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Written by: Mediware on Tuesday, March 27, 2012 Posted in: Inpatient Rehab

Thanks to a heads-up received while visiting a client in Florida who was reading the new IRF PAI Manual 2012 for her leisure reading the night before, we can share this link with you. I’m smiling with Saloni, because I am also accused of reading CMS literature as nighttime leisure reading!

This long awaited update was mainly necessary because of the ”Quality Indicator” section changes.   Previously, we had respiratory status, pain, pressure ulcer and safety items that ranged from number 48 – 54. On the new PAI, pressure ulcers are covered in all questions 48 A-C, 49 A-C and 50 A-D.   Unfortunately, there have been a few items that have been changed that were not updated in this manual, so I suggest you write them in.

In Appendix H, page 1 there was an opportunity to correct the fact that there are no longer 100 CMGs.  Originally the payment model had 95 CMGs and 5 special CMGs. This number was reduced due to a RAND study in the 2006 rule for FY 2007 and now there are 87 CMGs and 5 special for a total of 353 CMG possible payments. Unfortunately, I often see and hear a misquoted total. On page H-1 write that on the side line.

Another opportunity missed in the new PAI manual was the discussion on what the weighted motor score means and how that correlates in the grouper software to assigning the correct CMG. The picture inserted below demonstrates the weighting values to more closely assign burden of care reimbursement. Although this is fairly transparent to persons that input whole numbers into the PAI, it is very significant in finding the correct Case Mix Index for payment within a RIC. Add this to Appendix H area as well.


Other items to note:

  • Relative weights since they change annually are linked to the website
  • Appendix C – co-morbidities were linked to the website
  • Admission Class definitions under item 14 of the PAI still include ‘Evaluation’ which was the old description for a trial stay of less than 10 days.  After 2010, advise this is no longer acceptable.
  • Payer classifications continue to use code 13 called CHAMPUS (The “Civilian Health and Medical Program of the Uniformed Services”); it is now known as TRICARE. Write that in so new staff know it’s the same code.
  • They cautioned under the new Quality Indicator section II-29 that although it is not required, it will result in a 2 percent payment reduction in FY 2014 if not completed. They left off that the important time frame for submission is October 1, through Dec. 31, 2012.  Write that in.
  • Although there is a great description of discharge location 13 – sub-acute setting, even defining that the settings are not the CMS recommended name used for billing purposes on the (UB-92) which is now called the (UB-04), it is more important that persons are familiar with using it to define a patient that is discharged to a setting that continues to provide a multidisciplinary approach to care – such as a rehab oriented skilled (SNF) nursing stay. It’s important that coders DO NOT use this discharge location information to code the UB.  The Office of Inspector General (OIG) has already targeted improper discharge setting on IRF bills and this helps complicate that matter.
  • Appendix G is now a discussion on coding rather than the glossary
  • Previously Appendix H was a very helpful question and answer section for each of the 18 areas of scoring.  This was removed and has realigned the new Appendix H to be Relative Weights or the old Appendix J.
  • Old Appendix K is the new Appendix I – Privacy Rights
  • There is no longer an Appendix J
  • Scoring decision trees are the same although printing is much clearer. It is important that these remain the same so that longitudinal use of numbers are comparable.

I believe what we need now is a very active FAQ and ANSWER internet board through the help desk.  If we can take questions for clarifications on scoring to the help desk that allows subject matter expert debate and resolution with the final say published back to the FAQ so that everyone applies scoring consistently, I believe we could all rest a little more easily.

Although scoring should remain at a fairly basic and uncomplicated level, clinicians will often attempt to define their own ruler and application of scores. Follow the decision trees, they are extremely helpful. There is one more thing that did not change between publications, “Do not modify the FIM UDSMRTM  instrument itself”  page III-2.

Check out Mediware’s software solution to help ensure accurate IRFPAI scores.

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