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Medical Rehab

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RCPA members are reminded to consider soliciting nominations for a Technical Expert Panel (TEP) that will provide input on two new quality measures in development for post-acute care providers (including inpatient rehabilitation facilities, skilled nursing facilities, long-term care hospitals, and home health agencies).

The Centers for Medicare & Medicaid Services (CMS) has contracted with RTI International and Abt Associates to develop and refine a cross-setting, post-acute care transfer of health information and care preferences quality measure as required by the Improving Medicare Post-Acute Care Transformation Act of 2014. The two new quality measures include:

  • Transfer of Information at Post-acute Care Admission, Start, or Resumption of Care from Other Providers/Settings; and
  • Transfer of Information at Post-acute Care Discharge or End of Care to Other Providers/Settings.

In alignment with the CMS and National Quality Strategy objectives and goals, the purpose of this project is to develop, maintain, re-evaluate, and implement measures that will drive high quality in post-acute care through CMS’ quality reporting programs. This includes the inpatient rehabilitation facility, skilled nursing facility, long-term care hospital, and home health quality reporting programs.

CMS is seeking technical experts with expertise in care transitions and information transfer during transitions, admission and discharge planning, and care coordination, among other areas of knowledge. The call for technical expert panel members is open through August 21, 2016.

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The Centers for Medicare and Medicaid Services (CMS) will be conducting a two-day inpatient rehabilitation facility (IRF) quality reporting program (QRP) training event on Tuesday, August 9 & Wednesday, August 10 in Chicago, IL. For members that can’t attend the training in person, a live webcast will be available (Note: the title of the event on this page hosting the webcast will not be updated until August 9).

  • On August 9, the training will be conducted from 9:00 am to 6:00 pm EDT.
  • On August 10, the training will be conducted from 9:00 am to 3:30 pm EDT.

The focus of this training event will be to provide IRFs with assessment-based data collection instructions and updates associated with the changes in the October 1, 2016 release of the IRF-Patient Assessment Instrument (PAI) version 1.4 and other reporting requirements of the IRF QRP.

The training materials are now available under the Downloads section of CMS’ IRF Quality Reporting Training web page. If members have questions or need additional information about the logistics of the training session, please email CMS’ PAC Training mailbox.

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The Centers for Medicare and Medicaid Services (CMS) released the fiscal year (FY) 2017 inpatient rehabilitation facility (IRF) prospective payment system (PPS) final rule in today’s Federal Register.

The majority of the final rule focuses on changes in the IRF Quality Reporting Program (QRP), pursuant primarily to the requirements of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. The rule continues to address implementation of the IMPACT Act requirements regarding resource use and quality measures, adding five new measures to the IRF QRP. Four measures will begin October 1, 2016, and are collected from Medicare claims data, so no additional reporting action from providers is required. These four measures include:

  • Discharge to Community – Post-Acute Care (PAC) IRF QRP (claims-based);
  • Medicare Spending Per Beneficiary (MSPB) – PAC IRF QRP (claims-based);
  • Potentially Preventable 30 Day Post-Discharge Readmission Measure for IRFs (claims-based); and
  • Potentially Preventable Within Stay Readmission Measure for IRFs (claims-based).

The remaining measure, Drug Regimen Review Conducted with Follow-up for Identified Issues, will begin October 1, 2018, and will require additional items on the IRF Patient Assessment Instrument (IRF PAI).

Other key provisions included in the final rule:

Standard Payment Rate
The standard payment rate conversion factor will increase in FY 2017 to $15,708, compared to the proposed amount of $15,674. This amount is the result of a 2.7 percent rehabilitation-specific market basket increase, minus a productivity adjustment of 0.3 percent and a 0.75 percent ACA adjustment. The FY 2016 standard payment rate conversion factor was $15,478.

CMS used the rehabilitation market basket for the first time. It was adopted last year. The standard payment update also accounts for budget neutrality factors for the wage index and labor related share of 0.9992 and for the CMG weight revisions of 0.9992 plus changes to the outlier threshold. Table 5 in the rule (not reproduced here) displays the FY 2017 payment rates.

