irf pai

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Understanding the IRF PAIChallenge, Success & Mastery

How to TIPS after 7,000 Encoded Cases

Jan Brown, RN Mary Walters, RN

IRF PAI Coordinators – Best Practice Tips / Advice

Collaboratively Prepared:Darlene L. D’Altorio-Jones, PT. MBA HCM –

(21 years of IRF Experience)

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Understanding the IRF PAIInpatient Rehabilitation Facility Patient Assessment Instrument

This in-service is intended to be used as an orientation guideline for IRF Staff, Liaisons & Tool

Coordinators so they can better understand the intricacies of the Rehabilitation Service Line –

its history and present training needs.

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Objectives

• IRF PAI – Beginning & Purpose• Know your IRF ‘Alphabet Soup’• Compliance – 60/40 vs. Medically Necessary• What’s so Confusing?• Why the PAI and UB – 04’s Don’t Align• Organization & Understanding the Tool

• Experienced Tool User Tips…• Checklist Summary • Questions? – How to Get Them Answered.• Pre Test / Post Test

Encoding Advocacy through Appropriate PAI Documentation

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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.


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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; 7 part Functional Independence Measurement (FIM) scale

• Captures diagnosis/demographics & scores to define Medicare payment levels; tiered CMG grouper


1234567Eating

Grooming

Bathing

Dressing (upper)

Dressing (lower)

Toileting

Bladder

Bowel

Bed, Chair, Wheelchair Transfer

Toilet Transfer

Tub, Shower Transfer

Walk/Wheelchair Locomotion

Stair Locomotion

Comprehension

Expression

Social Interaction

P roblem Solving

Memory

Discharge

Admission

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Know Importance of IRF Alphabet Soup

• IRF/U – Inpatient Rehabilitation Facility/Unit• PAI – Patient Assessment Instrument – documentation

needed to support payment by Medicare.• IGC – Impairment Group Code = condition that requires

rehabilitation coded as the ‘diagnosis’ on the PAI – may differ from UB description.

• Etiology – Acute condition responsible for the encoded IGC


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• 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• Conditions ‘expected’ for an IGC are supposedly factored into

the payment category and are not required in the additional 10 fields – are helpful to list for condition data tracking even though it will 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.


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• 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• 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.


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• RIC – Rehab Impairment Category (21 in Rehab) – General vs. specific classification grouping

• UB-04 - Universal Billing document that utilizes Official Guidelines for Coding & Reporting. • Each Medicare Admission will be assigned a principal

diagnosis from the V57.xx series. This code is captured for ‘status post, history of and late effects’ that required admission for rehabilitation procedures/care.


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60/40 vs. Medically Necessary

• 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.

• Rehab ‘10’ was maintained until 2004 when ‘13’ more defined categories were established.


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60/40 vs. Medically Necessary• Prior to 2004, diagnosis permitted ‘fit for rehab’

assumption for attestation purposes.• Even though a legal ruling in 1985 established the ‘85-2’

clinically based criteria for medical necessity; few audits challenged placement.

• With the 2004 change to Rehab 13 • Local Medical Review Policies, now called Local Coverage

Determination guidelines (LMRP’s/LCD) severely restricted admission types applying these variances at state level reviews.


A LCD consists only of information pertaining to when a procedure is considered medically reasonable and necessary (e.g. indications and ICD-9-CM codes), whereas a LMRP also included information such as coding guidelines.

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• It was possible for patients to have a compliant diagnosis but still not meet state standards or the 85-2 ruling for Medically Necessary admissions. • Even though changing compliance downward is perceived to

assist facilities through a 60/40 compliant % mix:• Once challenged, HCFA compliance can only be argued by

defensible 85-2 standards.• 85-2 Ruling was established by Federal Law in 1985 and requires 2

clinically relevant requirements be met in 8 different areas.• The disjointed understanding of prevailing arguments of one

against the other continues to leave IRF’s baffled.


