coding update

Coding UpdateLisa Bazemore, MBA, MS, CCC-SLP

February 5, 2008

Exemption CriteriaPhysician 24/7 Documentation of medical

and rehab needs. Co-morbidities need listing.

Rehab Nursing 24 hrs Comprehensive Nursing Plan of Care.

Relative Intensity Documenting endurance in the pre-admission screen and for continued stay.

Multidisciplinary Team Goal statements. Assessments done before day four post-admission.

Basics

Exemption CriteriaComprehensive Plan Justifies the admission.

Significant Progress Toward Goals

Documentation matches between chart and IRF – PAI.

75/25 rule Each patient is assessed individually.

Pre-admission screening Add in CMG prediction for long stay – heavy care patients.

Basics

Basics

Exemption Criteria

Distinct space Beds contiguous.

Team Conference May change frequency.

3 to 10 day evaluation Graduated therapy time frame.

Annual evaluation IRF - PAI will be part of review.

Provider Payment Components

• Federal Base Payment (F) – base rate for 2008 is $13,241

• Labor Portion (F) –

• Wage (V)

• Rural Factor (F) – continue to move to new MSA model

• LIP (V) – Low income patient

• Case Mix (V)

Case Mix Groups

•Discharge-based system Payment is based on discharge information

•Case Mix Groups (CMG) 95 main groups 4 deaths 1 short stay

•Single lump payment for each stay

Case Mix Groups

• All inclusive* payment for each patient Off unit surgery, dialysis, and so on.

• 385 payment categories

• The base rate from the government last year Range of average discharge rates $6,100 - $39,348

with no co-morbidity Range of average discharge rates $8,656 – $55,006

with the highest co-morbidity

* Blood transfusion and certain medical education costs excluded

How A CMG is Determined

CMG DeterminantsImpairment Group Code

Broad codes that identify the main reason for the rehab stay. 21 main categories.

Motor Score of FIM (excludes tub/shower transfers)

Functional assessment based on 12 functional measures – determined upon admission

Co-morbidities Additional medical condition that has a significant effect on the rehabilitation stay & progress & cost.

Age The age of the patient upon admission

CMG Table Sample

Replacement of Lower Extremity Joint

0801 ALOS W/O CM 6

Relative Wt. .4607 $ 6100.13

0802 ALOS W/O CM 8Relative Wt. .6020

$ 7971.08

0803 ALOS W/O CM 12 Relative Wt. .8956

$11858.64


10302.82


$ 12977.37

0806 ALOS W/O CM 15Relative Wt. 1.1787

$ 15607.17

Motor >49.55

Motor > 37.05 & < 49.55

Motor > 28.65 & < 37.05& Age > 83.5

Motor > 28.65 & < 37.05& Age < 83.5

Motor > 22.05 & < 28.65

Motor < 22.05

Replacement of Lower

Extremity Joint

Weighted Motor Score Index

•Total Maximum Motor Score – 84

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

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

Item WeightEating .6Grooming .2Bathing .9Dressing – Upper Body

.2

Dressing – Lower Body

1.4

Toileting 1.2Bladder .5Bowel .2Transfer Bed, Chair, W/C

2.2

Transfer Toilet 1.4Transfer Tub, Shower Not included

as item for CMG

Locomotion 1.6Stairs 1.6

Motor Score Index

Item Score Weight ValueEating 5 .6 3Grooming 5 .2 1Bathing 4 .9 3.6UB Dressing 4 .2 .8LB Dressing 3 1.4 4.2Toileting 4 1.2 4.8Bladder 1 .5 .5Bowel 5 .2 1Transfer Bed, Chair, W/C 3 2.2 6.6Transfer Toilet 4 1.4 5.6Transfer Tub/Shower 4Locomotion 2 1.6 3.2Stairs 2 1.6 3.2Total 37.5

Motor Score Index Example

Item Score Weight ValueStairs 2 1.6 3.2Locomotion 2 1.6 3.2Transfer Tub/Shower 1LB Dressing 3 1.4 4.2Bathing 3 .9 2.7Transfer Bed, Chair, W/C 4 2.2 8.8Toileting 5 1.2 6 Transfer Toilet 0(2) 1.4 2.8Bladder 5 .5 2.5UB Dressing 5 .2 1Grooming 5 .2 1Bowel 1 .2 .2Eating 5 .6 3Total 38.6• CMG 0602 Neurological with M > 37.35 and M < 47.75