Update to the CMG Weights, Lengths of Stay, and Comorbidities
CMS updated the Case Mix Group (CMG) weights using FY 2014 cost report data and the FY 2015 claims data as well as the average lengths of stay (ALOS) per CMG. Approximately 99.5 percent of the cases affected by the change in weights would be changed by less than 5 percent.

Outlier Threshold
CMS updates the outlier threshold amount to $7,984 from $8,658 for FY 2016 in order to maintain the outlier payments at three percent of total IRF payments in FY 2017. The national cost-to-charge ratio ceiling for FY 2017 is 1.29; the ceiling for rural IRFs is 0.522 and 0.421 for urban IRFs.

ICD-10-CM Presumptive Compliance Coding Changes
Unfortunately, CMS did not address the problems with the ICD-10-CM codes which eliminated certain key diagnoses from being allowed for consideration in calculating a provider’s presumptive compliance in meeting the 60 percent rule. The largest set of affected codes fall into the area of brain injury under IGCs 2.21 and 2.22.

CMS did, however, comment that IRFs are permitted to use “D” as an eligible seventh character for traumatic brain injury diagnosis codes on both the claim and the IRF PAI. However, for the reasons indicated in the FY 2015 IRF PPS final rule effective with discharges occurring on or after October 1, 2015, ICD-10-CM codes with the seventh character extension of “D” are not included in the ICD-10-CM versions of the “List of Comorbidities,” “ICD-10-CM Codes That Meet Presumptive Compliance Criteria,” or “Impairment Group Codes That Meet Presumptive Compliance Criteria.”

The payment changes to the rule will apply to IRF discharges on or after October 1, 2016 and before September 30, 2017. The quality reporting requirements are effective for discharges on or after October 1, 2106.

A more complete analysis of the rule will be forthcoming and reviewed/discussed extensively at the upcoming RCPA Outpatient Rehabilitation Committee meeting on Thursday, August 18, 2016, and the Medical Rehab Committee meeting on Thursday, September 8, 2016.

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On July 19, 2016, the Office of Inspector General (OIG) for the US Department of Health and Human Services (HHS) issued a report, Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries, part of a series on adverse events in health care settings or harm resulting from medical care. This report cites that incidence of these events in rehabilitation hospitals is similar to that of acute care hospitals and skilled nursing facilities that has been reported in previous OIG findings. The findings from this report resulted from the review of a national sample of medical records from 417 Medicare beneficiaries discharged from rehab hospitals in March 2012.

The OIG recommended that the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ) raise awareness of patient safety issues in rehabilitation hospitals and other health care settings. CMS and AHRQ concurred with the OIG recommendations.

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The Centers for Medicare and Medicaid Services (CMS) published a proposed rule in the August 2, 2016 Federal Register that proposes to implement three new Medicare Parts A and B episode payment models under section 1115A of the Social Security Act, which are meant to improve quality and lower cost. The proposed rule includes a new mandatory bundled payment model for cardiac care in 98 geographical markets for patients who have a heart attack or undergo bypass surgery. The rule would also extend the existing bundled payment model for hip and knee replacements – the Comprehensive Care for Joint Replacement model – to include hip and femur surgeries. Also proposed are new incentive payments designed to increase the use of cardiac rehabilitation. Additionally, new pathways are outlined for physicians participating in bundled payment models to qualify for payment incentives under the proposed Quality Payment Program, which implements the Medicare Access and CHIP Reauthorization Act (MACRA). CMS issued a fact sheet to provide more detailed information on the key provisions of this proposed rule. Comments are due by October 3, 2016.

