1 Vol. 3 No. 10 October 2003 Your source for PPS success INSIDE Medical necessity FIs, starting with one in Georgia, have ideas about medical necessity that could cause serious repercussions in the IRF industry. Read up on the latest LMRPs and what you need to do to fight them on p. 2. Electronic IRF-PAI data Some IRFs have all the luck, including this one in Kentucky that gathers all its patient assessment information electronically meaning anyone can chart at any time resulting in automatic updates. Check out p. 4. Plus, these systems can create an army of reports so you ll always know how you score. See p. 5. Desperately seeking staff? Look for innovative recruiting ideas in your November PAIR. Beating the weekend blues Systems for getting good IRF-PAI data 24/7 Many IRFs have great methods for collecting data for the FIM instrument and the rest of the IRF-PAI that is, until the weekend rolls around. Once Saturday hits, they may have to contend with per diem staff or agency therapists, who may not be familiar with the system. Even worse, they may not all be FIM certified. weekend. Setting up a proper treatment program for a new patient is very difficult if your data s not correct. When talking to successful IRFs, there are five C s of a good system which ensure getting relevant weekend coding that come up again and again. Check out the guidelines and see whether there are some your facility could use: This may not exactly sound tragic, but if you don t have good weekend staff, you could wind up with Cinching carryover. First, 1. inaccurate assessment data especially you need to have people for new admissions who come in on Wednesday or Thursday and need their initial assessments who know what they re doing there on the weekends. We have FIM-certified people working on completed over the the weekend, explains > p. 6 IRFs not likely to be happy about proposed 75% rule changes Receive PAIR online! For more information, go to onlinepubs or call our Customer Service Center at 800/ FOR PERMISSION TO REPRODUCE PART OR ALL OF THIS NEWSLETTER FOR EXTERNAL DISTRIBUTION OR USE IN EDUCATIONAL PACKETS, PLEASE CONTACT THE COPYRIGHT CLEARANCE CENTER AT OR 978/ Although better than the status quo, CMS proposed changes to the 75% rule will likely disappoint most inpatient rehab providers and advocates. The proposed new criteria that determine which IRFs get paid under Medicare has loosened up somewhat, but is nowhere near what providers were hoping for. CMS first threatened to enforce the 75% rule in May and was stormed by industry advocates who claimed, through letter-writing campaigns and public meetings, that under such strict criteria, no IRF would qualify as a provider under the PPS that reimburses for the care of Medicare patients. CMS answered the charges September 2 in a press release announcing its proposed changes to the 75% rule. Not what IRFs asked for The results were formally published as a proposed rule in > p. 7
2 Medical necessity looms large on IRFs troubled horizon The buzz in the rehab world says fiscal intermediaries (FIs) are retooling their local medical review policies (LMRPs) concerning medical necessity and that this is not good news for inpatient rehab. FIs such as BlueCross BlueShield (BCBS), Riverbend, and Veritus are coming out with revised LMRPs that set very strict conditions for patients if they are to be admitted to an IRF. [The LMRPs] are extremely narrow, narrower probably than existing national coverage guidelines, says Carolyn Zollar, vice president of government relations and policy for the American Medical Rehabilitation Providers Association (AMRPA) in Washington, DC. It looks very strict and different from admission patterns we ve had in the past, agrees Andi Russell, MS, CCC-SLP, coordinator of inpatient and acute rehab at the Floyd Medical Center in Rome, GA, the state where the flap over medical necessity first began, as reported in the September PAIR. What happened in Georgia In September, BCBS of Georgia released its new version of the policy for medical necessity a very limiting one. Providers and their associations are reviewing it, preparing to make comments. At a recent meeting of the Georgia Hospital Association Rehabilitation Council, members dissected the LMRP, dividing participants into groups to review it in sections. We are as a group trying to look at the policy and identify what the real issues are, she explains. The comment period for responding to the LMRP began October 1 and will last for 45 days. At the meeting, participants split into groups and divided up the policy to review pieces separately. BCBS is the main FI for Georgia, but the LMRP it has drawn up would apply to such additional states as Pennsylvania, Alabama, and Tennessee. It could also apply to many states that are under the FI s secondary geographic jurisdiction. This matter, therefore regardless of which state you re in should be of great concern to you, advises Frances Fowler, president of Fowler Health Care Affiliates in Atlanta. These unforgiving LMRPs could become national policy and the standard of care for inpatient rehab. We were fortunate in Georgia to get our hands on it before it became final, she says. What the LMRP states So why should inpatient rehab providers be worried about this revamped LMRP? Fowler lists a few pervading themes that should give you cause for concern: Medical issues v. rehab. The admission criteria for medical necessity must be met before any of the rehab conditions apply [in the BCBS LMRP], she explains. This means that if the policy goes through as written, IRFs won t be about rehab anymore they ll be about treating acute conditions. So even someone who needs three hours of therapy per day and meets all the rehab conditions wouldn t be admitted unless he or she met the medical necessity criteria, Fowler goes on to explain. Despite all the hullabaloo about the 75% rule, the criteria will be applied regardless of the patient s diagnosis. If the policy is adopted, it would likely mean that your only admissions would be very sick patients coming directly from acute care, with active conditions you d need to treat. The problem is that patients who are that ill cannot stand three hours of therapy not to mention that acute care physicians would feel uncertain about discharging them [to rehab], she says. The policy could also make for increased readmissions to the hospital if patients who weren t ready for intense rehab were admitted because no one else met the admission criteria. Wary physicians. Once physicians become familiar with the stricter admissions guidelines Page HCPro, Inc.
3 for rehab patients, a huge amount of work will be added their plates. It will force physicians to change their documentation and how they get patients admitted to rehab, says Fowler. The amount of time physicians would have to take to get people admitted to [inpatient] rehab would be astronomical. A bevy of claims denials. Another dire consequence of FIs adopting this narrow definition of qualifying a patient for IRF services would be the increase in claims denials and the time facilities would have to spend fighting to get reimbursed for care already provided. As a matter of fact, Russell s facility went through an audit by BCBS last winter to determine whether claims met current medical necessity and other guidelines. Our FI did an audit of records across the state, so we knew what records were being requested and what was being denied, she says. At least that gave IRFs in Georgia an advantage in that they can already identify the FI s hotspots. We had a heads up that some kind of action was coming related to medical necessity, she explains. Unfortunately, that probe into 80 of her IRF s claims resulted in approximately 60 denials based upon lack of medical necessity. So this should be a bright red flag to other IRFs if they receive a similar request from their own FIs. She advises other IRFs to keep an eye on their intermediary s Web site for information about changing LMRPs. Floyd Medical Center also has a patient assessment coordinator who reviews what the facility s been paid for and what s still pending every month. According to the FI, many denied claims occur because when it requests further information, the billing and medical records departments do not send the correct paperwork to answer the query. Russell warns other facilities to have only trained professionals familiar with the process handle claims denials. What to do now The new LMRP is so stringent that Fowler predicts it could reduce rehab business by more than 40% if adopted the way it s currently written. It could be devastating to the field, adds Zollar. This may instill a feeling of helplessness in inpatient rehab providers, but there are steps you can take to fend off the very worst and soften the blow of a new LMRP. Fowler urges providers to get out there and take some drastic action. Experts suggest the following: Alert the billing department of the possible 1 change in the LMRP. When your FI rolls out a new LMRP concerning medical necessity in your state, the notice will probably go right to the billing department and could get lost in the shuffle or passed over as unimportant. Fowler points out that because the period for submitting comments is not very long, IRFs need to know immediately when change is on the horizon so they can take appropriate action. Make sure billing personnel keep their eyes and ears open for any shifts. Familiarize yourself now with your current 2 LMRP. Know the evidence that you have to use [to prove that a patient requires inpatient rehab care], and the evidence the FI has to accept; make sure your documentation is extensive and impeccable, says Zollar. This will also help you spot variations if you are presented with a new LMRP. 3 Finally, work with your state and national associations to craft a response to new guidelines for medical necessity. All the national organizations such as AMRPA, the American Occupational Therapy Association, the American Physical Therapy Association, etc. are working on this issue, Zollar says, but IRFs should be meeting with state rehab and hospital associations to draw up their own responses. People need to react and comment on these [LMRPs] effectively. Editor s note: Go to #Inpatient to read a draft version of an LMRP that contains stricter medical necessity definitions HCPro, Inc. Page 3
4 Computerized IRF-PAIs make for PPS success One facility s equation for getting accurate IRF-PAI documentation Different facilities have different ways of gathering data for the IRF-PAI which depends on such elements as who is FIM certified, how the PPS coordinator gets the relevant information, and how disciplines communicate with each other regarding a patient s progress. But for Lara Beth Sheets, MS, CCC-SLP, PAI coordinator at Cardinal Hill Rehabilitation Hospital in Lexington, KY, the whole process became a lot smoother when her information technology department created a computerized in-house system to handle not only PPS but a host of other necessary facility duties. We don t have to depend on staff completing a paper version [of the IRF-PAI], says Sheets. An electronic version is already in the computer, staff are trained [on it], and primary nurses and therapists are all FIM certified. They can put in the scores any day of the week. Together, but separate According to Sheets, facility management divided up the responsibility of filling out the IRF-PAI from the beginning, giving different sections to physical therapy, occupational therapy, speech therapy, nursing, and social work. That way, no single person had to shoulder the entire load of assessing and scoring a patient s abilities. However, no man or woman is an island in the Cardinal Hill system. Therapists look at their own notes, but then they review nursing documentation for their responses and combine that to capture 24 hours of a patient s function, says Sheets. They will also take time to talk with other therapists involved in the patient s care. The combination makes for a method that is both intra- and interdisciplinary. In addition to sharing information through notes and conversation, therapists use an internal worksheet to pass along patient information to other therapists. That way, when weekend or the occasional per diem therapists come in to work with patients, they can look at the worksheets and be up to speed on the patient s condition and progress. The FIM-certified staff are then able to use that information with the patient function data on day four of a patient s stay, even if it s on the weekend. It s not a perfect system, but it does keep staff abreast of therapy notes and assessments, as well as nursing documentation, says Sheets. Therefore, staff notice when the two differ. Reviewing nursing documentation also enlightens staff members to patients who perform differently at different times of the day. It keeps staff aware of the patient s functional differences to discuss. Better communication Sheets facility made some additional moves to strengthen communication among staff members. Nurses, for example, are benefiting from a new documentation style set up by the facility last year. Before the update, Sheets relates, nurses documented everything in narrative form, which wasn t always the best use of their time. Having switched to using language from the FIM instrument, the facility has created a form with common level of assistance triggers that nurses can simply initial and sign. On every shift, the nurses will assess whether an activity did occur and the level of assistance required, she explains. The standardized form allows them to spend less time writing out the same descriptions in longhand every shift. If staff observe an unusual event, they document that in an additional note. Nursing narrative notes focus on assessing changes in the patient s condition. Cardinal Hill also conducts huddles twice a week on each unit. These are brief, stand-up meetings during which staff can compare notes about different patients and explore assessment discrepancies. Through the inhouse software that holds FIM, as well as clinical, PPS, accounting, and billing information, staff can generate reports that are useful for meetings and analysis. Page HCPro, Inc.
5 The PAI coordinator Sheets herself works as one of the facility s two PAI coordinators, who together handle a total of 108 beds. As well as reviewing 100% of the facility s IRF-PAIs for accuracy, the PAI coordinators teach PPS and FIM scoring, troubleshoot problems, and work closely with the facility s certified coders so that patients diagnoses are coded correctly. Staff gather assessment information up through the fourth day after a patient s admission. On the morning of the fifth day, Sheets examines the computerized assessment instrument to make sure all the data is there. Then I lock the record so the data is secure, she says. Between the fifth and tenth days, she reviews the patient s record and makes sure there is documentation to support the scores in the computer. If necessary, she will unlock a record and correct erroneous scores so that they agree with the patient s actual status. If a team member missed a piece of documentation that would have changed the score either lowered or raised it we want the score to agree with the documentation, Sheets explains. After she corrects any errors, the software recalculates a patient s estimated stay, reimbursement rate, and case-mix group. Navigating PPS Since the advent of the new payment system, the IRF has held PPS steering committee meetings with representatives from all concerned departments clinical management, billing, patient services, information systems, compliance, and more. We got together and held every-other-week meetings initially, so it s been a total facility effort from the beginning, explains Sheets. The group still convenes on a monthly basis to talk about how to increase efficiency and streamline processes and systems. This allows everyone to feel that they have ownership in the process and that their input is valued. We feel there are things we still need to look at closely, such as timely billing, form use, communication between team members, and staying in compliance, she says. But it s not all PPS all the time, she adds. Staff try to keep the big picture in mind. We focus on all the various reasons staff must document clearly and completely, in addition to supporting FIM scores. FIM assessment documentation is only one part of the documentation process for quality patient care. All the reports you could want Having a computerized system for your IRF-PAI scoring can come in handy. Just ask Lara Beth Sheets, MS, CCC-SLP, PAI coordinator at Cardinal Hill Rehabilitation Hospital in Lexington, KY. Not only can staff enter pertinent patient data at any time, but the system will automatically update the entire patient record to reflect the new information. Even better, the system generates many different types of reports so Sheets can keep track of how assessments are going. She routinely pulls up reports to see what pieces are missing from a patient s IRF-PAI allow different clinicians to compare notes track transmissions to Medicare Staff use other helpful reports to analyze efficiency and quality indicators. The reports are completely customizable, and if Sheets makes a change in any part of a record, the system will automatically update itself and change that part on the report that goes to erehabdata or UDSMR, companies that analyze her assessment data. Because of the computerized reports, Sheets can do more thorough auditing of IRF-PAIs before they are locked and transmitted. The result is that billing is more efficient because bills contain fewer errors HCPro, Inc. Page 5
6 Weekend blues < p. 1 RoseMarie Pleskonko, RN, CRRN, rehab liaison at Gibson Rehabilitation Center in Williamsport, PA. Further, some of the same staff who work weekdays carry over to the weekend shift and therapists are on staff seven days per week. Shirley Crampton, BSN, RN, CRRN, rehabilitation educator and PPS co-coordinator at White Memorial Medical Center in Los Angeles, works under similar conditions. Most nurses at White Memorial work every other weekend, so there is overlap of FIMknowledgeable staff onto Saturdays and Sundays. The rehab therapists also work some weekends. All of the therapists have been trained on the FIM since they use it in the rest of the hospital, she says. On Monday, the IRF s primary therapists will check the weekend FIM scoring for accuracy. Completing consistently. Another point successful IRFs make is that it s easier to complete 2. assessments correctly if you have a tried-and-true system for them. For new admissions, PPS rules state that the facility has the first four days of that patient s stay to gather initial assessment data. For Wednesday and Thursday admissions, that means the last day occurs over the weekend. If the fourth day comes on a weekend, there s still staff here that can enter the information on the IRF- PAI so that the scores are captured on the form, says Crampton. Meanwhile, her coders, who work Monday through Friday, try to get the diagnosis codes on the chart by day two so that everything is completed in a timely manner. Staff in Pleskonko s facility also enter data all weekend on a paper copy of the IRF-PAI. We have a copy of the scoring based on every encounter with the patient. On Monday, I look back and take the lowest number for the FIM score. 3. Conducting audits. Crampton checks that White Memorial s IRF-PAIs are complete and accurate after they are done. I compare the documentation to what s on the chart so if I find errors, I work with the person responsible for that item to get it corrected so that it matches the chart, she says. Occasionally, Pleskonko will run across scoring that can t be substantiated by notes in the patient s record. If there s a discrepancy in FIM scoring, Pleskonko will track down the information or bring it up in the weekday huddle the stand-up meeting all therapists attend to review patient care and make sure FIM scores are correct. Correcting errors. Another important area is 4. IRF-PAI audits. Pleskonko s facility has a separate person who audits completed IRF-PAIs for accuracy and checks that everything is completed and coded. If there s a scoring discrepancy that appears to be a training problem, Pleskonko will go back to the manager of that department and arrange to bring the employee up to speed. Crampton says she hasn t run across more errors on the weekends than weekdays as a general rule of thumb. Physical therapists may code locomotion wrong but that s a tough one. Sometimes when they put the score together having figured both assistance level and distance they make mistakes. But that s something I can correct myself because I can see what the score should be, she adds. Confronting challenges. If your facility staffs 5. therapists and nurses who are familiar with FIM scoring on the weekends, you simply have to audit scores and you should be in good stead, right? Well, a further challenge lies in holidays and three-day weekends, says Crampton, when FIM-certified staff can become scarce. Sometimes we ll notice that on a holiday weekend we have more per diem staff and they don t work as often so the scores may not be as accurate, she explains. She makes sure to go over scoring more closely after those long weekends. But there s always someone in the facility who is experienced at FIM scoring, and less knowledgeable staff feel free to go to that person to ask questions, Crampton adds. Page HCPro, Inc.
7 75% rule changes < p. 1 the September 9 Federal Register. Basically, CMS dropped the 75% threshold lower but it added all types of restrictions, explains Frances Fowler, president of Fowler Health Care Affiliates in Atlanta. Some of the negatives for IRFs are as follows: CMS will reduce the percentage of IRF patients who must be diagnosed with one of the 10 original medical conditions from 75% to 65%, it said in its press release. This means the agency did not adopt industry advocates advice to change the original 10 diagnoses to the 20 Rehabilitation Impairment Categories used to determine payment levels under PPS. Further, this reduction in percentage will only be in effect for three years after this proposed rule is made final. Afterward, IRFs will be looking at 75% again. Though CMS has reduced the percentage temporarily, a large portion of inpatient rehab facilities won t meet even the 65% rule, points out Richard Linn, PhD, director of UDSMR in Amherst, NY. As an initial determination of IRFs compliance with the rule assuming it becomes final CMS will be monitoring the number of Medicare patients who place into one of the 10 conditions, rather than looking at an IRF s patient population as a whole. If an IRF doesn t make the cut counting just its patients under PPS, CMS will take a hard look at the entire patient population to determine 65% rule compliance, he warns. The sunny side Naturally, the news wasn t all bad, and IRFs did receive some concessions from CMS in the areas of arthritis and secondary conditions, called comorbidities, Linn explains. Because the definition of arthritis is split threefold, some providers are interpreting the proposed rule to mean that there are actually 12 conditions now. Here are two highlights: CMS proposes to delete the term polyarthritis from the list of the 10 diagnoses and replace it with three more precise terms that define arthritis-related ailments. Polyarthritis was defined in the proposed rule of May 2003, Linn explains, but the definition did not include osteoarthritis. Now osteoarthritis will count as a rehab category if it is severe or advanced and involving three or more major joints. But three or more major joints may be a hard quality to find in a patient, points out Fowler. The only choices open to providers are arthritis of the elbow, shoulder, hip, or knee. On top of that, active polyarticular rheumatoid arthritis and systemic vasculidities with joint inflammation will now count as one of the 10, or technically 12, conditions. This should allow for some additional cases to qualify under the > p. 8 PAIR Subscriber Services Coupon Start my subscription to PAIR immediately. Options: No. of issues Cost Shipping Total Print 12 issues $327 (PAIRP)* $17.00 Electronic 12 issues $327 (PAIRE) N/A Print & Electronic 12 issues of each $409 (PAIRPE)* $17.00 Order online at and save 10% Sales tax* MA residents please add 5.0% Grand total Mail to: HCPro, P.O. Box 1168, Marblehead, MA Tel: 800/ Fax: 800/ Web: Your source code: N0001 Name Title Organization Address City State ZIP Phone Fax address (Required for electronic subscriptions) Payment enclosed Please bill me Please bill my organization using PO # Charge my: AmEx MasterCard VISA Signature (Required for authorization) Card # Expires (Your credit card bill will reflect a charge to HCPro, the publisher of PAIR.) 2003 HCPro, Inc. Page 7
8 75% rule changes < p. 7 65% requirement, Linn says. Finally, IRFs may be able to squeak some hip and knee replacements into the 10 categories if those patients have comorbidities that are serious enough, Linn says. Patients with serious secondary medical conditions those that would require treatment in an IRF anyway instead of a skilled nursing facility, inpatient hospital, or outpatient setting will qualify under CMS proposed rule. Neutral areas There are those points from the rule that you should take notice of now because you may have to do something about them later, experts say. For example, CMS is proposing to change the time frame it uses to review patient data counting toward the 65% in the proposed rule. Instead of using the most recent 12-month cost reporting period, it wants to go by the calendar year. Not only does the agency plan to phase out the 65% rule requirement raising it back up to 75% three years after the current proposal is adopted but it will also renege on letting IRFs count patients with serious and complex comorbidities toward the 65% group. The changes will occur automatically on January 1, 2007, unless CMS comes out with something different before then, its press release noted. Time for action Now that IRFs know what they re up against, it s time for action. Remember, this is only a proposed rule, says Linn. I hope the industry reacts appropriately. This means taking some of the same steps IRF providers and advocates did in May to alert political leaders to problems in the rule. People just have to hunker down and fight, says Fowler. As stated in its press release, CMS will accept comments until November 3. Editor s note: Go to #Inpatient to read CMS press statement and the September 9 proposed rule. Editorial Advisory Board Shirley Crampton, BSN, RN, CRRN Rehabilitation Educator and PPS Co-coordinator White Memorial Medical Center Los Angeles, CA Sam Fleming Principal Fleming-AOD Inc. Washington, DC Frances J. Fowler President Fowler HealthCare Affiliates, Inc. Atlanta, GA Ann Lambert, MHSA, OTR/L Senior Manager Baker Newman & Noyes Portland, ME Richard T. Linn, PhD Director, UDSMR Buffalo, NY Patricia Trela Manager, Deloitte & Touche Boston, MA Carolyn Zollar, JD Vice President for Government Relations and Policy Development American Medical Rehabilitation Providers Association Washington, DC How may we help you? For news and story ideas: Contact Managing Editor Noelle Shough Phone: 781/ , Ext Mail: 200 Hoods Lane, Marblehead, MA Fax: 781/ Executive Editor, Christine Hannan Group Publisher, Kelly Wallask Publisher, Suzanne Perney Web site resources: To get the latest breaking news, visit For free resources available from HCPro, please visit Subscriber services and back issues: New subscriptions, renewals, change of address, back issues, billing questions, or permission to reproduce any part of PAIR, please call customer service at 800/ PPS Alert for Inpatient Rehab (ISSN ) is published monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA Subscription rate: $327/year. Postmaster: send address changes to PPS Alert for Inpatient Rehab, P.O. Box 1168, Marblehead, MA Copyright 2003 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc. or the Copyright Clearance Center at 978/ Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call 781/ or fax 781/ For renewal or subscription information, call customer service at 800/ , fax 800/ , or Visit our Web site at Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the Marketing Department at the address above. Opinions expressed are not necessarily those of PAIR. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. Page HCPro, Inc.