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Written by: Darlene D'Altorio-Jones (1959-2015) on Tuesday, June 18, 2013 Posted in: Inpatient Rehab

Don’t be shy, the IRF Proposed Rule was filed May 5, 2013, and published on May 8 for the very specific intention for you to review and COMMENT on the items proposed to affect you when operating in an Inpatient Rehabilitation Facility starting in October. You have one week left for comment! If you don’t review and make your comments known, we will live with what it is without chance to influence impactful change. There are 186 pages so don’t hesitate to pick out the sections you wish to provide comment toward. (Italicized & bolded discussion items are areas I chose for comment to CMS. The comments will be reviewed for approval and release at a BOD meeting of the  Ohio Association of Rehabilitation Facilities this Friday. See discussions*.) Of course you may have these or additional points to comment on.

FR Doc. 2013-10755 Filed 05/02/2013 at 4:15 pm; Publication Date: 05/08/2013

Pages 1-4  How to Respond – Contacts & Deadlines  (June 30 is quickly approaching!)

Pages 4 & 5  Executive Summary

Pages 6 – 9  Table of Contents

Pages 9 – 20  Regulatory Background/History  of IRF PPS & it’s Evolutional Updates

Pages 20 – 25 Payment Rates Updates & History

Pages 26 – 33 Table CMI/ALOS Table Update Proposals

Pages 34 – 48 Discussion and Rationale to Standard Conversion Factors

Page 49 –  Table 4 Review & Outline Calculations resulting in $14,865 Standard Payment Conversion

Pages 49 – 52 Resultant CMI payment amounts based on conversion factor above

Pages 53 – 54 Discussion and sample table that demonstrates a Rural vs Urban translation of payment

Page 55 – 57  High cost Outlier review and discussion

Pages 58 – 64  Presumptive Compliance Criteria Methodology Discussion

Pages 64 – 77  Proposed changes to presumptive compliance ICD-9 allowable inclusions & rationale. Utilization of appendix alphabet not previously associated with presumptive reporting.

*There are three appendices associated with IRF PAI completion published since inception as A, B & C. Appendix A was Compliance Review periods for 75 percent & now 60 percent ruling;  Appendix B was Impairment Group Codes that meet Presumptive Compliance and Appendix C was a list of co-morbid conditions resulting in the TIER application by RIC as included or not included. This proposed rule has utilized the name Appendix C for an Appendix B application and I feel this was an oversight (?).

Pages 78 – 88  Proposed Codes Table to be removed from Presumptive Compliance Criteria standards

Page 89 Medicare Type patients requiring IRF-PAI submission (A,B, C)?  Incorrect discussion regarding previous requirement of Type B submission by PAI to CMS – needs clarified.

* This needs clarified. Type B patients are not paid by HIPPS and the grouper software will associate a HIPPS code. Facilities must be very careful to utilize appropriate ‘reporting only’ criteria for C and if intended B submissions. Previous rules only mentioned A & C submission and this discussion makes it appear as though B had previously been included.

Pages 88 – 90  Proposed IRF-PAI CHANGES  (Non- Quality Outcomes Related).

Item 15A: Admit From (Formerly item 15);

Item 16A:  Pre-Hospital Living Situation (Formerly item 16)

Item 44D:  Patient’s Discharge Destination/Living Setting (Formerly item 44A)

*Attempt to align discharge destination more closely with the coding rules of the billing document, in doing so IRFs will lose the ability to capture subacute setting; although SNF placement which will change comparison for longitudinal review).

Item 20 B:  Payment Source – discusses Secondary but not Primary codes without appropriate key.

*Proposed rule states they are changing the ‘Secondary payer sources’ yet the rule fails to provide the standard previous key for Primary Payer sources on the IRF PAI itself.  I feel that at least the primary source should remain intact for longitudinal comparison for all facilities. Many facilities will have reports and other electronic documentation that have been built outside of the IRF PAI and they would lose granularity of comparison in outcomes data.

Pages 91 – 93  Proposed IRF-PAI ADDITIONS:

Item 25A: Height

Item 26A:  Weight

Item 24:  Co-morbid Conditions (15 additional spaces)

Item 44C:  Was the patient discharged alive?

Signature of Persons Completing the IRF-PAI

* Name of the document is misleading. It states “Signatures of Persons Completing the Assessment’; I believe they are looking for “Signatures of Persons Completing/Attesting to IRF-PAI accuracy”  as outlined in 412.612 of the Federal Register. Attestation for collating the ‘lowest score, and all other items for submission must pass through DESIGNATED personnel with responsibility to encode the PAI and release it. Hundreds of clinicians will have input to assessment but none of them will know for sure if the score they assessed actually made it to the released IRF PAI form.   

Pages 93 – 94  IRF-PAI DELETIONS:

Item 18: Pre-Hospital Vocational Category

Item 19: Pre-Hospital Vocational Effort

Item 25:  Is patient Comatose at admission?

Item 26:  Is patient delirious at admission?

Item 28:  Clinical signs of dehydration?

Pages 94 – 97  Technical Clarification to Federal Register  412.130 to capture previous regulatory language changes

Pages 97 – 98  Technical Clarifications to Federal Register 412.630 to capture previous regulatory language updates

Pages 98 – 99  Proposed Revision 412.29 to clarify basic pre-admission screening for all patients but that Medicare Part A must be reviewed and approved by a rehabilitation physician

Pages 99 – 106  Discussion of Previous Quality Monitors and payment schedule participation

Pages 106 –  138  Adoption of NEW Quality Measures for 2016 and 2017 Payment Cycle considerations

Influenza Coverage – Healthcare Personnel Reporting  NQF #0431 (with CAUTI & Pressure Ulcer) (2016 payment consideration cycle)

All-Cause Unplanned Readmission Measure for 30 Days Post Discharge from IRF (Discussion pg. 115)

*An item within the IRF-PAI should be designated to allow ‘expected’ return to acute care for planned procedural events; this makes it clear cut when it should  NOT be counted as a 30 day ‘all cause’ readmission that may possibly be punitive in the future.

          Appropriately Given the Seasonal Influenza Vaccine (Short-Stay) (NQF #0680)

NQF endorsed version of Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (Short-Stay) (NQF #0678).

Pages 123 – 135  IRF-PAI Proposed Changes Related to Quality Reporting

Pages 139 – 141  Disaster Waiver for Quality Reporting

Page 142 Public Display of Quality Reporting Discussion and invite for comments

Page 142 – 152  Applying Reductions for non-reporting and how this will be handled here and ongoing

Pages 153 – 162  Impact Analysis Discussions

Pages 163 –  165  Impact Table

Page 166 – Outlier Payment Impact Discussion

Page 167 – 180  Further Impact Discussions

Page 181 – 182  Accounting Impact Discussion

* Regulations state that “the Clinician of the IRF must have responsibility for: 412.612 the accuracy and thoroughness of the specific data recorded “by that Clinician” on the patients assessment instrument; and…” The impact statement calculations of cost should reference back to page 148 whereas they utilize an administrative assistant or medical secretary salary range to enter data to the medical record and/or CMS IRVEN. This is incongruent with present Federal Regulations and should be amended to change the salary calculation to a clinical equivalent – usually a NURSE.

Page 183 – 185  Actual CFR change language to be incorporated

Page 186 – Filing & Signature page – * See comments above ‘ Signature of Persons Completing the IRF PAI.’

I hope you find this outline particularly helpful in the final hours to comment. Pick the section you feel most impactful to your need to comment and don’t waste any time!  There are relatively few days left!

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