Rehabilitation Regulatory Compliance Risks

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1 Rehabilitation Regulatory Compliance Risks Christine Bachrach Vice President & Chief Compliance Officer University of Maryland Medical System 2011 AHIA Annual Conference

2 Agenda - Rehabilitation Compliance Risks Understand the basic requirements for Inpatient Rehabilitation Facilities (IRFs) and Outpatient Rehabilitation Facilities (ORFs) Conditions of participation, i payment system IRF Conditions of coverage Basics of payments system IRF CMGs Outpatient Therapy Fee Schedule and payment limitations Understand the risks for outpatient therapy, both in the hospital and ORF settings, including rounding, medical necessity Understand the risks for IRFs, including intensity of service, comorbidities Auditing and Monitoring rehabilitation risks for IRFs and ORFs 2

3 IRF Conditions of Participation IRFs must meet general hospital requirements and then additional requirements to be exempted from the regular acute care Inpatient Prospective Payment System (IPPS) See 42CFR Provider agreement to participate as a hospital PLUS: Free-standing facility or distinct unit of hospital Beds cannot be co-mingled with acute care patients Serve an inpatient population with 60% requiring intensive rehabilitation services for treatment of at least one of 13 specified conditions (60% Rule) Medical Director who Provides services to the hospital and its patients on a full-time basis (20 hours if unit) Medical Doctor (MD) or Doctor of Osteopathy (DO) minimum two years training in rehabilitation services 3

4 IRF Conditions of Participation (cont.) Develop a Plan of Care that is reviewed by a multidisciplinary team at least every two weeks to assess progress and further need for services Failure to meet any of the Conditions of Exclusion will result in loss of IPPS exempt status, and reimbursement will default to Diagnostic Related Groups (DRGs) Significant financial impact as average length of stay for IRFs is 16 days; for general inpatient it is 6 days (~ 60% reduction in reimbursement) 4

5 Changes to Medicare Benefit Policy Manual IRF care is reasonable and necessary if patient meets all requirements of revised 110 Preadmission Screening Required, Licensed clinician Post-Admission Physician Evaluation within 24 hours if not appropriately discharged within 3 days Medical Necessity Criteria met at time of admission Require intensive rehabilitation 3 hours per day, 5 days per week starting within 36 hours of admission Require an intensive and interdisciplinary approach Expectation of measurable improvement of a practical value 5

6 FY 2010 IRF PPS Final Rule Changes to Coverage Criteria i Fed Reg 8/7/09 Components Pre-Admission Screening New Coverage Requirements The Rehab Physician must document reasoning behind the decision to admit to an IRF IRF Services must be ordered by Rehabilitation Physician Screening must be done by competent staff that are trained and qualified to assess the patient s medical and functional status, assess the risk for clinical and rehab complications and assess other aspects of the patient s condition. These clinical staff must be designated by the Rehab Physician. Screening must be completed within 48 hours before admission to the IRF (note: CMS will allow the screening to be completed more than 48 hours of admission as long as it is updated within the 48 hours prior to admission. This update can be done by a face-to-face encounter or phone call and the Rehab Physician must be aware of this update prior to the admission). Pre-Admission Screening should address: 1) Patient appropriate therapy needs for placement in IRF; 2) 3 hours of therapy, 5 days a week; 3) Patient's condition is sufficiently stable; and 4) measurable improvement. All documentation must be maintained in the patient s medical record. Eliminated the 3-day to 10-day assessment period for trial admissions. 6

7 FY 2010 IRF PPS Final Rule Changes to Coverage Criteria i (Cont) Components Post-Admission i New Coverage Requirements Within 24 hours of admission the Rehab Physician must verify the information obtained in the pre-admission screening is accurate, identify any relevant changes since the pre-admission screening, and begin development of an overall plan of care designed to meet the individual patient s needs. All documentation must be included in the patient's medical record. Post-admission physician evaluation to (1) describe the clinical rehabilitation complications for which the patient is at risk, and the specific plan to avoid them, (2) describe the adverse medical conditions that might be created due to the patient s comorbidities and the rigors of the intensive rehabilitation program, and the methods that might be used to avoid them, and (3) predict the functional goals to be achieved within the medical limitations of the patient. Use of the physician s history/physical yp y to satisfy this requirement may not be adequate. The interdisciplinary team does not need to be consulted but their input should be considered if available. 7

