiveness to the expected protocol? Collecting data in and of itself is worthless. The end gain is managing the expected outcome and then rigidly applying and adhering to the standards that create the best outcome for patients and employees.  After all, this is the foundation for quality improvement.

From personal experience, the cost of data collection with so many expectations must be harnessed. Whenever possible, abstracting data directly from electronic charting with discrete elements available as a report is ideal. Letting technology work for you will be the sum gain for working smarter and not harder. It takes more than a small army to stay on top of so much work. Work that must be accurate and representative of the care you provide and take pride in performing is worth understanding and managing more accurately.

In alphabetical order, let me present a glimpse of what a small quality performance department juggled on a daily basis. Many required duplicated data for Process of Care reports (CMS required CORE Measures). This hospital did a full inventory for quality to find out exactly where it took place within their organization and ultimately where the data went. These reported below were in addition to their internal risk management incident reporting processes, although some of that data would be included in the measures sought by these various organizations.  Where available Web references are included.

1. AHA                             American Hospital Association                                AHA.ORG
2. AHRQ                          Agency for Healthcare Research & Quality          AHRQ.gov
3. ANTHEM                   Anthem Blue Cross & Blue Shield                              bdcadmins@bcbsa.com
4. DELTA GROUP         Delta Group                                                                       www.deltagroup.com
5. DELMARVA              Delmarva                                                                            DFMC.org
6. HCAHPS                      (To Quality Net)                                                               hcahpsonline.org  (CMS)
7. HOPQDRP                   (To Quality Net)                                                               CMS
8. HQA                              Hospital Quality Alliance(NQF type reports)      QualityNet.org
9. IHI                                Institute for Healthcare Improvement                  ihi.org  (National Patient Safety Goals)
10. ICPA                              Infection Control Prevention Assoc                      icpa.org
11. ISO 9001                    (Initial stages of preparation per manuals)
12. KePRO                          Ohio Medicare Quality Improvement Org            ohio.kepro.com/
13. Leapfrog                      Leapfrog Group                                                                leapfroggroup.org/
14. LogiCare                      Internal Data Base Emergency Dept                        logicare.com/
15. MedPar                        Medicare Provider Analysis and Review               healthdatastore.com/cms-medpar
16. NCDR-ACTION          National Cardiovascular Data Registry                 ncdr.com
17. NDNQI                         National Database Nursing QualityIndicators     nursingquality.org/
18. NEOHQC  OPSI          NE Ohio Hospitals Quality Collaborative               www.ohanet.org
19. NPSG                             National Patient Safety Goals                                     jointcommission.org
20. ODH                               Ohio Department of Health                                         ohio.gov
21. ORYX                            National Hospital Quality Measures                       approved vendor (erehabdata.com)
22. QAE                               Quality Assurance Entry Reports (MIDAS)         midasplus.com
23. QualityNet                  Quality Net Exchange Data Warehouse                 qualitynet.org
24. RHQDAPU                   Reporting Hosp Quality Data Annual Payment  qualitynet.org (to KePro CMS vendor)
25. Specialty cert. TJC  Various programs, stroke, diabetes etc.               jointcommission.org
26. STS                                  Society of Thoracic Surgeons Registry                sts.org
27. UHC                               United Healthcare                                                          uhc.com
28. VHA  (& VAH SPI)   Voluntary Hospital Association                              vha.com

Take this challenge and create your own Quality Improvement Database query. See who and how they manage data. Discover your reporting frequency requirements and accountability to meeting those schedules. Find out how much you budget for each department to perform and/or pay for data submission. Who is authorized by vendor for uploading data and does it require a digital certificate to upload? Roll all this information into one report. Ask yourself; Is there too much quality these days? Quality is here to stay and to our fortune or misfortune will continue to be transparent.  Take the time now to understand and develop the plans necessary to be sure that the information you share is of true quality. Healthcare reform demands value and quality. Take the first step towards both.

Healthcare and flight, with an adverse event, create a magnitude of difficulty that can result in horrible outcomes for those that depend on the expertise and steadfast commitment to the professions they practice.  There is no room for error, yet we see practice each day in healthcare that has a long stretch to meet the unconditional steadfast mindset of a pilot and quality outcomes. Capt. Harden quoted  James Conway, Institute for Healthcare Improvement (IHI) “Our systems are too complex to expect merely extraordinary people to perform perfectly 100% of the time. We, as leaders, have a responsibility to put into place systems to support safe practice.”  Those systems are often checklists or critical need to know data points. Points that leaders cannot take as happenstance and must assure that process, sequence and protocol are followed to enable the best possible outcomes even when contingency plans must be defaulted to.

The outcomes and successful results achieved by Capt. Sully were successful because of stringent, matter-of-fact training and strict adherence to process, sequence and protocol. He was trained and practiced every day in those three areas and was a leader to his highly skilled team. He faced a worst-case scenario and relied on specific contingency plans to calmly guide a positive outcome. It was immediate information processed just as immediately to protect from harm.

Perhaps you are not in a leadership position that makes life and death calls each day in healthcare, yet in total, all decisions you make guide highly skilled team members to service patient needs day in and day out.  Patients demand results that are driven by expectations toward specific outcomes.  Yes, clinical jobs are similar to a pilots, even minor mishaps can lead to poor outcomes. When Capt. Sully performed his job, he personally rechecked the plane before departing and then debriefed his crew to be certain that the protocol followed was measurably successful. He wasn’t thinking he would be a hero; he performed expertly what he was trained to do to avoid variance and mishap.

Capt. Harden stated we can expect that 3-5 percent of leadership will resist and will purposefully avoid a regimented approach even though they see those behaviors as holding consequences and risk.  This is the largest takeaway for me following his lecture that day.  He said “normalization of deviance, allowing the unexpected to occur is NOT ALLOWABLE.”   No harm, no foul leadership is nonsense and poses RISK; leadership of that nature produces fouls.  ”Systems are perfectly designed to get the results they produce,” a saying first coined by Dr. Paul Batalden,  Director of The Center for Leadership and Improvement, The Dartmouth Institute for Health Policy and Clinical Practice.  These two concepts say it all for the future of healthcare resistant to change but forced to accept and do so to lead highest standards of performance.

Leaders are held responsible in getting the right tools and processing the right sequence and protocols so that variance in expectations are minimum.  Expert clinical staff need real-time information and collaborative communication to make last minute choices. Allowing persons to act in a way that does not support the best outcome is allowing normalization of deviance to occur. Would you want to be a patient under that kind of leadership? It’s time to enact continuous quality improvement and design systems that provide enough data to guide real-time expected outcomes and appropriate instantaneous reactions when the unexpected occurs.  Patients depend on your leadership, leaders must disallow the unexpected.

Care provided in the next fiscal year will set standards for payment at higher levels beginning October 2013. By basing rates on the hospital’s performance in the preceding year for certain quality measures, or improvement during the performance period for a fiscal year, the higher the hospital’s value-based incentive payments will be.

This trend of pay for performance will require specific diligence in managing and correcting variance. A task that cannot be done without dedicated performance improvement monitoring and carry through. Although it begins at the acute care level, every level of care will be raised to a higher standard because of this base year activity.

Further evidence of this was just announced June 5th:

Post acute care providers are just being primed with enhanced quality monitors and debate on given payment modeling. Become familiar with high volume, problem prone practices and be serious leaders of change. The future demands real-time monitoring and management toward correction of variance so that more outcomes are predictable and specifically driven; facility value will depend on it!

It is correct that if only one service is provided and it is a timed service with the length of treatment less than eight minutes; that you may not bill for the seven minutes. The scenarios in the examples provided by Medicare below will help staff to understand when it is acceptable to drop a coded charge for services less than eight minutes. It is up to the discretion of the therapist to select when there are equal opportunities to choose a CPT code – even when only seven minutes is provided.

This particular section of the Claims Processing Manual is good to print and discuss often with staff. Their ability to bill correctly is linked to their understanding of the concepts presented when dropping charges for services rendered to Medicare beneficiaries. These are the examples Medicare provides:

-When more than one service represented by 15 minute timed codes is performed in a single day, the total number of minutes of service determines the number of units billed. If any 15 minute timed service that is performed for seven minutes or less than seven minutes on the same day as another 15 minute timed service that was also performed for seven minutes or less and the total time of the two is eight minutes or greater than eight minutes, then bill one unit for the service performed for the most minutes. This is correct because the total time is greater than the minimum time for one unit

-If seven minutes of neuromuscular reeducation (97112), seven minutes therapeutic exercise (97110), seven minutes manual therapy (97140) for 21 Total timed minutes is provided. Appropriate billing is for one unit. The qualified professional shall select one appropriate CPT code (97112, 97110, 97140) to bill since each unit was performed for the same amount of time and only one unit is allowed.

-If there are 33 minutes of therapeutic exercise (97110), and seven minutes of manual therapy (97140), for a total of 40 Total timed minutes. The following is how to determine appropriate billing for the 40 minutes or three units of service. Bill two units of 97110 and one unit of 97140. Count the first 30 minutes of 97110 as two full units. Compare the remaining time for 97110 (33-30 = three minutes) to the time spent on 97140 (seven minutes) and bill the larger, which is 97140.

If you are a free standing rehabilitation facility, it is quite obvious that based on the Tax Identification Number (TIN) of your facility, you have a limit of ADRs that may be requested  based on your prior calendar year of Medicare claims volume. It is a pure math equation on what your risk of audit may be for any given 45 day request as a freestanding IRF. You know the number of Medicare discharges and you apply the math. The baseline facts are as follows:

-The  maximum number of requests per 45 days is 400

-The limit is based on claims volume only.

-The type of claims do not factor into the limit.

-A provider’s limit will be applied across all claim types including professional services.

-The limit is equal to 2 percent of all claims submitted for the prior calendar year divided by eight.

However, if you are a unit within a very large medical center that generates hundreds of thousands Medicare claims per year, you may find yourself in a very different predicament. The maximum amount is ‘per campus’.  The definition of campus is ‘one or more facilities under the same TIN’.

Let us look at this scenario. Consider you are a 25 bed unit within this TIN. Your Medicare volume happens to be 360 discharges for a prior year. Using the example in the education flyer, we will say that your entire facility TIN is large enough to generate 156,253 claims in the prior year. Two percent of that claim volume is 3,125.  The limit is calculated by dividing by eight. In this example, the provider’s limit is no more than 390 requests every 45 days for this particular facility under the same TIN. Your IRF may be a small unit within that TIN. Surely they cannot request an entire 45 day limit from just one area, this could be every Medicare discharge in the prior year. Can they request every patient in the same 45 days?

Considering that the request is made at the TIN level, and the above scenario happens to be similar to what your situation might be; this could result in an ADR request asking for all 360 of your discharges in one 45 day period. Seems impossible, but it is probable. Imagine just half that number;  whereas you request that your own staff be involved in the preparation of all ADRs specific to an IRF level of care. Wow, you just got slammed. I am writing this blog because I am aware of a particularly similar occurrence. It can happen and it may happen to you! It led me to read the Audit Program flyer and sure enough, it not only can happen, it is happening.

After reading the guiding education document several times, it became apparent that the present rule permits this type of scenario to occur.  I also asked an CMS representative and received a prompt detailed response from one of their Senior Health Insurance Specialists in Baltimore.

The response stated that,  ”although they are aware that Recovery Auditors have not conducted many IRF-specific reviews until recently, we have not heard of instances where there was undue hardship placed on any particular provider.”

My response to YOU as IRF providers is:  ”has this happened to you?” If as a provider you have been one of those cases in which your small unit received an abundant of request within 45 days, you most likely obligated as required.   Did you also share this hardship at the government level as to  how that particular interpretation of the rule is a hardship? As an excluded unit within the TIN, it may be more fair across all provider types of IRF care to apply the standard calculation at the CMS Certification Number (CCN) level, rather than all claims submitted from a prior year at the TIN level.

If you do not voice these hardships, you run the risk of status quo. Our government often listens when we raise our voices to provide logic based on personal hardships. Testimony is key. Without testimony, your expectation to respond to ADR rests in the present interpretation.

Here is further discussion from the  CMS Senior Health Insurance Specialist that change will not happen unless you voice your concerns.  He responded, ”Recovery Auditor reviews are approved by CMS for a particular provider type, in this case IRF. As you mentioned, the size of any specific unit that generates those claims is not part of the ADR limit calculation. Therefore, if a recovery auditor chooses to use the majority of a facilities ADR limit on IRF claims, that would mean there would be very few ADRs for other claim types from that facility. Therefore, because the facilities fall under the same TIN, we would expect that the administration/management of the related facilities would coordinate and take the necessary steps to manage the process of responding to ADRs in a manner that makes the most sense for their organization.  The methodology used to determine ADR limits for facilities has been in place for some time now. CMS believes that this method is a fair and accurate way of calculating the ADR limits, and there is currently no plan to change this methodology.”

If you agree that this is a sensible method, sit still— there is nothing more to do.  If you believe this rationale would and will create undue hardship in ADRs  for IRF units within large hospital systems, than you need to comment BEFORE it happens. Voice your concerns to an individual in the Provider Compliance Group of the Office of Financial Management. Before a flurry of ADRs begin to mount for small units within hospitals, you need to make CMS aware that selecting all records in one 45 day period that is nearly equivalent to an annual discharge volume is not reasonable, particularly when very specific items must be tagged to validate compliance toward the 100-02 Chapter 1:110 guidelines.

Ultimately it’s our government; they are waiting to hear from you. Medically necessary audits have just begun and the government is searching for ways to achieve budget neutral. It’s your dime! Be a leader!

The question is, have you listened and have you adopted practice that falls specifically in line with the expectations? Do you know where you stand for each criteria? An IRF PPS Coverage Requirements National Provider Call took place on May 31, 2012.  It seemed fairly evident by the greater than 30 questions fielded during the call that there is still a significant amount of confusion on how the 11 areas of Section 110 from 110.1.1 – 110.3 will be applied during a compliance audit at either the FI/MAC or RAC level. It’s even harder to believe that these 11 areas require surveillance to over 45 specific measurable items and those items have created to date five separate clarification documents that further define how the audit contractors are to apply meaning to the standards. From areas covered on the most recent call, it is possible another document will also be prepared and posted.

