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Tags Posts tagged with "centers for medicare and medicaid services"

centers for medicare and medicaid services

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On July 31, 2019, the Centers for Medicare and Medicaid Services (CMS) released the fiscal year (FY) 2020 inpatient rehabilitation facility prospective payment system (IRF PPS) final rule. This final rule is scheduled to be published in the Federal Register on August 8, 2019.

Key provisions contained in the final rule include:

  • Motor Score Provisions: Based on feedback received with the proposed rule, CMS is adopting an unweighted motor score to assign patients to case-mix groups (CMGs), rather than the use of a weighted motor score as originally proposed. CMS also finalized as proposed the removal of GG0170A1 (roll left and right) from the motor score (leaving 18 unweighted data items).
  • CMGs, Relative Weights, & Average Length of Stay: The final rule includes three additional CMGs than were included in the proposed rule:
    • Stroke RIC (01) will have 6 CMGs, compared to 7 in the proposed rule
    • Non-traumatic spinal cord injury RIC (05) will have 5 CMGs, compared to 4 in the proposed rule
    • Replacement of lower extremity joint RIC (08) will have 5 CMGs, compared to 4 in the proposed rule
    • Rheumatoid other arthritis CMG RIC (13) will have 5 CMGs, compared to 4 in the proposed rule
    • Major multiple trauma without brain or spinal cord injury RIC (15) will have 5 CMGs, compared to 4 in the proposed rule
  • Rebasing and Revising IRF Market Basket: CMS is rebasing and revising the IRF market basket to reflect a 2016 base year and is forecasted to be 2.9 percent.
  • Clarification of “Rehabilitation Physician”: CMS is amending the regulations to clarify that the determination as to whether a physician qualifies as a rehabilitation physician (that is, a licensed physician with specialized training and experience in inpatient rehabilitation) is to be determined by the IRF, as the provider is in the best position to make that determination.
  • Ensuring Quality: CMS finalized two new quality measures to implement the final requirements of the Improving Medicare Post-Acute Transformation (IMPACT) Act. Those two measures are: 1) Transfer of Health Information (TOH) from IRF to another Provider, and 2) Transfer of Health Information (TOH) from IRF to the Patient.
  • IRF Quality Reporting Program (QRP): CMS is adopting two new quality measures that satisfy the IMPACT Act domain pertaining to the transfer of health information when a patient is transferred or discharged from the IRF to another PAC provider or the home of the individual. Specifically, both of these measures would assess whether the IRF provides a reconciled medication list at the time of transfer or discharge. They also support the CMS Meaningful Measures initiative of promoting effective communication and coordination of care, specifically the meaningful measure area of the transfer of health information and interoperability. In addition, CMS is adopting a number of standardized patient assessment data elements

(SPADEs). These SPADEs assess key domain areas including functional status, cognitive function and mental status, special services, treatments and interventions, medical conditions and comorbidities, impairments, and social determinants of health (SDOH). The addition of these SPADEs to the IRF-Patient Assessment Instrument (IRF-PAI) will improve coordination of care and enable communication between PAC providers and other members of the health care community, aligning with CMS’ strategic initiative to improve interoperability. CMS is also updating the specifications for the Discharge to Community PAC IRF QRP measure to exclude baseline nursing home residents. CMS is also finalizing their policy to no longer publish a list of compliant IRFs on the IRF QRP website. CMS proposed to collect standardized patient assessment data and other data required to calculate quality measures using the IRF PAI on all patients, regardless of the patient’s payer; however, in response to stakeholder feedback, they have decided not to finalize this proposal.

The payment provisions contained in the final rule become effective for discharges on or after October 1, 2019 and the new quality reporting requirements go into effect on October 1, 2020. Contact RCPA Director of Rehabilitation Services Melissa Dehoff with questions.

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The Centers for Medicare and Medicaid Services (CMS) filed the unpublished and proposed Medicare Physician Fee Schedule (MPFS) rule for calendar year 2020 on July 29, 2019. The proposed rule is scheduled to be published in the Federal Register on August 14, 2019. Payment is made under the PFS for services furnished by physicians and other practitioners in all sites of service, including nurse practitioners, physician assistants, physical therapists, etc.

