66304 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Health Care Financing Administration

42 CFR Parts 412 and 413

[HCFA–1069–P]

RIN 0938–AJ55

Medicare Program; Prospective

Payment System for Inpatient

Rehabilitation Facilities

AGENCY: Health Care Financing

Administration (HCFA), HHS.

ACTION: Proposed rule.

SUMMARY: This proposed rule would

establish a prospective payment system

for Medicare payment of inpatient

hospital services provided by a

rehabilitation hospital or by a

rehabilitation unit of a hospital. This

proposed rule would implement section

1886(j) of the Social Security Act (the

Act), as added by section 4421 of the

Balanced Budget Act of 1997 (Public

Law 105–33) and as amended by section

125 of the Balanced Budget Refinement

Act of 1999 (Public Law 106–113),

which authorizes the implementation of

a prospective payment system for

inpatient rehabilitation hospitals and

rehabilitation units. It also authorizes

the Secretary to require rehabilitation

hospitals and rehabilitation units to

submit such data as the Secretary deems

necessary to establish and administer

the prospective payment system. The

prospective payment system described

in this proposed rule would replace the

reasonable cost-based payment system

under which the rehabilitation hospitals

and rehabilitation units are currently

paid.

DATES: We will consider comments if

we receive them at the appropriate

address, as provided below, no later

than 5 p.m. on January 2, 2001.

ADDRESSES: Mail written comments (one

original and three copies) to the

following address ONLY:

Health Care Financing Administration,

Department of Health and Human

Services, Attention: HCFA–1069–P,

P.O. Box 8010, Baltimore, MD 21244–

8010.

If you prefer, you may deliver your

written comments (one original and

three copies) to one of the following

addresses:

Room 443–G, Hubert H. Humphrey

Building, 200 Independence Avenue,

SW, Washington, DC 20201; or Room

C5–14–03, Central Building, 7500

Security Boulevard, Baltimore, MD

21244–1850.

Comments mailed to the delivery

addresses may be delayed and could be

considered late.

FOR FURTHER INFORMATION CONTACT:

Robert Kuhl, (410) 786–4597 (General

information).

Pete Diaz, (410) 786–1235

(Requirements for completing the

Minimum Data Set for Post Acute

Care (MDS–PAC), and other MDS–

PAC issues).

Jacqueline Gordon, (410) 786–4517

(Payment system, the case-mix

classification methodology, transition

payments, relative weights/case-mix

index, update factors, transfer

policies, payment adjustments).

Nora Hoban, (410) 786–0675

(Calculation of the payment rates,

relative weights/case-mix index, wage

index, payment adjustments).

SUPPLEMENTARY INFORMATION:

Comments, Procedures, Availability of

Copies, and Electronic Access

Because of staffing and resource

limitations, we cannot accept comments

by facsimile (FAX) transmission. In

commenting, please refer to file code

HCFA–1069–P.

Comments received timely will be

available for public inspection as they

are received, generally beginning

approximately 3 weeks after publication

of a document, in Room 443–G of the

Department’s office at 200

Independence Avenue, SW.,

Washington, DC, on Monday through

Friday of each week from 8:30 a.m. to

5 p.m. (Phone: (202) 690–7890).

Copies: To order copies of the Federal

Register containing this document, send

your request to: New Orders,

Superintendent of Documents, P.O. Box

371954, Pittsburgh, PA 15250–7954.

Specify the date of the issue requested

and enclose a check or money order

payable to the Superintendent of

Documents, or enclose your Visa or

Master Card number and expiration

date. Credit card orders can also be

placed by calling the order desk at (202)

512–1800 or by faxing to (202) 512–

2250. The cost for each copy is $8. As

an alternative, you can view and

photocopy the Federal Register

document at most libraries designated

as Federal Depository Libraries and at

many other public and academic

libraries throughout the country that

receive the Federal Register. This

Federal Register document is also

available from the Federal Register

online database through GPO Access, a

service of the U.S. Government Printing

Office. The Website address is: http://

www.access.gpo.gov/nara/index.html.

To assist readers in referencing

sections contained in this document, we

are providing the following table of

contents.

Table of Contents

I. Background

A. Overview of Current Payment System

for Inpatient Rehabilitation Facilities

B. Research for Alternate Prospective

Payment Systems for Inpatient

Rehabilitation Facilities Prior to the

Balanced Budget Act of 1997

C. Requirements of the BBA and the BBRA

for Inpatient Rehabilitation Facilities

D. Policy Objectives in Developing a

Prospective Payment System for

Inpatient Rehabilitation Facilities

E. Discussion of Evaluated Options for the

Prospective Payment System for

Inpatient Rehabilitation Facilities

F. Inpatient Rehabilitation Facility

Prospective Payment System—General

Overview

G. Applicability of the Inpatient

Rehabilitation Facility Prospective

Payment System

II. Current Research to Support the

Establishment of the Inpatient

Rehabilitation Prospective Payment

System—Update of RAND Analysis

A. Overview of the Updated Work for the

Proposed Rule

B. Construction of Data File for Analysis

C. Description of Sources of the Data File

D. Description of the Methodology Used to

Construct the Data File

E. Representativeness of the Data File

F. Analyses to Support Future Adjustments

to the Payment System

III. The Minimum Data Set for the Post Acute

Care (MDS–PAC) Patient Assessment

Instrument

A. Implementation of the MDS–PAC

B. Overview of MDS–PAC Assessment

Process

C. The MDS–PAC Assessment and Medical

Necessity

D. The MDS–PAC Assessment Reference

Date

E. Performing the MDS–PAC Assessment

F. The MDS–PAC Assessment Schedule

G. Computerization of the MDS–PAC Data

H. Quality Monitoring

I. MDS–PAC Training and Technical

Support for IRFs

J. Patient Rights

K. Medical Review Under the IRF

Prospective Payment System

IV. Case-Mix Group Case Classification

System

A. Background

B. Case-Mix Groups

V. Payment Rates

A. Development of CMG Relative Weights

B. Transfer Payment Policy

C. Special Cases that Are Not Transfers

D. Adjustments

E. Calculation of the Budget Neutral

Conversion Factor Minus Two Percent

F. Development of the Federal Prospective

Payment

G. Examples of Computing the Adjusted

Facility Prospective Payments

H. Computing Total Payments During

Fiscal Year 2001

I. Method of Payment

J. Update to the Adjusted Facility Federal

Prospective Payment

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66305

VI. Provisions of the Proposed Rule

VII. Response to Comments

VIII. Regulatory Impact Statement

A. Background

B. Anticipated Effects of this Proposed

Rule

C. Alternatives Considered

IX. Collection of Information Requirements

Regulations Text

Appendix A—Technical Discussion of Cases

and Facilities Used in RAND Analysis

Appendix B—Variables Suggested for

Exclusion from the MDS-PAC Instrument

Appendix BB—Patient Assessment

Instrument: Minimum Data Set for Post

Acute Care; Version 1

Appendix BBB—Item-by-Item Guide to the

Minimum Data Set for Post Acute Care

(MDS–PAC)

Appendix C—List of Comorbidities

Appendix D—IRF Market Basket

In addition, because of the many

terms to which we refer by acronym in

this proposed rule, we are listing these

acronyms and their corresponding terms

in alphabetical order below:

ADL—Activities of Daily Living

BBA—Balanced Budget Act of 1997,

Public Law 105–33

BBRA—Balanced Budget Refinement

Act of 1999, Public Law 106–113

CMGs—case-mix groups

CMI—case-mix index

COS—Clinical Outcomes Systems

DRGs—diagnosis-related groups

FIM—functional independence measure

FIM—FRG-functional independence

measurement-function related group

FRG—Function Related Group

FY—Federal fiscal year

HCFA—Health Care Financing

Administration

HHAs—home health agencies

HMO—health maintenance organization

IRF—inpatient rehabilitation facilities

MDCN—Medicare Data Collection

Network

MDS—PAC-Minimum Data Set for Post

Acute Care

MedPAC—Medicare Payment Advisory

Commission

MEDPAR—Medicare provider analysis

and review

MPACT—MDS–PAC Tool—Minimum

Data Set for Post Acute Care Tool

OASIS—Outcome and Assessment

Information Set

ProPAC—Prospective Payment

Assessment Commission

RICs—Rehabilitation Impairment

Categories

SNF—skilled nursing facility

TEFRA—Tax Equity and Fiscal

Responsibility Act of 1982, Public

Law 97–248

UDSmr—Uniform Data Set for medical

rehabilitation

Y2K—Year 2000/Millennium

I. Background

When the Medicare statute was

originally enacted in 1965, Medicare

payment for hospital inpatient services

was based on the reasonable costs

incurred in furnishing services to

Medicare beneficiaries. The statute was

later amended by section 101(a) of the

Tax Equity and Fiscal Responsibility

Act of 1982 (Public Law 97–248) to limit

payment by placing a limit on allowable

costs per discharge. Section 601 of the

Social Security Amendments of 1983

(Public Law 98–21) added a new section

1886(d) to the Social Security Act (the

Act) which replaced the reasonable costbased payment system for most hospital

inpatient services. Section 1886(d) of

the Act provides for a prospective

payment system for the operating costs

of hospital inpatient stays effective with

hospital cost reporting periods

beginning on or after October 1, 1983.

Although most hospital inpatient

services became subject to a prospective

payment system, certain specialty

hospitals were excluded from that

system. As discussed in detail in section

I.A.1 of this preamble, rehabilitation

hospitals and distinct part rehabilitation

units in hospitals were among the

excluded facilities. Subsequent to the

implementation of the hospital inpatient

prospective payment system, both the

number of excluded rehabilitation

facilities, particularly distinct part units,

and Medicare payments to these

facilities grew rapidly. In order to

control escalating costs, the Congress,

through enactment of section 4421 of

the Balanced Budget Act of 1997 (BBA)

(Public Law 105–33) and section 125 of

the Balanced Budget Refinement Act of

1999 (BBRA) (Public Law 106–113),

provided for the implementation of a

prospective payment system for

inpatient rehabilitation facilities.

Section 4421 of the BBA amended the

Act by adding section 1886(j), which

authorizes the implementation of a

prospective payment system for

inpatient rehabilitation services. This

proposed rule would implement a

Medicare prospective payment system,

as authorized by section 1886(j) of the

Act, for inpatient rehabilitation

hospitals and units. We refer to these

inpatient rehabilitation hospitals and

units as ‘‘inpatient rehabilitation

facilities’’ or ‘‘IRFs’’ throughout this

proposed rule.

The statute provides for the

prospective payment system for IRFs to

be implemented for cost reporting

periods beginning on or after October 1,

2000. The statute also provides for a

new prospective payment system for

home health services for cost reporting

periods beginning on or after October 1,

2000, along with modifications to the

existing prospective payment systems

for acute care hospitals and skilled

nursing facilities.

Although we are working very hard to

implement the extensive changes

required by the statute, the demands of

simultaneously implementing new

prospective payment systems (for

example, outpatient hospital and home

health) and modifying existing payment

systems are significant. The creation of

each new payment system or

modification to an existing payment

system requires an extraordinary

amount of lead time to develop and

implement the necessary changes to our

existing computerized claims processing

systems. In addition, it requires

additional time after implementation to

ensure that these complex changes are

properly administered. After an

extensive analysis of the changes

required to HCFA’s systems, we have

concluded that it is infeasible to

implement the IRF prospective payment

system as of October 1, 2000. Therefore,

we plan to implement the IRF

prospective payment system for cost

reporting periods beginning on or after

April 1, 2001. We believe that this

implementation date is the earliest

feasible date given the scope and

magnitude of the implementation

requirements associated with this and

other mandated provisions.

In this proposed rule, we provide a

number of discussions useful in

understanding the development and

implementation of the IRF prospective

payment system. These discussions

include the following:

• An overview of the current payment

system for IRFs.

• A discussion of research on IRF

patient classification systems and

prospective payment systems, including

prior and current research performed by

the RAND Corporation.

• A discussion of statutory

requirements for developing and

implementing an IRF prospective

payment system.

• A discussion of the proposed

requirement that IRFs complete the

Minimum Data Set for Post Acute Care

(MDS–PAC) (a patient assessment

instrument) as a part of the data

collection deemed necessary by the

Secretary to implement and administer

the IRF prospective payment system.

• A discussion of the IRF patient

classification system using case-mix

groups (CMGs).

• A detailed discussion of the

proposed prospective payment system

including the relative weights and

payment rates for each CMG,

adjustments to the payment system,

additional payments, and budget

66306 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

neutrality requirements mandated by

section 1886(j).

• An analysis of the impact of the IRF

prospective payment system on the

Federal budget and inpatient

rehabilitation facilities, including small

rural facilities.

Finally, we are proposing conforming

changes to existing regulations as well

as new regulations that are necessary to

implement the proposed IRF

prospective payment system.

A. Overview of Current Payment System

for Inpatient Rehabilitation Facilities

1. Exclusion of Certain Facilities From

the Hospital Inpatient Prospective

Payment System

Although payment for operating costs

of most hospital inpatient services

became subject to a prospective

payment system when the hospital

inpatient prospective payment system

was implemented in October 1983,

certain types of specialty hospitals and

units were excluded from that payment

system. As set forth in section

1886(d)(1)(B) of the Act, the following

hospitals were originally excluded from

the hospital inpatient prospective

payment system: psychiatric,

rehabilitation, children’s, and long-term

care. Effective with cost reporting

periods beginning on or after October 1,

1989 cancer hospitals were added to

this list by section 6004(a) of the

Omnibus Budget Reconciliation Act of

1989 Public Law (101–239). In addition,

psychiatric and rehabilitation distinct

part units of hospitals are excluded from

the hospital inpatient prospective

payment system.

These specialty hospitals were

excluded by the Congress from the

hospital inpatient prospective payment

system because they typically treat cases

that involve lengths of stay that are, on

average, longer or more costly than

would be predicted by the diagnosis

related group (DRG) system and,

therefore, could be systematically

underpaid if the DRG system was

applied to them. These exclusions were

the result of concerns that DRGs—the

classification system on which payment

under the hospital inpatient prospective

payment system is based—might not

accurately account for the resource costs

for the types of patients treated in those

facilities.

The concern that DRGs might not

accurately account for costs in excluded

hospitals arose because the hospital

inpatient prospective payment system

was developed from the cost and

utilization experience of general

hospitals, which typically provide acute

care for a variety of medical conditions.

The hospital inpatient prospective

payment system is a system of averagebased payments that assume that some

patient stays will consume more

resources than the typical stay, while

others will demand fewer resources.

Thus, an efficiently operated hospital

should be able to deliver care to its

Medicare patients for an overall cost

that is at or below the amount paid

under the hospital inpatient prospective

payment system. In a Report to

Congress: Hospital Prospective Payment

for Medicare (1982), the Department of

Health and Human Services stated that

the ‘‘467 DRGs were not designed to

account for these types of treatment’’

found in the four special classes of

hospitals, and noted that ‘‘including

these hospitals will result in criticism

* * * (and) their application to these

hospitals would be inaccurate and

unfair.’’

Accordingly, this report to the

Congress suggested that a DRG system

might not work as well for these

treatment classes as they did for other

medical specialties. One concern was

that the resource needs of patients in

these excluded hospitals were not solely

correlated with diagnoses. A second

concern was that the mix of service

intensities provided by these specialty

hospitals significantly differed from that

of general medical/surgical hospitals.

The legislative history of the 1983

amendments to the Act stated that the

‘‘DRG system was developed for shortterm acute care general hospitals and as

currently constructed does not

adequately take into account special

circumstances of diagnoses requiring

long stays.’’ (Report of the Committee on

Ways and Means, U.S. House of

Representatives, to Accompany HR

1900, H.R. Rep. No. 98–25, at 141

(1983)).

Following enactment in April 1983 of

the Social Security Amendments of

1983, we undertook a number of

initiatives to ensure implementation of

the hospital inpatient prospective

payment system by October 1, 1983.

Important activities included the

publication of the rules and regulations

for the hospital inpatient prospective

payment system. The interim final rule

was published in the September 1, 1983

Federal Register (48 FR 39752). We

published a final rule in the January 3,

1984, Federal Register (49 FR 234)

following a public comment period,

evaluation of comments received, and

formulation of responses to and

regulatory revisions to the regulations

based upon the comments. Updates and

modifications of the regulations are

published annually in the Federal

Register. Together, the initial statutory

mandate and the published regulations

addressed several important program

issues. One program issue was the

implementation of the criteria for

hospitals that are seeking to be excluded

from the hospital inpatient prospective

payment system under one of the

specialty classes, including IRFs. The

regulations concerning exclusion from

the hospital inpatient prospective

payment system, in part 412, subpart B,

are discussed below.

2. Requirements for Inpatient

Rehabilitation Facilities To be Excluded

From the Hospital Inpatient Prospective

Payment System

Under section 1886(d)(1)(B) of the

Act, the prospective payment system for

hospital inpatient operating costs set

forth in section 1886(d) of the Act does

not apply to several specified types of

entities, including a rehabilitation

hospital ‘‘as defined by the Secretary’’

or, ‘‘in accordance with regulations of

the Secretary,’’ a rehabilitation unit of a

hospital which is a distinct part of the

hospital ‘‘as defined by the Secretary.’’

In general, existing regulations in part

412, subpart B provide that to be

excluded from the hospital inpatient

prospective payment system, an IRF

must—(1) Have a provider agreement or

be a unit in an institution that has in

effect an agreement to participate as a

hospital under part 489; and (2) except

for newly participating hospitals

seeking to be excluded, demonstrate

that they serve an inpatient population

of whom at least 75 percent require

intensive rehabilitative services for the

treatment of 1 or more of 10 specified

conditions. The specified conditions are

stroke, spinal cord injury, congenital

deformity, amputation, major multiple

trauma, hip fracture, brain injury,

polyarthritis including rheumatoid

arthritis, neurological disorders, and

burns. Patients in IRFs require frequent

physician involvement, rehabilitation

nursing, and care from a coordinated

group of professionals. (All IRFs that

meet the requirements in §§ 412.23(b),

412.25, and 412.29 would be paid under

the IRF prospective payment system

proposed in this rule.)

3. Payment System Requirements Prior

to the Balanced Budget Act of 1997

Hospitals that are excluded from the

hospital inpatient prospective payment

system are paid for inpatient operating

costs under the provisions of section

1886(b) of the Act. Until the IRF

prospective payment system is

implemented, IRFs are paid on the basis

of Medicare reasonable costs limited by

a facility-specific target amount per

discharge. Each facility has a separate

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66307

payment limit or target amount that is

calculated for that facility based on its

cost per discharge in a base year, subject

to caps. The target amount is adjusted

annually by an update factor called the

rate-of-increase percentage. Facilities

whose costs are below their target

amounts receive bonus payments equal

to the lesser of half of the difference

between costs and the target amount, up

to a maximum of 5 percent of the target

amount. For facilities whose costs

exceed their target amounts, Medicare

provides relief payments equal to half of

the amount by which the hospitals costs

exceeded the target amount up to 10

percent of the target amount. Facilities

that experience a more significant

increase in patient acuity can also apply

for an additional amount under the

regulations for Medicare exception

payments.

4. Strengths and Weaknesses of the

Current Payment System

Utilization of post-acute care services

has grown rapidly in recent years. Since

the implementation of the hospital

inpatient prospective payment system,

average length of stay in acute care

hospitals has decreased and patients are

increasingly being discharged to postacute care settings such as IRFs, skilled

nursing facilities (SNFs), home health

agencies (HHAs), and long-term care

hospitals to complete their course of

treatment. The increased utilization of

post-acute care providers, including

excluded facilities, has fueled the rapid

growth in payments in recent years.

With increased utilization and the

incentives associated with the

reasonable-cost based payment system,

discussed below, the number of IRFs

has also increased significantly.

In its March 1999 Report to the

Congress the Medicare Payment

Advisory Commission (MedPAC)

(formerly the Prospective Payment

Assessment Commission (ProPAC))

stated, ‘‘Aggregate spending has

increased at a fairly rapid pace,

reflecting increased patient volume

rather than increased payments per

discharge. Aggregate Medicare operating

payments to rehabilitation facilities rose

18 percent annually between 1990 and

1996, from $1.9 billion to $4.3 billion.

Since 1990, payments per discharge

have risen less than the rate of inflation,

reaching $10,500 in 1996.’’ (p. 90.) The

MedPAC report explains that the—

TEFRA system has remained in effect

longer than expected partly because of

difficulties in accounting for the variation in

resource use across patients in exempted

facilities. The unintended consequences of

sustaining that system have included a

steady growth in the number of prospective

payment system-exempt facilities and a

substantial payment inequity between older

and newer facilities. In particular, the

payment system encouraged new exempt

facilities to maximize their costs in the base

year to establish high cost limits. Once

subject to its relatively high limit, a recent

entrant could reduce its costs below its limit,

resulting in reimbursement of its full costs.

* * * By contrast, facilities that existed

before they became subject to TEFRA could

not influence their cost limits. Given the

relatively low limits of older facilities, they

are more likely to incur costs above their

limits and thus receive payments less than

their costs. (p. 72)

To address concerns such as the

historical growth in payments and

disparity in payments to existing and

newly excluded hospitals and units, the

BBA mandated several changes to the

current payment system. These changes

are outlined in section I.C.1 of this

preamble. In addition, we and other

organizations have conducted research

since the inception of the hospital

inpatient prospective payment system to

determine if alternate prospective

payment systems are feasible for these

excluded hospitals.

B. Research for Alternate Prospective

Payment Systems for Inpatient

Rehabilitation Facilities Prior to the

Balanced Budget Act of 1997

Below is a discussion of research

projects and other analyses concerning

prospective payment systems that are

relevant to the development of the IRF

prospective payment system that we are

proposing to implement in this rule.

The methods and tasks that must be

undertaken in order to develop an IRF

prospective payment system include

development of a patient classification

system that accounts for differences in

patient case mix. A patient classification

system is developed by classifying

patients into mutually exclusive groups

based on similar clinical characteristics

and similar levels of resource use. A

factor to weight differences in patient

case mix can be developed by

measuring the relative difference in

resource intensity among the different

groups. We are proposing to implement

a payment system that uses case-mix

groups and weighting factors that

account for the intensity of services

delivered to IRF Medicare patients.

