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IRF PPS Final Rule

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On July 20, 2021, the Centers for Medicare and Medicaid Services (CMS) issued the fiscal year (FY) 2022 inpatient rehabilitation facility prospective payment system (IRF PPS) final rule. This final rule updates the Medicare payment policies and rates for IRFs, as well as the policies under the IRF Quality Reporting Program (QRP). CMS also finalizes a Medicare Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) payment provision adopted in an interim final rule with comment period (IFC) issued on May 11, 2018, as well as a provision that was included in a DMEPOS proposed rule published in the Federal Register on November 4, 2020. Other key provisions included in this final rule include:

Updates to IRF Payment Rates:

CMS updates the IRF PPS payment rates by 1.9 percent based on the IRF specific market basket estimate of 2.6 percent, less a 0.7 percentage point productivity adjustment. In addition, the final rule contains an adjustment to the outlier threshold to maintain outlier payments at 3 percent of total payments. This adjustment will result in a 0.4 percentage point decrease in outlier payments.

IRF QRP Final Rule Updates:

The IRF QRP is a pay-for-reporting program. IRFs that do not meet reporting requirements are subject to a two-percentage point reduction in their annual increase factor. CMS is adopting one measure and finalizing its proposal to update the specifications for another measure. In addition, CMS is finalizing its proposal to modify the number of quarters used for public reporting of IRF quality measures due to the public health emergency and sought comments for two Requests for Information (RFI).

Closing the Health Equity Gap – RFI:

CMS is working to make health care quality more transparent to consumers and providers, enabling them to make better choices as well as promoting provider accountability around health equity. CMS’s ongoing commitment to closing the health equity gap in IRFs has been demonstrated by the adoption of standardized patient assessment data elements, which include several social determinants of health (SDOH) that were finalized in the FY 2020 IRF PPS final rule for the IRF QRP (84 FR 39149 through 39161).

CMS sought feedback in this RFI on ways to attain health equity for all patients through policy solutions and has indicated that they would take all comments received into consideration as they continue to address and develop policies on this topic. The provision of stratified measure results will allow IRFs to understand how they are performing with respect to certain patient risk groups and to support these providers in their efforts to ensure equity.

COVID-19 Vaccination Coverage Among Healthcare Personnel (HCP) Measure:

In the ongoing efforts to address the COVID-19 public health emergency (PHE), CMS is finalizing the adoption of the COVID-19 Vaccination Coverage among HCP Measure. This measure is designed to help assess whether IRFs are taking steps to limit the spread of COVID-19 among their HCP, reduce the risk of transmission within their facilities, and help sustain the ability of IRFs to continue serving their communities through the PHE and beyond. Public reporting of the COVID-19 Vaccination Coverage among HCP measure will begin with the September 2022 Care Compare refresh or as soon as technically feasible based on data collected for Q4 2021 (October 1, 2021 through December 31, 2021).

Transfer of Health (TOH) Information to the Patient-Post Acute Care (PAC) Quality Measure:

CMS is finalizing updates to the denominator for the TOH Information to the PAC quality measure. Currently, the measure denominators for both the TOH Information to the Patient-PAC and to the Provider-PAC quality measures include patients discharged home under the care of an organized home health service organization or hospice. In order to avoid counting these patients in both TOH measures, CMS is removing this location from the definition of the denominator for the TOH Information to the Patient-PAC measure.

Public Reporting of Quality Measures with Fewer than Standard Numbers of Quarters Due to COVID-19 PHE Exemptions:

In March 2020, and in response to the COVID-19 PHE, CMS granted an exception to the IRF QRP requirements for calendar year Q1 2020 (January 1, 2020–March 31, 2020) and Q2 2020 (April 1, 2020–June 30, 2020). CMS also stated that any IRF QRP data that might be significantly impacted in terms of measure reportability and reliability by these exceptions would not be publicly reported for Q1 and Q2 of 2020 due to the absence of useable data these exceptions created. CMS is finalizing its proposal to update the number of quarters used for public reporting to account for this exception.

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Policy Issues:
Exclusion from Fee Schedule Adjustments for Accessories (Including Seating Systems) and Seat and Back Cushions Furnished in Connection with Group 3 or Higher Complex Rehabilitative Power Wheelchairs and Complex Rehabilitative Manual Wheelchairs

CMS is finalizing an exclusion from fee schedule adjustments based on information from the DMEPOS Competitive Bidding Program (CBP) for wheelchair accessories (including seating systems) and seat and back cushions furnished in connection with group 3 or higher complex rehabilitative power wheelchairs. CMS is also extending this fee schedule adjustment exclusion to wheelchair accessories (including seating systems) and seat and back cushions furnished in connection with complex rehabilitative manual wheelchairs. Additionally, CMS is modifying the regulatory definition of “item” under the DMEPOS CBP at 42 CFR 414.402 to exclude complex rehabilitative manual wheelchairs and certain other manual wheelchairs and related accessories when furnished in connection with these wheelchairs from the DMEPOS CBP, as required by section 106(a) of the 2020 Further Consolidated Appropriations Act.

All of the provisions contained in this final rule will be reviewed and discussed in greater detail at the upcoming RCPA Outpatient Rehabilitation Committee and Medical Rehabilitation Committee meetings.

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The Centers for Medicare and Medicaid Services (CMS) recently announced the availability of the inpatient rehabilitation facility (IRF) provider preview reports. These reports have been updated and contain information based on quality data submitted by IRFs between Quarter 3 of 2018 and Quarter 2 of 2019. The data will reflect what will be published on IRF Compare during the March 2020 update of the website.

