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2009 IRF PPS Updates Clinical Training Call October 7, 2008

2009 IRF PPS Updates Clinical Training Call October 7, 2008. Lisa Bazemore, MBA, MS, CCC-SLP. How A CMG is Determined. Case Mix Groups. Discharge-based system Payment is based on discharge information Case Mix Groups (CMG) 95 main groups 4 deaths 1 short stay

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2009 IRF PPS Updates Clinical Training Call October 7, 2008

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  1. 2009 IRF PPS UpdatesClinical Training CallOctober 7, 2008 Lisa Bazemore, MBA, MS, CCC-SLP

  2. How A CMG is Determined

  3. 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

  4. 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 • Range of average discharge rates $6,108 - $36,561 with no co-morbidity • Range of average discharge rates $9,071 – $51,529 with the highest co-morbidity

  5. Review of Changes • The final rule introduced changes in these categories: • Relative weights and average length of stay based on the most current Medicare claims and cost report data. • Payment rates based on wage index and labor shares. • Update to the outlier threshold. • Update to the cost-to-charge ratio ceiling and national average urban and rural cost-to-charge ratios for purposed of determining outlier payments.

  6. Provider Payment Components • Federal Base Payment (F) • Base rate for October 1, 2007 was $13,451 • Change of rate on April 1, 2008 was $13,034 • Rate for October 1, 2008 is $12,958 • Labor Share (F) • Total is 75.464 of the Medicare payment. • Based on Global Insight’s 2008 second quarter forecast. • Wage (V) • Wage index is 1.0003 • Maintains budget neutrality.

  7. CMG Revisions • Weight revisions for the CMGs • Resulted in an overall payment weight of .9939. • National impact according to eRehabData looking back over the past 365 days is -$280.67 per case.

  8. CMG Revisions • Standard payment calculation: • $13,034 base rate 2008 • X 1.0 for zero percent increase factor • X 1.0003 for wage index change • X .9939 for CMG weight revisions • $12,958 base rate 2009

  9. CMG Revisions • Impact of CMG weight revision by RIC:

  10. CMG Revisions • Stroke CMGs: • Signification reduction in 0107 and 0109. • Associated length of stay decline was 2-3 days.

  11. CMG Revisions • Lower Extremity Fracture CMGs: • Most commonly used CMGs are 0702 and 0704 according to eRehabData national trends. • Increased average length of stay by 2 days. • Replacement of the Lower Extremity CMGs: • Most commonly used CMGs are 0802, 0804, and 0805 according to eRehabData national trends. • Increased average length of stay by 1-2 days.

  12. High Cost Outliers • Definition: Cases where cost exceeds reimbursement by a significant portion qualifying the facility for additional payment. • PPS Payment plus the adjusted threshold amount compared to estimated cost-to-charge ratio based on Medicare allowables. • GROUPER software detects the high cost and triggers payment if cost is greater than the adjusted outlier threshold. • Medicare pays the provider 80% of the difference between the estimated cost of the case and the outlier threshold. • 2009 outlier threshold is $10,250. • Expected to occur in 3% of IRF cases.

  13. Exceptions to full CMG Payment • No change to transfer rule, short stay, or interrupted stay provisions. • 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

  14. Transfer Rule Example • Base Rate $12,958 • Weight for CMG 108 Tier 3 = 1.8860 • Weight times base rate = $24,439 • LOS for CMG 108 Tier 3 is 23 • CMG 108 Tier 3 divided by 23 = $1063/day • Times 8 days = $8500 • Plus ½ one per diem = $9031.50

  15. Transfer Process • Works the same for transfers to: • Skilled Nursing Facilities & Nursing Homes • Long Term Acute Care • Acute Care • Another Rehab Program

  16. 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.

  17. 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.

  18. Short Stays • Short stays include patients who are admitted and discharged to a community setting before the end of the assessment period. • Revert to short stay CMG 5001. • CMG payment weight is .1476 with an average length of stay of 3 days. • Used for lengths of stay 3 days or fewer (day of discharge is not counted as a day).

  19. Expired on the Unit • If a patient expires on the rehabilitation unit, CMG weights are as noted: • 5101 expired, orthopedic with a length of stay of 13 days or fewer • .6783 • 5102 expired, orthopedic with a length of stay of 14 days or more • 1.5432 • 5103 expired, not orthopedic with a length of stay of 15 days or fewer • .7086 • 5104 expired, not orthopedic with a length of stay of 16 days or more • 1.9586

  20. Changes to Comorbidities that Tier • Tier 1: • V45.1 for renal dialysis status is no longer a valid code. • Replaced with V45.11 for renal dialysis status. • Tier 2: • No changes

  21. Changes in Cormobidities that Tier • Tier 3: • 038.12, Methicillin resistant Staphyloccoccus aureus septicemia • 482.42, Methicillin resistant pneumonia due to Stephylococcus aureus (excluded from RIC 15) • New conditions; not replacement codes. • Additional codes for active leukemia in relapse. • 204.02 active lymp leukemia in relapse • 205.02 active myel leukemia in relapse • 206.02 active mono leukemia in relapse • 207.02 active erth/erylk leukemia in relapse • 208.02 active unspecified leukemia in relapse