1. Early Studies

In October 1984, as mentioned in the

1987 Report to the Congress: Developing

a Prospective Payment System for

Excluded Hospitals (1987), the Medical

College of Wisconsin and the RAND

Corporation (RAND) began a joint effort

to investigate the feasibility of a

prospective payment system for

excluded hospitals including IRFs. The

RAND Corporation is a nonprofit

institution with extensive health care

background in improving policy and

decision making through research and

analysis. This joint effort was under a

HCFA cooperative agreement with the

RAND Corporation. The Medical

College of Wisconsin collected data

from a survey of patient records that

included standard discharge data,

diagnostic condition, functional status

and other impairment measures, billing

data, and facility information gathered

from telephone interviews. RAND

assisted in the design and analysis of

the survey data and obtained a 20

percent sample of the HCFA patient

billing file for FY 1984—the

implementation year of the hospital

inpatient prospective payment system.

The data were used to analyze the

delivery systems of rehabilitation care.

The Report to the Congress stated that

care in IRFs ‘‘emphasizes the treatment

of functional limitations and disability’’.

Functional limitations could be

measured by the patient’s ability to

perform activities of daily living such as

locomotion, dressing, eating, bathing,

etc. The patient’s level of performing

these activities of daily living is referred

to as the patient’s functional status. The

results of this analysis showed that

‘‘diagnostic condition explained little,

whereas functional status measures

explained substantially more, of the

variance in total charges for a

rehabilitation stay.’’ However, at the

time of this analysis, a nationallyaccepted set of functional status

measures had not been developed for

application in a classification system for

IRFs.

2. Functional Status Studies

While numerous studies involved

developing and assessing functional

status, several researchers (for example,

Batavia 1988; Johnston 1984) suggested

using functional status as the basis for

a rehabilitation payment system.

Functional status, as measured by a

patient’s ability to perform activities of

daily living and by mobility, can be

evaluated at admission and discharge or

any time during the stay. In addition,

change in functional status (the

difference in functional status from

admission to discharge) can be

measured.

Researchers evaluated several

methods of using functional status at

different stages of the patient’s stay to

develop a payment system. For the most

part, the use of these methods resulted

in payment systems that appeared to be

inadequate in creating the proper

incentives to care for high resource use

66308 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

patients and to produce quality

outcomes. Basing a payment system on

expected improvement in a patient’s

functional limitations requires a scale

that is sensitive to changes in functional

status. In addition, precise data

describing the functional status of the

patient would have to be collected on

admission and at periodic intervals

until discharge (Hosek et al.; 1986).

The development of a patient

classification system for a case-mix

adjusted prospective payment system

was hindered by the lack of an

appropriate and widely accepted

functional status measure for inpatient

rehabilitation. The functional

independence measure (FIM) was

developed to fill this need (Hamilton et

al., 1987). The functional independence

measure addresses a patient’s functional

status covering six domains—self-care,

sphincter control, mobility, locomotion,

social cognition, and communication.

There are two national sources of

functional independence measures. The

Uniform Data Set for Medical

Rehabilitation (UDSmr) is operated

within the Center for Functional

Assessment Research, U. B. Foundation

Activities, Inc. The UDSmr collects data

on patient age, sex, living situation prior

to hospitalization, the impairment that

is the primary reason for admission to

the IRF, and functional status at

admission and discharge. It also

includes patient admission and

discharge information as well as

hospital charges. The Clinical Outcomes

System (COS) is operated by

Caredata.com, Inc. (formerly Medirisk

Inc.), located in Atlanta, Georgia. The

COS contains the same type of patient

information as UDSmr. However, we

have been notified that the COS has

been discontinued as of July 2000.

3. Studies on Patient Classification

Systems

In 1991, Nancy Diane Harada

presented a study in her dissertation

titled ‘‘The Development of a ResourceBased Patient Classification Scheme for

Rehabilitation.’’ This study developed a

clinically-based, diagnosis-specific

patient classification system for

rehabilitation hospital services. The

final classification system in this study

includes 33 patient classification

groups. The patient classification groups

are referred to as Rehabilitation

Functional Related Groups.

Harada believed that, at the facility

level, the rehabilitation functional

related groups could be viewed as a

managerial tool to monitor the quality of

care, as well as the resources expended

in the treatment of rehabilitation

patients. From a policy perspective, use

of the rehabilitation functional related

groups could minimize the adverse

incentives for IRFs to underserve certain

groups that may arise from the lack of

case-mix index adjusted payments in

the current cost limit payment system.

The results of this study found that

rehabilitation functional related group

methodology may provide an

appropriate basis for the prospective

payment of rehabilitation services.

Using FIM data reported to UDSmr, a

team of researchers from the University

of Pennsylvania developed a patient

classification system, Function Related

Groups (FRGs), referred to as the FIM–

FRGs (Stineman et al., 1994). The

American Rehabilitation Association

(currently known as the American

Medical Rehabilitation Providers

Association) funded the development of

a prototype of function related groups.

Further work and revisions were funded

by the Agency for Health Care Research

and Quality, formerly known as the

Agency for Health Care Policy and

Research and the National Center for

Medical Rehabilitation Research at the

National Institutes of Health.

As FIM–FRGs were refined, they were

reframed using the International

Classification of Impairments,

Disabilities and Handicaps to ensure a

better measure of the consumption of

rehabilitation resources, prognosis, and

outcome (Stineman, 1997). These

classifications were designed to be

related to the major categories of the

DRGs and indirectly linked to the ICD–

9–CM with focus on disabilities and

impairment categorization.

This original work on a FIM–FRG

patient classification system identified

21 clinically defined rehabilitation

impairment categories (RICs) such as

stroke, traumatic brain dysfunction,

non-traumatic brain dysfunction, and

non-traumatic spinal cord injury. The

RICs were then subdivided into FIM–

FRGs using the FIM motor score, FIM

cognitive score, and age. Accordingly,

the FIM–FRG patient classification

system first sorted patients into a RIC

and then used assessments of patient

functional and cognitive abilities and

age to classify them into a FIM–FRG.

4. HCFA-Sponsored Analysis by RAND

In 1994, we contracted with RAND for

analyses designed to: (1) examine the

stability of the original FRGs; (2) extend

the FRGs to take account of previously

unexamined cases (re-admissions),

previously unused information

(interrupted stays), and newly available

data (Medicare data on comorbidities

and complications); and (3) evaluate the

performance of FRGs when cost rather

than length of stay is used to form

groups and when only Medicare cases

rather than all cases are used to form

groups.

RAND’s analyses: (1) evaluated the

suitability of the FIM–FRG patient

classification system; (2) evaluated a

prospective payment system for

inpatient rehabilitation facilities based

on the FIM–FRGs; and (3) prepared final

reports describing the evaluation of the

UDSmr, FIM, and FIM–FRGs. This

analysis used more current data to

replicate and update previous work

performed by RAND in 1990.

Two data systems—the UDSmr and

Medicare program information—were

the primary sources for these analyses.

UDSmr provided RAND with functional

status and demographic information for

rehabilitation discharge data on 139,360

cases from 352 IRFs from calendar year

1994. The Medicare program

information included Medicare bill and

cost report data for 1994.

The first step of the analysis involved

matching UDSmr cases with Medicare

records using patient and facility

identifiers. Because patient and facility

identifiers on the UDSmr records were

encrypted, it was necessary to use a

sophisticated matching probability

technique to match Medicare records to

a corresponding UDSmr case. In

addition, several thousand of the

Medicare discharges corresponded to

part of an interrupted rehabilitation

stay. For the purposes of this analysis,

a rehabilitation stay interrupted by a

single admission to an acute care

hospital is treated as two rehabilitation

discharges, one interrupted by two

admissions to an acute care hospital is

treated as three rehabilitation

discharges, and so on. Using this

definition of ‘‘interrupted stays’’, RAND

stated that the 139,360 cases found in

the UDSmr data corresponded to

144,719 Medicare discharges. A file

with the matched patient data was

created.

RAND then subjected this patient data

to a rigorous and complex statistical

algorithm to test the predictive power of

resource use to classify these patients

into RICs and corresponding FIM–FRGs.

As a result, RAND recommended that

the number of FRGs per RIC be limited

to a maximum of 5 and proposed a total

of 70 FRGs. Facility level data from the

hospital cost report information system

file was used to test the feasibility of

using the resulting FIM–FRGs to

develop an IRF prospective payment

system.

The results of the RAND study were

released in September 1997 and are

contained in two reports available

through the National Technical

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Information Service (NTIS). The reports

are—

• Classification System for Inpatient

Rehabilitation Patients—A Review and

Proposed Revisions to the Function

Independence Measure-Function

Related Groups, NTIS order number

PB98–105992INZ; and

• Prospective Payment System for

Inpatient Rehabilitation, NTIS order

number PB98–106024INZ. These reports

can be ordered by calling the NTIS sales

desk at 1–800–553–6847 or by e-mail at

orders@ntis.fedworld.gov.

RAND found that, with limitations,

the FIM–FRGs were effective predictors

of resource use based on the proxy

measurement: length of stay. FRGs

based upon FIM motor scores, cognitive

scores, and age remained stable over

time (prediction remained consistent

between the 1990 and 1994 data).

Researchers at RAND developed,

examined, and evaluated a model

payment system based upon FIM–FRG

classifications that explains

approximately 50 percent of patient

costs and approximately 60 to 65

percent of costs at the facility level.

Based on this analysis, RAND

concluded that a rehabilitation

prospective payment system using this

model is feasible. RAND’s design of a

rehabilitation prospective payment

system aimed to achieve the following

three important goals:

• To provide hospitals with

incentives for efficiency.

• To ensure access to high quality

and appropriate care for all Medicare

beneficiaries.

• To distribute Medicare payments to

hospitals in an equitable way.

RAND needed to account adequately

for each hospital’s patient mix and for

other appropriate factors that affect

costs. This aspect of the analysis was

based on the notion that Medicare

should not pay hospitals more for

inefficiency or even for a greater

intensity of care than is typically

received by patients with similar

clinical characteristics and social

support levels.

Two technical advisory panels

provided advice concerning this

research. The first panel reviewed the

reliability of the FIM scoring process

and the second panel provided guidance

on the development of the patient

classification system. These panels

raised some major concerns about the

FIM–FRG research.

First, the UDSmr data represented

only 24 percent of IRFs and accounted

for 40 percent of all Medicare cases in

IRFs. Second, the UDSmr data overrepresented free-standing rehabilitation

hospitals and under-represented

excluded units with a slight overrepresentation of teaching hospitals.

Third, while the FIM–FRG system is a

good predictor of length of stay, more

work was needed to determine the

system’s ability to predict the intensity

of services furnished during a stay.

Fourth, hospital charges might not

accurately reflect actual resource use in

this context, so relative weights based

on hospital charges might be distorted.

This problem would be further

exacerbated because there is evidence of

unexplainable distorted charging

patterns among facilities under the

current payment limits, which have

been in effect for a prolonged period of

time.

5. Prospective Payment Assessment

Commission Analysis for 1997 Report to

Congress

In its 1997 Report to Congress, the

Prospective Payment Assessment

Commission (ProPAC) recommended

that a prospective payment system for

IRFs based on patient case mix should

be implemented as soon as possible.

ProPAC stated that RAND’s work on the

FIM–FRGs could be an adequate basis

for prospective payment, and that

implementation of a system in the near

future is feasible. (ProPAC’s March 1,

1997 report was published as Appendix

F to our proposed rule ‘‘Medicare

Program; Changes to the Hospital

Inpatient Prospective Payment Systems

and Fiscal Year 1998 Rates’’ published

in the June 2, 1997 Federal Register (62

FR 29902).)

In response to this recommendation,

we cited in our final rule ‘‘Medicare

Program; Changes to the Hospital

Inpatient Prospective Payment Systems

and Fiscal Year 1998 Rates’’ published

in the August 29, 1997, Federal Register

(62 FR 45966), the concerns raised by

the technical advisory panels and our

review of the RAND analysis as issues

that needed to be further addressed

before implementing a prospective

payment system using the FIM–FRG

patient classification system. In

addition, we stated that our preference

is to focus on developing a coordinated

payment system for post-acute care

across all settings that relies on a core

assessment tool. Accordingly, one of our

goals in developing a prospective

payment system would be that it is

based on the characteristics of the

patient and their needs rather than the

characteristics or type of provider of

care.

C. Requirements of the BBA and the

BBRA for Inpatient Rehabilitation

Facilities

1. Provisions for the Current Payment

System

The following BBA provisions

relating to the current payment system

were explained in detail and

implemented in our final rule published

in the August 29, 1997 Federal Register

(62 FR 45966).

Section 4411 describes the update of

payments for specific fiscal years (FYs)

using the market basket effective for cost

reporting periods beginning on or after

October 1, 1997.

Section 4412 describes the reduction

of capital payments for FYs 1998

through 2002, effective October 1, 1997.

Section 4413 describes the provisions

for rebasing a facility’s target amount for

cost reporting periods beginning during

FY 1998.

Section 4414 describes the

requirement to cap and update the rateof-increase limits for cost reporting

periods beginning on or after October 1,

1997.

Section 4415 describes the provisions

regarding bonus and relief payments

effective for cost reporting periods

beginning on or after October 1, 1997.

Section 4419 eliminates the

exemptions from the target amounts

effective for cost reporting periods

beginning on or after October 1, 1997.

2. Provisions for a Prospective Payment

System

Section 4421(a) of the BBA amended

the Act by adding a new section 1886(j)

to the Act that provides for the

implementation of a Medicare

prospective payment system for all IRFs.

For cost reporting periods beginning on

or after the implementation date and

before October 1, 2002, payment to IRFs

will be based on a blend of—(1) the

amount that would have been paid

under Part A with respect to these costs

if the prospective payment system were

not implemented and (2) the IRF

Federal prospective payment. For cost

reporting periods beginning on or after

October 1, 2002, IRFs will be paid under

the fully implemented Federal

prospective payment system.

Under the prospective payment

system, rehabilitation facilities will be

paid based on predetermined amounts.

These prospective payments will

encompass the inpatient operating and

capital costs of furnishing covered

rehabilitation services (that is, routine,

ancillary, and capital costs) but not for

costs of approved educational activities,

bad debts, and other costs not subject to

the provisions of the IRF prospective

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payment system. Covered rehabilitation

services include services for which

benefits are provided under Part A (the

hospital insurance program) of the

Medicare program.

Section 1886(j)(1)(A) of the Act

provides that, notwithstanding section

1814(b) of the Act and subject to the

provisions of section 1813 of the Act

regarding beneficiary deductibles and

coinsurance responsibility, the amount

of payment for inpatient rehabilitation

hospital services equals an amount

determined under section 1886(j) of the

Act. Sections 1886(j)(1)(A)(i) and (ii) of

the Act provide for a transition phase

covering cost reporting periods that

begin during the first two Federal fiscal

years under the prospective payment

system. During this transition phase,

IRFs will receive a payment rate

comprised of a blend of the ‘‘TEFRA

percentage’’ of the amount that would

have been paid under Part A with

respect to those costs if the prospective

payment system had not been

implemented, and the ‘‘prospective

payment percentage’’ of payments using

the IRF prospective payment system

rate.

Section 1886(j)(1)(B) of the Act sets

forth a requirement applicable to all

facilities for the payment rates under the

fully implemented system.

Notwithstanding section 1814(b) of the

Act and subject to the provisions of

section 1813 of the Act regarding

beneficiary deductibles and coinsurance

responsibility, the amount of the

payment with respect to the operating

and capital costs of a rehabilitation

facility for a payment unit in a cost

reporting period beginning on or after

October 1, 2002, will be equal to the per

unit payment rate established under this

prospective payment system for the

fiscal year in which the payment unit of

service occurs.

Sections 1886(j)(1)(C)(i) and (ii) of the

Act set forth the applicable TEFRA and

prospective payment rate percentages

during the transition period. For a cost

reporting period beginning on or after

April 1, 2001 and before October 1,

2001, the ‘‘TEFRA percentage’’ is 662⁄3

percent and ‘‘the prospective payment

percentage’’ is 331⁄3 percent; and on or

after October 1, 2001, and before

October 1, 2002, the ‘‘TEFRA

percentage’’ is 331⁄3 percent and

‘‘prospective payment percentage’’ is

662⁄3 percent.

Section 1886(j)(1)(D) of the Act

contains the definition of ‘‘payment

unit.’’ Until the passage of the BBRA,

‘‘payment unit’’ was defined by the

statute as ‘‘a discharge, day of inpatient

hospital services, or other unit of

payment defined by the Secretary’’.

However, section 125(a)(1) of the BBRA

amended section 1886(j)(1)(D) of the Act

by striking ‘‘day of inpatient hospital

services, or other unit of payment

defined by the Secretary.’’ Accordingly,

the payment unit utilized in the IRF

prospective payment system will be a

discharge.

Section 125(a)(3) of the BBRA also

amended the Act by adding a new

section 1886(j)(1)(E) to the Act that

states: ‘‘(E) CONSTRUCTION

RELATING TO TRANSFER

AUTHORITY.—Nothing in this

subsection shall be construed as

preventing the Secretary from providing

for an adjustment to payments to take

into account the early transfer of a

patient from a rehabilitation facility to

another site of care.’’ We invite

comments on the proposed transfer

policy discussed in section V. of this

preamble.

Section 1886(j)(2)(A) of the Act, as

added by the BBA, directed the

Secretary to establish case-mix groups

based on the factors as the Secretary

deems appropriate, which may include

impairment, age, related prior

hospitalization, comorbidities, and

functional capability of the patient. This

section also requires the Secretary to

establish a method of classifying

specific patients in rehabilitation

facilities within these groups. The

BBRA amended section 1886(j)(2)(A)(i)

of the Act to describe the classification

system to read as follows: ‘‘Classes of

patient discharges of rehabilitation

facilities by functional-related groups

(each in this subsection referred to as a

‘case mix group’), based on impairment,

age, comorbidities, and functional

capability of the patient and such other

factors as the Secretary deems

appropriate to improve the explanatory

power of functional independence

measure-function related groups.’’

Section 1886(j)(2)(B) of the Act

provides that the Secretary will assign

each case-mix group a weighting factor

reflecting the facility resources used for

patients within the group as compared

to patients classified within other

groups.

Section 1886(j)(2)(C)(i) of the Act

directs the Secretary to adjust ‘‘from

time to time’’ the case-mix

classifications and weighting factors ‘‘as

appropriate to reflect changes in

treatment patterns, technology, casemix, number of payment units for which

payment is made under this title, and

other factors which may affect the

relative use of resources.’’ Such periodic

adjustments shall be made in a manner

so that changes in aggregate payments

are a result of real changes in case-mix,

not changes in coding that are unrelated

to real changes in case-mix. Section

1886(j)(2)(C)(ii) of the Act provides that,

if the Secretary determines that

adjustments to the case-mix

classifications or weighting factors

resulted in (or are likely to result in) a

change in aggregate payments that does

not reflect real changes in case-mix, the

Secretary shall adjust the per payment

unit payment rate for subsequent years

so as to eliminate the effect of the

coding or classification changes.

Section 1886(j)(2)(D) of the Act

authorizes the Secretary to require

rehabilitation facilities to submit such

data as the Secretary deems necessary to

establish and administer the IRF

prospective payment system.

Section 1886(j)(3)(A) of the Act

describes how the prospective payment

rate will be determined. A prospective

payment rate will be determined for

each payment unit for which an IRF is

entitled to payment under the

prospective payment system. The

payment rate will be based on the

average payment per payment unit for

inpatient operating and capital costs of

IRFs, using the most recently available

data, and adjusted by the following

factors:

• Updating the per-payment unit

amount to the fiscal year involved by

the applicable percentage increase (as

defined by section 1886(b)(3)(B)(ii) of

the Act) covering the period from the

midpoint of the period for such data

through the midpoint of fiscal year 2000

and by an increase factor specified by

the Secretary for subsequent fiscal years;

• Reducing the rate by a factor

equaling the proportion of Medicare

payments under the prospective

payment system as estimated by the

Secretary based on prospective payment

amounts which are additional payments

relating to outlier and related payments;

• Accounting for area wage variations

among IRFs;

• Applying the case-mix weighting

factors; and

• Adjusting for such other factors as

determined necessary by the Secretary

to properly reflect variations in

necessary costs of treatment among

IRFs.

Section 1886(j)(3)(B) of the Act directs

the Secretary to establish IRF

prospective payment system payment

rates during fiscal years 2001 and 2002

at levels such that, in the Secretary’s

estimation, total payments under the

new system will equal 98 percent of the

amount that would have been made for

operating and capital costs in those

years if the IRF prospective payment

system had not been implemented. In

establishing these payment amounts, the

Secretary shall consider the effects of

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the prospective payment system on the

total number of payment units from

IRFs and other factors.

Section 1886(j)(3)(C) of the Act

addresses the annual increase factor, to

be applied beginning with FY 2001.

This factor shall be based on an

appropriate percentage increase in a

market basket of goods and services

comprising services for which payment

is made under section 1886(j) of the Act.

Under section 1886(j)(4)(A) of the Act,

the Secretary is authorized but not

required to provide for an additional

payment to a rehabilitation facility for

patients in a case-mix group, based

upon the patient being classified as an

outlier based on an unusual length of

stay, costs, or other factors specified by

the Secretary. The amount of the

additional payment must approximate

the marginal cost of care above what

otherwise would be paid and must be

budget neutral. The total amount of the

additional payments to IRFs under the

prospective payment system for a fiscal

year may not be projected to exceed 5

percent of the total payments based on

prospective payment rates for payment

units in that year.

Section 1886(j)(4)(B) of the Act

establishes that the Secretary is

authorized but not required to provide

for adjustments to the payment amounts

under the prospective payment system

as the Secretary deems appropriate to

take into account the unique

circumstances of IRFs located in Alaska

and Hawaii.

Section 1886(j)(5) of the Act provides

for the Secretary to publish in the

Federal Register, on or before August 1

of each fiscal year, the classifications

and weighting factors for the IRF casemix groups and a description of the

methodology and data used in

computing the prospective payment

rates for that fiscal year.

Section 1886(j)(6) of the Act provides

that the Secretary shall adjust the

proportion (as estimated by the

Secretary from time to time) of IRFs’

costs that are attributable to wages and

wage-related costs, of the prospective

payment rates for area differences in

wage levels by a factor (established by

the Secretary) reflecting the relative

hospital wage level in the geographic

area of the IRF compared to the national

average wage level for such facilities.

