FY2013 IRF PPS Updates Clinical Training Call October 2, Lisa Werner, MBA, MS, CCC-SLP

Transcription

1 FY2013 IRF PPS Updates Clinical Training Call October 2, 2012 Lisa Werner, MBA, MS, CCC-SLP

2 How A CMG is Determined CMG Determinants Impairment Group Code Broad codes that identify the main reason for the rehab stay. 21 main categories. Motor Score of Functional Independence Measure Co-morbidities Functional assessment based on 12 functional measures determined upon admission (excludes tub/shower transfers) Additional medical condition that has a significant effect on the rehabilitation stay & progress & cost. Age The age of the patient upon admission

3 Case Mix Groups Discharge-based system Payment is based on discharge information Case Mix Groups (CMG) 87 main groups 4 deaths 1 short stay Single lump payment for each stay

4 Case Mix Groups All inclusive payment for each patient Off unit surgery, dialysis, and so on. 353 payment categories The base rate from the government last year Range of average discharge rates $7,395 - $33,256 with no co-morbidity Range of average discharge rates $10,678 $48,613 with the highest co-morbidity

5 Review of Changes The final rule introduced changes in these categories: Relative weights and average length of stay based on the most current Medicare claims and cost report data. Facility adjusters in a budget neutral manner. PPS rates per the recommended market basket increase. Payment rates based on wage index and labor shares. Update to the outlier threshold. Implement the quality reporting program provisions.

6 Provider Payment Components Federal Base Payment (F) Base rate for October 1, 2007 was $13,451 Change of rate on April 1, 2008 was $13,034 Rate for October 1, 2008 is $12,958 Rate for October 1, 2009 is $13,661 (2.5% increase) Rate for April 1, 2010 is $13,627 Rate for October 1, 2010 is $14,076 Rate for October 1, 2013 is $14,343

7 Provider Payment Components Labor Share (F) Total is of the Medicare payment. Down from last year. Wage (V) Maintains budget neutrality.

8 Provider Payment Components Changes to facility adjusters: 2013: No changes 2012: LIP:.4613 Rural: 18.4% Teaching:.6876 using a formula of (1+FTE interns and residents/adc) 2011: Stated as a per facility update (No changes) 2010: Stated as noted below LIP: versus Rural: 18.4% versus 21.3% Teaching: versus

9 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 outlier threshold is $10,466, which was a slight decrease from the 2012 rate of $10,660. Expected to occur in 3% of IRF cases.

10 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

11 Transfer Process Transfer Rule Example Base Rate = $14,343 Weight for CMG 0108 Tier 3 = Weight times base rate = $26,852 LOS for CMG 0108 Tier 3 = 23 days CMG 0108 Tier 3 divided by 23 = $1,221/day Times 8 days = $9,768 Plus ½ one per diem = $10,378

12 Transfer Process Works the same for transfers to: Skilled Nursing Facilities & Nursing Homes Long Term Acute Care Acute Care Another Rehab Program

13 Program Interruption Program Interruptions include transfers to acute and back to rehab during the stay. CMG includes paying for acute stays when: Patient is discharged to acute and returns to IRF by midnight of the 3 rd calendar day. All costs associated with the acute stay are recorded on the rehab cost report. True for discharges to acute care of your own facility or acute care of another hospital.

14 Program Interruption Acute stay greater than 3 days are different. If patient goes to acute care and does not return by midnight of the 3 rd calendar day, discharge and readmit. Patient will have a new admission and assessment reference period. New CMG will be assigned based on information gathered at admission.

15 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 CMG payment weight is.1494 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).

16 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 expired, orthopedic with a length of stay of 14 days or more expired, not orthopedic with a length of stay of 15 days or fewer expired, not orthopedic with a length of stay of 16 days or more

17 Changes to Comorbidities that Tier Tier 1: No changes Tier 2: No changes Tier 3: No changes

18 The Importance of Accuracy Three Tiers of Co-morbidities Average erehabdata utilization in the previous 365 days: Tier % Tier % Tier % Can be identified up to two days before discharge. Physician identification is mandatory.

19 Tier 1 Co-morbid Conditions Eight Tier 1 Comorbitites: VOCAL PARAL UNILAT PART VOCAL PARAL UNILAT TOTAL VOCAL PARAL BILAT PART VOCAL PARAL BILAT TOTAL EDEMA OF LARYNX V44.0 TRACHEOSTOMY STATUS V45.1 RENAL DIALYSIS STATUS V55.0 ATTEN TO TRACHEOSTOMY

20 Tier 2 Comorbidities Eleven Tier 2 Comorbidities: PSEUDOMONAS ENTERITIS INT INF CLSTRDIUM DFCILE PSEUDOMONAS INFECT NOS LATE EF CV DIS DYSPHAGIA INTEST POSTOP NONABSORB DYSPHAGIA NOS DYSPHAGIA, ORAL PHASE DYSPHAGIA, OROPHARYNGEAL DYSPHAGIA, PHARYNGEAL PHASE DYSPHAGIA, PHARYNGOESOPHAGEAL DYSPHAGIA NEC

21 Top Tier 3 Comorbidities Tier 3 (Top 30) MORBID OBESITY ACUTE RENAL FAILURE NOS NEUROPATHY IN DIABETES DMII NEURO NT ST UNCNTRL 486. PNEUMONIA, ORGANISM NOS CELLULITIS OF LEG UNSP HEMIPLGA UNSPF SIDE DIASTOLC HRT FAILURE NOS DMII RENL NT ST UNCNTRLD CHR DIASTOLC HRT FAILURE DMII NEURO UNCNTRLD PULM EMBOL/INFARCT NEC FOOD/VOMIT PNEUMONITIS SIRS-INFECT W/O ORG DYSF SYSTOLIC HEART FAILURE Tier 3 (Top 30) 515. POSTINFLAM PULM FIBROSIS PANCYTOPENIA DMII CIRC NT ST UNCNTRLD DMII OPHTH NT ST UNCNTRL POSTPROCEDURAL FEVER UNSP HEMIPLGA DOMNT SIDE UNSP HMIPLGA NONDMNT SDE SEPTICEMIA NOS DISRUP-EXTERNAL OP WOUND CELLULITIS OF TRUNK AC ON CHR DIASTOLIC HRT FL CELLULITIS OF ARM DMII RENAL UNCONTROLLED DMII OTHER UNCONTROLLED ACUTE KIDNEY FAILURE WITH LESION OF TUBULAR NECROSIS

22 Replacement of Lower Extremity Joint Replacement of Lower Extremity Joint Motor >49.55 Motor > & < Motor > & < & Age > 83.5 Motor > & < & Age < 83.5 Motor > & < Motor < ALOS W/O CM 7 Relative Wt $ 7, ALOS W/O CM 9 Relative Wt $ 9, ALOS W/O CM 12 Relative Wt $13, ALOS W/O CM 10 Relative Wt $11, ALOS W/O CM 13 Relative Wt $ 14, ALOS W/O CM 15 Relative Wt $ 17,844

23 Weighted Motor Score Index Item Eating Grooming Bathing Dressing Upper Body Dressing Lower Body Toileting Bladder Bowel Transfer Bed, Chair, W/C Transfer Toilet Transfer Tub, Shower Locomotion Stairs Weight Not included as item for CMG

24 Motor Score Index Item Score Weight Value Eating Grooming Bathing UB Dressing LB Dressing Toileting Bladder Bowel Transfer Bed, Chair, W/C Transfer Toilet Transfer Tub/Shower 4 Locomotion Stairs Total 37.5

25 Quality Measures New quality measures: Percent of Patient with New or Worsened Pressure Ulcers, NQF #0678 Catheter associated urinary tract infections will be reported to the CDC National Health Safety Network (NHSN)

26 Questions? Next call: November 1:00 EST