irf pps fy 2013 update and changes: what the cms notice ... · drive cmg placement co-morbidities...
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IRF PPS FY 2013 Update and Changes: What the CMS Notice Says and Means for
Rehabilitation Facilities
Carolyn C. Zollar J.D.
AMRPA
Darlene D’Altorio-Jones, PT, MBA-HCM
MediServe
Carolyn C. Zollar J.D.
AMRPA
Vice President for Government
Relations and Policy Development
Medical Rehab FY 2013 Notice and OPPS NPRM IRF Quality Reporting
Copyright 2012, AMRPA, Washington, DC
Inpatient Rehabilitation Facilities
Prospective Payment System (IRF PPS)
So You Want To Be Paid?
Copyright 2012, AMRPA, Washington, DC
Today‘s Agenda
• Brief IRF PPS Refresher Course
• FY 2013 Notice Changes
• IRF QRP Proposed Updates
• Financial Analysis and Implications
Copyright 2012, AMRPA, Washington, DC
Review: IRF-PPS Inclusions and Exclusions
• Includes:
• PPS Excluded Rehab Hospitals and Units in US
& Territories
• Capital and Inpatient Operating Costs
• Excludes:
• Hospitals and Units in Demo Programs (MD)
• Costs of Bad Debt, Educational Programs, Blood
Clotting Factor Units
• Physician, PA, NP, Midwife, Qualified
Psychologist & Anesthetists Services
Copyright 2012, AMRPA, Washington, DC
Review: IRF-PPS
• Applies to Traditional FFS Medicare Cases Only
• Physician Billing is Separate - Part B, Physician
Fee Schedule (PFS)
• Incentive is to Have the Patient‘s Costs Stay
Under the Payment
• Most Often Equated to Length of
Stay Management
• Bad, Bad, Bad Idea and CMS Agrees
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Review: IRF-PPS Basics
• Data Collection
• Inpatient Rehabilitation
Facility –Patient Assessment
Instrument (IRF-PAI)
• Patient Classification System-
Case Mix Groups (CMGs)
• Per Discharge Payment Adjusted
For Facility Characteristics
• Special Payment Policies, Outlier
Policy
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IRF-PPS Basic Components
Step One: Case Mix Groups
• Intended to Reflect Patient Characteristics and Cost of
Service
• Reflect Acuity of the Patient In Terms of:
• Comorbidities in 4 Comorbidity Tiers
• A (none) to B (most complex)
• Functional Independence/Dependence
• Total Score Ranges Up to 84 For Motor and Self
Care and 35 for Cognition
• FY 2013 CMGs, Weights-See Table 1, p. 44623
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IRF-PPS Basic Components
Case Mix Group Factors
Impairment Group Codes (Condition) ICD-9-Codes that identify the main
clinical condition
Rehabilitation Impairment Categories
(21) Categories
Groupings of similar IGCs
Functional Independence Measure Functional assessment based on 17
functional measures – determined
upon admission (excludes tub/shower
transfers); motor FIM scores tend to
drive CMG placement
Co-morbidities
(4 Tiers)
A condition secondary to principal
diagnosis; Generally represent san
increase in cost to serve the patient if
the condition is present.
Age
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IRF PPS Basic Components
Step Two: Standard Federal Payment Amount
• Determined from Historic Basis/2002
• Updated Through MB
• Subject to Statutory Change
• Case Mix Change
• Wage, Labor Share
• Budget Neutrality
• ACA Amendments
• MB
• Productivity
• P4RCopyright 2012, AMRPA, Washington, DC
IRF PPS Basic Components
Step Three: Why Facility Adjusters?
• To acknowledge variations in costs of care among
IRH/Us not captured by the CMG weights
• Low Income Percentage (LIP)
• Teaching
• Rural 18.4%
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IRF PPS Basic Components
Step Four: Special Payment Policies
• Majority of Cases Get One Payment
• IRH/Us Receive PIP
• Short Stay – Three Days or Less CMG 5001
• Death - CMGs 5101 – 5104
• Transfers
– Sent to Another IRH/U, LTCH, Acute, M+M SNF
Before Meeting CMS ALOS
• Formula T = ((CMG Payment/ CMG ALOS) x
LOS + 50 % of Per Diem)
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• Interrupted Stays
• Patient Returns to Same Facility On Day of
Discharge or By Midnight of Third Consecutive Day
• Stated Very Curiously Re: Payment (42 C.F.R.