Additionally, the Secretary is required

to make a budget-neutral update to the

area wage adjustment factor no later

than October 1, 2001, and at least once

every 36 months thereafter. The budget

neutral update is based on information

available to the Secretary (and updated

as appropriate) of the wages and wagerelated costs incurred in furnishing

rehabilitation services.

Sections 1886(j)(7)(A), (B), (C) and (D)

of the Act establish that there shall be

no administrative or judicial review

under sections 1869 and 1878 of the Act

or otherwise of the establishment of

case-mix groups, of the methodology for

the classification of patients within

these groups, the weighting factors, the

prospective payment rates, outlier and

special payments and area wage

adjustments.

Section 125(b) of the BBRA provides

that the Secretary shall conduct a study

of the impact on utilization and

beneficiary access to services of the

implementation of the IRF prospective

payment system. A report on the study

must be submitted to the Congress not

later than 3 years after the date the IRF

prospective payment system is first

implemented.

D. Policy Objectives in Developing a

Prospective Payment System for

Inpatient Rehabilitation Facilities

In developing the prospective

payment system for IRFs, we identified

policy objectives to evaluate the relative

merits of the various policy options

considered. The objectives we identified

include the following:

• The creation of a beneficiarycentered payment system that promotes

quality of care, access to care, and

continuity of care and is

administratively feasible while

controlling costs.

• The provision of incentives to

furnish services as efficiently as

possible without diminishing the

quality of the care or limiting access to

care.

• The creation of a payment system

that is fair and equitable to facilities,

beneficiaries, and the Medicare

program.

• The IRF prospective payment

system must be able to recognize

legitimate cost differences among

various settings furnishing the same

service; and any patient classification

system used to group patients and

services should be based on clinically

coherent categories and, at the same

time, reflect similar resource use. This

would limit opportunities to ‘‘upcode’’

or ‘‘game’’ the system.

In its March 1999 Report to the

Congress, MedPAC recommended in

detail the type of prospective payment

system it believed should be

implemented for IRFs. As will be

discussed further in this proposed rule,

MedPAC’s recommendations share

much with our approach and policy

objectives for the development of an IRF

prospective payment system. Both

HCFA and MedPAC believe the IRF

prospective payment system should

include the use of a comprehensive

patient assessment instrument such as

the MDS-PAC. HCFA and MedPAC both

seek sufficient data to devise a patient

classification system that effectively

predicts resource use. HCFA and

MedPAC believe the prospective

payment system should be based on

reliable and valid payment weights

using functional and other diagnostic

data. We agree with MedPAC’s

recommendation to use a per discharge

unit of payment. Also, there is a shared

belief that a discharge-based system

provides an inherent incentive to

discharge patients prematurely, and that

this impetus could be overcome by

implementing sound transfer and shortstay policies as part of the prospective

payment system. Accordingly, we have

taken steps to initiate the appropriate

research to meet our immediate needs in

developing this proposed rule and in

implementing an IRF prospective

payment system, as well as to collect

data for the future that may reflect

actual facility resources used to meet

the needs of Medicare beneficiaries.

E. Discussion of Evaluated Options for

the Prospective Payment System for

Inpatient Rehabilitation Facilities

We used the objectives identified

above in section I.D. of the preamble to

evaluate policy options under

consideration. The IRF prospective

payment system we are proposing

consists of the following major

components: the patient assessment

instrument; the patient classification

system; the unit of payment; and the

data used to construct the payment

rates. A brief discussion of the major

issues and options considered in

preparing this proposed rule follows.

1. Patient Assessment Instrument

Data from a patient assessment

instrument will allow us to: (1) Group

patients into a CMG for payment under

the prospective payment system; and (2)

monitor the effects the prospective

payment system has on the access and

the quality of patient care. We have

reviewed the data elements of the

UDSmr and COS instruments and the

MDS–PAC. We are proposing to use the

MDS–PAC because we believe it

contains the data elements that will

better enable us to implement and

administer the IRF prospective payment

system required by section 1886(j) of the

Act. In section III of this preamble, we

will discuss in detail the reasons for our

proposal to use the MDS–PAC patient

assessment instrument.

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2. Patient Classification System

The patient classification system is

another important component of the

prospective payment system. We

initially considered two primary patient

classification systems—one similar to

the hospital inpatient prospective

payment system and the other similar to

the one used in the skilled nursing

facility prospective payment system.

Ideally, we would like to maintain

similar classification systems for those

entities delivering comparable services.

We recognize a unified classification

system would have to recognize patient

needs and facilitate appropriate

compensation across various post-acute

care settings. Section 125(a) of the

BBRA mandated the use of a per

discharge payment unit and established

classes of patients by functional-related

groups. Therefore, in implementing the

IRF prospective payment system we will

use CMGs, consistent with section

1886(j)(2) of the Act.

3. Unit of Payment

Under the provisions of section

1886(j)(1)(D) as added by the BBA, we

considered using either a per diem or a

per discharge unit of payment. The vast

majority of rehabilitation episodes begin

with an acute event. The goal of

inpatient rehabilitation is functional

improvement that will allow the patient

to return to independent living in the

community, and, as evidenced by

ongoing research, the majority of cases

are, in fact, discharged to a community

setting. Further, a discharge is also the

current unit of payment under the

TEFRA payment system. Finally, as

noted above, the BBRA amends the Act

to provide that the ‘‘payment unit’’

under the IRF prospective payment

system is the discharge. Therefore, we

propose to use a per discharge payment

unit in accordance with section

1886(j)(1)(D) of the Act.

4. Data Used to Construct Payment Rates

We gave careful consideration in

deciding which data to use to create the

proposed relative weights and payment

rates. Two sources of data were

considered: (1) Medicare bill and

corresponding UDSmr/COS data; and

(2) patient level staff time

measurements. The methodology we are

proposing to use to calculate the relative

weights of each CMG attempts to

account for the cost variations among

rehabilitation facilities and focus on

variations among patient types. Further,

the payment rates we are proposing are

established in a budget neutral manner

in accordance with section 1886(j)(3)(B)

of the Act. Section V of the preamble

describes the methodology that we are

proposing to use to develop relative

weights and payment rates.

Under the current payment system,

payment limits are based on historical

costs in a base period. Accordingly,

payments to a given facility for a given

year might not accurately reflect the

facility’s actual costs in that year.

Creating a new payment system based

on costs that are a product of the

existing payment methodology raises

concerns that these costs may not

adequately reflect actual resource use.

In order to develop a prospective

payment system that is more reflective

of the actual costs of delivering care,

further work is needed to identify these

costs and the services and resources

required by patients. The IRF data from

calendar years 1996 and 1997 bills and

FY 1997 cost reports contain the most

recent available data we have to create

the new IRF prospective payment

system rates.

We will continue to explore other

options, including the use of staff time

measurements, later Medicare bill and

UDSmr/COS data, and other data to

improve the explanatory power of the

CMGs and to derive payments that more

directly reflect the resources used to

produce services delivered in the IRFs.

F. Inpatient Rehabilitation Facility

Prospective Payment System—General

Overview

In accordance with the requirements

of section 1886(j) of the Act, we are

proposing to implement a prospective

payment system for IRFs that will

replace the current reasonable costbased payment system. The new

prospective payment system will utilize

information from a patient assessment

instrument to classify patients into

distinct groups based on clinical

characteristics and expected resource

needs. Separate payments are calculated

for each group with additional case and

facility level adjustments applied, as

described below.

1. Patient Assessment Provisions

We are proposing to require IRFs to

complete the MDS–PAC patient

assessment instrument for all Medicare

patients admitted or discharged on or

after April 1, 2001. In accordance with

our proposed assessment schedule, the

MDS–PAC would be completed on the

4th, 11th, 30th, and 60th day from the

admission date of a Medicare patient

and upon the discharge of a Medicare

patient. In general, a 3-day observation

period would be required prior to the

completion of the MDS–PAC. Data from

the MDS–PAC will be used to—

• Determine the appropriate

classification of a Medicare patient into

a CMG for payment under the

prospective payment system (using data

from only the MDS–PAC completed on

the fourth day);

• Implement a system to monitor the

quality of care furnished to Medicare

patients; and

• Ensure that appropriate case-mix

and other adjustments can be made to

the proposed patient classification

system.

A computerized MDS–PAC data

collection system will be developed.

Facilities will be required to input the

MDS–PAC data into the data system. In

general, this system consists of a

computerized patient grouping software

program (grouper software) and data

transmission software.

Upon the discharge of the patient, the

existing Medicare claim form will be

completed with the appropriate CMG

indicated on the claim form so that the

prospective payment can be made. The

operational aspects and instructions for

completing and submitting Medicare

claims under the IRF prospective

payment system will be addressed in a

Medicare Program Memorandum once

the final system requirements are

developed and implemented.

Further details about the MDS–PAC

patient assessment instrument and data

collection system are discussed in

section III of this preamble.

2. Patient Classification Provisions

We are proposing a patient

classification system that uses case-mix

groups called CMGs. The CMGs classify

patient discharges by functional-related

groups based on a patient’s impairment,

age, comorbidities, and functional

capability. We began the development

of the CMGs by using the FIM–FRG

classification system and, with the most

recent data available, we identified

clinical aspects of the FIM–FRG system

that could be improved to increase the

ability of the CMGs to predict resource

use. Further details of the proposed

CMG classification system are discussed

in section IV of this preamble.

3. Payment Rate Provisions

The payment unit for the proposed

IRF prospective payment system for

Medicare patients will be a discharge.

The payment rates will encompass

inpatient operating and capital costs of

furnishing covered inpatient

rehabilitation hospital services,

including routine, ancillary, and capital

costs, but not the costs of bad debts or

of approved educational activities.

Beneficiaries may be charged only for

deductibles, coinsurance amounts, and

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66313

non-covered services (for example,

telephone, and television, etc.). They

may not be charged for the differences

between the hospital’s cost of providing

covered care and the proposed Medicare

prospective payment amount.

The prospective payment rates that

we are proposing to implement are

determined using relative weights to

account for the variation in resource

needs among CMGs. We would adjust

the payment rates to account for area

differences in hospital wages. We would

update the per discharge payment

amounts annually. During FYs 2001 and

2002, the prospective payment system

will be ‘‘budget neutral’’, in accordance

with the statute. That is, total payments

for IRFs during these fiscal years will be

projected to equal 98 percent of the

amount of payments that would have

been paid for operating and capital costs

of IRFs had this new payment system

not been enacted. This is discussed in

detail in section V of this preamble.

Based on our analysis of the data, we

are proposing to adjust the payment

rates for facilities located in rural areas

and for costs associated with treating

low income patients.

We are proposing to make additional

payments to IRFs for discharges meeting

specified criteria as ‘‘outliers.’’ For the

purposes of this proposed rule, outliers

are cases that have unusually high costs

when compared to the cases classified

in the same CMG. We are proposing

outlier payments that are projected to

equal 3 percent of total estimated

payments.

In conjunction with an outlier policy,

we are proposing payment policies

regarding short stay cases and for cases

that expire. In addition, we are

proposing to implement a transfer

policy, consistent with section

1886(j)(1)(E) of the Act, as added by the

BBRA. (A detailed description of these

policies appears in section V of the

preamble.)

4. Implementation of the Prospective

Payment System

The statute provides for a 2-year

transition period. During that time, 2

payment percentages will be used to

determine an IRF’s total payment under

the prospective payment system as

follows. For a cost reporting period

beginning on or after April 1, 2001 and

before October 1, 2001, the total

prospective payment will consist of

662⁄3 percent of the amount based on the

current payment system and 331⁄3

percent of the proposed Federal

prospective payment. For a cost

reporting period beginning during FY

2002, the total prospective payment will

consist of 331⁄3 percent of the amount

based on the current payment system

and 662⁄3 percent of the proposed

Federal prospective payment. For cost

reporting periods beginning on or after

October 1, 2002, Medicare payment for

IRFs will be determined entirely under

the proposed Federal prospective

payment methodology.

G. Applicability of the Inpatient

Rehabilitation Facility Prospective

Payment System

This proposed rule would not change

the criteria for a hospital or hospital

unit to be classified as a rehabilitation

hospital or a rehabilitation unit that is

excluded from the hospital prospective

payment systems under sections 1886(d)

and 1886(g) of the Act, nor would it

revise the survey and certification

procedures applicable to entities

seeking this classification. Accordingly,

for cost reporting periods beginning on

or after April 1, 2001, hospitals or

hospital units that are classified as

rehabilitation hospitals or rehabilitation

units under subpart B of part 412 of the

regulations will be paid under the

proposed IRF prospective payment

system (except for IRFs that are paid

under the special payment provisions at

§ 412.22(c) of the regulations) as

described below.

The following rehabilitation hospitals

and rehabilitation units, that are

currently paid under section 1886(b) of

the Act, would be paid under the

proposed IRF prospective payment

system for cost reporting periods

beginning on or after April 1, 2001:

1. Excluded Rehabilitation Hospitals

and Rehabilitation Units

We are proposing that the IRF

prospective payment system apply to

inpatient rehabilitation services

furnished by Medicare participating

entities that are classified rehabilitation

hospitals or rehabilitation units under

§§ 412.22, 412.23, 412.25, 412.29 and

412.30.

2. Excluded Rehabilitation Hospitals

and Rehabilitation Units Outside the 50

States and the District of Columbia

Excluded rehabilitation hospitals and

rehabilitation units located in Puerto

Rico, Guam, the Virgin Islands,

American Samoa, the Northern

Marianas, and the District of Columbia

will be subject to the IRF prospective

payment system.

The following hospitals are paid

under special payment provisions, as

described in § 412.22(c), and, therefore,

are not subject to the proposed IRF

prospective payment system rules:

• Veterans Administration hospitals.

• Hospitals that are reimbursed under

State cost control systems approved

under 42 CFR part 403.

• Hospitals that are reimbursed in

accordance with demonstration projects

authorized under section 402(a) of

Public Law 90–248 (42 U.S.C. 1395b–1)

or section 222(a) of Public Law 92–603

(42 U.S.C. 1395b–1 (note)).

II. Current Research To Support the

Establishment of the Inpatient

Rehabilitation Prospective Payment

System—Update of the RAND Analysis

A. Overview of the Updated Work for

the Proposed Rule

In July 1999, we contracted with the

RAND Corporation (RAND) to update

their previous research discussed in

section I of this proposed rule. The

update included an analysis of FIM

data, the FRGs, and the model

rehabilitation prospective payment

system using more recent data from a

greater number of IRFs. The purpose of

updating the previous research is to

develop the underlying data necessary

to assist us in designing, developing,

implementing, monitoring, and refining

the proposed Medicare IRF prospective

payment system based on case-mix

groups. In addition, RAND expanded

the scope of their previous research to

include the examination of several

payment elements, such as

comorbidities and facility-level

adjustments, as well as focus on

implementation issues, including

evaluation and monitoring. The update

is restricted to Medicare patient data

and the payment system is designed for

payment of Medicare inpatient

operating and capital costs only.

Specifically, for this proposed rule,

RAND performed the following tasks:

• Constructed an updated data file,

using the most recent data available

from UDSmr, COS, HCFA, and other

data sources.

• Determined the extent to which the

UDSmr and COS data are representative

of the Medicare population.

• Identified factors or variables that

may be used to help us design and

implement the payment system.

• Developed data on the elements of

the payment system regarding the

patient classification system, relative

weights and payment rates for each

case-mix group, facility-level

adjustments, and patient-level

adjustments.

• Developed data to examine the joint

performance of all of the payment

system elements by simulating facility

payments for our analysis of the impact

of implementing the payment system.

66314 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

• Developed data to assist in

identifying specific issues in connection

with implementing the payment system.

• Presented options regarding the

design and development of a system to

monitor the effects of the payment

system and other changes in the health

care market on IRFs and on other postacute care providers, including home

health agencies and skilled nursing

facilities, by measuring factors such as

access, utilization, quality, and cost of

care.

B. Construction of Data File for Analysis

Using the methodology in its previous

research, RAND constructed a data file

that was used to develop the proposed

CMG patient classification system and

the resulting payment weights, rates,

and payment adjustments using more

recent data. The analysis of this data file

forms the basis of our discussion on the

patient classification methodology and

the structure of the payment system

proposed in this rule. We expect that

further analysis of the data file and

review of the comments that we receive

in response to this proposed rule may

result in refinements to some patient

CMGs and corresponding weights and

rates.

C. Description of Sources of the Data

File

The essential sources of the data file

are Medicare program information and

patient case-mix data. The Medicare

program information includes patient

discharge files (patient demographic,

clinical, and financial information) and

facility-level files (facility

characteristics and financial

information). Patient case-mix data is

collected by IRFs using a patient

assessment instrument. We are

proposing to require the use of the

MDS–PAC patient assessment

instrument that includes patient casemix data similar to the data collected on

the UDSmr and COS, as described in

section III of this preamble. However,

the availability of MDS–PAC data

records is limited to the sample of

providers that participated in the pilot

and field tests during its development.

Therefore, to initially establish the IRF

prospective payment system, we will be

using a larger number of data records (as

compared to the 1994 data used in

RAND’s previous study) from UDSmr

and COS to represent more adequately

the total number of IRFs.

1. Medicare Program Data

For this proposed rule, RAND used

calendar year 1996 and 1997 Medicare

Provider Analysis and Review

(MEDPAR) files. The MEDPAR file

contains the records for all Medicare

hospital inpatient discharges (including

discharges for rehabilitation facilities).

The data in the MEDPAR file include

patient demographics (age, gender, race,

residence zip code), clinical

characteristics (diagnoses and

procedures), and hospitalization

characteristics (admission date,

discharge date, days in intensive-care

wards, charges by department, and

payment information).

The Medicare cost report data is

contained in the Health Care Provider

Cost Report Information System

(HCRIS). The cost report files contain

information on facility characteristics,

utilization data, and cost and charge

data by cost center. For this proposed

rule, RAND used the HCRIS file

containing the most current available

cost data for cost reporting periods

beginning during FYs 1996 and 1997.

Supplementary information to this file

includes—(1) The wage data for the area

in which an IRF is located, (2) data on

the number of residents assigned to

rehabilitation units and the distribution

of resident time across inpatient and

outpatient settings, (3) data on the

number of Medicare cases at each IRF

that represent Supplemental Security

Income (SSI) beneficiaries, and (4)

information about payments under the

current reasonable cost payment system.

The Online Survey, Certification and

Reporting System (OSCAR) file retains a

list of all IRFs that are currently

Medicare certified. For this proposed

rule, RAND used the OSCAR file to

identify instances in which we may be

missing facility-level data.

2. Patient Case-Mix Data

We entered into agreements with the

University at Buffalo Foundation

Activities, Inc. and Caredata.com, Inc. to

retrieve UDSmr and COS data,

respectively, for RAND’s updated

research. For this proposed rule, RAND

used both UDSmr and COS data that

describe rehabilitation stays in

participating hospitals for calendar

years 1996 and 1997. The data include

demographic descriptions of the patient

(birth date, gender, zip code, ethnicity,

marital status, living setting), clinical

descriptions of the patient (condition

requiring rehabilitation, ICD–9–CM

diagnoses, functional independence

measures at admission and discharge)

and the hospitalization data (encrypted

hospital identifier, admission date,

discharge date, charges, payment

source, and an indicator of whether this

is the first rehabilitation hospitalization

for this condition, a readmission, or a

short stay for evaluation).

D. Description of the Methodology Used

To Construct the Data File

Under a separate contract, we

contracted with RAND in September

1998 to construct a data file that linked

the 1996 and 1997 UDSmr and COS

patient records with patient records on

the respective MEDPAR files that

describe the same discharge. Under this

contract, RAND determined the

Medicare provider number(s) that

correspond to each UDSmr/COS facility

code. Next, RAND matched the UDSmr/

COS and MEDPAR patients within the

paired facilities.

Because of the proprietary and

sensitive nature of the UDSmr and COS

patient records, certain data fields that

specifically identify the patient and the

servicing IRF were encrypted.

Therefore, as in RAND’s previous study

(see section I of this preamble), it was

necessary to subject the UDSmr, COS,

and MEDPAR records to a sophisticated

and complex matching probability

technique. The result produces the most

statistically valid match of patient/

facility records and a data file that

contains the characteristics of each

Medicare beneficiary and his or her

servicing IRF.

Because of the complex scope and

nature of the matching technique used,

we have included in Appendix A of this

proposed rule a technical discussion of

each step taken to create the data file.

The tables contained in Appendix A

show the actual effects of applying the

matching technique on both the patient

and facility records.

E. Representativeness of the Data File

It is extremely important to examine

the quality of the resulting match,

including the extent to which the linked

MEDPAR and UDSmr/COS records are

representative of the MEDPAR universe.

After constructing the data file

described in Appendix A, we believe

that the file contains the best available

data to construct a prospective payment

system for all IRFs within the

parameters of the statutory

requirements. Our analysis of the data

file allows us to develop the proposed

CMG patient classification and payment

system, described below in sections IV

and V of this preamble.

F. Analyses To Support Future

Adjustments to the Payment System

The principal goal of the analysis

described above is to determine the

extent to which measurable patient

characteristics permit classification of

patients into identifiable groups that

accurately predict the use of resources

in inpatient rehabilitation facilities. The

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66315

research to date indicates that CMGs are

effective predictors of resource use as

measured by proxies such as length of

stay and charges. The use of these

proxies is necessary because data that

measures actual nursing and therapy

time spent on patient care, and other

resource use data, are not available. The

scientifically structured collection of

data on patient characteristics and

patient-specific resource use may

enhance our ability to refine the CMGs

in a manner that supports our policy

objectives for implementing a IRF

prospective payment system.

Accordingly, we have contracted with

Aspen Systems Corporation to collect

actual resource use data in a sample of

IRFs. The data collected by Aspen will

be submitted to RAND for analysis to

determine if it can be used to support

future refinements to the CMGs.

III. The Minimum Data Set for PostAcute Care (MDS–PAC) Patient

Assessment Instrument

A. Implementation of the MDS–PAC

Under section 1886(j)(2)(D) of the Act,

‘‘The Secretary is authorized to require

rehabilitation facilities that provide

inpatient hospital services to submit

such data as the Secretary deems

necessary to establish and administer

the prospective payment system under

this subsection.’’ The collection of

patient data is indispensable for the

successful development and

implementation of the IRF prospective

payment system. A comprehensive,

reliable system for collecting

standardized patient assessment data is

necessary for: (1) The objective

assignment of Medicare beneficiaries to

appropriate IRF CMGs; (2) the

development of a system to monitor the

effects of an IRF prospective payment

system on patient care and outcomes;

(3) the determination of whether future

adjustments to the IRF CMGs are

warranted; and (4) the development of

an integrated system for post-acute care

in the future.

