6 minute read
CMG Trends
Lisa Werner, MBA, MS, SLP Director of Consulting Services, Fleming-AOD, Inc.
14 AMRPA Magazine / February 2020 Beginning on October 1, 2019, the inpatient rehabilitation facility prospective payment system (IRF PPS) model shifted from FIM™-based case mix groups (CMGs) to functional items found in sections GG and H on the IRF Patient Assessment Instrument (IRF-PAI). Within eRehabData ® , we modeled the changes so our subscribers would have an idea of what was coming their way with respect to Medicare reimbursement. Using the information in the April 17, 2019, IRF PPS proposed rule, we presented the 2020 Proposed Grouper Model. The proposed grouper model indicated what your anticipated case mix index (CMI) would be based on the patients admitted in the time period you designated. Providers were able to access data on the difference in average expected reimbursement such that they could assess the likely impact of the transition of the sections GG/H CMGs to their hospitals.
Now that we have a full quarter of outcomes data in place, we have the opportunity to reflect on how the transition to the new CMGs has begun to impact the industry. The national CMI has increased as anticipated. At the time of writing, the CMI was 1.4210 for Medicare patients in the fourth quarter of 2019. This was up from the third quarter baseline of 1.3455, which was the last time period for the FIM™- based CMGs (with the section GG/H-based CMGs taking effect October 1). This represented $1,542.43 per discharge based on the average Medicare expected reimbursement for the fourth quarter.
The fourth quarter section GG/H functional scores were 49.49, while the third quarter section GG/H was 50.69. As I reflect on what has changed in the past quarter, I believe that the most obvious change was the addition of nurses in the assessment process admission scores. Prior to the anticipated CMG changes, the GG scores were largely coming from documentation provided by therapists. Since the nurses are the ones completing the first assessment upon admission, it makes sense to incorporate their observations in the functional scoring. Since we no longer have duplication of functional assessments, it should be expected that nurses capture the admission functional level in the areas that they typically assist with – such as bed mobility, transfers, toileting, eating and oral hygiene.
Make sure you are analyzing your data. Based on the difference in the CMI from quarter 3 to quarter 4, the increase in the CMI for Medicare patients was 0.0755. Unless you have experienced significant changes within your organization in the last quarter, the increase in the national CMI should be similar to the CMI change that you experienced.
If you did not experience a similar increase in your CMI, it is important to determine why. The first thing to check is the admission GG/H score and be sure that you are comparing the third quarter average to your current scores. Remember that when you compare your admission average to the weighted national or regional average, if you feel that your CMI is too low, then the group of patients that you are being compared to will be patients who are functioning at a higher level and belong in their assigned CMG. The weighted numbers are case mix adjusted. That means that the average value reported in eRehabData ® is adjusted to reflect how other facilities scored patients that are case mix matched to your population. When your CMIs are too low as a result of GG/H scores that did not reflect the amount of help your patients usually required, then the group of patients you are being compared to will also not represent the burden of care of your patients. Further, evaluate your self-care and mobility averages for additional information. Remember to review the functional scoring comparison graphs for the item-by-item comparison of your admission, discharge, and change scores.
While the GG/H assessment process is within your control, one of the components of the CMI that is not easily within your control is the impairment group breakdown. The consolidation of the CMGs in certain categories has the potential to reduce the CMG payments to some providers. If you have a higher than average percentage of stroke patients, you may be adversely impacted by the relatively fewer CMGs finalized for stroke in the FY 2020 IRF PPS final rule. Where lower functioning stroke patients were broken into more groups, now there are fewer choices for matching patients to payment.
If you feel that your CMI is lagging, there are a few things you can do to determine what you should be working on to get the payment that best matches your resource utilization. First, review your medical record documentation to ensure that your data collection reflects of the burden of care. Do not simply rely on your EMR to pull numbers into a report that you use to populate the IRF-PAI; instead review your records. It is impossible to know where errors may be occurring without reading what is written in the PT and OT evaluations and comparing that to the GG scores that were documented. Include nurses in the initial assessments. Read nursing notes to see what level of care was provided. Evaluate your score selection. Ensure that you are pulling the usual score. Make sure that what is documented reflects the assessments prior to the patient benefitting from therapeutic intervention. Continue to educate therapists and nurses on conducting assessments free of therapeutic intervention. Make sure to share findings from your chart audits with them. Rely on the analytical tools to highlight opportunities for improvement. If you feel that you do not have time to conduct this sort of review, seek outside assistance. This is too important to let slip away.
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AMRPA: Working Together To Preserve Access To Medical Rehabilitation Maggie Ramirez · VP of Membership Services · 347-573-3732 · mramirez@amrpa.org AMRPA: Working Together to Preserve Access to Medical Rehabilitation Elizabeth Katsion, AMRPA Member Services Coordinator, ekatsion@amrpa.org, 202-207-1102.
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