Transcript Case_Mix_Index

Managing the Case Mix Index
Lisa Bazemore, MBA, MS, CCC-SLP
Director of Consulting Services
Objectives
1. The participant will understand the components of the case
mix group and how Functional Independence Measures (FIM)
scoring affects the payment for a inpatient rehabilitation stay.
2. The participant will be able to explain the concept of burden of
care and describe how it is captured by the FIM instrument.
3. The participant will have performance management tools for
improving facility reimbursement through proper assignment
of the case mix group.
Basics
• Discharge-based system
 Payment is based on discharge information
• Single lump payment for each stay
• Case Mix Groups (CMG)
 87 main groups
 4 deaths
 1 short stay
Case Mix Groups
• All inclusive* payment for each patient
• 353 payment categories
• The base rate from the government
 Range of average discharge rates $5,800 - $37,500
with no co-morbidity
 Range of average discharge rates $8,300 – $54,000
with the highest co-morbidity
* Blood transfusion excluded and certain medical education costs
CMG - Case Mix Group
• Components:
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Rehab Impairment Classification
Comorbidities
FIM
Age
Comorbidity
• Definition:
 Specific patient condition secondary to principal
diagnosis or impairment
 Considered in context of principal diagnosis
• More than one comorbidity possible but does not include
additional reimbursement
• Presence of comorbidity could impact cost of patient care
Comorbidity Impact
RIC - 01 - Stroke
Comorbidities
Reimbursement
None
$20,151.20
Tier 3 – ex., Systolic Heart Failure
$20,574.90
Tier 2 – ex., C-diff
$23,160.48
Tier 1 – ex., Dialysis
$24,402.22
Replacement Of
Lower Extremity Joint
Motor > 49.55
Motor > 37.05 & < 49.55
Replacement
of Lower
Extremity Joint
Motor > 28.65 & < 37.05
& Age > 83.5
Motor > 28.65 & < 37.05
& Age < 83.5
Motor > 22.05 & < 28.65
Motor < 22.05
0801 ALOS W/O CM 6
Relative Wt. .4596
$2696.80
0802 ALOS W/O CM 8
Relative Wt. .6004
$4602.25
0803 ALOS W/O CM 12
Relative Wt. .8901
$8811.58
0804 ALOS W/O CM 10
Relative Wt. .7754
$7676.10
0805 ALOS W/O CM 13
Relative Wt. .9763
$12169.01
0806 ALOS W/O CM 15
Relative Wt. 1.1716
$17524.58
Ways We Use FIM Data
• Establish CMG
• Measure Change (Outcomes)
• Compare ourselves to other program
Purpose
 “The FIM instrument is intended to measure what the
person with disability actually does, whatever the diagnosis
or impairment, not what (s)he ought to be able to do, or
might be able to do under different circumstances.” (IRFPAI Training Manual Interim Version 10/03/01 page III-1)
Burden of Care
• The Concept of Burden of Care:
 Refers to type and amount of assistance
required for a disabled individual to perform
basic life activities effectively
 The question is: How much assistance does the
individual receive from another person or by the
use of an assistive device?
Weighted Motor Score Index
Item
Weight
Eating
.6
Grooming
.2
Bathing
.9
Dressing – Upper Body
.2
Dressing – Lower Body
1.4
Toileting
1.2
Bladder
.5
Bowel
.2
Transfer Bed, Chair, W/C
2.2
Transfer Toilet
1.4
Transfer Tub, Shower
Not included as
item for CMG
Locomotion
1.6
Stairs
1.6
Total Maximum Motor Score – 84
Total Minimum Motor Score – 12 (“0’s”
convert to “1’s” for CMG
determination)
If Transfer to Toilet coded “0” – will be
converted to a “2”
Motor Score Index
Item
Eating
Grooming
Bathing
UB Dressing
LB Dressing
Toileting
Bladder
Bowel
Transfer Bed, Chair, W/C
Transfer Toilet
Transfer Tub/Shower
Locomotion
Stairs
Total
Score
Weight
Value
5
5
4
4
3
4
1
5
3
4
4
2
2
.6
.2
.5
.2
1.4
1.2
.5
.2
2.2
1.4
3
1
2
.8
4.2
4.8
.5
1
6.6
5.6
1.6
1.6
3.2
3.2
37.5
Scoring Time Frames
• Most FIM items - Assessment period = 3 calendar days
• Function Modifiers - Bladder Frequency of Accidents & Bowel Frequency of
Accidents = 7 day assessment period
 Admission assessment timeframe includes 4 days prior to rehab
admission plus first 3 days in rehab
Scoring Time Frames
• Discharge Assessment Time Frame encompasses the day of discharge and
the 2 calendar days prior to the day of d/c.
