1. 2010 IRF PPS Updates Clinical Training Call November 3, 2009 Lisa Werner Bazemore, MBA, MS, CCC-SLP

2. 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

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 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.

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 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.

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. Top Tier 3 Comorbidities 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

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

30. 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

31. Motor Score Index Item ScoreWeight 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