irf pps fy 2013 update and changes: what the cms notice ...medilinks inpatient + documentation and...

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MediLinks Inpatient

+ Documentation and Workflow Specific To IRF requirements

+ Improve compliance, patient and financial outcomes and efficiency

+ Pre-Admission / Post-Admission / Therapy Evaluations – Real-time reporting

+ Billing is a by-product of Documentation – Increase Charge Capture & Revenue

+ FIM Scoring Integrity – Results = Improved Revenue Accuracy

+ IRFPAI Integration – Automated to select appropriate FIM scores

+ 3 hour rule compliance – Monitor 3/5 or 15/7 real-time

+ Interdisciplinary Plan of Care – Common view/document to meet CMS regulations

+ Goals Management – Short/Long Term goals - patients barriers to discharge

+ Task list - Data driven watch-dog custom for each user

Complementing Hospital Information Systems

Pre-built HL7 Interfaces • ADT In

• Orders In/Out

• Results In/Out

• Billing Out

• Narrative In/Out

• Scheduling In/Out

Experience with all HIS

Improved Workflow

MEDITECH

IRH/U PPS FY 2016

Proposed Rule & COMMENT PERIOD

CMS -1624-P

Darlene D’Altorio-Jones, PT, MBA-HCM

Senior Consultant, Strategist

Announcement

https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-09617.pdf

Change is the ONLY Constant…(true author unknown)

http://www.gpo.gov/fdsys/pkg/FR-2015-04-27/pdf/2015-09617.pdf

CMS-1624-P

2016 IRHospital/Unit Proposed Rule

+ Attendee will recognize payment and adjustments proposed for 2016 Federal Fiscal Year (FFY) as they relate to change from the present 2015 FY.

+ Unadjusted (standard) and Adjusted Federal Payment rates

+ Will appreciate changes to rural/urban designation in CBSA (core based statistical areas) / payment amounts – proposal to provide temporary steps to final process for 2016 payment formulas.

+ Attendee will understand that Implementation of ICD-10 will occur October 1st, 2015 for encoding the IRF PAI

+ Attendee will understand impact of proposed changes to future tracking of therapy services.

+ Attendee will become familiar with areas of change to the IRF PAI; version 1.3 (Fall 2015) & 1.4 (Fall 2016)

+ Attendee will be exposed to quality reporting changes for the 2016 year and proposed future years (2017, 2018)

+ Attendee will understand there is a proposed suspension of the IRF QRP data validation

process for FY2016 Payment and subsequent years until addressed by ruling.

+ Attendee will receive valuable links to download files and information on how to

comment toward final rule considerations.

Payment Component Impacts

• Standard v& ADJUSTED Federal Prospective Payment

Indices:

• Market Basket – IRF vs RPL based

• Wage & Labor Share / Cost Reporting indexes

• Budget Neutrality (case mix index adjustments)

• CBSA adjustments

• Rural or Urban Location Status

• ACA Amendments (Accountable Care Act Amendments) & other

rule adjustments

• Disproportionate Share Hospital % = LIP Adjustments (Low Income %)

• Teaching Status Y/N

• * Facility Level Adjustments no change since 2014

What is the IRF Specific Market Basket?

IHS Global Insight (IGI), Inc. is a nationally recognized economic and financial forecasting firm that CMS contracts to forecast components of the market baskets and multifactor productivity (MFP) percentages.

2016 FORMULA – Standard Payment

+ 2015 to 2016 Change

+ $15,198 to $15,529

Impact for Non-Participation QRP

+ Non participation conversion factor (Starts fresh – not a cumulative penalty)

+ 2014 Calendar year of Non-Participation

+ 2% Payment Reduction based on 2016 Market Basket Value

+ - $305 less payment per 1.0 CMI treated or $15,224

Payment Adjustment – QRP None Participation

+ At the time the proposed rule was prepared, CMS stated that 91, or 8% of the 1166 active Medicare-certified IRFs did not receive the full annual percentage increase for the FY 2015 annual payment update determination.

