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Written by: Darlene D'Altorio-Jones (1959-2015) on Friday, May 18, 2012 Posted in: Inpatient Rehab

When a Medicare Part A patient is admitted to inpatient rehabilitation, the commitment of the pre-admission screen and post-admission evaluation is such that you are attesting to the patient’s ability to meet the intensity of care required for payment. We all know that despite the greatest due diligence, that initial week could fall short. As discussed recently in the blog entitled, “Short Stay 5001 CMG Payment – How Close Have You Been Watching?”, this places the IRF at risk for lesser payment as explained in the 2010 guidelines.

We are allowing the IRF to begin making arrangements to transfer the patient to another setting of care and to receive the short stay outlier payment for IRF stays of 3 days or less (instead of having the entire claim denied),  pg.  39791 Federal Register Vol. 74, No. 151 / Friday, August 7, 2009 /Rules and Regulations.

The standard payment without influence of the facility adjusters is $2,074.80, given the applied 0.1474 CMI.  But lets consider another factor. Even if the facility recognizes within that first week that the patient is not able to participate at the intensity of an IRF level of care; staff  must begin making arrangements for discharge. At the very least, each patient must receive the mandated Detailed Notice of Discharge before they can officially discharge the patient.

If you are counting the number of days that the patient is now at the Inpatient Rehab Facility, you will see that often, upon discovery of not meeting intensity, many days can occur. Not meeting intensity within that first week can occur if any of the following are realized: The patient does not meet the initial  intensity of 3 hours of therapy by Noon of the third day (36 hours after Midnight of the admission day), or  is unable to tolerate three consecutive days (POC defined days) within the first week or is unable to receive 15 hours in total within the first week. Realizing that very often, patients are transferred to a rehab facility in the late afternoon on their admit day, the pressure is real and the ability to meet each of these very specific components is hugely important.

Let’s say the patient did not meet intensity as required for the initial seven days and NOW I must give them the detailed notice. It is day 10 before I can officially discharge the patient. Does the 10 day trial now begin to make sense?  I believe so, specifically when you may not discharge the patient before  following all the other federally mandated requirements.  Lets refer to the instructions for discharge notification found in the Medicare Claims Processing Manual Chapter 30.  Section 200.1.

“The final rule requires hospitals to use a revised version of the Important Message
from Medicare (IM), CMS-R-193, which is an existing statutorily required notice,
to explain discharge appeal rights. Hospitals must issue the IM within 2 calendar
days of the day of admission, and obtain the signature of the beneficiary or his or
her representative to indicate that he or she received and understood the notice.
The IM, or a copy of the IM, must also be provided to each beneficiary within 2
calendar days of the day of discharge. Thus, in cases where the delivery of the
initial IM occurs more than 2 days before discharge, hospitals will deliver a
follow up copy of the signed notice to the beneficiary as soon as possible prior to
discharge, but no more than 2 days before.”

Given all the resources provided by your facility to initially determine that the patient was capable to receive but then for any reason was not able to meet the rigid intensity definitions, is it truly fair to receive a flat payment of short stay in definition?  It may be more arguable that payment like that in the transfer rule would be appropriate. After all, a HIPPS code based on the burden within the first three days was achieved by that time. The care provided was not just therapy, but resources provided by the entire interdisciplinary team, and therefore transfer payment rather than short stay would be more appropriate IF the patient did not return to the community. If it was a community discharge, is there any question that the resources expended were valuable enough to warrant full payment despite a rocky start?  After all, due diligence met in the pre-admission screen and post admission evaluation that result in the expected disposition should be rewarded rather than penalized on technicalities.

If a specific percentage of any facilities admissions fell into this category making it appear as though they were “gaming” payment, then those statistics need dealt with. To automatically enforce limited short stay payment to every case is truly unconscionable; this is particularly true when a patient whose start was rocky did not meet the initial intensity, but was rehabilitated and met the goal of returning to the community!

Outcomes and documentation should trump the short stay payment classification in regards to initial week intensity criteria because as you can see, federal regulations place us between a rock and a hard place in getting it right and expediting a discharge with coverage at a 3 day payment rationale. Finally, the name of the CMG, short stay less than 3 days  is very confusing and will lead to persons not ever grasping the intention and use of the CMG correctly. Speak up!  This can’t be right!

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