I don’t have to remind you that these are ‘coverage criteria‘ so if they are not met in preponderance of chart audits, they will result in denial of payment, and if grossly ignored will jeopardize excluded status under IRF PPS payment. There are sanctions that default the payer model back to acute care DRG level and can be held there through an entire cost reporting cycle. Facilities that have a large population of Medicare beneficiaries  in their total census need to take a detailed adherence toward all expected workflows and documentation standards. You must audit internally to the greatest degree possible for each expected criteria so that you can continuously improve your processes to meet the expected target.

If you have clinical staff or physicians that beg to differ with these stringent mandates, they pose significant risks to your bottom line and livelihood. No one wants to experience denial and take back of payments for patients that have successfully been rehabilitated and returned to the community only through resource utilization you expertly provided; not even CMS. But if you ignore the obvious, rules are laws and laws not followed result in less than desirable outcomes. Payment neutral can be achieved in several different ways while protecting the Medicare Trust Funds. Foolhardy does not have to be one of those ways.

In this round of audit on medically necessary admissions, the specific criteria is to meet the conditions of coverage. They appear fairly straight forward and can more or less be defined by yes or no for charted presence and some rely on detail to time standards.   An appropriate admission depends on meeting these criteria. It has been said over and again; it is not necessarily just the diagnosis or where they are admitted from, but the ability to meet the coverage criteria. Do a self check. Demonstrate due diligence so that any chart can be pulled and fiercely upholds the outlined criteria. Medical necessity audits are just starting.  There has been time enough to get it right, so let’s get it right!

Stay tuned to this topic. MediServe will soon offer a searchable document to help pinpoint clarification statements specific to your needs!

Management gurus have utilized data analysis for improved performance in manufacturing for ages. Although health care relies heavily on scientific evidence to mold practice standards and new technology, health care has fallen short in business management because of the lack and ability to aggregate data.

It’s important to gather information and component facts that align to determine what direction to take next to guide performance both clinically and financially. Today’s practice of benchmarking, dashboards and scorecards have proven great value and will hardly be left behind as a fad.

Health care, by enlarge is built on scientific evidence and is finally leaning toward business models in all areas of change management. Aggregation, trending patterns, and outcomes provide enhanced abilities in predictive modeling, reducing harm and improving outcomes. Quality measurement in health care has led to significant changes in process and vigilance and has been attributed to saving millions of lives.

As a provider of clinical services and healthcare reform, managing data and sharing outcomes have become more prevalent during the past 10 years with quality reporting that was initiated in 2002 through  Hospital Quality Initiatives. Therapy outcomes have been the second seat to mandated medical outcomes, but therapy practice does not have to wait for mandated reform.

Where there is data, there is opportunity for measuring and managing outcomes; regardless of who said, “you can’t manage what you don’t measure.” Collecting and sharing data means healthcare reform will rely on information and change processes through data driven outcomes. Are you ready for data driven clinical reform? The hardest leap is accepting and leading the change!

Although it sounds fairly simple with just two items being monitored, new or worsened pressure ulcers and catheter-associated urinary tract infections (CAUTIs), it’s not as simple as you may think and there is preparation involved that cannot be delayed. Staff education always takes time and this certainly requires additional clarification and expectations to report effectively as directed.

Oct. 1st, 2012 is right around the corner. If you have read carefully though the new IRF PAI manual, you will have discovered that to begin submitting for all patients discharged by October 1 and thereafter, you must be ready at least a month or so before since patients discharged will have been admitted prior to that date. You must have skin inspection knowledge at admission and discharge to determine the appropriate answers for indicators 48A – 50 D; these  items replaced the previous PUSH Tool on the IRF PAI.

When it comes to CAUTI reporting, there are significant preparation details that must be completed at NHSN (National Health Safety Network) before you will be permitted to submit your data through that website.

You will want to become very familiar with the IRF Quality Reporting page at the CMS.gov website. In the “download” section at the bottom of that page is a most helpful 21 page presentation from the CMS Open Door Forum held April 19th, 2012. This particular presentation has all the resources necessary to guide your preparedness in meeting the Patient Protection and Affordable Care Act reporting guidelines.  Don’t hesitate, get ready!   Quality reporting is the next largest threshold to demonstrating value and effectiveness of IRF Care. The countdown begins NOW!

Personally, I had underestimated the learning that needed to occur to appropriately answer the questions for the selected indicators. The IRF-PAI pressure ulcer presentation was a good refresher on the basic concepts associated with pressure ulcer and the distinguishing differences between those and other skin conditions that may be confused with pressure ulcer staging.  The speaker, Elizabeth Ayello,PhD, RN, APRN, BC, CWOCN, FAPWCA, FAAN, has an entire career devoted to wound care and a particularly nurturing ability to explain and educate so that staff will be confident in their ability to answer the very simple numbers required for the various stages, and if those have appeared to worsen during a stay or become fully healed.   Through this education, the person responsible for entering answers to items 48 A – 50 D on the IRF-PAI will be able to do so confidently.

Of particular education to me was the fact that CMS has adapted the National Pressure Ulcer Advisory Panel’s (NPUAP) 2007 definition for pressure ulcer:  ”A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over bony prominence, as a result of pressure or pressure in combination with shear and/or friction.”  The classification leads to six categories of which the PAI manual is asking to report only three of the six or stage 2, 3 and 4. “Stage 1″, “unstageable” and  ”unstageable suspected deep tissue injury” are the three stages not included for reporting purposes, yet staff must understand the definition of those stages in order to classify 2,3 and 4 correctly.

Resources highlighted within the training materials are available at www.npuap.org along with guidelines for treatment and prevention. Of particular interest is the free color staging illustrations that will help staff more easily recognize and stage appropriate to expected reporting CMS guidelines.  Take advantage of these help tools so that documentation within the medical record is consistent and supportive of the classifications that appear on the encoded IRF-PAI record.

We are allowing the IRF to begin making arrangements to transfer the patient to another setting of care and to receive the short stay outlier payment for IRF stays of 3 days or less (instead of having the entire claim denied)“,  pg.  39791 Federal Register Vol. 74, No. 151 / Friday, August 7, 2009 /Rules and Regulations.

The standard payment without influence of the facility adjusters is $2,074.80, given the applied 0.1474 CMI.  But lets consider another factor. Even if the facility recognizes within that first week that the patient is not able to participate at the intensity of an IRF level of care; staff  must begin making arrangements for discharge. At the very least, each patient must receive the mandated Detailed Notice of Discharge before they can officially discharge the patient.

If you are counting the number of days that the patient is now at the Inpatient Rehab Facility, you will see that often, upon discovery of not meeting intensity, many days can occur. Not meeting intensity within that first week can occur if any of the following are realized: The patient does not meet the initial  intensity of 3 hours of therapy by Noon of the third day (36 hours after Midnight of the admission day), or  is unable to tolerate three consecutive days (POC defined days) within the first week or is unable to receive 15 hours in total within the first week. Realizing that very often, patients are transferred to a rehab facility in the late afternoon on their admit day, the pressure is real and the ability to meet each of these very specific components is hugely important.

Let’s say the patient did not meet intensity as required for the initial seven days and NOW I must give them the detailed notice. It is day 10 before I can officially discharge the patient. Does the 10 day trial now begin to make sense?  I believe so, specifically when you may not discharge the patient before  following all the other federally mandated requirements.  Lets refer to the instructions for discharge notification found in the Medicare Claims Processing Manual Chapter 30.  Section 200.1.

“The final rule requires hospitals to use a revised version of the Important Message
from Medicare (IM), CMS-R-193, which is an existing statutorily required notice,
to explain discharge appeal rights. Hospitals must issue the IM within 2 calendar
days of the day of admission, and obtain the signature of the beneficiary or his or
her representative to indicate that he or she received and understood the notice.
The IM, or a copy of the IM, must also be provided to each beneficiary within 2
calendar days of the day of discharge. Thus, in cases where the delivery of the
initial IM occurs more than 2 days before discharge, hospitals will deliver a
follow up copy of the signed notice to the beneficiary as soon as possible prior to
discharge, but no more than 2 days before.”

Given all the resources provided by your facility to initially determine that the patient was capable to receive but then for any reason was not able to meet the rigid intensity definitions, is it truly fair to receive a flat payment of short stay in definition?  It may be more arguable that payment like that in the transfer rule would be appropriate. After all, a HIPPS code based on the burden within the first three days was achieved by that time. The care provided was not just therapy, but resources provided by the entire interdisciplinary team, and therefore transfer payment rather than short stay would be more appropriate IF the patient did not return to the community. If it was a community discharge, is there any question that the resources expended were valuable enough to warrant full payment despite a rocky start?  After all, due diligence met in the pre-admission screen and post admission evaluation that result in the expected disposition should be rewarded rather than penalized on technicalities.

If a specific percentage of any facilities admissions fell into this category making it appear as though they were “gaming” payment, then those statistics need dealt with. To automatically enforce limited short stay payment to every case is truly unconscionable; this is particularly true when a patient whose start was rocky did not meet the initial intensity, but was rehabilitated and met the goal of returning to the community!

Outcomes and documentation should trump the short stay payment classification in regards to initial week intensity criteria because as you can see, federal regulations place us between a rock and a hard place in getting it right and expediting a discharge with coverage at a 3 day payment rationale. Finally, the name of the CMG, short stay less than 3 days  is very confusing and will lead to persons not ever grasping the intention and use of the CMG correctly. Speak up!  This can’t be right!

2010 Final Rule discussion facts as published and excerpted:

          – It is no longer appropriate to allow up to 10 days in an IRF merely to assess the patient, at that point, the average IRF patient would already be preparing to be discharged. (Ten day ‘trial’ went away)

          – Specifically, we mean that, at the time of admission to the IRF, there must be reasonable expectation that the patient is able to tolerate and benefit from the intensive rehabilitation services as generally prescribed in this rule so that he or she can progressively make the improvements needed to achieve results of practical value toward his or her functional capacity or adaptation to impairment.

          – We do not believe that it is appropriate to provide four days (at which point the IRF would GENERALLY receive a full CMG payment for the patient) or an undefined amount of time for the IRF to determine whether the patient meets the IRF medical necessity criteria.  This determination should be made at the time of the admission to the IRF.

          – Must consider whether the patient’s condition is sufficiently stable to allow the patient to actively participate in an intensive rehabilitation program

          – CMS does not believe that patients should be transferred to IRFs before their medical conditions are sufficiently stable to enable them to participate in the intensive rehabilitation therapy program provided in IRFs.

          – Must consider whether the patient requires the intensive services of an inpatient rehabilitation setting, which is typically MEASURED by whether the patient generally requires and can reasonably be expected to ACTIVELY participate in at least three hours of therapy per day at least five days per week.

         - If patients do not need the intensity of services uniquely provided in IRFs, or benefit from them, then it is not clear to us why they would be admitted to an IRF.

         - However, we note that this does not mean that patients’ medical conditions will be fully resolved when they are admitted to IRFs.  As one of the commenters summarized, we are requiring that a patient’s medical condition be such that it can be successfully managed in the IRF setting at the same time that the patient is participating in the intensive rehabilitation therapy program provided in an IRF.

Medicare Billing Manual description  140.3.4:  (Also answer #48 in the  National Follow Up Call – Series #4 document)

- “For atypical cases effective Jan. 1, 2010, the HCPCS/Rates must contain a five digit HIPPS Rate/CMG Code A5001. An atypical case occurs under the new IRF coverage requirements that became effective Jan. 1, 2010, where an IRF is eligible to receive the IRF short stay payment for three days or less (HIPPS Rate/CMG A5001) if a patient’s thorough preadmission screening shows that the patient is an appropriate candidate for IRF care but then something unexpected happens between the preadmission screening and the IRF admission such that the patient is no longer an appropriate candidate for IRF care on admission and the day count is greater than three. In this scenario only, if the patient is discharged/transferred on or after day four, we are instructing IRFs to bill HIPPS Rate/CMG A5001. Thus, whether or not the IRF is able to discharge the patient to another setting of care within three days, the IRF will only be eligible for and receive the IRF short stay payment for three days or less (HIPPS Rate/CMG A5001).”

It is a concept that has gained popularity for denial from pre-authorization to post provided and unfunded care.  Yet there are criteria aimed around the concepts, that if taught well, staff could easily defend requirements.

Criteria for Medically Necessary therapy care are generally met when:

• Therapy is aimed at PREVENTING disability, improving, adapting or restoring functions impaired or lost permanently as a result of illness, injury, loss of body parts or congenital abnormalities; AND
• Conditions require SKILLED  knowledge, and judgement for education and training as part of a skilled plan of treatment due to the complexity and sophistication of the medical condition; AND
• Expectation is that services will result in a practical improvement in the level of FUNCTION within a reasonable and predictable period of time.

Given these conditions, it would not be expected that function could reasonably be expected to improve normally or to such potential without SKILLED services within similar time frames.

* Skilled services are often identified as provided by a qualified practitioner. Qualified is defined through CMS and state practice guidelines.

Criteria must clearly be stated in the evaluation and plan of care and then validated by demonstrating the expected practical improvement has occurred within the time line predicted.  Where there is variation, appropriate cause and continued skilled intervention mediates the variance. So often the intended goal of service and the impact of that goal is not stated nor revisited so that functional gain toward attainment is clear.

When staff embrace the criteria within those three bullets and then revisit those requirements at appropriate intervals to document care, medical necessity is no longer a mystery and approved and reimbursed care occurs more successfully.

Healthcare is a severely complicated business. Most businesses are concerned with revenue generation and a now and again a ‘money back’ guarantee they offer that may take back their hard earned service cash flow. In healthcare, money back despite all services rendered is more real than ever.   In the fiscal year of 10/1/2010 through 9/30/2011, posted corrections of greater than 900 million were found. In fact, in the fourth quarter alone over-payments accounted for 78% of the corrections.  The odds are NOT in your favor as to whether over or under payments are of your greatest concern.

