1 Vol. 3 No. 11 November 2003 Your source for PPS success INSIDE LMRPs for IRF admission What s so scary about the draft LMRPs for medical necessity? Read a summary of the new, narrow definition of an IRF patient on p. 3. Got therapists? Many IRFs are scrambling for new hires, but not all are doing something about it. Check out one facility s recruitment and referral bonus program on p. 4. Scoring self-care It s not always as apparent as it looks. Brush up on your skills in the areas of eating, grooming, bathing, dressing, and toileting on p. 6. Flowsheets Find out why experts say flowsheets are not always the way to go on p. 7. 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/ Inpatient rehab s sky is falling Draft LMRPs will have dire consequences for industry Inpatient rehab providers have some big decisions on their horizons. Fiscal intermediaries (FIs) in Georgia, Pennsylvania, New Jersey, and Tennessee have revised the medical necessity criteria for IRF admissions within their local medical review policies (LMRPs). Inevitably, this will affect your business. The 2004 Work Plan is here: the list of projects that the Office of Inspector General (OIG) targets as the leading causes of fraud, waste, and abuse and which it intends to study closely during the next year or longer. For IRFs, this means you can figure out where to focus your latest compliance efforts to avoid investigations, audits, and charges of fraud and abuse. In its 2004 Work Plan, the OIG has expanded its focus from traditional of HRM, a revenue cycle management consultant company in Dallas. The patient now must require an intensive level of constant care, as documented in the medical record, in order to qualify for IRF PPS. For instance, inpatient rehab facilities in the past could admit patients who had just had knee surgery. Patients received around-the-clock attention, and recovery time was quicker than in outpatient settings. What is it about these revised LMRPs that will make things so different in the IRF world? Well, the patient s diagnosis will no longer be the main impetus for inpatient rehab admission, explains Keith Siddel, MBA, PhD(c), president But those patients today would be pushed to outpatient settings and skilled nursing facility stays under the new LMRP criteria, says Siddel. and chief executive officer Inpatient rehab is no > p. 2 OIG Work Plan hits the newsstands Work Plan topics, such as billing and coding, to cover quality of care, accreditation, and drug reimbursement. The OIG released its 2004 Work Plan on Wednesday, October 1. There are two top areas of focus for the latest OIG projects of which you should be aware. Inpatient rehab draws attention Besides the OIG s extensive hospital focus, the Work Plan contained two specific mentions of studies the office will conduct on > p. 8
2 LMRPs < p. 1 longer for fractures and single extremity deficits. [FIs have] taken a whole class of folks that used to qualify for inpatient rehab and pushed it to the outpatient setting. In the draft LMRPs, only a patient who had surgery on both knees, required intensive skilled intervention, and could not be treated in a lesser setting would qualify, he adds. (For a summary of the draft LMRP proposed by the FI Riverbend, see the story on p. 3.) Sink or swim If the situation sounds grim, that s because it is. Siddel recommends IRF providers take a hard look at their practices now because they will likely have to make changes to survive in the new era of tougher, stricter LMRPs for inpatient rehab medical necessity. He says IRFs should take the following steps: 1. Look to the past. The first thing you must do is examine the types of patients you ve admitted in the past, says Siddel. Take a historical perspective on patients from the last days, including the types of services they received during their stays. Next, determine how many of those patients would qualify for inpatient rehab care under PPS using the guidelines in the draft version of a more stringent LMRP, such as the Riverbend version on p Look to the future. Use your retrospective information to paint a prospective picture of what your business would look like under the new LMRPs, he says. Some hospitals may find, for instance, that it no longer benefits them to continue running an inpatient rehab unit. 3. Make the tough call. Ask yourself whether it still makes sense to have an IRF, recommends Siddel. For instance, there are several routes you can take to make changes. You may want to look at a scaleddown inpatient rehab model and switch some or all of your business to outpatient rehabilitation services. You can offset changes in your income with an influx of outpatients, he says. However, you