8 FY 2010 IRF PPS Final Rule Changes to Coverage Criteria i (Cont) Components New Coverage Requirements Individualized Overall Plan of Care Timeframe for finalizing the Plan of Care (POC) is same as that of the IRF-PAI (by the end of the 4th day following the patient s admission) The POC requires input from the Interdisciplinary Team 8

9 FY 2010 IRF PPS Final Rule Changes to Coverage Criteria i (Cont) Components Requirements for Evaluating Appropriateness of the IRF Admission New Coverage Requirements Patient s condition is sufficiently stable to allow the patient to actively participate in an intensive rehabilitation program. At the time of admission, there must be a reasonable expectation ti that t the patient t is able to tolerate t and benefit from intensive i rehabilitation ti services. Patient has the appropriate therapy needs for placement in an IRF, meaning that the patient requires the active and ongoing therapeutic intervention of at least two therapy disciplines (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics therapy), one of which must be physical or occupational therapy. Patient requires the intensive services of an inpatient rehabilitation setting, which is typically measured by whether the patient generally requires and can reasonably be expected to actively participate in at least 3 hours of therapy per day at least 5 days per week The Patient can reasonably be expected to make measurable improvement that will be of practical value to the patient s functional capacity or adaptation to impairments. 9

10 FY 2010 IRF PPS Final Rule Changes to Coverage Criteria i (Cont) Components Requirements for Interdisciplinary Team Meetings New Coverage Requirements Team must consist of professionals from the following disciplines (each of whom must have current knowledge of the beneficiary as documented in the medical record): (A) Rehabilitation physician with specialized training and experience in rehabilitation services; (B) Registered nurse with specialized training or experience in rehabilitation; (C) Social worker or a case manager (or both); and (D) Licensed or certified therapist from each therapy discipline involved in treating the patient. Meeting must occur at least once per week throughout the IRF stay The Rehab Physician must document concurrence with all decision made by the interdisciplinary team. 10

11 FY 2010 IRF PPS Final Rule Changes to Coverage Criteria i (Cont) Components Requirements for Physician Supervision Requirement regarding the Initiation of Therapy Services Provisions of Group Therapy New Coverage Requirements Face-to-face patient encounters no less than 3 times per week during the course of the patient s stay. Treatment must begin within 36 hours of midnight on the day of admission Group Therapy in an IRF should be adjunct to one-on-one therapy. Documentation must be kept in the patient s medical record 11

12 FY 2010 IRF PPS Final Rule Changes to Coverage Criteria i (Cont) Components New Coverage Requirements If the Post Admission Assessment does not support IRF need IRFs may bill for up to 3 days of care when the preadmission screening supports the IRF admission but subsequently during the post-admission assessment does not support treatment in an IRF. The IRF must take steps to immediately begin discharge planning and the situation must be well documented in the patient s medical record. MC Advantage/60 Percent Rule The final rule allows IRFs to use Medicare Managed Care patients to be used to determine compliance under the 60 percent rule. An IRF-PAI is required to be submitted for all Medicare Managed Care patients. Record Retention for IRF-PAIs on Medicare MA patients must be retained in the medical records or in electronic form for up to 10 years. 12

13 The IRF Prospective Payment System (IRF-PPS) Implemented October 2001 Effective first cost reporting period on or after that date For new units, first cost reporting period after full year as distinct unit Applies to Medicare Part A patients only Single payment for entire admission 13

14 The IRF Prospective Payment System (cont.) Requires completion of the Patient Assessment Instrument (PAI) Assignment to a case mix group (CMG) based on: Etiologic diagnosis Motor score and in some cases Cognitive score from PAI Comorbidities Age (in some cases) Certain comorbidities may increase reimbursement 14