Some of the key provisions in this proposed rule include:

  • Medicare Telehealth Services: Proposing to add HCPCS codes GYYY1, GYYY2, and GYYY3 to the list of telehealth services, which describe a bundled episode of care for treatment of opioid use disorders.
  • Payment for Evaluation & Management (E/M) Services: Proposing to align the E/M coding changes with changes presented by the CPT Editorial Panel for office/outpatient E/M visits. The CPT coding changes retain 5 levels of coding for established patients, reduce the number of levels to 4 for office/outpatient E/M visits for new patients, and revise the code definitions. The CPT changes also revise the times and medical decision-making process for all of the codes and requires performance of history and exam only as medically appropriate. The CPT code changes also allow clinicians to choose the E/M visit level based on either medical decision making or time.
  • Physician Supervision Requirements for Physician Assistants (PAs): CMS is proposing to modify their regulation on physician supervision of PAs to give them greater flexibility to practice more broadly in the current health care system in accordance with state laws and scope of practice.
  • Therapy Services: In the CY 2019 PFS final rule, in accordance with amendments to the Medicare law, CMS established modifiers to identify therapy services that are furnished in whole or in part by physical therapy (PT) and occupational therapy (OT) assistants, and set a de minimis 10 percent standard for when these modifiers will apply to specific services. CMS also established that the statutory reduced payment rate for therapy assistant services, effective beginning for services furnished in CY 2022, does not apply to services furnished by critical access hospitals because they are not paid for therapy services at PFS rates. Beginning January 1, 2020, these modifiers are required by statute to be reported on claims. CMS is proposing a policy to implement the modifiers as required by statute, and apply the 10 percent de minimis standard, while imposing the minimum amount of burden for those who bill for therapy services while meeting the requirements of the statute.
  • Review and Verification of Medical Record Documentation: CMS has received feedback from clinicians in response to their Patients Over Paperwork initiative request for information (RFI). Stakeholders have shared how undue burden is created when physicians and other practitioners, including those serving as clinical preceptors for students, must re-document notes entered into the medical record by other members of the medical team. To reduce burden, CMS is proposing broad modifications to the documentation policy so that physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives could review and verify (sign and date), rather than re-documenting, notes made in the medical record by other physicians, residents, nurses, students, or other members of the medical team.
  • Care Management Services: CMS is proposing to increase payment for Transitional Care Management (TCM), a care management service provided to beneficiaries after discharge from an inpatient stay or certain outpatient stays. CMS is also proposing a set of Medicare-developed HCPCS G-codes for certain Chronic Care Management (CCM) services.
  • Bundled Payments Under the PFS for Substance Use Disorders: CMS is proposing to create new coding and payment for a bundled episode of care for management and counseling for opioid use disorders (OUD).

Contact RCPA Director of Rehabilitation Services Melissa Dehoff with questions.

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The Centers for Medicare and Medicaid Services (CMS) recently announced an upcoming in person inpatient rehabilitation facility quality reporting program (IRF QRP) training. This two-day “train-the-trainer” event for providers is scheduled for August 15–16, 2019 at the Four Seasons Hotel, 200 International Drive, Baltimore, MD 21202.

The primary focus of this training, which is open to all IRF providers, associations, and organizations,  will be to provide those responsible for training staff at IRFs with information about IRF QRP changes and updates to the IRF Patient Assessment Instrument (PAI) v.3.0, which will become effective on October 1, 2019. Topics will include, but are not limited to:

  • An overview of the changes between the IRF-PAI v.2.0 and v.3.0;
  • Updated training materials for Section GG, which will include videos of patient scenarios; and
  • An interactive session on the use of reports to identify opportunities for process improvement and utilize information contained in reports available via the Certification and Survey Provider Enhanced Reports (CASPER) system, which will be used to develop quality improvement plans.

A full agenda is available for both days of the training. Registration is limited to 100 people on a first-come, first-served basis. Questions or additional information requests should be sent to the PAC Training mailbox.

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Today, the following important notice was issued by the American Medical Rehabilitation Providers Association (AMRPA) regarding a historic appeal settlement that they, along with the FAIR Fund and the Federation of American Hospitals, reached with the Centers for Medicare and Medicaid Services (CMS) that will allow inpatient rehabilitation facilities (IRFs) to settle their pending Medicare appeals.

