AMRPA suggests ways to improve IRF-PAI

CMS responds to pointed letter

In the early months of making the transition to the inpatient rehabilitation facilities patient assessment instrument (IRF-PAI), rehab facilities across the country found that there were some problems with the tool, and they notified the American Medical Rehabilitation Providers Association (AMRPA) of Washington, DC, about their concerns.

AMRPA wrote the Centers for Medicare and Medicaid Services (CMS), requesting that some adjustments be made to the assessment tool in order to better improve efficiency and quality.

Here are some of the key points from the April 24 letter that AMRPA sent CMS, as well as CMS’ June response:

AMRPA points out in an April letter that some of the items on IRF-PAI are not necessary for a rehab facility to complete in order to receive payment, and therefore these items should be deleted from the form. According to AMRPA, these unnecessary items include:

  • Admission information:

— Item 14: Admission information;

— Item 15: Admit from;

— Items 16 and 17: Pre-hospital living setting and pre-hospital living with;

— Items 18 and 19: Pre-hospital vocational category and pre-hospital vocational effort.

CMS responds: "CMS is concerned with AMRPA’s proposal to eliminate elements from the instrument because they are not directly related to payment, thus reducing burden. Many of the elements identified in the AMRPA letter are necessary to maintain the overall integrity of the instrument, facilitate matching with the administrative files, support the research protocol, and maintain consistency with data previously collected for monitoring purposes."

CMS further states that any changes to the instrument would be premature.

  • Payer information: Primary source and secondary source should be combined to read "Payment Source."
  • Medical needs and quality indicators: AMRPA supports keeping these items voluntary, but also recommends that they be deleted from the manual, page II - 27 and Section IV.

In the CMS letter to AMRPA, the agency says this section is entirely voluntary and that the sections were maintained on the IRF-PAI as place holders.

"Because agencies do not have to complete these, we feel that maintaining these sections on the IRF-PAI is important," CMS writes. "As placeholders, these sections reinforce the commitment that CMS is making to quality issues."

  • Function modifiers and functional independence measure (FIM) instrument: AMRPA’s members have suggested that changes be made to the items dealing with eating, dressing, grooming, bowel/bladder management, transfers, and locomotion. For example, item 39 (D&E) for dressing upper/lower could be divided into two separate activities and two separate time frames.

Also, there is a problem with items 29 and 31 for bowel/bladder management because independent rehab facilities have no ability to collect a seven-day assessment period of this information from the hospital from which the patient was transferred to the rehab facility.

CMS reviewed AMRPA’s request for clarification of the function modifiers and has decided that clarifications will be provided to rehab facilities through CMS’ section on the most frequently asked questions.

  • Coding: Coding continues to be a problem for rehab facilities making the switch to IRF-PAI. Among the problems are these:

— Does V461 apply to patients on C-PAP or Bi-Pap?

— Can dysphasia be coded if identified by the speech therapist?

CMS acknowledges these suggestions and continues to review them, according to the June 2002 letter to AMRPA.

AMRPA protests unnecessary challenges

  • Discharge information: AMRPA recommends that item 41 (Discharge against medical advice) and manual page II-23, which is not related to the payment system, be deleted and that item 43 (Program interruption dates) and manual pages II-23 be amended to parallel the definition of an interrupted stay.

Also, item 44A (Discharge to living setting), manual pages II 24-25, does not parallel the types of discharge settings that have an impact on payment, AMRPA says.

"This has presented many unnecessary challenges for providers," AMRPA writes. "They must develop painstaking audit procedures to ensure the codes on the PAI correspond to the UB-92."

In response to AMRPA’s suggestions of making changes to the manual pages in section II, CMS writes, "In general, these recommendations are related to the perception that the items collected are not direct payment items and are therefore not relevant."

However, these variables were maintained as part of the negotiations between CMS and the Uniform Data System for Medical Rehabilitation of Buffalo, NY, the company that created the FIM instrument, CMS adds. "In addition, these represent variables that are relevant to additional research and monitoring of the implementation of the inpatient rehabilitation prospective payment system."