Irf Medical Necessity


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A presentation designed to train individuals in the rationale and defense of Medically Necessary Documentation as it pertains to CMS guidelines in an Inpatient Rehabilitation Facility. Designing short and long term goals to improve documentation for defending Medical Necessity under RAC / MAC audits.

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Irf Medical Necessity

  1. 1. Medically Necessary Defense for IRF Cases Denied Payment on Audit Darlene L. D’Altorio-Jones, PT. MBA HCM Clinical Consultant, MediServe OARF presentation 5/21/09 (modified) MediServe Confidential © 2009 MediServe, Inc. All Rights Reserved.
  2. 2. Medical Necessity as Defined by the ‘RULE’ This in-service is intended to be used as:  1.) An understanding of the 85-2 Medical Necessity Ruling  2.) Background information leading up to intensified medical necessity audits/defense requirements  3.)Provide readily usable templates that help staff perform medical necessity rebuttal documentation for records challenged prior to 1/1/2010 given ‘new’ conditions of participation MediServe Confidential 2 © 2009 MediServe, Inc. All Rights Reserved.
  3. 3. LEARNING OBJECTIVES:  Medical Necessity – How is it defined for admission to an IRF?  Compliance – 60/40 vs. Medically Necessary; the importance and understanding that each is different!  85-2 / WHAT exactly does it mean; where did that rule come from?  Preparing a short and long term STRATEGIC DOCUMENTATION PLAN is critical for financial survival.  A template to successfully defend denied IRF cases.  A second template that demonstrates why Skilled WASN’T the appropriate level of care for round 2 rebuttals.  Outpatient Medical Necessity Review MediServe Confidential 3 © 2009 MediServe, Inc. All Rights Reserved.
  4. 4. IRF – Special Purpose Facility with Special Purpose Regulations  Prior to IRF PPS, Rehabilitation Hospitals/Units were exempted from standard Medicare Part A DRG payment  Defined by patient populations that generally required a rehabilitation level of care.  Annual facility attestation required that 75% of TOTAL admissions had to meet 10 rehab classified diagnoses to meet DRG exemption. (Changed SB514 12/07 =freeze 60%)  Rehab ‘10’ was maintained until 2004 when ‘13’ more defined categories were established and more thoroughly defined. Medicare Benefits Policy Manual Chapter 1; Fed Register Section 412.29 MediServe Confidential 4 © 2009 MediServe, Inc. All Rights Reserved.
  5. 5. IRF PAI – Beginning & Purpose  Prospective Payment System  Implemented in 2002 to cover Part A Medicare Rehab Patients – Enforced Balanced Budget Act expectation  Near 20 year wait for promised IRF PPS roll-out after acute DRG’s took effect with specialty carve outs 10/83.  Tool uses patient burden/resource care needs to define costs rather than diagnosis alone because scope of functional independence & severity of disablement is a complex equation. MediServe Confidential 5 © 2009 MediServe, Inc. All Rights Reserved.
  6. 6. IRF PAI – Beginning & Purpose  Prospective Payment System  Instrument completion defines payment & guides length of stay – Accuracy and detail to guidelines are paramount to ensure reimbursement compliance.  18 item; Functional measurement scale embedded in tool  Captures diagnosis/demographics & scores to define Medicare payment levels; with a tiered CMG grouper MediServe Confidential 6 © 2009 MediServe, Inc. All Rights Reserved.
  7. 7. 60/40 vs. Medically Necessary  These CMG classifications have payment criteria at every level of the 21 RICS (353 with 5 special cases possible).  The fact that CMG’s range from the very least complex to the most complex each having an attached payment weight signifies that each level and their range in length of stay is appropriate for that case.  However; if patients present at a level that may be ‘managed at a skilled’ level of care, it may be hard to justify rehabilitation in an IRF.  This is a major reason why 85-2 will be dissolved with specific rule guidance and conditions of participation redefined in Medicare Manual revisions by 1/1/2010. MediServe Confidential 7 © 2009 MediServe, Inc. All Rights Reserved.