Motor Score Index Example

•CMG 0602 Neurological with M > 37.35 and M < 47.75 • Total score = 38.6

Toilet Transfer was not scored 0 defaulted to a score of 2 If attempted and scored a 1, total would have been 37.2 CMG would have been 0603 Payment weight would have been 1.1965 instead of .9342 Difference of $3381

The Importance of Accuracy

•Three Tiers of Co-morbidities Average eRehabData utilization in 2007:

•Tier 3 21.33%•Tier 2 7.58%•Tier 1 5.40%

Can be identified up to two days before discharge. Physician identification is mandatory. Nursing Plan of Care follow up is critical. Logged on the IRF-PAI

Tier 1 Co-morbid Conditions

•Eight Tier 1 Comorbitites:

478.31 VOCAL PARAL UNILAT PART 478.32 VOCAL PARAL UNILAT TOTAL 478.33 VOCAL PARAL BILAT PART 478.34 VOCAL PARAL BILAT TOTAL 478.6 EDEMA OF LARYNX V44.0 TRACHEOSTOMY STATUS V45.1 RENAL DIALYSIS STATUS V55.0 ATTEN TO TRACHEOSTOMY

Tier 2 Comorbidities

• Eleven Tier 2 Comorbidities: 008.42 PSEUDOMONAS ENTERITIS 008.45 INT INF CLSTRDIUM DFCILE 041.7 PSEUDOMONAS INFECT NOS 438.82 LATE EF CV DIS DYSPHAGIA 579.3 INTEST POSTOP NONABSORB 787.20 DYSPHAGIA NOS 787.21 DYSPHAGIA, ORAL PHASE 787.22 DYSPHAGIA, OROPHARYNGEAL 787.23 DYSPHAGIA, PHARYNGEAL PHASE 787.24 DYSPHAGIA, PHARYNGOESOPHAGEAL 787.29 DYSPHAGIA NEC

Top Tier 3 Comorbidities

• Tier 3 (Over 100 occurrences) 278.01 MORBID OBESITY 357.2 NEUROPATHY IN DIABETES 250.60 DMII NEURO NT ST UNCNTRL 486. PNEUMONIA, ORGANISM NOS 584.9 ACUTE RENAL FAILURE NOS 342.90 UNSP HEMIPLGA UNSPF SIDE 682.6 CELLULITIS OF LE 998.59 OTHER POSTOP INFECTION 415.19 PULM EMBOL/INFARCT NEC 250.40 DMII RENL NT ST UNCNTRLD 250.80 DMII OTH NT ST UNCNTRLD 507.0 FOOD/VOMIT PNEUMONITIS 250.50 DMII OPHTH NT ST UNCNTRL 250.70 DMII CIRC NT ST UNCNTRLD 518.81 ACUTE RESPIRATRY FAILURE

• Tier 3 (Over 100 occurrences) 998.32 DISRUP-EXTERNAL OP WOUND 515. POSTINFLAM PULM FIBROSIS 250.62 DMII NEURO UNCNTRLD 995.91 SIRS-INFECT W/O ORG DYSF 342.91 UNSP HEMIPLGA DOMNT SIDE 342.92 UNSP HMIPLGA NONDMNT SDE 250.01 DMI WO CMP NT ST UNCNTRL 428.30 DIASTOLC HRT FAILURE NOS 284.1 PANCYTOPENIA 682.3 CELLULITIS OF ARM 038.9 SEPTICEMIA NOS 342.80 OT SP HMIPLGA UNSPF SIDE 518.5 POST TRAUM PULM INSUFFIC

Top Tier 3 Comorbidities

• Tier 3 (Over 100 occurrences) 434.91 CRBL ART OCL NOS W INFRC 682.2 CELLULITIS OF TRUNK 042. HUMAN IMMUNO VIRUS DIS 785.4 GANGRENE 250.61 DMI NEURO NT ST NCNTRLD 518.3 PULMONARY EOSINOPHILIA 682.7 CELLULITIS OF FOOT 348.1 ANOXIC BRAIN DAMAGE 514. PULM CONGEST/HYPOSTASIS 415.11 IATROGEN PULM EMB/INFARC 482.41 STAPH AUREUS PNEUMONIA 584.5 LOWER NEPHRON NEPHROSIS 250.82 DMII OTH UNCNTRLD

• Tier 3 (Over 100 occurrences) 250.42 DMII RENAL; UNCONTRLD 250.52 DMII OPHTH UNCNTRLD 342.82 OT SP HMIPLG NONDMNT SDE 996.62 REACT-OTH VASC DEV/GRAFT 250.92 DMII UNSPF UNCNTRLD 038.11 STAPH AUREUS SEPTICEMIA 428.20 SYSTOLIC HRT FAILURE NOS 433.11 OCL CRTD ART W INFRCT 250.72 DMII CIRC UNCNTRLD 421.0 AC/SUBAC BACT ENDOCARD 682.4 CELLULITIS OF HAND 428.1 LEFT HEART FAILURE 995.92 SIRS-INFECT W ORGAN DYSF

Comorbidity Impact

Comorbidities-RIC 01 Stroke

Reimbursement

None $28,665.44Tier 3 – ex., Diabetes $29,681.03

Tier 2 – ex., Dysphagia NOS $32,979.36

Tier 1 – ex., Vocal Cord Paralysis $34,806.62

Operational Process to the CMG

• Pre-admission screening (screener/physician) Gather apparent Impairment Group Code Gather co-morbid conditions Age information Payer status (Medicare vs. other payer)

• Admission Physician assessment is done and H&P is written IRF-PAI is started once Impairment Group Code and co-

morbid conditions are confirmed with physician documentation

Therapy and nursing assessment are completed and plan of care is written

FIM motor subscale scores are obtained

Operational Process to the CMG

• Assessment Coders review charts at the end of the assessment to assign

admission codes Beginning CMG is established Discharge plan identified

• Concurrent coding Additional comorbidities and complications are added to the

IRF-PAI as per physician documentation

• Discharge Discharge destination selected Length of stay set Final coding is complete IRF-PAI is locked and transmitted UB-04 is sent to FI for payment

How it Works 80%+ of the Time

S M T W Th F S

Discharge Home

Facility receives the full CMG payment.

1 2 3

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

4

Simple Payment Determination

•Base Rate x CMG/Tier weight

•Example:

$13,241 x 0.9998(CMG 0204 for TBI/Tier 3)= $13,238.35

How it Works:Co-morbidity Identification

S M T W Th F S

up to 2 days before discharge for the payment bump to be effective.

Co-morbid conditions can be identified by the physicianDC

Sample

CMG 108 C Weight ALOS 13,241

Tier 1 High (B) 2.2160 28 29,342

Tier 2 Med( C) 2.0997 29 27,802

Tier 3 Low (D) 1.8897 25 25,021

None (A) 1.8250 24 24,165

Exceptions to full CMG Payment

•Transfer Rule Discharge to Medicare or Medicaid certified

facility And -

•Has a LOS shorter than the LOS for the CMG they were assigned when discharged

•Per diem payment for the days on the unit plus ½ the per diem for the first day

Transfer Rule Example

• Base Rate $13,241• Weight for CMG 108 Tier 3 = 1.8897• Weight times base rate = $25,021• LOS for CMG 108 Tier 3 is 25• CMG 108 Tier 3 divided by 25 = $1001/day• Times 8 days = $8006• Plus ½ one per diem = $8506

Transfer Process

•Works the same for transfers to:

Skilled Nursing Facilities & Nursing Homes Long Term Acute Care Acute Care Another Rehab Program

Program Interruption

•Program Interruptions include transfers to acute and back to rehab during the stay.

CMG includes paying for acute stays when:•Patient is discharged to acute and returns to IRF by

midnight of the 3rd calendar day.•All costs associated with the acute stay are

recorded on the rehab cost report.•True for discharges to acute care of your own

facility or acute care of another hospital.

Program Interruption

•Acute stay greater than 3 days are different. If patient goes to acute care and does not return by

midnight of the 3rd calendar day, discharge and re-admit.

Patient will have a new admission and assessment reference period.

New CMG will be assigned based on information gathered at admission.

Correct Coding

• Why Correct Coding is Important

Assignment of appropriate case mix group (CMG) Correct payment tier for co-morbidities Prevention of issues with potential Medicare

compliance audits Compliance with the “75%” rule

Accurately coding documented diagnoses allows for appropriate reimbursement and permits us to capture all

possible resources for our patients’ care.

Correct Coding

• Assignment of Rehab Impairment Code

Assign the group that best describes the primary condition requiring admission to the rehabilitation program.

•PPS Coordinator will look at the condition for whether or not it meets 75% rule compliance

•If not, look at the acute care documentation to determine what the patient was being treated for

•Is there an etiologic diagnosis that will qualify the patient?

