Medicare Compliance & Reimbursement

Take heart: If FIs sell you short, the decision can be appealed

Many providers are still scratching their heads over how fiscal intermediaries will enforce the so-called "75 percent rule." But a fact sheet recently released by the Centers for Medicare & Medicaid Services makes clear what to expect.

CMS' 12-page fact sheet outlines for providers the basics of the inpatient rehab facility classification requirements, how FIs will enforce those requirements and the IRFs' role in the process.

Important points to note are:

If the majority of your patients are Medicare Part A fee-for-service beneficiaries, the FI will use the IRF-PAI "to make a presumptive judgment that the IRF's total patient population complies with the revised regulations," the fact sheet says.

If the FI cannot presume from the PAIs that the facility meets the percentage threshold, it will review a sample of medical records from the total patient population to determine whether the provider is in compliance and can be classified as an IRF.

Important point: To stand up to scrutiny, providers must ensure that all medical records include "proper, complete and accurate documentation," urges consultant Ken Mailly with Mailly & Inglett Consulting in Wayne, NJ. "The FI has a lot of discretion as to what records they'll look at, so the onus is on the facility" to ensure all records are complete, he says.

For a patient to be counted toward the percentage threshold under the "presumptive test methodology," the ICD-9 codes on the PAI must match the codes in the computer program that carries out the test.

Those codes are listed in Appendix A of CMS Change Re-quest 3503, located at www.cms.hhs.gov/manuals/pm_trans/R347CP.pdf.

This reliance on ICD-9 codes is a major flaw in the system, according to Mailly. "ICD-9 codes do a very poor job of describing the kind of patients we see," he says.

Alternative: Fortunately, the buck doesn't stop with the PAI. If the presumptive test does not determine that a provider has met the percentage threshold, the FI has "the discretion of using additional codes or medical information from a patient's medical record to make the determination," CMS makes clear.

IRFs should "maintain direct contact" with their FI to ensure it's using the "proper methodology" to determine compliance, the fact sheet says. If an FI has unfairly determined non-compliance, providers can appeal the decision.

That's great news, cheers consultant Fran Fowler with Fowler Healthcare Affiliates in Atlanta. However, the details on how the appeal process will work are not yet clear, she notes.

FIs can use their own discretion when determining what counts as "an appropriate, aggressive, and sustained course of outpatient therapy services in other less intensive rehabilitation settings" for patients that must meet this requirement to count toward the [...]