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The Centers for Medicare and Medicaid Services (CMS) issued the calendar year (CY) 2017 Medicare Physician Fee Schedule Proposed Rule, which was published in the July 15, 2016 Federal Register. Some of the key provisions proposed include:

New Physical Therapy and Occupational Therapy Codes

CMS is proposing new CPT codes for physical therapy and occupational therapy evaluative procedures. The new codes are listed on Page 350 of the proposed rule in table 19 and include: 97X61, 97X62, 97X63, 97X64, 97X65, 97X66, 97X67, and 97X68. These codes are deemed “always therapy” regardless of the type of provider who bills for the service, and thus are subject to the statutory therapy caps.

Misvalued Therapy Codes

As part of the continued misvalued code initiative, CMS identifies ten potential therapy codes that fall under the “codes that account for the majority of spending under the physician fee schedule” statutory category. The ten codes that CMS requests comment on include the following: 97032 electrical stimulation; 97035 ultrasound therapy; 97110 therapeutic exercises; 97112 neuromuscular reeducation; 97113 aquatic therapy/exercises; 97116 gait training therapy; 97140 manual therapy 1/regions; 97530 therapeutic activities; 97535 self-care management training; and G0283 electrical stimulation other than wound.

Physician Value-based Modifier

The Value-based Payment Modifier (VM) provides for differential payments under the PFS to self-employed physicians, groups of physicians, and other eligible professionals (EPs) based on the quality and cost of care they furnish to beneficiaries enrolled in the traditional Medicare Fee-for-Service (FFS) program. Under the VM Program, performance on quality and cost measures can translate into payment incentives for EPs who provide high quality, efficient care, while EPs who underperform may be subject to a downward adjustment. This program is set to expire on January 1, 2019, as a new comprehensive program required by the Medicare Access and CHIP Reauthorization Act, called the Merit-based Incentive Program, begins in CY 2019. For CY 2017, CMS requests feedback on four scenarios that aim to help physician groups and solo practitioners better predict the outcome of their final VM adjustment and to minimize claims reprocessing.

Medicare Shared Savings Program

Within the Medicare Shared Savings Program, CMS proposes to introduce beneficiary protections related to the use of the skilled nursing facility (SNF) 3-Day Waiver, currently limited to beneficiaries in a Track 3 Accountable Care Organization (ACO). CMS estimates the first SNF 3-day rule waiver applications from Track 3 ACOs to be accepted later this summer. The following additional beneficiary protections are proposed in order to ensure proper use of the SNF 3-day rule waiver:

  • Establishment of a 90-day grace period that would permit payment for SNF services provided to beneficiaries who were initially on an ACO’s prospective assignment list for a performance year, but subsequently excluded during the performance year;
  • Requirement that a beneficiary who was never prospectively assigned to a waiver-approved ACO is not subject to non-covered SNF services; and
  • Misuse of a waiver may result in CMS taking remedial action against an ACO. CMS has indicated they will develop a process for ACOs to confirm that they have met all the SNF 3-day rule waiver requirements and requests comments on the proposed beneficiary protection policies.

Medicare Advantage Provider Enrollment

CMS proposes to require Medicare Advantage (MA) organization providers and suppliers to also be enrolled in Medicare in an approved status. The statutory definition of a “provider of services” includes a hospital, critical access hospital, SNF, a comprehensive outpatient rehabilitation facility, a home health agency, or a hospice. According to CMS, this requirement is needed to ensure that MA enrollees receive appropriate or medically necessary items or services from health care providers and suppliers that fully comply with Medicare enrollment requirements and have not had their privileges revoked. The Medicare enrollment requirement would be part of CMS contracts with MA plans, and those failing to meet this requirement could be subject to contract actions ranging from sanctions to termination. This proposal would create consistency with the provider and supplier enrollment requirements for all other Parts of Medicare (i.e., Medicare Part A, Part B, and Part D), and would also parallel requirements for providers participating in Medicaid managed care organizations.

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The Centers for Medicare and Medicaid Services (CMS) will be hosting a two-day, in-person training event on Tuesday, August 9 and Wednesday, August 10, 2016 on the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) in Chicago, IL. This event will also be accessible via streaming media (registration is not required to participate via webcast). The event is scheduled to begin at 9:00 am EDT both days. This training is for IRF providers, associations, and organizations. The objective is to provide IRFs with assessment-based data collection instructions and updates associated with the changes in the October 1, 2016, release of the IRF-Patient Assessment Instrument V 1.4 and other reporting requirements of the IRF QRP. IRF preview reports and IRF Compare will also be discussed.

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The Centers for Medicare and Medicaid Services (CMS) published the proposed hospital outpatient prospective payment system (OPPS) payment rule for calendar year (CY) 2017 in the July 14, 2016 Federal Register. A key proposal in the rule is to implement Section 603 of the Bipartisan Budget Act of 2015 (also known as the Site Neutral Payments Provision), which provides that certain hospital off-campus outpatient departments would no longer be paid under OPPS. Currently, Medicare pays for the same services at a higher rate if those services are provided in a hospital outpatient department, rather than a physician’s office. This payment differential has encouraged hospitals to acquire physician offices in order to receive the higher rates. This acquisition trend and difference in payment has been highlighted as a long-standing issue of concern by congress, the Medicare Payment Advisory Commission, and the Department of Health and Human Services Office of Inspector General.

In addition, based on concerns raised by health care providers on the patient experience survey questions about pain management, CMS is proposing to remove the pain management dimension of the Hospital Consumer Assessment of Healthcare Providers and Systems survey, for purposes of the Hospital Value Based Purchasing Program. The goal is to eliminate any potential financial pressure clinicians may feel to overprescribe pain medications.

CMS has also included a provision to increase flexibility for hospitals that participate in the Medicare electronic health records (EHR) incentive program. Earlier this year, CMS conducted a review of the Medicare EHR Incentive Program for clinicians as part of the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), with the aim of reconsidering the program so we move closer to achieving the full potential that health information technology offers. Based on that review, CMS streamlined EHR reporting requirements under the proposed rule to implement certain provisions of MACRA, to increase flexibility and support improved patient outcomes. CMS is proposing to take a similar step for hospitals participating in the Medicare EHR Incentive Program. These changes include a proposal for clinicians, hospitals, and critical access hospitals to use a 90-day EHR reporting period in 2016 (down from a full calendar year for returning participants). This increases flexibility and lowers the reporting burden for hospital providers.

Finally, CMS proposes to add new quality measures to the Hospital Outpatient Quality Reporting Program that are focused on improving patient outcomes and experience of care. Other changes in the proposed rule would enhance the outcome requirements for organ transplant programs, so that the programs may help more beneficiaries accept more grafts, while maintaining compliance with Medicare standards for patient and graft survival.

CMS estimates that the updates in the proposed rule would increase OPPS payments by 1.6 percent. Comments on the proposed rule will be accepted through Tuesday, September 6, 2016.

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In an effort to reduce the large backlog of Medicare coverage and payment appeals, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule that would revise the procedures the Department of Health and Human Services (HHS) would follow at the Administrative Law Judge (ALJ) level for appeals of payment and coverage determinations. This proposed rule covers items and services provided to Medicare beneficiaries, enrollees in Medicare Advantage and other Medicare competitive health plans, and enrollees in Medicare prescription drug plans, as well as appeals of Medicare beneficiary enrollment and entitlement determinations, and certain Medicare premium appeals. In addition, the proposed rule would revise procedures that HHS would follow at CMS and the Medicare Appeals Council levels of appeal for certain matters affecting the ALJ level. As of April 2016, the Office of Medicare Hearings and Appeals (OMHA) had over 750,000 pending appeals, while OMHA’s adjudication capacity was 77,000 appeals per year, with an additional adjudication capacity of 15,000 appeals per year expected by the end of the current fiscal year. The proposed rule includes provisions to expand the pool of available OMHA adjudicators and improve the efficiency of the appeals process by streamlining the processes so less time is spent by adjudicators and parties on repetitive issues and procedural matters. The proposed rule was published in the July 5, 2016 Federal Register. Comments are due by Monday, August 29, 2016.

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