If you had linked to the flyer above, you’ll see there are more than a dozen more contractor types just as eager to assist us in getting it right!  Most importantly, you have to know that you actually understand the interpretations and that your staff also are well aware and following expected protocol.  Internal audits are key, but more importantly electronic documentation and systems guidance is the better way to go when it helps to discover, alert and help mitigate the thousands of items that must be cross checked day after day.  There are far too many items for staff to keep their finger on the pulse of each one of them.

Who is your assigned Recovery Audit Contractor (RAC), and what issues are presently under review? Acute care has the greatest number approved for review; inpatient rehabilitation and outpatient services can be found through search engine or by provider type sorting.  Utilize these web resources to determine areas of vulnerability, create appropriate teaching opportunities, increase utilization review activity and appropriate safeguards so that your facility isn’t caught up in ‘money back’ negative cash flows.

I also know that prior to those changes, there were many educational offerings to expose and redefine exactly how one should prove appropriateness for the rehabilitation admission. It was defined that if due-diligence in the pre-admission screen, detailing each of the required criteria were met and the physician concurred with the admission and saw the same needs within 24 hours after admission through the post admission evaluation, that THEN medical necessity is met and that a retrospective decision stating that they COULD have been treated at a SNF level of care would not be argued.

The defense provided in the pre-admission screen is clearly the largest evidence. It must define the exact purposes for treatment at an IRF/IRU level of care, even if that treatment mitigates potential risks that require greater surveillance than what is commonly available at a lesser level of care.

The discussion and audio transcript of that November 12th, 2009 call is at the CMS website.   Below, are very important paragraphs pulled from the discussions that took place that day.

1.)

2.) 

As Medical Necessity has been re-introduced into the RAC discussion for review, with at least two districts already reviewing REASONABLE and NECESSARY as the criteria for the admission decision, the items discussed above may HUGELY lead toward debate. Did you spend the time to justify the criteria required for admission? Does that documentation warrant a level of care that expects greater vigilance in medical and nursing management to maintain a safe effective intensive level of rehabilitation? Was the process a truly descriptive one and not just a page or two of check boxes, which CMS has stated will NOT meet the expectations for the pre-admission screen.

The first clarification document published by CMS states:

“Clarification regarding “check boxes” on the pre-admission screening form.
On the November 12 provider training conference call, CMS indicated that the pre-admission screening documentation must not be presented entirely in the form of “check boxes,” but instead must contain some narrative information. Thus, for example, the documentation cannot merely contain “yes/no” check boxes for whether the patient has a risk for clinical complications. It must describe in detail what conditions/comorbidities the patient has and why these indicate a specific risk for clinical complications that require physician monitoring in order for the patient to actively participate in an intensive rehabilitation therapy program. This detailed description, by the very nature of it, would need to be in narrative form. However, the rehabilitation physician is not required to write this narrative if the narrative is written by the licensed or certified clinician/clinicians conducting the preadmission screening.”

It takes time to complete a thorough pre-admission assessment, but an hour or two that can fully uphold reasonable and necessary loopholes gives some assurance that after you have expended your resources in full, that specific reimbursement will not be retracted.

Inpatient rehabilitation has demonstrated fiscal responsibility per the 2010 MedPac Report. There is evidence that all other post acute care service lines have shown a rise in spending whereas IRF care has a decreasing slope and excellent outcomes. Why not let us provide care to all those that require a multidisciplinary plan in the most efficient effective ways we have developed?

Reward where reward is due and hold level standard performers. If you pay for performance as all indicators say we should, then using today’s dollars as a distribution of outcome warranted payment may go far in ending an across-the-board freeze. Maybe redistribution is the best plan on the horizon. Let outcomes guide those answers.

This long awaited update was mainly necessary because of the ”Quality Indicator” section changes.   Previously, we had respiratory status, pain, pressure ulcer and safety items that ranged from number 48 – 54. On the new PAI, pressure ulcers are covered in all questions 48 A-C, 49 A-C and 50 A-D.   Unfortunately, there have been a few items that have been changed that were not updated in this manual, so I suggest you write them in.

In Appendix H, page 1 there was an opportunity to correct the fact that there are no longer 100 CMGs.  Originally the payment model had 95 CMGs and 5 special CMGs. This number was reduced due to a RAND study in the 2006 rule for FY 2007 and now there are 87 CMGs and 5 special for a total of 353 CMG possible payments. Unfortunately, I often see and hear a misquoted total. On page H-1 write that on the side line.

Another opportunity missed in the new PAI manual was the discussion on what the weighted motor score means and how that correlates in the grouper software to assigning the correct CMG. The picture inserted below demonstrates the weighting values to more closely assign burden of care reimbursement. Although this is fairly transparent to persons that input whole numbers into the PAI, it is very significant in finding the correct Case Mix Index for payment within a RIC. Add this to Appendix H area as well.

Other items to note:

• Relative weights since they change annually are linked to the cms.gov website
• Appendix C – co-morbidities were linked to the cms.gov website
• Admission Class definitions under item 14 of the PAI still include ‘Evaluation’ which was the old description for a trial stay of less than 10 days.  After 2010, advise this is no longer acceptable.
• Payer classifications continue to use code 13 called CHAMPUS (The “Civilian Health and Medical Program of the Uniformed Services”); it is now known as TRICARE. Write that in so new staff know it’s the same code.
• They cautioned under the new Quality Indicator section II-29 that although it is not required, it will result in a 2 percent payment reduction in FY 2014 if not completed. They left off that the important time frame for submission is October 1, through Dec. 31, 2012.  Write that in.
• Although there is a great description of discharge location 13 – sub-acute setting, even defining that the settings are not the CMS recommended name used for billing purposes on the (UB-92) which is now called the (UB-04), it is more important that persons are familiar with using it to define a patient that is discharged to a setting that continues to provide a multidisciplinary approach to care – such as a rehab oriented skilled (SNF) nursing stay. It’s important that coders DO NOT use this discharge location information to code the UB.  The Office of Inspector General (OIG) has already targeted improper discharge setting on IRF bills and this helps complicate that matter.
• Appendix G is now a discussion on coding rather than the glossary
• Previously Appendix H was a very helpful question and answer section for each of the 18 areas of scoring.  This was removed and has realigned the new Appendix H to be Relative Weights or the old Appendix J.
• Old Appendix K is the new Appendix I – Privacy Rights
• There is no longer an Appendix J
• Scoring decision trees are the same although printing is much clearer. It is important that these remain the same so that longitudinal use of numbers are comparable.

I believe what we need now is a very active FAQ and ANSWER internet board through the help desk.  If we can take questions for clarifications on scoring to the help desk that allows subject matter expert debate and resolution with the final say published back to the FAQ so that everyone applies scoring consistently, I believe we could all rest a little more easily.

Although scoring should remain at a fairly basic and uncomplicated level, clinicians will often attempt to define their own ruler and application of scores. Follow the decision trees, they are extremely helpful. There is one more thing that did not change between publications, “Do not modify the FIM UDSMR^TM  instrument itself”  page III-2.

Check out MediServe’s software solution to help ensure accurate IRFPAI scores.

The CMS Innovation Center will release multiple opportunities to demonstrate better care, lower costs and managing health outside of traditional brick and mortar establishments.  Just recently they released “Independence at Home Demonstration”, a model program that will surely affect outpatient services and new wave ‘home health’.

On Dec. 21, 2011, CMS released a call for applications for this new project and encouraged medical practices to test effectiveness of delivering primary care services in the home for Medicare beneficiaries with multiple chronic conditions. These comprehensive services are to focus on timely, appropriate care that improves quality of life while lowering costs; preferably by decreasing the need for care at institutional settings.

This project will also test ”whether home-based care can reduce the need for hospitalization, improve patient and caregiver satisfaction and lead to better health and lower costs to Medicare,” per the CMS announcement.

If you look at the number of beneficiaries that referred to ‘home health’ or ‘outpatient services’ upon leaving rehabilitation, you begin to understand the need for coordinated care management beyond discharge.

So who are the candidates for this type of program? Beneficiaries with multiple chronic conditions who require someone’s assistance with two or more activities of daily living; and who have had a hospital admission within the last 12 months that included rehabilitation services. The potential for growth beyond initial participants is quite remarkable.

Will these types of programs be sustainable and how much will they affect services presently provided by outpatient therapy settings and home health services? Will these programs help fill the gaps perceived to occur in the near future with an explosion in covered Medicare lives (whereas multiple caregivers and increased physician visits with increased co-morbidities is not a rare occurrence for people with chronic conditions)?  (The Silver Book: Chronic Disease and Medical Innovations in an Aging Nation; Partnership for Solutions. Chronic Conditions Making the case for ongoing care – September 2004 update.  Baltimore, MD: Johns Hopkins University, 2004.)  Small populations with chronic conditions may be responsible for more than 80 percent of health care cost dollars.

Medicare is asking that the Independence at Home Demonstration include primary care practices and associated multidisciplinary teams of which can include pharmacists, social workers and other ‘supporting staff’.  They must serve no less than 200 beneficiaries with multiple chronic conditions each year of the demonstration. Overall, the demonstration may include up to 10,000 beneficiaries and up to 50 such practices. The application process and instructions for how payments will be made during this 3 year demonstration are included HERE.

Payments will be tied to success in meeting six quality measures compared to a threshold equal to or less than the average utilization in an unmanaged, clinically similar population with case mix and geographic adjustments.

So the question remains, are the complexities for innovation within the capabilities of  standard payment models?  Medicare states providers ”will continue to bill and be paid standard Medicare FFS reimbursement, subject to beneficiary deductibles and coinsurance and balance billing rules.” Additional incentive payments will then be derived from targeted payment levels and the number of quality measures met.  Will providers take those risks?  To what level can ‘supportive staff’ be utilized within a home? Does this create a level of care dependent on extenders of a multidisciplinary team not yet recognized within ‘standard payment’ methodologies? Only time and creativity will tell.

We have been told post-acute care services may look very different from what we have today. Health care reform will take on many faces.  For up to 10,000 beneficiaries, this new face of health care will begin shortly after the deadline for applications in just a couple of months.

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Communication and the ability to link usage of the same CPT code across disciplines to trigger modifier usage at the point of documentation is available in the MediLinks OP software solution.  When a therapist charts, interventions are linked to CPT codes and the ingenuity of cross-referenced occurrences are alerted at the point of documentation which enables therapists to apply the 59 modifier up front; securing appropriate documentation with the bill as it is created.  This workflow curtails many pain points encountered when edits are applied after the fact, especially mounting take backs, error rate testing and denials of payment that can be applied by various Medicare contractor agencies.  With less than adequate tools, leaders must increase awareness and responsiveness to ensure appropriate billing knowledge is applied by all clinicians. Let’s learn a little about CCI edits and modifiers and risks associated with non-compliance.

An excellent Medicare Learning Matters education flyer was posted in 2006 explaining when and how CCI edits would be applied.  The education article states, “Application of the CCI edits ensures that all therapy providers are subject to the same billing and coding rules and requirements. It is believed that these changes will have a positive budgetary effect as it incorporates safeguards against improper coding and over-payment of therapy services.”  Some managers are confused and believe that the plan of care or discipline specific code edits should also indicate distinct and separate care; this is NOT the case.

The claim must include one of the following modifiers to distinguish the ”skilled” discipline of the plan of  care under which the service is delivered in outpatient therapy (Benefit policy manual definition of skilled provider):

GN – Services delivered under an outpatient SLP plan of care
GO – Services delivered under an outpatient OT plan of care
GP – Services delivered under an outpatient PT plan of care

Recall that there are situations when ‘always therapy’ or ‘sometimes therapy’ must be applied depending on who renders the various procedures.  The ANNUAL THERAPY UPDATES (posted Dec. 8, 2011) provide instructions on why and how GN, GO and GP modifiers should be used. Situations such as, “They are billed by practitioners/providers of services who are not therapists, i.e., physicians, clinical nurse specialists, nurse practitioners and psychologists; or they are billed to fiscal intermediaries by hospitals for outpatient services which are performed by non-therapists”, are examples of when the modifiers are NOT applied, however those providers are also subject to CCI edits – hence two sets of codes are needed.

Unfortunately, again many managers believe that GN, GO and GP is enough to denote ‘distinct and separate’ billable care.  However, particularly in multi-discipline clinics, there are often co-treatments provided and the time is not necessarily ‘distinct and separate’.  Providers are able to bill for co-treatment in various ways.  The provider can place all time billed to one discipline, or share the time between two disciplines, as defined through CMS: “Where a physical and occupational therapist both provide services to one patient at the same time, only one therapist can bill for the entire service or the PT and OT can divide the service units.” Be aware there are newer guidelines for counting of minutes for Skilled Therapy (published August, 2011) and if you work in skilled you must review the newest guidelines for that level of service.

HOW CAN YOU keep all of this straight?  Billing software is not often able to view across disciplines to recognize CCI edit scenarios.  When edits are not properly applied, this warrants take backs for “overpaid” claims on the same day for a provider.  I often see scrubbers apply edit information in an automated fashion that is not connected with documentation by the therapist at all.  These types of occurrences lay the groundwork for improper billing.  MediLinks embeds these tools to reduce probability of adverse occurrence.

It is far more effective in managing compliance at the front end, rather than paying for mis-communicated CCI edit pairings after the fact and/or only being reimbursed for portions of the care provided because distinct and separate CCI edit coding was not applied to the bill.

Should errors lead to an unacceptable error rate percentage, all Medicare claims could be placed into prepayment review. Prepayment review has serious cash flow consequences.  CMS reports a take back of $34.3 billion in improper payments in 2010. As electronic claims analysis becomes more expedient, take backs will increase. Payment extrapolation (statistically applying fault recouped payments based on historical sample), for those with continuous high error rates or previous education/training on faulty practices can see exponential take backs applied for years of service for which you have already been paid.

One of the best education primers I have seen on the subject of audits was published by AHIMA.  ”Understanding Governmental Audits.” Journal of AHIMA 82, no.7 (July 2011): 50-55 (see chart below).  I highly recommend placing a book mark to this site and using it to educate staff on the complexity and ever-growing vigilance for leaders in healthcare.