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• The fact that compliant diagnoses can be retrospectively denied by fiscal intermediaries through CERT & RAC audits left a nation of respected providers bewildered.• The balanced budget act demanded fiscal intermediary and

audit contractor due diligence.• Despite industry providers and payment enforcers non-agreement

on which standard of measures were being enforced.


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• Diagnosis was no longer the predominant factor in classifying compliance which left an entire industry puzzled.

• Reliance on HCFA 85-2 resurged helping those willing to refute cases 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.

• Law Judge review; one of the last steps in the legal defense process continues to use 85-2 as the sole criteria for establishing Medically Necessary rehabilitation level of care.


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• The 2004 published CMS changes and state level interpretations for the 10 to 13, despite rule% adjustments led to pandemonium.• The largest number of rule comments ever received by CMS

in the history of rule comments was received.• Arguments repeatedly presented statements that a ‘percent

compliance’ rule was no longer relevant with IRF-PAI CMG classification as part of the new PAI instrument, coupled with the 85-2 federal court rulings that established ‘sole’ criteria for MEDICALLY NECESSARY admissions to a rehabilitation level of care.


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• A December 2007 freeze (SB 543) was enacted and now known as the 60% rule.• This step was taken to allow time for further documented

evidence & research so that providers and CMS could come to agreements on clinically relevant rehabilitation levels of care.

• In the meantime, there are millions of dollars of disputed cases that recovered full payment for care rather than a lessened level of payment which have left facilities without any reimbursement even though patients were successfully rehabilitated and discharged.


Rule 60% vs. 40%

Compliant

Non-Compliant

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• Facilities are scrambling to survive and must struggle through prolonged processes of up to a year and a half to regain deserved payment in greater than 85% of all cases refuted.

• Going forward the most relevant preparation an IRF can make is to hard wire 85-2 for admission and continued need for rehab as their primary mission for all documentation.


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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:

• 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.


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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.


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What’s so 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 (Recovery Audit Contractor) audits:

• Medical Necessity documentation prevails; not 60/40 classification.

• 60/40 is a facility rolling % average on any given day.

• Even if it ‘fits’ 60/40 compliance, “Can you defend medical necessity is the real question?”

• 60/40 creates confusion for referral admission criteria

• Daily % balance creates confusion rather than seamless throughput from acute to post acute care.

• Referring stakeholders can’t understand fluid change in admission criteria.

• However, 60/40 still remains in the rule and is required for annual attestation review.


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What’s so Confusing?• Capturing appropriate CMG & tiers is a complex

learned abstractor skill• Keen clinical abstractor must capture information from

acute & rehab records with functional documentation @ key periods/look backs in order to score the PAI as intended.

• Aligns CMG that coincides with care & resources for the patient’s complex medical needs.


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What’s so Confusing?

• Referring Physician’s & Care/Case Mgmt. comprehension of rehab medical necessity is often suboptimal as rules don’t follow diagnosis alone.• FACT - Frustration is encountered when admission criteria

‘appears’ to change if facilities select patients as they juggle their 60/40 % ‘rule’.


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Why IRF & UB – 04’s Don’t Align

• Another confusing factor in the % compliance attestation is when less than 50% of admissions to an IRF are paid by Medicare, requested non-Medicare UB-04’s may not have PAI codes.• Fiscal Intermediaries look for PAI , CMG & IGC type

coding to determine complex % compliance criteria.• National health information management coding policies

do not recognize PAI rules for primary diagnosis coding.• Generally coded at discharge utilizing standard acute care

coding practices after the V code is captured.


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Why IRF & UB – 04’s Don’t Align

• Etiologic Diagnosis and reason for the rehabilitation stay will not match V codes used on a UB-04

• Without same rule classifications; comparison is difficult.• In addition, few facilities use PAI coding for non-

Medicare patients; it’s not required and could be confusing for non-Medicare payers.

• When attestation reviews 100% of admissions; comparison is made difficult because of this fact.

• Highly compliant facilities with low Medicare admissions could be unjustly criticized because bills do not look like Medicare UB - 04 documents coded to Medicare specificity.

