Transitioning to the New IRF-PAI 2014. FIM, UDS-PROi, UDSMR, and the UDSMR logo are trademarks of, a division of UB Foundation Activities, Inc. Agenda August 2014 final rule summary Discuss IRF PPS changes for FY 2015 Review FY 2015 standard payment conversion factor (SPCF) Compare the current IRF-PAI to the new IRF-PAI (effective October 1, 2014) Highlight UDS-PROi software changes specific to the new IRF-PAI form Review revisions and updates to the IRF quality measures Discuss strategies for collecting data for the new IRF-PAI 2 1
2014 Final Rule Summary Changes to SPCF Delay in changing the presumptive compliance codes for 60% compliance, now effective for compliance review periods beginning on or after October 1, 2015 Finalize new IRF-PAI (effective 10/1/2014) Introduced the next IRF-PAI for 10/1/2015 Includes fields for therapy times (individual, group, co-treat, and concurrent) ICD-10 implementation announced for 10/1/2015 Introduce new quality measures (impact all the way to FY 2017) 3 FY 2015 SPCF The SPCF is a standardized payment amount, based on average costs from a base year, that reflects the combined aggregate effects of the weighting factors, various facility- and case-level adjustments, and other adjustments 4 2
Updated SPCF Calculation to Determine the FY 2015 SPCF Explanation of Adjustment to SPCF Calculation Standard payment conversion factor from FY 2014 $14,846 Market basket increase factor for FY 2015 (2.7%), reduced by x 1.0220 0.4% point in accordance with sections 1886(j)(3)(C) and (D) of Act and a 0.2% reduction for the productivity adjustment as required by sections 1886(j)(3)(C)(D) of the Act Budget neutrality factor for the wage index and labor-related share x 1.0017 Budget neutrality factor for the revisions to the CMG relative x 1.0000 weights FY 2015 standard payment conversion factor = $15,198 5 UDSMR FY 2015 RIC-to-CMG Conversion Card 6 3
Outlier Payments Section 1886(j)(4) of the Social Security Act allows for additional payment for cases that incur extraordinarily high costs Used when the estimated cost of the case exceeds the adjusted outlier threshold CMS calculates an outlier payment by multiplying the overall cost-to-charge ratio (CCR) by the Medicare allowable covered charge If the estimated cost of the case is higher than the adjusted outlier threshold, CMS makes an outlier payment for the case equal to 80% of the difference between the estimated cost and the outlier threshold 7 Outlier Payments Update to payments for high-cost outliers under the IRF PPS Final determination: Outlier threshold amount of $8,848 (this figure has decreased by $424 from FY 2014) to maintain estimated outlier payments at approximately 3% of total estimated aggregate IRF payments for FY 2015 This update is effective October 1, 2014 We will continue to monitor trends in IRF outlier payments to ensure that they are working as intended to compensate IRFs for treating exceptionally high-cost IRF patients. 8 4
Comparing the Current IRF-PAI (Effective 10/1/2012) to the New IRF-PAI (Effective 10/1/2014) Examining UDS-PROi Software Changes Specific to the New IRF-PAI Form 9 IRF-PAI Form Comparison Current IRF-PAI: Effective 10/1/2012 3 pages 13 quality indicators fields Separate sections for identification information and admission information Separate sections for medical information and medical needs Space for 10 ICD codes Requires signature New IRF-PAI: Effective 10/1/2014 8 pages 45 quality indicator fields Admission Information section combined with Identification Information section Medical Needs section combined with Medical Information section Space for 25 ICD codes Requires signature on additional signature page 10 5
IRF-PAI Form Comparison: Page 1 Current IRF-PAI New IRF-PAI 11 IRF-PAI Form, Page 1: Summary of Changes New fields: Items 24K 24Y, Comorbid Conditions Item 25A, Height on Admission (in inches) Item 26A, Weight on Admission (in pounds) Deleted fields: Item 18, Pre-hospital Vocational Category Item 19, Pre-hospital Vocational Effort Item 25, Is Patient Comatose at Admission? Item 26, Is Patient Delirious at Admission? Item 28, Clinical Signs of Dehydration 12 6
IRF-PAI Form, Page 1: Summary of Changes Changed field values: Item 15, Admit From Item 16, Pre-hospital Living Setting Item 20A, Primary Payment Source Item 20B, Secondary Payment Source 13 IRF-PAI Form Comparison Current IRF-PAI: 15. Admit From 01 Home 02 Board and care 03 Transitional living 04 Intermediate care 05 Skilled nursing facility 06 Acute unit of own facility 07 Acute unit of another facility 08 Chronic hospital 09 Rehabilitation facility 10 Other 12 Alternate level of care unit 13 Subacute setting 14 Assisted living residence 16. Pre-hospital Living Setting (use same codes as item 15) New IRF-PAI: 15A. Admit From 01 Home (private home/apt., board/care, assisted living, group home, transitional living) 02 Short-term general hospital 03 Skilled nursing facility (SNF) 04 Intermediate care 06 Home under care of organized home health service organization 50 Hospice (home) 51 Hospice (institutional facility) 61 Swing bed 62 Another inpatient rehabilitation facility 63 Long-term care hospital (LTCH) 64 Medicaid nursing facility 65 Inpatient psychiatric facility 66 Critical access hospital 99 Not listed 16A. Pre-hospital Living Setting (use same codes as item 15A) 14 7
UDS-PROi Software Changes Admission Information section Updated: Changed values for items 15A, Admit From, and 16A, Pre-Hospital Living Setting 15 IRF-PAI Form Comparison Current IRF-PAI: 20A. Primary Payment Source 20B. Secondary Payment Source 01 Blue Cross 02 Medicare non-mco 03 Medicaid non-mco 04 Commercial insurance 05 MCO HMO 06 Workers compensation 07 Crippled Children s Services 08 Developmental disabilities services 09 State vocational rehabilitation 10 Private pay 11 Employee courtesy 12 Unreimbursed 13 CHAMPUS 14 Other 15 None 16 No-fault auto insurance 51 Medicare MCO 52 Medicaid MCO New IRF-PAI: 20A. Primary Payment Source 20B. Secondary Payment Source 02 Medicare Fee for Service 51 Medicare Medicare Advantage 99 Not listed 16 8
UDS-PROi Software Changes Payer Information section Update: Changed values for items 20A, Primary Source, and 20B, Secondary Source New fields: Items 20A1 and 20B1 can be used to capture details for not listed sources 17 UDS-PROi Software Changes Medical Information section Update: Added 15 CC fields (24K 24Y) New fields: 25A, Height on Admission, and 26A, Weight on Admission 18 9
UDS-PROi Software Changes Advanced Comorbid Conditions 19 UDS-PROi Software Changes Medical Information section: New: Added items 25A, Height on Admission, and 26A, Weight on Admission BMI is automatically calculated These units of measurement are interchangeable if you enter height in inches, the software will automatically calculate the height in centimeters 20 10
IRF-PAI Form Comparison: Page 2 Current IRF-PAI New IRF-PAI 21 IRF-PAI Form Comparison: Page 3 Current IRF-PAI New IRF-PAI 22 11
IRF-PAI Form, Page 3: Summary of Changes Deleted fields: Item 44B, Was Patient Discharged with Home Health Services? Item 48A, Stage 2 Pressure Ulcers Item 48B, Stage 3 Pressure Ulcers Item 48C, Stage 4 Pressure Ulcers Item 49A, Worsening Stage 2 Pressure Ulcers Item 49B, Worsening Stage 3 Pressure Ulcers Item 49C, Worsening Stage 4 Pressure Ulcers Item 50A, Healed Stage 2 Pressure Ulcers Item 50B, Healed Stage 3 Pressure Ulcers Item 50C, Healed Stage 4 Pressure Ulcers Changed field values: Item 44A, Discharge to Living Setting 23 IRF-PAI Form Comparison Current IRF-PAI: 44A. Discharge to Living Setting 01 Home 02 Board and care 03 Transitional living 04 Intermediate care 05 Skilled nursing facility 06 Acute unit of own facility 07 Acute unit of another facility 08 Chronic hospital 09 Rehabilitation facility 11 Died 10 Other 12 Alternate level of care unit 13 Subacute setting 14 Assisted living residence New IRF-PAI: 44D. Patient s Discharge Destination/Living Setting 01 Home (private home/apt., board/care, assisted living, group home, transitional living) 02 Short-term general hospital 03 Skilled nursing facility (SNF) 04 Intermediate care 06 Home under care of organized home health service organization 50 Hospice (home) 51 Hospice (institutional facility) 61 Swing bed 62 Another inpatient rehabilitation facility 63 Long-term care hospital (LTCH) 64 Medicaid nursing facility 65 Inpatient psychiatric facility 66 Critical access hospital 99 Not listed 24 12
UDS-PROi Software Changes Discharge Information section: Added field 44C, Was the Patient Discharged Alive? Update: Changed values of 44A to 44D, Patient s Discharge Destination/Living Setting 25 IRF-PAI Form Comparison: Pages 4 5 New IRF-PAI New IRF-PAI 26 13
IRF-PAI Form Comparison: Pages 6 7 New IRF-PAI New IRF-PAI 27 UDS-PROi Software Changes Quality Indicators section: New fields added to pages 4 7 of the IRF-PAI: M0210, Unhealed Pressure Ulcers One admission field One discharge field M0300, Current Number of Unhealed Pressure Ulcers Seven admission fields Twenty-three discharge fields I0900, Pressure Ulcer Risk Conditions Admission Six fields 28 14
UDS-PROi Software Changes Quality Indicators section: New fields added to pages 4 7 of the IRF-PAI: M0900, Healed Pressure Ulcers Discharge Four fields O0250, Influenza Vaccine Discharge Three fields 29 UDS-PROi Software Changes: Quality Indicators Section Skip logic and mandatory field logic have been built into the software Examples and screen captures appear on the next four slides 30 15