  8. 8. Medically Necessary & ‘co-morbid conditions’  Comorbidities – ICD-9-CM assigned for additional conditions that are MANAGED during the rehab stay that are ‘in addition to’ normally expected conditions of the admission IGC (impairment group code).  Conditions ‘expected’ for an IGC are factored into the payment category; there are an additional 10 fields – List conditions being treated even if they may not gain a tiered condition - order of listing is not important.  CMI or case mix index is assigned that weights severity & provides multiplier for specific facility payment rate. MediServe Confidential 8 © 2009 MediServe, Inc. All Rights Reserved.
  9. 9. Know Importance of IRF Alphabet Soup  Complications – ICD-9-CM assigned when additional conditions are managed in the IRF/U stay anytime prior to 24 hours of discharge.  CMG – Case Mix Group  Assigned with completion of the PAI – requires function / age / cognition / co-morbidities (Grouper then classifies case)  Defines burden & resource utilization in total that translates to payment and length of stay guidelines.  Letters A-D used for tier level A=0, B=1 (high), C=2 (medium), D=3 (low) severity = reimbursement weighted rating. MediServe Confidential 9 © 2009 MediServe, Inc. All Rights Reserved.
  10. 10. 60/40 vs. Medically Necessary  The 2004 published CMS changes along with LCD inclusion interpretation of 10 to 13 RIC’s; led to industry pandemonium.  The largest number of rule comments ever received by CMS in the history of rule comments was received.  Arguments that a ‘percent compliance’ rule and ‘medically necessary’ admission criteria was no longer relevant since PPS IRF-PAI CMG classification outlined payments congruent with resources utilized from minimal to maximal severity indexes.  The need for rehabilitation alone does NOT denote acceptance to an IRF level of care.  Why have payment guidelines for 0101 tier A or D? It’s a rhetorical question not easily answered.  Confusion has led CMS to significantly revamp Medicare Benefit Policy Manual and Conditions of Participation for the 2010 regulation updates. MediServe Confidential 10 © 2009 MediServe, Inc. All Rights Reserved.
  11. 11. 60/40 vs. Medically Necessary  A December 2007 freeze (SB 543) was enacted - known as the 60% rule.  This step was taken to allow time for further documented evidence & research enabling providers and CMS to define clinically relevant, MEDICALLY NECESSARY guidelines for IRF admission.  For facilities with challenged cases prior to 1/1/2010, they must defend & recover payment for care using the 85-2 criteria.  Documentation that is step in step with the criteria increases likelihood in your defense. Rule 60% vs. 40% Non-Compliant Compliant MediServe Confidential 11 © 2009 MediServe, Inc. All Rights Reserved.
  12. 12. 60/40 vs. Medically Necessary  It is possible for patients to have a compliant RIC diagnosis but not meet LCD standards or the 85-2 ruling for Medically Necessary admissions.  Changing compliance downward was perceived to assist facilities through a 60/40 compliant % mix, however:  Once challenged, HCFA compliance is upheld by defensible 85-2 standards, not whether a patient meets a 60% RIC category.  ALL DEFENSE is in the clarity of documentation that demonstrates clinical complexity and a skilled plan of care by the interdisciplinary team that addresses every roadblock for discharge.  MediLinks provides detailed interdisciplinary charting that meets these criteria to defend Medical Necessity. MediServe Confidential 12 © 2009 MediServe, Inc. All Rights Reserved.
  13. 13. 60/40 vs. Medically Necessary  Compliant diagnoses can be retrospectively denied by fiscal intermediaries through CERT & RAC audits.  The balanced budget act demanded fiscal intermediary and audit contractor due diligence which led to challenges never before faced in our industry.  These factors continue to cause significant POST-payment denials; rebuttal documentation, and the need to defend MEDICAL NECESSITY using 85-2 is paramount for success.  MediLinks is a specialty rehabilitation software that meets this special niche. MediServe Confidential 13 © 2009 MediServe, Inc. All Rights Reserved.
  14. 14. 60/40 vs. Medically Necessary  REPEAT ---  Rehab 13 is not the measurement for automatic Medically Necessary Admission Criteria.  Rehab 13 is the measurement of ATTESTATION required to maintain licensure as a condition of participation for SPECIALTY STATUS as a rehab facility /unit - showing your facility meets reimbursement under the PAI. It’s only a portion of Conditions of Participation as an IRF.  It’s extremely important to operationalize the difference. MediServe Confidential 14 © 2009 MediServe, Inc. All Rights Reserved.
  15. 15. Reference 85-2 Ruling  Was issued in 1985 & set clear, clinically-based rules for inpatient rehabilitation coverage and have been used by HCFA/CMS over more than two decades to determine what constitutes medically necessary inpatient rehabilitative care. MediServe Confidential 15 © 2009 MediServe, Inc. All Rights Reserved.
  16. 16. 60/40 vs. Medically Necessary  What exactly is the 85-2 Ruling?  It was established by Federal Law in 1985 and requires 2 clinically relevant requirements be met in 8 different areas.  This landmark ruling defined what made a rehabilitation facility ‘special & unique’ as a carve out facility and what criteria needed to be followed when deciding appropriate cases to admit to an inpatient rehabilitation facility/unit.  Up until 2010 it is the SOLE defense for medically necessary admissions. MediServe Confidential 16 © 2009 MediServe, Inc. All Rights Reserved.
  17. 17. 60/40 vs. Medically Necessary  This is why HCFA 85-2 criteria has resurged importance; defending each area to refute cases denied assists in the ability to regain payment.  Unfortunately this retrospective process adds costs and rework making predetermination documentation based on 85-2 criteria the most hallmark key for establishing admission criteria and continued treatment. * through 12/31/09.  Law Judge Review; One of the last steps in the legal defense process uses 85-2 as the sole criteria for establishing Medically Necessary rehabilitation level of care.  If documentation does not CLEARLY demonstrate the criteria as being met, you will have to abstract evidence within the chart to demonstrate it during the rebuttal process. MediServe Confidential 17 © 2009 MediServe, Inc. All Rights Reserved.
  18. 18. 60/40 vs. Medically Necessary  If you can’t defend 85-2, you will NOT RECOUP payment for your care; this is despite absolutely excellent outcomes.  Due-diligence in pre-admission assessments, following Medically Necessary criteria for admission must be followed.  If a pre/post admission case significantly changed, whereas the patient no longer required an intensive plan of care consistent with industry guidelines; it is your obligation to provide the patient advanced beneficiary notification stating why services may not be covered.  At the very least, this should be recognized by the first patient evaluation conference and communicated as a case that could be challenged.  Discharge Notification; allowing the patient the ability to challenge a continued stay and forcing a review of the medical record is useful.  Subsequent Quality Review will solidify coverage determination.  Automatic invocation of the 3-10 day trial has led to believed misuse of this timeframe – with removal from the new regulations! MediServe Confidential 18 © 2009 MediServe, Inc. All Rights Reserved.
  19. 19. 60/40 vs. Medically Necessary  Facilities are scrambling to survive and must struggle through prolonged processes of up to a year and a half to regain payment in greater than 85% of all cases refuted.  Unclear documentation or documentation that does not clearly support the eight criteria are at risk.  Clinicians must understand and document toward the skill sets they provide at a skill level unique to that provided at the intense level of care within an IRF.  Going forward until 12/31/09; the most relevant preparation an IRF can make is to hard wire 85-2 for admission and continued need for rehab as the primary mission for all documentation.  If you don’t have documentation software that clearly justifies the outlined criteria, it’s important to educate required documentation importance so that no areas are left in question. MediServe Confidential 19 © 2009 MediServe, Inc. All Rights Reserved.
  20. 20. Medically Necessary HCFA 85-2 Ruling  HCFA Ruling 85-2 established two basic requirements in 1985 that must be met for inpatient hospital stays to be covered for a rehabilitation level of care.  THERE WERE:  1. The services must be reasonable and necessary (in terms of efficacy, duration, frequency, and amount) for the treatment of the patient’s condition; and  2. It must be reasonable and necessary to furnish the care on an inpatient hospital basis, rather than in a less intensive facility, such as a skilled nursing facility (SNF), or on an outpatient basis. MediServe Confidential 20 © 2009 MediServe, Inc. All Rights Reserved.
  21. 21. FINAL RULE – pg. 39790 FR MediServe Confidential 21 © 2009 MediServe, Inc. All Rights Reserved.
