The Centers for Medicare & Medicaid Services (CMS) last month posted responses to questions submitted at the time of the August federal inpatient rehabilitation facility (IRF) training for quality measures. The entire document can be found on the IRF quality reporting training website here: (Q&A).
Based on the questions and responses in that document, one thing is clear: the who, how, and when of completing some of the assessment data is still not well-understood. Some of the key areas addressed in both the training and the follow-up questions are addressed below.
CMS has focused on a number of issues that should be considered in answering any questions related to the assessment of the quality indicators:
- The assessment period is three days, although the assessment should be completed as soon as possible after admission.
- While it is expected that a multidisciplinary team will complete the assessment, clinicians from one discipline may be assigned to gather specific information.
- The assessment should reflect the patient’s baseline ability prior to any benefit from therapy.
- Some items of the assessment might not be associated with day one of the admission, but day two or three.
Let’s look at some of these areas in more detail.
Can a single clinician assess a quality measure one time during the assessment period and still meet the requirements?
Our belief is that the answer to this question is “yes” in a number of circumstances, particularly in the areas of transfers and for some of the other self-care and mobility scores. Be aware, however, that while a therapist may assess the patient’s transfer ability on day one or early on day two of the admission, the therapist should collaborate with nursing staff in making a decision, keeping in mind how the patient transferred earlier in the IRF stay as part of the assessment. So, while the therapist may be the individual documenting the assessment score, the scoring should include input from multiple members of the treatment team, as well as information provided by the patient and/or family during the actual therapy assessment.
Certain Issues Persist Regarding Car Transfers
Car transfers have presented challenges for organizations, particularly when a car isn’t available or weather prohibits driving. Here are a few of the clarifications we’ve had in regard to car transfers:
- If safety issues or medical condition(s) prohibit the car transfer, code 88 should be used. Many patients may not be able to perform car transfers on admission because of their medical status.
- Use of an indoor car can be used to simulate transfers,but the vehicle must have a standard seat within a car cabin.
- If the patient typically uses only public transportation and does not use a car, use code 09 for “not applicable.” The same would be true if the IRF could not access a car during the assessment period. Again, use code 09 for not applicable.
When Walking “Not Walking”
Walking in the parallel bars is not acceptable when scoring “walking” for the GG section of the IRF-PAI. If the patient is unable to walk without the parallel bars, the clinician should use code 88, not attempted due to medical or safety issues.
This also applies when scoring walking 10 feet. If the patient walks less than 10 feet with a device and/or a helper but cannot complete the full 10 feet, use code 88. Follow the same scoring rules when addressing walking for distances of 150 feet.
The Bottom Line
Early experience with scoring and coding of the self-care and mobility sections of the IRF-PAI, which now include the quality measures, has resulted in a lot of questions. Many of these are addressed in the CMS Q&A documents that are posted online. Now that individual facilities have had more than 30 days of experience, it would be wise to review some records and compare scoring in these areas with the clarifications provided by CMS.
- Perform a “mini self-audit” now!
- Compare scoring on the self-care and mobility items with the information provided in the clarification documents.
- Provide follow-up training to staff using the Q&A documents.
About the Author
Angela M. Phillips, PT, is president and chief executive officer of Images & Associates. A graduate of the University of Pennsylvania’s School of Allied Health Professions, she has more than 35 years of experience as a consultant, healthcare executive, hospital administrator, educator, and clinician. Ms. Phillips is one of the nation’s leading consultants assisting inpatient rehabilitation facilities in operating effectively under the Medicare Prospective Payment System (PPS) and in addressing key issues related to compliance.
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