The MDS–PAC is the standardized

patient assessment instrument we are

proposing to use under the IRF

prospective payment system. We

acknowledge that the nature of the

patient data we would collect may

evolve over time. We believe that the

present structure of independent

Medicare post-acute benefits, which

includes payment systems, coverage

requirements, and quality assessment

instruments based primarily on site of

care, may provide incentives that result

in reduced access and choice for

beneficiaries and may contribute to

inappropriate care. As a result of this

fragmentation in the payment and

delivery of post-acute care under

Medicare, we are reevaluating the

payment and delivery of post-acute

services with the objective of

developing a more integrated approach

focusing on the entire post-acute

episode of care and each patient’s care

needs regardless of setting. We believe

the MDS–PAC will help to move

Medicare toward our long term objective

of creating a more integrated post acute

care payment and delivery system that

facilitates improved quality, choice and

access to care for beneficiaries.

Our goal of ultimately establishing a

common system to assess patient

characteristics and care needs for postacute providers was endorsed by

MedPAC in its March 1999 report to the

Congress. MedPAC recommended that

the Secretary collect a core set of patient

assessment information across all postacute settings. (Recommendation 5A). In

the narrative supporting this

recommendation, MedPAC ‘‘commends

HCFA’s development of the MDS–PAC

and encourages its refinement and use.

The instrument will facilitate greatly

comparisons of patient characteristics

and service use across inpatient postacute settings. Insights gleaned from

these data should inform future

prospective payment system policies, as

well as longer term policy

considerations about post-acute care.’’

We share MedPAC’s opinion of the

utility of a common patient data system

across post-acute settings. We believe

that future refinements in the design

and application of the MDS–PAC will

provide us with essential information to

inform policy decisions related to postacute care users and their

characteristics, quality, and payment.

The implementation of the per-case

prospective payment system based on

the ‘‘functional-related group’’

methodology requires the use of a

standardized data collection instrument

that contains the elements required to

classify a patient into a distinct CMG.

To classify a patient into a distinct CMG

the data collection instrument must first

assign the patient into one of the various

high level categories that are based

principally on ICD–9–CM diagnoses

plus some additional patient

information. These high level categories

are called Rehabilitation Impairment

Categories. After that initial

classification step a patient’s

comorbidity data (which is also based

on the ICD–9–CM codes), the level of

the patient’s impairment as determined

by the patient’s motor and cognitive

function scores, and the age of the

patient are used to classify a patient into

a distinct CMG within the higher level

Rehabilitation Impairment Group.

Additional data elements are required to

identify the patient and for monitoring

the quality of care furnished to patients

in IRFs.

Several approaches to the collection

of these data elements are available.

These include—(a) the development of

a new data collection instrument, the

MDS–PAC (as proposed in this rule); (b)

adoption of an instrument closely

modeled on the Uniform Data Set for

Medical Rehabilitation (UDSmr) and the

Caredata.com Clinical Outcome Set

(COS) that would contain the needed

data elements exactly as they have been

recorded in the past and as used in the

development of the FIM–FRG

classification of patients; and (c) the

incorporation verbatim into the new

instrument (MDS–PAC) of the UDSmr/

COS data elements that are relevant to

payment. We are proposing the first

option, the MDS–PAC, for the reasons

outlined in the section below.

1. Use of MDS as Foundation

The basis of the MDS–PAC system is

the Minimum Data Set (MDS)/Resident

Assessment Instrument (RAI). The

MDS/RAI was one of the key provisions

of the nursing home reform legislation

enacted by the Omnibus Budget

Reconciliation Act of 1987 (OBRA), Pub.

L. 100–203, and the first standardized

assessment instrument that the Congress

required to be used in a post-acute care

setting. The MDS is a core set of

screening and assessment elements,

including common definitions and

coding categories, which forms the

foundation of a comprehensive

assessment (the RAI). OBRA mandated

that we develop the MDS and require its

use for all residents of certified longterm care facilities as a condition of

participating in Medicare or Medicaid.

We originally implemented the MDS/

RAI in 1990 through 1991 in the

approximately 17,000 certified longterm care facilities nationwide. The

MDS/RAI has been used by long-term

care facilities to assess all residents at

specific points during their stay,

regardless of payer source. Residents are

assessed upon admission to the facility,

after experiencing a significant change,

and at least annually, with a review of

key items required every 90 days.

Regulations requiring all certified longterm care facilities to encode and

transmit MDS data to the State and

HCFA became effective June 22, 1998

((62 FR 67174) ‘‘Resident Assessment In

Long Term Care Facilities’’). As of

March 3, 2000, there were 23,829,196

records for 4,576,748 residents

submitted to our national MDS

repository.

66316 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

Long-term care facilities use the

assessment system as the basis of

developing an individualized plan of

care. However, the design of our longterm care facility payment and quality

of care systems relies on use of the

resident characteristic, health status,

and service use information derived

from the MDS to support a number of

our programs. For example, the SNF

prospective payment system

implemented in July 1998 relies on

MDS data to classify patients into the

appropriate case-mix categories. In

addition, in July 1999, we began to use

MDS data to generate quality indicators

for use in the long-term care facility

survey process. Also, long-term care

facilities may request real-time MDSbased quality indicator reports, from the

HCFA-sponsored State-level MDS data

system, that compare the facility’s

performance in key care areas with the

performance of other facilities within

the State. These reports can be used for

internal quality assurance and

improvement activities. Our Peer

Review Organizations (PROs) are using

MDS data to conduct long-term care

facility quality improvement activities

in a number of areas, including pain

management, pressure ulcers, and

urinary incontinence.

In keeping with our commitment to

the nursing home industry to refine the

MDS/RAI system over time to

incorporate advances in assessment

technology and changes in the nursing

home population, we developed a

second generation instrument, known as

the MDS version 2. The MDS 2 was

implemented nationally in 1996.

Shortly thereafter, we agreed to begin

work on a post-acute version of the

MDS, in response to the long-term care

industry’s concerns that the MDS had

not been constructed to address the

characteristics and needs of the

increasing numbers of short stay

patients admitted to SNFs for

rehabilitation and medically complex

care.

Before we started work on the MDS–

PAC, however, we made a policy

decision that our goal was to establish

a common instrument to assess patients

receiving services by all Medicare

institutional post-acute providers. This

broadened the scope of the instrument

to include freestanding rehabilitation

hospitals and hospital-based

rehabilitation units, as well as long-term

care hospitals. Our policy decision was

based on a belief that there is

considerable overlap among the patient

populations and services rendered by

post-acute care providers. The March

1999 MedPAC report to Congress

indicated that prior distinctions in the

types of patients and services provided

across settings have become less clear

for a number of reasons (p. 82), and that

lack of uniform patient-level data across

settings severely restricts our ability to

identify where differences and overlaps

occur.

This hypothesis regarding the overlap

of patient populations was tested by

collecting MDS 2 data for patients of

rehabilitation and long-term care

hospitals and comparing that data with

MDS records for SNF patients. The SNF

database included records for long-stay

nursing home residents who had been

readmitted after a hospitalization and

now qualified for a period of skilled

care. There were 1,535 SNF patient

records collected from initial MDS

assessments in 1996. Of these patient

records, 517 (34 percent) of the patients

were expected to be discharged within

30 days of admission. An additional 248

(16 percent) were expected to be

discharged in 31 to 90 days. For the

remaining patient records, discharge

status was unknown, not anticipated or

(in a limited number of cases) the

discharge variable was missing. This

activity was also conducted in order to

provide us with information about the

characteristics, health status, and

service utilization of rehabilitation and

long-term care hospital patients, as part

of our initial activities to inform

development of the MDS–PAC.

Staff from participating rehabilitation

hospitals, rehabilitation units of acute

care hospitals, and long-term care

hospitals were trained in the use of the

MDS 2.0, and were asked to complete it

for a sample of their newly admitted

patients during June through October

1998. Data were received for 614

patients in 26 rehabilitation hospitals

and units, and for 479 patients in 26

long-term care hospitals. Of the 52

providers participating in the baseline

data collection, 38 were recruited using

a random sample of Medicare-certified

providers.

We found many similarities in the

characteristics, health status, medical

diagnoses, and service utilization

patterns of SNF and rehabilitation

hospital patients. We note that our focus

groups indicated to us that many

rehabilitation hospitals and selfproclaimed ‘‘subacute’’ SNFs have as a

criteria for admission the patient’s

potential ability to be discharged from

the facility within a certain time period.

Thus, for comparative purposes we

differentiated between the MDS records

of SNF patients expected to be

discharged and those of SNF patients

not expected to be discharged. As

illustrated below by Table 1C, patients

in rehabilitation hospitals and SNF

patients who were expected to be

discharged demonstrated similar levels

of activity of daily living (ADL) overall

impairment, as measured by the MDS 2,

while a greater number of SNF patients

who were not expected to be discharged

experienced impairment in ‘‘late loss’’

ADLs or were fully dependent.

TABLE 1C.—PERCENT OF PATIENTS WITH ADL IMPAIRMENT BY FACILITY TYPE

ADL score (hierarchical) LTC

hospital

Rehab

hospital

SNF

discharge

expected

SNF

discharge

not expected

0—Independent ............................................................................................... 3.1 .8 4.2 3.4

1—Supervision ................................................................................................. 4.4 9.5 6.5 5.6

2—Limited ........................................................................................................ 12.8 25.4 29.3 17.9

3—Early Loss ADL—extensive or dependent ................................................. 4.2 14.8 8.2 9.8

4—Mid late loss ADL—extensive assistance late loss ADL ........................... 8.0 21.1 20.9 15.9

5—Mid late-some late loss ADL dependency ................................................. 34.8 22.5 27.3 33.8

6—Full dependency ......................................................................................... 32.9 5.9 3.7 13.5

In addition, fewer SNF patients were reported to have symptoms of delirium as compared to rehabilitation hospital

patients. While the number of SNF patients not expected to be discharged who experienced memory problems was

higher, the overall cognitive performance score (a composite measure based on several MDS items) for patients across

the four populations was remarkably similar, except for the higher number of long-term care hospital patients rated

as a ‘‘6’’ (that is, very severely cognitively impaired). A comparison of cognitive impairment by facility type can be

seen in Table 2C.

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66317

TABLE 2C.—PERCENT OF PATIENTS WITH COGNITIVE IMPAIRMENT BY FACILITY TYPE

Condition LTC

hospital

Rehab

Hospital

SNF

discharge

expected

SNF

discharge

not expected

Delirium Symptoms—New

Easily Distracted .............................................................................................. 12.0 15.4 3.1 1.7

Altered Perceptions ......................................................................................... 9.7 5.9 2.6 2.2

Disorganized Speech ....................................................................................... 8.8 10.5 2.4 2.2

Restlessness .................................................................................................... 13.6 8.9 2.0 3.0

Lethargy ........................................................................................................... 14.4 9.2 4.0 4.0

Mental Function Varies .................................................................................... 17.2 13.5 5.2 4.0

Cognitive Performance Scale

0=Intact ............................................................................................................ 40.5 49.3 46.0 17.9

1=Borderline Intact ........................................................................................... 14.3 13.6 16.7 17.6

2=Mild .............................................................................................................. 7.2 10.2 12.0 11.3

3=Moderate ...................................................................................................... 9.1 13.0 16.3 26.2

4=Moderate Severe ......................................................................................... 4.0 3.3 4.1 10.5

5=Severe .......................................................................................................... 3.0 5.7 3.3 6.9

6=Very Severe ................................................................................................. 21.9 4.9 1.6 9.6

Memory

Memory Problem—short term .......................................................................... 32.8 36.2 37.0 61.0

Memory Problem—long-term ........................................................................... 29.9 23.0 23.1 46.2

Memory Problem—situational .......................................................................... 37.5 12.4

We did not find significant differences across care settings in many of the disease diagnoses recorded in section

I of the MDS, although long-term care hospital patients had more cases of diabetes, cardiac dysrhythmia, post heart

surgery, peripheral vascular disease, paraplegia, respiratory conditions, renal failure, and antibiotic-resistant infections

(Table 3C).

TABLE 3C.—PERCENT OF PATIENTS WITH SPECIFIC CONDITIONS BY FACILITY TYPE

Condition LTC

hospital

Rehab

hospital

SNF discharge

expected

SNF discharge

not expected

Diseases

Diabetes ........................................................................................................... 37.0 25.0 27.0 24.2

Hyperthyroidism ............................................................................................... 0.4 0.7 0.7 0.3

Hypothyroidism ................................................................................................ 9.0 8.2 8.0 6.8

Arteriosclerotic heart disease .......................................................................... 17.3 14.7 15.7 18.3

Cardiac dysrhythmia ........................................................................................ 21.1 11.3 14.7 17.2

Post heart surgery ........................................................................................... 24.0 13.0 6.9 6.2

CHF .................................................................................................................. 23.0 8.5 21.6 22.9

Deep vein thrombosis ...................................................................................... 4.8 3.1 11.4 1.8

Hypertension .................................................................................................... 37.6 45.8 47.9 46.5

Hypotension ..................................................................................................... 2.8 1.3 1.5 1.0

Peripheral vascular disease ............................................................................ 15.0 9.0 8.6 6.0

Other cardiovascular disease .......................................................................... 14.8 10.3 19.5 20.8

Arthritis ............................................................................................................. 11.3 20.1 25.4 21.9

Hip fracture ...................................................................................................... 6.7 11.6 14.1 7.4

Missing limb ..................................................................................................... 5.4 4.9 3.0 3.5

Osteoporosis .................................................................................................... 7.1 3.6 8.0 10.5

Pathological bone fracture ............................................................................... 1.3 1.8 1.0 1.5

Alzheimer’s ...................................................................................................... 1.5 0.5 4.1 12.3

Aphasia ............................................................................................................ 2.3 6.5 3.8 7.2

CP .................................................................................................................... 0.2 0.7 ........................ ........................

CVA .................................................................................................................. 23.8 34.6 22.2 27.7

Other dementia ................................................................................................ 7.9 2.1 13.9 31.5

Hemiplegia/hemiparesis ................................................................................... 12.9 27.8 8.8 10.1

MS .................................................................................................................... 2.1 1.1 0.1 0.7

Paraplegia ........................................................................................................ 3.0 2.1 0.3 0.3

Parkinson’s ...................................................................................................... 2.5 1.6 3.3 4.0

Quadriplegia ..................................................................................................... 3.3 2.6 0.1 0.2

Seizure disorder ............................................................................................... 6.5 5.2 4.5 4.5

TIA ................................................................................................................... 1.0 23 4.0 4.0

Traumatic brain injury ...................................................................................... 4.2 7.0 0.3 0.3

Anxiety disorder ............................................................................................... 4.6 5.2 7.8 6.8

Depression ....................................................................................................... 10.2 14.4 14.6 13.6

Manic depression ............................................................................................. 0.8 1.1 0.9 0.7

66318 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

TABLE 3C.—PERCENT OF PATIENTS WITH SPECIFIC CONDITIONS BY FACILITY TYPE—Continued

Condition LTC

hospital

Rehab

hospital

SNF discharge

expected

SNF discharge

not expected

Schizophrenia .................................................................................................. 0.8 0.5 1.0 1.5

Asthma ............................................................................................................. 3.5 3.1 2.0 1.5

Emphysema/COPD .......................................................................................... 29.0 10.1 19.3 17.2

Pulmonary failure ............................................................................................. 24.0 4.3 ........................ ........................

Cataracts .......................................................................................................... 2.9 3.3 6.5 5.5

Diabetic retinopathy ......................................................................................... 1.9 1.8 0.7 0.5

Glaucoma ......................................................................................................... 3.8 2.9 5.9 4.0

Macular degeneration ...................................................................................... 1.5 0.7 1.2 0.8

Allergies ........................................................................................................... 9.4 15.2 28.2 28.9

Anemia ............................................................................................................. 15.7 11.9 18.2 19.5

Cancer ............................................................................................................. 12.1 7.5 14.4 15.3

Renal failure ..................................................................................................... 14.0 4.7 4.9 5.3

Amputated limb ................................................................................................ 5.4 5.0 N/A N/A

Post surgery—elective hip ............................................................................... 4.0 13.0 ........................ ........................

Antibiotic resistant infection ............................................................................. 16.7 2.8 1.0 0.5

Pneumonia ....................................................................................................... 19.2 3.1 8.5 6.5

UTI ................................................................................................................... 21.9 19.9 21.1 23.1

Bladder Continence

Continent, no catheter ..................................................................................... 28.0 60.9 63.4 45.6

Continent, catheter .......................................................................................... 52.1 15.2 N/A N/A

Some incontinence .......................................................................................... 50.8 31.6 36.6 54.4

Bowel Continence ............................................................................................ 48.0 75.0 71.3 47.9

Complications

Inability to lie flat—loss of breath .................................................................... 44.0 6.5 6.9 6.2

Shortness of breath—exertion ......................................................................... 52.0 21.7 ........................ ........................

Shortness of breath—at rest ........................................................................... 32.0 0.0 ........................ ........................

Difficulty coughing/clearing airways ................................................................. 40.0 2.2 N/A N/A

Recurrent respiratory infection ........................................................................ 28.0 2.2 ........................ ........................

Surgical wound ................................................................................................ 48.0 56.5 ........................ ........................

Pain

None ................................................................................................................ 45.4 25.6 36.0 58.8

Less than daily ................................................................................................. 17.3 19.5 31.0 22.3

Daily ................................................................................................................. 37.3 55.0 33.0 18.9

Health Complications

Syncope ........................................................................................................... 2.3 1.0 .07 0

Unsteady Gait .................................................................................................. 26.2 52.5 48.0 40.1

Limited ROM—Arm .......................................................................................... 20.7 9.3 6.3 12.5

Limited ROM—Hand ........................................................................................ 18.0 7.2 3.5 8.8

Limited ROM—Foot ......................................................................................... 26.4 10.5 5.7 14.7

Pressure Ulcers—Any (stage 1–4) .................................................................. 36.0 17.9 17.7 21.6

Expectations (Rehabilitation Potential)

Patient believes self could be more independent ........................................... 53.7 74.5 45.1 16.2

Staff believes patient could be more independent .......................................... 59.1 76.4 50.9 31.3

Patient able to perform tasks slowly ................................................................ 26.1 33.9 12.7 12.4

Major difference in ADLs AM and PM ............................................................. 8.1 16.7 1.9 3.2

Behavior

Wander ............................................................................................................ 3.6 4.1 2.8 9.1

Verbally abusive .............................................................................................. 3.4 3.8 3.0 5.4

Physically abusive ........................................................................................... 1.8 2.1 1.4 5.9

Socially inappropriate ...................................................................................... 3.2 4.8 4.2 8.6

Resists care ..................................................................................................... 12.2 8.6 9.8 16.3

The diagnostic profiles of patients in

rehabilitation hospitals and SNFs were

similar, although rehabilitation

hospitals treated a higher percentage of

patients with strokes, hemiplegia/

hemiparesis, and traumatic brain injury

and fewer patients with congestive heart

failure and emphysema or chronic

obstructive pulmonary disease. Both

bladder and bowel continence levels

were similar for rehabilitation hospital

and SNF patients who were expected to

be discharged. Pain levels for

rehabilitation hospital and SNF patients

were also similar overall, although more

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66319

SNF patients were reported to

experience pain less frequently than

daily and more rehabilitation hospital

patients were assessed as having daily

pain. Pressure ulcer rates for

rehabilitation hospital and SNF patients

were comparable, as were the number of

patients with unsteady gait and

limitations in range of motion.

Rehabilitation hospitals reported a

higher use of restraints. Rehabilitation

hospital and SNF patients who were

expected to be discharged had a similar

number of behavioral symptoms, which

were less overall as compared to the

number of behavioral symptoms

experienced by SNF patients not

expected to be discharged.

These results confirmed anecdotal

information reported by rehabilitation

hospital and SNF clinicians during our

focus groups. While Medicare coverage

policies allow payment to SNFs for a

wider range of patients than

rehabilitation hospitals, both groups

reported that their patient populations

had changed over the past few years,

leading to some convergence in the

types of patients treated by

rehabilitation hospitals and SNFs. Both

reported a large increase in the number

of comorbidities and clinical

complexities for patients admitted

primarily for rehabilitative services,

saying that ‘‘uncomplicated’’ patients

were no longer admitted for inpatient

rehabilitation, (instead, for example,

‘‘uncomplicated’’ patients requiring

rehabilitation after a hip fracture now

generally receive therapy in their

homes).

It is our view that any system used to

classify rehabilitation patients should be

based on the same measures of a

patient’s health status and care needs as

are used in other segments of the postacute care industry. However, for

purposes of this proposed rule, we are

most concerned that the classification

instrument work well with IRF patients.

Given our use of the MDS in SNFs, it

is logical to extend an MDS-based

system to IRFs.

We are developing version 3 of the

MDS/RAI, which we envision as

containing sections for specific

populations (for example, traditional,

long stay resident; short-stay patient;

those receiving palliative or end of life

care; and pediatrics).

2. Other Options

We recognized that many

rehabilitation hospitals already use a

patient assessment instrument that

contains the functional independence

measures (FIM). The FIM were

developed by researchers who were

funded by a consortium of rehabilitation

professional associations and the

Department of Education, at the State

University of New York (SUNY) at

Buffalo in the 1980s. The FIM are

contained in a patient assessment

instrument that is marketed by the

Uniform Data System for Medical

Rehabilitation (UDSmr) maintained by

SUNY/Buffalo. Caredata.com Clinical

Outcome System (COS) used to market

a patient assessment instrument that

contained the FIM, but we have been

notified that Caredata.com has

discontinued its business related to FIM

reporting as of July 2000. The patient

assessment instrument marketed by

UDSmr is proprietary.

Many rehabilitation providers are

clients of UDSmr. Our 1997 data shows

that approximately 68 percent of

Medicare patients had a UDSmr or COS

data file, indicating that these patients

were assessed with the FIM. There is

extensive experience with the FIM

contained in the UDSmr and COS

patient assessment instruments and the

uses of the FIM data. This is

documented by a substantial list of

publications produced both in the

United States and overseas (for example,

Sweden and Japan), by the developers of

the system, and by independent

investigators.