Today CMS, AMRPA, the FAIR Fund, and the Federation of American Hospitals announced that an agreement has been reached with CMS which will allow IRFs to settle their pending Medicare appeals. For most pending claims, providers will be able to settle their pending appeals for 69% of the net payable amount of the claim. This is the highest percentage global settlement CMS has ever agreed to. In addition, some claims, such as those denied for failing to justify the use of group therapy, can be settled at 100% of the net payable amount. Here are some of the key things AMRPA members should know:

  • The settlement is voluntary. Providers can choose whether to settle their claims or continue to exercise their appeal rights.
  • Providers choosing to settle claims will receive 69% of the net payable amount (Medicare approved amount, less any applicable deductible or co-insurance).
  • Claims denied solely on the basis of threshold of therapy time not being met (3-hour or 15-hour rule), where the claim did not undergo further review for medical necessity, will be paid at 100% of the net payable amount. Claims denied solely because justification for group therapy was not documented will also be paid at 100% of the net payable amount.
  • If participating in the settlement, providers must settle all currently pending appeals. Providers cannot choose only select claims to settle.
  • To be eligible for settlement, the claim must have been denied in full, and the denial must have been appealed on or before August 31, 2018. The appeal must also still currently be pending at any level of appeal, and appeal rights must not have been exhausted at time of settlement.

Providers should read the entire template agreement for additional important details. CMS has provided instructions for how providers can participate in the settlement on its website.

This settlement was reached due to the diligent efforts of AMRPA’s sister organization, the FAIR Fund, in collaboration with AMRPA and the Federation of American Hospitals. AMRPA would especially like to thank longtime counsel to AMRPA and the FAIR Fund, Peter Thomas and Ron Connelly of Powers Law Firm, whose dedication to the rehabilitation field led to this historic settlement.

Contact Melissa Dehoff, RCPA Rehabilitation Services Director, with questions.

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The Centers for Medicare and Medicaid Services (CMS) has published a new “Outpatient Rehabilitation Therapy Services: Complying with Medicare Billing Requirements” booklet. Outpatient rehabilitation therapy services include physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) services.

The booklet describes common outpatient rehabilitation therapy services Comprehensive Error Rate Testing (CERT) program errors, how CMS calculates improper payment rates, the necessary documentation to support billed Medicare Part B claims; and managing potential overpayments. Contact Melissa Dehoff, RCPA Rehabilitation Services Director, with questions.

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The Centers for Medicare and Medicaid Services (CMS) identified a typographical error in the publication of the fiscal year (FY) 2020 inpatient rehabilitation facility prospective payment system (IRF PPS) proposed rule that was published in the April 24, 2019 Federal Register. The error was in the calculation of the estimated burden for the IRF quality reporting program (QRP).

On page 17329 of the proposed rule it states, “Specifically, we believe that there will be an addition of 7.4 minutes on admission, and 11.1 minutes on discharge, for a total of 8.9 minutes of additional clinical staff time to report data per patient stay.” This sentence should have stated, “Specifically, we believe that there will be an addition of 7.8 minutes on admission, and 11.1 minutes on discharge, for a total of 18.9 minutes of additional clinical staff time to report data per patient stay.”

The final values and the overall burden proposed in the rule are correct despite these minor typographical errors. CMS will correct the figures in the final rule. A technical correction will not be issued due to the nature of the errors.

Contact Melissa Dehoff, RCPA Rehabilitation Services Division Director, with questions.

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The Centers for Medicare and Medicaid Services (CMS) recently announced the Primary Cares Initiative, which includes a new set of payment models that will transform primary care to deliver better value for patients throughout the health care system. The initiative will seek to reduce administrative burdens and empower primary care providers to spend more time caring for patients while reducing overall health care costs. The initiative will be administered through the Center for Medicare and Medicaid Innovation (CMMI) under two paths: Primary Care First (PCF) and Direct Contracting (DC). The PCF payment models are focused on individual primary care providers, while the DC payment model options target a wider range of organizations that are capable of tending to larger patient populations and are experienced in handling financial risk, such as Medicaid managed care organizations, accountable care organizations, and Medicare Advantage plans.

The PCF models will be tested for five years and are currently scheduled to begin in January 2020. The DC models are expected to launch for a performance period in January 2021. CMS is seeking public comment on the DC model with comments being accepted until May 23, 2019.

Additional information is provided on the CMS website, including dates/times for webinars for interested stakeholders.

