Five major areas will challenge IRF providers in 2018, including the troublesome “presumptive compliance.”

Let’s face it: there are a multitude of areas that Inpatient Rehabilitation Facility (IRF) leadership must focus on every day to be successful. As we begin a new year of compliance with a plethora of regulations, it’s a great time to take stock and focus on top priorities that we see as challenges for IRFs.

Presumptive Compliance

Presumptive compliance is far from a new concept, but during recent months there has been an increase in the number of facilities that are failing the “presumptive” test and being subjected to desk audits to prove that they can be compliant with the requirement that 60 percent of patients admitted to the IRF fall into one of the CMS-13 diagnostic categories. While failure to meet the presumptive test doesn’t mean an IRF is not compliant – this is tested further through the desk audit – it does add a significant administrative burden for the organization. 

IRFs can increase their likelihood of passing the presumptive test by ensuring that the data submitted on the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) is correct, including both the Rehab Impairment Category (RIC) and the etiological diagnosis reported in Field 22. Some IRFs mistakenly applied common coding principles to the diagnosis in Field 22, as it relates to the seventh character for ICD-10, and inadvertently had cases fail the presumptive test that should have passed. Additionally, each organization should be aware of the exact reporting period start and stop dates and monitor compliance on a real-time basis for this period.

When an IRF receives notification that a desk audit will be conducted, it is essential to carefully assemble the medical record and include a cover sheet that indicates what CMS-13 category the IRF believes the case meets, along with a summary of the evidence in the record that supports that diagnosis.

Medicare’s Direction to Auditors Related to Therapy Minutes and Mode of Treatment

On Dec. 11, 2017, an MLN Matters article was published regarding the recent advisement from the Centers for Medicare & Medicaid Services (CMS) to its medical review contractors related to both the intensity of therapy services and individualized one-to-one therapy expectations as the standard of care for IRFs. CMS instructed medical review contractors that claims that did not meet the general standard of three hours of therapy per day (or 15 hours per week) should undergo further medical review.

While it is appreciated that CMS believes that the total minutes should not arbitrarily be utilized to deny a claim and that the contractors are being directed to use clinical review judgment to determine medical necessity, it is also likely that more cases will be reviewed based on the intensity of therapy services. 

Additionally, CMS again instructed contractors that individualized (one-to-one) therapy is the expected mode of therapy delivery. Prior clarifications have indicated that the predominance of therapy must be individualized. The updated direction to contractors did not specify any percentage, but indicated that group and concurrent therapy could be used on a limited basis.

What does this mean to providers? It is likely that more claims will be reviewed (and potentially denied) based on therapy service modes and minutes. Organizations should be diligent in ensuring that therapy intensity is clearly defined in the Individualized Patient Plan of Care (IPOC) and that reasons for missed therapy minutes are clearly documented, both in daily treatment notes and in the interdisciplinary team meetings, where patient progress, barriers, and changes in the plan are discussed.

Targeted Probe and Educate (TPE)

With the August 2017 CMS announcement of the expansion of the pilot program for Targeted Probe and Educate (TPE), we expected an increase in the number of IRFs identified for review. Not surprisingly, there has been an increase in the number of IRFs reporting that they have recently been notified of their “selection” for the audit.

The notices of selection sent to IRFs indicate whether 20 or 40 cases will be reviewed, along with the general categories of diagnosis that will be included. Cases being reviewed often include hip fractures, patients with debility, patients with no tier-level co-morbidities, and patients in the lowest-level CMG within a category (example: CMG AXX01)

What should you do if you’re “selected”? Since the TPE review is a prepayment review, it is essential that each IRF respond quickly and prevent denials by ensuring that the complete record is submitted in a timely fashion. Additionally, we recommend the preparation of a cover sheet identifying the location of the key documents the reviewer will need for deciding (preadmission assessment, history and physical, post-admission physician evaluation, therapy minute tables, if available, team meeting notes, etc.)

Coding the GG-Functional Items on the IRF-PAI

On Dec. 20, 2017, CMS posted web-based training modules for Section GG of the required Quality Reporting Program for Post-Acute Care. Because we believe that Medicare will achieve the goal of implementing a unified payment system by 2021, it is important for IRFs to be preparing now to accurately assess patient characteristics that will drive payment under that system.

CMS has mandated that patient functional status will be utilized as part of the standardized assessment and payment approach, and the GG codes have been or will be implemented in all post-acute settings. Organizations that fine-tune their patient assessment and documentation practices to meet this requirement, and those that train and retrain staff to ensure consistent and accurate scoring, are more likely to be successful with the transition to the post-acute unified payment system.

Still an Issue Eight Years Later

While the technical requirements for IRF documentation – both timing and content – have been in effect since Jan. 1, 2010, we continue to see problems when performing audits for our clients. The issues seem to be more complex in IRFs that are units within hospitals due to the various templates being completed, but they continue to occur in freestanding IRFs as well. IRFs must make accuracy in meeting both the timing and content requirements of these rules a non-negotiable endeavor for the coming year.

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