IRFs Begin Final Countdown for Big Changes Ahead

We have been reminding inpatient rehabilitation facilities (IRFs), repeatedly of late, and now we’re down to the final two months before the transition away from utilizing Functional Independence Measures (FIM^tm) to assign patients to a case-mix group (CMG) and toward using key quality indictor data – specifically, the GG Self-Care and Mobility Codes – to determine CMG placement and Medicare fee-for-service payment for IRF admissions.

As the transition date of Oct. 1, 2019 approaches, IRFs need to be finalizing preparation and training; we’ve developed this series of articles to address some final steps for IRFs engaged in that process.

Timing Is Everything
While the final rule for the 2020 fiscal year has not yet been published as of today, this change was authorized in prior rules and applies to discharges occurring on or after Oct. 1, 2019. Between now and then, IRFs should continue to collect both quality indicator and FIM^tm data for patients who will discharge around the transition date, to ensure that adequate data is documented and available to support billing for such patients.

Key Steps in Preparation
While it might be easy to become complacent and take the approach of “we’ll just stop collecting one set of data,” organizations need to address this change from all perspectives and take a final look at what it means in terms of workflow, documentation practices, and financial impacts. Fine-tuning these processes can make a significant impact on an organization’s success with the transition.

Determine the Impact
Along with the proposed rule for 2020, the Centers for Medicare & Medicaid Services (CMS) posted rate-setting files, which included data for FY 2018 through FY 2020, with actual payment data for 2018 and projected data for the subsequent years. The proposed rule noted that the changes were budget-neutral – note that the calculations compared FY 2018’s actual figures with FY 2020 projected figures – and that only 48 IRFs would have a reduction in total revenue. However, when we look at those same tables – again, submitted with the proposed rule – and compare projected FY 2019 to projected FY 2020, a total of 207 IRFs had reductions in overall Medicare payment. That’s a big difference! IRFs need to determine whether they are in this group, and if so, develop a strategy for managing the change.

Address Documentation Changes
Whether organizations are using an electronic medical record (EMR) or continue to use some or all paper documentation tools, it is not enough to simply remove the FIM^tm elements from the existing tools and leave the quality indicator self-care and mobility codes that have been in use for several years. Clear descriptors must be included to support the scores recorded, and it is not enough to enter a score without support.

Look at Process
While the assessment period remains three days, we are no longer considering a single performance of a task, but the usual/baseline performance before therapeutic interventions begin. While each IRF has a three-day assessment period, many of the key items will be assessed early in the stay, with therapy initiated. For these items, the assessment period ends when therapy begins. Having clear processes defined for when the assessment is completed is critical to capturing the admission assessment score.

Training Remains Key
Training is essential, as the numerical scores for the quality indicators do not crosswalk from the earlier FIM^tm measures. Clinical staff who have many years of experience scoring FIM^tm may struggle to give a patient a score of 3 = partial/moderate, assist, for an activity that under the previous scoring methodology may have been scored a 4=minimal assist. Consistent and persistent training is a must, and fortunately, there are many external training opportunities available.
CMS continues to provide online and in-person training related to the quality indicators, and a recent CMS posting includes videos for scoring practice: Spring 2019 Training. Because of the long history of scoring using a different system, including differing language and definitions, all staff need to understand the change and its impact on success.

Audit and Retrain
Since accurate completion of the quality indicator scores is essential for both payment and outcomes monitoring for each IRF, each organization must focus on accurate scoring. By completing internal audits and sharing the results, ongoing feedback and training can be provided to staff.

What’s the Bottom Line?
The clock keeps ticking! We’re down to just two months before the transition and should be completing our final assessment of practices prior to the change.

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