Courtesy: AHIMA

Start these discussion with your staff:

1. How do you presently determine frequency in your plan of care?
2. Is frequency a stable number – starts at a level not changed in the plan?
3. Does acuteness of a condition determine greater frequency at the start of care?
4. Payer’s often dictate visits; how do staff utilize limited visits when establishing the plan?
5. How often is the established frequency adhered to by the patient?
6. Does staff modify the plan if the original plan is not maintained?
7. Did the patient meet stated goals that adhered to the frequency plan?
8. Did the patient meet stated goals that did not adhere to frequency plan?
9. How often was the outcome unknown because the patient did not return to complete visits?

I believe these are enough questions to begin a review.  Pull the last 50 to 100 persons discharged from your clinic and be sure you gather standard demographic information (gender, age) along with the primary diagnosis code (there is no magical number, however the greater the sampling, the more data to base future decisions).

Share information with staff and discuss the impact of your findings on developing frequency. Are there any patterns given a specific diagnosis. Can staff use this information to improve realistic frequency plans? Can you help provide patients with expected outcomes based on their behavior/adherence to the plan?
Let us know how your discussions went!

What is the Next Model of Rehab Care? Read that blog from Darlene to find out!

As skilled professionals, our unique training and experiences should lead us to success in what percent of the population we serve?  Do you know your past performance? This might be a start in developing future success.  Know your performance outcomes and continuously work toward improving those measurements.

The route we take is often riddled with many unknowns, yet we overlook the fact that specific answers and lessons in taking the most direct route are within our reach.  Have we done the research or homework to develop the best route and have we created the plan to truly meet the ideal with the straightest most direct plan available?

What are the signs, roadblocks and directions to lead us in the future?  In the era of GPS, conditionally the answers should be at our fingertips.

Lets start with a few questions.

- What is the highest volume condition treated within your clinic?
- What are the most significant symptoms specific to that problem?
- What was the functional goal measurement to determine success in meeting the plan?
- What skilled treatments were provided in the plan?
- What was the established frequency in the plan for that condition?
- What was the provided frequency?
- Was the stated goal met?
- How many treatments occurred to meet the stated goal?
- What were the total charges toward meeting the stated goal?

Almost all answers lie within the data held within charting.   Let me ask again, what percent of the population had success in meeting the stated goal within your population?

At this time in healthcare reform, if your clinic is not already aggregating data like the above, now more than ever, these questions need answers because quality will be measured by outcomes and costs to achieving those outcomes.  It will be one of the most potent ways of reducing healthcare costs.  Provide only what is needed in the amounts required to be successful.  Anything more is wasteful.

More often than not, similar problems will hold similar plans of care to meet successful outcomes. Someone other than our professional skill sets should not dictate the best plan,  but  it will happen soon.  Guidelines for payment often change practice; scrutiny is only just beginning.  As professionals we need to know how successful we are in meeting stated objectives and we need to stand behind the outcomes those decisions and unique skill sets have created within our clinics.

Which route will you take?

Read how MediLink’s Outpatient Rehabilitation Software Solution to see how we help improve your facility’s plan of care.

A percent classification system is an arbitrary definition of status. Do facilities capable of caring for patients needing rehabilitation need to waste time defending status of a specific type of disability if  the real impairment is inability to return to the community shared by all? If a patient cannot go home after an inpatient acute stay (IPPS), regardless of the condition, shouldn’t  the patient have access to rehabilitation specialty care?  What are the important statistics?  I feel outcomes in the face of adversity are the numbers to watch AND REWARD! 

Given IRF/IRUs  present reimbursement is leveled around a 1.0 case mix index; and given those numbers are correlated now to an average length of stay, we have some historical benchmarks.  We should develop an effectiveness and efficiency ratio for each rehabilitation provider.   Make that NUMBER the number to watch and be rewarded to maintain status as an inpatient rehabilitation provider.  These are the numbers that distinguish the good from the great.   Allow the efficiency ratio to define market basket increase or decrease.   Take into consideration the total percent of population treated in hard to return home conditions such as SCI, TBI and high level CVA so that those hard to treat conditions are weighted even greater for successes in return to community.  Reward those providers that do not shy away from the toughest conditions. Include in the ratio a reduction if patients return to acute within 30 days.  Reductions should be shared by a specific percent for all inpatient providers of care; not just the acute hospital.  This is a more tangible definition of  ”accountable care” and improved access.

If we made the numbers to watch acuity and percent discharge to home;  the focus is now on outcomes and not arbitrary access.  Any diagnosis that cannot return home because of medical and functional impairment will be given an equal chance to access care with the right motivation and intentions – to get home expeditiously.  Given those conditions, the better facilities get greater compensation. Everyone strives to be best!  Stop wasting time; work toward the appropriate resources to get the desired results and reimburse based on those results given the level of acuity presented.

A percent admission based on a diagnosis and not the resultant impairment does not align with World Health Organization initiatives. Let’s change it!  The only question is can the patient return to the community, yes or no?  If no, determine resource needs, weight payment and bonus expeditious long standing outcomes.  Is it pay for performance?  Absolutely.

Percent compliant admissions that define a level of care is discriminatory to any patient that cannot return home based on their functional capability.  Impairment rather than diagnosis is the defining factor.   Returning to a 75% rule is NOT the answer to deficit reduction when impairment will not allow a patient to go home.   Rewarding quick access and payment commensurate to outcomes based on acuity is the answer and fits more closely with Medicare’s newest focus.

Write your congressional leaders and tell them why percentage access rules are incomprehensible to individual rights. After all, someday it could be themselves or a relative they vote access discrimination upon.  IRFs/IRUs cannot and should not return to a 75% rule to justify existence as a specialty rehab provider.  Outcomes given acuity should be  the marker.  Educate and lead leaders.  Be a voice for your patients.  Let’s think out-of the 75% rehab rule box.

This is not so for rehabilitation.  In contrast, rehabilitation is a word that is used quite extensively for many venues of care from drug rehabilitation to the housing market!  There is a distinct difference for physical rehabilitation and the various levels of care associated with post acute care rehabilitation. Post acute care rehabilitation is predominantly focused on the medical and functional needs of the individual and the level and percent of management between medical and functional seems to hold the key to what determines reasonable and necessary.   The resources to maintain vigilance of care and how rapidly the resources can be provided will help accelerate a preferred community discharge.

If regulations presently practiced were placed on hold, long enough to allow medical professionals the time to create the decision tree for moving a patient along the continuum of recovery without barriers and with shared and continued management at the intensity specifically required for the patient; it is likely that inpatient can be represented as a continuum, and not partitioned venues of LTCH, IRF and SNF as it is today.

If this is an immensely scary statement (because you are one of so many companies that now operate as a total definition of one level of the post acute care service line) you should look at the potential rather than challenges you could face.  Regulations could incorporate levels – patient access to the RIGHT level of care required by the individual.   Can every site now operating as a post acute care single model define service minimum, medium and extensive medical oversight that enables management of all levels within their setting?   Can every model have similar characteristics and scoring tools that rely on the same definitions so that the entire episode of care is captured and comparative?   Medicare believes so and whether that is done through an accountable care organization (ACO), a continuing care hospital (CCH) or the CARE Tool assessment schematic,  the most important factor is that a patient’s recovery is dependent upon internal and external resource ability. Furthermore, every patient has the right to return to the community at the pace most advantageous to them and not respective of a  front end matching process that is too prescriptive. Read how one rehab hospital increased revenue by $1000 per patient thanks to a new scoring process.

A patient could enter the post acute setting, be appropriately assessed by clinicians familiar to set post acute plans of care at the right level and then the patient is moved as quickly as tolerated each day. What’s important is keeping the patient engaged all day, appropriate to their required discharge expectations without regard to arbitrary three hour rules, or patterns of intensity now prescribed by skilled.   Be ready to do one thing – focus on the barriers as a team with the resources you have available to expedite discharge and appropriately meet the patients able and desired engagement potential. For the sake of the patient add more points of access for every level of post acute rehab.

Single point access to all post acute care venues pushes the outcome as being the defining marker.  Reward those that provide the greatest outcomes for comparative resource requirements based on patient acuity.  I worked in a facility that had rehab and skilled within the same location (different units), and despite our gut feelings of where a patient might succeed best, we were limited by the regulations that defined conditional process rather than flexibility appropriate to a patients day to day needs.

We should embrace a post acute rehabilitation model of care whose sole focus is meeting barriers to discharge, and measuring success daily toward functional progress in meeting the defined requirements.  Post acute rehabilitation should stop wasting time counting prescriptive therapy minutes so that continuous rehabilitative practices by all who touch the patient becomes key in training the success needed to get the patient home.  Yes, 24/7 the patient deserves rehabilitative type care and it doesn’t require a level of care label. It means continuous advancement of a patients self re-engagement of their own care as they themselves can absorb it with one goal in mind – HOME.   

Although the phone update on quality outcomes in November was informational, it left more questions than answers for those of us that help guide practice in IRF/IRUs.   The ability to provide feedback and ask for clarification following Open Door Forums has been most helpful.  After the educational session in November, and after reviewing the various reports and capabilities present within the National Health Safety Network, I emailed a response and wrote a blog. It questioned if the intent of the newly established requirements were met if in fact inpatient rehabilitation units could not specifically compare themselves to other certified facilities and instead were meshed into comparison with specialty care areas or inpatient “rehabilitation predominant” wards within acute care hospitals.

I asked for your feedback to the Centers for Disease Control and Prevention and received a speedy response for discussion on the topic.  Our request was immediately considered, and as a result, the National Health Safety Network website has posted this anticipated response:

Therefore, facilities MUST wait until after January to enroll in NHSN so that certified IRF/IRUs can be identified uniquely within the reporting system.  This is excellent news because in retrospect there are a limited number of facilities that have participated in providing data in the past who have blazed the trail for quality outcomes and that data will be migrated and pulled out of  acute care reporting fields.  Baseline data is already there!

Our leap to enhancing patient outcomes is just around the corner.  We anticipate an update and final release of the IRF PAI reporting tool that specifies wound reporting criteria to be uploaded to CMS as well.  Stay tuned!  It won’t be long now and we can all finalize what needs to be done to be up and running by October.

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Yet, every day when witnessing the path from admit to discharge by a patient in rehabilitation, I don’t often see evidence of this straight and narrow approach.  The interdisciplinary team may not have the exact requirements for discharge fully identified; making it hard for every caregiver to reach that specific level to enable a successful discharge in a timely direct fashion.  Reaching the discharge goals as quickly as possible requires the entire team to be focused on the straight line.

Sure, staff complete evaluations that define impairments and resource gaps.   Each patient has their own subset of impairment and their own subset of available resources.  Clinicians provide evaluations to identify the various impairments/conditions.  These evaluations provide information on functional capability and limitations, along with ability to provide self care against expected capability in their own environment at discharge.  Then through experience and knowledge, clinicians create individual plans to attain a specific functional level.   The team conference should substantiate those individual goals and work toward the interdisciplinary goal statements.

As patient learning is achieved, it must be exercised by the interdisciplinary team to create meaningful carryover at all times in a normal day-to-day fashion.   There should be enough overlap to enable the patient sufficient practice to feel competent and safe once discharged.  It’s expected 24/7 for an IRF/IRU rehabilitation level of care.

In retrospect, these outline to some degree what the World Health Organization defines in an International Classification of Function. A  model view and explanation is available in a beginner’s guide on its website.

The rehabilitation that our plans of care must address is the connection to the specific type of impairment (health condition or contextual factor), that enables the patient to return home given the resources available to them.  The quickest path to meeting the requirement is knowing the discharge expectation so that every encounter of the interdisciplinary team is addressed collaboratively for discharge.  This creates the straight line; a common discharge expectation.

Given the level of function that can be handled upon discharge by the patient or caregiver,  the plans of care must all be designed in the specific disciplines to support attainment of that criteria.

It means that continuous practice, experience and coordination of care must build on each others’ successes so that the strength of the patient and eventual caregivers, if required, are all capable of meeting the participation level expected.

The line should be as straight as possible so that effective, efficient and focused care is provided.  Although highly individualized to meet specific resource capability, the straight and narrow should always point toward the discharge expectation.

When the expected level of one area is achieved, time and resources should point to the areas most resistant so everyone is focused on improving those items through supported practice.  To do this, it must be apparent on the progress that has been made and which areas lag behind.  It must always be referencing present status to expected outcome – always keeping the entire team on the straight line toward discharge.  Shortest distance is important; the value of care will be defined by meeting objectives in the least costly manner.  Adopting these expectations provides an efficient model to meet those expectations.

H.R. 3630 is one such amendment.  Therapy caps which were dealt with in H.R. 1546 have been rolled up into H.R. 3630 “Temporary Payroll Tax Cut Continuation Act of 2011″.  It is defined as: “A bill to extend the payroll tax holiday, unemployment compensation, Medicare physician payment, provide for the consideration of the Keystone XL pipeline, and “FOR OTHER PURPOSES“, as stated by www.govtrack.us.   Medicare physician payment and other purposes is where you will want to pay attention.   These other purposes were listed under Title III of H.R. 3630 and they significantly impact outpatient rehabilitation, therefore it’s time to take notice!

This amendment held in deadlock as a political gesture was more than just about payroll taxes.  It temporarily held physician sustainable growth rate (S.G.R.) from a 27.4 percent payment cut and kept the exceptions process for Medicare therapy caps extended, both which would have occurred Jan. 1, 2012.   This is a temporary win for those paid under the physician fee schedule and affected by therapy caps; keeping in mind that as of 2012 this would also include hospital practices which it had not previously affected.

Below are the two sections of H.R. 3630 concerning outpatient therapy:

“Temporary Payroll Tax Cut Continuation Act of 2011”

TITLE III—TEMPORARY EXTENSION OF HEALTH PROVISIONS

Sec.301.Medicare physician payment update.

Sec.304.Extension of exceptions process for Medicare therapy caps.

Even though in a leap year we will have an extra day added to February, time passes quickly.   If either of these items will adversely affect your ability to care for patients and meet projected budgets established at this time; find out HOW you can voice your concerns and push the House and Senate to acting more responsibly.   H.R. 3630 may morph into another unrecognizable number housed in Washington.  Provide your feedback before another countdown begins!

