irf medical necessity

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

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)

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

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

Medical Necessity as Defined by the ‘RULE’


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


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


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.


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


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.


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.


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.



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.



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.

Compliant

Non-Compliant

Rule 60% vs. 40%



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.



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.



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.


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.



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.


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.


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!


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.


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.


FINAL RULE – pg. 39790 FR


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.

22Encoding Advocacy through Appropriate PAI Documentation


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?”


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.


How to defend challenged records

Educate Staff on guidelines of medical necessity.

Create a template that ‘tags’ information specific to 85-2 ruling

When permitted, tag each area and summarize your argument for each of the 8 criteria.

Review short and long term liability plans.

Utilize best of breed rehabilitation software such as MediLinks, which enables you to meet regulatory nuances in a seamless ‘behind the scenes’ manner.

Compliance is BUILT IN to MediLinks workflow.


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.


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).


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!


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.


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

3. Relatively intense level of rehabilitation services:


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.


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.


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.


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.


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.


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.


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.

http://www.cms.hhs.gov/eRulemaking/downloads/CMS-1551-PPaperComments7-13.pdf


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.


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


OP Coverage & Medical NecessityChapter 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 ServicesChapter 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.

http://www.cms.hhs.gov/transmittals/downloads/r88bp.pdf


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.


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.


AHAAccesstoRehab.pdf

Excellent Training References:


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.


March 2007, Healthcare Financial Management Association www.hfma.org Published this article encouraging IRF providers to use 85-2 as a rebuttal argument to medical necessity.

http://www.hfma.org/�


MedPaC Report to Congress Medicare Payment Policy pgs. 201 – 215. Chapter 3 C.

irf medical necessity

Documents

mediserve confidential5

mediserve oarf presentation

irf pai

adrg payment

payment criteriaat

payment guides length

denied irf cases

rehabilitation level