Cahaba GBA’s 2014 Medicare Expo

Cahaba GBA’s 2014 Medicare Expo

August 6-7, 2014 – Chattanooga, TN

Inpatient Rehabilitation Facility (IRF)-Guidelines and Documentation

As directed a copy of the presentation is available for viewing or download on the Cahaba GBA website

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Disclaimer

This resource is not a legal document. The presentation was prepared as a tool to assist providers and was current at the time of creation.

Responsibility for correct claims submission lies with the provider of services.

Reproduction of this material for profit is prohibited; providers are encouraged to share this education with staff.

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Preventing Improper Payments

The Affordable Care Act of 2010

• Proposals to protect the Medicare Trust Fund• Authority to recover overpayments

Social Security Act

• Sections 1833(e), 1842(a)(2)(B), and 1862(a)(1)(A)

Centers for Medicare and Medicaid Services (CMS)

• Protect the Medicare Trust Fund• Identify inappropriate payments• Take corrective actions

Payment Accuracy: www.paymentaccuracy.gov/about-improper-payments

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Medical Review

Goal Reduce payment errors by identifying and addressing billing errors related to coverage and coding of services

Data Driven o Indentify vulnerabilities o Identify questionable billing patternso Prevent and/or address provider errorso Reduce paid claims error rateo Publish Local Coverage Determinations (LCD)

Medical Review and Education - Overview: www.cms.gov/Medical-Review/

Program Integrity Manual - Pub. 100-08 - Medical Review Program: www.cms.gov/manuals/downloads/pim83c03.pdf

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Comprehensive Error Rate Testing (CERT)

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Documentation Contractor

Reviews Medical Records

Requests Medical Records

Protect, Measure, Assess, EvaluateCERT

Review Contractor

Skilled Services

Types

• Physical Therapy (PT)• Occupational Therapy (OT)• Speech Therapy (ST)• Prosthetics/Orthotics

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Required Documentation

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Pre-admission Screening

Medical Record

• Pre-Admission Screeningo Must be completed within 48 hours prior to IRF

admission

o Detailed assessment of the patient’s condition and need for rehab

o Justifies the patient’s need for rehab o Must be completed by a licensed or certified

professionalo Rehab physician must review, sign, and date

screening

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Pre-admission Screening

Must include: Specific condition Prior level of function Expected level of improvement Expected length of stay Risk for clinical complications Treatment needed Expected frequency and duration of treatment Anticipated discharge destination Anticipated post discharge treatments Information relevant to the care needs of the patient

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Medical Necessity at Admission

Reasonable and Necessary

• Documentation in medical record should demonstrate:o Reasonable expectation that the following was met at

the time of admission:1. Require active and ongoing treatment of

multiple therapy disciplines, at least one of which must be PT or OT

2. Require intensive rehabilitation therapy program

3. Reasonably be expected to actively participate in and benefit significantly from intensive therapy

4. Physician Supervision by a rehab physician5. Intensive and coordinated interdisciplinary team

approach

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Admission Orders

Requirements

• Must be generated by a physician at the time of admissiono Any licensed physiciano Includes physician extenders working in

collaboration with MD

• Admission orders must be retained in the patient’s IRF medical record

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Post-admission Screening

• Post-Admission Screening

• Documentation of patient’s status post admission to SNF

• Completed by physician in facility within 24 hours of admission

• Supports medical necessity of admissiono If it does not support the medical necessity,

then discharge from the facility must begin immediately

oServices after the third day will not be considered reasonable and necessary

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Individualized Plan of Care

Plan of care

• Individual outline of the care provided to the patiento Must be completed within four days of

admissiono Diagnosiso Therapy services provided

Type Amount Duration Frequency

o Detailed functional outcome

• Includes anticipated discharge plan13

Intensive Therapy

• Treatment Requirementso3 hours per day for 5 days a week

ORo15 hours of intensive therapy

within a 7 consecutive day periodoBegins on day of admissionoMust be well-documented

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Intensive Therapy

Reasonable and Necessary Services

• Medical Record must have documentation that therapy was initiated within 36 hours from midnight of admission

• Standard of care is one on one therapy• Group therapy is acceptable

Must be well documented Cannot constitute the majority of therapy

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Interdisciplinary Team Conference

Team Meetings• Periodic team meetings are to be held at least

once per weeko Assesses the patient’s progress toward rehabilitation

goalso Analyzes possible resolutions to problems that could

hinder the progress towards goalso Reassesses the previous rehabilitation goals

establishedo Monitor and evaluate the overall plan of care

• Documentation of team meetings must includeo Names and profession of each participating membero The occurrence of the team meetingo The decisions that were discussed related to overall

plan of care16

Common Errors

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Part A-CERT Review-All States: May 2014

Service Denial Denial Rationale Action Required

Al , GA, TN-IRF Therapy

Medically unnecessary

service or treatment

05/29/2014 Per CERT Medical Director, Disagree; Inpatient rehabilitation admission not reasonable & necessary: the beneficiary did not receive the required amount of therapies, including the fact that a significant portion of the therapies were provided in group settings.

