Medicare Compliance & Reimbursement

Rule could put some IRFs out of business.  Now that the comment period has ended for inpatient rehab providers to tell the Centers for Medicare & Medicaid Services what they think about its attempt to fix the 75 percent rule, it's time for providers to call their congressmen - and figure out how they'll comply with the rule if it isn't changed. CMS published its proposed inpatient rehab criteria rule (i.e., the 65 percent rule) in the Federal Register Sept. 9. And although the rule looks okay at first glance - since it drops the percentage of patients who must fit into its specifications from 75 percent to 65 percent - a closer look reveals that it's cause for real concern. Aside from the 75 percent threshold being dropped to 65 percent, another area of the rule that looks good on the surface is CMS' proposed comorbidity provision. This provision stipulates that a patient who does not have one of the 12 qualifying diagnoses can still count toward the 65 percent threshold if that patient also has a comorbidity that is among the 12 qualifying conditions and that comorbidity is serious enough that it would require inpatient rehab even in the absence of the primary diagnosis. For example, many patients receive inpatient rehab following open-heart surgery because they became anoxic during the surgery, notes consultant Ann Lambert Kremer with Baker Newman & Noyes in Portland, ME. In such cases, the patient is actually receiving rehab due to damage resulting from lack of oxygen to the brain during a complication in the surgery, she says. The open-heart surgery would not qualify the patient to count toward the 65 percent threshold, but that comorbidity would, she explains. "So there's a good example of one that would fit," she says. "But there's not a lot of examples." And that's the problem, experts agree. On the surface, the comorbidity provision is all well and good - the trouble is that there are so few real-life scenarios in which a comorbidity would count toward the 65 percent that the provisions are practically useless. "If you have one of the CMS 12 as a comorbidity and it's significant enough to require rehab," then that comorbidity usually will be listed as the primary diagnosis anyway, argues Cheri Rinehart, vice president of integrated delivery services for the Hospital & Healthsystem Association of Pennsylvania. Polyarthritis Removal Makes It Harder To Reach Threshold  Had CMS left "polyarthritis" on the list of qualifying conditions, the comorbidity provisions would have been a bit more helpful, notes consultant Fran Fowler, with Fowler Healthcare Affiliates Inc. in Atlanta. Polyarthritis often is a comorbidity for cardiac patients, and thus could have qualified a lot of people, [...]