  22. Changes in Comorbidities that Tier • Tier 3: • New category for secondary diabetes. • In the fifth digit, 0 denotes not stated as uncontrolled • In the fifth digit, 1 denotes uncontrolled 249.41    SEC DM RENAL UNCONTRLD    249.50    SEC DM OPHTH NT ST UNCN    249.51    SEC DM OPHTH UNCONTRLD    249.60    SEC DM NEURO NT ST UNCN    249.61    SEC DM NEURO UNCONTRLD    249.70    SEC DM CIRC NT ST UNCNTR    249.71    SEC DM CIRC UNCONTRLD    249.80    SEC DM OTH NT ST UNCONTR    249.81    SEC DM OTHER UNCONTRLD    249.91    SEC DM UNSP UNCONTROLD   

  23. Changes to Comorbidities that Tier • Tier 3: • New code in the gastritis section: • 535.71    EOSINOPHILC GASTRT W HEM    • New code range for fevers which was expanded to distinguish different types of fevers. • 780.62    POSTPROCEDURAL FEVER  • One new code for non-specific wound disruption • 998.30    WOUND DISRUPTION NOS  • 998.31 for disruption of internal operative wound remains • 998.32 for disruption of external operative wound remains

  24. Coding Additions • Other coding changes: • Many other coding changes were published. • Those mentioned impact payment under the IRF PPS payment system

  25. Coding Additions • Other coding changes: • Broad overview of coding changes, which you should research further: • Staphylococcus Aureus- • Carrier codes • Methacillin resistant codes • Methacillin susceptible codes • Category 046 codes for prion disease of the central nervous system • Malignant neoplasm of transplanted organs • Headaches • Coronary atherosclerosis due to lipid rich plaque • Malignant pleural effusion • Hematuria • Pressure ulcers require site and stage codes • Stress fractures • Functional urinary incontinence • Ventilator associated pneumonia • Infusion and transfusion reaction

  26. Coding Additions • V Code Additions: • V46.3, wheelchair dependence, denotes confinement to a wheelchair • History codes for personal history of fracture • V13.51 pathologic fracture • V13.52 stress fracture • V13.59 other musculoskeletal fracture • V15.51 traumatic fracture • V15.59 other fracture

  27. The Importance of Accuracy • Three Tiers of Co-morbidities • Average eRehabData utilization in the previous 365 days: • Tier 3 22.56% • Tier 2 7.76% • Tier 1 5.70% • Can be identified up to two days before discharge. • Physician identification is mandatory.

  28. 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

  29. 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

  30. Tier 3 (Top 30) 278.01 MORBID OBESITY 357.2 NEUROPATHY IN DIABETES 250.60 DMII NEURO NT ST UNCNTRL 584.9 ACUTE RENAL FAILURE NOS 486. PNEUMONIA, ORGANISM NOS 342.90 UNSP HEMIPLGA UNSPF SIDE 682.6 CELLULITIS OF LEG 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 250.62 DMII NEURO UNCNTRLD 518.81 ACUTE RESPIRATRY FAILURE 250.70 DMII CIRC NT ST UNCNTRLD 250.50 DMII OPHTH NT ST UNCNTRL Tier 3 (Top 30) 998.32 DISRUP-EXTERNAL OP WOUND 515. POSTINFLAM PULM FIBROSIS 995.91 SIRS-INFECT W/O ORG DYSF 428.30 DIASTOLC HRT FAILURE NOS 342.91 UNSP HEMIPLGA DOMNT SIDE 284.1 PANCYTOPENIA 342.92 UNSP HMIPLGA NONDMNT SDE 038.9 SEPTICEMIA NOS 682.2 CELLULITIS OF TRUNK 518.3 PULMONARY EOSINOPHILIA 518.5 POST TRAUM PULM INSUFFIC 434.91 CRBL ART OCL NOS W INFRC 682.3 CELLULITIS OF ARM 342.80 OT SP HMIPLGA UNSPF SIDE 250.01 DMI WO CMP NT ST UNCNTRL Top Tier 3 Comorbidities

  31. Replacement of Lower Extremity Joint 0801ALOS W/O CM 7 Relative Wt. .4714 $ 6108.40 Motor >49.55 Motor > 37.05 & < 49.55 0802 ALOS W/O CM 9 Relative Wt. .6137 $ 7952.32 Motor> 28.65 & < 37.05 & Age > 83.5 Replacement of Lower Extremity Joint 0803 ALOS W/O CM 12 Relative Wt. .9013 $11679.05 Motor> 28.65 & < 37.05 & Age < 83.5 0804 ALOS W/O CM 10 Relative Wt. .7910 $10249.78 Motor > 22.05 & < 28.65 0805 ALOS W/O CM 13 Relative Wt. .9874 $ 12794.73 Motor < 22.05 0806ALOS W/O CM 15 Relative Wt. 1.2215 $ 15828.20

  32. Weighted Motor Score Index

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

  34. Questions? Next call: November 4 @ 1:00 EST Writing an Appeal Letter

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