15 The Patient Assessment Instrument (PAI) Multi page form Demographic information Function Modifiers Functional Independence Measure (FIM) Instrument Initial assessment completed by day 4 of admission Covers first 3 days of admission (except bowel/bladder accidentsgo back 7 days) Discharge assessment required within 5 days of discharge No penalty for late assessment; 25% penalty for late submission 15

16 The Patient Assessment Instrument (PAI) (cont.) Measures patient s ability at admission and discharge in specific areas, divided into Motor and Cognitive functions on FIM FIM items are weighted Each area of assessment is assigned a score of 1 to 7 (1= most dependent, 7 = most independent ) ADD MORE INFO Total score for motor and for cognition affects the Case Mix Group p( (CMG) ADD MORE INFO 16

17 Outpatient Therapy Payment System Same payments across settings hospital outpatient, private practice, physician office, nursing home, outpatient rehabilitation facility Fees established in the physician fee schedule Reported using Current Procedural Terminology (CPT) codes Performed by licensed personnel Physical Therapist (PT), Occupational Therapist (OT), Speech Language Pathologist (SLP) Also physicians, Nurse Practitioner (NP), Physician Assistant (PA), Clinical Nurse Specialist (CNS) if allowed by state PT and OT Assistants if supervised Therapy caps of $1,870 for 2011 (for PT/SLP and separately for OT) applicable in all settings except hospital outpatient Exemption from therapy caps if medically necessary Automatic process for patients with qualifying conditions use of KX modifier to indicate exemption 17

18 Inpatient Rehabilitation Risks Category Sub-Category Sub-sub Category Risk Hospital Medical Medicare Failure to perform and document all requirements Billing Integrity Necessity Coverage Criteria (see earlier slides) Failure to document need for 24 hour/day nursing care Therapy Services Failure to furnish skilled therapy services Services Licensed Unlicensed personnel (e.g. Rehab Techs) furnishes Performed within Scope of Practice Personnel treatment not permitted by state rules Licensed personnel (e.g. Physical Therapy Assistant (PTA) /Athletic Trainer Certified (ATC)) furnishes treatment not permitted by state scope of practice rules Unlicensed Personnel PTA/ATC (licensed personnel) treats patient when payor does not allow treatment 18

19 Inpatient Rehabilitation Risks Category Sub-Category Sub-sub Category Hospital Case-Level Early Transfers Delaying discharge dates in order to avoid early Billing Payment transfer payments for Medicare patients Integrity Adjustments Coding Interrupted Stays Short Stays IRF - CMGs, FIM, PAI, Risk Improperly billing for two separate and distinct stays when a Medicare patient is discharged and re- admitted within 3 days Delaying discharge dates in order to avoid short stay payments for Medicare patients Late submission/filing of PAI Inaccurate diagnosis codes placed on PAI leading to incorrect comorbidity tier Inaccurate FIM score placed on PAI IRF- Discharge Disposition Integration of codes into Case Mix Group is inaccurate Incorrect assignment of discharge disposition 19

20 Inpatient Rehabilitation Risks Category Sub-Category Risk Conditions of Classification of IRF Facility does not meet required threshold for CMS-13 qualifying Participation - 60% Rule diagnosis as a percentage of all discharges Inaccurate assignment of impairment or qualifying diagnosis code Vendor Orthotics and Substantial price concessions offered by a vendor for PPS- Relationships Prosthetics (O&P) covered O&P items in exchange for referrals of items that a vendor may bill directly to Medicare Ambulance/ Transportation Failing to pay an outside vendor for an O&P item that is necessary during the inpatient stay for which hospital is responsible Failing to pay an outside vendor for transportation tat o that is necessary during the inpatient stay for which hospital is responsible 20

21 Outpatient Therapy Risks Category Sub-Category Risk Billing Services Unlicensed personnel (e.g. Rehab Techs) furnishes treatment not Integrity Performed within Proper Scope permitted by state rules Licensed personnel (PTA/ATC) furnishes treatment not permitted by state scope of practice rules PTA/ATC (licensed personnel) treats patient when payor does not allow treatment Coding - CPT Incorrect rounding of minutes for therapy units Incorrect modifier usage (Specifically the review of the use of the KX modifier) 21

