Managing the Case Mix Index Lisa Bazemore, MBA, MS, CCC-SLP Director of Consulting Services

1. Managing the Case Mix IndexLisa Bazemore, MBA, MS, CCC-SLPDirector of Consulting Services

2. Objectives • The participant will understand the components of the case mix group and how Functional Independence Measures (FIM) scoring affects the payment for a inpatient rehabilitation stay. • The participant will be able to explain the concept of burden of care and describe how it is captured by the FIM instrument. • The participant will have performance management tools for improving facility reimbursement through proper assignment of the case mix group.

3. Basics • Discharge-based system • Payment is based on discharge information • Single lump payment for each stay • Case Mix Groups (CMG) • 87 main groups • 4 deaths • 1 short stay

4. Case Mix Groups • All inclusive* payment for each patient • 353 payment categories • The base rate from the government • Range of average discharge rates $5,800 - $37,500 with no co-morbidity • Range of average discharge rates $8,300 – $54,000 with the highest co-morbidity * Blood transfusion excluded and certain medical education costs

5. CMG - Case Mix Group • Components: • Rehab Impairment Classification • Comorbidities • FIM • Age

6. Comorbidity • Definition: • Specific patient condition secondary to principal diagnosis or impairment • Considered in context of principal diagnosis • More than one comorbidity possible but does not include additional reimbursement • Presence of comorbidity could impact cost of patient care

7. Comorbidity ImpactRIC - 01 - Stroke

8. Replacement Of Lower Extremity Joint 0801ALOS W/O CM 6 Relative Wt. .4596 $2696.80 Motor > 49.55 Motor > 37.05 & < 49.55 0802 ALOS W/O CM 8 Relative Wt. .6004 $4602.25 Motor> 28.65 & < 37.05 & Age > 83.5 Replacement of Lower Extremity Joint 0803 ALOS W/O CM 12 Relative Wt. .8901 $8811.58 Motor> 28.65 & < 37.05 & Age < 83.5 0804 ALOS W/O CM 10 Relative Wt. .7754 $7676.10 Motor > 22.05 & < 28.65 0805 ALOS W/O CM 13 Relative Wt. .9763 $12169.01 Motor < 22.05 0806ALOS W/O CM 15 Relative Wt. 1.1716 $17524.58

9. Ways We Use FIM Data • Establish CMG • Measure Change (Outcomes) • Compare ourselves to other program

10. Purpose • “The FIM instrument is intended to measure what the person with disability actually does, whatever the diagnosis or impairment, not what (s)he ought to be able to do, or might be able to do under different circumstances.” (IRF-PAI Training Manual Interim Version 10/03/01 page III-1)

11. Burden of Care • The Concept of Burden of Care: • Refers to type and amount of assistance required for a disabled individual to perform basic life activities effectively • The question is: How much assistance does the individual receive from another person or by the use of an assistive device?

12. 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”

13. Motor Score Index ItemScoreWeight Value Eating 5 .6 3 Grooming 5 .2 1 Bathing 4 .5 2 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

14. Scoring Time Frames • Most FIM items - Assessment period = 3 calendar days • Function Modifiers - Bladder Frequency of Accidents & Bowel Frequency of Accidents = 7 day assessment period • Admission assessment timeframe includes 4 days prior to rehab admission plus first 3 days in rehab

15. Scoring Time Frames • Discharge Assessment Time Frame encompasses the day of discharge and the 2 calendar days prior to the day of d/c. • “Should reflect the lowest functional score within any 24-hour period within the 3 calendar days comprising the discharge assessment”. • Bowel and Bladder Frequency of Accidents still require 7 day look back • Bowel and Bladder Level of Assistance still require 3 day look back.

16. Keys to Success • Accuracy of FIM scoring based on 24 hour per day and 7/day per week patient performance • Timeliness of scoring • Documentation must support scoring

17. Breaking Down the CMI Are we getting paid for the work that we do? • Does it seem like your CMI is lower than your burden of care? • Capturing the proper CMI is essential to enable you to staff appropriately. • Since many of us predict staffing ratios based on patient acuity as realized through the CMI, it is important to capture what most closely reflects the care being rendered on the unit.

18. Breaking Down the CMI FIM Scoring: • Evaluate your admission FIM scores • How does your admission FIM score compare to those in your region and across the nation?

19. Breaking Down the CMI • FIM Scoring: • How do you compare to the weighted averages? • How do you compare to the unweighted averages? • How do you know which one to use?