Providers have 30 days (December 9, 2019 – January 9, 2020) to review their performance data. While corrections to the underlying data will not be permitted during this time, providers can request CMS to review their data during the preview period if they believe the quality measure scores that are displayed are inaccurate.

Additionally, providers are reminded that the data for the quality measure Percent of Residents or Patients that have new or worsened Pressure Ulcers (short stay), will continue to reflect data collected between Quarter 3 2017 – Quarter 2 2018, and will continue to be publicly displayed until the new Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury, is publicly displayed in fall 2020, as finalized in the fiscal year (FY) 2018 IRF PPS Final Rule.

As of the March 2020 refresh, CMS will no longer publicly display the measure Percent of Residents or Patients who were assessed and appropriately given the seasonal influenza vaccine (short stay), as finalized in the FY 2019 IRF PPS Final Rule. This change is reflected in preview reports. Contact RCPA Rehabilitation Services Director Melissa Dehoff with questions.

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The Centers for Medicare and Medicaid Services (CMS) published the fiscal year (FY) 2019 inpatient rehabilitation facility prospective payment system (IRF PPS) final rule in the August 6, 2018 Federal Register.

Removal of the FIM Instrument and Revisions to the IRF PPS Case-Mix Groups
RCPA was discouraged to see that CMS finalized its proposals to enact new case-mix groups (CMGs) based on function data from the Quality Indicators section of the inpatient rehabilitation facility patient assessment instrument (IRF PAI) and remove the Functional Independence Measures (FIM) instrument from the IRF PAI effective October 1, 2019 (FY 2020). On a positive note, CMS will now have two years of data (FY 2017–2018) in its analysis to develop the FY 2020 CMGs rather than using FY 2017 data alone as originally proposed. CMS has indicated that any changes to the revised CMG definitions will be addressed in future rulemaking prior to implementation in FY 2020. In addition, CMS states it plans to provide training and educational resources on the data items in the Quality Indicators section of the IRF PAI before the new policies take effect on October 1, 2019. The final rule does not include additional analytical reports or data beyond what was published in the proposed rule, but members are encouraged to review the technical report that was referred to in the proposed rule (Analyses to Inform the Potential Use of Standardized Patient Assessment Data Elements in the Inpatient Rehabilitation Facility Prospective Payment System by RTI International).

Changes to IRF PPS Coverage Requirements
CMS adopted all of its proposals relating to the IRF coverage requirements, including:

  • Proposal to allow the Post-Admission Physician Evaluation to count towards one of the required three weekly face-to-face physician visits during the first week of a patient’s stay in an IRF.
  • Remote physician attendance and allowance to lead discussion at interdisciplinary team meeting without any additional documentation requirements. CMS notes that hospitals would still be able to set their own policies about remote attendance, and that this proposal would alleviate documentation burden on physicians and allow the physicians “increased flexibility for time management.”
  • Admission order documentation requirement. CMS adopted its proposal to remove the requirement under the IRF PPS regulations that there be a physician order for inpatient care in the medical record. CMS believes this requirement is duplicative of the requirements under the Medicare Conditions of Participation (CoPs) regulations as well as the requirements under the general Medicare Part A payment regulations that are applicable to IRFs. Therefore, even though this requirement is eliminated, there will still need to be an admission order when a patient is admitted to an IRF since IRFs must adhere to all CoPs.
  • Input on additional changes to the physician supervision requirements. CMS requested input on two areas being considered for future changes. The first area is whether some of the three weekly required physician visits could be completed remotely. The second area CMS requested information on was the use of non-physician practitioners, such as physician assistants, to satisfy some of the coverage criteria that must currently be completed only by a physician. CMS did not provide a detailed response to comments submitted, but said it would consider these stakeholder comments for future rulemaking.

Proposed Changes to IRF QRP
CMS adopted its proposals to remove two measures from the IRF quality reporting program (QRP):

  • National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716).
    • IRFs will no longer be required to submit data on this measure for the purposes of the IRF QRP beginning with October 1, 2018 admissions and discharges.
  • Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF #0680).
    • Providers will no longer be required to submit data on this measure for the purposes of the IRF QRP beginning with patients discharged on or after October 1, 2018. The IRF-PAI data items associated with reporting this measure (O0250A, O0250B, and O0250C) will be removed from the IRF-PAI version 3.0 effective October 1, 2019.
    • Beginning with October 1, 2018 discharges and until IRF-PAI version 3.0 is effective, IRFs should enter a dash (–) for items O0250A, O0250B, and O0250C. CMS states that it will provide ongoing guidance to providers to clarify that use of a dash for these assessment items beginning October 1, 2018 is appropriate and will not cause a non-compliance determination.

CMS finalized its proposals to begin publicly displaying data on the following four assessment-based measures in CY 2020, or as soon thereafter as technically feasible:

  • Change in Self-Care (NQF #2633);
  • Change in Mobility Score (NQF #2634);
  • Discharge Self-Care Score (NQF #2635); and
  • Discharge Mobility Score (NQF #2636).

Changes to the IRF PPS Payment Rates for FY 2019
CMS finalized most of its payment proposals for FY 2019. However, it made small adjustments to the originally proposed outlier threshold and labor-related share due to updated data that had become available since the proposed rule.

RCPA was asked to submit a letter of support from the House Ways and Means Committee; view a copy of that letter here.

These regulations become effective on October 1, 2018. For additional information, CMS has posted a fact sheet. Contact Melissa Dehoff, RCPA Director of Rehabilitation Services, with questions.