It is very confusing to review a daily rate and predispose a correlation or that one is less expensive than another without reviewing a full episode of care in each venue and its outcomes.  What is the cost-based on the start and finish of that level of care?  When doing so, it’s easier to determine one factor of comparison (cost of care).  To determine what level of care is most appropriate for the patient, generally speaking, how long will it take to meet the expected outcome should also be considered.   If you hear a blanket statement that skilled is less expensive than inpatient rehabilitation or an IRF level of care, you must consider the cost of the episode of care and its outcomes.   For Medicare, the payment is an all-inclusive episode of care payment rather than a daily paid rate for IRF.  A nursing homes daily rate and length of time to complete a care plan must be considered before one can truly determine which level costs more.  A full episode of care paid by a daily rate dependent on the resource utilization group (RUG), may out cost an IRF stay.

The other factor that must be reviewed is the cost of the outcomes achieved.   What is the better value?   One might defend a slightly higher cost if the outcomes are more desirable for the long term.

Don’t be complacent; if you hear comments that may not align with reality, take the opportunity to educate.  Value is the next great expectation in health care and blanket statements of one level being more cost-effective over others specifically by third party payers requires education.  Education only we can provide.  Take note that in the 2012 Skilled regulations,  page 14 of 77 (first column), CMS took the time to dispel a blanket statement myth on which level is more costly?

CMS stated,

”We do, however, intend to conduct additional research to update these findings with more recent data. Any changes in utilization patters, length of stay, and/or care outcomes will be addressed during future rule-making.”

Currently there are up to $1 billion that will be rewarded through a Health Care Innovation Challenge to test creative ways to deliver high quality medical care and save money.   How creative can you be in demonstrating value and worth?  Future rule-making must be guided by outcomes driven with data.

CMS  provided attendees to the open door forum with an email address to ask questions as they always do after educational sessions. When I emailed my question, I received an immediate response.  Colleagues and I from MediServe were able to speak with representatives from CMS, the Centers for Disease Control and Prevention and RTI in an informative call this past week to discuss the ability to aggregate data specific to certified facilities and units.   They were happy to report that by late January or early February,  there will be updates written that will address our concerns. In those updates we’ll learn of new “location” categories that will be published specific to certified facilities/units.  In addition, certified hospitals/units that have sent their data into the National Health Safety Network (approximately 20)  should be able to have their data migrated over to the newer location designations once they are created.   These new insights are incredibly helpful and important as IRFs/units begin to compare outcomes.

As we move rapidly toward changes in regulations, it is important to ask questions.  Questions lead to improved insight toward industry needs.  Don’t be shy, I learned CMS and the CDC wholeheartedly appreciate questions and constructive criticism; by addressing our needs, expectations will become clearer as we near closer to 2012 reporting.

Whether we like to believe it or not, we as a continuum of health care need to be more mindful of the entire flow of care available to a patient.  If  for one moment we believe that our niche is the most important niche, it’s time to face reality.  I encourage everyone to  follow this link,  GovTrack.us.  Become familiar with health care issues and discuss them often with your state representatives.  They are OUR VOICES in Washington.  This particular item needs attention before they recess in 2011!

I found out that  my particular representative in Ohio is already a sponsor of H.R. 1546.  I wanted to thank him and educate him on the importance of supporting rehabilitation issues like this one.  Outpatient access is important because inpatient timelines are critically short.  If you are a facility, CAPS have probably not meant much to you. But there are patients that hospitals discharge who cannot access their post acute care at a hospital and must rely on services outside that umbrella.  Our advocacy must always be about the patient.  This is an excerpt of the letter I sent to my state representative:

“I was reviewing bill sponsorship and noticed that you are a co-sponsor for The Medicare Access to Rehabilitation Services Act of 2011 (H.R. 1546).  I wanted to take a moment to thank you for protecting access to your constituents.   Too often, the press provides detailed progress on improvements for persons like U.S. Rep. Gabrielle Giffords,  yet there are so many more without her status that are affected by similar circumstances or unfortunate health problems that do not get the time nor attention they deserve to return to productive lifestyles.”

As an education moment,  the government publishes each year a health insurance prospective payment system code (HIPPS) for persons receiving inpatient rehabilitation at a certified rehab facility/unit. In the 2012 IRF regulations,  the HIPPS code B0207, which is the highest acuity (2.70) for traumatic brain injury, provides, on average, a 35 day inpatient rehabilitation stay.  Had Congresswoman Giffords been a Medicare recipient,  the facility would have been hard pressed to perform the outcomes they did for that type of brain injury in so few ‘average’ days. Last years regulations were 37 days in the published HIPPS average lenth of stay.

Although H.R. 1546 is NOT about inpatient stays,  and is geared for outpatient,  it is clear to see that the recovery of persons permitted so few days on inpatient rehabilitation rely heavily on the outpatient continuum of our professions (PT, OT and Speech Language) to produce desired results for your constituents.  The CAPS process must be halted and the plan of care must demonstrate results and outcomes as the focus for payment.  I presume DOTPA (Developing Outpatient Therapy Payment Alternatives) will hold some promise for the future of outpatient services payment modeling.  That CMS sponsored study is just gearing up.   I strongly encourage you to share this story and support the rehabilitation professions so that we can take arbitrary caps away to bring focus on appropriate care and outcomes driven performance.”

Please visit the link to H.R. 1546.  See if your state representative is on board with preserving access to rehabilitation.  Either way, comment so that our representatives continue to hear our voices on legislative issues.   Going to the polls is powerful, but once a person is seated it is as important to influence actions in ways you wish for them to act.  Start NOW!

Because there seems to be such focus and interest in knowing what is the correct time, I asked this question of Susanne Seagrave, Inpatient Rehab Team Lead, CMS/CMM/CCPG/Div., of Institutional Post Acute Care recently while attending her discussion on “CMS Update on Coverage Criteria for IRF’s and IRF Current Policy and New Initiatives”, AMRPA Conference, Miami, FL.,  Sept. 28, 2011.

Susanne informed all that the intent of the the admission definition was to capture the time the patient arrived on the unit and was expected to be cared for by the IRF staff. That time should be reflected in the documentation and it is NOT the time necessarily that a physician writes the order unless the patient arrives and orders are written simultaneously.

I think most facilities agree that there are generally standing orders and transfer orders that initiate the on-site plan of treatment. Often physicians will provide verbal clarification of those admission orders and sign off in person within a time frame acceptable to the policies of the facility.

These types of influences in tracking the time admit orders are authenticated would make it difficult to count both the 48 hour preadmission assessment concurrence and approval of admission and the 24 hour H&P and post admission evaluation paper work completion. It is not difficult however to observe the patient enter the unit and track the actual time of arrival so that the electronic system of record accurately portrays the time the IRF accepts responsibility for the care of the patient.

If this is a time you doubt in your system, it is worth validating process and practices to be sure the time of record is as closely accurate to the time of arrival as possible. Sloppy practice of data entry hours after a patient arrives may have unintended consequences; although it was confirmed again by Susanne that technical denials is not the focus of this stringent time frame. On the contrary, it is specifically to have the most current information available both prior and just after admission (physical appearance to the unit) so that the patient receives the quickest physician led plan of care that leads to discharge and goal attainment success.

Therapy provided in PAC is demanding further attention.  As health care transformation evolves, it is more evident that keeping persons out of facilities and managing their own health will grow ever more popular to meet specific recovery to maintain function.  Whether services were provided in outpatient or other post acute care settings, predominantly four health care procedural terminology codes (therapeutic exercises,  manual therapy, therapeutic activities  and neuro-muscular re-education) dominated the top services provided as noted in a study by RTI International, Therapy Utilization Report completed in 2007.

Taking into account that Medicare Beneficiaries are expected to climb at an alarming rate from 39 million to 79 million between 2000 and 2030 according to a Kaiser Family Foundation Fact Sheet, finding payment alternatives, types of services, and most effective procedures for various health care ailments must occur rapidly!  Analyzing effectiveness and costs naturally fall in line.

Health care professionals more than ever must increase awareness of the effectiveness and the costs of care provided so that redundant non-effective treatment is written out of practice and only the most advantageous types of care are retained.  It’s a difficult task because procedural terminology defines a broad spectrum of therapeutic interventions. And no matter where practiced in the various PAC settings;  top use of procedural codes concentrated to four to five major areas without clear definition of exactly what technique is practiced when dropping those codes is alarming.  It demands more discrete data aggregation and few providers are gathering the type of data needed.

The various studies that RTI and Medicare have recently embarked upon (C.A.R.E. TOOL and DOTPA) are two studies that hope to increase awareness and further guide direction for payment and level of services required for PAC.

Outpatient services alone for Medicare Part B covered individuals equated to approximately 3.5% of Medicare spending in 2007, with costs at $4.37 billion for more than 140 million claims filed that calendar year per RTI International.  With those types of costs and expected growth, those that direct and manage therapy services should turn greater attention to quality of care and accomplishing goal objectives in the most cost-effective manner.  Why? Because fee for service is a term quickly being abandoned in payment methodologies with pay for performance and prospective payment mounting ever more rapidly.

If not, this blog is for you.

I listened in on the Open Door Forum to hear more specifically about how CAUTI and wound quality reporting would be rolled out for 2012 so that as a documentation company, capable of extracting discrete data elements, we could roll out the necessary solutions for our clients to gather data electronically rather than by manual abstraction of the necessary elements.

I believed that in listening to this call I could have many questions answered as we begin NEW abilities to monitor and share patient safety data specific to facility types by location as mandated by the Affordable Care Act Section 3004 (b) and the Quality Reporting Program for IRF.

What I heard were messages that appeared to mix criteria as posted by NHSN. I heard that IRF’s would be required to report CAUTI; broken down by adult and pediatric whenever the unit population was a minimum of 80 percent rehabilitation. This statement confused me, because rehabilitation facilities/units have 100 percent of the population admitted for rehabilitation. Where did 80 percent come into play? I went directly to the NHSN website to see if I could get further clarification and I found this table:

The NHSN table shows reporting criteria for acute care hospitals that will begin in January 2012 for CAUTI measures and those are broken down by adult and pediatric ICUs. Is it possible that the open door forum was mixing information on these two different requirements?

It is clear that inpatient rehabilitation facilities do not show this distinct separation on this table. I wrote to the email address that permitted reporting comments: LTCH-IRF-Hospice-Quality-ReportingComments@cms.hhs.gov. I advise that you do the same.

What I discovered is that long term care hospitals have their own specialty care area reporting designation, whereas rehabilitation hospitals and units do not. It appears that if we do not get a separate designation our data will be aggregated along with inpatient acute care facilities making it difficult for us to recognize information specific to IRFs; excluded exempted units designated by federal classification criteria as units and free standing facilities. Without a separate area to aggregate data, how can we compare similar populations that define the patients screened specifically for our level of care?

Why do I feel our data will be aggregated with non-licensed units? Because presently there are rehabilitation hospitals that report data to NHSN. Those facilities appear to be aggregated with all other inpatient wards displayed in the 2009 Annual Report available for viewing at the Website. That report shows that 19 facilities were classified as rehabilitation hospitals. Data is displayed within the inpatient ward section rather than in the specialty care area where you can see LTAC has the ability to report separately with their peers.

Right now, while there is still time, those facilities that are uniquely licensed as an IRF/IRU must appeal to the Web address provided for comments that our data remain discretely comparable to like facilities. At the very least licensed IRFs, who by our 2012 regulations were asked to report as IRFs need a code added that defines this unique exempted level of care within the specialty care area of NHSN report capability. A long term care hospital has that ability, and IRF/IRUs should be provided the same capability.  A NEWLY defined specialty care area for IRF/IRU is necessary so that these patients are not co-mingled with rehabilitation inpatient ward data.

This is a call to action: Email LTCH-IRF-Hospice-Quality-ReportingComments@cms.hhs.gov to voice your concern, so that as we begin to gather and compare quality data we can do so in a manner that truly reflects the unique care provided in inpatient rehabilitation. Data specific to IRF/IRU should not be combined with rehabilitation wards within acute care facilities treating no less than 80 percent rehabilitation patients. IRF level of care is NOT THE SAME.

(SEATTLE) November 11, 2010 — Milliman Care Guidelines will provide its evidence-based clinical guidelines to Centers for Medicare & Medicaid Services (CMS) healthcare review contractors through a license with Buccaneer Computer Systems and Services, Inc.”

Milliman website company description: “Parent company Milliman is among the world’s largest independent actuarial and consulting firms. Founded in Seattle in 1947 as Milliman & Robertson, the firm has more than 50 offices worldwide, and employs more than 2,400 people in healthcare, employee benefits, property and casualty insurance, life insurance and financial services consulting practices.”

Its  history and strength is actuarial driven with guidelines that provide LOS targets, utilization models, guidance for extended stay and  continued stay discharge criteria.  They note these are driven through best practice and evidence-based management articles.  However, last I checked, beneficiary reasonable and necessary decisions were legally based on Medicare manual regulations.    If you feel we have been doing a great job in post acute care to provide the needed published research that helps to support specific criteria to determine IRF versus SNF specific care and continued stay – you can stop reading and let these predictive guidelines be your marker for decision.

If you are still reading (and I hope you are), you agree there is limited best practice publications and only recently specific rules to begin tracking quality outcomes.  Take notice that per the Milliman announcement, CMS  ”Contractors will have access to Milliman Care Guidelines products spanning the continuum of care, including Ambulatory Care, Inpatient and Surgical Care, General Recovery Guidelines, Recovery Facility Care, Home Care and Behavioral Health Guidelines.  They will access the guidelines using CareWebQI^® interactive software, enabling reviewers to track variances and clearly document decisions during concurrent and retrospective reviews.”   And I question, do the unique skills and interventions of an inpatient rehabilitation facility fall under “General Recovery” or “Recovery Facility”?

