Medicare Issues Series of Proposed Regulations Affecting Health Care Facilities
During the week of April 27, the Centers for Medicare & Medicaid Services (CMS) released a series of proposed regulations that would alter payment rates and policies for skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), acute-care hospitals and long-term-care hospitals, and hospice. AOTA is reviewing the proposed rules (and draft Medicare Manual revisions for IRFs) and will submit written comments to CMS by the deadlines specified below. If you have comments on any of the following proposed rules, please provide the comments to AOTA and reference the facility/setting you are addressing in an e-mail to: email@example.com.
1. Skilled Nursing Facilities
CMS will publish a proposed rule in the Federal Register on May 12 containing adjustments to fiscal year (FY) 2010 payment rates that are intended to better reflect the cost of caring for Medicare beneficiaries in nursing homes. In addition to recalibrating and updating the SNF prospective payment rates for FY 2010, this proposed rule would:
- Propose a revised case-mix classification methodology (RUG-IV) and implementation schedule for FY 2011, reflecting updated staff time measurement data derived from the recently completed Staff Time and Resource Intensity Verification (STRIVE) project;
- Invite comment on a possible new rate component to account for the use of non-therapy ancillaries (as recommended by MedPAC);
- Include information on the transition to the Minimum Data Set, Version 3.0 (MDS 3.0) redesigned nursing home resident assessment instrument, including an implementation schedule;
- Invite comment on a possible new requirement for the quarterly reporting of nursing home staffing data; and
- Make changes to policies related to the provision of concurrent therapy.
You may access a copy of the proposed rule online here. Click here for the CMS press release on the proposed rule. CMS will accept comments on the proposed rule through June 30, 2009.
2. Inpatient Rehabilitation Facilities
CMS will publish a proposed rule in the Federal Register on May 6 that would update payment rates and clarify the framework for Medicare patient selection and care in IRFs during FY 2010. CMS has also posted draft Medicare Benefit Policy Manual revisions for IRFs. In order to be paid for providing rehabilitation services under the IRF prospective payment system, current Medicare law requires an IRF to demonstrate that its annual patient population consists of at least 60% of patients with one or more of 13 “qualifying conditions” as a principal or secondary diagnosis. Importantly, CMS is proposing to update the case-mix group relative weights and average length of stay values using FY 2007 data, which reflect recent changes in IRF patient populations resulting from the 60% rule and medical review activities. In addition, the proposed revisions would clarify requirements for preadmission screening to determine whether a patient should receive rehabilitation services in an IRF or in another, less-intensive setting, post admission treatment planning, and ongoing care coordination throughout the inpatient stay. Specifically, CMS is proposing to:
- Update and clarify the IRF admission criteria to specify that the patient should be able and willing to actively participate in an intensive rehabilitation program and should be expected to make measurable improvement in his or her functional capacity or adaptation to impairments;
- Require that IRF services be ordered by a rehabilitation physician with specialized training and experience in rehabilitation services and be coordinated by an interdisciplinary team, including at least a registered nurse with specialized training or experience in rehabilitation; a social worker or case manager (or both); and a licensed or certified therapist from each therapy discipline involved in treating the patient. The rehabilitation physician would be responsible for making the final decisions regarding the patient’s treatment in the IRF;
- Specify that IRFs use qualified personnel to provide required rehabilitation nursing, physical therapy, occupational therapy, speech-language pathology, social services, psychological services, and prosthetic and orthotic services;
- Emphasize the importance of the post admission evaluation to document the status of the patient after admission to the IRF, compare it to that noted in the preadmission screening documentation, and begin developing an overall plan of care to meet the individual patient’s specific needs. The proposed rule would require the overall plan of care to be completed with input from all of the interdisciplinary team members and to be maintained in the patient’s medical record; and
- Require the interdisciplinary team to meet weekly to review the patient’s progress and make any needed modifications to the individualized overall plan of care.
AOTA has been actively involved in working with CMS on IRF policy changes through participation in a technical advisory panel working group gathered by CMS in February.
You may access a copy of the proposed rule online here. Click here for the CMS press release. CMS has published Fact Sheets on the IRF rule payment update and coverage requirements. CMS will accept comments on the proposed rule through June 29, 2009.
The draft IRF Medicare Benefit Policy Manual revisions are online at http://www.cms.hhs.gov/InpatientRehabFacPPS/Downloads/Revised_Section_110_MBP_Manual_DRAFT_for_Comment.pdf. Comments on the draft revisions should be submitted through a link that will be supplied on the CMS Web site, rather than through the site used for the submission of comments on proposed regulatory language.
3. Inpatient Services in Acute-Care Hospitals and Long-Term-Care Hospitals
CMS will publish a proposed rule in the Federal Register on May 22 that would change Medicare policies and payment rates for inpatient services furnished by both acute-care hospitals and long-term-care hospitals in FY 2010. Beginning on October 1, 2008, Medicare adopted a new classification system for general acute- and long-term-care-hospitals to better recognize the severity of illness and the cost of treating Medicare patients. However, CMS states that hospitals changed their documentation and coding of patient diagnoses under the new system in a manner that leads to an increase in aggregate payments without corresponding growth in actual patient severity. CMS believes that the proposed documentation and coding adjustments would help curtail this practice.
In addition, under current Medicare law, hospitals that successfully report the 2010 quality measures included in the Reporting Hospital Quality Data for Annual Payment Update program will get the full update. Hospitals that do not participate in the quality reporting program will get the update, less 2 percentage points. Ninety-seven percent of participating hospitals received the full update last year. The proposed rule adds four new measures. Two of these measures are additions to the existing Surgical Care Improvement Project (SCIP) measure set, and CMS believes that the other two measures will promote hospital participation in nursing-sensitive care and stroke care registries.
You may access a copy of the proposed rule online at http://www.federalregister.gov/OFRUpload/OFRData/2009-10458_PI.pdf. Click here for the CMS press release on the proposed rule. CMS has also published three Facts Sheets on the proposed rule addressing: (1) specific payment and policy changes; (2) the documentation and coding adjustment; and (3) quality of care proposals for inpatient stays. CMS will accept comments on the proposed rule through June 30, 2009.
4. Inpatient Psychiatric Facilities
CMS published a proposed rule in the Federal Register on May 1 that would change Medicare payment rates for the Medicare prospective payment system for inpatient psychiatric hospital services provided by inpatient psychiatric facilities (IPFs). The IPF rule appears to address technical payment updates only, but AOTA is analyzing the rule to assure that any policy changes relevant to occupational therapy are addressed. The updated IPF prospective payment rates are effective for discharges occurring on or after July 1, 2009, through June 30, 2010.
You may access a copy of the proposed rule in the Federal Register at http://edocket.access.gpo.gov/2009/pdf/E9-9962.pdf. CMS will accept comments on the proposed rule through June 30, 2009.
Finally, CMS recently proposed a regulation that would set forth the hospice wage index for FY 2010. The proposed rule would also adopt a MedPAC recommendation regarding a process for certification and recertification of terminal illness. The rule was published in the Federal Register on April 24.
The proposed hospice rule can be accessed at: http://edocket.access.gpo.gov/2009/pdf/E9-9417.pdf. Occupational therapy is mentioned on page 12. CMS also issued a Fact Sheet on the proposed rule. Comments on the hospice rule are due to CMS by June 22, 2009.