The developers of the FIM offer a

certification course to train assessors in

the use of the instruments. This results

in very high rates of intra and inter rater

reliability, with Cronbach alpha

coefficients of more than 0.9 for both the

motor and cognitive subscores. The

Cronbach alpha coefficient is a

statistical measure of inter-rater

reliability with perfect reliability equal

to 1.0. Therefore, a score of 0.9 indicates

a very high level of inter-rater

reliability.

The MDS-PAC is a modification of the

MDS, the patient assessment instrument

developed for use in nursing facilities.

The principal objective of the MDS is to

facilitate care planning through a

description of the needs of the patient

for services. In contrast, the principal

objective of the FIM is to assess person

level disability in the inpatient medical

rehabilitation setting.

The strength of the FIM assessment

instrument is that it is a well-evolved

and extensively tested approach to the

assessment of the critical components of

care provided by IRFs, the impact on the

patient improvement in functional

capacity, and the purpose of the care

provided by the IRFs. The variations

among facilities in the difference

between the observed and expected

improvement in function are used as

indicators of the quality and the

effectiveness of the facilities. The

organization that analyzes FIM data for

providers generates benchmark data that

allows IRFs to compare the outcome of

their performance on the functional

independence measures relative to other

providers participating in the system.

One drawback of the FIM assessment

instrument is that it is specifically

focused on functional performance.

Information is collected only on the

matters directly related to functional

performance and only at admission and

discharge, and, when possible, 6 months

after discharge. There is, therefore, a

lack of detail on the needs of the patient

or on the evolution of the condition of

the patient during the course of the

admission. However, given that the

mean length of stay in an IRF is 15.81

days (median length of stay is 14 days),

we are specifically soliciting comments

on the benefits of mid-stay assessments.

We are not proposing to use the FIM

assessment instruments marketed by

either the UDSmr or COS as the basis for

an IRF prospective payment, because of

our desire to have a common

measurement instrument across

different post-acute provider settings.

Our proposal to use an MDS-based

approach comes from our conviction

that the use of common item labels and

definitions across different provider

settings would be essential to

monitoring patient care across different

provider settings. While we recognize

that there are differences between the

MDS and the MDS–PAC, our intention

is, at some point in the future, to

reconcile these differences. Structuring

the IRF assessment instrument

consistent with the MDS would allow

for comparison of patients across

different institutional settings. The

MDS–PAC collects information on many

of the same activities or functional

measures as the FIM but defines these

activities more specifically in some

cases. It would also help facilitate

continuity of care in that comparable

baseline data would accompany the

patient’s transfer from one setting to the

other. Standardized information across

provider types would also be extremely

useful in comparing patient

characteristics and potentially the

appropriateness of care in different

settings that serve the same populations.

This is especially important since

analysis by RAND (1997) shows that

costs for the same services vary

significantly by provider.

When we began to develop the MDS

in the 1980s, the possibility of using the

FIM ADL scoring schema was

considered. However, field experience

demonstrated that nursing home staff

did not feel comfortable making the

level of distinctions required in the FIM.

66320 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

The FIM serve as a functional-based

system designed to capture specific

aspects of ADL performance. Therefore,

the FIM’s ability to measure items that

are not functionally related, such as

cognition, may be problematic. For

example, in order to score

communication on the FIM,

compromises must be made to blend

cognitive and performance ideas into a

single construct. The scoring schema

used in the MDS–PAC allows the

instrument to describe a concept like

communication from a functional

performance perspective as well as from

the cognitive perspective based on how

much caregivers have to intervene to

help compensate for the patient’s

communication deficits.

UDSmr requires that users of the FIM

(for example, therapists) be trained. An

evaluation of the FIM scoring will be

performed by RAND before a final rule

is published. FIM scoring rules assign

the lowest (most dependent) value to

missing data which is likely to bias

scores downward, especially upon

admission when data are more likely to

be missing. The payment implications

may generally be to place patients in a

more service intensive CMG. The MDS–

PAC addresses this by having a separate

coding entry (8) for activities that do not

occur rather than instructing users to

code with the most dependent level.

An independent team of technical

experts highlighted areas of concern

regarding the FIM’s accuracy in

predicting costs for patient care.

Panelists were concerned that the

scoring of some items, such as cognitive

functioning, gave raters a great deal of

discretion in determining what evidence

was used in the assessment and how

often the behavior had occurred. These

technical experts also agreed that a

functional status assessment for

payment purposes should be based on

clinical observation of performance

rather than on the rater’s assessment of

the patient’s capacity to perform the

task.

The MDS–PAC uses the same FIM

constructs as were originally designed

by the UDSmr team but rewords them

in such a way so that these items better

fit into the context of the MDS

instrument. In addition, the item

language and definitions and

instructions are integrated into the

instrument. The administration of the

MDS–PAC at more than one point in a

patient’s stay will permit assessment of

patient changes during that episode of

treatment and may lead to possible

refinements to the patient classification

system.

We seek public comment on our

proposal to use the MDS–PAC as the

assessment instrument for the IRF

prospective payment system, including:

comments and supporting data

regarding the additional burden and

cost, if any, associated with this

instrument; the suitability of the

instrument for the rehabilitation setting

and as a model for other post-acute care

settings; views on whether the

instrument has been properly tested and

validated for industry-wide use; and the

utility and reliability of the quality data

items contained in the instrument.

3. Combining the MDS–PAC and the

FIM

The MDS–PAC covers several topics,

for example, nutrition, swallowing, and

pain, that are either not included in the

FIM or not covered in sufficient detail

in the FIM for clinical assessment

purposes, and that are not currently

used in classifying patients for payment.

An alternative to using the MDS–PAC

would be to retain the non-payment

items from the MDS–PAC and

incorporate the FIM items for patient

classification into CMGs. Because of our

concerns, as outlined above (for

example, compatibility with

assessments in other settings), we have

rejected this option for purposes of this

proposed rule and propose to use

payment-related questions that are

compatible with the FIM.

However, the FIM assessment system

has been under development since the

mid 1980s and is currently recognized

as a valid and reliable instrument to

measure impairments in IRFs. The FIM

are in current and increasing use in

rehabilitation facilities, the data analysis

being performed by UDSmr and by COS,

with the data analysis organization

depending on which of these two

organizations the IRF has selected.

Thus, there has been extensive training

in and experience with the data

elements, particularly the functional

components, that enter into the

construction of the CMGs. We will be

testing whether the MDS–PAC results in

patient classifications that are

equivalent to the classifications that

occurred with the FIMs (that is, the

assessment instruments that were used

to design the payment system).

If the tests show that patients are

classified differently using the MDS–

PAC, HCFA will, in the final rule,

incorporate the phrasing, definitions,

and order of the items required by the

payment system, based on the FIM,

replacing the proposed equivalent

sections of the MDS–PAC. This would

meet our objective to field the more

extensive instrument to provide a more

complete picture of the evolution of

condition of the patient and of the care

provided in the IRF, but also to retain

confidence in the validity of the

classification of the patient. Using the

phrasing, definitions, and order of the

items would minimize the effect on

reliability and validity inherent in the

design of new data collection

instruments.

4. The MDS-PAC Development Process

Under contract, a team led by John N.

Morris, Ph.D., at the Hebrew

Rehabilitation Center for the Aged,

began to develop the MDS-PAC in 1997.

This team played a key role in designing

the original MDS/RAI system and MDS

2.

The MDS–PAC development process

relied on broad-based input from a large

and diverse constituency, representing

rehabilitation facilities, SNFs, long-term

care hospitals, and the viewpoints of

individual and corporate providers,

clinical disciplines, consumers, States,

other Federal agencies, and researchers.

Examples of organizations representing

rehabilitation providers and clinicians

include the American Medical

Rehabilitation Providers Association,

the American Hospital Association

(representing hospital-based

rehabilitation units), the Federation of

American Health Systems, the

Commission on Accreditation of

Rehabilitation Facilities, the National

Head Injury Foundation, the Uniform

Data System for Medical Rehabilitation,

the Association of Academic

Physiatrists, and the American

Academy of Physical Medicine and

Rehabilitation.

Representatives and staff of over 40

national organizations and agencies

with a stake in the MDS–PAC were

brought together in a technical expert

panel, which met at the outset of the

MDS–PAC development process, and at

key intervals thereafter. The purpose of

the technical expert panel was to

provide us with advice on technical and

operational issues associated with

assessment of post-acute patients. We

requested that technical expert panel

representatives disseminate project

information to their constituents,

coordinate input from their members

back to our project team, and assist with

identifying facilities to participate in

field testing of the instrument. We

solicited comments from technical

expert members on several drafts of the

MDS–PAC, and also conducted a

mailing that solicited comments from

over 1100 facilities and individuals,

identified in part by technical expert

panel members. We also posted a

project summary and various drafts of

the MDS–PAC on our MDS web site. In

addition, the project team reviewed the

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66321

comments we received on the

assessment instrument.

We began development of the MDS–

PAC by gathering baseline information

through focus groups, a provider survey,

and collection of MDS data within

rehabilitation hospitals/hospital-based

units and long-term care hospitals. We

held two focus groups, consisting of

physicians, nurses, and therapists who

were involved in patient assessment and

care planning on a daily basis within

rehabilitation hospitals and units, SNFs,

and long-term care hospitals. The

clinicians who participated in the focus

groups were all nominated by the

national associations representing

rehabilitation hospitals, SNFs, and longterm care hospitals. The purpose of the

focus groups was to solicit real-world

input regarding current assessment and

care planning practices for post-acute

patients.

We also conducted a survey of SNF,

rehabilitation hospital, and long-term

care hospital providers to gather

information about their patient

populations, assessment and care

planning practices, care processes, care

delivery models, and the availability of

various types of specialized staff.

Facility staff were asked to comment on

the perceived clinical utility of MDS

items and each of the RAPs for their

own patient populations. Providers

participating in our focus groups were

asked to pilot the questionnaire, which

was subsequently refined. The

questionnaire was then distributed to

over 900 SNFs, rehabilitation hospitals

and units, and long-term care hospitals

that had requested information on the

project or whose names we had received

from associations participating on the

technical expert panel. A total of 416

providers (224 SNFs, 131 rehabilitation

hospitals or units, and 61 long-term care

hospitals) responded to the survey

during January through March 1998. A

summary of these responses was

presented during our March 1998

meeting with the technical expert panel.

Using the input gathered from our

initial activities, we developed an initial

draft of the MDS–PAC in September

1997. In developing the initial MDS–

PAC draft, it is important to note that

we did not start with the current MDS

2. Rather, we used a ‘‘bottom-up’’

approach to build the MDS–PAC. This

means that we started by listing the

various domains and issues that had

been identified through our initial focus

groups and provider survey as relevant

for the post-acute patient. We then

selected items to measure those specific

issues from the MDS 2 or other HCFA

assessment instruments, such as the

Outcome and Assessment Information

Set (OASIS) or the Uniform Needs

Assessment Instrument. New items were

developed for those areas in which no

item currently existed within our group

of assessment tools. In building and

refining the MDS–PAC items we relied

extensively on the input of clinical

experts serving on, or identified by, our

technical expert panel. Appendix B

contains a summary of the survey items

and the responses of the clinical

experts.

The original MDS–PAC draft was

refined through the production of 10

major draft revisions over a 2-year

period. We solicited comments on

various drafts through mailings to our

technical expert panel, and to over 1100

providers that had been identified by

the technical expert panel or otherwise

indicated an interest in the project, as

well as through posting of various drafts

on our web site.

One of the guiding principles of our

MDS–PAC development has been that

the instrument had to include items that

were compatible with the FIM and

would result in the same patient

classifications generated using the FIM.

In nearly all instances, we did not

simply insert the functional

independence measures items into the

MDS–PAC. Generally, the goal was to

develop blended items that were

consistent with the general MDS model

and scales, but were also capable of

generating the type and level of detail

contained in a specific functional

independence measure item. This work

was conducted through extensive

collaboration with Dr. Carl Granger,

who was a member of our MDS–PAC

technical expert panel, and his UDSmr

team. Prior to our final rule, we will be

conducting further research to

determine whether the MDS–PAC will

classify patients into the same CMGs as

they would have been classified into

using FIM.

5. Developmental Testing of the MDS–

PAC

Drafts of the MDS–PAC were

subjected to substantial field testing, to

ensure it is both reliable and feasible for

use as the patient data collection system

needed to implement the IRF

prospective payment system. Formal

testing consisted of an initial pilot test,

as well as two larger rounds of field

testing, in rehabilitation hospitals and

units, SNFs, and long-term care

hospitals. In conducting research, a

pilot test allows a preliminary trial of an

instrument to discover and rectify any

major problems before the main study

begins. A pilot test uses a small study

sample of facilities, whose results

enable researchers to make last minute

corrections and adjustments. A field test

uses a larger sample and more formally

delineated procedures and protocols.

In conducting our tests we worked

with a number of providers that

volunteered to participate either directly

or through their provider associations.

However, most of the participants in

each of the testing rounds were

recruited randomly from our listing of

Medicare-certified providers maintained

in the Online Survey and Certification

Reporting System; we designed our

sample to ensure that participating

facilities varied in geographic location,

size, etc.

Pilot testing of the MDS–PAC was

conducted in September through

October 1998, with a total of 20

providers (7 rehabilitation hospitals or

units, 4 long-term care hospitals, 9

SNFs; 15 sites recruited randomly). A

total of 161 assessments were completed

as part of the pilot test, with 69

completed by rehabilitation hospitals,

68 by SNFs, and 24 by long-term care

hospitals.

MDS–PAC testing consisted of a pilot

test and two field tests. A total of 16

assessors participated in the pilot test

conducted in IRFs and 96 and 75

assessors participated in the first and

second field tests, respectively. The

MDS–PAC was used to assess a total of

885 admissions and 345 discharges in

these IRFs during this pilot and field

testing. The average length of stay for

these admissions was 18.9 days with a

median of 16 days.

The initial field test occurred in

January through April 1999, in 85

providers total (40 rehabilitation

hospitals or units, 21 long-term care

hospitals, 22 SNFs, and 2 facilities for

which the above category was not

properly recorded; 51 sites recruited

randomly). A total of 1164 patients were

assessed using draft 8 of the MDS–PAC,

with 599 cases assessed in rehabilitation

hospitals or units, 284 in SNFs and 281

in long-term care hospitals.

The second field test was conducted

in June through September 1999, in a

total of 57 providers (33 rehabilitation

hospitals and units, 11 long-term care

hospitals, 13 SNFs; 39 sites recruited

randomly). A total of 462 cases were

completed in the second field test, with

285 patients assessed by rehabilitation

hospitals, 80 by SNFs, and 97 by longterm care hospitals.

Testing focused on the inter-rater

reliability and clinical validity of MDS–

PAC items, as well as the administrative

feasibility and burden associated with

completion of the assessment tool.

Paired assessments were completed for

a sample of cases during each of the

field trials (N=171 assessments

66322 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

conducted using the June 30, 1999

version of the MDS–PAC used in field

test 2) and reliability coefficients were

calculated using a weighted Kappa

statistic. Reliability measures whether

the instrument would result in the same

findings if it were administered at a

later date or by a different person. The

average reliability for the 315 items on

the version of the MDS–PAC tested in

the second field test (draft 9) was 0.78.

A frequently cited standard in the

research community, Fleiss (1975),

establishes item reliability of 0.5 as

acceptable, with levels of 0.75 or better

considered as superior for tools of this

nature. Reliability coefficients ranged

from 0.51 for ‘‘repetitive health

complaints’’ to 1.0 for several items.

Facility staff were asked to log the

amount of time spent on each MDS–

PAC assessment, and also categorize

how that time was spent. There was

general comparability across provider

types in how time was spent. Review of

the clinical record consumed the most

time and interaction with the patient’s

physician or family was conducted by

only a minority of assessors.

Recognizing the learning curve

associated with any new process,

burden estimates were calculated for

both the initial few cases completed by

staff and subsequent cases after staff had

become more familiar with the process

(that is, after completing approximately

10 MDS–PAC assessments).

Rehabilitation hospital staff initially

required a median of 105 minutes to

complete the intake assessment and 85

minutes after they became familiar with

the Version 9 MDS–PAC, as compared

to the 85 and 77 minutes respectively,

required by SNF staff. The time required

to complete follow-up or discharge

MDS–PAC assessments was also

calculated, as these assessments involve

fewer items than the initial MDS–PAC

assessment. Rehabilitation hospital staff

required a median of 75 minutes to

complete the first few cases using this

shorter assessment and 48 minutes after

they completed approximately 10 cases.

SNF staff spent a median of 50 minutes

on the first few follow-up assessments

they completed, and 45 minutes

subsequently.

B. Overview of the MDS–PAC

Assessment Process

1. Description of the MDS–PAC

We include, in Appendix BB of this

proposed rule, the MDS–PAC Version 1,

which we refer to throughout this

preamble as the MDS–PAC. Appendix

BBB contains the Item-by-Item Guide to

the MDS–PAC, which consists of

instructions for completing the MDS–

PAC. The MDS–PAC that is included in

Appendix BB is a modified version of

the MDS–PAC that was the product of

the previously described pilot and field

testing. This modified version MDS–

PAC reflects changes we made in order

to ensure that the MDS–PAC items used

to classify a patient into a CMG cover

all of the same subjects as the functional

independence measures items that were

used to develop the classification

system.

Before the final rule, we will conduct

field testing of the modified MDS–PAC,

Version 1, to establish its validity,

reliability, and equivalence for payment.

In addition, we will study a sample of

facilities that are currently using

UDSmr’s FIM patient assessment

instrument and the COS. These facilities

will complete their instruments (either

UDSmr’s or COS) and the MDS–PAC on

the same patient at the same time.

Results of this paired assessment will be

compared to determine the capability of

the MDS–PAC instrument to accurately

and consistently assign CMGs and

whether the MDS–PAC assigns the same

CMGs as the UDSmr/COS instrument

would. If the results of this study do not

indicate that the MDS–PAC accurately

and consistently assigns CMGs as the

UDSmr/COS instrument would, then

the MDS–PAC will be redesigned to

incorporate the phrasing, content, and

coding conventions of the UDSmr/COS

instruments. This study will be

completed this fall by researchers from

RAND, and the results will be

incorporated into the final rule. The

study and any modifications to the

assessment instrument will be

completed prior to the publication of

the IRF prospective payment system

final rule.

The MDS–PAC is a patient-centered

assessment tool that emphasizes a

patient’s care needs, rather than the

characteristics of the provider. The

assessment instrument consists of 15

sections, each collecting different

categories of patient information. These

categories include identification and

demographic information about the

patient, as well as the following

categories of information: cognition;

communication; behavior and mood;

functional status; bowel and bladder

continence; diagnoses; medical

complexities and other health

conditions; oral and nutritional

information; pain status information;

information on procedures and services;

functional prognosis; and resources for

discharge.

2. Use of the MDS–PAC

We propose to require that IRFs use

a standardized patient data collection

assessment instrument for Medicare

patients in IRFs, the MDS–PAC. We

propose to require that IRFs must

computerize and electronically report

the MDS–PAC data.

Each year tens of thousands of

Medicare patients are treated in IRFs. As

discussed in more detail in section III.F.

of this preamble, we propose that each

of these patients would be assessed on

the average at least of three times, with

the MDS–PAC being used as the patient

assessment instrument. Therefore, there

will be a very large quantity of data

collected and submitted to us each year.

As a result, it would be unrealistic for

us to perform a meaningful analysis of

this large amount of data for payment,

medical review, and quality monitoring

purposes in the absence of the

capability to use automated data

collection. An analysis of MDS–PAC

data would allow us to use MDS–PAC

data in a manner similar to how we use

SNF MDS data.

One use of SNF MDS data is to

support quality of care monitoring. The

SNF MDS data is reliable and effective

in supporting early identification of

potential quality of care problems. Early

identification, in turn, helps to focus the

survey process upon these identified

problem areas.

Using MDS data we have developed

indicators of the quality of care in SNFs.

The quality of care indicators are used

to support analytical evaluations of the

quality of services that SNFs furnish.

For example, we use MDS data to

provide us with objective and detailed

measures of the clinical status and care

outcomes of residents in a SNF. In

addition, quality of care indicators can

be used to analyze the relationship

between Medicare policy changes and

quality of care.

Computerization of the MDS–PAC

data would make it easier and more

practical for an IRF to use the MDS–

PAC data to classify a patient into a

CMG. Electronic transmission of the

MDS–PAC data by the IRF makes the

creation of an MDS–PAC database

feasible. An MDS–PAC database, in

turn, permits the data to be accessed

easily in various formats for different

analytical purposes, which can be used

to support the Medicare program’s fraud

and abuse efforts, for medical review

purposes, and for uses similar to how

the SNF MDS data is used.

We propose that beginning on April 1,

2001, IRFs must collect MDS–PAC data

as part of the IRF’s inpatient assessment

process for patients who are receiving

Medicare-covered Part A services. This

MDS–PAC data collection requirement

applies to Medicare beneficiaries who

are already inpatients as of April 1,

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66323

2001, as well as beneficiaries admitted

as inpatients on or after April 1, 2001.

In addition, we propose that the IRFs

must use the MDS–PAC to assess

inpatients in accordance with the MDS–

PAC assessment schedule specified in

section III.F. of this preamble.

The IRFs would encode the MDS–

PAC data by entering the MDS–PAC

data into a computer software program.

MDS–PAC records would be considered

‘‘locked’’ when they passed all HCFAspecified edits and were accepted by the

MDS–PAC database to which the IRF

transmitted its records.

We propose in § 412.610 that IRFs

must also maintain all completed MDS–

PAC assessments for the previous 5

years, either in a paper format in the

patient’s clinical record or in an

electronic computer file format that can

be easily obtained, because the

assessments may be needed as part of a

retrospective review conducted at the

IRF for various purposes, for example,

as part of the documentation that the

IRF used to determine the medical

necessity of the Medicare-covered

services the IRF furnished. Also,

completed MDS–PAC assessments that

are available at the IRF could be

beneficial to other entities that

appropriately have access to these

records (for example, a State or Federal

agency conducting an investigation due

to a complaint of patient abuse or a

suspicion of fraud). In addition,

retention of the MDS–PAC assessment

by the IRF would provide a backup to

the electronic database.

Data from the initial MDS–PAC

assessment would be used to classify

patients into a CMG. The CMG would

correlate with the payment rate that the

IRF receives for the Medicare-covered

Part A services furnished by the IRF

during the Medicare beneficiary’s

episode of care.