• Angst is encountered by financial departments and enforcers of compliance because the knowledge gap of coding inconsistencies is greater than rationalization can conceive.


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Experienced Tool User Tips

• The FIM Tool was developed to see if functionally related groups and burden of care indexes could translate to similar costs and resource requirements for rehabilitation. • FRG (Functional Related Group studies)• It was determined to be reliable when grouped by resource

utilization.• FIM scores 18 items with 7 independence levels (burden of

care) creates a 128 point scale.


1234567Eating

Grooming

Bathing

Dressing (upper)

Dressing (lower)

Toileting

Bladder

Bowel

Bed, Chair, Wheelchair Transfer

Toilet Transfer

Tub, Shower Transfer

Walk/Wheelchair Locomotion

Stair Locomotion

Comprehension

Expression

Social Interaction

P roblem Solving

Memory

Discharge

Admission

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• Diagnosis, Comorbidity & Complication abstraction guides the internal grouper software.• Knowledge of regulatory rules and capturing adequate

information cannot be under emphasized• It’s imperative to train for inter-rater reliability as scoring

guidelines are KEY to accurate ‘helper’ level selection • Breakdown of tasks and helper requirements make

significant differences• Grouper pools data & assigns CMG / TIER / LOS &

PAYMENT• Encoding the PAI as intended through guidelines

is imperative so that medical & fiscal resources match.


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Experienced Tool User Tips• Multiplying the CMG weight X the Standard

payment conversion rate is key.• 16 step process to determine facility specific rates:

incorporates; location (rural vs. non-rural), labor & non-labor factors, low income % (LIP) and teaching components. Table 6 pgs. 66&67 CMS- 1554 - F


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• Pre-Admission Screening:• When prescreen tools with logic are available; use them!

• Liaison / Admission staff must know IRF tool as well as the encoding coordinator.

• Knowing patient needs and 85-2 ruling criteria provides improved expectations/communication to family & patient on LOS probability.

• Often OT cannot see pt. in acute; difficult to address detailed burden of care and probable FIM levels for ADL. Ask relevant patient/family questions for tentative scoring.

• Bowel / Bladder have 4 day acute look behind; utilize detail when possible to capture appropriate level.

• Ascertain payer. Watch for age or disability Medicare applications. If they turn 65 or are approved for disability while in the IRF, they may be eligible for Medicare but not have a number. Submit and correct later by encoding to Medicare as a corrected submission.


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• Pre-Admission Screening / Admission documentation:• Attempt to identify REHAB Dx. – discuss agreement with admitting

physician.• Include prelisted Comorbidities that need continued medical care.• TIP: Post a comordiity tier list for physicians to refer to in their

documentation area. • Provide tips regarding specific examples:

• Eg: Diabetic Retinopathy is a level 3 tier

• Will Comorbid conditions listed from their acute stay still be treated in the rehabilitation unit? If so, these must be listed and addressed in the physician plan of care; even if observation for variance to maintain health is the treatment.

• Debility is not always ‘debility’. Look for preclusion issues; anoxic encephalopathy or metabolic toxic myopathy & poly neuropathy can often be coded in a neuro category. Weakness with clinical manifestations are important to catch. Not everything is ‘disuse atrophy’.

• Physician must manage patient care every 2 – 3 days


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• New Admits:• Pull all documentation from acute – physician, tests, nursing &

therapy review for relevant PAI information.

• Utilize Rehab H&P and physiatry consult if pertinent to base PAI documentation and ICD-9 comorbidity & complications lists.

• Review multidisciplinary FIM or score based on burden of care over first 72 hours.

• Discuss disparities between caregivers to ascertain relevant cause for discrepancy especially if Plan of Care adaptations must be made.


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Experienced Tool User Tips • Create a Tracking Tool that can be sorted on various categories.

• Include Name, IGC, CMG, Admission encode date (day 4), probable discharge (LOS) date (submit by day 10), acute transfer date & return dates. If Excel or other tools are used, try to auto fill due dates based on rule expectations.

• Several persons must be able to access & encode and all must follow same tool tips.

