2009 IRF PPS UpdatesClinical Training Call

October 7, 2008Lisa Bazemore, 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-morbidities Additional medical condition that has a significant effect on the rehabilitation stay & progress & cost.

Age The age of the patient upon admission

Case Mix Groups

•Discharge-based system Payment is based on discharge information

•Case Mix Groups (CMG) 95 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.

• 385 payment categories

• The base rate from the government Range of average discharge rates $6,108 - $36,561

with no co-morbidity Range of average discharge rates $9,071 – $51,529

with the highest co-morbidity

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.

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

• Labor Share (F) Total is 75.464 of the Medicare payment. Based on Global Insight’s 2008 second quarter forecast.

• Wage (V) Wage index is 1.0003 Maintains budget neutrality.

CMG Revisions

• Weight revisions for the CMGs

Resulted in an overall payment weight of .9939. National impact according to eRehabData looking back over

the past 365 days is -$280.67 per case.

CMG Revisions

•Standard payment calculation:

• $13,034 base rate 2008• X 1.0 for zero percent increase factor• X 1.0003 for wage index change• X .9939 for CMG weight revisions• $12,958 base rate 2009

CMG Revisions

• Impact of CMG weight revision by RIC:

RIC Variance01 Stroke ($683.49)02 Traumatic brain injury ($902.85)03 Nontraumatic brain injury ($873.14)04 Traumatic spinal cord ($784.55)05 Nontraumatic spinal cord ($233.95)06 Neurological $164.3007 Fracture of LE $8.9908 Replacement of LE joint ($16.28)09 Other orthopedic ($133.71)10 Amputation, lower extremity ($75.41)11 Amputation, other ($316.45)12 Osteoarthritis $1.1913 Rheumatoid, other arthritis ($179.43)14 Cardiac ($355.20)15 Pulmonary ($678.15)16 Pain Syndrome ($137.16)17 Major multiple trauma, no brain injury or spinal cord injury ($31.25)18 Major multiple trauma, with brain or spinal cord injury ($1,247.27)19 Guillain Barre ($429.67)20 Miscellaneous ($130.31)21 Burn $3,110.87

CMG Revisions

• Stroke CMGs: Signification reduction in

0107 and 0109. Associated length of stay

decline was 2-3 days.

CMG Variance101 ($493.74)102 ($329.92)103 ($329.25)104 ($324.95)105 ($692.29)106 ($736.86)107 ($1,001.87)108 $168.18109 ($1,076.47)110 $14.82

CMG Revisions

• Lower Extremity Fracture CMGs:

Most commonly used CMGs are 0702 and 0704 according to eRehabData national trends.

Increased average length of stay by 2 days.

• Replacement of the Lower Extremity CMGs:

Most commonly used CMGs are 0802, 0804, and 0805 according to eRehabData national trends.

Increased average length of stay by 1-2 days.

CMG Variance701 ($157.71)702 $7.86703 ($210.48)704 $594.08801 ($199.79)802 $307.40803 $1.81804 $88.73805 ($32.53)806 $397.36

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.

2009 outlier threshold is $10,250. 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 ½ the per diem for the first day

Transfer Rule Example

• Base Rate $12,958• Weight for CMG 108 Tier 3 = 1.8860• Weight times base rate = $24,439• LOS for CMG 108 Tier 3 is 23• CMG 108 Tier 3 divided by 23 = $1063/day• Times 8 days = $8500• Plus ½ one per diem = $9031.50

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 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.

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.

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).

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

Changes to Comorbidities that Tier

•Tier 1: V45.1 for renal dialysis status is no longer a valid code. Replaced with V45.11 for renal dialysis status.

•Tier 2: No changes

Changes in Cormobidities that Tier

• Tier 3: 038.12, Methicillin resistant Staphyloccoccus aureus

septicemia 482.42, Methicillin resistant pneumonia due to

Stephylococcus aureus (excluded from RIC 15) New conditions; not replacement codes.

Additional codes for active leukemia in relapse.• 204.02 active lymp leukemia in relapse• 205.02 active myel leukemia in relapse• 206.02 active mono leukemia in relapse• 207.02 active erth/erylk leukemia in relapse• 208.02 active unspecified leukemia in relapse

Changes in Comorbidities that Tier

• Tier 3: New category for secondary diabetes. In the fifth digit, 0 denotes not stated as uncontrolled In the fifth digit, 1 denotes uncontrolled

249.41    SEC DM RENAL UNCONTRLD    249.50    SEC DM OPHTH NT ST UNCN    249.51    SEC DM OPHTH UNCONTRLD    249.60    SEC DM NEURO NT ST UNCN    249.61    SEC DM NEURO UNCONTRLD    249.70    SEC DM CIRC NT ST UNCNTR    249.71    SEC DM CIRC UNCONTRLD    249.80    SEC DM OTH NT ST UNCONTR    249.81    SEC DM OTHER UNCONTRLD    249.91    SEC DM UNSP UNCONTROLD   

Changes to Comorbidities that Tier

• Tier 3:

New code in the gastritis section:• 535.71    EOSINOPHILC GASTRT W HEM   

New code range for fevers which was expanded to distinguish different types of fevers.

• 780.62    POSTPROCEDURAL FEVER 

One new code for non-specific wound disruption• 998.30    WOUND DISRUPTION NOS  • 998.31 for disruption of internal operative wound remains• 998.32 for disruption of external operative wound remains

Coding Additions

• Other coding changes:

Many other coding changes were published. Those mentioned impact payment under the IRF PPS

payment system

Coding Additions

• Other coding changes: Broad overview of coding changes, which you should research

further:• Staphylococcus Aureus-

Carrier codes Methacillin resistant codes Methacillin susceptible codes

• Category 046 codes for prion disease of the central nervous system• Malignant neoplasm of transplanted organs• Headaches• Coronary atherosclerosis due to lipid rich plaque• Malignant pleural effusion• Hematuria• Pressure ulcers require site and stage codes• Stress fractures• Functional urinary incontinence• Ventilator associated pneumonia• Infusion and transfusion reaction

Coding Additions

• V Code Additions: V46.3, wheelchair dependence, denotes confinement to a

wheelchair History codes for personal history of fracture

• V13.51 pathologic fracture• V13.52 stress fracture• V13.59 other musculoskeletal fracture• V15.51 traumatic fracture• V15.59 other fracture

The Importance of Accuracy

•Three Tiers of Co-morbidities Average eRehabData utilization in the previous 365

days:

•Tier 3 22.56%•Tier 2 7.76%•Tier 1 5.70%

Can be identified up to two days before discharge. Physician identification is mandatory.

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

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

Top Tier 3 Comorbidities

• Tier 3 (Top 30) 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 250.40 DMII RENL NT ST UNCNTRLD 250.80 DMII OTH NT ST UNCNTRLD 507.0 FOOD/VOMIT PNEUMONITIS 250.62 DMII NEURO UNCNTRLD 518.81 ACUTE RESPIRATRY FAILURE 250.70 DMII CIRC NT ST UNCNTRLD 250.50 DMII OPHTH NT ST UNCNTRL

• Tier 3 (Top 30) 998.32 DISRUP-EXTERNAL OP WOUND 515. POSTINFLAM PULM FIBROSIS 995.91 SIRS-INFECT W/O ORG DYSF 428.30 DIASTOLC HRT FAILURE NOS 342.91 UNSP HEMIPLGA DOMNT SIDE 284.1 PANCYTOPENIA 342.92 UNSP HMIPLGA NONDMNT SDE 038.9 SEPTICEMIA NOS 682.2 CELLULITIS OF TRUNK 518.3 PULMONARY EOSINOPHILIA 518.5 POST TRAUM PULM INSUFFIC 434.91 CRBL ART OCL NOS W INFRC 682.3 CELLULITIS OF ARM 342.80 OT SP HMIPLGA UNSPF SIDE 250.01 DMI WO CMP NT ST UNCNTRL

Replacement of Lower Extremity Joint

0801 ALOS W/O CM 7Relative Wt. .4714

$ 6108.40

0802 ALOS W/O CM 9Relative Wt. .6137

$ 7952.32

0803 ALOS W/O CM 12 Relative Wt. .9013

$11679.05

0804 ALOS W/O CM 10Relative Wt. .7910

$10249.78

0805 ALOS W/O CM 13Relative Wt. .9874

$ 12794.73

0806 ALOS W/O CM 15Relative Wt. 1.2215

$ 15828.20

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

Weighted Motor Score Index

Item Weight

Eating .6

Grooming .2

Bathing .9

Dressing – Upper Body .2

Dressing – Lower Body 1.4

Toileting 1.2

Bladder .5

Bowel .2

Transfer Bed, Chair, W/C 2.2

Transfer Toilet 1.4

Transfer Tub, Shower Not included as item for CMG

Locomotion 1.6

Stairs 1.6

Motor Score Index

Item Score Weight Value

Eating 5 .6 3Grooming 5 .2 1Bathing 4 .9 3.6UB Dressing 4 .2 .8LB Dressing 3 1.4 4.2Toileting 4 1.2 4.8Bladder 1 .5 .5Bowel 5 .2 1Transfer Bed, Chair, W/C 3 2.2 6.6Transfer Toilet 4 1.4 5.6Transfer Tub/Shower 4Locomotion 2 1.6 3.2Stairs 2 1.6 3.2

Total 37.5

Questions?

Next call: November 4 @ 1:00 ESTWriting an Appeal Letter