March 4, 2015

CMS-13 Qualifying Diagnoses: Arthritis as a Qualifying Condition

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On Jan. 15, 2015 the Centers for Medicare & Medicaid Services (CMS) held a provider training call to address several key issues related to the IRF-PAI and the changes in reporting that will be required for discharges on or after Oct. 1, 2015. Based on the number of questions that were posed on that call, we are attempting to provide a summary of what is required for using arthritis as a qualifying condition under the 60-percent rule.

While patients must still meet the guidelines for “reasonable and necessary” care, we are seeking to help identify those patients that should be counted as being afflicted by CMS-13 qualifying conditions.

Arthritis attestation: What does Item 24a mean?

Item 24a of the updated IRF-PAI document requires the inpatient rehabilitation facility (IRF) to indicate whether an arthritis condition included in the impairment group, etiologic diagnosis, or comorbid conditions sections of the IRF-PAI meets the regulatory requirements to be included in the CMS-13 diagnostic categories. While this appears to demand a straightforward yes/no response, IRFs need to be certain that they have the supporting documentation in the patient’s IRF record when choosing “yes” as the response.

What are the requirements for arthritis to be a qualifying condition?

There are two areas of consideration in determining whether the condition qualifies. Conditions will qualify if the patient presents with significant functional impairments:

  • that have not improved after “an appropriate, aggressive, and sustained course of outpatient therapy services or services in other less intensive rehabilitation settings immediately preceding the inpatient rehabilitation admission,” or
  • in the case of systemic vasculidities and active, polyarticular conditions, that “result from a systemic disease activation immediately before admission, but have the potential to improve with more intensive rehabilitation.”

Chapter 3, Section 140.1.1 of the Medicare Claims Processing Manual describes “an appropriate, aggressive, and sustained course of outpatient therapy services or services in other less intensive rehabilitation services” as meaning:  

  • A course of rehabilitation therapy of at least three weeks minimum;
  • Including at least two individual (non-group) sessions per week;
  • Targeting all clinically impaired joints;
  • Supported by documentation in the medical record that includes periodic assessment for clinical functional improvement;
  • Within 20 calendar days of an acute hospitalization immediately prior to the IRF admission, or 20 calendar days immediately preceding an IRF admission.

While this description is available, the language in the manual allows the Medicare Administrative Contractor (MAC) the discretion to develop, document, and use other interpretations based on local practices and current clinical information.

What does the IRF need to do to support an answer of “yes”?

When completing the attestation statement, it is important that the IRF has sufficient documentation to support the prior rehabilitation program and/or the systemic activation of the condition. CMS expects the IRF to obtain copies of appropriate therapy notes and to include these in the patient’s medical record. 

Other issues

In a follow-up clarification, CMS has instructed providers that if there are no arthritis conditions reported in sections 21, 22, or 24 of the IRF-PAI, the organization should code item 24.A as “no.”

What to do next

As Oct. 1 approaches, IRFs should watch for any additional clarifications related to this section of the IRF-PAI. Additionally, IRFs should review their practices’ protocols for obtaining information as part of the preadmission assessment screening process to be certain that key therapy documentation is obtained, verified, and included in the IRF medical record.

About the Author

Angela M. Phillips, PT, is president and chief executive officer of Images & Associates. A graduate of the University of Pennsylvania’s School of Allied Health Professions, she has more than 35 years of experience as a consultant, healthcare executive, hospital administrator, educator, and clinician. Ms. Phillips is one of the nation’s leading consultants assisting inpatient rehabilitation facilities in operating effectively under the Medicare Prospective Payment System (PPS) and in addressing key issues related to compliance.

Contact the Author

angela.phillips@att.net

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Angela Phillips, PT

Angela M. Phillips, PT, is president and chief executive officer of Images & Associates. A graduate of the University of Pennsylvania’s School of Allied Health Professions, she has 40 years of experience as a consultant, healthcare executive, hospital administrator, educator and clinician. Ms. Phillips is one of the nation’s leading consultants assisting Inpatient Rehabilitation Facilities in operating effectively under the Medicare Prospective Payment System (PPS) and in addressing key issues related to compliance.

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