412.624(g))
Special Payment Policies
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• O = 0.80 X ((Cost-Outlier Threshold + CMG
Payment))
• NTE 3% of Total IRF Payments
• FY 2013 Threshold - $10,466 from $10,713 FY 2012
IRF PPS Basic Components
Step Five: Outliers
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Late Transmission Penalty
• Penalty Assessed If Actual IRF PAI Assessment
Data Transmission Date > 10 Days from
Transmission Date
• IRF Has 27 Days From (and including) Day of
Discharge to Transmit
• 25% Reduction in CMG Payment
• Some Exceptions
• See 412 CFR 610, 614; CR 3885, 7/29/2005
Copyright 2012, AMRPA, Washington, DC
IRF PPS Payment Formula
P =
1. (Standard Federal Payment Amount) x (CMG
Weight1) x
2. Labor Share = Labor Portion of Federal Payment x
3. (Wage Index) = Wage Adjusted Amount + Non Labor
Amount 2 =
4. Wage Adjusted Federal Payment x
5. Rural Adjustment 3 x LIP Adjustment 4 = Wage,
Rural, LIP Adjusted/FPP1. Calculated from age, motor and cognitive function and comorbidities
2. Non labor amount = Unadjusted Federal Prospective Payment – Labor
3. (1.184) Portion of Federal Payment
4. (1 = DHS ^ (0.4613)
5. (T = FTE/ADC)^(06876))
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IRF PPS Payment Formula
P =
6. Wage and Rural Adjusted Payment Only +
7. Teaching Status Adjustment 5 x =
8. Teaching Status Adjustment Amount 6 =
9. Teaching Status Adjustment + Wage, Rural, LIP
Adjusted Rate = Total Payment
10. Outlier (0.80 x (Cost Outlier Threshold + CMG
Payment)
5. (T = FTE/ADC)^(06876))
6. Can be + or -
Copyright 2012, AMRPA, Washington, DC
• Payment Rate for FY 2013 - $14,343 from $14, 076
Effective for Discharges On or After October 1, 2012
• Labor Share is 69.981 Down from 70.199 (FY 2008
Market Basket)
• Average Est. Weight Per Discharge FY 20121 -
1.1425 to FY 2013 -1.1441
• No Change in Facility Adjusters Exponential Values
or Percentage (Rural)
• Appendix C – List of Comorbidities Unchanged
from 8/20/11 List1
FY 2013 Rate Adjustment File
FY 2013 Final IRF PPS Notice: Snapshot
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• Outlier Threshold is $10,466 Down from $10,713
• Average Wage Index FY 2013 is 0.9574 v. 09583, FY
2012
• 95% of IRF Cases in CMGs Where Weights Changed by
Less than 5%
• 0.5% Increased by 15%+
• 3.0% Decreased between 5%-15%
• Largest Increase in Weights Affecting Most Cases Is
CMG 0802 No Comorbidity
• CMS Says Reflects Response to 60% Rule
• Largest Decrease in CMG Weight Affecting Most
Cases– 2.3% is CMG D2004 - Misc
FY 2013 Final IRF PPS Notice: Snapshot
Copyright 2012, AMRPA, Washington, DC
Standard Payment Amounts
Year Payment Rate Percentage Change
FY 2004 $12,525 +2.7%
FY 2005 $12,958 +3.5%
FY 2006 $12,762 -1.5%
FY 2007 $12,981 +1.7%
FY 2008 $13,451 +3.62%
FY 2008 Adjusted $13,034 -3.10%
FY 2009 $12,958 -.5830%
Final FY 2010 $13,661 +5.43%
Adjusted FY 2010 per PPACA $13, 627 -0.25
FY 2011 $13,860 +1.70%
FY 2012 $ 14,076 +1.59%
FY 2013 $14,343 +1.89
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FY 2012 and FY 2013 Statistics from CMS
FY 2012 FY 2013
Average Wage Index 0.9583 0.9574
Number of Rural Hospitals 195 189
Number of Teaching Programs 116 115
Average DSH 0.1355 0.1385
Average Est. Weight per Discharge 1.14251 1.1441
Average IRF Payment with Outlier $5,881,7601 $5,993,666
1From FY 2013 Rate File
Source: CMS Final Rate Setting Files, Post Correction FY 2012, FY 2013
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Pay for Reporting:
Quality Measures for IRH/Us
Starting Soon!