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The Centers for Medicare and Medicaid Services (CMS) released the proposed rule for the inpatient rehabilitation facility prospective payment system (IRF PPS) for fiscal year (FY) 2020.

Some of the key proposals in the rule include:

  • Net Payments: Net payments for IRF’s would increase by 2.3 percent, including a 3.0 percent market basket update, offset by a statutorily mandated cut of 0.5 percentage points for productivity, and a 0.2 percent decrease in outlier payments. This update reflects the proposed revision and rebasing of the market basket using data from 2016 as the base year instead of 2012.
  • Case-Mix Revisions: The Functional Independence Measure (FIM) and Functional Modifier items were removed from the IRF Patient Assessment Instrument (PAI) as finalized in the FY 2019 IRF PPS final rule. CMS also indicated that the FY 2020 case-mix groups (CMGs) would be based on a patient’s motor function, age, memory function, and communication function. However, in this proposed rule CMS made the decision not to include the communication and memory scores because their inclusion in the CMG definitions resulted in lower payments for patients with cognitive deficits (based on their analysis of two years of data).
  • Outlier Threshold and Cost-to-Charge Ratio: CMS proposes to update the outlier threshold amount from $9,402 for FY 2019 to $9,935 for FY 2020 to ensure outlier payments account for 3 percent of total payments, as they did for FY 2019. CMS notes that its initial analysis showed that outlier payments would be 3.2 percent and made the above proposed adjustment to maintain it at 3 percent.
  • Rehabilitation Physician Definition: CMS proposes to clarify that compliance with the regulatory definition of “rehabilitation physician” (a licensed physician with specialized training and experience in inpatient rehabilitation) will be determined by the IRF. Currently, the regulations do not specify the level or type of training or experience that are required to satisfy this criteria.
  • Proposed Changes to IRF Quality Reporting Program (QRP): CMS proposes to adopt two measures to the IRF QRP with data collection for discharges beginning October 1, 2020.
  • Transfer of Health Information to the Provider
  • Transfer of Health Information to the Patient

Transfer of Health Information is a required domain of the IMPACT Act and CMS has been developing these measures since 2016. The measures are process-based measures that assess if a “current reconciled medication list” is given to either the subsequent provider or to the patient/family/caregiver when the patient is discharged or transferred from his or her current PAC setting. CMS proposes to start collecting the measure via the IRF-PAI for discharges beginning October 1, 2020.

  • Proposed Revision to Discharge to Community Measure: CMS proposes to revise the Discharge to Community post-acute care measure to exclude baseline nursing facility (NF) residents from the measures beginning with the FY 2020 IRF QRP due to stakeholder recommendations.

CMS proposes to define baseline NF residents as those who had a long-term NF stay in the 180 days preceding their hospitalization and IRF stay.

  • Proposed Standard Patient Assessment Data Elements (SPADEs): This proposal is slated for reporting beginning in October 2020. In line with the IMPACT Act, CMS is required to develop and collect standardized patient assessment data in PAC settings. In this rule, CMS proposes to adopt ”many of” the standardized patient assessment data elements (SPADEs) it had previously proposed in the FY 2018 IRF PPS proposed rule, as well adopt new SPADEs on social determinants of health. Some proposed items, such as the Brief Interview of Mental Status (BIMS), are currently on the IRF-PAI, in which case CMS is proposing to formally adopt them as SPADEs. However, most of the proposed items would entail adding new, additional reporting elements to the IRF-PAI.
  • Proposal to Collect All-Payer IRF PAI Data: CMS proposes to expand the reporting of the IRF-PAI data to include data on all patients, regardless of their payer, beginning with patients discharged on or after October 1, 2020.

The proposed rule will be published in the April 24, 2019 edition of the Federal Register. Comments on the provisions contained in the proposed rule will be accepted until June 17, 2019. Contact Melissa Dehoff, RCPA Rehabilitation Services Director, with questions.

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The Centers for Medicare and Medicaid Services (CMS) recently updated the inpatient rehabilitation facility (IRF) provider preview reports. The data contained in these reports is based on quality data that was submitted by providers between Quarter 3 for 2017 and Quarter 2 for 2018 and reflects what will be published on IRF Compare when the site is refreshed in June 2019. Instructions are available for providers on how to review the reports. The reports will be available for providers to review until April 3, 2019. Contact Melissa Dehoff, RCPA Director of Rehabilitation Services, with questions.

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