2012 IRF PPS Updates Clinical Training Call October 4, 2011 Lisa Werner, MBA, MS, CCC-SLP How A CMG is Determined CMG Determinants Impairment Group Code Broad codes that identify the main reason for the rehab stay. 21 main categories. Motor Score of Functional Independence Measure Functional assessment based on 12 functional measures determined upon admission (excludes tub/shower transfers) Co-morbiditiesAdditional medical condition that has a significant effect on the rehabilitation stay & progress & cost. AgeThe age of the patient upon admission 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 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 last year Range of average discharge rates $6,880 - $40,964 with no co-morbidity Range of average discharge rates $8,086 $61,648 with the highest co-morbidity * Blood transfusion and certain medical education costs excluded 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. Facility adjusters in a budget neutral manner. PPS rates per the recommended market basket increase. 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. Implement the quality reporting program provisions. 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, 2009 is $13,661 (2.5% increase) Rate for April 1, 2010 is $13,627 Rate for October 1, 2010 is $14,076 Labor Share (F) Total is of the Medicare payment. Down from last year. Wage (V) Maintains budget neutrality. Provider Payment Components Changes to facility adjusters: 2012: LIP:.4613 Rural: 18.4% Teaching:.6876 using a formula of (1+FTE interns and residents/ADC) 2011: Stated as a per facility update (No changes) 2010: Stated as noted below LIP: versus Rural: 18.4% versus 21.3% Teaching: versus CMG Revisions Impact of CMG weight revision by RIC: CMG Revisions Published CMG differences for 2011 versus actual variances 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. 2012 outlier threshold is $10,660. Expected to occur in 3% of IRF cases. 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 the per diem for the first day Transfer Rule Example Base Rate$14,076 Weight for CMG 108 Tier 3 = Weight times base rate = $26,236 LOS for CMG 108 Tier 3 is 23 CMG 108 Tier 3 divided by 23 = $1140/day Times 8 days = $9120 Plus one per diem = $9690 Transfer Process Works the same for transfers to: Skilled Nursing Facilities & Nursing Homes Long Term Acute Care Acute Care Another Rehab Program 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 3 rd 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. Program Interruption Acute stay greater than 3 days are different. If patient goes to acute care and does not return by midnight of the 3 rd 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. 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 CMG payment weight is.1475 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). 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.5856 5102 expired, orthopedic with a length of stay of 14 days or more 5103 expired, not orthopedic with a length of stay of 15 days or fewer.6970 5104 expired, not orthopedic with a length of stay of 16 days or more Changes to Comorbidities that Tier Tier 1: No changes Tier 2: No changes Changes in Comobidities that Tier Tier 3 Additions: Chemo induced pancytopenia Other drug induced pancytopenia Other pancytopenia Deleted Pancytopenia Saddle embolic pulmonary artery Flu due to NVL A virus with pneumonia Idiopathic pulmonary fibrosis Idiopathic non-specific inter pneumonia Acute interstitial pneumonia Resp bronchial interstitial lung Changes to Comorbidities that Tier Tier 3 Additions: Acute resp failure following trauma/surgery Other pulmonary insufficiency following trauma/surgery Acute on chronic acute respiratory failure following trauma/surgery Deleted Other nonspecific abnormal findings of the lung fields Postoperative shock, NOS Postoperative shock, cardiogenic Postoperative shock, septic Postoperative shock, other Deleted Blood infection due to central venous catheter LCL infection due to central venous catheter Changes in Comorbidities that Tier Tier 3 Deletions: Pancytopenia Post-traumatic pulmonary insufficiency Postoperative shock Coding Additions Other coding changes: Many other coding changes were published. Those mentioned impact payment under the IRF PPS payment system The Importance of Accuracy Three Tiers of Co-morbidities Average eRehabData utilization in the previous 365 days: Tier % Tier % Tier % Can be identified up to two days before discharge. Physician identification is mandatory. Tier 1 Co-morbid Conditions Eight Tier 1 Comorbitites: VOCAL PARAL UNILAT PART VOCAL PARAL UNILAT TOTAL VOCAL PARAL BILAT PART VOCAL PARAL BILAT TOTAL EDEMA OF LARYNX V44.0 TRACHEOSTOMY STATUS V45.1 RENAL DIALYSIS STATUS V55.0 ATTEN TO TRACHEOSTOMY Tier 2 Comorbidities Eleven Tier 2 Comorbidities: PSEUDOMONAS ENTERITIS INT INF CLSTRDIUM DFCILE PSEUDOMONAS INFECT NOS LATE EF CV DIS DYSPHAGIA INTEST POSTOP NONABSORB DYSPHAGIA NOS DYSPHAGIA, ORAL PHASE DYSPHAGIA, OROPHARYNGEAL DYSPHAGIA, PHARYNGEAL PHASE DYSPHAGIA, PHARYNGOESOPHAGEAL DYSPHAGIA NEC Top Tier 3 Comorbidities Tier 3 (Top 35) MORBID OBESITY ACUTE KIDNEY FAILURE NOS NEUROPATHY IN DIABETES DMII NEURO NT ST UNCNTRL 486. PNEUMONIA, ORGANISM NOS UNSP HEMIPLGA UNSPF SIDE CELLULITIS OF LEG OTHER POSTOP INFECTION ACUTE RESPIRATRY FAILURE DIASTOLC HRT FAILURE NOS PULM EMBOL/INFARCT NEC DMII RENL NT ST UNCNTRLD DMII NEURO UNCNTRLD SIRS-INFECT W/O ORG DYSF DMII OTH NT ST UNCNTRLD FOOD/VOMIT PNEUMONITIS CHR DIASTOLIC HRT FAILURE DMII CIRC NT ST UNCNTRLD Tier 3 (Top 35) CHR SYSTOLIC HEART FAILURE 515. POSTINFLAM PULM FIBROSIS SYSTOLIC HRT FAILURE NOS DMII OPHTH NT ST UNCNTRL PANCYTOPENIA DISRUP-EXTERNAL OP WOUND Postprocedural fever SEPTICEMIA NOS UNSP HEMIPLGA DOMNT SIDE Disruption of an external op (surgical) wound UNSP HMIPLGA NONDMNT SDE CELLULITIS OF TRUNK POST TRAUMATIC PULM INSUFFIC ACT KIDNEY FAILURE w/ LESION DMI WO COMP NT ST UNCONT CELLULITIS OF ARM Replacement of Lower Extremity Joint 0801 ALOS W/O CM 7 Relative Wt $ ALOS W/O CM 9 Relative Wt $ ALOS W/O CM 12 Relative Wt $ ALOS W/O CM 10 Relative Wt $ ALOS W/O CM 13 Relative Wt $ ALOS W/O CM 15 Relative Wt $ Motor >49.55 Motor > & < Motor > & < & Age > 83.5 Motor > & < & Age < 83.5 Motor > & < Motor < Replacement of Lower Extremity Joint Weighted Motor Score Index ItemWeight Eating.6 Grooming.2 Bathing.9 Dressing Upper Body.2 Dressing Lower Body1.4 Toileting1.2 Bladder.5 Bowel.2 Transfer Bed, Chair, W/C2.2 Transfer Toilet1.4 Transfer Tub, Shower Not included as item for CMG Locomotion1.6 Stairs1.6 Motor Score Index Item ScoreWeight Value Eating Grooming Bathing UB Dressing LB Dressing Toileting Bladder Bowel Transfer Bed, Chair, W/C Transfer Toilet Transfer Tub/Shower 4 Locomotion Stairs Total 37.5 Quality Measures Three measures: Percent of Patient with New or Worsened Pressure Ulcers, NQF #0678 Catheter associated urinary tract infections will be reported to the CDC National Health Safety Network (NHSN) The third item under consideration is 30day comprehensive All- Cause Risk-Standardized Readmission Measure. CMS will publish the electronic specifications related to reporting the pressure ulcer measure on the CMS website no later than January 31, 2012. Questions? Next call: November 1:00 EST