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CMS Says First Months Are For
Training
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CMS‘s Final Quality Measures for FY 2014 Reporting
• National Health Safety Network (NHSN) Catheter Associated
Urinary Tract Infection (CAUTI) Outcome Measure
• Collected For All Patients Without Regard to Payer
• Percent of Residents Who Have New or Worsened Pressure
Ulcers NQF# 0678
• Using Data from Pressure Ulcer, Section M, MDS 3.0
• CMS Revised the IRF PAI
• Medicare FFS and Medicare Advantage Patients
• Data Collected from 10/1/2012 to 12/31/2012
• Information on Data Submission Posted 1/31/2012
• CMS Holding Training Sessions – Open Door Forums
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• Address When and How a Measure May Be
Amended, Retired
• NPRM Will Be Issued Unless The Data Collection
Process Reveals a Safety Issue
• Addresses When NQF Changes a Measure How CMS
Will Determine Whether to Issue NPRM or ―Sub
Regulatory Guidance‖ Like a Transmittal
• Determinant: Does The Change Substantially
Change the Nature of the Measure
Outpatient Prospective Payment System
Proposed Rule: IRF QRP Proposals
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Outpatient Prospective Payment System
Proposed Rule: IRF QRP Proposals
• Pressure Ulcer Measure Potential Changes
• Expand to Include IRH/Us and Others
• Add ―Patients‖ to Title of Data Collection List
• CAUTI Changes
• Change Title to the Above
• Change Calculation Eventually to Standardized
Infection Ratio (SIR)
• Requires At Least 12 Months of Data Collection
ListCopyright 2012, AMRPA, Washington, DC
CONTACT INFORMATION
Carolyn C. Zollar J.D.
V.P. for Government Relations & Policy Development
American Medical Rehabilitation Providers Association
1710 N Street N.W.
Washington, D. C. 20036-2907
Toll-free: 888-346-4624
Phone: 202-223-1920
Fax: 202-223-1925
E-mail: [email protected]
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APPENDIX
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IRF Regulations
Regulation No. Title Year
CMS-1433-NMedicare Program; Inpatient Rehabilitation Facility Prospective Payment System
for Federal Fiscal Year 20132013
CMS-1349-P
Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System
for Federal Fiscal Year 2012; Changes in Size and Square Footage of Inpatient
Rehabilitation Units and Inpatient Psychiatric Units
2012
CMS-1349-CN
Medicare Program: Inpatient Rehabilitation Facility Prospective Payment System
for Federal Fiscal Year 2012; Changes in Size and Square Footage of Inpatient
Rehabilitation Units and Inpatient Psychiatric Units; Correction
2012
CMS-1349-F
Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System
for Federal Fiscal Year 2012; Changes in Size and Square Footage of Inpatient
Rehabilitation Units and Inpatient Psychiatric Units
2012
Website: http://www.cms.gov/InpatientRehabFacPPS/LIRFF/list.asp#TopOfPage
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IRF Regulations
Regulation No. Title Year
CMS-1344-N
Prospective Payment System for Inpatient Rehabilitation
Facilities for FY 2011 2011
CMS 1538-P
Inpatient Rehabilitation Facility Prospective Payment System for
Federal Fiscal Year 2010; Proposed Rule 2010
CMS-1538-CN
Medicare Program; Inpatient Rehabilitation Facility Prospective
Payment System for Federal Fiscal Year 2010; Correction 2010
CMS-1538-F
Medicare Program; Inpatient Rehabilitation Facility Prospective
Payment System for Federal Fiscal Year 2010 2010
CMS-1554-CN IRF PPS for Fiscal Year 2009; Correction Notice 2009
CMS-1554-F IRF PPS for Fiscal Year 2009; Final Rule 2009
CMS-1554-P IRF PPS for Fiscal Year 2009; Proposed Rule 2009
CMS-1551-F
Inpatient Rehabilitation Facility Prospective Payment System for
Federal Fiscal Year 2008; Final Rule (72 FR 44283) 2008
CMS-1551-P
Inpatient Rehabilitation Facility Prospective Payment System for
Federal Fiscal Year 2008; Proposed Rule (72 FR 26230) 2008
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Regulation No. Title Year
CMS-1540-F
Inpatient Rehabilitation Facility Prospective Payment System
for Federal FY 2007; Provisions Concerning Competitive
Acquisition for Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS); Accreditation of
DMEPOS Suppliers; Final Rule (71 FR 48354) 2007
CMS-1540-CN
Inpatient Rehabilitation Facility Prospective Payment System
for Federal Fiscal Year 2007; Certain Provisions Concerning
Competitive Acquisition for Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies (DMEPOS); Accreditation
of DMEPOS Suppliers; Correction (71 FR 57447) 2007
CMS-1290-F