3. Transmission of the MDS–PAC Data

We propose that between February 1

and February 28, 2001, IRFs must

complete a successful transmission of

test MDS–PAC data to the HCFA MDS–

PAC system. A successful transmission

by the IRFs of test MDS–PAC data to the

HCFA MDS–PAC system is necessary to

determine connectivity with the system

and to identify any transmission

problems. The HCFA MDS–PAC system

would transmit a test data feedback

report to each IRF indicating that the

test data transmission was either

completely successful or experienced

problems. The problems would be

specified in the test data transmission

report.

On March 1, 2001, the HCFA MDS–

PAC system would begin to purge all

test data from the system to allow for

acceptance of production data, that is,

data that would be associated with the

MDS–PAC assessment schedule and

CMG payment rates, as specified in

sections III. F. and V. of this preamble.

For example:

February 1, 2001, to February 28,

2001—Period for transmission of test

MDS–PAC data.

March 1, 2001, to March 7, 2001—The

HCFA MDS–PAC system purges test

data.

April 1, 2001—Assessments

completed on or after this date must be

transmitted as production data.

As specified in section III. I. of this

preamble, we would provide training

and technical support to the IRFs on

administering and completing the MDS–

PAC, as well as transmitting the MDS–

PAC data.

C. The MDS–PAC Assessment and

Medical Necessity

The initial MDS–PAC assessment

would be used to classify each Medicare

patient into a CMG, with the CMG being

the basis for IRF payment. One principle

governing appropriate Medicare

payment and utilization of Medicare

inpatient services is that there must be

documentation establishing appropriate

medical necessity for the inpatient

services furnished to a patient.

When the data recorded on the MDS–

PAC accurately reflect the patient’s

clinical status, they form the basis for

documenting the medical necessity of

the services furnished to the IRF

Medicare inpatient. There may be cases

in which a medical review (or other

type of facility or patient review)

questions the accuracy of the recorded

MDS–PAC items and, by extension, the

associated medical necessity of the

services that the IRF furnished. In these

cases, other documentation would be

examined to verify the information

recorded on the MDS–PAC, and the

medical necessity for the services as

indicated by the MDS–PAC. Other

documentation that would support the

accuracy of the recorded MDS–PAC

information (and the medical necessity

for the services furnished to the

inpatient) must be recorded in the

patient’s medical record and could

include, but is not limited to: (1)

physician’s orders; (2) physician’s notes;

(3) nursing notes; (4) notes from

therapists; (5) diagnostic tests and their

results; and (6) other associated

information, such as social worker or

case manager notes.

A patient’s clinical status for a given

time period, as indicated by a

completed MDS–PAC form, must be

verifiable and consistent with the

clinical information independently or

separately recorded in the patient’s

clinical record. Otherwise, inaccurately

completed MDS–PAC assessments

might be used to classify patients into

CMGs that would, in turn, form the

basis for Medicare payment for

medically inappropriate or unnecessary

services. We will continue to conduct

medical review activities to verify and

monitor the medical necessity of

services furnished in conjunction with

our continuing efforts to eliminate

Medicare payment errors.

In proposed § 412.614, facilities will

transmit each Medicare inpatient’s

MDS–PAC assessments to the HCFA

MDS–PAC system, and submit claims

for Medicare payment to the fiscal

intermediary, in accordance with the

current claims procedures. Payment to

the IRF would be made according to the

CMG recorded on the claim sent to the

fiscal intermediary. We will have the

capability to analyze the claim

information against the transmitted

MDS–PAC data. The results of this

analysis may necessitate additional

review of a particular claim and the

associated MDS–PAC data to determine

if payment was made accurately.

D. The MDS–PAC Assessment Reference

Date

In § 412.610(c) we propose that each

assessment would have a specific

assessment reference date. The purpose

of the assessment reference date is to

establish a common temporal reference

point for the care team participating in

the patient’s assessment. Although staff

members may work on completing a

patient’s MDS–PAC on different days,

establishment of the assessment

reference date ensures the commonality

of the assessment period (that is,

‘‘starting the clock’’), so that all

assessment items refer to the patient’s

objective performance and clinical

status during the same period of time.

The assessment reference date is a

specific endpoint in the MDS–PAC

assessment observation time period.

Almost all MDS–PAC items refer to the

patient’s status over a continuous three

calendar day time period, which is the

observation time period.

During the patient’s current

hospitalization, an IRF must indicate on

the MDS–PAC one of the following

assessment reference dates—

• For the assessment that covers

calendar days 1 through 3 of the

patient’s current hospitalization the date

that is the third calendar day after the

patient started being furnished

Medicare-covered Part A services.

• For the assessment that covers

calendar days 8 through 10 of the

66324 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

patient’s current hospitalization the date

that is the 10th calendar day after the

patient started being furnished

Medicare-covered Part A services.

• For the assessment that covers

calendar days 28 through 30 of the

patient’s current hospitalization the date

that is the 30th calendar day after the

patient started being furnished

Medicare-covered Part A services.

• For the assessment that covers

calendar days 58 through 60 of the

patient’s current hospitalization the date

that is the 60th calendar day after the

patient started being furnished

Medicare-covered Part A services.

• For the assessment that must be

completed when the patient stops

receiving Medicare-covered Part A

services but is not discharged from the

IRF, the assessment reference date must

be the actual date that the patient stops

receiving Medicare-covered Part A

services.

• For the assessment that is

completed when the patient stops

receiving Medicare-covered Part A

services and is discharged from the IRF

the assessment reference date must be

the actual date of discharge from the

patient rehabilitation facility.

The general concept is that the

assessment reference date sets the

designated endpoint of the common 3-

day observation period, and the MDS–

PAC items will usually refer back in

time from this point. The assessment

reference date establishes the end of the

assessment time period that the

clinician(s) will use for the data

gathering. As specified in proposed

§ 412.606(c), these data are obtained

through patient observation, patient

interview, the clinical record or other

means, in order for the clinician(s) to

complete an MDS–PAC assessment that

covers a given data-gathering time

period.

For discharge assessments, the date

when the patient either is discharged or

stops receiving Medicare-covered Part A

services is the assessment reference

date. The observation time period

includes either the date that the patient

is discharged, or the date that the

patient stops receiving Medicarecovered Part A services, along with the

preceding 2 calendar days. In a situation

when the discharge occurs

unexpectedly, the clinical record would

become a prime source of the data

recorded on the MDS–PAC.

E. Performing the MDS–PAC Assessment

In § 412.606, we propose that

Medicare beneficiaries who are

inpatients of an IRF must be assessed by

a professional clinician(s), and that the

MDS–PAC must be used to perform the

patient assessment. Because the MDS–

PAC will be used to obtain a variety of

assessment data, we believe that the

assessment process should be a

collaborative team effort, employing the

clinical skills of a variety of professional

clinicians.

The data recorded for a specific MDS–

PAC item may be more accurate if the

information used to record the data for

that specific item was obtained by a

professional clinician with specialized

training related to that specific MDS–

PAC item. A professional clinician may

be a dietitian, an occupational therapist,

a physical therapist, a physician, a

practical (vocational) nurse, a registered

nurse, a speech-language pathologist or

a social worker.

For purposes of this proposed rule,

we propose to incorporate the existing

definition of a qualified dietitian

specified in § 483.35(a)(2). For purposes

of this proposed rule, we propose to

incorporate the existing standard at

§ 482.56(a)(2) of who may perform

occupational therapy and physical

therapy as defining the terms

occupational therapist and physical

therapist. Section 482.56(a)(2) states that

physical therapy and occupational

therapy ‘‘must be provided by staff who

meet the qualifications specified by the

medical staff, consistent with State

law.’’ Therefore, an occupational

therapist and a physical therapist are

individuals who meet the qualifications

of the provider’s medical staff and State

law.

A practical (vocational) nurse, a

registered nurse, and a speech-language

pathologist are individuals who meet

the applicable definitions of § 484.4. For

purposes of this proposed rule, an

individual would be considered a social

worker if that person meets either the

definition in § 483.15(g)(3) or the one in

§ 483.430(b)(5)(vi), because these two

sections define a social worker in terms

of varying levels of education and

experience.

For purposes of this proposed rule,

we propose to define the term physician

as an individual who is a doctor of

medicine or osteopathy who is currently

legally licensed to practice medicine

and surgery by the State in which that

function or action is performed.

Performing an MDS–PAC assessment

is a process that involves patient

interview, patient observation, and, if

necessary, obtaining information from

other sources, such as the clinical

record or the patient’s family. The data

recorded on the MDS–PAC would be the

result of that total assessment process,

and the manner in which data is

obtained for a specific MDS–PAC item

would depend on a combination of the

instructions on the MDS–PAC form

itself, the Item-by-Item Guide to the

MDS–PAC, and provisions set forth via

rulemaking. Although different

professional clinicians may be involved

in the MDS–PAC assessment process, in

order to ensure that the MDS–PAC

assessment process is properly

followed, we propose that only specific

clinicians be authorized to sign item

AB1a of the MDS–PAC.

In general, we believe that physicians,

registered nurses, physical therapists,

and occupational therapists are the only

disciplines equipped with the education

and experience to accurately assess the

entire range of an individual’s

functional/motor performance and

medical/clinical status. Additionally,

the licensure requirements of some

States restrict the human services

disciplines that may perform a clinical

assessment. Therefore, we propose that

only an occupational therapist, a

physical therapist, a physician, or a

registered nurse be authorized to sign

item AB1a of the MDS–PAC and

provide the data for items AB1b thru

AB1g of the MDS–PAC. Item AB1a is

where the clinician who is attesting to

the completion of the assessment signs.

Items AB1b thru AB1g are the items that

identify the clinician who signed item

AB1a and the date that item AB1a was

signed.

The clinician who signs item AB1a

would be responsible for the accuracy

and thoroughness of a specific patient’s

MDS–PAC assessment, and would be

responsible for the accuracy of the date

inserted in item AB1g. The signatures of

other professional clinicians who

contributed to the data recorded on the

MDS–PAC would be recorded in item

AB, lines 2a through item 2f.

The data for the MDS–PAC items that

require the collection of data that is not

associated with the observation of an

activity by the patient can be obtained

from the patient, the patient’s clinical

record, and, if necessary, from the

patient’s family. If the patient is

uncooperative we believe that the data

that is not associated with the

observation of an activity by the patient

can be obtained from the patient’s

clinical record, or other easily obtained

documentation that contains patient

information. We believe that the data for

the MDS–PAC items related to the

observation of a particular activity

would always be recorded on the MDS–

PAC, because these items allow for the

recording of the data in different ways,

including recording that the activity did

not occur. For the items related to

observation of a patient activity we want

to emphasize that the clinician assessor

should not require a patient to perform

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66325

an activity that in the clinician’s

professional judgment is clinically

contraindicated or hazardous. The Itemby-Item Guide to the MDS–PAC in

Appendix BBB contains information

concerning observational techniques

and provides more guidance for

clinicians in performing the MDS–PAC

assessment.

F. The MDS–PAC Assessment Schedule

1. General Rule

We propose in § 412.610 that an IRF

Medicare patient be assessed by a

clinician(s) using the MDS–PAC to

gather and record the patient assessment

data. The length of the patient’s

hospitalization would determine how

many MDS–PAC assessments are

required. Table 4C below, entitled

‘‘MDS–PAC Assessment Schedule and

Associated Dates,’’ illustrates the

proposed MDS–PAC assessment

schedule for the following ‘‘MDS–PAC

Assessment Type’’: Day 4, Day 11, Day

30, and Day 60 assessments. The term

‘‘day’’ as used in the assessment

schedule is a calendar day, and is

counted as including the first day of the

patient’s current IRF hospitalization

when the patient started receiving

Medicare-covered Part A services,

(which is generally the day of admission

to the IRF). As specified in proposed

§ 412.620(a)(3), in general only data

from the Day 4 assessment would

determine the CMG classification that

would in turn determine the payment

that the IRF would receive for the entire

episode of the patient’s hospitalization.

If a patient is not hospitalized in the IRF

for the time period needed for the Day

4 assessment, then the patient’s CMG

would be determined as specified in

section V.C. of this preamble.

TABLE 4C.—MDS–PAC ASSESSMENT SCHEDULE AND ASSOCIATED DATES

MDS–PAC

assessment

type

Hospitalization

time period and

observation time

period*

MDS–PAC assessment reference date*MDS–PAC must

be completed

by:*

Hospitalization episode covered

by this assessment:

MDS–PAC must

be encoded by:*

MDS–PAC must

be transmitted

by:*

Day 4 ........... First 3 Days ...... Day 3 ................ Day 4 ................ Entire Hospitalization Time Period.Day 10 .............. Day 16

Day 11 ......... Days 8 to 10 ..... Day 10 .............. Day 11 .............. ...................................................... Day 17 .............. Day 23

Day 30 ......... Days 28 to 30 ... Day 30 .............. Day 31 .............. ...................................................... Day 37 .............. Day 43

Day 60 ......... Days 58 to 60 ... Day 60 .............. Day 61 .............. ...................................................... Day 67 .............. Day 73

Currently, on the MDS–PAC, item B4

‘‘Indicators of Delirium—Periodic

Disordered Thinking/Awareness,’’

requires an assessment time period that

is 7 days in length. Item F1 ‘‘Bladder

Continence,’’ and item F4 ‘‘Bowel

Continence’’ require an assessment time

period that is 7 to 14 days in length.

Therefore, the assessment time period

and associated coding for these three

items affect the dates for the

‘‘Hospitalization Time Period and

Observation Time Period,’’ the ‘‘MDS–

PAC Assessment Reference Date,’’ the

‘‘MDS–PAC Must Be Completed by:,’’

the ‘‘MDS–PAC Must be Encoded By:,’’

and the ‘‘MDS–PAC Must be

Transmitted By:’’. As stated previously,

we will be conducting additional testing

of the MDS–PAC. This additional

testing will determine if the assessment

time period for items B4, F1, and F4 can

be changed, or if the instructions on

assessing these items should be

changed. If our additional testing

indicates that the assessment time

periods or the instructions for assessing

items B4, F1, and F4 should not be

changed, then in the final rule we will

change the proposed MDS–PAC

assessment schedule and associated

dates to reflect the current assessment

time periods of these three items.

Table 4C represents the generic

assessment schedule and other

associated MDS–PAC dates. Table 5C.—

Example Applying the MDS–PAC

Assessment Schedule and Associated

Dates, below is an example of how

Table 4C would be applied using actual

calendar dates. In Table 5C it is

assumed that the patient was admitted

on April 3, 2001.

TABLE 5C.—EXAMPLE APPLYING THE MDS–PAC ASSESSMENT SCHEDULE AND ASSOCIATED DATES

MDS–PAC assessment type Hospitalization time period and observation time

period

MDS–PAC

assessment

reference

date

MDS–PAC

must be

completed

by:

MDS–PAC

must be encoded by:

MDS–PAC

must be

transmitted

by:

Day 4 ........................................... First 3 Days ........................................................... 4/5/01 4/6/01 4/12/01 4/18/01

Day 11 ......................................... Days 8 to 10 .......................................................... 4/12/01 4/13/01 4/19/01 4/25/01

Day 30 ......................................... Days 28 to 30 ........................................................ 5/2/01 5/3/01 5/9/01 5/15/01

Day 60 ......................................... Days 58 to 60 ........................................................ 6/1/01 6/2/01 6/8/01 6/14/01

Each patient is assessed by a

clinician(s) using an MDS–PAC to

perform a comprehensive assessment

according to the schedule stated above.

More than one clinician can contribute

to completion of the MDS–PAC. We

believe that MDS–PAC assessment

accuracy would be enhanced if the data

collected for an MDS–PAC item is

collected by a clinician with specialized

training and experience in the area of

the data being collected. For example,

although a registered nurse could fully

assess all aspects of a patient and collect

all the MDS–PAC data, a physical

therapist or an occupational therapist

has the specialized training which may

contribute to a more accurate

assessment of some neuro-muscular

items. Our objective is to have data

collected that would best reflect the

patient’s unique circumstances and

clinical status during the assessment

observation period, considering that an

MDS–PAC item may provide for several

possible responses and that the accuracy

of patient assessment is contingent on

the training and experience of the

clinician assessor.

In section IV. of this preamble, we

specify the MDS–PAC items that would

be used to classify a patient into a

specific CMG. We propose to require

66326 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

that data be collected not only for the

items that would be used to classify a

patient into a CMG, but also for any of

the other MDS–PAC items for which

data collection is appropriate according

to one or more of the following: (1) the

instructions on the MDS–PAC; (2) the

Item-by-Item Guide to the MDS–PAC;

and (3) applicable rulemaking

provisions.

The example that follows, with ‘‘day’’

referring to a calendar day, illustrates a

typical IRF’s Medicare beneficiary

hospitalization assessment schedule:

• Hospitalization Day 1. Patient

admission day and the day that the IRF

begins to furnish Medicare-covered Part

A services. This is the day that starts the

count as ‘‘day 1’’ when determining the

assessment time periods for the MDS–

PAC assessments.

• Hospitalization Day 3. The last day

of the 1 through 3 calendar day

assessment observation period and, as a

general rule, the last day that can be

used to set the assessment reference

date for the initial (Day 4) MDS–PAC

assessment.

• Hospitalization Day 4. The day by

which the Day 4 MDS–PAC must be

completed.

• Hospitalization Day 10. The last day

of the 8 through 10 calendar day

assessment observation period and, as a

general rule, the last day that can be

used to set the assessment reference

date for the first re-assessment.

• Hospitalization Day 11. The day by

which the Day 11 MDS–PAC must be

completed.

• Hospitalization Day 30. The last day

of the 28 through 30 calendar day

assessment time period and, as a general

rule, the last day that can be used to set

the assessment reference date for the

second re-assessment.

• Hospitalization Day 31. The day by

which the Day 30 MDS–PAC must be

completed.

In the above example, if the patient is

instead discharged on day 22 of the

hospitalization, then the discharge day

is the assessment reference date.

2. Interrupted Stays

a. Definition of an Interrupted Stay.

As specified in proposed § 412.602 an

interrupted stay is one in which an IRF

patient is discharged from the IRF and

returns to the same IRF within 3

calendar days. For purposes of the

MDS–PAC assessment process, if a

patient has an interrupted stay, then: (1)

the initial CMG classification from the

‘‘initial’’ (Day 4) MDS–PAC assessment

would remain in effect (no new initial

MDS–PAC assessment would be

performed); and (2) the required

scheduled MDS–PAC update

assessments must still be performed. A

patient who returns to the same IRF

more than 3 calendar days after being

discharged is considered a ‘‘new’’

patient for purposes of the MDS–PAC

assessment schedule process. Being

considered a ‘‘new’’ patient for the

MDS–PAC assessment schedule process

means that a new Day 4 assessment

needs to be performed. That new Day 4

assessment would determine a new

CMG. That new CMG may or may not

be the same CMG into which the patient

classified prior to the interrupted stay.

In counting the 3 calendar day time

period to determine the length of the

interrupted stay, the first day of the start

of the interrupted stay is counted as

‘‘day 1,’’ with midnight of that day

serving as the end of that calendar day.

The 2 calendar days that immediately

follow would be days 2 and 3. If the

patient returns to the IRF by midnight

of the third calendar day, then it would

be determined that the patient had an

interrupted stay of 3 calendar days or

less.

When a patient has an interrupted

stay, the interrupted stay must be

documented on the MDS–PAC

interrupted stay tracking form. The data

recorded on the interrupted stay

tracking form must be transmitted to the

HCFA MDS–PAC system within 7

calendar days of the date the patient

returns to the IRF.

b. Effect of an Interrupted Stay Upon

the Assessment Schedule

When an interruption of a patient’s

IRF stay occurs it may affect the MDS–

PAC—(1) assessment reference dates; (2)

completion dates; (3) encoding dates;

and (4) transmission dates.

As discussed in section III. D. of this

preamble, the assessment reference date

generally is the designated endpoint of

the common 3-day observation period,

and the MDS–PAC items will usually

refer back in time from this point.

Therefore, in order to set an assessment

reference date, the patient must be an

inpatient of the IRF during the 3-day

observation time period. The 3-day

observation time period must be

continuous.

In order to facilitate the discussion

that follows regarding the effect of an

interrupted stay upon the assessment

schedule Table 5C has been reproduced

below.

TABLE 5C—EXAMPLE APPLYING THE MDS–PAC ASSESSMENT SCHEDULE AND ASSOCIATED DATES

MDS–PAC

assessment type

Hospitalization time period and observation

time period

MDS–PAC

assessment

reference

date

MDS–PAC

must be

completed

by:

MDS–PAC

must be

encoded by:

MDS–PAC

must be

transmitted

by:

Day 4 ................................................. First 3 Days ...................................................... 04/05/01 04/06/01 04/12/01 04/18/01

Day 11 ............................................... Days 8 to 10 .................................................... 04/12/01 04/13/01 04/19/01 04/25/01

Day 30 ............................................... Days 28 to 30 .................................................. 05/02/01 05/03/01 05/09/01 05/15/01

Day 60 ............................................... Days 58 to 60 .................................................. 06/01/01 06/02/01 06/08/01 06/14/01

In Table 5C above, if an interruption

of 3 calendar days or less occurred for

any of the ‘‘MDS–PAC Assessment

Type’’ assessment observation time

periods (for example, the days specified

in the ‘‘Hospitalization Time Period and

Observational Time Period’’ column in

the Table), then the associated

assessment reference dates, MDS–PAC

completion dates, MDS–PAC encoded

by dates, and MDS–PAC transmitted by

dates for that particular ‘‘MDS–PAC

Assessment Type’’ would be shifted

forward by the number of days that the

patient was not an inpatient of the IRF.

We refer to Table 5C to illustrate the

shifting forward of dates. With regard to

the Day 4 assessment assume that the

patient’s stay began with admission to

the IRF on April 3, 2001, but was

interrupted on April 4, 2001, which

would be day 2 of the patient’s IRF

hospitalization. The patient returned to

the same IRF prior to midnight of April

6, 2001, and had an interrupted stay of

3 calendar days. The assessment

reference date observation time period

for the Day 4 assessment would be

shifted to April 6, 7, and 8. (Without the

interrupted stay, the Day 4 assessment

reference date observation time period

would have been April 3, 4, and 5, with

the assessment reference date being

April 5, 2001). Because of the

interruption in stay, the MDS–PAC Day

4 assessment reference date would be

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66327

reset to April 8, 2001. The Day 4 MDS–

PAC completion date would be reset to

April 9, 2001. The Day 4 ‘‘MDS–PAC

Must Be Encoded By’’ date would be

reset to April 15, 2001. The Day 4

‘‘MDS–PAC Must Be Transmitted By’’

date would be reset to April 21, 2001.