UDS-PROi Software Changes: Quality Indicators Section Example 1: If item M0210 is coded no at both admission and discharge, the software will skip the M0300 fields and collapse those sections of the data entry form 31 UDS-PROi Software Changes: Quality Indicators Section 32 16
UDS-PROi Software Changes: Quality Indicators Section Example 2: If item M0210 is coded yes at both admission and discharge, the software will expand the sections associated with item M0300 and highlight the mandatory fields in orange 33 UDS-PROi Software Changes: Quality Indicators Section 34 17
Voluntary/Mandatory IRF-PAI Quality Indicators 35 IRF-PAI Form Comparison: Page 8 Current IRF-PAI Signature Required Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) The IRF-PAI gathers data to determine the payment for each Medicare Part A FFS patient admitted to an IRF. The IRF-PAI form must be included in the patient s IRF medical record in either electronic or paper format. Information in the IRF-PAI must correspond with all information in the patient s IRF medical record. The IRF-PAI must be dated, timed, and authenticated in the written or electronic form. One signature (attached in some way to the IRF-PAI, either in a cover page or handwritten somewhere on the form) from the person who completed (or transmitted) the IRF-PAI is sufficient. MLN Matters, July 2012 Proposed IRF-PAI Must be signed by one or more staff members who were involved in gathering information from the patient s medical record to complete the IRF-PAI. These staff members are responsible for transferring the patient s information from the medical record to the IRF-PAI for transmission. 36 18
UDS-PROi Software Changes IRF-PAI signature: Added electronic signature functionality Use the user setup module to set up IRF-PAI signature privileges for each account 37 IRF Quality Measures 38 19
Quality Measures Apply to freestanding IRF hospitals and units affiliated with acute care facilities, which includes critical access hospitals 39 Quality Measures Affecting FY 2016 IRF PPS adjustments: Catheter-Associated Urinary Infection (CAUTI) (NQF #0138) Submitted through NHSN Application of Percent of Residents with Pressure Ulcers that are New or Worsened (NQF #0678) Quality indicator for IRF-PAI submission 40 20
Quality Measures Affecting FY 2016 IRF PPS adjustments: Influenza Vaccination Coverage among Healthcare Personnel (NQF #0431) Required submission once per influenza vaccination season Submitted through NHSN Final deadline: May 15 of each year http://www.cdc.gov/nhsn /inpatient-rehab/hcp-vacc/index.html 41 Quality Measures Affecting FY 2016 IRF PPS adjustments: Percent of Residents or Patients Who Were Assessed and Appropriately Given Seasonal Influenza Vaccine (NQF #0680) Quality indicator for IRF-PAI submission Season takes place from October 1 (or when the vaccine becomes available) through March 31 each year 42 21
Quality Measures Affecting FY 2017 IRF PPS adjustments: All-Cause Unplanned Readmission Measure for 30 Days Post-Discharge from Inpatient Rehabilitation Facilities No reporting required Percent of Residents or Patients Who Were Assessed and Appropriately Given Seasonal Influenza Vaccine (NQF #0680) Quality indicator for IRF-PAI submission Season takes place from October 1 (or when the vaccine becomes available) through March 31 each year 43 Quality Measures Affecting FY 2017 IRF PPS adjustments: The NQF-endorsed version of Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (NQF #0678) Quality indicator for IRF-PAI submission 44 22
Quality Measures Affecting FY 2017 IRF PPS adjustments: National Healthcare Safety Network (NHSN) Facility-Wide Inpatient Hospital-Onset Methicillin-Resistant Staphylococcus aureus (MRSA) Outcome Measure (NQF #1716) NHSN Facility-Wide Inpatient Hospital-Onset Clostridium difficile Infection (CDI) Outcome Measure (NQF #1717) 45 Quality Measures Affecting FY 2017 IRF PPS adjustments: Both the MRSA measure and the C. diff. measure will be submitted using CDC/NHSN Data collection will begin on January 1, 2015 Quarter CDC/NHSN Data Collection Period CDC/NHSN Data Submission Deadline Q1 January 1, 2015 March 31, 2015 August 15, 2015 Q2 April 1, 2015 June 30, 2015 November 15, 2015 Q3 July 1, 2015 September 30, 2015 February 15, 2016 Q4 October 1, 2015 December 31, 2015 May 15, 2016 46 23
