Managing 75% Rule Compliance
Lisa Bazemore, MBA, MS, CCC-SLP
Director of Consulting Services
Learning Objectives
• As a result of this session, the learner will:
 Have new strategies for identifying patients that are 75%
rule compliant
 Know what documentation needs to be in place for qualifying
a patient as 75% rule compliant
 Be able to analyze reports and sleep well at night knowing
that you are operating within compliance
Identifying Opportunities
 Basic principles in identifying opportunities are:
• Determining who we are looking for
• Knowing where to find them
• Documenting to substantiate their admission
Who are we looking for?
• Patients that presumptively qualify by Rehab Impairment
Category
• Patients that presumptively qualify by etiologic diagnosis
• Patients that presumptively qualify by co-morbidities
• Patients that meet the conditions of compliance for arthritis
conditions
Who are we looking for?
• IGC qualification beyond the obvious:
 Non-traumatic spinal cord injury
• Is there documentation in the acute or rehab chart to support lower
extremity weakness, myopathy, myelopathy, neurogenic bladder?
• Has your Medical Director examined the patient for these conditions?
 Arthritis
• Don’t forget to look for documentation of active treatment of a systemic
condition.
• Look at the MAR. If the reason for pharmacological treatment is not
stated, ask for more specific documentation for the need for an arthritis
medication.
 Multiple Fractures with Trauma
• If a patient sustained multiple fractures, is there mention of further organ
damage or systems trauma?
• Review physician documentation, radiology reports, labs for signs of
further involvement.
Who are we looking for?
• Etiologic diagnosis and co-morbidities beyond the obvious:
 Stroke:
• Late effects CVA can qualify a patient if there is documented evidence
that we are bringing the patient in to treat that condition. Further, they
must require rehab for that condition in the absence of the admitting
impairment group.
• When does this occur? When a patient’s symptoms are exacerbated by
the admitting condition that results in decreased function.
 Brain Injury:
• Late effects from a traumatic or non-traumatic condition may meet the
same conditions as noted above for stroke.
Who are we looking for?
• Etiologic diagnosis and co-morbidities beyond the obvious:
 Neurological conditions:
• Parkinson’s may qualify a patient when there is evidence of active
treatment of the condition by the physician and therapists.
• Polyneuropathy is a condition that qualifies a patient in certain situations.
Look at the documentation in the chart. If there isn’t enough evidence to
tell the origin of the neuropathy, request more specific documentation of
the condition.
• Critical Illness Myopathy is a common condition seen in patients that have
long stays in the ICU. If not documented, ask for further diagnostics to
determine if this condition exists.
 Arthritis as a comorbidity:
• If a patient requires rehab for any condition other than a joint
replacement, qualifying arthritis as an active comorbidity still requires
conditional compliance.
• This means that arthritis must be actively treated and the patient would
have needed IRF level of care for arthritis in the absence of the RIC
condition.
• Further evidence of prior, failed therapy and joint deformity…
Who are we looking for?
• Etiologic diagnosis and co-morbidities beyond the obvious:
 Pelvic Fractures:
• Be sure that documentation is very specific as to the point of fracture and
the type of fracture.
• Look at radiology reports and physician documentation. If they do not
match, ask for clarification.
 Multiple Fractures:
• Coders will code the individual fractures, but we follow the instructions in
the IRF-PAI Manual for assigning an etiologic diagnosis. That allows the
program to assign a code not necessarily provided by the coding team.
• Utilize codes 828.0, 828.1, 819.0, 819.1 where applicable. These codes
are presumptively compliant. The individual fractures can be included as
co-morbidities.
How do we find them?
• Pre-Admission Screening
 Don’t be afraid to ask for more information
 Look at all acute documentation for consistency
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Physician documentation
Nursing and therapy notes
MARs
Radiology reports
Labs
 Know the presumptively compliant conditions so you can be on
the look-out
 Ask questions
 Request diagnostic evidence as needed
How do we find them?
• During the Rehabilitation Stay
 Never stop looking for compliant conditions
 Educate your Medical Directors and consulting physicians on
presumptively and conditionally compliant diagnoses
 Ask questions during Team Conference/Patient Staffing
 Communicate with coders
 Review the assigned codes and ask questions of the coders and
staff if codes do not reflect reported conditions
 Report the codes properly on the IRF-PAI
How do we find them?
• Tools:
 Do you know what your hospital census is? Look at the census
report daily for:
• Patients with a rehab diagnosis
• Medicare patients with a length of stay greater than 3 days
 Meet with case managers and med/surg therapists to identify
patients in need of rehab
 Follow-up on patients that came to your ER and were transferred
elsewhere
 Follow-up on patients sent to SNF or TCU because they were not
able to tolerate 3-hours of therapy. Are they ready now?