22 Outpatient Therapy Risks Category Sub-Category Risk Billing Individual vs. Billing Medicare for individual therapy when group therapy was Integrity Group Therapy performed Medical Necessity Plan of Care (POC) Treatment cannot be medically supported Services performed fail to conform to POC Physician signature not received timely on initial POC POC does not meet technical standards for payment (e.g. goals, frequency, etc.) Re-evaluation evaluation billed without appropriate documentation regarding medical necessity POC extension not developed and signed by physician in a timely manner 22

23 Types of Controls Preventive Education / Training Example All administrators and sales personnel complete sales & marketing training annually Approvals Contracts Example Legal does not draft / approve any contracts with referral sources unless appropriate Compliance approvals are present Chargemaster Example Information Services does not make requested change without VP Business Operations approval Pre-Billing Edits Example All therapy claims that do not meet Coverage Determinations (Local or National) are suspended and must be manually reviewed before billing 23

24 Types of Controls Detective Audits Outpatient Example 100% automated review of coded versus billed CPTs Outpatient Example Random sample of Medicare Plans of Care reviewed each quarter Outlier Analysis IRF Comorbidity Code Usage Hospital usage compared to benchmarks (similar to PEPPER reports of complex v. simple DRG usage in acute care) 24

25 Control Questions For All Control Types: What is the control action? Who is involved? How is the action carried out? Where is the action carried out (i.e. facility, division, corporate)? How often is the action carried out? For Detective Controls (other than outliers) also add these: What is the audit or monitoring activity? How many files, claims, etc. reviewed? Are there error/compliance thresholds associated with the audit/review? When are corrective action plans (CAPs) initiated? Who follows-up on the action plans? Where is the CAP remediation information reported once completed? For Outlier Controls add these: What is being measured? How often should it be measured? Are there error/compliance thresholds associated with the analysis? When are corrective action plans (CAPs) initiated? Who follows-up on the action plans? Where is the CAP remediation information reported once completed? 25

26 Monitoring Compliance with the 60% rule Presumptive e Actual Self-audits Coding accuracy Therapy hours 26

27 Monitoring Questions What risk areas are monitored? How often is the monitoring? i What changes have been made if any issues have been identified? Are all parties involved in the self-audits- nursing, therapy, physician, coding and billing? 27

28 Rehabilitation Risks Potential Audits Services Performed within Proper Scope Licensing Preventive Control: Each new licensed employee has primary source verification of active license in good standing verified before first day of employment. Preventive Control: Each new non-licensed employee (i.e. aides, rehab techs, exercise physiologists, i athletic ti trainers, massage therapists) is required to sign a copy of their job description within the first 3 days of employment, which includes information from the state practice act regarding scope of practice, to be kept in their personnel file. Audit: Review of personnel files to determine if Licensed - dates of licensure verification before first day of employment Non-licensed personnel file contains signed copy of job description dated within first 3 days of employment 28

29 Rehabilitation Risks Potential Audits Inpatient Coding Potential Surveillance Audit: ICD-9-CM and CMG Coding. Random sample of at least 30 Medicare claims is selected from the universe of all IRF Medicare discharges during the period for review. Medical records are reviewed to determine Accuracy of the Impairment Group Codes Accuracy of case-mix group (CMG) Accuracy of the tier billed based on the ICD-9-CM Correct Functional Impairment Measure (FIM) scores contained in the medical record (i.e., the FIM score in the medical record was transcribed correctly) 29

30 Rehabilitation Risks Potential Audits Inpatient Coding Potential surveillance audit: Timely submission of PAIs to CMS. For each claim selected for surveillance review, the reviewer also verifies that the Patient Assessment Instrument (PAI) was submitted to the CMS national database in a timely manner. 30

