Coding Update Lisa Bazemore, MBA, MS, CCC-SLP February 5, 2008 Exemption Criteria Physician 24/7Documentation of medical and rehab needs. Co-morbidities need listing. Rehab Nursing 24 hrsComprehensive Nursing Plan of Care. Relative IntensityDocumenting endurance in the pre-admission screen and for continued stay. Multidisciplinary TeamGoal statements. Assessments done before day four post- admission. Basics Exemption Criteria Comprehensive PlanJustifies the admission. Significant Progress Toward Goals Documentation matches between chart and IRF PAI. 75/25 ruleEach patient is assessed individually. Pre-admission screeningAdd in CMG prediction for long stay heavy care patients. Basics Exemption Criteria Distinct spaceBeds contiguous. Team ConferenceMay change frequency. 3 to 10 day evaluationGraduated therapy time frame. Annual evaluationIRF - PAI will be part of review. Provider Payment Components Federal Base Payment (F) base rate for 2008 is $13,241 Labor Portion (F) Wage (V) Rural Factor (F) continue to move to new MSA model LIP (V) Low income patient Case Mix (V) Case Mix Groups Discharge-based system Payment is based on discharge information Case Mix Groups (CMG) 95 main groups 4 deaths 1 short stay Single lump payment for each stay Case Mix Groups All inclusive* payment for each patient Off unit surgery, dialysis, and so on. 385 payment categories The base rate from the government last year Range of average discharge rates $6,100 - $39,348 with no co-morbidity Range of average discharge rates $8,656 $55,006 with the highest co-morbidity * Blood transfusion and certain medical education costs excluded How A CMG is Determined CMG Determinants Impairment Group Code Broad codes that identify the main reason for the rehab stay. 21 main categories. Motor Score of FIM (excludes tub/shower transfers) Functional assessment based on 12 functional measures determined upon admission Co-morbiditiesAdditional medical condition that has a significant effect on the rehabilitation stay & progress & cost. AgeThe age of the patient upon admission CMG Table Sample Replacement of Lower Extremity Joint 0801 ALOS W/O CM 6 Relative Wt $ ALOS W/O CM 8 Relative Wt $ ALOS W/O CM 12 Relative Wt $ ALOS W/O CM 10 Relative Wt ALOS W/O CM 13 Relative Wt $ ALOS W/O CM 15 Relative Wt $ Motor >49.55 Motor > & < Motor > & < & Age > 83.5 Motor > & < & Age < 83.5 Motor > & < Motor < Replacement of Lower Extremity Joint Weighted Motor Score Index Total Maximum Motor Score 84 Total Minimum Motor Score 12 (0s convert to 1s for CMG determination) If Transfer to Toilet coded 0 will be converted to a 2 ItemWeight Eating.6 Grooming.2 Bathing.9 Dressing Upper Body.2 Dressing Lower Body1.4 Toileting1.2 Bladder.5 Bowel.2 Transfer Bed, Chair, W/C 2.2 Transfer Toilet1.4 Transfer Tub, Shower Not included as item for CMG Locomotion1.6 Stairs1.6 Motor Score Index Item ScoreWeight Value Eating Grooming Bathing UB Dressing LB Dressing Toileting Bladder Bowel Transfer Bed, Chair, W/C Transfer Toilet Transfer Tub/Shower 4 Locomotion Stairs Total 37.5 Motor Score Index Example Item ScoreWeight Value Stairs Locomotion Transfer Tub/Shower 1 LB Dressing Bathing Transfer Bed, Chair, W/C Toileting Transfer Toilet 0(2) Bladder UB Dressing Grooming Bowel Eating Total 38.6 CMG 0602 Neurological with M > and M < 47.75 Motor Score Index Example CMG 0602 Neurological with M > and M < Total score = 38.6 Toilet Transfer was not scored 0 defaulted to a score of 2 If attempted and scored a 1, total would have been 37.2 CMG would have been 0603 Payment weight would have been instead of.9342 Difference of $3381 The Importance of Accuracy Three Tiers of Co-morbidities Average eRehabData utilization in 2007: Tier % Tier % Tier % Can be identified up to two days before discharge. Physician identification is mandatory. Nursing Plan of Care follow up is critical. Logged on the IRF-PAI Tier 1 Co-morbid Conditions Eight Tier 1 Comorbitites: VOCAL PARAL UNILAT PART VOCAL PARAL UNILAT TOTAL VOCAL PARAL BILAT PART VOCAL PARAL BILAT TOTAL EDEMA OF LARYNX V44.0 TRACHEOSTOMY STATUS V45.1 RENAL DIALYSIS STATUS V55.0 ATTEN TO TRACHEOSTOMY Tier 2 Comorbidities Eleven Tier 2 Comorbidities: PSEUDOMONAS ENTERITIS INT INF CLSTRDIUM DFCILE PSEUDOMONAS INFECT NOS LATE EF CV DIS DYSPHAGIA INTEST POSTOP NONABSORB DYSPHAGIA NOS DYSPHAGIA, ORAL PHASE DYSPHAGIA, OROPHARYNGEAL DYSPHAGIA, PHARYNGEAL PHASE DYSPHAGIA, PHARYNGOESOPHAGEAL DYSPHAGIA NEC Top Tier 3 Comorbidities Tier 3 (Over 100 occurrences) MORBID OBESITY NEUROPATHY IN DIABETES DMII NEURO NT ST UNCNTRL 486. PNEUMONIA, ORGANISM NOS ACUTE RENAL FAILURE NOS UNSP HEMIPLGA UNSPF SIDE CELLULITIS OF LE OTHER POSTOP INFECTION PULM EMBOL/INFARCT NEC DMII RENL NT ST UNCNTRLD DMII OTH NT ST UNCNTRLD FOOD/VOMIT PNEUMONITIS DMII OPHTH NT ST UNCNTRL DMII CIRC NT ST UNCNTRLD ACUTE RESPIRATRY FAILURE Tier 3 (Over 100 occurrences) DISRUP-EXTERNAL OP WOUND 515. POSTINFLAM PULM FIBROSIS DMII NEURO UNCNTRLD SIRS-INFECT W/O ORG DYSF UNSP HEMIPLGA DOMNT SIDE UNSP HMIPLGA NONDMNT SDE DMI WO CMP NT ST UNCNTRL DIASTOLC HRT FAILURE NOS PANCYTOPENIA CELLULITIS OF ARM SEPTICEMIA NOS OT SP HMIPLGA UNSPF SIDE POST TRAUM PULM INSUFFIC Top Tier 3 Comorbidities Tier 3 (Over 100 occurrences) CRBL ART OCL NOS W INFRC CELLULITIS OF TRUNK 042. HUMAN IMMUNO VIRUS DIS GANGRENE DMI NEURO NT ST NCNTRLD PULMONARY EOSINOPHILIA CELLULITIS OF FOOT ANOXIC BRAIN DAMAGE 514. PULM CONGEST/HYPOSTASIS IATROGEN PULM EMB/INFARC STAPH AUREUS PNEUMONIA LOWER NEPHRON NEPHROSIS DMII OTH UNCNTRLD Tier 3 (Over 100 occurrences) DMII RENAL; UNCONTRLD DMII OPHTH UNCNTRLD OT SP HMIPLG NONDMNT SDE REACT-OTH VASC DEV/GRAFT DMII UNSPF UNCNTRLD STAPH AUREUS SEPTICEMIA SYSTOLIC HRT FAILURE NOS OCL CRTD ART W INFRCT DMII CIRC UNCNTRLD AC/SUBAC BACT ENDOCARD CELLULITIS OF HAND LEFT HEART FAILURE SIRS-INFECT W ORGAN DYSF Comorbidity Impact Comorbidities-RIC 01 StrokeReimbursement None $28, Tier 3 ex., Diabetes $29, Tier 2 ex., Dysphagia NOS $32, Tier 1 ex., Vocal Cord Paralysis $34,806.62 Operational Process to the CMG Pre-admission screening (screener/physician) Gather apparent Impairment Group Code Gather co-morbid conditions Age information Payer status (Medicare vs. other payer) Admission Physician assessment is done and H&P is written IRF-PAI is started once Impairment Group Code and co- morbid conditions are confirmed with physician documentation Therapy and nursing assessment are completed and plan of care is written FIM motor subscale scores are obtained Operational Process to the CMG Assessment Coders review charts at the end of the assessment to assign admission codes Beginning CMG is established Discharge plan identified Concurrent coding Additional comorbidities and complications are added to the IRF-PAI as per physician documentation Discharge Discharge destination selected Length of stay set Final coding is complete IRF-PAI is locked and transmitted UB-04 is sent to FI for payment How it Works 80%+ of the Time SMTWThFS Discharge Home Facility receives the full CMG payment. 123 Patient stays at least to the fourth day and discharged home. 4 Simple Payment Determination Base Rate x CMG/Tier weight Example: $13,241 x (CMG 0204 for TBI/Tier 3) = $13,238.35 How it Works: Co-morbidity Identification SMTWThFS up to 2 days before discharge for the payment bump to be effective. Co-morbid conditions can be identified by the physician DC Sample CMG 108 CWeightALOS13,241 Tier 1High (B) ,342 Tier 2Med( C) ,802 Tier 3Low (D) ,021 None(A) ,165 Exceptions to full CMG Payment Transfer Rule Discharge to Medicare or Medicaid certified facility And - Has a LOS shorter than the LOS for the CMG they were assigned when discharged Per diem payment for the days on the unit plus the per diem for the first day Transfer Rule Example Base Rate$13,241 Weight for CMG 108 Tier 3 = Weight times base rate = $25,021 LOS for CMG 108 Tier 3 is 25 CMG 108 Tier 3 divided by 25 = $1001/day Times 8 days = $8006 Plus one per diem = $8506 Transfer Process Works the same for transfers to: Skilled Nursing Facilities & Nursing Homes Long Term Acute Care Acute Care Another Rehab Program Program Interruption Program Interruptions include transfers to acute and back to rehab during the stay. CMG includes paying for acute stays when: Patient is discharged to acute and returns to IRF by midnight of the 3 rd calendar day. All costs associated with the acute stay are recorded on the rehab cost report. True for discharges to acute care of your own facility or acute care of another hospital. Program Interruption Acute stay greater than 3 days are different. If patient goes to acute care and does not return by midnight of the 3 rd calendar day, discharge and re- admit. Patient will have a new admission and assessment reference period. New CMG will be assigned based on information gathered at admission. Correct Coding Why Correct Coding is Important Assignment of appropriate case mix group (CMG) Correct payment tier for co-morbidities Prevention of issues with potential Medicare compliance audits Compliance with the 75% rule Accurately coding documented diagnoses allows for appropriate reimbursement and permits us to capture all possible resources for our patients care. Correct Coding Assignment of Rehab Impairment Code Assign the group that best describes the primary condition requiring admission to the rehabilitation program. PPS Coordinator will look at the condition for whether or not it meets 75% rule compliance If not, look at the acute care documentation to determine what the patient was being treated for Is there an etiologic diagnosis that will qualify the patient? Diagnosis Coding Etiologic diagnosis Use ICD-9 