Inpatient Rehabilitation Facility Prospective Payment System
for FY 2006; Final Rule (70 FR 47880) 2006
CMS-1290-CN
Inpatient Rehabilitation Facility Prospective Payment System
for FY 2006; Correction (70 FR 57166) 2006
CMS-1480-N
Inpatient Rehabilitation Facility Compliance Criteria; Notice
(70 FR 36640) 2005
IRF Regulations
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IRF Regulations
Regulation No. Title Year
CMS-1360-CN
Inpatient Rehabilitation Facility Prospective Payment System
for FY 2005; Correction Notice (69 FR 60157) 2005
CMS-1360-N
Inpatient Rehabilitation Facility Prospective Payment System
for Fiscal Year 2005 (69 FR 45721) 2005
CMS-1474-P
Inpatient Rehabilitation Facility Prospective Payment System
for FY 2004; Proposed Rule (68 FR 26786) 2004
CMS-1262-P
Changes to the Criteria for Being Classified as an Inpatient
Rehabilitation Facility; Proposed Rule (68 FR 53266) 2004
CMS-1262-F
Changes to the Criteria for Being Classified as an Inpatient
Rehabilitation Facility; Final Rule (69 FR 25752) 2004
CMS-1205-N
Inpatient Rehabilitation Facility Prospective Payment System
for FY 2003; Notice (67 FR 49928) 2003
CMS-1069-P
Prospective Payment System for Inpatient Rehabilitation
Facilities; Proposed Rule (65 FR 66304) 2002
CMS-1069-F
Prospective Payment System for Inpatient Rehabilitation
Facilities; Final Rule (66 FR 41316) 2002
CMS-1069-F2
Prospective Payment System for Inpatient Rehabilitation
Facilities; Correcting Amendment (67 FR 44073) 2002
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IRF Program Transmittals
File Date Title
7760 2012-07-18Systematic Validation of Payment Group Codes for Prospective
Payment Systems (PPS) Based on Patient Assessment
7760 2012-04-27Systematic Validation of Payment Group Codes for Prospective
Payment Systems(PPS) Based on Patient Assessments
7674 2012-01-25Inpatient Rehabilitation Facility (IRF) No-Pay Billing for Medicare
Advantage (MA) Patients Update
7609 10/26/2011
Inpatient Rehabilitation Facility (IRF) and Inpatient Psychiatric Facility (IPF) Cost-to-
Charge Ratios (CCRs)
7510 09/13/2011
Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System
(PPS) Pricer Changes for FY 2012
7464 06/17/2011
Revision to Formula to Compute the Time Value of Money under the Inpatient
Prospective Payment System (IPPS), Outpatient Prospective Payment System (OPPS),
Inpatient Rehabilitation Facility (IRF PPS), Inpatient Psychiatric Facility (IPF PPS) and
Long Term Care Hospital (LTCH PPS)
Website: http://www.cms.gov/InpatientRehabFacPPS/LSIRF/list.asp#TopOfPage
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File Date Title
7151 05/13/2011
Processing Claims Spanning More than Ten Years with Unlimited Occurrence Span
Codes (OSCs): Final Completion
7150 01/21/2011
Processing Claims Spanning More than Ten Years with Unlimited Occurrence Span
Codes (OSCs): Phase III
6699 1/15/2010 Coverage of Inpatient Rehabilitation Services
7019 7/30/2010
Revised Instructions for Reporting Assessment Dates under the
Inpatient Rehabilitation Facility (IRF), Skilled Nursing Facility
(SNF), and Swing Bed (SB) Prospective Payment Systems (PPS)
6699 1/15/2010 Coverage of Inpatient Rehabilitation Services
7019 7/30/2010
Revised Instructions for Reporting Assessment Dates under the
Inpatient Rehabilitation Facility (IRF), Skilled Nursing Facility
(SNF), and Swing Bed (SB) Prospective Payment Systems (PPS)
7029 7/15/2010
Updates to the Inpatient Prospective Payment System (IPPS), Long
Term Care Hospital (LTCH) PPS, Outpatient Prospective Payment
System (OPPS), and Inpatient Rehabilitation Facility (IRF) PPS
Changes due to the Affordable Care Act (ACA)
IRF Program Transmittals
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File Date Subject
7029 7/15/2010
Updates to the Inpatient Prospective Payment System (IPPS), Long Term
Care Hospital (LTCH) PPS, Outpatient Prospective Payment System
(OPPS), and Inpatient Rehabilitation Facility (IRF) PPS Changes due to
the Affordable Care Act (ACA)
7076 8/13/2010
Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective
Payment System (PPS) Pricer Changes for FY 2011
7088 8/13/2010
Processing Claims Spanning More than Ten Years with Unlimited
Occurrence Span Codes (OSCs)
7122 10/28/2010
Processing Claims Spanning More than Ten Years with Unlimited
Occurrences Span Codes (OSCs): Phase II
7163 11/12/2010 Update to the Frequency Billing Requirements
7192 12/3/2010
Outlier Reconciliation and other Outlier Manual Updates for the
Inpatient Prospective Payment System (IPPS), Outpatient Prospective
Payment System (OPPS), Inpatient Rehabilitation Facility (IRF) PPS,
Inpatient Psychiatric Facility (IPF) PPS and Long Term Care Hospital
(LTCH) PPS
IRF Program Transmittals
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IRF Program Transmittals
File Date Subject
6607 8/28/2009
Inpatient Rehabilitation Facility Annual Update: Prospective Payment
system Pricer Changes for FY2010
1479 3/14/2008
April 2008 Inpatient Rehabilitation Facility (IRF) Prospective Payment
System (PPS) Pricer Changes
5965 3/14/2008
April 2008 Inpatient Rehabilitation Facility (IRF) Prospective Payment
System (PPS) Pricer Changes
6002 7/25/2008
Clarification on the Correct Condition Code to Report on Provider
Adjustment Requests to Indicate a Health Insurance Prospective
Payment System (HIPPS) Code Change
6166 9/5/2008
Inpatient Rehabilitation Facility Annual Update: Prospective Payment
System Pricer Changes for FY 2009
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IRF Program Transmittals
File Date Subject
5597 7/13/2007
IOM Pub. 100-09, Chapters 3- Provider Inquiries and Chapter 6-
Provider Customer Service Program Updates
5694 8/24/2007
Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective
Payment System (PPS) Pricer Changes for FY 2008
5597 6/29/2007
IOM Pub 100-09, Chapters 3, Provider Inquiries and Chapter 6 -
Provider Customer Service Program Updates
5846 12/14/2007
The Supplemental Security Income (SSI)/Medicare Beneficiary
Data for Fiscal Year (FY) 2006 for Inpatient Prospective Payment
System (IPPS) Hospitals, Inpatient Rehabilitation Facilities (IRFs),
and Long Term Care Hospitals (LTCHs)
1137 12/22/2006
CR 5325 - Inpatient Rehabilitation Facility (IRF) Teaching Status
Adjustment
938 5/5/2006
CR 5016 - Inpatient Rehabilitation Facility Prospective Payment
System (IRF PPS)
619 1/3/2006
CR 3885 - Late IRF-PAI Data Submission Penalty Protocol Within
the Inpatient Rehabilitation Facility Prospective Payment System
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IRF Program Transmittals
File Date Subject
478 2/18/2005
CR 3704 - Clarification of the Verification Process to be Used to
Determine if the IRF Meets...
680 9/16/2005
CR 4037 - Inpatient Rehabilitation Facility Annual Update: PPS
Pricer Changes for FY 2006
207 6/18/2004
CR 3309 - Expansion of Policy Where Patient is a Member of a
Medicare Advantage (MA) Organization For Only a Portion of the
Billing Period to Include Inpatient Rehabilitation Facilities (IRF) and
Long Term Care Hospitals (LTCH)
221 6/25/2004 CR 3334 - Medicare IRF Classification Requirements
263 7/30/2004
CR 3378 - Inpatient Rehabilitation Facility (IRF) Annual Update:
Prospective Payment System (PPS) Pricer Changes for FY 2005
347 10/29/2004
CR 3503 - Inpatient Rehabilitation Facility (IRF) Classification
Requirements
392 12/10/2004
CR 3567 - The Supplemental Security Income (SSI) Medicare
Beneficiary Data for Fiscal Year 2003 for Inpatient Rehabilitation
Facility Prospective Payment System (IRF PPS)
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IRF Program Transmittals
File Date Subject
39 12/8/2003
CR 2978 - Updated data for determining additional payment
amounts for the low-income patient adjustment applicable for
facilities subject to the IRF PPS
A-01-110 9/14/2001
CR 1851 - Instructions for Implementing the IRF PPS: Revision
and Modification of Transmittal A-01-92
A-01-131 11/1/2001 CR 1921 -Additional instructions for implementing the IRF PPS
A-01-146 12/21/2001 CR 2003 - IRF PPS Revenue Code File Update
A-01-92 7/31/2001 CR 1657 - Instructions for Implementing the IRF PPS
A-00-91 11/30/2000
CR 1343 - This PM is informational only. Specific contractor
claims processing instructions will follow
A-02-058 N/A
CR 2250 - IRF Annual Update: Prospective Payment System
Pricer Changes for FY 2003
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Additional Resources
• Billing
Pub 100-4, Chapter 3, Section 140
• CMS IRF Home Page
• http://www.cms.hhs.gov/ImpatientRehabFacPPS
/
• CMG for FY 2013
• FY 2013 IRF PPS Notice, July XX, 2012
• IRVEN V.2.4 (9/8/10)
Copyright 2012, AMRPA, Washington, DC
Items For Your Toolkit
• IRF PPS Documents
• Be Familiar With:
1. FY 2002 Final Rule, August 7, 2001 (The
Original Payment System)
2. FY 2006 Final Rule, August 12, 2005 (FY 2006
Refinements)
3. Final Rule FY 2007, August 18, 2006 Federal
Register
4. Final Rule FY 2007 Correction Notice,
September 29, 2006 Federal Register
5. Final Rule for FY 2008, August 7, 2007 Federal
RegisterCopyright 2012, AMRPA, Washington, DC
Items For Your Tool Kit
• IRF PPS Documents
• Section 1886 (j) Social Security Act
• 42 CFR Subpart P, 412.600 et. seq.
• New, Revised IRF PAI Training Manual, 2012
• Annual SSI , Comorbidity etc., Updates on CMS
Website
• UB Billing Form
• New Inpatient Rehabilitation Facility Patient
Assessment Instrument (IRF-PAI), 2012
• CMS IRF PPS website –
www.cms.gov/inpatientrehabfacpps/
Copyright 2012, AMRPA, Washington, DC
Items For Your Toolkit
• IRF PPS Documents cont’d
• Be Familiar With:
6. Final Rule for FY 2009, August 8, 2008 Federal
Register
7. Final Rule for FY 2010, August 7, 2009 Federal
Register
8. FY 2011 Notice, July 22, 2010 Federal Register
9. Final Rule for FY 2012, August 5, 2011 Federal
Register
10. FY 2012 Correction Notice, September 26, 2011
Federal Register
11. FY 2013 Notice, July XX, 2012 Federal RegisterCopyright 2012, AMRPA, Washington, DC
FY 2006: First Refinements
• Now 92 Total CMGs, 353 Payment Groups
• Changed Comorbidities
• Revised Tier Structure
• Moved to Weighted Motor FIM
• Added Teaching Adjustment
• Adjusted Outlier Policy
• Took a 1.9 % Reduction for Coding
• Move To Core Based Statistical Areas (CBSAs)
Copyright 2012, AMRPA, Washington, DC
Key Concepts
• Be Familiar with Rehab Impairment Categories
and Impairment Group Codes
• Be Familiar with Comorbidity Tiers
• A = None − B = Most Severe
• Tier 1 = Most Severe − Tier 3 = Least
Severe
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Key Concepts
• Be Familiar with ICD-9-CMG
• Provide Complete Verbal, Written, Dictated
Description of Patient On Admission, in H+P and Post
Admission Evaluation So Coders Can Properly Assign
IGC, RIC, then CMG, Comorbidities and Tiers
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Facility Adjusters:Low Income Percentage
• ((1+DSH)^(0.4613))
• DSH Patient Percent = (Medicare SSI Days/Total
Medicare Days) + (Medicaid, Non-Medicare
Days/Total Patient Days)
• SSI Ratio Important, Published Annually by CMS
• Used by IRFs to Estimate the LIP Adjustment
• See CMS IRF PPS Website for SSI Ratio Annual
Updates
• If DSH Phased Out What Happens?
Copyright 2012, AMRPA, Washington, DC
TABLE 6: Example of Computing the IRF FY 2013 Federal Prospective Payment
Steps Rural Facility A
(Spencer Co.,
IN)
Urban Facility B
(Harrison Co., IN)
1 Unadjusted Federal Prospective
Payment
$30,513.30 $30,513.30
2 Labor Share X 0.69981 X 0.69981
3 Labor Portion of Federal
Payment
= $21,353.51 = $21,353.51
4 CBSA Based Wage Index
(shown in the Addendum ,
Tables 1 and 2)
X 0.8551 X 0.8900
5 Wage-Adjusted Amount = $18,259.39 = $19,004.63
6 Nonlabor Amount + $9,159.79 + $9,159.79
7 Wage-Adjusted Federal
Payment
= $27,419.18 = $28,164.41
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TABLE 6: Example of Computing the IRF FY 2013 Federal Prospective Payment
Steps Rural Facility A
(Spencer Co.,
IN)
Urban Facility B
(Harrison Co., IN)
8 Rural Adjustment X 1.184 X 1.000
9 Wage- and Rural- Adjusted
Federal Payment
= $32,464.30 = $28,164.41
10 LIP Adjustment X 1.0228 X 1.0666
11 FY 2013 Wage-, Rural- and
LIP- Adjusted Federal
Prospective Payment Rate
= $33,204.49 = $30,040.16
12 FY 2013 Wage- and Rural-
Adjusted Federal Prospective
Payment
$32,464.30 $28,164.41
13 Teaching Status Adjustment X 0 X 0.0610
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TABLE 6: Example of Computing the IRF FY 2013 Federal Prospective Payment
Steps Rural Facility A
(Spencer Co.,
IN)
Urban Facility B
(Harrison Co., IN)
14 Teaching Status Adjustment
Amount
= $0.00 = $1,718.03
15 FY 2013 Wage-, Rural-, and
LIP-Adjusted Federal
Prospective Payment Rate
+ $33,204.49 + $30,040.16
16 Total FY 2013 Adjusted Federal
Prospective Payment
= $33,204.49 = $31,758.19
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Facility Adjusters: Teaching Adjustment
• (( 1+FTE Residents Training in the IRF/ADC)^
(0.6876))
• ADC=Average Daily Census
• Subject to a Cap on the FTE Count
• FY 2012 Rule Provides Temporary Cap Adjustment
Due To IRH/U Closure or Residency Program
Closure
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Payment Example
• Medical Record Shows
• CVA – Left Sided Hemi Paresis
Renal Dialysis, Prostate Cancer, Severe Malnutrition, Dehydration
• Weighted Motor FIM 24
• Age 78
• IRF-PAI Shows
• Motor FIM 26
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Payment Example Unadjusted
• RIC = Stroke
• Scores = CMG 0109
• Comorbidities = V45.11 = Tier 1
• Unadjusted Payment = $30,444.45 for FY 2013
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Table 13—Possible Future Measures And Topics For The IRF
Quality Reporting Program
Overarching Goal: Safety and Prevention
• VTE Prophylaxis.
• Patient Immunization for Influenza.
• Patient Immunization for Pneumonia.
• Staff Immunization.
Overarching Goal: Safety and Healthcare Acquired Conditions—
HAIs
• Surgical site infections.
• Multidrug resistant organism infection.
Copyright 2012, AMRPA, Washington, DC
Overarching Goal: Better, Person Centered-Care: Care
Coordination/Care Outcome
• Functional Change: Change in Motor Score.
• Change in Cognitive Function: Change in Cognitive Score.
• Communication.
• Percent of patients whose individually stated goals were met.
• Care Transitions Measure–3 (CTM–3).
• Discharge Outcome/Discharge disposition:
• Home.
• Assisted Living.
• Nursing Home.
• LTCH.
• Hospital.
• Hospice.
Table 13—Possible Future Measures And Topics For The IRF
Quality Reporting Program
Copyright 2012, AMRPA, Washington, DC
• Patient Preferences for care, treatment and management of
symptoms by healthcare providers.
Overarching Goal: Better, Person Centered-Care: Symptom
Management
• Percent of patients on a scheduled pain management regime
on admission who report a decrease in pain intensity or
frequency.
• Percent of patients with pain assessment conducted and
documented prior to therapy.
• Percent of patients who self-report moderate to severe pain.
• Percent of patients with dyspnea improved within one day of
assessment.
Table 13—Possible Future Measures And Topics For The IRF
Quality Reporting Program
Copyright 2012, AMRPA, Washington, DC
Overarching Goal: Better, Person Centered-Care: Experience of
Care
• Patient Survey, for example, Hospital Consumer
Assessment of Healthcare Providers & Systems.
• Percent of patients for whom care delivered was consistent
with patient stated care preferences.
* Consistent with NQF Serious Reportable Events.
** Consistent with Healthcare Acquired Conditions (HAC)
Prevalence Measure.
Table 13—Possible Future Measures And Topics For The IRF
Quality Reporting Program
Copyright 2012, AMRPA, Washington, DC
IRF PPS FY 2013 Update and Changes: What the CMS Notice Says and Means for Rehabilitation Hospitals and Units Starting October 1, 2012
Darlene L. D‘Altorio-Jones, PT., MBA HCM
Strategist, Rehabilitation Management; MediServe
HOW MIGHT THIS
IMPACT YOU?
Overall Impact – Facility Adjusters
59
Standard Payment Conversion (formally known as Budget Neutral
Conversion Factor)
Weighting & LOS factors
• Standard Base Payment Rate $14,076 to $14,343
• Outlier Payment Rate:
• 2012 payments expected 2.8% to be outlier payments.
• Estimated 2013 aggregate IRF payments @
approximately 3% provides a $10,466 outlier 2013 rate
• (Compared to $10,713 from the 2012 Correction Notice
payment amount.)
• CMG Weights & ALOS Table Updates – Let‘s
Review
Updates to Budget Neutrality
60
• CMG Weights & ALOS Table
• Relative Weights for 353 CMG‘s
• 199 or 56 % of cases weighted more or equal to 2012
• 154 or 44 % of cases weighted less
• Affect of Standard Payment @ $14,343 rate:
• 272 or 77 % of cases paid more or equal to 2012
• 81 or 23 % of cases paid less
• ALOS
• 51 or 14 % have Greater ALOS Published days
• 148 or 42 % have Less ALOS Published days
• 154 or 44 % have no change in the ALOS Published days
CMG Relative Weights - 1433 Notice
61
2013 Table Comparison
62
56%
44%
CMG Affects 2013 to 2012
CMG Weighted More or Equal
14%
42%44%
ALOS Affects 2013 to 2012
ALOS Greater
ALOS Less
ALOS Equal
Affects By RIC /CMG Breakdown
63
• 377,040 Cases in 2012 with distributional effects given the
CMG relative weight changes
• Total estimated aggregate payments to IRFs for FY 2013 will
not be affected as a result of the CMG relative weight
revisions. However, the revisions will affect the distribution
of payments within CMGs per a rule statement.
and tiers
Cases - Distributional Change Effect
64
• Timely IRF PAI assessment is critical to confirm
appropriate Case Mix Index (CMG) being applied.