• Monthly Desk Calendar Method:• Name on admit date, Write Name in Red when with planned D/C

and patient has left. Check means encoded after admit & D/C.

• Pencil names for interrupted stay, change @ 72 hours for d/c.


NAME75% RULEY or N

ADMIT DATE

ARD DATE

ADMIT PAI 72 hour date

PAI D/C by ENCODE DAY

#10

Target D/C CMG IGC

D/C REF

DATE

5 DAYS POST D/C PAI

D/C ENCODE

/ Transmitted DATE

PAYOR

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• Daily:• Reconcile census – check for unexpected discharges; if

sent to acute care; hold for 72 hours to determine discharge vs. interruption status.

• Tip – create 3 folders: • 1.) In acute & waiting = less than 72 hours.• 2.) Gone for 72 hours gathering final FIM

documentation from last 24 hours of documentation.

• 3.) Completed and ready for Encoding; must complete within 10 days of d/c date.


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Experienced Tool User Tips • Interrupted Stay:

• If patient returns within 72 hours, use same PAI but may change expected LOS date by adding days gone to the previous reference date if the interruption occurred within the first 3 days of admission.

• If initial 72 hours has passed when the interruption occurred, you may add the days away to the expected previous d/c LOS date.


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• When reason for interruption will be managed upon return:

• And there is greater than 24 hours left before discharge; be sure to add to complication list and to area on PAI for ‘reason for interrupted stay’.

• Code using ICD-9 CM. Pick most clinically relevant if more than one reason for discharge occurred.

• Be certain continued documentation addresses intervention or surveillance of symptoms for complications / comorbid conditions.


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Experienced User Tips- Continued • Daily:

• Scoring FIM daily or per shift:• Incorporate into daily nursing notes so that unexpected d/c’s will

result in appropriate recording of the FIM for a 24 hour period within last 3 days.

• Best practice software is available that can abstract appropriate scores based on documentation templates.


Eating (3 parts: scooping to mouth, chew & swallow) D E N

Pt feeds self 7 7 7

Feeds self with adaptive equipment / dentures/ modified diet 6 6 6

Feeds self with set-up/cues /supervision 5 5 5

Needs help steadying or checking mouth for pocketing 4 4 4

Unable to put food on utensil 3 3 3

Unable to put food on utensil and bring food to mouth 2 2 2

Performs own tube feeding 6 6 6

Needs only set-up/cues/supervision to perform tube feeding 5 5 5

Staff performs feeding (including tube feeds) 1 1 1

LPN/ppn/IV fluids for hydration 1 1 1

Did not occur 0 0 0

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Experienced User Tips- Continued

• Daily:• When discharge is anticipated, it’s imperative

that all staff encourage independence & exercise the urge NOT to assist or hurry the patient so that the best independent score level can be encoded.

• Note: When OT only practices a full ADL, it’s important to schedule a full ADL within 1 day of D/C so that the 24 hour period within the last 72 hours is used for all disciplines scored.


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• Patient Evaluation Conferences:• Team discussions should always revolve around

barriers to discharge.

• Be sure notes meet required evaluation, goals & updated status in meeting goals. Focus on change in the POC to overcome barriers.

• Listen to each other, identify additional complications or comorbidities still needing addressed.

• Focus time on areas most pressing that delay discharge!


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• Patient Evaluation Conferences:• Be sure signatures, updates to the POC and firm

discharge plans are recorded.

• Summary must address 3 hour rule and medical necessity criteria for continued stay.

• Be certain that patient and significant caregiver have initiated all appropriate support plans and acquired needed resources so that discharge plan can occur as expected.


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Experienced Tool User Tips – Daily Checklist


Preadmission data gathering – thorough & accurate per guidelines.

Establish Medical Necessity through 85-2 Criteria – then admit!

Reconcile Daily Census; target deadlines for submission (initial vs. final) encoding.

Know Regulations for interruptions, comorbid conditions, complications & Allowable CMG’s for 60% compliance.

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Experienced Tool User Tips – Daily Checklist


Communicate LOS, Barriers to Discharge

Review consistency in FIM documentation across disciplines.

