2010 IRF PPS Updates Clinical Training Call November 3, 2009

1. 2010 IRF PPS UpdatesClinical Training CallNovember 3, 2009 Lisa Werner 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) • 87 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. • 353 payment categories • The base rate from the government • Range of average discharge rates $6,392 - $43,381 with no co-morbidity • Range of average discharge rates $9,020 – $53,084 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 • Rate for October 1, 2090 is $13,661 (2.5% increase) • Labor Share (F) • Total is 75.779 of the Medicare payment. • Wage (V) • Maintains budget neutrality.

7. Provider Payment Components • Changes to facility adjusters: • LIP: 0.4613 versus 0.6229 • Rural: 18.4% versus 21.3% • Teaching: 0.6876 versus 0.9012

8. CMG Revisions • Weight revisions for the CMGs • Resulted in an overall payment increase of $145 million to inpatient rehab facilities. • National impact according to eRehabData looking back over the past fiscal year is $574.03 per case.

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

10. 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. • 2010 outlier threshold is $10,652. • Expected to occur in 3% of IRF cases.

11. 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

12. Transfer Rule Example • Base Rate $13,661 • Weight for CMG 108 Tier 3 = 1.8963 • Weight times base rate = $25,905 • LOS for CMG 108 Tier 3 is 23 • CMG 108 Tier 3 divided by 23 = $1126/day • Times 8 days = $9010 • Plus ½ one per diem = $9573

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

14. 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.

15. 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.

16. 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).

17. 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

18. Changes to Comorbidities that Tier • Tier 1: • No changes • Tier 2: • No changes

19. Changes in Cormobidities that Tier • Tier 3: • 285.3 Anemia d/t antineo chemo  416.2 Chronic pulmonary embolism exclude RIC 15 488.0 Flu due to identified avian virus exclude RIC 15 488.1 Flu due to identified H1N1 virus exclude RIC 15

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

21. Coding Additions • Other coding changes: • Broad overview of coding changes, which you should research further: • Merkel cell carcinoma • Secondary neuroendocrine tumor • Gouty arthritis • Late effect CVA, dysarthria and fluency • Chronic venous embolism and thrombosis • Acute venous embolism and thrombosis • Hypoxic-ischemic encephalopathy • Speech disturbance codes • Poisoning • Behavioral codes

22. Coding Additions • V Code Additions: • History codes for personal history of traumatic brain injury – V15.52 • Special screening for traumatic brain injury – V80.01 • Special screening for other neurological conditions – V80.09

23. Coding Deletions • Codes discontinued: • 239.8 - Neoplasm of unspecified nature of other specified sites • 274.0 - Gouty arthropathy • 279.4 - Autoimmune disease, not elsewhere classified • 348.8 - Other conditions of brain • 453.8 - Other venous embolism and thrombosis of other specified veins • 488*** - Influenza due to identified avian influenza virus • 768.7 - Hypoxic-ischemic encephalopathy (HIE) • 784.5 - Other speech disturbance • 799.2 - Nervousness • 969.0 - Poisoning by antidepressants • 969.7 - Poisoning by psychostimulants • V10.9 - Unspecified personal history of malignant neoplasm • V80.0 - Special screening for neurological conditions

24. Coding Revisions • Codes revised: • 008.65 - Enteritis due to calicivirus • 041.3 - Klebsiella pneumoniae • 041.86 - Helicobacter pylori [H. pylori] • 453.2* - Other venous embolism and thrombosis of inferior vena cava • 453.4x - Acute venous embolism and thrombosis of lower extremity • 572.2 - Hepatic encephalopathy • 584.x - Acute kidney failure • 784.40 - Voice and resonance disorder, unspecified • 784.49 - Other voice and resonance disorders • 793.x - Nonspecific (abnormal) findings on radiological and other examination • 813.45 - Torus fracture of radius (alone) • 996.43 - Broken prosthetic joint implant

25. The Importance of Accuracy • Three Tiers of Co-morbidities • Average eRehabData utilization in the previous 365 days: • Tier 3 24.34% • Tier 2 8.80% • Tier 1 6.26% • Can be identified up to two days before discharge. • Physician identification is mandatory.

26. 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

27. 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

28. Tier 3 (Top 35) 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 518.81 ACUTE RESPIRATRY FAILURE 250.40 DMII RENL NT ST UNCNTRLD 250.80 DMII OTH NT ST UNCNTRLD 507.0 FOOD/VOMIT PNEUMONITIS 250.62 DMII NEURO UNCNTRLD 428.30 DIASTOLC HRT FAILURE NOS 995.91 SIRS-INFECT W/O ORG DYSF 250.50 DMII OPHTH NT ST UNCNTRL Tier 3 (Top 35) 515. POSTINFLAM PULM FIBROSIS 250.70 DMII CIRC NT ST UNCNTRLD 998.32 DISRUP-EXTERNAL OP WOUND 342.92 UNSP HMIPLGA NONDMNT SDE 284.1 PANCYTOPENIA 342.91 UNSP HEMIPLGA DOMNT SIDE 038.9 SEPTICEMIA NOS 428.20 SYSTOLIC HRT FAILURE NOS 682.2 CELLULITIS OF TRUNK 342.80 OT SP HMIPLGA UNSPF SIDE 682.3 CELLULITIS OF ARM 518.3 PULMONARY EOSINOPHILIA 518.5 POST TRAUM PULM INSUFFIC 250.01 DMI WO CMP NT ST UNCNTRL 780.62 Postprocedural fever 042. HUMAN IMMUNO VIRUS DIS 428.22 CHR SYSTOLIC HEART FAILURE 434.91 CRBL ART OCL NOS W INFRC Top Tier 3 Comorbidities

29. Replacement of Lower Extremity Joint 0801ALOS W/O CM 7 Relative Wt. .4714 $ 6391.98 Motor >49.55 Motor > 37.05 & < 49.55 0802 ALOS W/O CM 9 Relative Wt. .6317 $ 8614.63 Motor> 28.65 & < 37.05 & Age > 83.5 Replacement of Lower Extremity Joint 0803 ALOS W/O CM 12 Relative Wt. .9013 $12006.65 Motor> 28.65 & < 37.05 & Age < 83.5 0804 ALOS W/O CM 10 Relative Wt. .7910 $10790.82 Motor > 22.05 & < 28.65 0805 ALOS W/O CM 13 Relative Wt. .9874 $ 13438.33 Motor < 22.05 0806ALOS W/O CM 15 Relative Wt. 1.2215 $ 16546.20

30. Weighted Motor Score Index

31. 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

32. Questions? Next call: December 1 @ 1:00 EST PAS Tool