 Know your utilization percentage! MedPar and Solucient provide
diagnostic breakdowns of patients seen in your hospital. What
percent of each RIC are you capturing?
What does the paper trail look like?
• Qualifying by RIC:
 Pre-Admission Screening outlines the need for an inpatient rehabilitation
stay
 Physician H&P states the rehab impairment condition
 Therapy and nursing evaluations substantiate the physician’s exam
 Ongoing documentation addresses the condition and progress being made
• Qualifying by etiologic diagnosis or co-morbid condition:
 Acute chart identifies the condition as being actively treated
 Pre-Admission Screening identifies the condition and justifies the need for
inpatient rehabilitation
 Physician documentation identifies the condition at admission
 Therapy and nursing evaluations also identify the patient’s limitations
secondary to the condition
 Ongoing documentation addresses the condition and progress being made
What does the paper trail look like?
• Qualifies based on a condition identified during the IRF stay:
 Physician diagnoses the condition
 Coders include the condition on the coding sheet
 Therapists documents treatment of the condition and/or its
impact on the course of rehabilitation
 Nursing documents treatment of the condition and/or its impact
on the course of rehabilitation
 Common trap: Physician documents the condition, but therapy
and nursing do not or vice versa
What does the paper trail look like?
• Coding is the key!
 What does your coding process look like?
• Best practice-coders are coding the chart concurrently
• Most common-coders code after the first 3-days and following
discharge
 What does that mean for you?
• The responsibility lies with the program manager to ensure that there
are no surprises with any patients admitted
• Assign someone to review the charts concurrently for evidence of
documentation to support the RIC, etiologic diagnosis, and comorbidities
• That person should participate in team conferences and other patient
care meetings to listen for complicating conditions
 Who is reviewing the final IRF-PAI before transmission?
• Do all codes reflect the patient you treated?
• Are all codes in the proper place on the IRF-PAI?
• Are there lessons learned about conditions that were coded differently
than suspected? Remember to educate for the next time.
Analyzing the compliance reports
• How do you know what your 75% rule compliance really is?
 Track all admissions
 Know how you will report your compliance to the FI: admissions
or discharge
 Confirm the final IRF-PAI with the patient’s status on the
compliance report
• On the report, your compliance percentage shows presumptive and
conditional compliance by payor type.
• In order to appear on this report correctly, you will answer questions
on the eRD tab to determine if the patient is 75% compliant or not.
Are the patients entered correctly?
• Review the detailed assessment to determine what makes the patient
compliant. Is the selected reason on the report right?
Analyzing the compliance reports
• Review the reports for potential entry errors:
 Does the IGC match the etiologic?
• Example: 8.51 unilateral hip replacement with 435.9 transient
cerebellar ischemia non-specified
 Do all patients listed as 75% compliant meet the conditions of
eligibility?
• Example: Is there adequate documentation to prove that a
sustained course of OP therapy for the condition was provided within
20 day of the IRF admission?
• Example: Does the active co-morbidity conclusively show the
necessity for rehab in the absence of the admitting condition?
 Are patients with co-morbidities found to make them compliant
following admission represented properly?
• Example: An accurate BMI is taken that shows the patient to have a
BMI>50 while on the unit
Operationalizing compliance
• What is a safe percentage to maintain?
 Provided that each patient is properly identified on your 75% report,
the compliance threshold established for your current reporting
period is adequate.
 Every patient that meets the criteria for inpatient rehabilitation
deserves to receive that level of care. Therefore, operating at a
higher compliance while beds are empty is essentially denying a
patient an opportunity to regain independence.
 The key is to be sure that you capture the 75% status of each
patient correctly.
Operationalizing compliance
• Marketing strategies:
 Maximize internal case finding
 Develop a system for capturing weekend, after hours, and holiday
referrals and admissions-Be accessible
 Follow ER outmigration
 Utilize graduated therapy appropriately
 Follow TCU/SNF admissions that have potential to work up to an
IRF level of care
 Develop a target list of discharge planners, case managers, and
therapists at each facility that you visit. Be consistent in your
visits and message.
 Market directly to physicians
 Market to home care agencies
Operationalizing compliance
• Keep your marketer in the know
 Be sure that all screeners know your current compliance threshold
 Screeners should be prepared to provide a fast turn around on
admission decisions
 That requires access to the program director and medical director
for admission decision making
 Advocate for the patient. Everyone deserves the best possible care,
so our goal should be to leave no stone unturned when looking for
compliant conditions.
Questions?