3 hours x 5 days/weekStandard is one on oneGroup therapy cannot constitute as the majority of therapy services.

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Part A-CERT Review-All States: April 2014

Service Denial Denial Rationale Action Required

Al , GA, TN-IRF Therapy

Insufficient documentation

02/26/2014 Disagree per Pub.100-02, Chpt.1, Sec.110 Inpatient Rehabilitation Facility PPS Services; Pub.100-02, Chpt.1, Sec.110- Inpatient Rehabilitation Facility Services; Sec. 110.1 Documentation Requirements Sec.110.1.1 Required Pre-admission Screening; intensity/frequency/duration; and Sec.110.1.5 Required IRF-PAI; & Medical Necessity Requirements -Missing documentation to support Required IRF-PAI, Pre-Admission Screening; and physician documentation of Intensive level of Rehabilitation specifics for intensity/frequency/duration in plan of care.

Submission of documentation to supportMedical necessity of admission,Including:

•Pre-Admission Screening•Required IRF-PAI•Physician documentation of Intensive level of rehab Specifics for intensity, frequency, and duration in plan of care.

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Common Case Mix Group (CMG) Errors

• CMG A0801-A0806– Replacement of Lower Extremity Joint

• CMG A0701- A0703– Fracture of Lower Extremity

• CMG A2001 – A2004– Debility

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Common Errors• Preadmission screen was not completed within the 48 hour time

frame of admission to give accurate, recent findings of the patient’s condition.

• Physician signature was dated, but is not timed to validate physician review and concurrence of preadmission screen prior to IRF admission.

• Preadmission screen was not always submitted as required by Medicare prior to IRF admission.

• Post admission M.D. evaluation was not always submitted as required by Medicare.

• Overall plan of care was not individualized as defined by CMS. 3 hours/day 5 days/wk or 15 hours over 7 days or 90 min of PT and 90 min of OT does not meet CMS intent for individualized plan of care.

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Common CMG Errors Cont. • Physician signature on overall plan of care or on progress notes was not

always timed

• Potential risk for clinical complications as documented on preadmission screen (fall, DVT, infection, unsteady gait, decreased balance, need for post-op wound/incision care, or continued antibiotic meds, etc) does not raise the patient’s needs to the level which would require inpatient care.

• No detailed justification for IRF admission on the preadmission screen or on the post-admission physician evaluation. The documentation will state that the patient requires intense services of inpatient rehabilitation and direction by rehabilitation physician and 24 hour rehabilitation nursing care however no details are documented to support this statement.

• Functional status as documented on preadmission screen would not support the need for an intense therapy program or for multiple therapy disciplines.

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Patient Assessment Instrument

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IRF-Patient Assessment Instrument

• Include in the medical record• Electronic or paper• Correspond with medical record• Dated, timed and authenticated• CR 7901

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CMS PAI

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http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Downloads/IRFPAI-manual-2012.pdf

Quality Measures

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Discharge

Discharge

• Begins at the time of admission• Established goals have been reached • Further progress is unlikely• Must report the appropriate discharge

code

• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0801.pdf

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Please Take Our Survey

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Resources• Change Request 8105 ‐ Program Integrity Manual Pub. 100 ‐ 8:

Chapter 3, Section 3.3.2.5 Amendments, Corrections and Delayed Entries in Medical Documentation http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R442PI.pdf

• Medicare Benefit Policy Manual Pub 100-02 Chapter 1 Section 110 (Inpatient Hospital Services)

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c01.pdf

• Medicare Program Integrity Manual Pub 100-08 Chapter 6

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c06.pdf

• Program Integrity Manual Pub. 100 - 8: Chapter 3, Section 3.3.2.4:http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf

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Resources

• MM6698: Signature Guidelines for Medical Review Purposes:

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm6698.pdf

• MLN Matters: Inpatient Rehabilitation Therapy Services: Complying with Documentation Requirements: Fact Sheet

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Inpatient_Rehab_Fact_Sheet_ICN905643.pdf

• MMSE0801: Clarification of Patient Discharge Status Codes and Hospital Transfer Policies http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE0801.pdf

• Social Security Act 1862 (a)(1)(A) http://www.ssa.gov/OP_Home/ssact/title18/1862.htm

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Questions

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Thank You

The Part A Provider Outreach and Education staff would like to thank you for participating

in today’s event.

Provider Contact Center: 1-877-567-7271

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