Be certain elements encoded are supported by ALL documentation starting with the physician and H & P to all other clinical caregivers.

Be timely in final submission.

Communicate with Finance & HIM coders for accurate capture to the UB and other billing documents.

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Questions – How to Get them Answered

• Utilize user forums like those established by tool vendors (UDSMR™, eRehabdata™ etc.)

• [email protected] CMS Help Desk• IRF PAI scoring hotline: 1-866-216-8089• Call designated Help Desk – Indicate within the PAI tool who

you spoke to, date & information received that helped you score/code the PAI.

• Keep a list of Q& A and resource that provided the answer as the PAI manual has not been updated.

• Use embedded comparison tools for standard regional and national benchmarks for like cases


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Questions – How to Get them Answered

• Maintain list of most likely comorbid conditions with certain etiologic diagnoses to be sure you haven’t missed clinical manifestations that are documented within the medical record.

• Look at Warnings within vendor software tools as they are there to guide accuracy for appropriate CMG capture.

• Network through user forums and maintain updated CEU training with annual regulation publications

• Maintain updated references for comorbid & 60% rule inclusions


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Pre Test / Post TestTrue or False:

1.) IRF reimbursement for Medicare beneficiaries began using a PPS patient assessment instrument called the PAI in 2002? T or F

2.) The FIM is embedded in the tool in an effort to classify functionally related diagnostic scores that predict resource utilization when combined with other clinically relevant data? T or F

3.) Medical Necessity supersedes the % compliance rule when a chart is audited by a fiscal intermediary during CERT or RAC audits? T or F

4.) Annual Attestation to a percent compliance rule no longer occurs to maintain IRF designated licensure? T or F

5.) Comorbid conditions may still classify a given diagnosis into the 60% compliance rule? T or F

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Pre Test / Post TestTrue or False:

6.) The UB – 04 is coded the same as the PAI? T or F

7.) There are still 10 conditions that fall into the 60% rule? T or F

8.) A freeze was enacted to allow time for further study of the IRF designated admission criteria? T or F

9.) Pre-Admission screening is a necessary step in denoting whether a patient is appropriate for a rehab level of care? T or F

10.) There is no particular abstractor skills required to know how to complete the IRF PAI? T or F

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Pre Test / Post TestFill in the Blanks:11.) ___________ of Care is the basis of the FIM model when determining

scoring criteria and level of independence.

12.) A patient must be away from an inpatient rehabilitation unit for more than ________ hours to be coded as a ‘discharge’ from rehab.

13.) Within the last 72 hours before discharge, the _______ scores used must all be taken from the same 24 hour span?

14.) Debility caused by clinical manifestations can sometimes be classified under the _______________diagnosis in the 21 RIC categories.

15.) The letter used for ‘no corbidity’ in conjunction with the CMG is (circle one) A B C or D ?

16.) The high resource classification attached to the CMG for payment purposes is (circle one) A B C or D ?

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Pre Test / Post TestFill in the Blanks:17.) CMI is the __________ __________ Index, which is a number that is

considered the weighted multiplier when determining facility based payments.

18.) Name four of the eight criteria listed under the 85-2 ruling when determining a Medically Necessary IRF admission & continued stay.1.)_______________________ 2._________________________

3.)_______________________ 4._________________________

19.) The days away in an ‘interrupted stay’ may be (circle one) added to or subtracted from the original LOS when a patient returns within 72 hours.

20.) There are _______ spaces to code Comorbidities on the PAI.21.) Principle diagnosis on the UB – O4 are ____57.xx series codes.22.) A patient that turns 65 before they are discharged from an IRF may be

eligible for payment under ___________ part A so initially the PAI should be encoded and then later resubmitted when appropriate information is received.

Each answer is 4 pts. ______ X 4 = ______% 80 is required for Passing Grade.

irf pai

Travel

appropriate pai documentation

irf pai challenge

objectives irf pai

irf staff

irf alphabet soup compliance

payment category

drg payment

promised irf pps