Coding Update
Lisa Bazemore, MBA, MS, CCC-SLP
February 5, 2008
Exemption Criteria
Physician 24/7
Documentation of medical and
rehab needs. Co-morbidities
need listing.
Rehab Nursing 24 hrs
Comprehensive Nursing Plan of
Care.
Relative Intensity
Documenting endurance in the
pre-admission screen and for
continued stay.
Multidisciplinary Team
Goal statements. Assessments
done before day four postadmission.
Exemption Criteria
Comprehensive Plan
Justifies the admission.
Significant Progress Toward
Goals
Documentation matches
between chart and IRF – PAI.
75/25 rule
Each patient is assessed
individually.
Pre-admission screening
Add in CMG prediction for long
stay – heavy care patients.
Basics
Exemption Criteria
Distinct space
Beds contiguous.
Team Conference
May change frequency.
3 to 10 day evaluation
Graduated therapy time frame.
Annual evaluation
IRF - PAI will be part of review.
Provider Payment Components
• Federal Base Payment (F) –
 base rate for 2008 is $13,241
• Labor Portion (F) –
• Wage (V)
• Rural Factor (F) –
 continue to move to new MSA model
• LIP (V) – Low income patient
• Case Mix (V)
Case Mix Groups
• Discharge-based system
 Payment is based on discharge information
• Case Mix Groups (CMG)
 95 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.
• 385 payment categories
• The base rate from the government last year
 Range of average discharge rates $6,100 - $39,348
with no co-morbidity
 Range of average discharge rates $8,656 – $55,006
with the highest co-morbidity
* Blood transfusion and certain medical education costs
excluded
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 FIM
Functional assessment based on 12 functional
measures – determined upon admission
(excludes tub/shower
transfers)
Co-morbidities
Additional medical condition that has a
significant effect on the rehabilitation stay &
progress & cost.
Age
The age of the patient upon admission
CMG Table Sample
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 6
Relative Wt. .4607
$ 6100.13
0802 ALOS W/O CM 8
Relative Wt. .6020
$ 7971.08
0803 ALOS W/O CM 12
Relative Wt. .8956
$11858.64
0804 ALOS W/O CM 10
Relative Wt. .7781
10302.82
0805 ALOS W/O CM 13
Relative Wt. .9816
$ 12977.37
0806 ALOS W/O CM 15
Relative Wt. 1.1787
$ 15607.17
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
• Total Maximum Motor
Score – 84
• Total Minimum Motor
Score – 12 (“0’s” convert
to “1’s” for CMG
determination)
• If Transfer to Toilet
coded “0” – will be
converted to a “2”
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
Motor Score Index Example
Item
Stairs
Locomotion
Transfer Tub/Shower
LB Dressing
Bathing
Transfer Bed, Chair, W/C
Toileting
Transfer Toilet
Bladder
UB Dressing
Grooming
Bowel
Eating
Score
2
2
1
3
3
4
5
0(2)
5
5
5
1
5
Weight
Value
1.6
1.6
3.2
3.2
1.4
.9
2.2
1.2
1.4
.5
.2
.2
.2
.6
4.2
2.7
8.8
6
2.8
2.5
1
1
.2
3
Total
• CMG 0602 Neurological with M > 37.35 and M < 47.75
38.6
Motor Score Index Example
• CMG 0602 Neurological with M > 37.35 and M < 47.75
• Total score = 38.6






Toilet Transfer was not scored
0 defaulted to a score of 2
If attempted and scored a 1, total would have been 37.2
CMG would have been 0603
Payment weight would have been 1.1965 instead of .9342
Difference of $3381
The Importance of Accuracy
• Three Tiers of Co-morbidities
 Average eRehabData utilization in 2007:
• Tier 3
21.33%
• Tier 2
7.58%
• Tier 1
5.40%
 Can be identified up to two days before discharge.
 Physician identification is mandatory.
 Nursing Plan of Care follow up is critical.
 Logged on the IRF-PAI
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:











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 (Over 100 occurrences)















278.01 MORBID OBESITY
357.2 NEUROPATHY IN DIABETES
250.60 DMII NEURO NT ST UNCNTRL
486. PNEUMONIA, ORGANISM NOS
584.9 ACUTE RENAL FAILURE NOS
342.90 UNSP HEMIPLGA UNSPF SIDE
682.6 CELLULITIS OF LE
998.59 OTHER POSTOP INFECTION
415.19 PULM EMBOL/INFARCT NEC
250.40 DMII RENL NT ST UNCNTRLD
250.80 DMII OTH NT ST UNCNTRLD
507.0 FOOD/VOMIT PNEUMONITIS
250.50 DMII OPHTH NT ST UNCNTRL
250.70 DMII CIRC NT ST UNCNTRLD
518.81 ACUTE RESPIRATRY FAILURE
• Tier 3 (Over 100 occurrences)













998.32 DISRUP-EXTERNAL OP WOUND
515. POSTINFLAM PULM FIBROSIS
250.62 DMII NEURO UNCNTRLD
995.91 SIRS-INFECT W/O ORG DYSF
342.91 UNSP HEMIPLGA DOMNT SIDE
342.92 UNSP HMIPLGA NONDMNT SDE
250.01 DMI WO CMP NT ST UNCNTRL
428.30 DIASTOLC HRT FAILURE NOS
284.1 PANCYTOPENIA
682.3 CELLULITIS OF ARM
038.9 SEPTICEMIA NOS
342.80 OT SP HMIPLGA UNSPF SIDE
518.5 POST TRAUM PULM INSUFFIC
Top Tier 3 Comorbidities
• Tier 3 (Over 100 occurrences)













434.91 CRBL ART OCL NOS W INFRC
682.2 CELLULITIS OF TRUNK
042. HUMAN IMMUNO VIRUS DIS
785.4 GANGRENE
250.61 DMI NEURO NT ST NCNTRLD
518.3 PULMONARY EOSINOPHILIA
682.7 CELLULITIS OF FOOT
348.1 ANOXIC BRAIN DAMAGE
514. PULM CONGEST/HYPOSTASIS
415.11 IATROGEN PULM EMB/INFARC
482.41 STAPH AUREUS PNEUMONIA
584.5 LOWER NEPHRON NEPHROSIS
250.82 DMII OTH UNCNTRLD
• Tier 3 (Over 100 occurrences)













250.42 DMII RENAL; UNCONTRLD
250.52 DMII OPHTH UNCNTRLD
342.82 OT SP HMIPLG NONDMNT SDE
996.62 REACT-OTH VASC DEV/GRAFT
250.92 DMII UNSPF UNCNTRLD
038.11 STAPH AUREUS SEPTICEMIA
428.20 SYSTOLIC HRT FAILURE NOS
433.11 OCL CRTD ART W INFRCT
250.72 DMII CIRC UNCNTRLD
421.0 AC/SUBAC BACT ENDOCARD
682.4 CELLULITIS OF HAND
428.1 LEFT HEART FAILURE
995.92 SIRS-INFECT W ORGAN DYSF
Comorbidity Impact
Comorbidities-RIC 01 Stroke
Reimbursement
None
$28,665.44
Tier 3 – ex., Diabetes
$29,681.03
Tier 2 – ex., Dysphagia NOS
$32,979.36
Tier 1 – ex., Vocal Cord Paralysis
$34,806.62
Operational Process to the CMG
• Pre-admission screening (screener/physician)




Gather apparent Impairment Group Code
Gather co-morbid conditions
Age information
Payer status (Medicare vs. other payer)
• Admission
 Physician assessment is done and H&P is written
 IRF-PAI is started once Impairment Group Code and comorbid conditions are confirmed with physician
documentation
 Therapy and nursing assessment are completed and plan of
care is written
 FIM motor subscale scores are obtained
Operational Process to the CMG
• Assessment
 Coders review charts at the end of the assessment to assign
admission codes
 Beginning CMG is established
 Discharge plan identified
• Concurrent coding
 Additional comorbidities and complications are added to the
IRF-PAI as per physician documentation
• Discharge





Discharge destination selected
Length of stay set
Final coding is complete
IRF-PAI is locked and transmitted
UB-04 is sent to FI for payment
How it Works
80%+ of the Time
S
M
1
T
2
W
3
Th
4
F
S
Discharge Home
Patient stays at least to the fourth day and discharged home.
Facility receives the full CMG payment.
Simple Payment Determination
• Base Rate x CMG/Tier weight
• Example:
$13,241 x 0.9998
(CMG 0204 for TBI/Tier 3)
= $13,238.35
How it Works:
Co-morbidity Identification
S
M
T
W
Th
F
S
Co-morbid conditions can be identified by the physician
up to 2 days before discharge for the
payment bump to be effective.
Sample
CMG 108 C
Weight
ALOS
13,241
Tier 1
High (B)
2.2160
28
29,342
Tier 2
Med( C)
2.0997
29
27,802
Tier 3
Low (D)
1.8897
25
25,021
None
(A)
1.8250
24
24,165
Exceptions to full CMG Payment
• 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
•
•
•
•
•
•
•
Base Rate
Weight for CMG 108 Tier 3 =
Weight times base rate =
LOS for CMG 108 Tier 3 is 25
CMG 108 Tier 3 divided by 25 =
Times 8 days =
Plus ½ one per diem =
$13,241
1.8897
$25,021
$1001/day
$8006
$8506
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.
Correct Coding
• Why Correct Coding is Important
 Assignment of appropriate case mix group (CMG)
 Correct payment tier for co-morbidities
 Prevention of issues with potential Medicare compliance
audits
 Compliance with the “75%” rule
Accurately coding documented diagnoses allows for appropriate
reimbursement and permits us to capture all possible resources
for our patients’ care.
Correct Coding
• Assignment of Rehab Impairment Code
 Assign the group that best describes the primary
condition requiring admission to the rehabilitation
program.
• PPS Coordinator will look at the condition for
whether or not it meets 75% rule compliance
• If not, look at the acute care documentation to
determine what the patient was being treated for
• Is there an etiologic diagnosis that will qualify the
patient?
Diagnosis Coding
• Etiologic diagnosis
Use ICD-9 codes, but official coding guidelines do not apply
• Comorbid conditions
Use ICD-9 codes, official coding guidelines sometimes apply
Etiologic Diagnosis
• Etiologic diagnosis
 Diagnosis that led to condition for which the patient is
receiving rehabilitation
 May use code for an acute condition causing the
impairment
 May use code for a late effect of an acute condition if a
rehabilitation program was completed previously for
same impairment
Co-morbidities
• Co-morbid condition
 Patient condition other than the impairment or etiologic
diagnosis
 Exists at the time of admission/may develop during stay
 Affects treatment received and/or LOS
• Co-morbid conditions should be reported if they require:





Clinical assessment
Additional diagnostic procedures
Therapeutic treatment
Extension of the length of stay
Enhanced nursing care and/or monitoring
• List on IRF-PAI even if not in payment tier
Complications
• Complications are medical conditions
 Not present at time of admission to rehabilitation
 Identified during rehabilitation stay
 That slow or compromise the rehabilitation program
Coding Complications
• Conditions occurring day prior to discharge or on day of
discharge
 Do not add to the burden of care, so they do not yield
additional payment
 Document conditions early or as identified rather than
waiting until the discharge summary
Coding
• Coding the IRF-PAI and the UB-04 is not
the same!
 Common question: Should the codes on
these documents be the same?
• NO!
Diagnosis Coding
Etiologic Diagnosis
Principal Diagnosis
The problem that lead to
the impairment requiring
rehabilitation
The circumstances of
inpatient admission always
govern the selection of
principal diagnosis.
Using ICF terminology, the
disease, disorder or injury
that resulted in impairment
It is “that condition
established after study to
be chiefly responsible for
occasioning the admission
of the patient to the
hospital for care"
Diagnosis Coding
IRF-PAI Coding
Etiology is selected by
identifying the cause of
the primary impairment
Acute Care Coding
Principal diagnosis is
always a V57 code –
Care involving use of
rehabilitation procedures
V57.89 – Other specified
rehabilitation procedure
Diagnosis Coding
IRF-PAI Coding
Limited to ten codes to
report comorbid conditions
Acute Care Coding
Limited to spaces on the
UB04 – eighteen spaces
Diagnosis Coding
IRF-PAI Coding
Codes should be sequenced
according to PPS strategy:
1.) tier assigning
2.) conditions that affect the
patient (increase need for
heath care resources or LOS)
3.) support medical
necessity
Acute Care Coding
Codes are sequenced
using specified
procedures, software
scrubbing
Diagnosis Coding
IRF-PAI Coding
Codes are reported for
actively treated conditions,
only. Do not code
"probable", "suspected",
"likely", "questionable", or
"possible“ conditions
Acute Care Coding
If the diagnosis documented
at the time of discharge is
qualified as "probable",
"suspected", "likely",
"questionable", "possible", or
"still to be ruled out", code
the condition as if it existed
or was established. The bases
for this guidelines are the
diagnostic workup,
arrangements for further
workup or observation, and
initial therapeutic approach
that correspond most closely
with the established
diagnosis.
Diagnosis Coding
IRF-PAI Coding
Late effect codes are used
when the patient has
completed a rehabilitation
program for the condition
in the past
Acute Care Coding
A late effect is the residual
effect (condition produced)
after the acute phase of an
illness or injury has
terminated. The residual
may be apparent early, such
as in cerebrovascular
accident cases, or it may
occur months or years later,
such as that due to a
previous injury
Diagnosis Coding
IRF-PAI Coding
Code significant symptoms
that require health care
resources
Code residual effects of the
primary impairment
treated in rehabilitation
Acute Care Coding
Signs and symptoms that
are integral to the disease
process should not be
assigned as additional
codes
Diagnosis Coding
IRF-PAI Coding
Code concurrently
Acute Care Coding
Recent change from coding
at discharge to coding
concurrently
Diagnosis Coding
IRF-PAI Coding
Coding may be done by
HIM professional or by a
clinician (PPS coordinator)
Acute Care Coding
Official rules for who does
coding
Diagnosis Coding
IRF-PAI Coding
Do not code conditions
that are recognized the
day of discharge or the day
preceding discharge
*Coding comparison from Dr. Pam
Smith, Extreme Makeover for
Medical Rehabilitation
Acute Care Coding
No stipulation on when a
condition is identified
Documentation Tips
• In the H&P note all active conditions and plan to address the
conditions
• Medication changes – document why changed
• Lab results – document decisions made based on lab results
• Ordering additional tests/labs – document reason why ordered,
discuss risks, advantages, hasten rehab participation and
discharge
Coding Points to Remember
• When in question, distinguish between obesity and morbid
obesity
 Involve dietitian
 Morbid obesity is a BMI of 40 or more
• Physician delineation of manifestations of diabetes mellitus
assists coders
 Peripheral neuropathy
 Nephropathy
 Retinopathy, etc.
Contact Information:
Lisa Bazemore
lbazemore@erehabdata.com
(202) 588-1766