• “Should reflect the lowest functional score within any 24-hour period
within the 3 calendar days comprising the discharge assessment”.
 Bowel and Bladder Frequency of Accidents still require 7 day
look back
 Bowel and Bladder Level of Assistance still require 3 day look
back.
Keys to Success
• Accuracy of FIM scoring based on 24 hour per day and
7/day per week patient performance
• Timeliness of scoring
• Documentation must support scoring
Breaking Down the CMI
Are we getting paid for the work that we do?
 Does it seem like your CMI is lower than your burden of
care?
• Capturing the proper CMI is essential to enable you to
staff appropriately.
• Since many of us predict staffing ratios based on patient
acuity as realized through the CMI, it is important to
capture what most closely reflects the care being
rendered on the unit.
Breaking Down the CMI
FIM Scoring:
• Evaluate your admission FIM scores
• How does your admission FIM score compare to those in
your region and across the nation?
Breaking Down the CMI
• FIM Scoring:
 How do you compare to the weighted averages?
 How do you compare to the unweighted averages?
 How do you know which one to use?
Breaking Down the CMI
• FIM Scoring:
 Identify the FIM items that are consistently falling outside of
range
• FIM progression warnings
• FIM comparison graphs
 Train staff
• Full item FIM training annually or greater
• Proficiency testing annually or greater
• Performance improvement plans to work on items outside
of range
• FIM scoring hints in staff lounge areas
 Communicate findings
• Give staff reports of scoring averages and performance on
individual items
Difficult to Score Items
• Bladder Level of Assistance:
 Includes complete and intentional control of the urinary
bladder and, if necessary, use of the equipment or agents for
bladder control.
 Do NOT use code “0”
 If patient does not void due to renal failure and is on dialysis,
score as a 7 – Complete Independence
Difficult to Score Items
• Bladder Level of Assistance:
 At level 7 –
• Controls bladder completely and intentionally without
equipment or devices
• Is never incontinent
Difficult to Score Items
• Bladder Level of Assistance:
 At level 6 –
• Needs urinal, bedpan, catheter, absorbent pad, diaper,
urinary collecting device, or urinary diversion
• If catheter is used, patient cleans, sterilizes, and sets up
the equipment for irrigation without assistance
• If patient uses a device, assembles and applies device
without assistance of another person
• Patient empties, removes, puts on, and cleans device
• Uses medication for control
• Has no accidents
Difficult To Score Items
• Urinal Scoring:
 6 – Patient retrieves urinal and empties it
 5 – Urinal is set-up and/or is emptied by helper
 4 – Patient needs help placing urinal in appropriate position,
includes touching
Difficult To Score Items
• Bladder Scoring Hints:
• 4 – Assistance with application of external catheter but
can do rest of tasks – emptying and managing bags and
tubing
• 4 – Needs only incidental help such as placement of
equipment in his/her hand or help to performs just one of
several tasks included in bladder management
• 3 – Requires help to insert catheter, emptying, managing
bags & tubing
• 1 – Timed voiding programs
• 1 – Helper changes patient’s absorptive pad
Difficult To Score Items
• Function Modifier-Bladder Frequency of Accidents:
 Act of wetting linen or clothing with urine and includes bedpan
and urinal spills
• 7 - No accidents
• 6 - No accidents; uses device such as catheter, medication
• 5 - One bladder accident including bed pan and urinal spills
in the past 7 days
• 4 - Two bladder accidents including bed pan and urinal spills
in the past 7 days
• 3 - Three bladder accidents including bed pan and urinal
spills in the past 7 days
• 2 - Four bladder accidents including bed pan and urinal spills
in the past 7 days
• 1 - Five or more bladder accidents including bed pan and
urinal spills in the past 7 days
Difficult To Score Items
• Bowel Management:
 Includes complete and intentional control of bowel
movements
• including use of equipment or agents for control
 FIM score is the lower of the scores for Level of Assistance
and Frequency of Accidents
 Do not use code “0” for Bowel Level of Assistance or
Frequency of Accidents
Difficult To Score Items
• Bowel Management-Level of Assistance:
 At level 7 –
• Controls bowel completely and intentionally
• Never incontinent
 At level 6 –
• Requires bedpan, digital stimulation or stool softeners,
suppositories, laxatives, or enemas on a regular basis
• Uses other medications for control
Difficult To Score Items
• Suppository Scoring:
 6 – Pt. self inserts
 5 – Setup of supplies
 4 – Helper lubricates and inserts suppository
 1 – Pt. needs help with positioning, placement of absorptive
pad, lubrication and insertion of suppository, and help to
evacuate the bowel
Difficult To Score Items
• Function Modifier-Bowel Frequency of Accidents:
 Act of soiling linen or clothing with stool (includes bedpan
spills)
• 7- No accidents
• 6- No accidents; uses device such as ostomy,
medications, devices
• 5- One accident in the past 7 days
• 4- Two accidents in the past 7 days
• 3- Three accidents in the past 7 days
• 2- Four accidents in the past 7 days
• 1- Five or more accidents in the past 7 days
Difficult To Score Items
• Lower Body Dressing:
 Dressing and undressing from the waist down, as well as
applying and removing prosthesis
 Must use clothing that is appropriate to wear in public
 Commercially obtained sneakers with Velcro closures are not
considered an adaptive device
 Includes dressing and undressing from the waist down
 Applying and removing a prosthesis or orthosis when
applicable
 Assess all of the steps that are performed
Difficult To Score Items
• Lower Body Dressing:
 Lower limb prosthesis• If applied by patient and patient does not use the
prosthesis as a device and no other assistance is needed
–7
• If applied by patient and patient does use as device – 6
• If applied by helper and no other assistance is needed –
5 – set-up
Difficult To Score Items
• Lower Body Dressing:
 If patient dresses himself in bed, only needs helper to bring
him his clothes, then 5 – setup
 If patient dresses himself while standing and requires helper
for steadying assistance – 4 – minimal contact assistance
 Assistance with putting on anti-embolic stockings
(compression stockings) is considered a set-up - level 5
Difficult To Score Items
• Toileting:
 3 Activities
• Adjusting clothing before toilet use
• Cleansing
• Adjusting clothing after toilet use
 Use of bedpan – addressed under items of Bladder
Management and/or Bowel Management and Transfers
Difficult To Score Items
• Transfers: Bed, Chair, Wheelchair:
 Includes all aspects of transferring to and from a bed, chair
and wheelchair
 Including coming to a standing position if walking is the
typical mode of locomotion.
 During the bed-to-chair transfer, the patient begins and ends
in the supine position
 Lifting limbs: Lifting limbs:
• Assistance with one limb only - Level 4
• Assistance with two limbs - Level 3
Difficult To Score Items
• Wheelchair Transfers:
 7 – Transfers in a safe and timely manner with no device
 6 – Uses part of wheelchair in transfer, takes more than a
reasonable amount of time
 5 – Assistance provided in locking brakes, positioning of chair
 4 – Steadying assistance given, or help with one limb
 3 – Helper provides assistance in lifting body
 2 – Lot of assistance needed in lifting body
 1 – Patient does not help or unable to bear weight
Breaking Down the CMI
• Determine what percentage of the time you are scoring
a tiering comorbidity
Top Tiering Comorbidities
• Tier 1
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V45.1 RENAL DIALYSIS STATUS
V44.0 TRACHEOSTOMY STATUS
V55.0 ATTEN TO TRACHEOSTOMY
478.31 VOCAL PARAL UNILAT PART
478.33 VOCAL PARAL BILAT PART
478.6 EDEMA OF LARYNX
478.32 VOCAL PARAL UNILAT TOTAL
478.34 VOCAL PARAL BILAT TOTAL
Top Tiering Comorbidities
• Tier 2
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787.2 DYSPHAGIA
008.45 INT INF CLSTRDIUM DFCILE
041.7 PSEUDOMONAS INFECT NOS
438.82 LATE EF CV DIS DYSPHAGIA
579.3 INTEST POSTOP NONABSORB
008.42PSEUDOMONAS ENTERITIS
Top Tiering Comorbidities
•Tier 3 (Top 30)
278.01 MORBID OBESITY
357.2 NEUROPATHY IN DIABETES
250.60 DMII NEURO NT ST UNCNTRL
486.7 PNEUMONIA, ORGANISM NOS
584.9 ACUTE RENAL FAILURE NOS
682.6 CELLULITIS OF LEG
342.90 UNSP HEMIPLGA UNSPF SIDE
998.59 OTHER POSTOP INFECTION
415.19 PULM EMBOL/INFARCT NEC
250.40 DMII RENL NT ST UNCNTRLD
250.80 DMII OTH NT ST UNCNTRLD
515. POSTINFLAM PULM FIBROSIS
250.70 DMII CIRC NT ST UNCNTRLD
250.50 DMII OPHTH NT ST UNCNTRL
507.0 FOOD/VOMIT PNEUMONITIS
•Tier 3 (Top 30)
995.91 SIRS-INFECT W/O ORG DYSF
518.81 ACUTE RESPIRATRY FAILURE
998.32 DISRUP-EXTERNAL OP
WOUND
250.62 DMII NEURO UNCNTRLD
342.91 UNSP HEMIPLGA DOMNT SIDE
038.9 SEPTICEMIA NOS
682.3 CELLULITIS OF ARM
342.80 OT SP HMIPLGA UNSPF SIDE
342.92 UNSP HMIPLGA NONDMNT
SDE
250.01 DMI WO CMP NT ST UNCNTRL
518.5 POST TRAUM PULM INSUFFIC
042. HUMAN IMMUNO VIRUS DIS
284.1 PANCYTOPENIA
434.91 CRBL ART OCL NOS W INFRC
428.30 DIASTOLC HRT FAILURE NOS
Breaking Down the CMI
• Pay attention to the most commonly used comorbidity
lists
Breaking Down the CMI
• Pull reports to show your CMG breakdown
• Are you missing high acuity patients, low acuity patients?
Breaking Down the CMI
• Pay attention to the warnings to tell you when there is a
mismatch between IGC and Etiologic diagnosis
Breaking Down the CMI
• Action Plan Suggestions:
 Start with the documentation. Review charts to determine if
your physicians are including IGC and etiologic conditions in
their H&P. Are they correct?
 Are all conditions being treated diagnosed in the physician
assessments, consults, or progress notes? Audit, inservice,
and follow-up.
 Ensure that the coders are on top of the rehab coding
process.
Breaking Down the CMI
• Action Plan Suggestions:
 Communicate with the coders to be certain that the
physician’s documentation is adequate enough to provide
them with what is needed to select the most specific codes.
 Inservice staff on FIM scoring regularly. Utilize proficiency
exams.
 Focus on staff education for accurate FIM scoring.
Questions?
Lisa Bazemore, MBA, MS, CCC-SLP
[email protected]
(202) 588-1766