With daily headlines about potential changes in healthcare regulations emerging, inpatient rehabilitation facilities (IRFs), along with other post-acute care providers, need to focus on the current state of the industry while monitoring regulatory activity for changes. 

With the increased burden created by documentation and data collection mandates implemented on Oct. 1, 2016 barely behind us, additional provisions are scheduled for implementation in the fall, as audits performed by a variety of agencies continue to increase in number. With that in mind, IRFs should take stock of important processes and procedures and assess their readiness for continued administrative burdens in order to meet the requirements. 

Key Issues Unlikely to Change

Regardless of the outcome of current discussions about repealing portions of the Patient Protection and Affordable Care Act (PPACA), IRFs can and should expect the following to continue:

  • Audits and claims scrutiny
  • Increasing requirements for data collection with the expansion of quality indicators
  • A continued push toward bundled payments and/or unified payment for post-acute services.

With this in mind, it’s a good time for IRFs to perform some self-assessment related to these issues and related processes. As we kick off 2017, it is an excellent time to assess operational processes to evaluate how well IRFs are doing with the more recent changes and to take a look at how well we are managing adjustments in requirements regarding coding and documentation.

Audits, Audits, Audits, and More Audits 

IRFs continue to undergo prepayment review, post-payment review, Comprehensive Error Rate Testing (CERT) review, and other scrutiny from payers – and the demands for records take a toll on medical records and administrative staff. A solid process for assembling, paginating, validating, and sending records in response to documentation requests will help avoid denials for failure to respond, and great preparation of each record improves the likelihood that the reviewer will be able to locate the required information.

Internal audits for common denial reasons – often the technical components of the Medicare documentation requirements – can assist in identifying opportunities to reduce the risk of denials on this front. And ongoing education of staff to improve the quality, completeness, and timeliness of documentation can add another layer of support for success.

Quality Indicators: GG Codes Versus FIM Scores

At four months into data collection for the expanded quality indicators, including the functional GG Codes, IRFs should evaluate the accuracy of those codes and also assess if this added documentation requirement has impacted the accuracy of Functional Independence Measurement (FIM) scoring. If there have been changes in FIM scoring trends, it might be time to reeducate staff in correct scoring for both sets of data.

ICD-10 and CMS-13 Compliance

Some IRFs have noted a decrease in Centers for Medicare & Medicaid Services (CMS)-13 compliance since the onset of ICD-10, even though their patient populations have not changed dramatically. If this is the case for your organization, a review of cases you believe should qualify as compared to those that were identified by your computer software needs to be completed. In some cases, paired ICD-10 codes must be entered on the IRF-PAI to support a CMS-13 diagnosis. IRFs should work closely with their coding staffs to address the differences between coding the IRF-PAI and coding for the UB-04.

And it’s equally important to understand the differences that are allowable in coding the etiological diagnosis section of the IRF-PAI as compared to the entries on the UB04.

The Bottom Line

There are many factors that contribute to success for IRFs, and leaders and managers will continue to juggle efforts to comply with multiple sets of regulations and confusing and conflicting documentation requirements. Managing how these issues interact isn’t simple and requires ongoing assessment, planning, and practice.

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