Diagnosis Coding

• Etiologic diagnosisUse ICD-9 codes, but official coding guidelines do not apply

• Comorbid conditionsUse ICD-9 codes, official coding guidelines sometimes apply

Etiologic Diagnosis

• Etiologic diagnosis Diagnosis that led to condition for which the patient is

receiving rehabilitation

May use code for an acute condition causing the impairment

May use code for a late effect of an acute condition if a rehabilitation program was completed previously for same impairment

Co-morbidities

• Co-morbid condition Patient condition other than the impairment or etiologic

diagnosis Exists at the time of admission/may develop during stay Affects treatment received and/or LOS

• Co-morbid conditions should be reported if they require: Clinical assessment Additional diagnostic procedures Therapeutic treatment Extension of the length of stay Enhanced nursing care and/or monitoring

• List on IRF-PAI even if not in payment tier

Complications

• Complications are medical conditions

Not present at time of admission to rehabilitation

Identified during rehabilitation stay

That slow or compromise the rehabilitation program

Coding Complications

• Conditions occurring day prior to discharge or on day of discharge

Do not add to the burden of care, so they do not yield additional payment

Document conditions early or as identified rather than waiting until the discharge summary

Coding

•Coding the IRF-PAI and the UB-04 is not the same!

Common question: Should the codes on these documents be the same?

•NO!

Diagnosis Coding

Etiologic Diagnosis

The problem that lead to the impairment requiring rehabilitation

Using ICF terminology, the disease, disorder or injury that resulted in impairment

Principal Diagnosis

The circumstances of inpatient admission always govern the selection of principal diagnosis.

It is “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care"

Diagnosis Coding

IRF-PAI Coding

Etiology is selected by identifying the cause of the primary impairment

Acute Care Coding

Principal diagnosis is always a V57 code – Care involving use of rehabilitation procedures

V57.89 – Other specified rehabilitation procedure

Diagnosis Coding

IRF-PAI Coding

Limited to ten codes to report comorbid conditions

Acute Care Coding

Limited to spaces on the UB04 – eighteen spaces

Diagnosis Coding

IRF-PAI Coding

Codes should be sequenced according to PPS strategy:1.) tier assigning2.) conditions that affect the patient (increase need for heath care resources or LOS)3.) support medical necessity

Acute Care Coding

Codes are sequenced using specified procedures, software scrubbing

Diagnosis Coding

IRF-PAI Coding

Codes are reported for actively treated conditions, only. Do not code "probable", "suspected", "likely", "questionable", or "possible“ conditions

Acute Care Coding

If the diagnosis documented at the time of discharge is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out", code the condition as if it existed or was established. The bases for this guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.

Diagnosis Coding

IRF-PAI Coding

Late effect codes are used when the patient has completed a rehabilitation program for the condition in the past

Acute Care Coding

A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. The residual may be apparent early, such as in cerebrovascular accident cases, or it may occur months or years later, such as that due to a previous injury

Diagnosis Coding

IRF-PAI Coding

Code significant symptoms that require health care resources

Code residual effects of the primary impairment treated in rehabilitation

Acute Care Coding

Signs and symptoms that are integral to the disease process should not be assigned as additional codes

Diagnosis Coding

IRF-PAI Coding

Code concurrently

Acute Care Coding

Recent change from coding at discharge to coding concurrently

Diagnosis Coding

IRF-PAI Coding

Coding may be done by HIM professional or by a clinician (PPS coordinator)

Acute Care Coding

Official rules for who does coding

Diagnosis Coding

IRF-PAI Coding

Do not code conditions that are recognized the day of discharge or the day preceding discharge

*Coding comparison from Dr. Pam Smith, Extreme Makeover for Medical Rehabilitation

Acute Care Coding

No stipulation on when a condition is identified

Documentation Tips

• In the H&P note all active conditions and plan to address the conditions

• Medication changes – document why changed

• Lab results – document decisions made based on lab results

• Ordering additional tests/labs – document reason why ordered,

discuss risks, advantages, hasten rehab participation and

discharge

Coding Points to Remember

• When in question, distinguish between obesity and morbid obesity

Involve dietitian Morbid obesity is a BMI of 40 or more

• Physician delineation of manifestations of diabetes mellitus assists coders

Peripheral neuropathy Nephropathy Retinopathy, etc.

Contact Information:Lisa Bazemore

[email protected](202) 588-1766

mailto:[email protected]

coding update

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