codes, but official coding guidelines do not apply Comorbid conditions Use ICD-9 codes, official coding guidelines sometimes apply Etiologic Diagnosis Etiologic diagnosis Diagnosis that led to condition for which the patient is receiving rehabilitation May use code for an acute condition causing the impairment May use code for a late effect of an acute condition if a rehabilitation program was completed previously for same impairment Co-morbidities Co-morbid condition Patient condition other than the impairment or etiologic diagnosis Exists at the time of admission/may develop during stay Affects treatment received and/or LOS Co-morbid conditions should be reported if they require: Clinical assessment Additional diagnostic procedures Therapeutic treatment Extension of the length of stay Enhanced nursing care and/or monitoring List on IRF-PAI even if not in payment tier Complications Complications are medical conditions Not present at time of admission to rehabilitation Identified during rehabilitation stay That slow or compromise the rehabilitation program Coding Complications Conditions occurring day prior to discharge or on day of discharge Do not add to the burden of care, so they do not yield additional payment Document conditions early or as identified rather than waiting until the discharge summary Coding Coding the IRF-PAI and the UB-04 is not the same! Common question: Should the codes on these documents be the same? NO! Diagnosis Coding Etiologic Diagnosis The problem that lead to the impairment requiring rehabilitation Using ICF terminology, the disease, disorder or injury that resulted in impairment Principal Diagnosis The circumstances of inpatient admission always govern the selection of principal diagnosis. It is that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care" Diagnosis Coding IRF-PAI Coding Etiology is selected by identifying the cause of the primary impairment Acute Care Coding Principal diagnosis is always a V57 code Care involving use of rehabilitation procedures V57.89 Other specified rehabilitation procedure Diagnosis Coding IRF-PAI Coding Limited to ten codes to report comorbid conditions Acute Care Coding Limited to spaces on the UB04 eighteen spaces Diagnosis Coding IRF-PAI Coding Codes should be sequenced according to PPS strategy: 1.) tier assigning 2.) conditions that affect the patient (increase need for heath care resources or LOS) 3.) support medical necessity Acute Care Coding Codes are sequenced using specified procedures, software scrubbing Diagnosis Coding IRF-PAI Coding Codes are reported for actively treated conditions, only. Do not code "probable", "suspected", "likely", "questionable", or "possible conditions Acute Care Coding If the diagnosis documented at the time of discharge is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out", code the condition as if it existed or was established. The bases for this guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. Diagnosis Coding IRF-PAI Coding Late effect codes are used when the patient has completed a rehabilitation program for the condition in the past Acute Care Coding A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. The residual may be apparent early, such as in cerebrovascular accident cases, or it may occur months or years later, such as that due to a previous injury Diagnosis Coding IRF-PAI Coding Code significant symptoms that require health care resources Code residual effects of the primary impairment treated in rehabilitation Acute Care Coding Signs and symptoms that are integral to the disease process should not be assigned as additional codes Diagnosis Coding IRF-PAI Coding Code concurrently Acute Care Coding Recent change from coding at discharge to coding concurrently Diagnosis Coding IRF-PAI Coding Coding may be done by HIM professional or by a clinician (PPS coordinator) Acute Care Coding Official rules for who does coding Diagnosis Coding IRF-PAI Coding Do not code conditions that are recognized the day of discharge or the day preceding discharge *Coding comparison from Dr. Pam Smith, Extreme Makeover for Medical Rehabilitation Acute Care Coding No stipulation on when a condition is identified Documentation Tips In the H&P note all active conditions and plan to address the conditions Medication changes document why changed Lab results document decisions made based on lab results Ordering additional tests/labs document reason why ordered, discuss risks, advantages, hasten rehab participation and discharge Coding Points to Remember When in question, distinguish between obesity and morbid obesity Involve dietitian Morbid obesity is a BMI of 40 or more Physician delineation of manifestations of diabetes mellitus assists coders Peripheral neuropathy Nephropathy Retinopathy, etc. Contact Information: Lisa Bazemore (202)