ONCE AGAIN, THE time has come for prospective payment sys- tem (PPS) updates. For inpatient rehabilitation facilities (IRFs), some positive changes went into effect on October 1, 2017. Ac- cording to the IRF PPS final rule, the reimbursement rate up- dates for fiscal year (FY) 2018 are estimated to increase payment o IRFs by $75 million, and the quality reporting revisions are projected to reduce costs for IRFs by $2.6 million. The updates to the PPS for FY 2018 are based on FY 2016 claims data and FY 2015 cost report data for IRFs. The case mix group (CMG) relative weight increase that affects the greatest number of IRF discharges is that of CMG 0603, Neurological with a motor score greater than 25.85 and less than 37. 35, with
a tier 1 diagnosis. The relative weight went from 1.6411 in FY
2017 to 1.7073 in FY 2018, which is a four percent increase. Conversely, the CMG relative weight decrease affecting the greatest
number of IRF cases is a tier 3 -0506, Non-traumatic spinal cord
injury with a motor score less than 23.75. The relative weight
went from 2.0369 in FY 2017 to 1.9632 in FY 2018. Overall, the
changes in relative weight affecting the most cases are less than
five percent in either direction.
Other factors affecting IRF PPS include adjustments made to
PPS payment rates in order to cover costs of providing high quality care. Those adjustments include the market basket update
and productivity adjustment, labor-related share, and wage index. Because of section 411(b) of the Medicare Access and CHIP
Reauthorization Act (MACRA), the market basket update must
be a one percent increase regardless of forecasting calculations.
The labor-related share went from 70.9 percent to 70.7 percent
for FY 2018, and the budget-neutral wage adjustment factor is
1.0007. The steps taken to calculate these adjustments can be
found in the final rule.
Removal of the 25 Percent Payment Penalty for
IRF-PAI Late Submissions
In the FY 2002 IRF PPS final rule, the IRF-PAI data collection instrument was implemented so IRFs could collect and electronically submit required patient data for all Medicare Part A fee-for-service (FFS) patients according to section 1886(j)( 2)(D) of the
Social Security Act. In order to encourage timely filing, the Centers
for Medicare and Medicaid Services (CMS) imposed a 25 percent
payment penalty if the IRF-PAIs were not submitted within the required deadline. Beginning with FY 2010, CMS required that the
IRF-PAI be submitted on Medicare Part C (Medicare Advantage)
patients. In the event the IRF PAIs were not submitted on Part C
patients within the required deadline, the data from those Part C
submissions could not be used in the calculations for determining
eligibility for exclusion from the inpatient PPS (IPPS). Reimbursement under IPPS is different than reimbursement under IRF PPS,
so this could severely impact the expected revenue for the IRF.
In FY 2012, a new claim edit was created to return an error
message if a UB-04 is submitted on a Part A patient and there
is no IRF-PAI on file to match the claim with. Because a facility
can only receive payment on a Medicare Part A patient if both
a UB-04 and an IRF-PAI are submitted and matched, CMS felt
the 25 percent payment penalty for late transmission of the IRF-PAI is no longer needed to encourage providers to submit data.
Additionally, CMS felt it was placing an unnecessary burden on
IRFs when they needed to apply for a waiver from the penalty.
Fiscal Year 2018 Updates to the
By Maria N. Ward, MEd, RHIA, CCS, CCS-P