Before this interrupted stay, the Day

11 assessment reference date was set to

be day 10 of the patient’s

hospitalization, which would be April

12, 2001. Because of the shifting

forward of the Day 4 assessment

reference date from April 5, 2001, to

April 8, 2001, the Day 11 assessment

dates, and only the Day 11 assessment

dates, would also be shifted forward.

The Day 11 assessment reference date

would then be April 15, 2001. The Day

11 MDS–PAC completion date would be

reset to April 16, 2001. The Day 11

‘‘MDS–PAC Must Be Encoded By’’ date

would be reset to April 22, 2001. The

Day 11 ‘‘MDS–PAC Must Be

Transmitted By’’ date would be reset to

April 28, 2001. When there is a shifting

forward of the Day 4 or Day 11

assessment dates they would not affect

the assessment timeframes for the

subsequent (for example, Day 30 or Day

60) assessments, because the purpose of

shifting forward an assessment due to

an interruption in stay is to keep the

time periods between assessments to at

least 7 calendar days.

Again, we refer to Table 5C to

illustrate the shifting forward of dates.

Assume that for the Day 11

reassessment the patient, who was

admitted to the IRF on April 3, 2001,

started an interrupted stay on April 11,

2001, which would be day 9 of the

patient’s IRF hospitalization. (For this

example, do not assume that the patient

also had a Day 4 interrupted stay.) The

patient returned to the same IRF prior

to midnight of April 13, 2001, and had

an interrupted stay of 3 calendar days.

The assessment reference date

observation time period for the Day 11

assessment would be shifted to April 13,

14, and 15. (Before the interrupted stay,

the Day 11 assessment reference date

observation time period was April 10,

11, and 12, with the assessment

reference date being April 12, 2001.)

Due to the interruption in stay, the

MDS–PAC assessment reference date

would be reset to April 15, 2001. The

MDS–PAC completion date would be

reset to April 16, 2001. The ‘‘MDS–PAC

Must Be Encoded By’’ date would be

reset to April 22, 2001. The ‘‘MDS–PAC

Must Be Transmitted By’’ date would be

reset to April 28, 2001. The various

dates, as illustrated in Table 5C, for the

Day 30 and Day 60 assessments would

not be affected by the shifting forward

of the Day 11 assessment associated

dates. However, if the patient had an

interrupted stay during the time period

that is associated with the Day 30 or Day

60 assessment as indicated in the Table

5C column entitled ‘‘Hospitalization

Time Period and Observation Time

Period’’ then the same shifting forward

methodology described above for the

Day 11 assessment would apply.

3. MDS–PAC Dates Associated with the

Discharge Assessment

As specified in proposed

§ 412.610(c)(5) and (6) the assessment

reference date for the discharge

assessment is the day when one of two

events occurs first: (1) the day the

patient is discharged from the IRF or (2)

the day the patient ceases receiving

Medicare-covered Part A inpatient

rehabilitation services. The MDS–PAC

assessment is performed only at the first

point in time either of these events

occur. There may be cases when a

patient ceases receiving inpatient

rehabilitation Medicare-covered

services, but is not discharged from the

IRF.

After the assessment reference date

for the discharge MDS–PAC assessment

is determined the completion date for

the discharge MDS–PAC assessment

must be set. As specified in proposed

§ 412.610(e)(2) the completion date for

the discharge MDS–PAC assessment is

the 5th calendar day in the period

beginning with the discharge MDS–PAC

assessment reference date. To count the

5 calendar days, count the discharge

MDS–PAC assessment reference date as

day 1 of the 5 calendar days. For

example, if the MDS–PAC assessment

reference date is May 1, 2000, then the

MDS–PAC completion date would be

May 5, 2000.

The method used to determine the

completion date for the discharge MDS–

PAC assessment is not the same method

used to determine the completion date

for the Day 4, Day 11, Day 30 or Day 60

MDS–PAC assessments. The reason for

using a different method to determine

the discharge MDS–PAC completion

date is because of the definition of an

interrupted stay. Previously we

specified that after the patient returns to

the IRF after an interrupted stay another

Day 4 assessment is not performed, and

the CMG into which the patient

classified prior to starting the

interrupted stay is still in effect.

Therefore, in order to ensure that a

clinician does not perform a discharge

assessment on a patient who meets the

criteria of an interrupted stay, it is

necessary to make the completion date

of the discharge MDS–PAC assessment

a date that exceeds the interrupted stay

defined time period. This safeguard

prevents the performance of

unnecessary MDS–PAC discharge

assessments by the IRF.

In addition, any discharge MDS–PAC

assessment that is transmitted to the

HCFA MDS–PAC system is used by the

system to indicate that a patient is no

longer hospitalized in the IRF.

Therefore, if a discharge assessment that

is only associated with an interrupted

stay is transmitted to the HCFA MDS–

PAC system, it would result in the

HCFA MDS–PAC system rejecting any

subsequent update (either a Day 11, Day

30 or Day 60) assessments that are

associated with the patient’s continued

hospitalization in the same IRF

following an interrupted stay.

As specified in proposed

§ 412.610(e)(3) the discharge MDS–PAC

‘‘must be encoded by’’ date is the 7th

calendar day in the period beginning

with the discharge MDS–PAC

completion date. To count the 7

calendar days, count the discharge

MDS–PAC assessment completion date

as day 1 of the 7 calendar days. For

example, if the MDS–PAC assessment

completion date is May 5, 2000, then

the MDS–PAC must be encoded by date

would be May 11, 2000.

As specified in proposed § 412.614(c)

the discharge MDS–PAC ‘‘must be

transmitted by’’ date is the 7th calendar

day in the period beginning with the

discharge MDS–PAC ‘‘must be encoded

by’’ date. To count the 7 calendar days,

count the discharge MDS–PAC

assessment ‘‘must be encoded by’’ date

as day 1 of the 7 calendar days. For

example, if the MDS–PAC assessment

must be encoded by date is May 11,

2000, then the MDS–PAC must be

transmitted by date would be May 17,

2000.

66328 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

Table 6C below illustrates the discharge MDS–PAC dates discussed above:

TABLE 6C.—EXAMPLE APPLYING THE MDS–PAC DISCHARGE ASSESSMENT DATES

MDS–PAC

assessment type

Discharge

date*

MDS–PAC

assessment

reference

date

MDS–PAC

must be

completed

on:

MDS–PAC

must be

encoded by:

MDS–PAC

must be

transmitted

by:

Discharge Assessment ............................................................................ 5/1/00 5/1/00 5/5/00 5/11/00 5/17/00

*This is either: (1) the day the patient is discharged from the IRF; or (2) the day the patient ceases receiving Medicare-coverred Part A inpatient rehabilitation services.

Data from recent studies indicate that

the vast majority of patients are

discharged from IRFs within the first

twenty calendar days of their

hospitalization. Therefore, we believe

that, in most cases, IRFs would only

perform three assessments under this

proposal: The Day 4, Day 11, and the

discharge assessment. Early data

indicated that the mean length of stay

was 18.9 days, that the median length of

stay was 16 days, with a standard

deviation of 13. More recent data from

the RAND Institute indicates that the

mean length of stay is 15.81 days, and

that the median length of stay is 14

days. The recent RAND data also

indicates that less than 9 percent of

patients would require a Day 30

assessment and less than 1⁄2 of 1 percent

of patients would require a Day 60

assessment. We are especially interested

in Day 30 and Day 60 assessments

because these cases will be very unusual

when compared to the average length of

stay; therefore, we want to understand

what characteristics make these cases

atypical. In addition, Day 30 assessment

data may be useful in making any future

CMG refinements; for example,

providing outlier information after the

IRF prospective payment system has

been implemented. We are specifically

soliciting comments on the benefits of

performing interim assessments on days

11, 30, and 60.

4. Assessment Rule to Use If Medicare

Beneficiaries Are Receiving IRF Services

on the Effective Date of this Regulation

We propose a special MDS–PAC

assessment rule for the Medicare

beneficiaries who already are IRF

patients on the date that this regulation

becomes effective. For these patients we

are proposing that only one MDS–PAC

assessment must be performed. The one

MDS–PAC assessment would be used to

classify a patient into a CMG, and that

CMG would determine the payment the

IRF would receive for all the Part A

services the IRF furnished to the patient

during the patient’s current

hospitalization. For Medicare

beneficiaries who already are IRF

patients on the date that this regulation

becomes effective the one MDS–PAC

assessment would, as applicable, cover

one of the following calendar day time

periods and associated conditions: (1)

When this regulation becomes effective

if a patient currently hospitalized

continues being an IRF patient for at

least 3 calendar days, then the data for

the MDS–PAC assessment items must be

collected according to the instructions

on the MDS–PAC form and the Item-byItem Guide to the MDS–PAC. (2) When

this regulation becomes effective if a

patient currently hospitalized continues

being an IRF patient for only 2 calendar

days, then the data for the MDS–PAC

assessment items that must be collected

would pertain to only these 2 calendar

days, unless the instructions on the

MDS–PAC form and the Item-by-Item

Guide to the MDS–PAC specify a shorter

time period. (3) When this regulation

becomes effective if a patient currently

hospitalized continues being an IRF

patient for only 1 or less than 1 calendar

day then the data for the MDS–PAC

assessment items that must be collected

would pertain to 1 or less than 1

calendar day, unless the instructions on

the MDS–PAC form and the Item-byItem Guide to the MDS–PAC specify a

shorter time period.

For this special MDS–PAC assessment

we propose that, no later than 30

calendar days from the date this

regulation becomes effective, all the

following would apply—(1) the data for

this special MDS–PAC assessment must

be collected; (2) this special MDS–PAC

must be completed; (3) the MDS–PAC

data for this special assessment must be

encoded; and (4) the MDS–PAC data for

this special assessment must not only be

transmitted to but also be accepted by

the HCFA MDS–PAC system. We

propose that if the IRF does not, as

specified above, collect, complete,

encode, and transmit the data for this

special MDS–PAC assessment, then the

IRF would receive no payment for any

of the Part A services furnished to

Medicare beneficiaries who already are

IRF patients on the date that this

regulation becomes effective.

5. What MDS–PAC Items Are Collected

On Each Assessment

The MDS–PAC assessments must be

performed according to the schedule

specified previously. Table 7C’s.—

MDS–PAC Items Required by Type of

Assessment, title indicates the data for

each MDS–PAC item that we propose to

require collecting for the Day 4, Day 11,

Day 30, Day 60, and discharge

assessments.

It should be noted that recording data

on the MDS–PAC for a particular item

may require, according to the

instructions for that item on the MDS–

PAC form, that the clinician not record

data for certain other items. For

example, the MDS–PAC instructions

state that if data is recorded indicating

a patient is comatose in item B1, the

clinician assessing the patient must

proceed from item B1 to item E1. This

means that the data for the items

between B1 and E1 are not recorded.

(The term ‘‘update’’ in Table 7C below

refers to the Day 11, Day 30, and Day 60

assessments. An ‘‘X’’ indicates that the

MDS–PAC item is required for that

assessment type.)

TABLE 7C.—MDS–PAC ITEMS REQUIRED BY TYPE OF ASSESSMENT

MDS–PAC Item

Assessment type

Admission Update Discharge

ITEM AA1 and ITEM A1. Legal Name of Patient ................................................................................... X X X

ITEM AA2 and ITEM A2. Admission Date (2a and, if applicable, also 2b) ............................................ X X X

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66329

TABLE 7C.—MDS–PAC ITEMS REQUIRED BY TYPE OF ASSESSMENT—Continued

MDS–PAC Item

Assessment type

Admission Update Discharge

ITEM AA3 and ITEM A3. Reason for Assessment ................................................................................. X X X

ITEM AA4. Assessment Reference Date ................................................................................................ X X X

ITEM AA5a and AA5b. Discharge Status ............................................................................................... .................... .................... X

ITEM AA6a and AA6b. Social Security (6a) and Medicare Numbers (6b) ............................................. X X X

ITEM AA7. Medical Record Number ....................................................................................................... X X X

ITEM AA8. Facility Provider Number (Both 8a and 8b) .......................................................................... X X X

ITEM AA9. Medicaid Number .................................................................................................................. X X X

ITEM AA10. Gender ................................................................................................................................ X X X

ITEM AA11. BirthDate ............................................................................................................................. X X X

ITEM AA12. Ethnicity/Race ..................................................................................................................... X X X

ITEM AA13a and AA13b. Interrupted Stay * (Only appears on the interrupted stay tracking form.

Record and submit data if applicable.).

ITEM AA14a thru AA14f. Clinician Completing Assessment * (Only appears on the interrupted stay

tracking form. Record and submit data if Item 13 data is recorded and submitted.).

Item AB1a thru AB1g. Person Completing Assessment ......................................................................... X X X

Item AB2a thru AB2f. Signature of Staff Completing Part of the Assessment ....................................... X X X

ITEM A4. Admission Status ..................................................................................................................... X X X

ITEM A5. Goals for Stay ......................................................................................................................... X X X

ITEM A6. Admitted From ......................................................................................................................... X X X

ITEM A7. Precipitating Event Prior to Admission .................................................................................... X X X

ITEM A8. Primary and Secondary Payment Source For Stay ................................................................ X X X

ITEM A9. Marital Status .......................................................................................................................... X X X

ITEM A10. Education ............................................................................................................................... X .................... ....................

ITEM A11a and A11b. Language ............................................................................................................ X X X

ITEM A12. Dominant Hand ..................................................................................................................... X .................... ....................

ITEM A13. Mental Health History ............................................................................................................ X .................... ....................

ITEM A14. Conditions Related to MR/DD Status ................................................................................... X .................... ....................

ITEM A15a thru A15e. Responsibility/Legal Guardian ............................................................................ X .................... ....................

ITEM A16a thru A16e. Advance Directives ............................................................................................. X .................... ....................

ITEM B1. Comatose ................................................................................................................................ X X X

ITEM B2a thru B2d. Memory/Recall Ability ............................................................................................. X X X

ITEM B3a and B3b. Cognitive Skills for Daily Decision Making ............................................................. X X X

ITEM B4a thru B4f. Indicators of Delirium-Periodic Disordered Thinking/Awareness ............................ X X X

ITEM C1. Hearing .................................................................................................................................... X X X

ITEM C2a thru C2e. Modes of Communication ...................................................................................... XXX

ITEM C3a and C3b. Making Self Understood ......................................................................................... X X X

ITEM C4. Speech Clarity ......................................................................................................................... X X X

ITEM C5a and C5b. Ability to Understand Others ..................................................................................X X X

ITEM C6a and C6b. Vision ...................................................................................................................... X X X

ITEM D1a thru D1k. Indicators of Depression, Anxiety, Sad Mood ....................................................... X X X

ITEM D2. Mood Persistence ................................................................................................................... X X X

ITEM D3a thru D3e. Behavioral Symptoms ............................................................................................ X X X

ITEM E1a thru E1l. 3-Day ADL Self-Performance .................................................................................. XXX

ITEM E2a thru E2l. ADL Assist codes .................................................................................................... X X X

ITEM E3a and E3b. ADL Changes ......................................................................................................... X X X

ITEM E4a thru E4f. Instrumental Activities of Daily Living ..................................................................... XXX

ITEM E5. IADL Areas Now More Limited ............................................................................................... X X X

ITEM E6a thru E6j. Devices/Aides .......................................................................................................... X X X

ITEM E7a and E7b. Stamina ................................................................................................................... X X X

ITEM E8a thru E8c. Walking and Stair Climbing .................................................................................... X X X

ITEM E9a and E9b. Balance Related to Transitions .............................................................................. X X X

ITEM E10a thru E10c. Neuro-musculoskeletal Impairment .................................................................... X X X

ITEM F1a and F1b. Bladder Continence ................................................................................................ X X X

ITEM F2a thru F2g. Bladder Appliance ................................................................................................... X X X

ITEM F3. Bladder Appliance Support ...................................................................................................... X X X

ITEM F4. Bowel Continence .................................................................................................................... X X X

ITEM F5a thru F5d. Bowel Appliances ................................................................................................... X X X

ITEM F6. Bowel Appliance Support ........................................................................................................ X X X

ITEM G1. Impairment Group ................................................................................................................... X .................... ....................

ITEM G2a thru G2aq. Other Diseases .................................................................................................... X X X

ITEM G3a thru G3l. Infections ................................................................................................................. X X X

ITEM G4A and G4B. Other Current or More Detailed Diagnoses and ICD–9–CM Codes (Line ‘‘a’’

thru line ‘‘e’’ as applicable.) ................................................................................................................. X X X

ITEM G5. Complications/Co-Morbidities (Line ‘‘a’’ thru line ‘‘d’’ as applicable.) ..................................... X X X

ITEM H1. Vital Signs ............................................................................................................................... X X X

ITEM H2a, H2b, H2d thru H2t, and H2w. Problem Conditions .............................................................. X X X

ITEM H2c, H2u, and H2v. Problem Conditions ...................................................................................... X .................... ....................

ITEM H3a thru H3h. Respiratory Conditions ........................................................................................... X X X

ITEM H4a thru H4f. Pressure Ulcers ...................................................................................................... X X X

ITEM H5a and H5b. Other Skin Integrity ................................................................................................ X X X

66330 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

TABLE 7C.—MDS–PAC ITEMS REQUIRED BY TYPE OF ASSESSMENT—Continued

MDS–PAC Item

Assessment type

Admission Update Discharge

ITEM H5c. Other Skin Integrity ............................................................................................................... X .................... ....................

ITEM H6a thru H6e. Other Skin Problems or Lesions Present .............................................................. X X X

ITEM I1a and I1b. Pain Symptoms ......................................................................................................... X X X

ITEM I1c. Pain Symptoms ....................................................................................................................... X .................... ....................

ITEM J1a and J1b. Oral Problems .......................................................................................................... X X X

ITEM J2. Swallowing ............................................................................................................................... X X X

ITEM J3a. Height ..................................................................................................................................... X .................... ....................

ITEM J3b. Weight .................................................................................................................................... X X X

ITEM J4a and J4b. Weight Change ........................................................................................................ X .................... ....................

ITEM J5a and J5b. Parenteral or Enteral Intake .................................................................................... X X X

ITEM K1a thru K1e. Clinical Visits and Orders ....................................................................................... X X X

ITEM K2a thru K2ai. Treatments and Services ...................................................................................... X X X

ITEM K3a thru K3k. Nursing Practice or Restorative Care .................................................................... X X X

ITEM K4a thru K4f. Therapy Services .................................................................................................... X X X

ITEM K5a thru K5d. Devices and Restraints .......................................................................................... X X X

ITEM L1a thru L1h. Functional Improvement Goals ............................................................................... X X X

ITEM L2a thru L2c. Attributes Relevant to Rehabilitation ....................................................................... XXX

ITEM L3a and L3b. Change over last 3 days ......................................................................................... X X X

ITEM L4. Estimated Length of Stay from Date of Admission ................................................................. X X X

ITEM M1a thru M1e. Available Social Supports ..................................................................................... X X X

ITEM M2a and M2b. Caregiver Status .................................................................................................... X .................... X

ITEM M3a and M3b. Living Arrangement ............................................................................................... X X X

* Note: Data for items AA13 and AA14 would only be recorded and submitted to the HCFA MDS–PAC system if the patient has an interrupted

stay according to how interrupted stay is defined in this preamble. This means each time the patient has an interrupted stay, as that term is defined in this preamble, data for items AA13 and AA14 would be recorded and submitted to the HCFA MDS–PAC system. The other items on the

interrupted stay tracking form would also be submitted. However, these other interrupted stay tracking form items are identification information

items that have previously been collected and recorded by the IRF clinician and, therefore, do not require collection as new items of data.

6. The MDS–PAC Completion Date

We propose in § 412.610(e) that for

the Day 4, Day 11, Day 30, and Day 60

assessments that IRFs ‘‘complete’’ the

MDS–PAC on the calendar day that

follows the assessment reference date.

Previously we discussed the completion

date for the discharge assessment. For

all assessments ‘‘completion’’ of the

MDS–PAC means that accurate

information has been recorded for each

MDS–PAC item, and that the MDS–PAC

has been signed and dated by the

clinicians that recorded information on

the MDS–PAC. It is our belief that the

IRF clinician(s) can easily access or

recall specific patient information if

only a short period of time has elapsed,

between the patient interview/patient

observation time period and the

recording of that information on the

MDS–PAC.

7. Penalties for Late Assessments

In § 412.610(d) we propose that the

MDS–PAC assessment is late if the

assessment is not in accordance with

the assessment reference date

specification for the Day 4 assessment

discussed previously in this preamble. If

the MDS–PAC assessment is late then

the IRF would either receive a reduced

CMG-determined payment or no

payment. If the MDS–PAC assessment is

less than or equal to 10 calendar days

late then the reduced CMG-determined

payment would be a default rate. We

propose to set the default rate at 25

percent less than the CMG-determined

payment that the IRF would otherwise

have received. If any assessment is more

than 10 calendar days late, then the IRF

would receive no payment for the

Medicare-covered Part A services

furnished.

G. Computerization of the MDS–PAC

Data

1. Encoding the MDS–PAC Data

The data for all MDS–PAC

assessments must be encoded. Encoding

the data means entering the MDS–PAC

data into the IRF’s computer using

appropriate software, including

performing data edits. In § 412.610(e)(3),

we propose that IRFs encode and edit

the data for Medicare patients within 7

calendar days of the date that the MDS–

PAC is completed. We propose to

specify a maximum of 7 calendar days

because we believe that this is a

reasonable amount of time for IRFs to

complete these tasks.

In determining the first day to count

as being ‘‘within 7 calendar days of the

date that the MDS–PAC is completed,’’

the assessment completion date itself

would be counted as ‘‘day 1’’ of the 7

calendar days. For example, if the MDS–

PAC completion date is April 6, 2001,

then the MDS–PAC must be encoded by

April 12, 2001. As previously stated,

MDS–PAC records are considered

‘‘locked’’ when they pass all HCFAspecified edits and are accepted by the

MDS–PAC database to which the IRF

transmits its records.