+ Just a few days before the cut off to report 2 indicators to National Health Safety Network, CMS pushed REMINDERS and MedLearn Matters 9106

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9106.pdf

Just a few days before the deadline, only 54% of Inpatient Rehab Hospitals/UNITS reported successfully to NHSN. We hope that gap was closed by 11:59 on May 15th!

Case Mix & Average LOS – CMS Table

ICD-10 Co-morbid Tier 1 & 2

+ Tier 3’s Include > 1,140 codes:

+ Abscesses

+ Cellulitis Conditions

+ Diabetes & Underlying Issues

+ Diverticulitis Conditions

+ Pneumonias

+ TB (many!)

+ Sepsis Conditions

+ Meningitis Conditions

+ Hepatitis Conditions

+ Myelitis Conditions

+ Whopping Coughs

+ Etc. etc

+ *All ICD-9 combination codes have A&B codes now!

Co-morbid Conditions – Tier 3

+ http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Data-Files.html

What Changes in Payment Formula?

Depends on Facility Area+ Core Based Statistical Areas

+ Transitional Step Values

+ Designation as Rural/Urban?

+ None, One or Both? Where are you?

Review for your Facility

+ County & Provider #

Tables 12 & 13 - Rural/Urban Status

No Change Status / Just CBSA Designation

+ In some cases a facility my be in a county that has a CBSA change but no change to the designation of their URBAN status. (Table 14)

Estimated Impact Given 2016 Proposals

+ Table 24:

Standard Payment with Facility Adjustment Formula

+ Proposal to Freeze the Facility-Level Adjustments at FY 2014 levels.

Case Mix Index Annual Adjustments

+ When comparing 2016 to 2015 published values, the tables below signify whether the 2016 value is GREATER than (green) or LESS than (red) last years values.

Standard Payment X CMI Compare

Outlier Threshold Payments

+ CMS proposes to update the outlier threshold amount to $9,698 to maintain estimated outlier payments at approximately 3 percent of total estimated aggregate IRF payments for FY 2016.

+ A case qualifies for an outlier payment if the estimated cost of the case exceeds the adjusted outlier threshold.

+ CMS calculates the adjusted outlier threshold by adding the IRF PPS payment for the case (the CMG payment adjusted by all of the relevant facility-level adjustments) and the adjusted threshold amount (also adjusted by all of the relevant facility-level adjustments).

+ CMS then calculates the estimated cost of a case by multiplying the IRF’s overall CCR by the Medicare allowable covered charge. If the estimated cost of the case is higher than the adjusted outlier threshold, we make an outlier payment for the case equal to 80 percent of the difference between the estimated cost of the case and the outlier threshold.

CODING

+ Impairment Group Codes

+ Presumptive Compliance under ICD-10 Listings

+ IRF PAI - New Arthritis Attestation Section

+ ICD-10 FILES

IGC Codes without EXCLUSIONS

Status Post Unilateral Hip Replacement

Status Post Bilateral Hip Replacements

Status Post Unilateral Knee Replacement

Status Post Bilateral Knee Replacements

Status Post Knee and Hip Replacements (Same Side)

Status Post Knee and Hip Replacements (Different Sides)

60% Rule Presumptive Compliance ICD-10’s

• CMS stated that a patient’s need for intensive inpatient rehabilitative services for the treatment of one or more of these conditions would depend on the presence of additional comorbidities that caused significant decline in his or her functional ability to an extent that would necessitate treatment in an IRF.

• If the patient has one or more of the comorbiditieson the list of “ICD-10-CM Codes that Meet Presumptive Compliance Criteria,” then the patient would already qualify as meeting the presumptive compliance criteria.

Co-morbid Conditions & Presumptive Compliance

ICD-10 CODING Presumed 10/1/2015

Govtrack.us

• An Attestation that you have listed an arthritic condition in either the Impairment Group Code, Etiologic Diagnosis OR a co-morbid condition ANDthat you have meet all the required documentation to validate conditional vs inclusion.

IRF PAI 1.3 Has a NEW FIELD 24A.

1.) Active Polyarticular Arthritis

2.) Systemic Vasculidities,

3.) Severe or advanced osteoarthritis.

These were each described as having to have significant functional impairment of gait and ADL’s. Each of these conditions must also have not shown improvement after an appropriate sustained course of outpatient therapy just immediately preceding the rehabilitation admission. CMS felt that the factors indicating these conditions were met requires some disclosure to enable conditional application of the rule. THEY CAN STILL AUDIT.

CONDITIONAL COMPLIANCE Attestation 24A.

As Promised – THERAPY MODES

+ The therapy items on the IRF-PAI are strictly a data collection exercise only for weeks 1 and 2 of the IRF stay

+ Definitions will be updated in the manual.

IRF PAI Version Updates

+ Version 1.3 October 1st, 2015

+ Version 1.4 October 1st, 2016

+ Significant changes are covered in this 31 page pdf file for the 2017 Fiscal Year beginning October 1st, 2016! Stay Tuned for discussion – late summer when we cover the IRF FINAL RULE!!

Quality Initiatives

Claims DATA Extracted

IRF PAI DATA Extracted

NHSN – to CDC - Extracted

How are Quality Data Collected?

October 1st, 2016 - NO CHANGES

? Voluntary / Mandatory Sections

2013 = Reduction 2015

2014= Reduction 2016

2015= Reduction 2017

2016= Reduction 2018* (3 months)

CHANGE OCCURRING!!! TIMELINE

2017= Reduction 2019 (Calendar Yr)

Non-Participation Fiscal Years

Table 22 gives future time tables for collection & Submission

Transition Annual Increase Factor

Same Measures

Continued… AND WITH CHANGES!!

You will note that most of these ARE ALSO going to create the needed changes for the 2017 FY IRF PAI –version 1.4.

Continued…

6 new proposed quality measures fall 2016(1) an application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (NQF #0674);

(2) an application of Percent of LTCH Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function (NQF #2631; under review);

(3) IRF Functional Outcome Measure: Change in Self- Care Score for Medical Rehabilitation Patients (NQF #2633; under review);

(4) IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634; under review);

(5) IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635; under review);

(6) IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636; under review).

Summary; Future Considerations PAI 1.4

CMS is requesting FEEDBACK on these measures

Future Considerations - QRP

• 2015 SAID THIS…

• CMS is proposing a validation of records process to randomly check accuracy of data submitted against medical records.

Validation –Random Selection Compliance Audit

CMS proposes a suspension of this previously finalized policy…

Data accuracy validation will have no bearing on the applicable FY annual increase factor reduction for FY 2016 and subsequent years unless and until we propose to either reenact this policy, or propose to adopt a new validation policy through future notice-and-comment rulemaking.

Validation – Suspended!Random Selection Compliance Audit

PUBLIC REPORTING (2010 promised!)

+ We propose a policy to display performance information regarding the quality measures, as applicable, required by the IRF QRP by fall 2016 on a CMS website, such as the Hospital Compare website: http://www.hospitalcompare.hhs.gov, after a 30-day preview period.

What Will Public Items Published Be?

+ The initial display of information would contain IRF provider performance on the following three quality measures:

+ Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678)

+ NHSN CAUTI Outcome Measure (NQF #0138)

+ All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From IRFs

DATES: To be assured consideration, comments must be received no later than 5 p.m. on June 22, 2015.In commenting, please refer to file code CMS-1624-P

ELECTRONIC: http://www.regulations.gov

Follow the "Submit a comment" instructions.

If you would like to send regular mail and or overnight, please follow the instructions provided on page one of the actual rule.

Proposal Comment Deadline

HELPFUL RESOURCE LINKS

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THANK – YOU

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