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2010 Regs&Medi Links2


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A summary of the newest 2010 regulations with \'highlighted\' emphasis to the changes from the 2009 regulations.

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2010 Regs&Medi Links2

  1. 1. 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.
  2. 2. 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.
  3. 3. Learning Objectives for this Presentation:  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? MediServe Confidential 3 © 2009 MediServe, Inc. All Rights Reserved.
  4. 4. Learning Objectives for this Presentation:  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. MediServe Confidential 4 © 2009 MediServe, Inc. All Rights Reserved.
  5. 5. Compliance Outcomes Revenue Efficiency MediServe Confidential © 2009 MediServe, Inc. All Rights Reserved.
  6. 6. 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. MediServe Confidential 6 © 2009 MediServe, Inc. All Rights Reserved.
  7. 7. 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. MediServe Confidential 7 © 2009 MediServe, Inc. All Rights Reserved.
  8. 8. 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. MediServe Confidential 8 © 2009 MediServe, Inc. All Rights Reserved.
  9. 9. 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) MediServe Confidential 9 © 2009 MediServe, Inc. All Rights Reserved.
  10. 10. 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 MediServe Confidential 10 © 2009 MediServe, Inc. All Rights Reserved.
  11. 11. 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. MediServe Confidential 11 © 2009 MediServe, Inc. All Rights Reserved.
  12. 12. 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. MediServe Confidential 12 © 2009 MediServe, Inc. All Rights Reserved.
  13. 13. 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. MediServe Confidential 13 © 2009 MediServe, Inc. All Rights Reserved.
  14. 14. 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. MediServe Confidential 14 © 2009 MediServe, Inc. All Rights Reserved.
  15. 15. 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. MediServe Confidential 15 © 2009 MediServe, Inc. All Rights Reserved.
  16. 16. 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. MediServe Confidential 16 © 2009 MediServe, Inc. All Rights Reserved.
  17. 17. 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) MediServe Confidential 17 © 2009 MediServe, Inc. All Rights Reserved.
  18. 18. 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. MediServe Confidential 18 © 2009 MediServe, Inc. All Rights Reserved.
  19. 19. 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) MediServe Confidential 19 © 2009 MediServe, Inc. All Rights Reserved.
  20. 20. 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) MediServe Confidential 20 © 2009 MediServe, Inc. All Rights Reserved.
  21. 21. 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. MediServe Confidential 21 © 2009 MediServe, Inc. All Rights Reserved.
  22. 22. 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) MediServe Confidential 22 © 2009 MediServe, Inc. All Rights Reserved.
  23. 23. 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 MediServe Confidential 23 © 2009 MediServe, Inc. All Rights Reserved.
  24. 24. Medical Necessity Criteria: 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 MediServe Confidential 24 © 2009 MediServe, Inc. All Rights Reserved.
  25. 25. 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) MediServe Confidential 25 © 2009 MediServe, Inc. All Rights Reserved.
  26. 26. 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. MediServe Confidential 26 © 2009 MediServe, Inc. All Rights Reserved.
  27. 27. Medical Necessity Criteria:  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. MediServe Confidential 27 © 2009 MediServe, Inc. All Rights Reserved.
  28. 28. Predictability and Planning are Key for Future Success Management Reports, Tools & Trending is available in MediServe Confidential 28 © 2009 MediServe, Inc. All Rights Reserved.
  29. 29. 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) MediServe Confidential 29 © 2009 MediServe, Inc. All Rights Reserved.
  30. 30. 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) MediServe Confidential 30 © 2009 MediServe, Inc. All Rights Reserved.
  31. 31. 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. MediServe Confidential 31 © 2009 MediServe, Inc. All Rights Reserved.
  32. 32. 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. MediServe Confidential 32 © 2009 MediServe, Inc. All Rights Reserved.
  33. 33. 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) MediServe Confidential 33 © 2009 MediServe, Inc. All Rights Reserved.
  34. 34. 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. MediServe Confidential 34 © 2009 MediServe, Inc. All Rights Reserved.
  35. 35. 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. MediServe Confidential 35 © 2009 MediServe, Inc. All Rights Reserved.
  36. 36. No Surprises - No Silos MEDILINKS TRANSPARENCY of INFORMATION THROUGHOUT INTERDISCIPLINARY CHARTING is UNIQUE and unrivaled in an IRF ENVIRONMENT – MediLinks keeps everyone on TRACK! MediServe Confidential 36 © 2009 MediServe, Inc. All Rights Reserved.
  37. 37. Making Compliance Simple AUDITS ARE HERE TO STAY MAKE YOUR STRATEGY LASTING, DEPENDABLE & CONSISTENT! MediServe Confidential 37 © 2009 MediServe, Inc. All Rights Reserved.
  38. 38. 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 MediServe Confidential 38 © 2009 MediServe, Inc. All Rights Reserved.
  39. 39. 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 MediServe Confidential 39 © 2009 MediServe, Inc. All Rights Reserved.
  40. 40. 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) MediServe Confidential 40 © 2009 MediServe, Inc. All Rights Reserved.
  41. 41. 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! MediServe Confidential 41 © 2009 MediServe, Inc. All Rights Reserved.
  42. 42. 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. MediServe Confidential 42 © 2009 MediServe, Inc. All Rights Reserved.
  43. 43. 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. MediServe Confidential 43 © 2009 MediServe, Inc. All Rights Reserved.
  44. 44. 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? MediServe Confidential 44 © 2009 MediServe, Inc. All Rights Reserved.
  45. 45. 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! MediServe Confidential 45 © 2009 MediServe, Inc. All Rights Reserved.
  46. 46. Provides SOLUTIONS for REHABILITATION BUSINESS MANAGEMENT MediServe Confidential © 2009 MediServe, Inc. All Rights Reserved.
  47. 47. THANK YOU We look forward to helping you with your CORE Business Strategies! 480-831-7800 MediServe Confidential © 2009 MediServe, Inc. All Rights Reserved.