Coding Update

1. Coding Update Lisa Bazemore, MBA, MS, CCC-SLP February 5, 2008

2. Basics

3. Basics

4. Basics

5. 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)

6. 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

7. 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

8. How A CMG is Determined

9. CMG Table Sample

10. Replacement of Lower Extremity Joint 0801ALOS W/O CM 6 Relative Wt. .4607 $ 6100.13 Motor >49.55 Motor > 37.05 & < 49.55 0802 ALOS W/O CM 8 Relative Wt. .6020 $ 7971.08 Motor> 28.65 & < 37.05 & Age > 83.5 Replacement of Lower Extremity Joint 0803 ALOS W/O CM 12 Relative Wt. .8956 $11858.64 Motor> 28.65 & < 37.05 & Age < 83.5 0804 ALOS W/O CM 10 Relative Wt. .7781 10302.82 Motor > 22.05 & < 28.65 0805 ALOS W/O CM 13 Relative Wt. .9816 $ 12977.37 Motor < 22.05 0806ALOS W/O CM 15 Relative Wt. 1.1787 $ 15607.17

11. 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” Weighted Motor Score Index

12. 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

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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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 Top Tier 3 Comorbidities

20. Comorbidity Impact

21. 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

22. 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

23. How it Works 80%+ of the Time Discharge Home 1 2 3 4 Patient stays at least to the fourth day and discharged home. Facility receives the full CMG payment.

24. Simple Payment Determination • Base Rate x CMG/Tier weight • Example: $13,241 x 0.9998 (CMG 0204 for TBI/Tier 3) = $13,238.35

25. How it Works:Co-morbidity Identification DC Co-morbid conditions can be identified by the physician up to 2 days before discharge for the payment bump to be effective.

26. Sample

27. 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

28. 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

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

30. 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.

31. 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.

32. 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.

33. 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?

34. Diagnosis Coding • Etiologic diagnosis Use ICD-9 codes, but official coding guidelines do not apply • Comorbid conditions Use ICD-9 codes, official coding guidelines sometimes apply

35. 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

36. 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

37. Complications • Complications are medical conditions • Not present at time of admission to rehabilitation • Identified during rehabilitation stay • That slow or compromise the rehabilitation program

38. 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

39. 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!

40. 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

41. 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

42. IRF-PAI Coding Limited to ten codes to report comorbid conditions Acute Care Coding Limited to spaces on the UB04 – eighteen spaces Diagnosis Coding

43. IRF-PAI Coding Codes should be sequenced according to PPS strategy: 1.) tier assigning 2.) 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

44. 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

45. 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

46. 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

47. IRF-PAI Coding Code concurrently Acute Care Coding Recent change from coding at discharge to coding concurrently Diagnosis Coding

48. 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

49. 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 Diagnosis Coding

50. 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