6/30 Comment Deadline For Proposed Inpatient Rehab Payment and Quality Reporting Rules

On May 1, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule outlining proposed fiscal year (FY) 2015 Medicare payment policies and rates for inpatient rehabilitation facilities (IRFs) and the IRF Quality Reporting Program (IRF QRP). The FY 2015 proposals are summarized below. 

  • Changes to the payment rates under the IRF Prospective Payment System (PPS). We are proposing to update the IRF PPS payments for FY 2015 to reflect an estimated 2.1 percent increase factor (reflecting a 2.7 percent market basket, reduced by a 0.4 percent multi-factor productivity adjustment and a 0.2 percentage point reduction mandated by the Affordable Care Act). An additional 0.1 percent increase to aggregate payments due to updating the outlier threshold results in an overall update of 2.2 percent (or $160 million), relative to payments in FY 2014.
  •  Facility-level adjustment updates. CMS is proposing to freeze the facility-level adjustment factors for FY 2015 and all subsequent years at the FY 2014 levels, while we continue to monitor the most current IRF data available and evaluate the effects of the FY 2014 changes. Additionally, we want to allow providers time to acclimate to the FY 2014 changes.
  • ICD-10-CM Conversion. The FY 2015 IRF PPS proposed rule discusses the transition from ICD-9-CM to ICD-10-CM for all diagnosis codes used in the IRF PPS Grouper software and the software for evaluating IRFs’ compliance with the 60 percent rule. Using the General Equivalence Mappings (GEMs) tool, we have transitioned the following lists of diagnosis codes used in the IRF PPS: the List of Comorbidities, Codes That Meet Presumptive Compliance Criteria, and Impairment Group Codes That Meet Presumptive Compliance Criteria. Our intent was to keep the same meaning of the codes in transitioning from ICD-9-CM to ICD-10-CM. We did not intend to add or delete conditions, or otherwise change the meaning of the code lists. We are addressing the conversion of ICD-9-CM to ICD-10-CM codes for the IRF PPS in this proposed rule, but in light of the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. No. 113-93), the effective date of those changes would be the date when ICD-10-CM becomes the required medical data code set for use on Medicare claims and IRF-PAI submissions. Until that time, we will continue to require use of the ICD-9-CM codes for the IRF PPS.
  • Further Refinements to the Presumptive Methodology. In the FY 2014 IRF PPS final rule (78 FR 47860), we revised the list of ICD-9-CM diagnosis codes that are compared with a patient’s comorbidities in determining an IRF’s presumptive compliance with the 60 percent rule. However, a patient’s comorbidities are not the only aspect of a patient’s record that is evaluated in determining whether that patient should be counted towards an IRF’s presumptive compliance. In the FY 2014 IRF PPS final rule, we addressed only the comorbidity portion of the presumptive compliance determination, and did not address the IGC or Etiologic Diagnosis portions. In this proposed rule, CMS is proposing some additional revisions to the comorbidity, IGC, and Etiologic Diagnosis portions of the presumptive compliance determination to be consistent with the changes we implemented in the FY 2014 final rule.
  • Therapy Data Collection. CMS is proposing to add a new item to the inpatient rehabilitation facility-patient assessment instrument (IRF-PAI) that would require IRFs to record how much and what type of therapy (i.e., individual, group, co-treatment) patients receive in each therapy discipline (i.e., physical therapy, occupational therapy, and speech-language pathology), similar to what is currently reported on the minimum data set in the skilled nursing facility setting.
  • New IRF-PAI Item for Arthritis Diagnosis Codes. CMS is proposing to add an item to the IRF-PAI form in which providers could indicate that the prior treatment and severity requirements had been met for patients with arthritis conditions. The addition of this item would mitigate a potential increase in burden due to the changes in the presumptive compliance methodology finalized in the FY 2014 IRF PPS final rule (78 FR 47860 at 47887 through 47890) and the changes proposed in this year’s NPRM. For providers that fail the presumptive compliance test, the new IRF-PAI item would first be used to determine whether or not the inclusion of all of the arthritis cases indicated as meeting the severity and prior treatment requirements would be enough for the facility to comply with the 60 percent rule requirement. If so, instead of the Medicare Administrative Contractor (MAC) doing a medical review on all cases, the MAC could take a random sample of the arthritis cases to determine if the requirements were met by including these cases. Only in those instances where the facility did not meet the compliance requirements including the arthritis cases, would the MAC need to complete a medical review on all cases.
  • New Measure Proposals.  CMS also is proposing to adopt two additional quality measures to the IRF QRP: NHSN Facility-Wide Inpatient Hospital-Onset Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716), and NHSN Facility-Wide Inpatient Hospital-Onset Clostridium difficile Infection (CDI) Outcome Measure (NQF #1717).

CMS also is proposing various new policies including the following: 

  • Reconsideration Process. CMS is proposing a formal reconsideration policy for the IRF QRP, which proposes to require that IRF providers follow specific procedures when submitting a request for CMS’ reconsideration of an initial IRF QRP provider compliance determination. 
  • Extraordinary Circumstances Waiver Process.  CMS is proposing to change the name of the previously finalized “Disaster Waiver” process to “Extraordinary Circumstances Exception/Extension.” We are also proposing to expand the process, previously finalized in the FY 2014 IRF PPS Final Rule, to allow IRF providers to request exceptions or extensions for other circumstances beyond their control, including those that are not classified as natural disasters.
  • CMS IRF QRP Thresholds and Data Validation. CMS is proposing a new Data Accuracy Validation policy, which will require randomly selected IRF providers to meet a proposed 90% data reliability threshold for required IRF-PAI quality indicator data items.

The proposed rule will be published in the Federal Register on May 7, 2014. CMS will accept comments on the proposed rule until June 30, 2014.


For More Information Or Assistance

If you need assistance reviewing or responding to these or other health care related risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer, may be able to help. Vice President of the North Texas Health Care Compliance Professionals Association, Past Chair of the ABA Health Law Section Managed Care & Insurance Section and the former Board Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has more than 24 years experience advising health industry clients about these and other matters. Her experience includes advising hospitals, nursing home, home health, rehabilitation and other health care providers and health industry clients to establish and administer compliance and risk management policies; prevent, conduct and investigate, and respond to peer review and other quality concerns; and to respond to Board of Medicine, Department of Aging & Disability, Drug Enforcement Agency, OCR Privacy and Civil Rights, HHS, DOD and other health care industry investigation, enforcement and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns.

A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical staff performance, quality, governance, reimbursement, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns. Her presentations and programs include a wide range of other workshops, programs and publications on fraud and other compliance, operational and risk management, and other health industry matters.

Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications.  You can get more information about her health industry experience here. If you need assistance responding to concerns about the matters discussed in this publication or other health care concerns, wish to obtain information about arranging for training or presentations by Ms. Stamer, wish to suggest a topic for a future program or update, or wish to request other information or materials, please contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here.

If you or someone else you know would like to receive future updates about developments on these and other concerns from Ms. Stamer, see  here.

About Solutions Law Press

Solutions Law Press™ provides business risk management, legal compliance, management effectiveness and other resources, training and education on human resources, employee benefits, compensation, data security and privacy, health care, insurance, and other key compliance, risk management, internal controls and other key operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press resources including:

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile here. For important information about this communication click here.


©2014 Cynthia Marcotte Stamer, P.C.  Non-exclusive license to republish granted to Solutions Law Press.  All other rights reserved.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: