CMS compliance
What is the 60%40% rule
CMS requires 60%of our patients beCMS compliant andthe 40% can be anydiagnosis
Patient comes in after being found down, has generalized weakness, requires min- mod A for mobility and diagnosed with Rhabdomyolysis. Name that RIC and is it CMS?
RIC: Other
How many therapy disciplines arerequired for apatient to qualify for IRF?
Any combination of 2: PT/OT/ SLP
What is the expected average turn around time fora prescreen to be completed?
2 hours
What are the conditions for a joint replacement to qualify for CMS diagnosis?
BMI >50, age >85y/o or Bilateraljoints
Patient comes inwith confusion,multiple falls withhead strike w/ LOC,UTI, Name that RIC
TBI
How many hours of therapy does each patient get daily? How many in a SNF?
3-3.5 hours daily; 14 mins on average in a SNF
Who is responsible for sending the prescreen to the physician?
Admissions liaison
Are all Neuro RICs CMS-13?
No, not all neurodiagnoses are CMScompliant; extlumbar surgery withradiculopathy=neuro diagnosis, buttypically not codedout as CMS.
Bilateral pubic rami fracture with disruption of the pelvic ring; Name that RIC
Hip fracture/fracture of femure
A patient only needs SLP and OT; do they meet criteria?
YES! it can be any combination of two therapies PT/OT/ SLP
Who is responsible for communicating with the Case manager?
BOTH AL and RLs are responsible; ALs in careport and RLs in the field
What are the 13 CMS categories?
Stroke, SCI, Congenital deformity, Amputation, MMT, Major multiple fracture, Hip fracture, TBI, Neurological, Burns, Arthritis, Systemic Vasculitis, Joint replacement
Patient present for R THA is 78 y/o and has a histroy of CVA- with no residual deficits, CKD, and CHF; Name that RIC and is it CMS?
Ortho other- would need other complications post op; cannot be stroke due to no residual deficits
A case manager is hesistant to send a referral because he/she do not think the patient will be independent in 7-10 days; Does the patient need to be independent at time of discharge from Encompass? How would you navigate the conversation?
No, the patient does not need to be independent at discharge.
A physician signed a prescreen, but I am not sure if the patient meets criteria, What do I do?
Call Lauren, Jon, or Diana; Discuss it with your AL
What happens if we are non compliant with CMS ? Is this monthly, quarterly, or yearly?
Our Medicare license could be removed and the hospital could have to pay back Medicare dollars.
Metabolic encepholpahty; patient is alert and oriented x3 and being treated for AKI, generalized weakness and chronic CHF
RIC; NTBI, but may not code out at CMS due to patient being alert and oriented
A patient is supervision level for mobility, however requires min A for dressing and bathing; Does this patient meet the criteria for IRF?
It depends on how it is documented; does the patient need rest breaks? Did the patient have LOB? Are they using a walker and they did not previously? PT needs to be justified for skilled intervention, supervision is not a skilled intervention.
Who is the physician suppose to communicate with if he/she has quesitons on a patient?
The AL! The AL is responsible for knowing their caseload and the patients they are pulling in; If the AL does not have the answer the AL will reach out to the RL.