2010 Regs&Medi Links2

Risk Containment Strategies using MediLinks
A Long Term STRATEGY to Keeping Your Hard Earned Cash
Internal Checks and Balance for Inpatient Rehabilitation Given NEW REGS

Darlene L. D’Altorio-Jones, PT., MBA HCM
Clinical Consultant, MediServe

MediServe Confidential © 2009 MediServe, Inc. All Rights Reserved.

Learning Objectives for this Presentation:

 HOW do 2010 IRF Regulations differ ?
 SPECIFIC GUIDELINE CHANGES

 provides SOLUTIONS for changes.

 Preparedness and workflow strategies
 Self Assessment Checklist - assess facility workflow
readiness.
 Percent Rule Attestation vs. Medical Necessity
Criteria

MediServe Confidential 2 © 2009 MediServe, Inc. All Rights Reserved.


 Medical Necessity;
 IRF AUDIT TARGET

 What makes you unique?

 What tools do you have to stay on top of DAILY
Burden of Care & Functional COSTS?

 How quickly can you assess patient status to planned
/projected functional improvement?



 What are your roadblocks?
 Understand the detail of CMS requirements?
 Workflow?
 Communication?
 Timeliness?

 Minimize potential risk through thorough documentation.

Is a Full Interdisciplinary
Workflow Solution.


Compliance

Outcomes

Revenue

Efficiency


What’s on the HORIZON?:

 Manual Revisions Chapter 1 – 110.1-110.3
published 10/23/09.

 Federal Register updated 8/7/09.

 Workflow regulations effective January 1, 2010.
Implementation by January 4th, 2010.

 Reimbursement and encoding guidelines 10/1/09.


THE REGS SAY

 IRF is not an alternative to acute inpatient care
 CMS does not believe that patients should be
transferred to IRF’s before their medical conditions are
sufficiently stable to enable them to participate in the
intensive rehabilitation program provided by the IRF.
(CFR42 part 112 pg. 39793)
 This was ALWAYS intended but not specifically spelled out.


Dispelled Coverage Criteria vs. Classification Criteria

 Regulations updated IRF coverage criteria, NOT
IRF CLASSIFICATION criteria. (CFR42 part 112 pg.39789)

 No intention for coverage criteria to have bearing
on facility exclusion from IPPS, the requirements
for the classification of facilities as IRFs, or the
60 percent rule.


IRF Conditions of Participation:

 PRE-Admission Screen: 110.1
 Performed by IRF clinical personnel within the 48
hours immediately preceding IRF admission; or
 IF > 48 hours before IRF admission
 OK if an update is conducted in person or by
phone within 48 hours prior to admission and
documented in the medical record to update the
medical and functional status. (DETAILED &
COMPREHENSIVE)


Qualifications Required to ‘Screen’

 Individual elements of the preadmission
screening may be evaluated by
any clinician or group of clinicians
designated by a rehabilitation physician,
as long as the clinicians are licensed
(to the extent possible under State licensure laws and
and qualified to perform the
requirements),
evaluation within their scopes of practice
and training. (CFR42 part 112 pg.39790 &39791


Detailed Preadmission Criteria

 The preadmission screening documentation must
indicate: (Chapter 1 110.1 Required Documentation)
 Prior level of function.
 Expected level of improvement.
 Expected length of time to achieve Expected Improvement.
 Evaluation of patient risk for clinical complications.
 Conditions that caused need for rehabilitation.
 Combinations of treatments needed (therapies)
 Expected frequency
 Duration for IRF treatment.
 Anticipated D/C destination
 Post-D/C treatment and other information relevant
to the care needs of the patient.


Pre Admission – Physician Holds the Key

 Findings:
 must be conveyed to a rehabilitation
physician prior to the IRF
admission.
 In addition, the rehabilitation
physician must document that he or
she has reviewed and concurs
with the findings and results of the
preadmission screening.
(Chapter 1 110.1 Required Documentation)
 MediLinks makes this a seamless process.


Post Admission Evaluation:

 Post-admission physician evaluation must
identify relevant changes that may have
occurred since the preadmission
screening. (Chapter 1 - 110.2)
 Must include a documented history and
physical exam,
 1.)Clinical complications/risks and plans to avoid
them.
 2.) Patient’s prior and current medical status and
adverse conditions that could be created with co-
morbidities & intense rehab.
 3.) Prediction of functional goals to be achieved
within medical limitations. As such the combination
of resources for the POC.