Quality Reporting Program IRFs that are noncompliant with the reporting requirements during a given reporting cycle will be notified and will be scheduled to receive a 2% reduction in their annual payment update for the upcoming FY Adjusted standard federal rate: $15,198 (for IRFs that failed to meet the quality reporting requirements) The IRF may file a request for reconsideration and follow a defined process for appeal 47 Quality Reporting Program IRF QRP completion threshold for the required quality indicators on the IRF-PAI: IRF providers must meet or exceed two separate program thresholds to avoid receiving a 2% reduction to their IRF PPS annual increase factor for a given FY 95% data completion threshold for data collected using the quality indicator items on the IF-PAI and submitted through QIES. 95% of IRF-PAIs submitted must have 100% of the mandatory QI data items completed a field with a dash (-) is not complete! 100% threshold for data collected and submitted through the CDC s NHSN (CAUTIs and influenza vaccination coverage among healthcare personnel) 48 24
Strategies for Collecting Data for the New IRF-PAI 49 Strategies for Data Collection What we know: Any cases created and discharged on or before 09/30/2014 must use the current IRF-PAI (effective 10/01/2012) Any cases created on or after 10/1/2014 must use the new IRF-PAI (effective 10/1/2014) Admission and discharge dates are on or after 10/1/2014 Admission date prior to 10/1/2014 and discharge date on or after 10/1/2014 50 25
Strategies for Data Collection Which IRF-PAI should you complete if a patient is admitted prior to 10/01/2014 but you are unsure when the patient will be discharged? Answer: We recommend both! This will ensure that you have gathered all necessary information for the new IRF-PAI (effective 10/1/2014) Consider using a hard copy of the new IRF-PAI for patients who are admitted in September 2014 but who have the potential to be discharged on or after 10/1/2014 Leaving fields blank will have an impact be prepared! 51 Strategies for Data Collection If a case is created prior to 10/1/2014 but discharged after, a warning message in the software will prompt you to enter case data into the new IRF-PAI form This message will explain that any data entered in the fields that have been changed in or deleted from the current IRF-PAI will not carry over to the new IRF-PAI form Once you click the OK button to acknowledge the message, the software will load all applicable case data for the record into the new form, after which you can continue entering case data into the new form in the software 52 26
Strategies for Data Collection How can we prepare? Educate! Pre-admission screeners, any nurse wound care/skin specialists, PPS coordinators, billing personnel/coders Consider the new IRF-PAI fields that will require data Add new items to the pre-admission screen and nursing assessments: height, weight, pressure ulcer information, influenza vaccines, etc. 53 Strategies for Data Collection How can we prepare? Are you screeners qualified? Do they have the clinical expertise to locate the required data in an acute care chart review? Who will detect and assess pressure ulcers? Do you have a process in place for capturing the patient s height and weight upon admission? 54 27
Strategies for Data Collection Things to consider: Review your admission/discharge processes for capturing the results of pressure ulcer assessments Do you have a wound, ostomy, and continence (WOC) nurse available? Or a skin specialist nurse? When patients are admitted and discharged, how will you communicate to the WOC nurse or skin specialist that an assessment is required? How will it be tracked to ensure compliance? How will you track the influenza vaccine information during the flu season? Use UDS-PROi custom fields to track data 55 Strategies for Data Collection New IRF-PAI discharge destination codes and the UB-04 It is important that these fields match code for code This will require ongoing communication with PPS and coding personnel 56 28
Strategies for Data Collection How can you track? All-Cause Unplanned Readmission Measure for 30 Days Post-Discharge from Inpatient Rehabilitation Facilities If you conduct follow-up calls, include this in your questionnaire Use this data to track patients that have an unplanned readmission within thirty days post-discharge from your IRF Use the PEPPER (Program for Evaluating Payment Patterns Electronic Report) 57 Strategies for Data Collection 58 29
Resources FY 2015 final rule: http://www.gpo.gov/fdsys/pkg /FR-2014-08-06/pdf/2014-18447.pdf IRF-PAI, effective 10/1/2015 http://www.cms.gov/medicare /Medicare-Fee-for-Service-Payment /InpatientRehabFacPPS/Downloads /IRF-PAI-FINAL-for-Use-Oct2014-updatedv4.pdf UDSMR IRF-PAI crosswalk Voluntary/Mandatory Items for IRF-PAI Quality Indicator Items sheet UDSMR RIC-to-CMG Conversion Sheet 59 Thank You! If you have questions, press *6 on your phone 60 30