Reality sets in as rehab facilities struggle with using IRF-PAI tool

Collaborating with coders is crucial

As rehab facilities nationwide adjust to using the inpatient rehabilitation facilities patient assessment instrument (IRF-PAI), a few irksome problems have arisen, and it would appear that the Centers for Medicare and Medicaid Services (CMS) has no immediate plans to resolve these issues.

The American Medical Rehab Providers Association (AMRPA) of Washington, DC, has written letters to CMS with suggestions on how the tool, a data collection instrument used to classify patients for payment purposes, can be improved and made more efficient. For example, AMRPA has suggested that CMS eliminate the medical needs and quality indicators items because they already are voluntary and some of them do not reflect specific rehab issues. CMS, in a recent response, disagreed with this advice and said that plans were to continue to include the information. 

Rehab facilities initially welcomed IRF-PAI

Most rehab facilities were so relieved at not being forced to use the assessment tool CMS originally proposed that the IRF-PAI was at first welcomed, notes Peggy Kirk, BSN, vice president of operations of day rehab and former corporate director for inpatient services at the Rehabilitation Institute of Chicago (RIC).

Nonetheless, RIC staff found that implementing IRF-PAI has taken significant training time and has required the facility to develop new systems and processes for collecting information, Kirk says.

"We formerly collected similar information for UDS [Uniform Data System for Medical Rehabilitation of Buffalo, NY], which is true for many in the industry, but we had to rethink who was collecting the information and how to match the changes in scoring rules and ensure the accuracy of the data," Kirk says.

Kirk says she agrees with many of the suggestions AMRPA has made with regard to improving the tool. "We’d like to see them delete unnecessary items that don’t relate to grouping and payment," Kirk explains.

Kessler Institute for Rehabilitation of West Orange, NJ, has fully implemented the tool since Jan. 1, 2002, for all Medicare patients, and mostly the change went smoothly, says Joan Alverzo, CRRN, MSN, vice president of clinical support services.

UB-92 conflicts with IRF-PAI

"We’re generally pleased CMS chose to use the functional independence measure [FIM] scores," Alverzo says. "But there are some problems with the new regulations, and the first one has to do with the UB-92 billing document and the kind of language it requires regarding coding as compared with the IRF-PAI document."

This is apparently a common concern among rehab providers, as the UB-92 document existed since before the inpatient rehabilitation prospective payment system (PPS) and it has not been updated to reflect changes in the assessment tool.

"So we have two systems that don’t connect in how we code patients," Alverzo says. "CMS is in the process of reviewing that, but currently we’re using two different nomenclatures or taxonomies of documents."

Kirk also notes that the discharge disposition and patient assessment instrument are very different from the coding CMS requires for the UB-92 bill, and this means it is not easy for facilities to translate the assessment data into a coding and billing system.

"So we struggle with that," Kirk says. "The language and things adopted in the PAI don’t line up with the other things that are required. You try to be efficient, and it impedes you from being as efficient as you would like."

In a recent letter to AMRPA, CMS acknowledges that there are some issues surrounding potential duplication and overlap with the UB-92.

"This is an issue that touches all our payment systems," CMS writes. "However, CMS considers it to be premature to make modifications to the instrument."

CMS adds, "Potential of collection processes is only one of the issues that must be considered in instrument revision."

Also, CMS plans to maintain the internal consistency of the instrument for a minimum of 12-18 months so data may be collected for the purposes of monitoring the system and assessing potential modifications to the instrument, the CMS letter states.

Making the transition to PPS was not as difficult as some rehab providers might have anticipated, despite the problems with the IRF-PAI.

"Compared with the transition to skilled nursing PPS, the rehab PPS was light-years easier," says Melinda Clark, president of SSM Rehab of St. Louis.

"As far as the IRF-PAI tool itself, we had to have internal checks and balances and audit functions in place to ensure staff aren’t making errors," Clark says. "But we thought it was going to be a lot worse than it was."

SSM Rehab put together a team that focuses on PPS and IRF-PAI, and there’s an auditing process that independently catches errors before the information is sent to CMS, Clark adds.