31 Rehabilitation Risks Potential Audits Inpatient Coding - Outlier Potential data analysis: Information from IRF PAI repository vendor is used to benchmark utilization of ICD-9-CM comorbid codes (excluding primary etiological codes) that effect Medicare tier assignments. Hospitals with utilization for any of the selected codes during the review period above a designated threshold level are designated as outliers and subject to further review. Potential Audit: For each comorbid code that is determined to be an outlier, a file is obtained of Medicare discharges during the review period for that code (i.e., the universe). From each of the universes, a random sample is selected for review. These records are reviewed to determine whether the comorbid condition is supported in the record. 31

32 Rehabilitation Risks Potential Audits Inpatient Coding Preventive Control: Each new coder receives training. All coding reviewed 100% until training is completed. Audit: Review of personnel files / training records to determine if / when coder received training Review of documentation of 100% review by another coder until date of training 32

33 Rehabilitation Risks Potential Audits Medicare Coverage Criteria Preventive Control: Training Detective Control/Monitoring: Self-monitoring of completion of all elements of Medicare Coverage Criteria Pre-Admission Screening Licensed / certified clinicians designated by the Rehab Physician Screening completed / updated within 48 hours before admission Physician i concurrence with pre-admission i screening prior to admission i Post-Admission Physician evaluation completion with 24 hours Plan of Care Signed by the Rehab Physician within 4 days of admission Interdisciplinary Team meetings Includes Rehab Physician, RN, Social worker/case manager, each therapy discipline Meets a minimum of once per week Physician must document concurrence with decisions Therapy Begins with 36 hours of midnight of the day of admission Audit: Review of monitoring results to determine if Accuracy of review independent review comes to same conclusion as to coverage criteria elements met Accuracy of following process random selection, etc. 33

34 Rehabilitation Risks Potential Audits Functional Independence Measure (FIM) Scoring Preventive Control: Bi-annually, at least 80% of licensed clinicians is re-certified in FIM scoring Detective Control/Monitoring: Percentage of usage of Case Mix Groups (CMGs) in certain Rehabilitation Impairment Categories (RICs) Review of FIM scores for the more subjectively scored FIM items Audit: Review of FIM scoring Requirement for concurrent because of nature of observation versus documentation based scoring. Must also be done by competent independent FIM scorers. Intra-operator consistency could be tested with some type of video scenarios 34

35 Rehabilitation Risks Potential Monitoring Inpatient Interrupted Stays Analysis of the claims data semiannually, using the previous 6 months data to identify claims with potential errors (i.e., two admission dates within 3 days for same patient or an actual interrupted stay code is used) for an interrupted stay. Follow-up is performed for each potential error. 35

36 Rehabilitation Risks Potential Audits Outpatient Therapy Coding Potential Surveillance Claims Audit - random sample of at least 30 Medicare claims is selected from the universe of all outpatient Medicare therapy claims for services provided during the review period. Reviewer uses a template(s) to review the medical and billing records for each claim to verify that Medicare billing and coding requirements are met, including Outpatient Plan of Care (i.e., timely physician signatures, completion of required elements, and timely physician signatures on re- certifications); Licensed staff provided all services rendered; and the services that were billed are adequately supported in the medical records the applicable CPT codes and units were billed correctly (e.g., the correct CPT codes were billed, the minutes of service were rounded correctly into billable units). 36

37 Rehabilitation Risks Potential Audits Outpatient Therapy Coding Group Therapy. A sub-sample of claims is selected to assess the accuracy of group versus individual therapy billing. All Medicare services furnished by the therapist for the date of the claim are reviewed for compliance with Medicare group therapy rules in accordance with a template. 37

38 Rehabilitation Risks Potential Audits Outside Services All outside service agreements with suppliers include an attachment which includes the guidelines that all invoices/bills for Medicare inpatients must be submitted to hospital and not to third party payors. Potential Audit review of any outside services provided to patients. Review of documentation to determine: Contract in place for services Invoice received by hospital Invoice/bill charges match contract terms Invoice paid by hospital 38

39 Contact Information Christine Bachrach Vice President & Chief Compliance Officer University of Maryland Medical System

40 Save the Date: August 26-29, st Annual Conference in Philadelphia Pennsylvania 40

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