may have stiffer competition, as outpatient clinics are generally more available than IRFs. So you ll have to become savvy quickly about attracting and keeping outpatients. Who will feel the pinch? If you hope to go about in blithe denial of the new restrictions on inpatient rehab admissions for Medicare, don t. Siddel predicts that the changes will hit IRFs across the board, and no one will be spared. Some facilities are looking at closing down, some will operate on a smaller scale, and some will see a change, but not one that s that significant. It all depends on the patient population, he says. For instance, IRFs in sparsely populated areas may feel a real pinch because they don t have the largest patient base. And IRFs that focus on one niche of rehabilitation such as coma, cognitive, cardiac, pulmonary, or pain, may find their businesses completely eliminated under the proposed LMRPs. But there will still be complex patients who need nursing care 24 hours per day coupled with all the other benefits of an intensive therapy program. Urban-based IRFs and those that have a large volume of complex patients will probably fare the best. It s going to be those facilities that focus on patients who suffer from much more debilitating illnesses or acute accidents [that will draw the inpatient rehab population], Siddel says. Think before you speak Concerned IRF providers especially those under the payment regions of the FIs Georgia Medicare, Veritas Medicare Services, and Riverbend are no doubt anxious to convey to the intermediaries that the draft LMRPs restrict too many patients from inpatient rehab, not to mention that they will drastically reduce business. > p. 4 Page HCPro, Inc.
3 Summarizing the Riverbend LMRP When you re entering the lion s den, it s good to have an idea of the beast that resides within. Keith Siddel, MBA, PhD(c), president and chief executive officer of HRM, a revenue cycle management consultant company in Dallas, took a hard look at the draft local medical review policy released by Riverbend. Here s how he describes the narrowed scope of inpatient rehab admissions as stated in the Riverbend policy: 1. The patient must require around-the-clock availability of a registered nurse (RN) with specialized training or experience in rehabilitation i.e., a higher level of care than is normally found in a skilled nursing facility and/or frequent assessment (every two to three days) and intervention by a physician. 2. A multidisciplinary team must include, at a minimum, a physician, rehabilitation nurse, and one therapist. The patient s record must reflect evidence of a coordinated program that includes joint involvement in evaluation and decision-making. 3. The patient must require intensive therapy typically three hours per day at least five days a week or other skilled rehabilitative modalities such as speech-language therapy or prosthetic-orthotic services. 4. The patient can t receive services in a less-intensive setting because of one or more of the following: There is a need for 24-hour access to an RN The patient requires frequent physician assessments or interventions due to a significant risk of rapid change in physical or medical status The patient must have specialized equipment at such a frequency and duration as to make it impractical for the patient to use the equipment at an outpatient facility Inpatient rehabilitation is typically covered for the following conditions: Pathology that results in significant loss of function to two or more extremities Major trauma, which is defined as a mechanism or pattern of injury sufficient to appropriately activate emergency medical system major trauma protocols Central nervous system pathology that results in a significant functional deficit, typically paralysis, contracture, incapacitating paresis, or incapacitating ataxia of at least two extremities or one extremity with significant involvement of higher functions Single extremity loss of function combined with medical complications that necessitate continuous RN or physician supervision, which is not part of the normal acute inpatient recovery process Inpatient rehabilitation is typically NOT covered for the following conditions: Single extremity deficits, except for amputations Minor trauma involving simple fractures Joint replacement/fracture Compression fractures and laminectomies/fusion Diffuse weakness or general debility Postoperative single extremity orthopedic recovery Niche rehabilitation, such as coma, cognitive, cardiac, pulmonary, pain, etc HCPro, Inc. Page 3
4 Don t just wish for more therapists for your facility go out and get some If you work in the rehab industry, you ve probably noticed the recent crunch when it comes to hiring physical therapists (PTs), occupational therapists (OTs), and other clinicians skilled in therapy. That can translate to extreme difficulty filling the open positions in your IRF. But maintaining a fully staffed facility or unit isn t an impossible dream it just takes some hard work and strategy. Lots of IRFs think about how to fill positions, but not all of them are taking action. Now is the time to rev up your recruiting program so you can beat the pack. Wyoming Medical Center, located in Casper, was experiencing a dearth of staff, with three PT positions open for more than six months. I spoke with a recruiter about the shortage and he stated that PT enrollment in schools is down 40%. Where he got his data I m not sure, but if this is true, it is going to get even harder to recruit, says Tamara Hawk, MPT, rehab and therapy operational manager for the center. A three-tiered structure Management knew it would have to come up with a comprehensive recruitment system to ease its staffing woes so it first initiated a recruitment bonus system. Everyone has friends in the field, Hawk points out. We ve pulled [new staff] from nursing homes, other hospitals, all different settings. The management team set up a system in which members meet on a quarterly basis to determine which positions within the facility are eligible for referral rewards. There are three levels to the bonus structure the employee who refers a new hire can receive a $2,000 referral bonus, a $1,000 bonus, or a $500 bonus. Right now, respiratory therapy, physical therapy, and nursing are at the highest demand, so they re at the $2,000 mark, explains Hawk. At the $1,000 mark are positions such as medical technicians and radiology technicians, while licensed pharmacy technicians occupy the lowest rung. But for the next quarter, the positions and referral bonus amounts could change due to need. A fair payout The facility states in its referral bonus policy that the program is voluntary, meaning that if the program is LMRPs < p. 2 And well they should, though it s going to be difficult to loosen the guidelines, says Siddel. That s why you need to have a strategy for your comments. It s important providers watch all the draft LMRPs and comment on them, but they need to give a case or example in their comment where a patient under the [draft] rule would not get the level of care needed to recover. Good cases to use are those in which the FI reviewed and ruled that the services were medically necessary yet those cases would not qualify for IRF care under the new LMRPs. Other good cases to comment on are those in which the patient could not receive the care necessary to treat all of his or her conditions in a skilled nursing facility. If enough providers give solid evidence [of these cases] to the FIs, the medical director [who penned the LMRP] could be persuaded to make changes, he says. IRFs will need to make a strong argument, and it is certain the face of inpatient rehab will change nonetheless, says Siddel. What remains to be seen is how dramatic the change will be. Page HCPro, Inc.
5 no longer necessary in the future, management can dissolve it. But so far, things are working well, says Hawk. One employee just referred a therapist whom we hired. He gets a bonus. The reward arrives at the referring employee s doorstep in two neat packages, according to facility policy. The first half of the reward goes out to the employee after the new hire completes orientation successfully. The remaining half will be paid after the referred employee completes one year of service, the facility s policy states. And the facility isn t strict about former employees it allows employees who left the company to return under the referral program provided they ve been gone for at least six months. Additionally, they must have left under good circumstances. Other recruitment strategies The referral program isn t the only trick the center has up its sleeve. We are also offering up to $3,000 to a new graduate for the reimbursement of tuition, Hawk says. Employees just have to show proof of the expense. This perk has already kept one new therapist aboard. After [the therapist] learned about the tuition reimbursement program, she decided to stay on for a year at least. Employees must remain at the facility for at least a year to qualify for reimbursement. We also have a relocation expense reimbursement of up to $5,000, explains Hawk. This is because Wyoming Medical Center is a bit off the beaten path, so management has to entice candidates to come to the facility. Unfortunately, not all recruitment efforts have been successful. We ve done some advertising in the