• Validation and completion of functional measurement
and admit PAI items guide expectations towards
clinical resource needs and utilization.
• Staff must understand the importance of accurate
measurement as it leads to appropriate payment to
match the intensity/care cost burden required at the
individual patient level.
Scoring Accuracy Paramount
65
Rule Example:
Rule Payment Example A0110
66
• Using the same Indiana Facilities A & B used in the
previous example. How does this translate for other
common case types?
• MediServe offers a free tool that enables you to
review facility payment with YOUR facility
adjusters.
• This html link is provided upon request and adjusts
payment based on your unique payment criteria.
Snapshot Variances Rural/Urban
67
How Inpatient Rehab Providers Are Paid
68
http://mediserve.com/resources
Wage Index
Disproportionate Share
Rural or Urban
Teaching Status
Outlier Payments
Short Stays
Expired Patients
http://mediserve.com/resources
69
• Given 1.28 as an average CMI payment for all facilities,
MediServe applied the facility adjustment formulas to each
facility (CMS data file) and compared a 2013 to 2012 value for
a net change in reimbursement . (Positive vs. Negative effects in dollars)
• Positive > $1
• 44% -
• 483 facilities
• Positive >$500
• 49%
• 543 facilities
• Negative 7%
• 77 facilities
1,108 Facilities - Facility Adjusters Applied
70
Negative Change
7%
Positive > $144%
Positive > $50049%
Average Change in Reimbursement - After FacilityLevel Adjusters
Standard Payment Base Rates: ( Note* 3,2,1 – None Order)
Stroke Base Rate Change 2013 to 2012
71
2013 to 2012 Standard Rate Change Compare
72
2013 to 2012 Standard Rate Change Compare
73
Standard Payment Base Rates: ( Note* 3,2,1 – None Order)
Fracture LE Base Rate Change 2013 to 2012
74
2013 to 2012 Standard Rate Change Compare
75
• Stroke
• Fx. LE
ALOS Variance Snapshots 2013 to 2012
76
Standard Payment Base Rates: ( Note* 3,2,1 – None Order)
Replacement LE Base Rate Change 2013 to 2012
77
LE Jt. Replacement Base Rate Change 2013 to 2012
78
Standard Payment Base Rates: ( Note* 3,2,1 – None Order)
Miscellaneous Base Rate Change 2013 to 2012
79
80
2013 to 2012 Standard Rate Change Compare
• Replacement LE – ALOS Changes
• Miscellaneous – ALOS Changes
ALOS Variance Snapshots 2013 to 2012
81
• Without focus and interdisciplinary communication it will be
nearly impossible to drive expectations expeditiously.
• Keep focus on impending barriers and the teams ability to
eradicate any that stand in the way of the discharge plan.
• Focus at this level always meets the individuals needed
LOS rather than predetermined averages.
• Review facility ability to meet discharge expectations against
YOUR own outcomes.
• Are the published ALOS significantly different than yours?
• Manage to individual patient expectations/abilities.
• Coverage Criteria (2010 Rules) will not go away!
• Getting paid and keeping payment requires leadership
vigilance.
Challenges
82
• Keeping Medicare payment is contingent on
following the Coverage Criteria ‗specifically‘ as
detailed.
Expectations & Reality
83
14 Criteria = 145 Clarifications *
84
www.mediserve.com/irf-clarification/
85
www.mediserve.com/irf-clarification/
• Keep your hard earned cash!
• Know your numbers and continually audit for
coverage criteria compliance.
• Margins can only be managed well when
communication and expectations are clearly
defined from front to end in the patients‘
experience.
Monitor & Correct
86
Questions?
MediServe
www.MediServe.com
1-800-279-8456
Email: [email protected]
AMRPA
www.amrpa.org
1- 888-346-4624
Email: [email protected]
*CEU forms provided in follow-up email
Thank You!
ACA Section 3004: Quality Reporting Program
for IRFs
August 16, 1-2:30 p.m.
Call: 1-800-837-1935
Conference ID: 20492286.
CMS Special Open Door Forum
• Founded in 1985 ( HQ - Chandler, AZ)
• Specialists - Knowledge & Experience
• Acute, IRF & Outpatient Rehab
• Respiratory
• Service 300+ Organizations
MediServe