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2012 IRF PPS Updates Clinical Training Call October 4, 2011

2012 IRF PPS Updates Clinical Training Call October 4, 2011. Lisa Werner, MBA, MS, CCC-SLP. How A CMG is Determined. Case Mix Groups. Discharge-based system Payment is based on discharge information Case Mix Groups (CMG) 87 main groups 4 deaths 1 short stay

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2012 IRF PPS Updates Clinical Training Call October 4, 2011

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  1. 2012 IRF PPS UpdatesClinical Training CallOctober 4, 2011 Lisa Werner, 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 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

  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. • 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.

  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, 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 70.119 of the Medicare payment. • Down from 75.271 last year. • Wage (V) • Maintains budget neutrality.

  7. Provider Payment Components • Changes to facility adjusters: • 2012: • LIP: .1897 • Rural: 18.7% • Teaching: .4888 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: 0.4613 versus 0.6229 • Rural: 18.4% versus 21.3% • Teaching: 0.6876 versus 0.9012

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

  9. CMG Revisions • Published CMG differences for 2011 versus actual variances

  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. • 2011 outlier threshold is $10,660. • 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 $14,076 • Weight for CMG 108 Tier 3 = 1.8639 • 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 ½ one per diem = $9690

  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 .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).

  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 • .5856 • 5102 expired, orthopedic with a length of stay of 14 days or more • 1.4718 • 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 • 1.8779

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

  19. Changes in Comobidities that Tier • Tier 3 Additions: • 284.11 Chemo induced pancytopenia • 284.12 Other drug induced pancytopenia • 284.19 Other pancytopenia • Deleted 294.1 Pancytopenia • 415.13 Saddle embolic pulmonary artery • 488.81 Flu due to NVL A virus with pneumonia • 516.31 Idiopathic pulmonary fibrosis • 516.32 Idiopathic non-specific inter pneumonia • 516.33 Acute interstitial pneumonia • 516.34 Resp bronchial interstitial lung

  20. Changes to Comorbidities that Tier • Tier 3 Additions: • 518.51 Acute resp failure following trauma/surgery • 518.52 Other pulmonary insufficiency following trauma/surgery • 518.53 Acute on chronic acute respiratory failure following trauma/surgery • Deleted 518.5 • 793.19 Other nonspecific abnormal findings of the lung fields • 998.00 Postoperative shock, NOS • 998.01 Postoperative shock, cardiogenic • 998.02 Postoperative shock, septic • 998.09 Postoperative shock, other • Deleted 998.0 • 999.32 Blood infection due to central venous catheter • 999.33 LCL infection due to central venous catheter

  21. Changes in Comorbidities that Tier • Tier 3 Deletions: • 284.1 Pancytopenia • 518.5 Post-traumatic pulmonary insufficieny • 998.0 Postoperative shock

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

  23. The Importance of Accuracy • Three Tiers of Co-morbidities • Average eRehabData utilization in the previous 365 days: • Tier 3 27.16% • Tier 2 8.55% • Tier 1 5.81% • Can be identified up to two days before discharge. • Physician identification is mandatory.

  24. 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

  25. 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

  26. Tier 3 (Top 35) 278.01 MORBID OBESITY 584.9 ACUTE KIDNEY FAILURE NOS 357.2 NEUROPATHY IN DIABETES 250.60 DMII NEURO NT ST UNCNTRL 486. PNEUMONIA, ORGANISM NOS 342.90 UNSP HEMIPLGA UNSPF SIDE 682.6 CELLULITIS OF LEG 998.59 OTHER POSTOP INFECTION 518.81 ACUTE RESPIRATRY FAILURE 428.30 DIASTOLC HRT FAILURE NOS 415.19 PULM EMBOL/INFARCT NEC 250.40 DMII RENL NT ST UNCNTRLD 250.62 DMII NEURO UNCNTRLD 995.91 SIRS-INFECT W/O ORG DYSF 250.80 DMII OTH NT ST UNCNTRLD 507.0 FOOD/VOMIT PNEUMONITIS 428.32 CHR DIASTOLIC HRT FAILURE 250.70 DMII CIRC NT ST UNCNTRLD Tier 3 (Top 35) 428.22 CHR SYSTOLIC HEART FAILURE 515. POSTINFLAM PULM FIBROSIS 428.20 SYSTOLIC HRT FAILURE NOS 250.50 DMII OPHTH NT ST UNCNTRL 284.1 PANCYTOPENIA 998.32 DISRUP-EXTERNAL OP WOUND 780.62 Postprocedural fever 038.9 SEPTICEMIA NOS 342.91 UNSP HEMIPLGA DOMNT SIDE 998.32 Disruption of an external op (surgical) wound 342.92 UNSP HMIPLGA NONDMNT SDE 682.2 CELLULITIS OF TRUNK 518.5 POST TRAUMATIC PULM INSUFFIC 584.5 ACT KIDNEY FAILURE w/ LESION 250.01 DMI WO COMP NT ST UNCONT 682.3 CELLULITIS OF ARM Top Tier 3 Comorbidities

  27. Replacement of Lower Extremity Joint 0801ALOS W/O CM 7 Relative Wt. .4888 $ 6880.35 Motor >49.55 Motor > 37.05 & < 49.55 0802 ALOS W/O CM 9 Relative Wt. .6573 $ 9252.15 Motor> 28.65 & < 37.05 & Age > 83.5 Replacement of Lower Extremity Joint 0803 ALOS W/O CM 12 Relative Wt. .9062 $12755.67 Motor> 28.65 & < 37.05 & Age < 83.5 0804 ALOS W/O CM 10 Relative Wt. .8004 $11266.43 Motor > 22.05 & < 28.65 0805 ALOS W/O CM 13 Relative Wt. .9856 $ 13873.31 Motor < 22.05 0806ALOS W/O CM 15 Relative Wt. 1.2034 $ 16939.06

  28. Weighted Motor Score Index

  29. 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

  30. 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 “30–day 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.

  31. Questions? Next call: November 1 @ 1:00 EST

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