I am not sure what due diligence was done to align the Code of Federal Regulations and  CMS Manual mandates against each and every Milliman guideline.  So it begs to question that when Medicare administrative contractors and recovery audit contractors have access to these products, are the clinical standards close enough to published federal standards to approve or deny access and payment?  If Milliman guidelines can be used to judge  appropriateness of care and continued access with CMS approval,  everyone with Medicare provider status needs to completely understand how they will be used.  A whole host of insurance companies other than Medicare reference Milliman, therefore, to advocate for patient access and continued care it seems facilities need to know information requirements for documentation.  If you don’t agree with the standards as they relate to an IRF level of care, what can be done to provide the evidence to help update the standards?

I think we would all agree that practices must be adopted with specific expectations so that variances are appropriately managed.  Staff and processes must be supported to fulfill expectation criteria.  Those of us long in the field have had some dispute with actuarial guidelines used to inappropriately limit access to care.  The clinical picture and progress of documented care and response to care is hugely important.  The patients documented functional and clinical care and training to enable increased independence is crucial.

What can you do to be sure the patients you treat show continued response to the care provided?  Does your documentation provide information that can be used to concurrently and retrospectively stand toward Milliman specific measurements?  Can you be sure that resources provided can stand up to payment scrutiny?  If these standards are not consistent with Medicare manual guidelines, is your staff ready to recognize the differences and to dispute where appropriate?   Another level of pay for performance has been unveiled.  Were you ready?  Did you recognize that it already occurred?

Outcomes are important – swift changes are occurring!  Evidence-based clinical standards are highly dependent on evidenced-based management.  We must know our expectations and clearly be accountable toward them.   First and foremost – you also must know the standards used to guide decisions.

Finally, a search for Milliman Guidelines at the CMS website revealed no matches.  Generally I receive a Medicare Learning Network (MLN) update for significant beneficiary access and payment criteria.  Don’t you?

As discussed in a previous blog, the Code of Federal Regulations, or CFR, holds key legal guidance for conditions of participation for healthcare facilities. Inpatient Rehabilitation facilities/units (IRFs/IRUs) are no exception. Actually, they are an “exception” if you refer to the legal terminology used to describe the services and level of care for IRFs/IRUs.  Inpatient Rehabilitation was carved out in the early 1980’s, along with other types of specialty care such as Children’s Hospitals and Psychiatric care, when acute care facilities started getting paid by diagnostic related group (DRG).  Therefore, in reality, Excluded Hospitals/Units are truly exceptions.

For this reason, being an exception to standard inpatient prospective payment system (IPPS) rules, there is a special section in the law written specifically for Excluded Services.

Title 42, Volume 2, Subpart 412 of the CFR is dedicated to Excluded PPS Systems and Conditions of Participation. Therefore, rehabilitation hospitals/units paid as IRFs are guided by this section. IRFs/IRUs are a level of care also paid/covered under Hospital Benefits – Medicare Part A; services under this section have additional excluded conditions of participation, or variations from the standard Medicare IPPS conditions because they have unique requirements all to themselves. There are real reasons why specific IPPS conditions are not applicable to these levels of care and this section helps carve out those reasons.

Because IRFs/IRUs are covered under the hospital section of Medicare guidance, it’s the largest reason for confusion when deeming status organizations survey these units as they attempt to apply IPPS standards, like CORE measure review, while exempted units were still waiting for guidance in these areas. In some states, the Departments of Health and Human Services have a state law to gather and review measures at least annually. Still, those measures are specific to IPPS, leaving IRFs/IRUs further frustrated and confused.

Excluded IRF/IRU must follow Section 482 conditions of participation, except for the areas where more detailed instructions supersede the standard hospital areas, or are not applicable to an IRF level of care.  Regulations in 482 alone do not govern IRF hospitals/units. You must consider the subpart specialty section of the law to be in full compliance.

Sections 412 of Title 42 cover the laws dealing specifically with excluded hospitals/units are found in Subparts A – P.   

Subpart N covers Psychiatric Hospitals/Services, Subpart O is Long Term Care Hospitals/Units and Subpart P is specific to inpatient rehabilitation hospitals and units; not to be confused with rehabilitation services also found in 482.56, which is therapy provided for hospital patients that are not in excluded specialty IRF PPS care.

Once laws are final in the CFR, CMS provides Transmittals and Change Requests to update  information in their Internet Online Manuals (IOM), these transmittals provide guidance documentation for providers, fiscal intermediaries, Medicare Administrative Contractors (MAC) and all other enforcement bodies. Becoming familiar with where to find information needed in day-to-day monitoring of expected performance is key and is often located within the many manuals provided at the CMS website.

Subpart P for rehab is translated through different manuals, such as the Medicare Benefit Policy Manual  Chapter 1, Section 110 and the Medicare Claims Processing Manual Chapter 3, Section 140. These manuals contain the laws for IRFs on oversight, admission, payment, medical necessity, quality and standards of practice, just to name a few.

Medicare payment is conditional on following published updates to code and guidance regulations. Not following published guidelines can lead to loss of approved IRF status, and or prosecution by the various fraud and abuse contractors, depending on areas of issue.

In the last week of July, 2011, the Department of Health and Human Services released the IRF PPS 2012 Final Rule through the Code of Federal Regulations. Most areas of the rule will go into effect on October 1, 2011 for the 2012 fiscal year. I recommend you create “favorite” links to these areas of the internet as many items often debated have clear definitions among these referenced areas.

Although clinicians scoring the PAI should have thorough knowledge of the rules within the manual,  I will often review data and quickly identify the areas persons are unfamiliar with; such as when it’s permissible to score a zero at admission and discharge. What’s the difference between not observing an area (deserving no assessment), versus committing to the answer “does not occur,” which is a Medicare definition that has specific meaning when applied.

Another example is the use of coding professionals to assist with coding the PAI. The PAI manual encourages collaboration and validation with a coding expert. However, it’s necessary for that coding expert to apply the PAI manual criteria when completing the PAI and then standard coding practices when completing the Universal Bill.  It is allowable for a certain level of disconnect between these two documents – but often, those are not exercised because there is not a strong clinician validating and assimilating the information placed on the PAI.

The PAI is the historical validation of the types of patients we treat in an IRF. This information is aggregated to direct present burden of care cost allocation and further practice guidelines, rules and regulations. It’s very important!  The baseline of the document guides the direction of care provided to each patient as a plan of care and what areas need tackling so an individual has the ability to relearn function sufficiently to match caregiver abilities with the hopes of returning to the community.

If it was you, or a family member, you would want an accurate record of change. The information provided in the PAI is as critical as the care provided;  it is part of the medical record and should accurately describe the baseline and improvements made.

Therefore, in regards to who must have responsibility for the IRF PPS, generally, the person called the IRF – PAI Coordinator must meet these requirements.

This answer is found in the electronic Code of Federal Register under the section that is specific to conditions of participation for IRFs.

CFR; Title 42, Chapter IV., Subpart P 412.612 

“412.612 Coordination of the collection of patient assessment data.

(a) Responsibilities of the clinician. A clinician of an inpatient
rehabilitation facility who has participated in performing the patient
assessment must have responsibility for -

(1) The accuracy and thoroughness of the specific data recorded by that
clinician on the patient’s assessment instrument; and

(2) The accuracy of the assessment reference date inserted on the patient
assessment instrument completed under 412.610(c).

(b) Penalty for falsification. (1) Under Medicare, an individual who
knowingly and willfully  -

(i) Completes a material and false statement in a patient assessment is
subject to a civil money penalty of not more than $1,000 for each
assessment; or

(ii) Causes another individual to complete a material and false statement in
a patient assessment is subject to a civil money penalty of not more than
$5,000 for each assessment.

(2) Clinical disagreement does not constitute a material and false
statement.”

Take for instance what I read this past weekend while thumbing through the final 2012 SNF Regulations; 1351F.

About 14 pages into the 77 page document, I had seen that the government was providing empirical evidence for a statement made by someone when the proposed rule was published. The individual apparently commented that it was better to serve hip fracture patients at a skilled level of care because it saved the Medicare Trust Fund money. CMS responded:

“Finally, as one commenter highlighted, shifting IRF patients toward SNF care does not necessarily improve the quality of care provided to the beneficiaries. A March 2005 report in the Archives of Physical Medicine and Rehabilitation (available at http://
www.archives-pmr.org/article/PIIS0003999304012493/abstract) found that 81.1 percent of IRF patients were discharged to home, compared to 45.5 percent of SNF residents. Additionally, IRF patients appeared to have shorter lengths of stay, averaging approximately
a 13-day stay, compared to the average 36-day stay for a SNF resident. Finally, when patients discharged from each setting were reviewed 24 weeks after discharge, IRF patients had consistently better outcomes and displayed a faster rate of recovery. Given these findings,
we do not agree with those commenters who would assume that shifting patients from the IRF setting to a SNF setting is necessarily more beneficial to the patient or the Medicare Trust Fund. We do, however, intend to conduct additional research to update these findings with more recent data.”

To this I comment. The purpose of the pre-admission screen for inpatient rehab is to defend a level of care that meets each of the 2010 IRF coverage criteria. If you see a patient that meets those criteria and clearly has the ability to return quickly to the community given intense, multidisciplinary level of care while keeping risks at bay, defend an IRF level of care. If you feel the patient is not at great risk and will do well with perhaps just a little less intense rehabilitation and does not require continued education or training that would be provided with higher rehabilitation nursing contact time then skilled should be recommended. Nursing care coverage is defined for your area locality at the SNF Compare CMS website.

Our professional obligation is to do the right thing for each patient and to utilize their benefits in the most cost economical fashion. Value will continue to be defined as post acute care struggles to better align care levels to patients specific needs. Knowing the guidelines and using this type of information makes that job just a little easier. So for that…I’ll keep reading the regulations. I am quite happy carrying my tablet and linking in when the moment allows it.

The rule covers:

- Reduction in payment rates (table 64); looking at Clinical Labor, Supplies Expense, Equipment Expense, Direct Practice Expenses/hour, Clerical Payroll, Office Expense, Other Expense and Indirect Practice Expenses/hour for 89 geographical regions initially established in 1997.

- Continued Multiple Procedure Payment Reductions (MPPR) for always therapy procedures initiated in the 2011 rule. (Listed below which maintains the 25% reduction for facility practices and 20% for non-facility practices. Types of facilities are defined in Title 42, Section 414.22)

- Review of potentially misvalued codes which includes 3 highly used therapy codes, 97140 (manual therapy), 97112 (Neuromuscular re-education) 97001 (PT Evaluation) – seeking AMA review for update in 2012 for 2013 application.

- Additional incentive programs for a 12 month quality reporting period yielding .5% incentive payments and e-prescribing for physician practices.

In addition, CMS finalized the 2013 reporting calendar year toward payment penalty in 2015 (very similar to time frames chosen for IRF full quality reporting and penalties).

The specific therapy cap exceptions process will expire on December 31, 2011, unless Congress acts to extend it. Given an extension continues, those rates will be set at $1,880 beginning January 1st 2012 along with the other payment updates described within the blog.

The final rule announces a 27.4% cut in Medicare payments for physicians, physical therapists, and other healthcare professionals based on a flawed sustainable growth rate (SGR) formula unless Congress takes action to prevent these cuts. IF the cut does NOT go into effect, regulatory impact of the work, practice expense, and malpractice RVU’s could net physical therapy payments by a positive 4.0%. Now more than ever it is time to contact your congressional leaders to discuss adverse impact on access to care; specifically for those facilities with a high percentage of Medicare Beneficiaries.

The MPPR policy will apply in all settings where outpatient therapy services are paid under Part B. This includes services paid under PFS furnished in the office setting, institutional services paid at the PFS rates furnished by outpatient hospitals, home health agencies, comprehensive outpatient rehabilitation facilities (CORFs), and other entities that are paid under Medicare Part B for outpatient therapy services. Codes affected in MPPR are listed in addendum H of the proposed rule and are those listed here (AMA CPT coding manual).

Addendum H–CY 2011 “ALWAYS THERAPY” SERVICES SUBJECT TO THE MULTIPLE PROCEDURE PAYMENT REDUCTION * CPT Code Short Descriptor

92506 Speech/hearing evaluation
92507 Speech/hearing therapy
92508 Speech/hearing therapy
92526 Oral function therapy
92597 Oral speech device evaluation
92607 Ex for speech device Rx, 1hr
92609 Use of speech device service
96125 Cognitive test by HCPro
97001 PT evaluation
97002 PT re-evaluation
97003 OT evaluation
97004 OT re-evaluation
97012 Mechanical traction therapy
97016 Vasopneumatic device therapy
97018 Paraffin bath therapy
97022 Whirlpool therapy
97024 Diathermy (e.g. microwave)
97026 Infrared therapy
97028 Ultraviolet therapy
97032 Electrical stimulation
97033 Electric current therapy
97034 Contrast bath therapy
97035 Ultrasound therapy
97036 Hydrotherapy
97110 Therapeutic exercises
97112 Neuromuscular re-education
97113 Aquatic therapy/exercises
97116 Gait training therapy
97124 Massage therapy
97140 Manual therapy
97150 Group therapeutic procedures
97530 Therapeutic activities
97533 Sensory integration
97535 Self care mgmt training
97537 Community/work reintegration
97542 Wheelchair mgmt training
97750 Physical performance test
97755 Assistive technology assess
97760 Orthotics mgmt and training
97761 Prosthetic training
97762 C/o for orthotics/prosthetics use
G0281 Electrical stimulation unattend for press
G0283 Electrical stimulation other than wound
G0329 Electromagntic tx for ulcers

Although this highly awaited final rule was just published, it is anticipated that for therapy practices the time has come to define and defend services from a value platform. Can practices provide services that effectively meet outlined results in a timely, efficient manner? At what point payment and outcome measures will be more directly related to functional outcomes obtained in therapy practices?

Although the final rule may not apply directly to timely, efficient care it is possible that further research, like that being conducted under DOTPA (Developing Outpatient Therapy Payment Alternatives), will provide guidance for therapy payments outside of Physician Fee Schedules and may relate more to the practice and outcomes of “Always Therapy” providers.

A nurse requested information on outcomes and the ability to provide documentation to a Medicare HMO (Part C Plan) that rehabilitation vs. skilled care is most advantageous. Let me preface all this by saying every decision is individual, but that more often than what’s being advocated. Patients that have access to an inpatient rehabilitation stay are often denied because we, as professionals, do not take the time to educate and advocate when we have screened an appropriate patient and a payer does not agree.  Admissions must be ready with information, facts and outcomes so that patients can access an appropriate level of care.

