Alicia:Q: Can anyone elaborate on IRF coding?
A: This was pretty interesting because I had to do some research on IRF coding. It wasn’t something I was familiar with.
So what does IRF stand for? The first thing you need to know is it’s inpatient rehabilitation facility (IRF) coding. It is, I want to say, a different ballgame, is what I’m trying to say. It can be a challenge due to Medicare Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS). Now, the acronym for that is IRF PPS. This was implemented way back in 2002 to cover patients paid under Medicare Part A.
What IRF PPS requires is a completion of the IRF-Patient Assessment Instrument. Now, I’m going to be repeating this more and more, but I’m just going to use the acronym and that is called the PAI. It’s a data collection form that’s completed on admission and discharge. The conditions reported on the UB-04 (the form that’s sent in for inpatient billing) and the IRF-PAI differ, and as do the guidelines for code assignment.
These two, UB-04 and IRF-PAI kind of butt heads as we’ll show you here in just a minute. They don’t always match. So, what you put on the form to get paid for inpatient, the UB-04 and what’s put on the IRF-PAI — they aren’t going to be the same a lot of the times.
A measure was developed by the American Academy of Physical Medicine and Rehab way back in the 1980s and the American Congress of Rehab Medicine did this. It is the FIM or Functional Independence Measure. All of these abbreviations can really get you.
IRF Coding – Video
There is a link to these. There’s the IRF-PAI Training Manual, you have the Prospective Payment System (IRF PPS). You can look at that and that’s what you use to fill out these forms.
What is the PAI? CMS provides payment for inpatient rehab facilities through case-mix groups. Now, what they’re going to do is the information is collected on the IRF-PAI during the first three days of admission when they first get there, and include the impairment that the patient has, the FIM score, and the age of the patient. Those are all pertinent. This information is used to classify the patient into a case-mix group.
There are four payment tiers to each case-mix – that’s important to know.
Well, when you get to doing this IRF, there are a lot of challenges that I found. The guidelines change and then they’re not in the training manual on a timely basis. You know how the manuals we get for our coding come out every year, this is a different ballgame and it doesn’t come out in a timely manner.
There’s limited education available. The training is not focused on ICD-9-CM assignment. So, the training that you do get is training not how to code, like you would get with ICD-9 training. It’s just about pretty much how to fill out these forms.
They have different guidelines. The IRF-PAI has different guidelines than the UB-04 forms. Now, if you’ve never looked at a UB-04 form, it’s similar to the CMS 1500 that we’re used to for physician-based billing except that it’s longer because it allows for a lot diagnoses in there. So, you can imagine you’ve got the UB-04 form and then what the IRF-PAI looks like.
The documentation doesn’t always focus on impairment or etiology. That’s one of the problems of the documentation that they’re given and that’s what the IRF-PAI is based on. And the communication between the clinicians and the coders can be a problem when you’re dealing with the IRF-PAI.
Example of reporting, this is an excellent example of how this would happen: Conditions first discovered or identified on the day prior to or the day of discharge are reported on the UB-04 but not on the IRF-PAI. Conditions reported as acute by a short-term acute care hospital are reported as status post, late effects, et cetera. (That’s the way they’re going to be reported)
This is confusing for coders that code for both an acute care hospital and a rehabilitation unit.
The code reported on the UB-04 as the principal diagnosis, say, V57.89, admission for rehabilitation, is not reported on the IRF-PAI because it does not provide diagnostic information.
Example of Communication: A patient who is admitted following a CVA and a hip fracture. Either impairment could be reported by the [Impairment Group Code] IGC. If the hip fracture is reported as the impairment, the etiology should be reported with a code for hip fracture. Clinicians and coding professionals need to effectively communicate so sufficient documentation is available to support accurate code assignments.
That is very important when we’re dealing with these two separate entities.
What should a coder do? Here are a few things to keep in mind: Stay up to date with CMS changes that affect code assignments – that means, be on top of ICD-9 and ICD-10. Keep current IRF training manual – so you always want to have the current. When all the new stuff comes out you have the new manual. Keep current on conditions in the 75% rule and network with others.
Again, that is across the broad, any type of coding that you do. You want to have a network in place so that you guys can assist each other.
I just wanted to make a point that this Patricia Trela, her article that she wrote was absolutely fascinating and where I got most of this information, very knowledgeable. I enjoyed it very much reading and learning more about that.