Admission Orders:

 Post-Admission physician evaluations go
beyond an H&P.
 Thus we believe post-admission physician
evaluations requires the unique training &
experience of the rehabilitation physician as
they perform a hands on evaluation.
 We believe it is necessary for a patient to be
seen by a rehabilitation physician within 24 hours.
(CFR42 part 112 pg. 39792)

 It is important for a rehabilitation physician to note
the discrepancy and to document any deviations
from the preadmission screening as a result.
Retained in the medical record at the IRF.


Post-Admission Evaluation:

 MediLinks unique design ‘pulls forward’ pre-admission
documentation to assist the physician in creating the
integrated POC.
 Must include:
 An estimated length of stay.
 Detailed medical prognosis
 Anticipated interventions / RISKS
 Expected functional outcomes
 Expected discharge destination from the IRF stay.
= The Medical Necessity of the Admission.
 Admission orders must be generated & retained.


Plan of Care Completion: 72 hrs Post Admit

 The documented overall plan of care (including an
estimated length of stay, intensity, frequency, duration) must be
completed within the first 4 days of the IRF
admission; it must support the determination that
the IRF admission is reasonable and necessary
and it must be retained in the medical record of the
IRF. (Chapter 1 – 110.1.3)
 Good practice to conduct the first
interdisciplinary conference within
the first 4 days of admission.


Post-Admission Evaluation Holds Weight:

 Any IRF admission for the
sole purpose of determining
whether the patient can
benefit significantly from
treatment in the IRF or
other settings is not
considered reasonable and
necessary. (CFR42 part 112 pg.39790 &
39791 & Chapter 1 – 110.1.1)


Post-Admission Evaluation Holds Weight:

 10 day ‘trial’ admit goes
away. Determination is made
by preadmission
screening/concurrence by
physician and SEALED
through the 24 hour post
admission physician
evaluation which must again
substantiate clinically
relevant criteria that MATCH
an expected medically
necessary admission.


Pre / Post Clinical Picture Discrepancy:

 In rare cases when pre/post
review reveals marked
improvement in functional
ability or an inability to meet
the demands of the IRF
rehabilitation program, the IRF
must immediately begin the
process of discharging the
patient to another setting of
care. (Chapter 1 – 110.1.2)


Pre / Post Clinical Picture Discrepancy:

 IRF Services provided after the
3rd day of admission will not be
considered reasonable and
necessary.
 Medicare has authorized
contractors to down-code IRF
claims to the appropriate CMG for
IRF patient stays of 3 days or less.
(CFR42 part 112 pg. 39791 & Chapter 1 – 110.1.2)


Functional Goal Assessments:

 Consideration or
reassessment of the
patient’s functional goals at
least 3 times per week by
the rehabilitation physician
and his/her documentation
of these visits in the
medical record is the
minimum standard that
should be applied in an IRF.


Medical Necessity Criteria

 In order for IRF care to be considered
reasonable and necessary, the
documentation in the patient’s medical
record (which must include the preadmission
screening described in section 110.1.1, the post-
admission physician evaluation described in section
110.1.2, and the overall plan of care described in
section 110.1.3 and admission orders 110.1.4) must
demonstrate a reasonable expectation that
the following were met AT THE TIME of
ADMISSION to the IRF; (Chapter 1 -110.2)


Medical Necessity Criteria:

1. Must require active & ongoing therapeutic intervention.
2. Must generally require and reasonably be expected to
actively participate in, and benefit significantly from, at
least 3 hours of therapy per day at least 5 days per week,
as defined in section 110.2.1
 3 hours is ‘minimum expected 5x/week’ or ‘15 hours defined
as a 7 consecutive day period starting from admission’.
 Well documented deviation for 15hr/average per wk.
( pg. 39794)

tracks 3 hour rule compliance



3.) Reasonably expected to actively participate
and benefit significantly from the intensive
rehab. Reasonably expected to make
MEASURABLE IMPROVEMENT OF
PRACTICAL VALUE to IMPROVE
FUNCTIONAL STATUS. Within a
prescribed period of time.
4.) Face to face visits; 3x/ week to assess
medical & functional status.
5.) Intensive and coordinated program as
defined in 110.2.5


Physician Supervision:

 Close physician involvement in the patient’s care
is generally demonstrated by face-to-face visits
from a rehabilitation physician or other licensed
treating physician with specialized training and
experience in rehabilitation at least 3 days per
week throughout the patient’s IRF stay.
 The purpose of the face-to-face visits is to assess the
patient both medically and functionally, as well as to
modify the course of treatment as needed.
 The PIP keeps the physician current on the most
recent interdisciplinary documented functional
status. (Chapter 1 - 110.2.4)


Reasonable and Necessary:

 Considered reasonable and necessary if at
the time of admission to the IRF the
documentation in the patient’s medical
record indicates that the complexity of the
patient’s nursing, medical management,
and rehabilitation needs requires an
inpatient stay and an interdisciplinary team
approach to the delivery of rehabilitation
care. (CFR42 part 112 pg. 39793 & Chapter 1 – 110.2.5)
 Care can only be achieved through close
physician involvement and periodic team
conferences; at least once a week.



 The patient’s condition and functional status must be such
that the patient can reasonably be expected to make
measurable improvement (that will be of practical value to
improve the patient’s functional capacity or adaptation to
impairments) as a result of the rehabilitation treatment, and
that such improvement can be expected to be made within
a prescribed period of time.

Burden of Care reports provide adjusted daily CMI based on real
time functional assistance needs. Management can track continuous
improvement and resource reduction as improvement from clinical
care is achieved.


Predictability and Planning are Key
for Future Success

Management Reports, Tools & Trending is available in


Therapy Requirements:

 Many IRF patients will medically benefit from more
than 3 hours of therapy per day, when all types of
therapy are considered.
 The required therapy treatments must begin within 36
hours from midnight of the day of the patient’s admission
to the IRF. Evaluations satisfy this requirement.(CFR42 part
112 pg. 39796)


Intensity/Skill of therapy:

 This means that an IRF patient’s daily
therapy requirements must generally be
met by one-on-one therapy services, as
documented in the patient’s medical
record. Group therapies are to be used
in IRFs primarily as an adjunct to one-
on-one therapy services. (CFR42 part 112 pg. 39797)
 Therapy aide services are NOT considered
skilled, and would not meet the IRF intensity
of therapy criterion used to evaluate the
appropriateness of IRF care. (CFR42 part 112 pg.
39802)


TEAM CONFERENCE:
 At a minimum, the interdisciplinary team
must document participation by
professionals from the following disciplines
(each of whom must have current knowledge of the
patient as documented in the medical record):
 A rehabilitation physician with specialized
training and experience in rehabilitation
services; A registered nurse with specialized
training or experience in rehabilitation; A social
worker or a case manager (or both); and A
licensed or certified therapist from each
therapy discipline involved in treating the
patient.


TEAM CONFERENCE
 The interdisciplinary team must be led by a
rehabilitation physician who is responsible for
making the final decisions regarding the patient’s
treatment in the IRF. This physician must
document concurrence with team decisions at
each meeting.
 Interdisciplinary status relating to TEAM GOALs are
uploaded into the Patient Evaluation
Template for physician editing/signature
in MediLinks.


TEAM CONFERENCE FOCUS
 CONFERENCE must focus on:
 Assessing the individual's progress
towards established rehabilitation goals;
 Considering possible resolutions to any
problems that could impede progress
towards the goals;
 Reassessing the validity of the
rehabilitation goals previously
established; and
 Monitoring and revising the treatment
plan, as needed. (Chapter 1 – 110.2.4)


Therapy Emphasis

 During most IRF stays, therefore, the
emphasis of therapies would generally shift
from traditional, patient centered therapeutic
services to patient/caregiver education,
durable medical equipment training, and
other similar therapies that prepare the
patient for a safe discharge to the home or
community-based environment (Chapter 1 – 110.3)
 Documentation must concentrate on
FUNCTIONAL TEAM GOALS and work to
remove those barriers vs. discipline specific
chatter.


Presumptive Methodology vs. Medical Review

 With continual increase in Medicare Advantage
or Part C populations; 50% or greater of a
facilities population may not be Medicare part A,
making presumptive methodology of the total
inpatient population within the 60% rule difficult.
 Therefore: IRF’s must encode & transmit IRF-
PAI data on all part A and Medicare Advantage
part C patients to facilitate better calculations
under the 60% rule. 10/1/09 is the effective date
adopted. The Medicare identification number
must be provided.


No Surprises - No Silos

MEDILINKS TRANSPARENCY of INFORMATION
THROUGHOUT INTERDISCIPLINARY
CHARTING is UNIQUE and unrivaled in an IRF
ENVIRONMENT –
MediLinks keeps everyone on TRACK!


Making Compliance Simple

AUDITS ARE HERE TO STAY
MAKE YOUR STRATEGY LASTING,
DEPENDABLE & CONSISTENT!


WHO will be Affected by RAC Audits?

 Inpatient Hospitals, IRF’s, SNF’s, Hospice
 10% of the average monthly Medicare claims (max 200) per
every 45 days per NPI.
 If you bill fee-for-service programs, your claims will be
subject to review by the RACs on a post-payment
basis.
 RACs use the same Medicare policies as Carriers, FIs and
MACs
 NCDs, LCDs, CMS Manuals

 EDUCATION & PREPARATION STRATEGIES ARE KEY


Time Frames – per CMS RAC Office

*RACs may
not begin
A
reviewing
until there is D B
provider
outreach in
the state

C

Claims Available for Analysis Provider Outreach Earliest Correspondence
March 1, 2009 March 1, 2009 March 1, 2009
March 1, 2009 March 1, 2009 March 1, 2009
August 1, 2009 August 1, 2009 August 1, 2009


How Will the RAC’s Be Implemented?

Limit the RAC “look back period” to three years
 Maximum look back date is October 1, 2007
 Demand letter will be issued by the RAC
 RAC will offer an opportunity for the provider to discuss
the improper payment determination with the RAC (this
is outside the normal appeals process).
 If a RAC loses at any level of appeal, the RAC must
return the contingency fee
 Two types of review:
 Automated (no medical record needed)
 Complex (medical record required)


Sample Population & Risk

 10% of the average monthly Medicare claims (max
200) per 45 days per NPI can be Audited.
 If a facility has 60% Medicare Claims and discharges
700 patients per year.
 700 X .60 = 420 patients are Medicare
 420 / 12 = 35 pts/ on avg. per month.
 Reviews can occur every 45 days. (365 / 45 = 8.1 possible
reviews annually).
 10% of 35 = 4 patients per each 45 days or 32 patients per
year.
 If a CMI of 1.0 is paid @ $13,661 X 32 pts. = $437,152.00 of
defensible risk. If your CMI is higher so is your RISK!


The Collection Process

 Same as FI and MAC identified overpayments
 A Remittance Advice notice is issued:
 Remark Code N432: “Adjustment Based on Recovery Audit”
 Carrier; FI/MAC recoups by offset unless provider has
submitted a check or a valid appeal within the time lines
provided.

 MediLinks was designed specifically for the rehabilitation
niche to meet the unique criteria for interdisciplinary
TEAM oriented care and is designed to seamlessly meet
the regulations outlined.


What is Your RISK Strategy?

 MediLinks has Tools and Reports that permit
compliance checking, continuous
communication and measurement of ongoing
CMI improvements.
 Information that provides leadership solutions for day to day
management of financial, clinical & resource utilization.
 Burden of Care:
 Continuous CMI monitoring; What information can you gather for clinical
and financial decisions ? How can monitoring the daily CMI demonstrate
nursing hours per day above and beyond that provided at a SNF level of
care?
 Daily Functional Measurement Report:
 How can this relate to improved treatment focus and target GOAL
completion work? How can staff utilize information for proactive POC
changes.


Regulatory Compliance

 FI/MAC and RAC audits can occur
simultaneously.
 Given these stringent guidelines/timelines.
Are you prepared for an audit for each of
the checklist items provided?


FUTURE STRATEGY – DO YOU HAVE YOURS?

 Without electronic documentation; abstracting
charts in a way that demonstrates each of
these criteria being met for every patient would
be extremely time & labor intensive.
 With MediLinks – it’s seamless & reportable;
our solutions were created with rehabilitation
needs in mind.
HAS THE SOLUTION
for 2010 IRF
Compliance!


Provides SOLUTIONS
for
REHABILITATION
BUSINESS
MANAGEMENT


THANK YOU
We look forward to helping
you with your CORE
Business Strategies!
www.MediLinks.com
480-831-7800


2010 Regs&Medi Links2

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