  22. 22. Medically Necessary HCFA 85-2 Ruling  The Ruling then sets forth eight criteria, which, if satisfied, demonstrate that both of these two requirements for inpatient rehabilitation are satisfied. These eight criteria stipulate that the patient must require:  1. Close medical supervision by a physician with specialized training or experience in rehabilitation;  2. Twenty-four hour rehabilitation nursing;  3. A relatively intense level of rehabilitation services;  4. A multi-disciplinary team approach to delivery of the program;  5. A coordinated program of care;  6. A significant practical improvement must be likely;  7. The rehabilitation goals must be realistic; and  8. The length of the rehabilitation program must be reasonable. Encoding Advocacy through Appropriate PAI Documentation 22 MediServe Confidential 22 © 2009 MediServe, Inc. All Rights Reserved.
  23. 23. Confusing?  Medical Necessity 85-2 court case ruling supersedes 60/40 in a challenged medical record:  As individual cases are challenged through CERT (Comprehensive Error Rate Testing) & RAC/MAC (Recovery Audit Contractor/Medicare Administrative Contractor) audits:  Medical Necessity documentation must meet 85-2; not 60/40 RIC inclusion classification.  60/40 is the facility rolling % average on any given day up to the final day of the attestation period.  Even if a RIC ‘fits’ 60/40 compliance; “Can you defend the 8 criteria required to meet a Medically Necessary level of care for an IRF/U is the REAL question?” MediServe Confidential 23 © 2009 MediServe, Inc. All Rights Reserved.
  24. 24. Use the OIG website to Review Concerns  ‘Care could have been rendered in a less intensive setting & or the patient was NOT capable of SIGNIFICANT improvement’ are reasons the OIG asked for increased case review.  The Office of the Investigator General believes inappropriate patients have been admitted to IRF’s based on poor documentation. Documentation to support the 8 criteria decreases your liability for denied payment. MediServe Confidential 24 © 2009 MediServe, Inc. All Rights Reserved.
  25. 25. How to defend challenged records  Educate Staff on  Review short and long guidelines of medical term liability plans. necessity.  Utilize best of breed  Create a template that rehabilitation software ‘tags’ information specific such as MediLinks, to 85-2 ruling which enables you to  When permitted, tag meet regulatory nuances each area and in a seamless ‘behind summarize your the scenes’ manner. argument for each of the  Compliance is BUILT IN 8 criteria. to MediLinks workflow. MediServe Confidential 25 © 2009 MediServe, Inc. All Rights Reserved.
  26. 26. TEMPLATE for 85-2 Medical Necessity Defense  Provider Number & Name:  Patient Name:  HICN: (Covered SS # with letter)  DCN: (Medicare document control # for this episode of care)  From/Through: (dates)  Denial Code: Provided with documentation from audit contractor.  Patient Introduction: -------------- is a ---------- year old (male/female) transferred to IRF NAME --- days post ------------ . State GOAL for admission & relate the goal to their previous functional capacity and abilities; non-institutional residence.  IRF NAME feels that -------------- met the ruling 85-2 definition of ‘reasonable and necessary’ and required a rehabilitation level of care because the following eight screening criteria established by CMS for ‘reasonable and necessary’ have been met in the following ways. MediServe Confidential 26 © 2009 MediServe, Inc. All Rights Reserved.
  27. 27. 1 .Close medical supervision by a physician with specialized training or experience in rehabilitation.  Dr. --------, MD Board Certified PMR, was the physiatrist for ------------. (Outline credentials of they physician with specialized training responsible for the POC). The physicians admission consult summarized medical and physical limitations and goals along with the plan for attaining those goals. (Tab # ) He reviewed his plan during ------- different team conferences outlining progress and continued need for rehabilitation. His last note summarized progress on --------- date (outcomes and disposition). MediServe Confidential 27 © 2009 MediServe, Inc. All Rights Reserved.