In 2007, when CMS asked for input on 1551-P, prior to publishing the final rule, one of the largest responses to a proposed rule flooded CMS. The first document contains very good articles to support rehabilitation over skilled care in appropriate patients. Some of the recommendations in these documents were enacted.
Please note, when opening the links below that contain page numbers, you will need to open them in Adobe to access a corresponding page.

https://www.cms.gov/eRulemaking/downloads/CMS-1551-PPaperComments7-13.pdf  (Pages 134 to end)

Specific discussions on sufficient nursing services and outcomes comparisons start around these pages.

Pay special attention to sufficient nursing services for the patient you are trying to admit. The Medicare Compare website for SNFs can easily tell you the expected average for patients in your area, then you can discern whether the needs of the patient you are trying to admit can be handled with the care averages published.

https://www.cms.gov/eRulemaking/downloads/CMS-1551-PPaperComments3-6.pdf  (Pages 59-60, list evidence-based research)

This link may also be helpful, available at CMS.gov

https://www.cms.gov/InpatientRehabFacPPS/09_Research.asp  (Bottom of page, PDF # 2)

Most important, with a CMS Part C plan, the plan must provide the same access to care as original Medicare would. I used this process when I managed the admissions office at an IRF where I was the director of rehab.

Go to this link and familiarize yourself with what is expected of Medicare HMO products. Because they are required by contract to cover all of the services original Medicare would cover, they must also utilize 2010 guidelines when distinguishing which patients are appropriate for access to care.

http://www.medicare.gov/navigation/medicare-basics/medicare-benefits/part-c.aspx

“What Does a Medicare Advantage Plan Cover?”

In all types of Medicare Advantage Plans, you’re always covered for emergency and urgent care. Medicare Advantage Plans must cover all of the services that Original Medicare covers, except hospice care. Original medicare covers hospice care even if you’re in a Medicare Advantage Plan. Medicare Advantage Plans aren’t supplemental coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D).”

(These plans can offer more, not less than a beneficiary normally has access to.)

The route we took was to talk to the physician in charge of the plan. Send a copy of the pre-admission screening document demonstrating all of the criteria being met for rehab admission. (When I did these, we had the HCFA-85-2 ruling. Now it’s the 2010 Coverage criteria.) Given a physician signature on that document also attesting that the coverage criteria and the need for rehabilitation exists for the patient you are advocating on behalf of, Medicare HMO plans should reconsider access.Using your own outcomes for a particular population can also be very convincing. You want to be sure that your ducks are neatly in a row and that you adhere very tightly to all other criteria and timelines, or they will just as quickly play the same game and deny payment just as original Medicare would if criteria is not followed! I cannot stress that enough.

In addition, you have another recourse. All patients, before being discharged from acute care, by law must be provided the 72 hour notice when they are Medicare Beneficiaries.That notification tells them how to apply for a fast appeal regarding decisions for discharge. The patient/caregiver must then follow the instructions and state they have been notified that discharge to a rehabilitation facility has been advised and the Medicare Part C program is denying access. This is an appeal, and not a grievance. The quality organization for that area will then gather all the information. Make sure the discharge planner, or whoever is responsible for providing information to the quality organization, has a copy of the pre-admission screening along with the physician recommendation.Chances are very good that the quality organization will make a recommendation. All evidence from that interaction can then be forwarded to the Part C provider.

We must take the time to educate and provide the details necessary to provide appropriate services for our patients. Generally, patients don’t have this level of knowledge into our very complex systems – each and every one of us is responsible for advocating appropriately. This is one of my soapboxes! Pardon the length of this post.

It appears to me that it is reserved for times of absolute must and not a rule of performance. However, given the age we live in where medical records are available via internet and Web conferencing, where everyone can see and contribute to the documentation; I’m not so sure that Medicare can hold everyone to this strict interpretation for long.  There are so many viable concrete options taking hold in this age of “telemedicine.” This particular clarification will require further review very soon! We allow diagnostics, interpretation of radiologic exams and robotic surgeries that can be controlled miles away; surely team conference conducted via webinar, as long as connections are secured toward HIPAA compliance, will certainly come up for discussion soon.

These are the answers Medicare provides via the linked documents above:

23. Clarification regarding whether the rehabilitation physician can occasionally participate in the interdisciplinary team meetings by telephone.
Answer: As long as it is clearly demonstrated in the documentation in the IRF medical record that the rehabilitation physician was leading the interdisciplinary team meeting, he or she may conduct the meeting by telephone.

We understand that it may occasionally be difficult for the rehabilitation physician to be physically present in the meetings. The specific reasons that the rehabilitation physician led the
interdisciplinary team meeting by telephone rather than in person must be well-documented in the patient?s medical record at the IRF.

24. Clarification regarding the documentation of the rehabilitation physician?s participation in the interdisciplinary team conference if the rehabilitation physician led the meeting via telephone from an offsite location.

Answer: It must be clear in the documentation that the rehabilitation physician led the interdisciplinary team meeting, as required in the regulation, even if the rehabilitation physician called into the meeting by telephone. One of the participants of the interdisciplinary team meeting must document in the IRF medical record that the rehabilitation physician led the team meeting by telephone and the reasons why. The rehabilitation physician must confirm this documentation in the IRF medical record when he or she returns to the IRF. In addition, the rehabilitation physician must document concurrence with all decisions made by the interdisciplinary team at the team meeting.”

In short, becoming familiar with Title 42 increases your awareness of the legal responsibilities in leading and managing healthcare.  Title 42 of the Electronic version of the Government Printing Office provides access to  regulations.

Once regulations are made final, Medicare provides transmittals and change requests that are published into the Internet Only Online Manuals (IOM)  .  The Internet only manuals were created in 2003 as Web-based to offer day-to-day operating instructions, policies and procedures based on statutes and regulations, guidelines, models and directives. Manuals are updated when sections of the Federal Register are published and are often communicated through the use of transmittals.

Program transmittals are used to communicate new or changed policies, and/or procedures that are being incorporated into a specific Centers for Medicare & Medicaid Services (CMS) program manual. The cover page (or transmittal page) summarizes those changes.

When asked a question about health care policy – start here to find the answer!

If admissions were challenged by a Fiscal Intermediary (FI) or Medicare Administrative Contractor (MAC) for a particular patient or set of patients, hospital leaders would feel threatened. There was some unfounded belief that coverage debates could lead to loss of certification status or state licensure as an IRF.

Despite many CMS calming attempts, specifically when the 85-2 criteria was in place prior to 2010,  facilities all over the US feared their doors would be closed when a MAC questioned admission appropriateness.

All too often however, decisions were overturned with rebuttals on a large scale. IRFs defended their level of care decisions and continued to argue IRF appropriateness as a level of care through use of classification criteria and treating a population that predominantly met the 60% rule.

At that time, CMS clearly separated discussions on classification and coverage. As a matter of fact, even today on the cms.gov IRF web page, there are clear distinctions and links that discuss classification and coverage requirements.

Classification clearly is upheld by attesting annually to 60% of one’s admission population to be within the defined scope of those 13 diagnoses that generally are best served by a rehabilitation intensity.  To operate new beds or sustain beds in a survey, the survey and certification criteria worksheet would be utilized.  But because within the survey and certification documents, the coverage requirements are listed, this again brings question for confusion.  Are classification and coverage criteria one and the same?

Coverage requirements sunset the HCFA 85-2 ruling in 2010 and re-established  the 2010 guidelines as criteria that must be met to be covered or paid at a rehabilitation level of care.  Not meeting these guidelines will certainly create non-payment for a particular patient.

On page 47872 of the final 2012 Rule Vol. 76, the final regulation talks about enhancing consistency in the enforcement of coverage and classification criteria.  This being said, there is likely argument that classification and coverage requirements should be similar.  Made more clear however is that although one or “several” patients may fall short of having coverage criteria completed (such as pre-admission screening and physician oversight), it will be reviewed as to whether there are processes in place to meet the requirements overall.  Stating further, if a large percent of coverage criteria are not adequately followed, presumably the classification as an IRF can be challenged.

Given these discussions and intentions, it is imperative that leadership tightly review and manage the expectations surrounding coverage of an IRF.  If physicians are not agreeable to the mandates and timelines so clearly defined for coverage, such that large percentages can be found out of compliance; beware that your certification as an IRF can be challenged and all staff may not be working for an IRF much longer – your viability is at stake.

Fairly early in the 80-page report, attention is centered toward the costs of post acute care, stating that  expenditures (and services) have dramatically increased to SNFs, LTCHs and IRFs and that payments are in excess of the costs of providing high quality and efficient care, thereby placing a drain on Medicare.

Oddly, it is not stated that it’s Medicare that has developed the policies in line with cost reporting and budget neutral policies in their quest for PPS systems that set these payments;  but for now we’ll look past that.

Within this plan, “The Administration supports the policies that will save $42 billion over 10 years and improve the quality of care.”

This is followed by four specific post acute care items and the savings in theory they could provide.

-  Adjust payments for certain post acute care providers (no detail) other than to hold payment adjustments rates from 2014 through 2021. Normally adjustments are made annually.  This is the highest chunk of proposed savings at $32 billion.

-  Equalize payments for certain conditions treated at IRFs and SNFs, such as hip and knee replacements, hip fractures and certain pulmonary diseases. Saying this should begin in 2013 and pronouncing that costs are significantly greater now when treated in an IRF. No evidence provided that the payment models are quite different and a capped payment for shorter stays may actually outweigh benefits against daily payments for an extended stay. But at least they are “encouraging care in the clinically most appropriate setting,” saving $4 billion over 10 years.

-  Encourage appropriate use of inpatient rehabilitation hospitals. This proposal recommends returning to the 75% rule that was in effect in 1984. Again, leaving out facts that conditions to gain access were made more strict and therefore adjustments were made to enable access.  Do you think this will include going back to the 1984 conditions of participation to include the Rehab 10 diagnoses rather than the newer Rehab 13? After all, if they don’t, the argument just made in bullet two of treating patients in the most clinically appropriate setting goes out the window. The Medicare & Medicaid SCHIP Extension Act of 2007 that permanently lowered the threshold to 60% will require modification of course.  This by the way is proposed to save $3 billion over 10 years.

-  Adjust SNF payments to reduce hospital readmissions. Stating 14% of patients discharged from SNF return to acute for conditions that could have been avoided.  Those adjustments are proposed to save $2 billion over 10 years.

I personally have only peeked at this portion of the plan so far, but I strongly encourage all to read it from front to back and to direct their attention toward providing facts, figures and discussion on Living Within Our Means and Investing in the Future.  If not,  your future and growth as initially stated could be stunted.

Medicare is announcing Advantage Plan early open enrollment for beneficiaries this year and that overall prices are down 4%  with an expected increase of 10% enrollment.   In addition, persons will receive greater benefits (wellness visits) and cheaper prescription plans! More for less … how novel! Why is this newsworthy? Because many private companies don’t seem to share that same excitement and many employer plans being told premiums are rising, not falling and that we should beware as costs can creep up more than 10 % annually.  I am sure these plans use the same health care facilities.  Why the disconnect?

How can Advantage Plans with persons predominantly aged make such bold advances when plans of mixed populations are less apt to do so?  Fiscal responsibility and holding costs low is just beginning to rear debate! But wait, there’s more.

Just like all other insurance plans, for Medicare, there is an open enrollment time frame. Often strict rules govern when you can move in and out of those plans. Yet, as stated in this release, “For the first time in 2012, CMS will provide financial rewards to those Medicare Advantage plans with high quality scores, under its Five-Star rating methodology. CMS is also allowing Five-Star Medicare Advantage and Part D plans to continuously market and enroll beneficiaries throughout the year as an extra incentive for high quality performance.”

Medicare is adding information to the Five-Star rating to further define recommended plans by adding a gold star icon to high performing plans. Ratings are in step with a digital society. Businesses now bank on the ability to gain favor and followers through ratings; just look at the number of businesses asking you to follow them on Facebook, Twitter and the like. Your service and outcomes must rate top end, in this case Five-Star to gain extra privileges and improved access. It is the future.

The freight train has left the station and the message is to get on board.  Lead, manage or retire – it’s pretty simple. There will be less room for under performers in healthcare staring now.

Medicare is giving rewards, incentives and non-traditional exceptions to rules when quality is accomplished. Effectiveness and efficiency are proven value outcomes both clinically and financially, this announcement is another mounting example of the benefits that will come with those traits. It’s a win for Medicare when they can move covered lives to plans that hold the risk.  How much pressure will those plans place on facilities like yours to deliver quality? Lots!

More than ever before, hospitals will have to become lean process managers of time, resources and outcomes; defending value to gain share in volumes or get written out of the preferred rating altogether. Are you able to demonstrate through discrete data elements that your patients get great quality and outcomes for comparable or less costs?

If you haven’t thought of how you will capture, report, and continuously improve the outcomes you provide, you might want to start because pretty soon it won’t be an option. Get on board! Data is your future.

Many values become a portion of how IRFs are paid, the facility adjusters create some of the largest differences in payment of case rates. One area of facility adjusters is the Market Basket value. Market Basket is a value that is influenced by many factors and one that relies on inputs from cost reports, benchmark I&O data and various industry calculations.

Stated in the 2012 regulations for IRFs is the following:

"Section 1886(j)(3)(C) of the Act requires the Secretary to establish an increase
factor that reflects changes over time in the prices of an appropriate mix of goods and
services included in the covered IRF services, which is referred to as a market basket
index. According to section 1886(j)(3)(A)(i) of the Act, the increase factor shall be used
to update the IRF Federal prospective payment rates for each FY."

The last full year of cost reports (2008),  used to review the future market basket re-basing (from 2002) and increase values has hit a SNAFU in an attempt to provide free standing and unit based IRFs a unique set of values.  Presently, the Market Basket reflects RPL which is a rolled up value for rehabilitation, psychiatric and long term care markets.

