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CMS Posts Clarifications to Newly Added IRF PAI Sections

Written by: Darlene D'Altorio-Jones (1959-2015) on Sunday, July 12, 2015 Posted in: Inpatient Rehab

Clarifications discussed on the CMS January provider call regarding Oct. 1, 2015 changes to the IRF PAI were published recently on the CMS website. (IRF Fiscal Year 2016.) These clarifications included information on start and stop times in therapy mode definitions and the new subsection to comorbid conditions to validate if an arthritic condition has met all the criteria for inclusion in the 60% rule.

OLD DEFINITION for Concurrent Therapy Oct. 1, 2015 IRF PAI MANUAL:

Concurrent Therapy: The provision of therapy services by one licensed or certified therapist (or licensed therapy assistant, under the appropriate direction of a licensed or certified therapist) treating 2 patients at the same time who are performing different activities.

NOTE: Concurrent therapy sessions must begin and end at the same time for both patients involved.

NEW DEFINITION – IRF PAI MANUAL: Per Follow Up Clarification and soon to be published IRF PAI manual updates.

1. Clarification regarding start and end time when coding concurrent or group therapy on the IRF PAI.

When conducting concurrent and group therapy sessions, start and end times do not need to be the same for all patients participating. The exact time spent for each individual participating in a concurrent or group therapy session should be reported as such.\”

Do not be alarmed that the recently revised IRF PAI manual Section II, posted on the CMS website under downloads, still contains the wrong definitions of start and stop times for \’concurrent\’ therapy on page 22 and the example on page 23.   

CMS acknowledged that further updates to the IRF PAI Manual will be published to coincide with the clarification determination posted in January.   Despite this, just last week it was stated that the revised manual was ready, yet the revision at CMS still does not address the January clarification and definition of concurrent therapy minutes.  I would print and staple the January clarification to the manual until a matching manual definition is published at CMS.

Also in the 2015 IRF PAI (Oct. 1, 2015 which is the 2016 Fiscal Year), CMS is adding a subsection to item #24 (Comorbid Conditions). That section will be called # 24A.

Annually, the Medicare Administrative Contractor (MAC) determines whether a facility with greater than 50% Medicare admissions have met the 60% rule to remain an exempted IRF PPS entity. Prior to fiscal year 2016, they did not have an automated way to validate if conditional arthritic requirements had fulfilled all of the criteria to be counted in the 60% rule.

Since the MAC receives filed data on both part A and part C Medicare patients for the purpose of Presumptive/Conditional coding, this added section will enable transparency for improved workflow and determination of an IRF\’s exempted status.

CMS has always stated that an arthritic code on any of the PAI conditions was open for MAC review; this remains true in the updated manual. If a \’1\’ – yes is indicated in #24A, CMS further states \”prior records will be available to the MAC staff who reviews the medical records for compliance with the applicable regulatory requirements.\” Meaning, the IRF must have copies of all validation criteria documentation in the IRF medical record when they answer 24A \’YES\’. Facilities should make sure their medical record departments retain arthritic treatment validation documentation even when that documentation is NOT from their own healthcare facility. Discuss retention policies with your records department. I have often seen in chart reviews that record departments \’purge\’ non-facility documentation unless directed otherwise.

Added Subsection #24A IRF PAI; October 1st, 2015:

24A. Arthritis Conditions: Enter one of the following codes to indicate whether one or more of the arthritis conditions recorded in items #21 (Impairment Group), #22 (Etiologic Diagnosis), or #24 (Comorbid Conditions) meet all of the applicable regulatory requirements for IRF classification (in 42 Code of Federal Regulations 412.29(b)(2)(x), (xi), and (xii)).

(0- No; 1- Yes) 

Arthritic conditions resulting in significant functional impairment for #21, #22 or #23 items:

  • Active, polyarticular  rheumatoid arthritis, psoriatic arthritis, and seronegative arthropathies
  • Systemic vasculidities with joint inflammation
  • Severe or advanced osteoarthritis (osteoarthrosis or degenerative joint disease) involving two or more major weight bearing joints (elbow, shoulders, hips, or knees, but not counting a joint with a prosthesis) with joint deformity and substantial loss of range of motion, atrophy of muscles surrounding the joint.

In the same follow up clarification to the January 15th call, CMS was asked how to code the item if there are no arthritis conditions as the Impairment Group, Etiologic Diagnosis or the Comorbid Conditions. CMS responded, \”If the patient does not have any arthritis conditions recorded in items #21, #22, or #24 of the IRF-PAI, then the IRF should code \”0 – No\” in item #24A.\”

Chart Review Exercise:   Practicing record completion even prior to the fall, if a facility is contemplating an arthritic condition as the reason for the rehabilitation stay, makes great sense. To determine how your facility is doing in this area, randomly sample all Medicare patients with arthritic condition codes in any of the 3 item areas of the IRF PAI above. Check your medical record to determine if documentation is present to validate application of the conditional 60% rule inclusion. Choose a few records to discuss with your admissions and IRF PAI coordinator staff as to how a record should be validated going forward should a \’yes\’ be coded on the October 1st IRF PAI.

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