2012 IRF PPS Updates
Clinical Training Call
October 4, 2011
Lisa Werner, MBA, MS, CCC-SLP
How A CMG is Determined
CMG Determinants
Impairment Group
Code
Broad codes that identify the main reason for
the rehab stay. 21 main categories.
Motor Score of
Functional
Independence
Measure
Functional assessment based on 12 functional
measures – determined upon admission
Co-morbidities
Additional medical condition that has a
significant effect on the rehabilitation stay &
progress & cost.
Age
The age of the patient upon admission
(excludes tub/shower transfers)
Case Mix Groups
• Discharge-based system
 Payment is based on discharge information
• Case Mix Groups (CMG)
 87 main groups
 4 deaths
 1 short stay
• Single lump payment for each stay
Case Mix Groups
• All inclusive* payment for each patient
 Off unit surgery, dialysis, and so on.
• 353 payment categories
• The base rate from the government last year
 Range of average discharge rates $6,880 - $40,964
with no co-morbidity
 Range of average discharge rates $8,086 – $61,648
with the highest co-morbidity
* Blood transfusion and certain medical education costs
excluded
Review of Changes
• The final rule introduced changes in these
categories:
 Relative weights and average length of stay based on
the most current Medicare claims and cost report data.
 Facility adjusters in a budget neutral manner.
 PPS rates per the recommended market basket
increase.
 Payment rates based on wage index and labor shares.
 Update to the outlier threshold.
 Update to the cost-to-charge ratio ceiling and national
average urban and rural cost-to-charge ratios for
purposed of determining outlier payments.
 Implement the quality reporting program provisions.
Provider Payment Components
• Federal Base Payment (F)
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Base rate for October 1, 2007 was $13,451
Change of rate on April 1, 2008 was $13,034
Rate for October 1, 2008 is $12,958
Rate for October 1, 2009 is $13,661 (2.5% increase)
Rate for April 1, 2010 is $13,627
Rate for October 1, 2010 is $14,076
• Labor Share (F)
 Total is 70.119 of the Medicare payment.
 Down from 75.271 last year.
• Wage (V)
 Maintains budget neutrality.
Provider Payment Components
• Changes to facility adjusters:
 2012:
• LIP: .4613
• Rural: 18.4%
• Teaching: .6876 using a formula of (1+FTE interns and
residents/ADC)
 2011: Stated as a per facility update (No changes)
 2010: Stated as noted below
• LIP: 0.4613 versus 0.6229
• Rural: 18.4% versus 21.3%
• Teaching: 0.6876 versus 0.9012
CMG Revisions
• Impact of CMG weight revision by RIC:
01 Stroke
02 Traumatic brain injury
03 Nontraumatic brain injury
04 Traumatic spinal cord
05 Nontraumatic spinal cord
06 Neurological
07 Fracture of LE
08 Replacement of LE joint
09 Other orthopedic
10 Amputation, lower extremity
11 Amputation, other
12 Osteoarthritis
13 Rheumatoid, other arthritis
14 Cardiac
15 Pulmonary
16 Pain Syndrome
17 Major multiple trauma, no brain injury or spinal cord injury
18 Major multiple trauma, with brain or spinal cord injury
19 Guillain Barre
20 Miscellaneous
21 Burn
$
214.59
$
373.49
$
345.19
$ 2,984.77
$
558.05
$
216.89
$
426.03
$
347.26
$
204.88
$
693.93
$
842.51
$
427.93
$
264.66
$
411.40
$
302.64
$
116.94
$
288.06
$
(967.30)
$
874.48
$
346.41
$ (4,619.34)
CMG Revisions
• Published CMG differences for 2011 versus actual variances
CMG
101 Stroke M>51.05
102 Stroke M>44.45 and M<51.05 and C>18.5
103 Stroke M>44.45 and M<51.05 and C<18.5
104 Stroke M>38.85 and M<44.45
105 Stroke M>34.25 and M<38.85
1
106 Stroke M>30.05 and M<34.25
107 Stroke M>26.15 and M<30.05
108 Stroke M<26.15 and A>84.5
109 Stroke M>22.35 and M<26.15 and A<84.5
110 Stroke M<22.35 and A<84.5
Variance
$166.93
$277.55
$775.37
$202.51
$26.62
$188.50
$164.92
$467.59
-$109.35
$299.67
High Cost Outliers
• Definition: Cases where cost exceeds reimbursement by a
significant portion qualifying the facility for additional
payment.
 PPS Payment plus the adjusted threshold amount compared
to estimated cost-to-charge ratio based on Medicare
allowables.
 GROUPER software detects the high cost and triggers
payment if cost is greater than the adjusted outlier
threshold.
 Medicare pays the provider 80% of the difference between
the estimated cost of the case and the outlier threshold.
 2012 outlier threshold is $10,660.
 Expected to occur in 3% of IRF cases.
Exceptions to full CMG Payment
• No change to transfer rule, short stay, or
interrupted stay provisions.
• Transfer Rule
 Discharge to Medicare or Medicaid certified
facility
 And •Has a LOS shorter than the LOS for the
CMG they were assigned when discharged
•Per diem payment for the days on the unit
plus ½ the per diem for the first day
Transfer Rule Example
•
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•
Base Rate
Weight for CMG 108 Tier 3 =
Weight times base rate =
LOS for CMG 108 Tier 3 is 23
CMG 108 Tier 3 divided by 23 =
Times 8 days =
Plus ½ one per diem =
$14,076
1.8639
$26,236
$1140/day
$9120
$9690
Transfer Process
• Works the same for transfers to:
 Skilled Nursing Facilities & Nursing Homes
 Long Term Acute Care
 Acute Care
 Another Rehab Program
Program Interruption
• Program Interruptions include transfers to
acute and back to rehab during the stay.
 CMG includes paying for acute stays when:
• Patient is discharged to acute and returns to IRF by
midnight of the 3rd calendar day.
• All costs associated with the acute stay are
recorded on the rehab cost report.
• True for discharges to acute care of your own
facility or acute care of another hospital.
Program Interruption
• Acute stay greater than 3 days are different.
 If patient goes to acute care and does not return by
midnight of the 3rd calendar day, discharge and readmit.
 Patient will have a new admission and assessment
reference period.
 New CMG will be assigned based on information
gathered at admission.
Short Stays
• Short stays include patients who are admitted and
discharged to a community setting before the end of the
assessment period.
 Revert to short stay CMG 5001.
 CMG payment weight is .1475 with an average length of stay
of 3 days.
 Used for lengths of stay 3 days or fewer (day of discharge is
not counted as a day).
Expired on the Unit
• If a patient expires on the rehabilitation unit, CMG
weights are as noted:
 5101 expired, orthopedic with a length of stay of 13 days or
fewer
• .5856
 5102 expired, orthopedic with a length of stay of 14 days or
more
• 1.4718
 5103 expired, not orthopedic with a length of stay of 15 days
or fewer
• .6970
 5104 expired, not orthopedic with a length of stay of 16 days
or more
• 1.8779
Changes to Comorbidities that Tier
• Tier 1:
 No changes
• Tier 2:
 No changes
Changes in Comobidities that Tier
• Tier 3 Additions:
 284.11 Chemo induced pancytopenia
 284.12 Other drug induced pancytopenia
 284.19 Other pancytopenia
• Deleted 294.1 Pancytopenia
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415.13
488.81
516.31
516.32
516.33
516.34
Saddle embolic pulmonary artery
Flu due to NVL A virus with pneumonia
Idiopathic pulmonary fibrosis
Idiopathic non-specific inter pneumonia
Acute interstitial pneumonia
Resp bronchial interstitial lung
Changes to Comorbidities that Tier
• Tier 3 Additions:
 518.51 Acute resp failure following trauma/surgery
 518.52 Other pulmonary insufficiency following
trauma/surgery
 518.53 Acute on chronic acute respiratory failure following
trauma/surgery
• Deleted 518.5
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793.19
998.00
998.01
998.02
998.09
Other nonspecific abnormal findings of the lung fields
Postoperative shock, NOS
Postoperative shock, cardiogenic
Postoperative shock, septic
Postoperative shock, other
• Deleted 998.0
 999.32 Blood infection due to central venous catheter
 999.33 LCL infection due to central venous catheter
Changes in Comorbidities that Tier
• Tier 3 Deletions:
 284.1 Pancytopenia
 518.5 Post-traumatic pulmonary insufficiency
 998.0 Postoperative shock
Coding Additions
• Other coding changes:
 Many other coding changes were published.
 Those mentioned impact payment under the IRF PPS
payment system
The Importance of Accuracy
• Three Tiers of Co-morbidities
 Average eRehabData utilization in the previous 365
days:
• Tier 3
• Tier 2
• Tier 1
27.16%
8.55%
5.81%
 Can be identified up to two days before discharge.
 Physician identification is mandatory.
Tier 1 Co-morbid Conditions
• Eight Tier 1 Comorbitites:
 478.31 VOCAL PARAL UNILAT PART
 478.32 VOCAL PARAL UNILAT TOTAL
 478.33 VOCAL PARAL BILAT PART
 478.34 VOCAL PARAL BILAT TOTAL
 478.6 EDEMA OF LARYNX
 V44.0 TRACHEOSTOMY STATUS
 V45.1 RENAL DIALYSIS STATUS
 V55.0 ATTEN TO TRACHEOSTOMY
Tier 2 Comorbidities
• Eleven Tier 2 Comorbidities:
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008.42 PSEUDOMONAS ENTERITIS
008.45 INT INF CLSTRDIUM DFCILE
041.7 PSEUDOMONAS INFECT NOS
438.82 LATE EF CV DIS DYSPHAGIA
579.3 INTEST POSTOP NONABSORB
787.20 DYSPHAGIA NOS
787.21 DYSPHAGIA, ORAL PHASE
787.22 DYSPHAGIA, OROPHARYNGEAL
787.23 DYSPHAGIA, PHARYNGEAL PHASE
787.24 DYSPHAGIA, PHARYNGOESOPHAGEAL
787.29 DYSPHAGIA NEC
Top Tier 3 Comorbidities
• Tier 3 (Top 35)
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278.01 MORBID OBESITY
584.9 ACUTE KIDNEY FAILURE NOS
357.2 NEUROPATHY IN DIABETES
250.60 DMII NEURO NT ST UNCNTRL
486. PNEUMONIA, ORGANISM NOS
342.90 UNSP HEMIPLGA UNSPF SIDE
682.6 CELLULITIS OF LEG
998.59 OTHER POSTOP INFECTION
518.81 ACUTE RESPIRATRY FAILURE
428.30 DIASTOLC HRT FAILURE NOS
415.19 PULM EMBOL/INFARCT NEC
250.40 DMII RENL NT ST UNCNTRLD
250.62 DMII NEURO UNCNTRLD
995.91 SIRS-INFECT W/O ORG DYSF
250.80 DMII OTH NT ST UNCNTRLD
507.0 FOOD/VOMIT PNEUMONITIS
428.32 CHR DIASTOLIC HRT FAILURE
250.70 DMII CIRC NT ST UNCNTRLD
• Tier 3 (Top 35)
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428.22 CHR SYSTOLIC HEART FAILURE
515. POSTINFLAM PULM FIBROSIS
428.20 SYSTOLIC HRT FAILURE NOS
250.50 DMII OPHTH NT ST UNCNTRL
284.1 PANCYTOPENIA
998.32 DISRUP-EXTERNAL OP WOUND
780.62 Postprocedural fever
038.9 SEPTICEMIA NOS
342.91 UNSP HEMIPLGA DOMNT SIDE
998.32 Disruption of an external op
(surgical) wound
342.92 UNSP HMIPLGA NONDMNT SDE
682.2 CELLULITIS OF TRUNK
518.5 POST TRAUMATIC PULM
INSUFFIC
584.5 ACT KIDNEY FAILURE w/ LESION
250.01 DMI WO COMP NT ST UNCONT
682.3 CELLULITIS OF ARM
Replacement of Lower
Extremity Joint
Motor >49.55
Motor > 37.05 & < 49.55
Replacement
of Lower
Extremity Joint
Motor > 28.65 & < 37.05
& Age > 83.5
Motor > 28.65 & < 37.05
& Age < 83.5
Motor > 22.05 & < 28.65
Motor < 22.05
0801 ALOS W/O CM 7
Relative Wt. .4888
$ 6880.35
0802 ALOS W/O CM 9
Relative Wt. .6573
$ 9252.15
0803 ALOS W/O CM 12
Relative Wt. .9062
$12755.67
0804 ALOS W/O CM 10
Relative Wt. .8004
$11266.43
0805 ALOS W/O CM 13
Relative Wt. .9856
$ 13873.31
0806 ALOS W/O CM 15
Relative Wt. 1.2034
$ 16939.06
Weighted Motor Score Index
Item
Weight
Eating
.6
Grooming
.2
Bathing
.9
Dressing – Upper Body
.2
Dressing – Lower Body
1.4
Toileting
1.2
Bladder
.5
Bowel
.2
Transfer Bed, Chair, W/C
2.2
Transfer Toilet
1.4
Transfer Tub, Shower
Not included as item for
CMG
Locomotion
1.6
Stairs
1.6
Motor Score Index
Item
Eating
Grooming
Bathing
UB Dressing
LB Dressing
Toileting
Bladder
Bowel
Transfer Bed, Chair, W/C
Transfer Toilet
Transfer Tub/Shower
Locomotion
Stairs
Total
Score
5
5
4
4
3
4
1
5
3
4
4
2
2
Weight
Value
.6
.2
.9
.2
1.4
1.2
.5
.2
2.2
1.4
3
1
3.6
.8
4.2
4.8
.5
1
6.6
5.6
1.6
1.6
3.2
3.2
37.5
Quality Measures
• Three measures:
 Percent of Patient with New or Worsened Pressure Ulcers, NQF
#0678
 Catheter associated urinary tract infections will be reported to the
CDC National Health Safety Network (NHSN)
 The third item under consideration is “30–day comprehensive AllCause Risk-Standardized Readmission Measure.”
 CMS will publish the electronic specifications related to reporting the
pressure ulcer measure on the CMS website no later than January
31, 2012.
Questions?
Next call: November 1 @ 1:00 EST