Denver papers but it s just horribly expensive, says Hawk. Additionally, she s tried to contact the local schools with therapy and nursing programs and had the institutions post available positions. So far, she s had no luck on that front, either. But these are possible avenues to try to recruit new staff for your own IRF. Keeping staff happy Once you reel in your new OTs, PTs, and others, you ve got to make the effort to keep them. Wyoming Medical Center is gearing up in that area, too. One possible solution management came up with is the career ladder, a mechanism that recognizes and promotes employees based on advanced skill in their area of expertise. We have begun looking at career ladders for therapists to offer growth opportunities to the employees, Hawk explains. Currently, facility management has developed a team to overhaul the one used for nursing staff. Hawk says she is waiting to see where that one goes before she starts one for the therapy department. 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 5
6 Conquer scoring self-care on the FIM instrument Best practices to wind up with accurate scores and documentation Whether you re new to the FIM instrument or a wily veteran of inpatient rehab, a lesson in self-care scoring can always be beneficial. After all, it s an integral part of the IRF-PAI and it affects how much reimbursement you receive for the care of a patient. Any one of the FIM items, if you score it wrong, can be enough to put you into a different case-mix group, either higher or lower, says Patricia Trela, a manager with Deloitte & Touche in Boston. If you re at the lower level of the motor score and you incorrectly score one item to drop down to the next-lower case-mix group, you ll receive a higher level of reimbursement. This can resemble Medicare fraud to a fiscal intermediary conducting an audit. And this has happened, Trela warns. One facility had problems with how occupational therapists (OTs) scored the bathing section of the self-care items. Nursing actually bathed the patient, so OT did not have a record of how the patient performed that task. As far as OT was concerned, it wasn t getting done, she relates. That translated to artificially low FIM scores and unearned extra reimbursement, a very dangerous result. General scoring advice But that s a more radical example of how things can go wrong when you score the FIM. Basically, you just want to avoid errors that don t reflect the patient s level of ability and could possibly change your payment rate. Here are some easy steps you can take to improve your accuracy: Know the definitions in and out. Always 1. look at the definition of the item in the IRF-PAI Manual before you assess someone in that area, advises Terrie Black, MBA, BSN, RN, BC, CRRN, manager of education and training for UDSMR in Amherst, NY. A common error is when clinicians juxtapose the scoring guidelines for the six different items eating, grooming, bathing, dressing the upper half of the body, dressing the lower half of the body, and toileting with other items on the FIM. For example, when someone is walking to the bathroom, sometimes the clinician will get the walking, toileting, toilet transfers, and bowel and bladder scores confused, says Black. So first make sure you have a clear idea of which activities you re going to assess, she recommends, because that way you can go back and read the definition if it s not clear in your mind. And I think that s fundamental for any item not just self-care, she adds. Don t project scores. The most important 2. thing to remember is it s what the patient actually does, not what the patient could or should do, says Trela. For instance, if you score a patient on buttoning up a shirt but the patient does not have a shirt with buttons, don t guess at his or her capabilities. Try real-time training. UDSMR conducts FIM 3. training workshops, during which participants complete a self-assessment first to get a baseline knowledge for how well they know the scoring guidelines. Then it presents scenarios live or in video format that attendees have to score. So it s not just pen and paper and PowerPoint presentations, Black points out. By showing what the patient actually does instead of explaining it on paper, FIM scorers get a real sense of the complexity of correctly gauging each item. Some focused advice Once you re all set on the definitions, it s time to move on to scoring each of the six areas on the assessment instrument. Here are some tips to overcome the stumbling blocks you might run into while trying to score accurately: Eating. The only red flag that Black brings up about eating is if someone codes a patient at level Page HCPro, Inc.
7 0 on the FIM instrument. It s very unusual to see someone use the code 0 even though it is permissible. It means the patient didn t eat or receive nutrition during the entire assessment period, she says. Even if a patient receives tube feedings and isn t able to assist staff in the feeding process that person is still coded as a level 1, Black adds. Additionally, if the patient does require assistance, you need to clearly document it in the medical record, in addition to the reasons why. If the patient was a level 6 for eating, you would want to have supporting documentation, Black says, such as whether the patient was on a modified diet or required dentures. If the patient uses an assistive device, make sure you score it as modified independence, not straight independence, adds Trela. Grooming. When it comes to grooming, the IRF- PAI Manual is pretty clear, says Black. We generally instruct the clinician to look at the activities involved and assign a percentage to each of those activities. For instance, there could be five activities involved, from oral hygiene to hair care, and if the patient is doing three of the five activities, that equates as 60%. That s a level 3, she says. Bathing. You can assess bathing using a bed bath, or one done at the sink, in the tub, or in the shower. Don t confuse this item with transfers in and out of the bathtub, says Black. Dressing, upper and lower. Everyone dresses differently, so a helpful hint to coding this item is to identify what articles of clothing the patient will be donning and then map out the steps to putting each one on. For instance, when a patient puts on a sweatshirt, separate the act into four steps threading the arm through the left sleeve, then the right sleeve, then getting the sweatshirt over the head, and finally pulling it down over the trunk, advises Black. Depending on how many of the steps the patient completes, determine your FIM score that way. Make sure you compensate for how many articles of clothing a patient dons, she adds, such as a bra, then a blouse, and finally a sweater. Toileting. Use the same counting-the-steps method to score toileting. There are three distinct steps pulling the clothes down, peri-hygiene, and adjusting the clothing afterward, says Black. If you assign each step 33% of the total score, and the patient only completes one out of the three, then the patient has completed 33% of the task, making him or her a level 2. Be careful with flowsheet scoring Flowsheets can be a convenient tool to help staff keep track of patients abilities for later scoring on the IRF-PAI. But they aren t the endall, be-all, warns Terrie Black, MBA, BSN, RN, BC, CRRN, manager of education and training for UDSMR in Amherst, NY. Although many facilities develop flowsheets to make sure they capture the burden of care during the assessment period as required by the Inpatient Rehab PPS Final Rule make sure that s not the only thing on which you rely. You ve got to have supporting documentation in the medical record, she says. Another tip she gives is to obtain input on patient abilities and progress 24/7 from all pertinent staff. It s critical to have that interdisciplinary communication over the 24-hour period, says Black. Finally, don t mistake the FIM score itself as providing sufficient documentation of a patient s status, adds Patricia Trela, a manager with Deloitte & Touche in Boston. You want some verbiage to go along with it. Because of this, be leery of flowsheets that only include checkboxes without room for additional documentation HCPro, Inc. Page 7
8 OIG < p. 1 IRFs. First, the OIG intends to examine the medical necessity of inpatient rehab stays. Because quality improvement organizations stopped monitoring PPS-exempt services on a regular basis in 1995, the OIG has concerns that some specialty rehab hospitals or units may receive payments from the government for services that are not covered or not needed. We will assess the adequacy of controls to detect improper payments for inpatient rehabilitation facility services, the rule states. The other item IRFs should be aware of is the OIG s plan to check up on payment accuracy when patient assessments are entered late. The agency wants to make sure fiscal intermediaries reduce payments correctly for late assessments. This means more incentive for facilities to complete and transmit assessments on time. The JCAHO gets some heat The agency will also review the oversight of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). This concern ties back to quality of care issues, says James Kopf, president of Health Care Oversight, a New York City consulting firm. Some people in the government feel that the JCAHO is responsible for too much on the quality of care front, says William Sarraille, Esq., a partner in the Washington, DC, office of Sidley Austin. They feel there should be a review of how stringent JCAHO s standards are and how accurate its work is. A JCAHO spokesperson said this review is a followup to a 1999 study by the OIG. We welcome their follow-up review, the spokesperson says. Health care organizations should follow the OIG s lead and assess their organization s overall operations. Compliance officers need to look at every aspect of the hospital its not just billing and coding anymore it s everything, says Kopf. Editor s note: Go to to read the 2004 Work Plan. 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 Senior Managing Editor Noelle Shough Phone: 781/ , Ext Mail: 200 Hoods Lane, Marblehead, MA Fax: 781/ Group Publisher, Bob Croce 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.