20. Breaking Down the CMI • FIM Scoring: • Identify the FIM items that are consistently falling outside of range • FIM progression warnings • FIM comparison graphs • Train staff • Full item FIM training annually or greater • Proficiency testing annually or greater • Performance improvement plans to work on items outside of range • FIM scoring hints in staff lounge areas • Communicate findings • Give staff reports of scoring averages and performance on individual items

21. Difficult to Score Items • Bladder Level of Assistance: • Includes complete and intentional control of the urinary bladder and, if necessary, use of the equipment or agents for bladder control. • Do NOT use code “0” • If patient does not void due to renal failure and is on dialysis, score as a 7 – Complete Independence

22. Difficult to Score Items • Bladder Level of Assistance: • At level 7 – • Controls bladder completely and intentionally without equipment or devices • Is never incontinent

23. Difficult to Score Items • Bladder Level of Assistance: • At level 6 – • Needs urinal, bedpan, catheter, absorbent pad, diaper, urinary collecting device, or urinary diversion • If catheter is used, patient cleans, sterilizes, and sets up the equipment for irrigation without assistance • If patient uses a device, assembles and applies device without assistance of another person • Patient empties, removes, puts on, and cleans device • Uses medication for control • Has no accidents

24. Difficult To Score Items • Urinal Scoring: • 6 – Patient retrieves urinal and empties it • 5 – Urinal is set-up and/or is emptied by helper • 4 – Patient needs help placing urinal in appropriate position, includes touching

25. Difficult To Score Items • Bladder Scoring Hints: • 4 – Assistance with application of external catheter but can do rest of tasks – emptying and managing bags and tubing • 4 – Needs only incidental help such as placement of equipment in his/her hand or help to performs just one of several tasks included in bladder management • 3 – Requires help to insert catheter, emptying, managing bags & tubing • 1 – Timed voiding programs • 1 – Helper changes patient’s absorptive pad

26. Difficult To Score Items • Function Modifier-Bladder Frequency of Accidents: • Act of wetting linen or clothing with urine and includes bedpan and urinal spills • 7 - No accidents • 6 - No accidents; uses device such as catheter, medication • 5 - One bladder accident including bed pan and urinal spills in the past 7 days • 4 - Two bladder accidents including bed pan and urinal spills in the past 7 days • 3 - Three bladder accidents including bed pan and urinal spills in the past 7 days • 2 - Four bladder accidents including bed pan and urinal spills in the past 7 days • 1 - Five or more bladder accidents including bed pan and urinal spills in the past 7 days

27. Difficult To Score Items • Bowel Management: • Includes complete and intentional control of bowel movements • including use of equipment or agents for control • FIM score is the lower of the scores for Level of Assistance and Frequency of Accidents • Do not use code “0” for Bowel Level of Assistance or Frequency of Accidents

28. Difficult To Score Items • Bowel Management-Level of Assistance: • At level 7 – • Controls bowel completely and intentionally • Never incontinent • At level 6 – • Requires bedpan, digital stimulation or stool softeners, suppositories, laxatives, or enemas on a regular basis • Uses other medications for control

29. Difficult To Score Items • Suppository Scoring: • 6 – Pt. self inserts • 5 – Setup of supplies • 4 – Helper lubricates and inserts suppository • 1 – Pt. needs help with positioning, placement of absorptive pad, lubrication and insertion of suppository, and help to evacuate the bowel

30. Difficult To Score Items • Function Modifier-Bowel Frequency of Accidents: • Act of soiling linen or clothing with stool (includes bedpan spills) • 7- No accidents • 6- No accidents; uses device such as ostomy, medications, devices • 5- One accident in the past 7 days • 4- Two accidents in the past 7 days • 3- Three accidents in the past 7 days • 2- Four accidents in the past 7 days • 1- Five or more accidents in the past 7 days

31. Difficult To Score Items • Lower Body Dressing: • Dressing and undressing from the waist down, as well as applying and removing prosthesis • Must use clothing that is appropriate to wear in public • Commercially obtained sneakers with Velcro closures are not considered an adaptive device • Includes dressing and undressing from the waist down • Applying and removing a prosthesis or orthosis when applicable • Assess all of the steps that are performed

32. Difficult To Score Items • Lower Body Dressing: • Lower limb prosthesis- • If applied by patient and patient does not use the prosthesis as a device and no other assistance is needed – 7 • If applied by patient and patient does use as device – 6 • If applied by helper and no other assistance is needed – 5 – set-up