  28. 28. 2. Twenty-four hour rehabilitation nursing:  (Patient name) required (special nursing interventions & dates) . (Review fall risk, pain level, safety interventions, skin interventions, bowel/bladder, medically complex vigilance in neuro/medical checks & interventions). Nursing assisted the patient in the rehabilitation plan of care providing 24/7 intervention and training towards independence.  Do you know your daily CMI (case mix index)? Can you defend hours of nursing care per day greater than a skilled nursing home level of care? MediLinks users can! MediServe Confidential 28 © 2009 MediServe, Inc. All Rights Reserved.
  29. 29. Each patient requires different nursing hppd The patient care required at a Rehabilitation Level is significantly greater than these noted for skilled care. KNOW your individual patient CMI . Demonstrate their care required the level provided and that it was GREATER than the skilled Requirement. MediServe Confidential 29 © 2009 MediServe, Inc. All Rights Reserved.
  30. 30. 3. Relatively intense level of rehabilitation services:  Provide amount of therapy provided; gather evidence and calculations demonstrating that the patient met the 3 hour rule; flag documentation that may support when unable to meet for appropriate medical purposes. Include specialty consults; orthotics etc.  These reports are built in features of MediLinks. 30 MediServe Confidential 30 © 2009 MediServe, Inc. All Rights Reserved.
  31. 31. 4. Multi-disciplinary team approach to delivery of program:  (Patient name) received daily nursing & attended therapy ______ days a week. HE/She received PT, OT, Speech, Respiratory, Psychology etc., in addition to Recreational therapy, support groups, spiritual support etc. Notes were written at and documented in treatment and progress areas. Weekly progress and an updated plan of care is presented in the evaluation conference documentation. Dr. ---------------- summarized conferences for Mr./Ms.______ stay, care and provided outcomes on the discharge summary dated ---.(Tab # ).  MediLinks creates interdisciplinary (new 2010 regulation wording) plans of care and goal documentation unrivaled in any other software system. MediServe Confidential 31 © 2009 MediServe, Inc. All Rights Reserved.
  32. 32. 5. Coordinated program of care:  Pre-admission assessment revealed ------------------ summary of H&P information (Tab # ). Also, please see medical director comments attached (Tab # ). See Pre-Admission screening tool and rationale for admission. (Tab #) (Previously these were not mandated as part of the Medical Record; this is an opportunity to provide a copy of the screening information when you performed a due diligence assessment.) The areas tagged should reveal multiservice LOC needs.  MediLinks pre-admission screening is specific to meeting regulatory guidelines. MediServe Confidential 32 © 2009 MediServe, Inc. All Rights Reserved.
  33. 33. 6. Significant practical improvement:  (Create a radar or bar graph with relevant comparison of pre/post functional gains.) Highlight specific FUNCTIONAL goals and how those translated to gaining the least possible assistance required for specific important functions. Patient name, made a ------- point functional gain ------------------------ and was able to return -------------------------- meeting significant practical improvement over their admission functional status.  MediLinks has reports that demonstrate goal achievement. MediServe Confidential 33 © 2009 MediServe, Inc. All Rights Reserved.
  34. 34. 7. Realistic Goals:  (Describe portion of goals met esp. if home going along with improved independence or ability to avoid institutional placement). Discuss road blocks that were met in order to gain non- institutional discharge. Highlight caregiver training etc. If institutional d/c occurred despite caregiver’s original intentions; note and tag when this change occurred. It is extremely important to demonstrate all areas where predefined expectations were met. MediServe Confidential 34 © 2009 MediServe, Inc. All Rights Reserved.
  35. 35. 8. Length of rehabilitation program:  After completing (pt name) care and improving his/her overall medical condition; List summary of functional improvements. This required a ----#---- day stay (compared to published CMG LOS) of ----------- days. IRF NAME utilizes the published CMG LOS as a guideline and tailors a patient’s stay based on individual needs. In 200_ we treated ------ patients with the same CMG whose average LOS was ---- days, which is ------ days less/greater than the expected LOS for CMG ------- -. Use any historical reference that denotes logical LOS based on patient conditions present.  There are reports available in MediLinks that alert you of individual patient status in relation to expected LOS. MediServe Confidential 35 © 2009 MediServe, Inc. All Rights Reserved.
