Health Reform WK-EDGE CMS proposes modest IRF payment increase, asks for policy feedback
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Monday, May 8, 2017

CMS proposes modest IRF payment increase, asks for policy feedback

CMS issued a Proposed rule of its fiscal year (FY) 2018 inpatient rehabilitation facility (IRF) prospective payment system (PPS) that would impose only a modest $80 million payment update, but would make changes to the 60-percent rule, remove the penalty for late patient assessment instruments (PAIs), and update the Quality Reporting Program (QRP). The proposal also includes a Request for Information (RFI) soliciting general feedback about the Medicare Program. Comments will be accepted until June 27, 2017 (Proposed rule, 82 FR 20750, May 3, 2017).

Payment updates. CMS anticipates an overall update of $80 million for FY 2018, relative to FY 2017. The proposed payment update reflects a 1.0 percent increase factor, as required by section 411(b) of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 114-10), but CMS does not anticipate any change in aggregate outlier payments for FY 2018, as estimated FY 2017 outlier payments are 3 percent of total payments. Facility-level adjustments remain frozen at FY 2014 levels. FY 2018 marks the end of the transition period for 20 providers whose status changed from rural to urban as a result of changes related to delineations in Metropolitan Statistical Areas, Micropolitan Statistical Areas, and Combined Statistical Areas; they will receive no rural adjustment.

60-percent rule changes. The 60-percent rule holds that, in order to be classified as IRFs, facilities must demonstrate that at least 60 percent of their inpatient population requires intensive rehabilitative services for the treatment of one of 13 specific medical conditions. CMS has reviewed International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM) codes that were implemented in 2015. It is now proposing to refine the ICD-10-CM lists used to determine 60-percent rule compliance to ensure that they accurately reflect requirement. It would remove G72.89—Other specified myopathies, since it was identified as inappropriately applied to patients with generalized weakness, along with certain non-specific and arthritis diagnosis codes that were inadvertently reintroduced through the ICD-10-CM conversion process. It would also address certain codes for patients with traumatic brain injury and hip fracture conditions and identify major multiple trauma codes that did not translate precisely between ICD-9-CM and ICD-10-CM. CMS is soliciting comments on the 60-percent rule, including comments related to the list of qualifying conditions, to assist in classifying facilities as IRFs.

Late penalty removal. IRFs are required to submit PAIs to CMS electronically within a specific time period related to a beneficiary’s discharge, in accordance with 42 C.F.R. sections 412.610 and 412.614, or their payment will be reduced by 25 percent. CMS is proposing the removal of this penalty, noting that IRFs can now only receive payment for Medicare Part A fee-for-service (FFS) patients when both an IRF claim and an IRF-PAI are submitted and matched accordingly, providing sufficient financial motivation for IRFs to timely file both claims and IRF-PAIs. In addition, CMS believes that waiver request procedures are unduly burdensome.

QRPchanges. Section 3004(b) of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) amended section 1886(j) of the Social Security Act (SSA) and required the Secretary to establish the IRF QRP. IRFs that fail to submit required QRP data to CMS have their annual payment update reduced by two percentage points. CMS is proposing to update QRP reporting requirements, including removing the All-Cause Unplanned Readmission measure for FY 2019 and replacing the current pressure ulcer measure, Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678) with a modified version, Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury, for FY 2020. CMS also proposed that IRFs begin reporting standardized patient assessment data in FY 2020 with respect to the following five legally-required patient assessment categories: (1) functional status, (2) cognitive function, (3) special services, treatments and interventions, (4) medical conditions and co-morbidities, and (5) impairments. CMS also proposed publicly reporting six new measures on the IRF Compare website by Fall 2018.

Technical process revisions. CMS proposed the following:

  • removing the duplicative Voluntary Item 27 (Swallowing Status) from the IRF-PAI;
  • establishing a formal process to distinguish between non-substantive updates and substantive revisions to the ICD-10-CM codes on the lists used to determine IRFs’ presumptive compliance with the 60 percent rule; and
  • using IRF-PAI data to determine patient body mass index (BMI) greater than 50 cases of lower extremity single joint replacement.

RFI. CMS announced its solicitation of feedback on the Medicare program in general, in order to "start a national conversation about improving the health care delivery system . . . how Medicare can contribute to making the delivery system less bureaucratic and complex, and how we can reduce burden for clinicians, providers and patients in a way that increases quality of care and decreases costs." It specifically welcomes proposals for "regulatory, sub-regulatory, policy, practice and procedural changes," but emphasized that the agency will not respond to these comments in the Final rule. Instead, it will consider them in future regulatory proposals or sub-regulatory guidance.

FederalRegisterIssuances: ProposedRules AgencyNews InpatientFacilityNews MedicarePartANews QualityNews FedTracker HealthCare

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