"We were very pragmatic in the way we approached the change and did historical work on the patients we admit. We looked at the coding processes to make sure we had the right checks and balances and time lines," Clark says.

Advance planning pays off

Glancy Rehabilitation Center, which is part of the Gwinnett Hospital System in Duluth, GA, spent more than two years planning and preparing for the PPS change, and the advance efforts have paid off, says Mona Lippitt, assistant director of Glancy Rehabilitation Center - Inpatient and Outpatient Rehab Program.

With the use of a multidisciplinary PPS team that included staff from billing, coding, and medical records, the rehab facility made a smooth transition into PPS and using the IRF-PAI tool, Lippitt says.

"We hired a nurse to be the PPS coordinator, and she has done a beautiful job," Lippitt says. "Her role is to coordinate the whole process, communicate with all disciplines, and meet daily with a medical records coder to review the documentation."

If the PPS coordinator sees a discrepancy in the IRF-PAI documentation, she will talk with the staff who completed the information and correct it before it’s sent to CMS, Lippitt adds.

Despite some improvements that could be made to the IRF-PAI, its problems are not AMRPA’s top priority, says Carolyn Zollar, JD, vice president for government relations at AMRPA.

For the most part, CMS has responded well to AMRPA’s suggestions regarding PPS, so while rehab providers would like to see the IRF-PAI honed to be more efficient and unburdensome, it’s not as big a problem as the 75% rule that rehab providers must follow, says Kenneth W. Aitchison, chief executive officer of Kessler Rehabilitation Corp. in West Orange, NJ. Aitchison also is the chairman of the AMRPA PPS task force.

The 75% rule is an exclusion criterion used to determine whether a rehab facility qualifies to be excluded from inpatient acute PPS. The rule requires rehab facilities to have at least 75% of patients within a recent 12-month reporting period to have a diagnosis in one of 10 categories: stroke, spinal cord injury, congenital deformity, amputation, major multiple trauma, fracture of the femur, brain injury, polyarthritis, neurological disorders, and burns.

AMRPA is more concerned about whether CMS will follow its suggestions to change the rehab 75% rule, which has been increasingly difficult for rehab facilities to adhere to since PPS was implemented, Aitchison says.

"The 75% rule is a far more important issue that has, frankly, the attention of virtually everyone in the field," Aitchison says.

AMRPA had requested that CMS review and reconsider the 75% rule in light of the other demands placed on rehab facilities operating under PPS. CMS has responded by asking regional offices and fiscal intermediaries how they collect data for the 75% rule, Aitchison and Zollar say.

"I fully expect that there will be sufficient information into CMS sometime in the third quarter where they can begin to come to a conclusion," Aitchison says. "The bottom line is that all patients being served in a rehab facility should be served in a rehab facility."

Need More Information?

  • Kenneth W. Aitchison, Chief Executive Officer, Kessler Rehabilitation Corp., 300 Executive Drive, West Orange, NJ 07052. Telephone: (888) 721-3214.
  • Joan Alverzo, CRRN, MSN, Vice President of Clinical Support Services, Kessler Institute for Rehabilitation, 1199 Pleasant Valley Way, West Orange, NJ 07052. Telephone: (973) 243-6840.
  • Melinda Clark, President, SSM Rehab, 6420 Clayton Road, St. Louis, MO 63126. Telephone: (314) 768-5362.
  • Peggy Kirk, BSN, Vice President of Operations of Day Rehab, Rehabilitation Institute of Chicago, 345 E. Superior St., Chicago, IL 60611. Telephone: (312) 238-3305.
  • Mona Lippitt, CTRS, Assistant Director of Glancy Rehabilitation Center - Inpatient and Outpatient Rehab Program, Gwinnett Hospital System, 3215 McClure Bridge Road, Duluth, GA 30096. Telephone: (678) 584-6793.
  • Carolyn Zollar, JD, Vice President for Government Relations, American Medical Rehabilitation Providers Association, 1606 20th St. NW, Suite 300, Washington, DC 20009. Telephone: (202) 265-4404. Web site: