Medical Rehab

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On April 23, the Centers for Medicare and Medicaid Services (CMS) released the fiscal year (FY) 2016 inpatient rehabilitation facility prospective payment system (IRF PPS) proposed rule. RCPA will review the provisions contained within the proposed rule with members, for their input, to include in comments to CMS. Highlights of the proposed rule are provided below.

Proposed Changes to the IRF Quality Reporting Program
The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) added Section 1899B to the Social Security Act to require that IRFs report data on measures that satisfy domains specified under the IMPACT Act, which will also be implemented in other post-acute care (PAC) settings (Skilled Nursing Facilities, Long-Term Care Hospitals, and Home Health Agencies). This rule proposes to adopt measures that satisfy three of the quality domains required by the IMPACT Act in FY 2016: skin integrity and changes in skin integrity, functional status, cognitive function, and incidence of major falls. IRFs that fail to submit the required quality data to CMS will be subject to a two percentage point reduction to their applicable FY annual increase factor.

The domains specified by the IMPACT Act and the quality measures proposed are as follows:

  • Domain 1. Skin integrity and changes in skin integrity:
  • Quality Measure: “Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened” (NQF #0678)
  • Domain 2. Functional status, cognitive function, and changes in function and cognitive function:
  • Quality Measure : Application of the “Percent of Long-Term Care Hospital Patients With an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function” (NQF #2631; under review)
  • Domain 3. Incidence of major falls:
  • Quality Measure: Application of the “Percent of Residents Experiencing One or More Falls with Major Injury” (NQF #0674)

Additionally, CMS proposes to adopt four additional functional status quality measures, as well as proposing the previously finalized quality measure “All-Cause Unplanned Readmission Measure for 30 Days Post Discharge from Inpatient Rehabilitation Facilities” (NQF #2502), in order to establish its newly NQF-endorsed status.

The four functional status quality measures under consideration include:

  • IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (NQF #2633; under review);
  • IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634; under review);
  • IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635; under review); and
  • IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636; under review).

CMS proposes to publicly report IRF quality reporting program data beginning in fall 2016. A period of time will be provided for review and correction of quality data by IRFs prior to its publication of the performance data.

Continuation of Reporting Previously Collected IRF QRP Measures
For the FY 2018, adjustments to the IRF PPS annual increase factor, CMS is retaining previously discussed measures, including:

  • NHSN CAUTI Outcome Measure (NQF #0138);
  • Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short-Stay) (NQF #0680);
  • Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (NQF #0678);
  • All-Cause Unplanned Readmission Measure for 30 Days Post-Discharge from IRFs (NQF #2502);
  • Influenza Vaccination Coverage among Healthcare Personnel (NQF #0431);
  • NHSN Facility-Wide Inpatient Hospital-Onset MRSA Bacteremia Outcome Measure (NQF #1716); and
  • NHSN Facility-Wide Inpatient Hospital-Onset CDI Outcome Measure (NQF #1717).

A future update to the numerator of the quality measure Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678) is being considered. This update would hold providers accountable for the reporting of unstageable pressure ulcers, including suspected deep tissue injuries (sDTIs). If this proposed change were to be implemented, the numerator of the quality measure would be updated to include unstageable pressure ulcers, including sDTIs, that are new or developed in the facility, as well as Stage 1 or 2 pressure ulcers that become unstageable due to slough or eschar (indicating progression to a Stage 3 or 4 pressure ulcer) after admission.

Proposed Changes to the IRF Prospective Payment System

  • Standard Payment Rate: The standard payment rate conversion factor is proposed to be increased in FY 2016 to $15,529 from the FY 2015 amount of $15,185. This amount is the result of a 2.7 percent market basket increase minus a productivity adjustment of 0.6 percent, minus a 0.2 percent legislative adjustment. CMS is also proposing a new rehabilitation only market basket.
  • Update to CMG Weights, Lengths of Stay and Comorbidities: CMS updated the Case Mix Group (CMG) weights using FY 2013 cost report data and the FY 2014 claims data and the lengths of stay (ALOS) per CMG.
  • Labor Related Share and Area Wage Adjustments: The proposed labor related share for FY 2016 is 69.6, a slight increase over FY 2015’s labor-related share of 69.294. CMS used the same methodology it has previously employed in calculating previous IRH/U labor-related shares.
  • Outlier Threshold: CMS updates the outlier threshold amount to $9,698 in order to maintain the outlier payments at three percent of total IRF payments in FY 2016. The national cost-to-charge ratio ceiling is set for FY 2016 at 1.36; the ceiling for rural IRFs is 0.569 and 0.437 for urban IRFs.
  • Changes to Facility Adjusters: CMS made significant changes to the methodology used to develop the facility-level adjustment factors in the FY 2014 IRF PPS final rule. For FY 2016, CMS continues to freeze the LIP, rural, and teaching adjustments at the FY 2014 levels, which are: LIP factor of 0.3177; rural adjustment at 14.9 percent; and teaching adjustment factor at 1.0163.

Revised Version of the IRF PAI
A revised version (FY 2017, version 1.4) of the inpatient rehabilitation facility patient assessment instrument (IRF PAI) has been published, to account for changes in measure reporting occurring as a consequence of the IMPACT Act. CMS has also published a chart that compares the IRF PAI versions 1.4 (effective FY 2017) and 1.3 (effective FY 2016).

The proposed rule will be published in the April 27, 2015 Federal Register. Comments on the provisions contained within this proposed rule will be accepted through June 22.