33. Difficult To Score Items • Lower Body Dressing: • If patient dresses himself in bed, only needs helper to bring him his clothes, then 5 – setup • If patient dresses himself while standing and requires helper for steadying assistance – 4 – minimal contact assistance • Assistance with putting on anti-embolic stockings (compression stockings) is considered a set-up - level 5

34. Difficult To Score Items • Toileting: • 3 Activities • Adjusting clothing before toilet use • Cleansing • Adjusting clothing after toilet use • Use of bedpan – addressed under items of Bladder Management and/or Bowel Management and Transfers

35. Difficult To Score Items • Transfers: Bed, Chair, Wheelchair: • Includes all aspects of transferring to and from a bed, chair and wheelchair • Including coming to a standing position if walking is the typical mode of locomotion. • During the bed-to-chair transfer, the patient begins and ends in the supine position • Lifting limbs: Lifting limbs: • Assistance with one limb only - Level 4 • Assistance with two limbs - Level3

36. Difficult To Score Items • Wheelchair Transfers: • 7 – Transfers in a safe and timely manner with no device • 6 – Uses part of wheelchair in transfer, takes more than a reasonable amount of time • 5 – Assistance provided in locking brakes, positioning of chair • 4 – Steadying assistance given, or help with one limb • 3 – Helper provides assistance in lifting body • 2 – Lot of assistance needed in lifting body • 1 – Patient does not help or unable to bear weight

37. Breaking Down the CMI • Determine what percentage of the time you are scoring a tiering comorbidity

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

39. Top Tiering Comorbidities • Tier 2 • 787.2 DYSPHAGIA • 008.45 INT INF CLSTRDIUM DFCILE • 041.7 PSEUDOMONAS INFECT NOS • 438.82 LATE EF CV DIS DYSPHAGIA • 579.3 INTEST POSTOP NONABSORB • 008.42PSEUDOMONAS ENTERITIS

40. Tier 3 (Top 30) 278.01 MORBID OBESITY 357.2 NEUROPATHY IN DIABETES 250.60 DMII NEURO NT ST UNCNTRL 486.7 PNEUMONIA, ORGANISM NOS 584.9 ACUTE RENAL FAILURE NOS 682.6 CELLULITIS OF LEG 342.90 UNSP HEMIPLGA UNSPF SIDE 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 515. POSTINFLAM PULM FIBROSIS 250.70 DMII CIRC NT ST UNCNTRLD 250.50 DMII OPHTH NT ST UNCNTRL 507.0 FOOD/VOMIT PNEUMONITIS Tier 3 (Top 30) 995.91 SIRS-INFECT W/O ORG DYSF 518.81 ACUTE RESPIRATRY FAILURE 998.32 DISRUP-EXTERNAL OP WOUND 250.62 DMII NEURO UNCNTRLD 342.91 UNSP HEMIPLGA DOMNT SIDE 038.9 SEPTICEMIA NOS 682.3 CELLULITIS OF ARM 342.80 OT SP HMIPLGA UNSPF SIDE 342.92 UNSP HMIPLGA NONDMNT SDE 250.01 DMI WO CMP NT ST UNCNTRL 518.5 POST TRAUM PULM INSUFFIC 042. HUMAN IMMUNO VIRUS DIS 284.1 PANCYTOPENIA 434.91 CRBL ART OCL NOS W INFRC 428.30 DIASTOLC HRT FAILURE NOS Top Tiering Comorbidities

41. Breaking Down the CMI • Pay attention to the most commonly used comorbidity lists

42. Breaking Down the CMI • Pull reports to show your CMG breakdown • Are you missing high acuity patients, low acuity patients?

43. Breaking Down the CMI • Pay attention to the warnings to tell you when there is a mismatch between IGC and Etiologic diagnosis

44. Breaking Down the CMI • Action Plan Suggestions: • Start with the documentation. Review charts to determine if your physicians are including IGC and etiologic conditions in their H&P. Are they correct? • Are all conditions being treated diagnosed in the physician assessments, consults, or progress notes? Audit, inservice, and follow-up. • Ensure that the coders are on top of the rehab coding process.

45. Breaking Down the CMI • Action Plan Suggestions: • Communicate with the coders to be certain that the physician’s documentation is adequate enough to provide them with what is needed to select the most specific codes. • Inservice staff on FIM scoring regularly. Utilize proficiency exams. • Focus on staff education for accurate FIM scoring.

46. Questions? Lisa Bazemore, MBA, MS, CCC-SLP Lbazemore@erehabdata.com (202) 588-1766