Somewhere in all the data,  it was proposed there could be a formula or mechanism to easily discern whether a free standing rehabilitation hospital and a unit within a hospital could/should have distinct and separate calculations.  2010 regulations stated they would re-review the concept in 2011.  Unfortunately, when cost reports were evaluated between provider types,  cost levels and comparability were less than optimal and there was not enough time to understand the differences to make a separate market basket specific to rehabilitation. Upon further review, CMS will add additional cost report instructions and forms specific to staffing and benefits (one of the largest costs for all hospitals) to gather more granular data for future decision making.

The next attempt may be to provide an RP value for rehabilitation and psychiatric facilities, leaving LTACH their own model for market basket. Although it’s too early to tell, one thing is for certain, it will be important to closely monitor cost report data as future reductions (non-participation in quality indicator reporting) and or incentives will be placed into that value to determine payment — a payment that will remain in effect for one full fiscal year.

New bed confusion?

-  Regulations treat new and existing beds differently when increasing bed size. Many facilities that had operated IRF beds at some time in the past were confused about whether or not reopening beds would be considered “new.” In the 2012 regulations, a time limit of five years has been established for whether to treat beds as new. Even if operated previously by the same hospital, but kept out of circulation for more than five years, the facility must start over.  However, if it is less than five years, notify the CMS Regional Office (RO) within a 30 day period, follow all other classification and coverage criteria and bed capacity can be increased.

-  Bed changes can occur only one time per cost reporting period. Again, notify the RO within a 30 day period.

-  Keep in mind that when bed sizes are changed, the 60% rule is in effect as a new overall percentage, based on the day of opening and applies for the rest of that fiscal year.

-  States having a Certificate of Need (CON) law must follow state laws for adding beds as well as approval through the CMS RO.

-  Change of ownership requires application for certification of beds

The rule states that if beds were de-licensed or de-certified it will require written RO approval and a twelve (12) month cost report lapse to add beds into service.

With today’s mergers, acquisitions and needs to adopt quickly,  the regulation strangled ability to provide service in a timely manner. CMS hopes these changes improve access and reduce prolonged uncertain processes previously enforced.

Changes in square footage for IRF usage has also changed since allocation of capital costs were not relevant for individual payment methods. Square footage change requires a written RO approval with 30 day notification.

IRF unit acquisitions were not dealt with in this rule since Medicare stated payment status could not be bought, sold or transferred and therefore, requiring application for Medicare status.

It states the rule takes effect October 1st, 2011.  It is very possible this opens an entirely new possibility for someone reading this post right now!

Since we were asked by more than one client, we decided to ask the CMS Help desk if there was a change for the assessment data gathered at discharge.

On July 6, 2011, the CMS  Help Desk responded, “The IRF PAI Training Manual, version last updated in 2004, provides the most recent guidance to the discharge assessment time frame.” Further,  Susanne Seagrave, Ph.D, of CMS, stated, “The policy referred to in the question has not changed.  IRFs must continue to follow the guidance provided in the manual on this issue.”

When discharges are planned,  we have seen facilities incorporate a “performance” or “graduation” day, encouraging patients and staff to re-validate functional capabilities.  By specifying an exact day, it guarantees that all staff are challenging the patient to perform before assisting too eagerly, thereby providing the most valid score the patient is capable of performing. This improves success in providing sufficient information in a contiguous 24 hour period in the discharge window for all areas of assessment.  This celebration and re-validation provides the IRF PAI coordinator a full set of data to draw the values needed to upload to the PAI.

DOTPA was authorized by section 545 of the Benefits Improvement and Protection Act (BIPA) of 2000.  This rule requires the Secretary of the Department of Health and Human Services to report on the development of standardized assessment instruments that could be used as alternatives for post acute care services, including outpatient therapy practices as we know them today.

Section 545: Development of Patient Assessment Instruments.

This position requires the Secretary to submit to Congress a report on the development of standard instruments for the assessment of the health and functional status of patients who are furnished the following services: inpatient and outpatient hospital services; inpatient and outpatient rehabilitation services; covered SNF services; home health services; physical or occupational therapy or speech-language pathology services; items or services furnished to beneficiaries with ESRD; partial hospitalization services and other mental health services; and any other service for which payment is made that the Secretary deems appropriate.

This, along with continued developments from the 2005 Deficit Reduction Act, will shape the future of healthcare practice.  There is no escape; become familiar with how guidance will be developed, specifically for outpatient services.

Short term alternatives such as placing a CAP on utilization to a dollar amount was largely contested as an ineffective way to managing payment guidelines.  Despite guidelines on standard content required for evaluation, certification and progress summary; very little has been done to aggregate meaningful information on the dollars spent in treatment rendered by therapy practice including the overall value for those dollars spent.  Where are we most successful and is treatment effective in meeting the goals established to reduce the impairments presented for outpatient care?

RTI recently stated on their website,  ”Presently,  CMS cannot adequately assess the appropriateness of utilization patterns or the impact of changes in payment policy without access to better information tied to patient need and the effectiveness of the outpatient services provided.” RTI has established assessments that will include both patient and self-reported items.  If patients are unable to complete items, a proxy can provide the required information. According to the website, RTI is recruiting providers to participate from various types of settings that provide therapy services covered under the Medicare Part B Medicare Benefit.

These include:

- Hospital outpatient departments
- Nursing facilities (NFs)/Skilled nursing facilities (SNFs)
- Comprehensive outpatient rehabilitation facilities (CORFs)
- Outpatient rehabilitation facilities (ORFs)
- Private practices (PT, OT and SLP)

Barabara Gage of RTI recently spoke at the MediServe Annual Conference.  She shared information on opportunities for engagement at various levels of studies RTI is conducting and specifically addressed the need for 190 participants for Part B covered services studies.

RTI proposes the following breakdown for participation: 29 hospital OP departments,  29 ORF/CORF departments, 29 private practices, 29 PT/OT practices, 29 SLP practices, 45 skilled or assisted living part B providers.

RTI will develop a set of alternative payment models that could refine or replace the current method of paying per claim subject to discipline-specific caps or those not affected by caps, such as hospital based providers.   The project team will analyze the measures collected via the assessment instrument merged with claims data and provide recommendations based on the results and analyses. This process will also include assessing the feasibility of incorporating pay-for-performance aspects into payment for these services.

Development of alternative payment models may focus on case-mix classification, bundling, patient-level payment limits and pay-for-performance. It is important to note that these approaches are not independent, and alternative models could include elements of each.

Stay engaged on the progress of DOTPA by creating a link to the RTI website.

Per the PEPPER website, ”PEPPER provides hospital-specific Medicare data statistics for  discharges vulnerable to improper payments. PEPPER can support a hospital or facility’s compliance efforts by identifying where it is an outlier for these risk areas. This data can help identify both potential overpayments as well as potential underpayments.”  Look for the this icon on the PEPPER website:

When will this all occur?  September 2011, the Centers for Medicare and Medicaid Services (CMS) will make available free hospital-specific comparative data reports for IRFs nationwide. Distinct part units will receive information electronically, free standing IRFs will receive hard copy reports by FedEx addressed to their CEO/Administrator and can expect those sometime around September 22, 2011, per the email sent out by nih.gov.

When information and education are provided such as this, there is usually a follow up to the outliers that gain attention within the reports.  Sign up for the training provided at the website (enrollment is open to IRF staff only.)

Release and training are just a day apart.  Visit the website and be certain you know how to interpret your reports.  Identify areas of risk and complete a self assessment for managing change toward improvements. Self awareness and management toward change is essential to reducing risk associated with highly visible outliers.

I have been in healthcare for nearly 30 years now.  In just as much time, I have been involved in countless strategic plans on small and large scales to operationalize change and forge toward some known future growth. The unsettling part is “known future growth” could always be envisioned and measurement toward that success was obtainable and tangible.  I felt secure in knowing I could lead others toward that vision.

So what has changed? As clinicians or leaders headed into the next several years, I believe more than ever that strategic planning, dashboards for success and tight operational management will still be key to driving successful healthcare futures.  Will you really “know the future” and exactly what you’re driving to deliver?

NOT SO MUCH!!  (Borrowed from a colleague affectionately, and I hope she is smiling in eastern PA!)

There are so many possibilities ahead of us, each with less certainty than the convictions originally imagined as possible solutions to tomorrow’s pains. Only a few things are certain. We will be held accountable, but are Accountable Care  Organizations the driver? Stiff opposition says twice as much paper will be needed to sort out success for that venue. Until we are willing to give a lot more to get much less personally, but more for the greater good of the public,  we will continue to struggle with “what’s in it for me.”

Are operations as tight as they could be so that margin can still be achieved LEAN? If they were, could we be more creative for future patients and the solutions to healthcare issues at large?  To know the future will take stretches of imagination so great; and are you prepared for that long term strategic plan?  Can you envision it? Can you lead it?

We must be more efficient and effective because dollars to support healthcare are becoming more scarce and the lofty perks and “bonus packages” employers used to entice their employees with have nearly disappeared.  Even the workforce itself has taken a hit in the down turned economy.  How can we lead successful practice and sustain enough margin to prosper and grow toward tomorrows continuous expectations?   What has to happen to align the moon and stars before the big cataclysmic attack?

If I knew that answer, I would obviously be writing a book and not a blog.  The  future strategic plan and our accountability toward meeting those expectations will require continuous analytic decisions that continuously tweak day-to-day decisiveness toward a skill so precise that you will predict and guide effortlessly toward better than expected outcomes.  Why? Because we have to.  The future of healthcare depends on the unknown and forever improving long term strategic plan delivered in bursts of short term strategic objectives.

Do you answer that question after you’ve gathered demographic information and after you know who the insurer is?

I ask this because I recently stumbled upon a Huffington News Post that cited the Federal Government is about to go undercover, and will gather information, on how primary care doctors respond to these  questions.*

In the name of research, these secret shoppers will pose as new patients to gather data on the availability of primary care physicians’ willingness to accept privately insured patients over federally and state insured patients, such as Medicaid and Medicare. They will block the caller ID and will gather data on the proposed ability to access care. Is this required to see the long term effects of healthcare reform?

How does that make you feel? Do you believe federal dollars are used prudently to gather this data? Do you believe, if polled blindly, they can obtain similar results?  Do you think this can spread to hospitals, therapy practices and all other venues of patient care access? I do!

If you are a registered Medicare provider, does it make you appear as though you are “cherry picking” the best case load?

Given this type of information, should you examine how your staff would answer these questions on a blind call?  Let’s find out.

Answer YES if you  believe it is a good idea to see  how your staff would answer these questions,  and NO if you feel it isn’t a concern as to how the question is answered.

*Fox News did the initial story.

Can we be accountable to very specific interpretations of a rule and hold to those standards without question?  For the areas that are time-driven or require specific information, it seems fairly simple to figure out.  Having everyone work on the same page for “measureable improvement” is quite another story.

Section 1: 110.3 of the Medicare Benefit Policy Manual for inpatient rehabilitation practice is the final section of the 2010 IRF regulations. I realize it is 2011 and we are still discussing old news, but this last section should be read and discussed at a theoretical level with staff. It leads a harsh realism in my grasp of expectations as a therapist and in my guidance as a teacher to manage rehabilitation facility practices.

This section says what it means and will challenge healthcare reform to the fullest extent in several ways. Read Section 1:110.3  carefully!

This section challenges the basic premise of what we do every day in the value of care we provide and implores us as clinicians that our practice will generally shift from “traditional, patient-centered therapeutic services to patient/caregiver education, durable medical equipment training, and other similar therapies that prepare the patient for a safe discharge to the home or a community-based environment.”  Furthermore, the same section states that our patients are not “expected to achieve complete independence in the domain of self-care.”

The specific role of an inpatient rehabilitation facility is to resolve barriers that result in return to the community.  Therefore, from the moment of admission you must seek the specific level required to prepare a patient for safe discharge.  We tend to say “at the highest possible level of independence,” but this is not exactly what this section implores.  In contrary,  it acknowledges that as a specialty we have a specific highly specialized expectation to act as an interdisciplinary team that cannot easily be replicated (because of its interdisciplinary nature) by any other level of care to reasonably and predictably improve function in a “reasonable amount of time.”   Whoa, what does that mean?  We have guideline standards for the average length of stay for each CMG but each patient is unique so we are asked not to consider those numbers.  What?

But those are the resource allocations for what it should cost to care for this type of individual so how can I separate from the expectations those numbers suggest is my reasonable average?

It’s a tall order for my yester-year NDT perfectionist nature in building a firm and stable foundation for all other normal movement to be practiced from.  This regulatory description of “measurable improvement” has shattered my previous ideals of goal attainment as I used to define it. It’s not all about perfecting the skills but to accommodate enough skill that my patient or caregiver can manage safely, given education and devices to swiftly move onto the next appropriate (least costly) level of care.

Every burden has a price tag; expedient movement through a costly interdisciplinary model must be done more expeditiously or we’ll cost ourselves right out of the future of health care reform. Our  patients deserve better and we need to strike a balance that works towards demonstrating cost effective and efficient management of their care.

Read section 1:110.3, internalize what this final section means to you and post your thoughts/comments. How will you define “measurable improvement” and how will you be accountable in obtaining it at an IRF level of care?

If you read and interpret this section differently, please post a comment to dialogue on this topic.  We are struggling as an industry to grasp meaning on this topic.

And yet with so much information, what are the other important elements to defend a solid case of medically necessary care at an IRF?

Two things that come to my mind are the time required to fulfill the needed proposed plan of care and the time reasonably available at a SNF level of care within my immediate practice surroundings.

Given those two items, you may change how the physician “summarizes” and “concurs” with the appropriateness for admission to your IRF.

How clever would a summary statement that states,  ”based on the pre-admission screen and the information provided, medical management and clinical contact care would take no less than five hours per patient day to fulfill the plan of care established to manage this patient’s needs for both medical and functional retraining. These needs are in addition to the three hours required for therapy intensity.  Given these totals, the care specifically surpasses skilled standards that average closer to two hours of clinical contact care.” Make sure you know the standards in your state, and more specifically in your practice area as noted on the CMS Compare website.

See a detailed discussion on this topic that will make your decision to admit more audit proof HERE.