  36. 36. The ending statement should read like this  Based on the documentation provided which meets the criteria set in HCFA Ruling 85-2, issued July 31st, 1985, as the sole standard for determining the medical necessity of services provided by inpatient rehabilitation hospitals and units, we would like you to reconsider the denial of this claim which clearly meets each of the required elements of Medically Necessary care. MediServe Confidential 36 © 2009 MediServe, Inc. All Rights Reserved.
  37. 37. Template # 2. > SNF LOC Argument  When the 85-2 template argument is still denied; yet the patient had risks that were managed effectively by the intensity of the rehabilitation level of care; the reverse argument can be presented stating why SNF was not the practical alternative to the care the patient received.  Follow the link below to review research specific to total joint replacement outcomes when reviewing skilled vs. a rehab level of care. Use this literature in your defense for appropriate placement to your rehabilitation program when patients met medical necessity.  MS-1551-PPaperComments7-13.pdf MediServe Confidential 37 © 2009 MediServe, Inc. All Rights Reserved.
  38. 38. Defending THERAPY OUTPATIENT CARE  It’s important to review the regulatory guidelines for required documentation criteria when charting for Medicare part B outpatient care.  Train staff on the minimum standards so that all areas are complete.  MediLinks outpatient documentation and billing assists staff in meeting rigorous requirements in the course of their normal documentation.  Workflow templates and scheduling software in conjunction with the outpatient product increase ability to track preapproved visits and the need for recertification. MediServe Confidential 38 © 2009 MediServe, Inc. All Rights Reserved.
  39. 39.  220 - Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance  (Rev. 88, Issued: 05-07-08, Effective: 01-01-08, Implementation: 06-09-08) Medicare Benefit Policy Manual Ch. 6 Transmittal 63 has been replaced by Transmittal 88, published on May 7, 2008 MediServe Confidential 39 © 2009 MediServe, Inc. All Rights Reserved.
  40. 40. OP Coverage & Medical Necessity Chapter 6 - Hospital Services Covered Under Part B  20 - Outpatient Hospital Services  20.2 - Distinguishing Outpatient Hospital Services Provided Outside the Hospital  20.4.1 - Coverage of Outpatient Therapeutic Services Chapter 13 - Local Coverage Determinations 13.5.1 - Reasonable and Necessary Provisions in LCDs Specific Therapy Policies. Sections 220 and 230 of this chapter describe the standards and conditions that apply generally to outpatient rehabilitation therapy services. MediServe Confidential 40 © 2009 MediServe, Inc. All Rights Reserved.
  41. 41. Defending OP Process & Med Necessity  POC & Certifying the POC  Services written to a specific Rx plan  Signature/identity/date must be recorded.  Content:  Dx, LTG (for entire episode or the part being certified).  Type, Amount, Duration & Frequency  Plan consistent with related evaluation. MediServe Confidential 41 © 2009 MediServe, Inc. All Rights Reserved.
  42. 42. PLEASE NOTE:  The additional attached slides are excellent resources for education and planning as a strategy to proactive documentation and or to defend Medical Necessity using regulatory guidelines.  The areas listed on the following slides were utilized in gathering information required to complete this presentation and credit and acknowledgement is given for this purpose as well. MediServe Confidential 42 © 2009 MediServe, Inc. All Rights Reserved.
  43. 43. Excellent Training References: AHAAccesstoRehab.pdf MediServe Confidential 43 © 2009 MediServe, Inc. All Rights Reserved.
  44. 44. MediServe Confidential 44 © 2009 MediServe, Inc. All Rights Reserved.
  45. 45. NGS (Previously Administar Federal) published the LCD for Ohio Inpatient Rehab Facilities Reviewed Federal Register Sections 110.1 – 110.5 Guidelines for admission and medical necessity. MediServe Confidential 45 © 2009 MediServe, Inc. All Rights Reserved.
  46. 46. March 2007, Healthcare Financial Management Association Published this article encouraging IRF providers to use 85-2 as a rebuttal argument to medical necessity. MediServe Confidential 46 © 2009 MediServe, Inc. All Rights Reserved.
  47. 47. MedPaC Report to Congress Medicare Payment Policy pgs. 201 – 215. Chapter 3 C. MediServe Confidential 47 © 2009 MediServe, Inc. All Rights Reserved.
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