To encode the MDS–PAC data, the

IRF may: use a commercial application

from a private software vendor; develop

its own data entry program based on our

specifications; or use the free data entry

and data transmission software program

developed by HCFA, which is the MDS–

PAC Tool (MPACT). The IRF will be

able to download MPACT from our

Inpatient Rehabilitation Facility

Prospective Payment System website.

The MPACT data entry tool

accommodates standard HCFA edit

specifications for MDS–PAC data.

It is preferable for the edits and

corrections to be made as soon as

possible after the assessment activity,

because the clinician’s recall of the

patient assessment at that point is likely

to be more detailed and easier to

associate with any clinical notes related

to the assessment. Therefore, it is

reasonable to expect that IRFs will have

the MDS–PAC data encoded, edited,

and ready for transmission within 7

calendar days of the completion date. In

addition, if the IRF chooses to use the

MDS–PAC information in patient care

planning, our timeframes would

contribute to the facility’s efforts to

produce a current and workable plan of

care.

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IRFs will have flexibility in the

process used to encode their data. Once

the assessment is completed by the

clinician(s), the data may be encoded by

a clinician, or by a clerical staff member

using a paper copy of a completed

MDS–PAC, or by a data entry

technician. Non-clinical staff may not

assess patients or complete clinical

assessment items. However, clerical

staff or data entry operators may enter

the MDS–PAC data that has been

collected by the clinician into the

computer.

In entering the data, IRFs must

comply with requirements for

safeguarding the confidentiality of

patient identifiable information, as

specified in section III.I.1. of this

preamble. In addition, IRFs must train

personnel with access to patient

information to disclose that patient

information only to those recipients

who are authorized to have access to it.

On August 12, 1998, we published in

the Federal Register a proposed rule

entitled ‘‘Security and Electronic

Signature Standards’’ (63 FR 43242),

and on November 3, 1999, we published

another proposed rule entitled

‘‘Standards for Privacy of Individually

Identifiable Health Information’’ (64 FR

59918). When these proposed rules are

published as final rules, the security

and privacy criteria specified in these

rules may supplement or supersede the

security and privacy criteria specified in

this proposed rule.

Once the IRF encodes the MDS–PAC

information, the computer software is

used to review and edit the data to

create a file that will be transmitted to

the HCFA MDS–PAC system. The

software program edits are designed to

help preclude the transmission of

erroneous or inconsistent information.

2. Accuracy of the Encoded MDS–PAC

Data

In § 412.610(f) we propose that the

encoded MDS–PAC data must

accurately reflect the patient’s status at

the time the data are collected. Because

the patient’s clinical status may change

over time, the MDS–PAC data must

accurately represent a patient’s clinical

status as of a particular assessment

reference date. Before transmission, the

IRF must ensure that the data items on

the MDS–PAC paper copy match the

encoded data that are sent to the HCFA

MDS–PAC system. We are requiring that

once the clinician(s) completes the

MDS–PAC assessment, using either a

paper copy of the MDS–PAC or an

electronic version, the IRF must ensure

that the data encoded into the computer

and transmitted to the HCFA MDS–PAC

system accurately reflects the data

collected by the clinician. We will leave

to the IRFs the development of methods

that ensure the accuracy of the MDS–

PAC data that is transmitted. However,

it should be noted that because the

policies of the IRF prospective payment

system only apply to Medicare

beneficiaries, the HCFA MDS–PAC

system will reject all transmitted

assessment data for which a nonMedicare payment source is indicated.

3. Transmission of the MDS–PAC Data

We will utilize the most current

technology to secure the safety of the

information transmitted to and from the

HCFA MDS–PAC system. In § 412.614,

we propose to require that the IRF

electronically transmit to the HCFA

MDS–PAC system accurate, complete,

and encoded MDS–PAC data for each

Medicare patient. We also propose that

the data must be transmitted in a format

that meets the general requirements

specified in § 412.614. We believe that

once the MDS–PAC data are encoded

and edited, it is a relatively simple

procedure to complete the preparation

of the data for transmission to the HCFA

MDS–PAC system. Therefore, we are

proposing that encoded and edited data

that has not previously been

transmitted, must be transmitted within

7 calendar days of the day by which the

data must be encoded by as specified in

Table 4C ‘‘MDS–PAC Assessment

Schedule and Associated Dates’’. In

addition, the data must be transmitted

in a manner that meets the locked data

criteria previously discussed in this

section of the preamble. At the end of

the transmission file, an entry

concerning the number of records being

transmitted is required to complete the

transmission process.

We believe that the 7 calendar day

transmission requirement would

support claim review efforts, because

prompt transmission of MDS–PAC data

would facilitate our ability to compare

a claim promptly against the associated

MDS–PAC data which, in turn, would

enhance our ability to make any

necessary adjustment to the IRF’s

payment amount in a timely manner.

We will maintain a national MDS–PAC

repository to which State Agencies,

fiscal intermediaries and peer review

organizations will have access. An

adjustment to the IRF claim may be

made if a discrepancy is discovered

between what the MDS–PAC data

indicated the CMG on the claim should

be and what is actually on the claim.

The IRF must have a system that

supports dial-up communications for

the transmission of MDS–PAC data to

the HCFA MDS–PAC system. The MDS–

PAC data will be submitted to the HCFA

MDS–PAC system via HCFA’s Medicare

Data Collection Network (MDCN). The

MDCN is a secured private network.

Specific instructions and telephone

numbers will be provided to the IRFs to

access the MDCN. For security

purposes, there are two levels of user

authentication required. To obtain

access to the MDCN, the IRF must

obtain an individual networkidentification code for each person

submitting the HCFA MDS–PAC data.

This identification code is distributed

by the HCFA system administrator or

HCFA’s agents. To obtain access to the

HCFA MDS–PAC system, an IRF must

also obtain a facility-identification code

from the HCFA system administrator.

The IRF will transmit the MDS–PAC

data via secured lines, and not via the

Internet, to the HCFA MDS–PAC

system, where the data will be checked

to ensure it complies with HCFA MDS–

PAC system data formatting

specifications. The IRF will receive two

reports, the initial and final validation

reports. The initial validation report

will notify the IRF if the submission is

accepted or rejected. If the submission

is rejected, the IRF is notified of the

reason for the rejection. If the

submission is accepted, the report alerts

the IRF of any changes or discrepancies

in the facility and vendor information.

After the initial edit checks and

acceptance of the file, the MDS–PAC

data are validated to ensure that the data

conforms to the HCFA specifications. If

there are errors found in an assessment

record, it will be rejected. Upon

completion of the validation, the IRF

receives the final validation report. This

report includes the total number of

assessment records submitted and the

total number of assessment records

rejected, as well as the total number of

assessment records added to the

database. The final validation also

includes alert messages pertaining to an

assessment record when appropriate; for

example, ‘‘Assessment was submitted

out of sequence.’’

In order to test transmission of MDSPAC data using the HCFA MDS–PAC

system IRFs must make a successful test

transmission of test MDS–PAC data to

the HCFA MDS–PAC system between

February 1 and February 28, 2001. The

initial test must include the following:

(1) a transmission of MDS–PAC data

that passes the HCFA edit checks built

into the software program used by the

IRF to encode the assessment data; and

(2) a validation report back from the

HCFA MDS–PAC system confirming

transmission of data. This test data will

not be included in the HCFA national

repository. The test data are to contain

MDS–PAC data on all Medicare

66332 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

inpatients, both newly admitted and

those previously receiving care, that are

inpatients during the test transmission

time period.

If an IRF does not have Medicare

inpatients receiving care during the

specified test transmission time period,

we propose that the IRF transmit test

MDS–PAC data for Medicare inpatients

that received care in the most recent 30

calendar day time period. This would

require that these IRFs use the clinical

record and professional clinical

judgment to obtain the information

required for the MDS–PAC items. In this

way, these facilities could transmit test

data in order to ascertain how well their

system is functioning, and become

familiar with entering data into the

computerized version of the MDS–PAC.

In order to both assist all IRFs in

constructing MDS–PAC test data and to

test the volume data capacity of the

HCFA MDS–PAC system we may use

and provide the IRFs with ‘‘dummy’’

MDS–PAC records or test data.

We will provide training to the IRFs

on the MDS–PAC instrument (including

any modification arising from research

examining the equivalence of the MDS–

PAC and the FIM for classifying

patients), the HCFA provided MPACT,

the data transmission process, and the

interpretation of the validation reports.

Training will be provided prior to the

implementation of IRF prospective

payment system. The most current

MDS–PAC will be available on our

HCFA Inpatient Rehabilitation Facility

Prospective Payment System website.

IRFs and software vendors will be able

to access the website and download the

most current MDS–PAC. In addition, the

MPACT will be available on the HCFA

Inpatient Rehabilitation Facility

Prospective Payment System website,

and IRFs and software vendors will be

able to download the MPACT at no

charge. This website will include the

data specifications, data dictionaries,

the Item-by-Item Guide to the MDS–

PAC, and the IRF data submission

procedures.

We may also post other educational

materials for IRFs on the website. We

intend the website to provide current

information to IRFs, State agencies,

software vendors, professional

organizations, and consumers. We

encourage vendors, IRFs, and other

interested parties to review the website

regularly for information and issues

related to the IRF prospective payment

system.

4. Late Transmission Penalty

In section III.G.2. of this preamble, we

propose §§ 412.606 and 412.610 to

require that MDS–PAC data be collected

and transmitted not only for the items

that would be used to classify a patient

into a CMG, but also for the other MDS–

PAC items, if collection and

transmission of that data are appropriate

according to one or more of the

following: (1) the instructions on the

MDS–PAC; (2) the Item-by-Item Guide

to the MDS–PAC; and (3) applicable

rulemaking provisions. In addition, if

the IRF transmits MDS–PAC data for a

particular patient that is not in

accordance with the data record

specifications, that data would be

rejected by the HCFA MDS–PAC

system. If the data is rejected by the

HCFA MDS–PAC system, then the data

is not ‘‘locked’’ as that term was defined

previously, and the data must be retransmitted.

We propose in § 412.614 to impose a

penalty for an IRF’s late transmission of

MDS–PAC data to the HCFA MDS–PAC

system. ‘‘Late transmission’’ means that

the IRF did not transmit MDS–PAC data

in accordance with the transmission

timeframes previously specified in

Table 4C of section III of this preamble.

We propose that if the IRF transmits the

MDS–PAC data late, then the IRF is

either paid a reduced CMG-determined

payment or no CMG-determined

payment. If the IRF transmits the MDS–

PAC data 10 or less calendar days late

then the IRF would receive a payment

that is 25 percent less than the CMG

payment that the IRF would otherwise

have received. If the MDS–PAC data is

transmitted more than 10 calendar days

late, then the IRF would receive no

payment for the Medicare-covered Part

A services furnished.

5. The MDS–PAC and Computer

Software

In § 412.614(c) we propose that the

IRF encode and transmit the MDS–PAC

data using the MPACT software

available from HCFA or other software

that conforms to the HCFA standard

data specifications, data dictionary, and

other HCFA-specified data

requirements, and that includes the

MDS–PAC data items that match the

most updated version of the MDS–PAC.

HCFA’s MPACT software will be able to

be used for several purposes, such as to

encode MDS–PAC data, to maintain IRF

and patient-specific MDS–PAC

information, to create export files to

submit MDS–PAC data, and to test

alternative software. MPACT software

will provide comprehensive on-line

help to users in encoding, editing, and

transmitting the MDS–PAC data.

Additionally, there will be a toll-free

hotline to support this software product.

We caution IRFs that the MPACT

software system would provide only the

minimum requirements to encode and

format the data. We will support these

functions and applications; however, we

do not intend to provide any other

applications related to care planning,

financial information, durable medical

equipment, medications, or personnel

issues. Software vendors are encouraged

to use the MPACT software as a

minimum system, until they have

developed their own software to

accommodate HCFA specifications and

other applications useful for IRFs.

H. Quality Monitoring

Before we present our specific

strategies for quality monitoring in IRFs,

we want to discuss our conceptual

framework for understanding and

advancing quality in the setting of IRFs,

as well as other post-acute settings.

Quality of care is complex, sometimes

difficult to define, and is multidimensional in nature. One dimension

is that the care achieve its intended

result, which in the context of the IRF

setting is most often to improve the

patient’s functioning in order to foster

more independent living. A second

dimension of quality is the prevention

of avoidable complications or other

adverse events and minimizing the

effects of adverse events. A third related

dimension is to improve management of

the patient’s medical impairments, with

the goal being to promote ‘‘improved’’

health as well as function, or at least to

improve the management of the

patient’s medical conditions. In

addition, it is also important to use data

to identify other sentinel events that

may potentially impact care negatively.

Our specific quality monitoring

processes should be developed in a way

that supports this multi-dimensional

view of quality.

The consequences of detecting quality

of care problems may be varied and

could include increasing educational

efforts to beneficiaries to help them

make better informed selections of

providers, guiding investigators to

survey institutions (including

verification surveys performed in

JCAHO-accredited facilities), and if the

problem(s) is not remedied

consideration of whether the IRF should

be permitted to continue to participate

in the Medicare program. An IRF’s own

staff may use quality of care information

from the MDS–PAC for their own

quality assurance and, ultimately,

quality improvement activities. We also

have the potential to develop

refinements to the case-mix

methodology which provide incentives

for improving quality.

As our payment policies continue to

evolve, our objective is to move forward

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with a quality assessment and

improvement agenda that is based on

standardized data, beneficiaries’ clinical

characteristics, and patient care

outcomes. To achieve that objective, we

need to collect common data elements

and develop standardized assessment

tools that will enable us to focus on

beneficiary care needs rather than the

characteristics of the provider. We

believe that the most important shortterm goal of post-acute care quality

monitoring is to assess the effects of

implementing the changes in the

payment system and the quality of postacute care.

We are aware of MedPAC’s concern

that we may have only a limited ability

to assess the impact of Medicare

payment changes that either have been

implemented or will soon be initiated—

for example, the IRF prospective

payment system. There is a need to

enhance our ability to assess this impact

in order to improve the policies

associated with our Medicare

prospective payment systems.

In the March 2000 MedPAC Report to

Congress, MedPAC states that quality

monitoring systems are important to

ensure that payment systems are

designed so that providers are

responding appropriately to the

system’s incentives. MedPAC believes

that such information could assist in

tracking trends over time or provide an

early warning of impending problems in

quality. ‘‘Attaining any of these ends

requires routine, systematic

measurement of health care quality.’’ (p.

62) We believe that the MDS–PAC is a

first step towards developing such a

measure.

The MDS–PAC is a multi-dimensional

assessment instrument which provides a

detailed picture of the patient. The nonpayment related items in the instrument

are necessary to provide a

comprehensive inventory of patient

factors that are necessary to monitor

quality and risk adjust. This data can be

used by facilities to identify patients at

risk for adverse outcomes. In addition,

MDS–PAC information may contribute

to development of the patient care plan.

Information collected can identify

patients at risk for adverse outcomes,

such as weight loss, aspiration, or

pressure ulcers, and support the

monitoring of these patients to prevent

outcomes that might negatively impact

patients’ likelihood of optimal

rehabilitation.

We believe that the MDS–PAC items

are needed to monitor the impact of the

IRF prospective payment system upon

IRFs and beneficiaries, including

beneficiary access to care. Section 125

of the BBRA directs the Secretary to

conduct a monitoring study, and to

submit a report to the Congress no later

than 3 years from the date that the IRF

prospective payment is implemented.

To both monitor the impact of the IRF

prospective payment system upon IRFs

and beneficiaries, and support this

BBRA-mandated report to the Congress,

we need a data-driven monitoring

system that would give us the capability

to acquire objective (as opposed to

anecdotal) data for analysis.

The MDS–PAC discharge assessment

would provide data about a patient’s

clinical status at discharge, and give us

the ability to compare a patient’s

clinical status at discharge with the

patient’s clinical status at the Day 4

assessment. Comparison of the patient’s

clinical status at Day 4 and at discharge

would give us the data to analyze the

relationship between any changes in the

patient’s clinical status and the quantity

and effectiveness of the services the IRF

furnished to the patient. That

comparison would provide us with data

that would indicate the quality of the

IRF services furnished, and if an IRF

was not furnishing the level of

Medicare-covered services the patient

needed.

Many studies have examined overall

and condition-specific functional gain

from admission to discharge as a

measure of the effectiveness of a

rehabilitation program. National

benchmarks of functional gain have

been used by providers to measure their

performance relative to other facilities.

In addition, some work has also been

devoted to understanding providers’

efficiency by linking measures of length

of stay and functional gain.

Update assessments would yield the

type of structured data that we can use

to analyze the effectiveness of treatment

services at a point in time when the

services were still being furnished.

Update assessments provide the

information during treatment and allow

measurement of changes in the patient’s

clinical status during a defined time

period when the patient is still in

treatment. We can then compare the

patient’s clinical status at that point in

time to the patient’s clinical status at

either the Day 4 or discharge

assessments, which would provide us

with data about any changes in the

patient’s clinical status between the

update assessments and these other

assessments.

In essence, update assessments

provide a ‘‘snapshot’’ of the patient

while the patient is still being treated.

This snapshot provides a method to

analyze the changes in the patient’s

clinical status that are a result of the IRF

services furnished either up to, or from,

a predetermined point in the patient’s

hospitalization stay. The snapshot is

similar to how a clinician evaluates a

patient’s reaction to treatment at points

in time after the clinician has

implemented a plan of care, and,

therefore, the snapshot can be used by

the IRF in a similar manner. Because we

propose to mandate the data

requirements for update assessments,

the snapshot will provide us with the

same structured and detailed data that

is comparable across IRFs, permitting us

to analyze clinical outcomes related to

the IRF services furnished up to, and

from, a predetermined point in time at

one or many IRFs. The update

assessments could also provide us with

the some of the data needed to analyze

the effectiveness of the services being

furnished at more than just the time

period between the patient’s admission

and discharge. That analysis could be

used to evaluate the quality and

quantity of services the IRF furnished at

different periods of time during the

patient’s hospitalization.

The data associated with each MDS–

PAC item would enhance our ability to

monitor and, thus, safeguard the quality

of care that beneficiaries receive. A

quality of care improvement monitoring

system that is based on the MDS–PAC

data is consistent with other

information-based quality monitoring

programs, such as the ORYX process

used by the Joint Commission on

Accreditation of Health Care

Organizations.

While only some MDS–PAC items

would be used to determine the CMG,

we believe that the data provided by

MDS–PAC items are an essential first

step in developing the type of quality

monitoring system that both MedPAC

and HCFA favor. Possible uses of the

data could include: (1) strengthening

existing quality assurance mechanisms;

(2) generating indicators that would

allow providers to assess their

performance, and to compare it against

benchmarks derived from standards of

care or the performance of peers; and (3)

creating a system that assists

beneficiaries in making informed

decisions when choosing among

providers. In addition, MDS–PAC items

may be useful in developing core

measures that provide meaningful

information on patient characteristics

and outcomes across post-acute care

settings.

1. Monitoring the IRF Prospective

Payment System

We are planning a system that can be

used to monitor access to rehabilitation

facilities as well as to monitor the

quality of the care delivered in these

66334 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

facilities. This will be done through the

monitoring of payment for the care and

the associated cost of the delivered care.

Monitoring will include variables as

length of IRF stay, percent of IRF

discharges to SNF, long-term care

hospital, or intensive outpatient

rehabilitation program, change in motor

function between admission and

discharge, and the case-mix distribution

of the facility. We plan to examine

changes within ‘‘market areas’’ as well

as individual facilities.

In addition, we will be developing a

variety of methods for monitoring the

impact of the IRF prospective payment

system. Monitoring may describe

changes in access to rehabilitation, in

payments to rehabilitation facilities, in

quality of care, and in the cost of

rehabilitation care. This monitoring

would also help to identify unintended

changes in the operations of providers,

and would help to identify refinements

needed in the IRF prospective payment

system. In addition, because the IRF

prospective payment system may have

effects on non-IRF providers, and

because changes in the payment systems

for other providers may affect IRFs once

common core data elements are required

across post-acute providers and linked

with other data, the monitoring system

could also describe changes in access,

utilization, quality, and cost of care in

different types of post-acute sites

including but not limited to HHAs and

SNFs. We could start these activities as

early as 2002.

2. Quality Indicators

Quality indicators are markers that

indicate either the presence or absence

of potentially poor facility care practices

or outcomes. The development of

quality indicators depends on the

collection and analysis of sufficient

MDS–PAC data from a representative

national sample. We are attempting to

design a monitoring system that would

not only describe quality indicators, but

also show how they can be used

together to obtain a clear description of

access, outcomes, and cost in IRFs.

Quality indicators will be developed

around the different dimensions of

quality discussed earlier in this section.

We believe that quality indicators

developed for individual IRFs would

help identify the IRFs that require

attention because they may be coding

incorrectly or providing lower quality

care. Analysis of the distribution of

hospital indicators within specific

classes of hospitals (for example,

teaching hospitals, rural hospitals, etc.)

would help us to evaluate whether

facility level adjustments are warranted.

We currently have a contractor

conducting analysis for purposes of

developing quality indicators to be used

in IRFs. Quality indicators are not direct

measures of quality but rather point

towards potential areas that require

further investigation. Quality indicators

identify the percent of a patient

population with a certain condition and

compare this percent to a state level and

a national level. If a facility ‘‘flags’’ for

scoring ‘‘high’’ on a particular quality

indicator, this does not necessarily

mean that the facility has a quality of

care problem but simply that further

focussed review of care practices may be

required. Quality indicators have

already been developed by the

University of Wisconsin for use in SNFs

and are being effectively used by State

surveyors to target facilities for closer

on-site review of care practices as well

as by some nursing homes to identify

potential problems within their facility.

We have already begun consideration

of quality indicators that may be

collected from MDS–PAC data to

evaluate care delivered in IRFs. We

agree with MedPAC’s advice that

quality monitoring efforts be closely

coordinated across different types of

post-acute care providers. We expect to

develop measures to be applied across

different settings. We anticipate that

measures of functional improvement

from admission to discharge will be

examined. In addition, during 2000, the

infrastructure to collect the data to

identify quality indicators for IRFs will

be under development. Field validation

of these indicators is expected to begin

in 2001. Once the indicators have been

field tested, the State quality

infrastructure can begin to utilize these

data to monitor quality and to target

facilities to survey for accreditation. The

next step will be validation of the

assessment data. Piloting the reporting

of data will be ongoing during this time

period. There is funding in the 2001

budget for analysis of the accuracy of

the assessment data collected. ‘‘Tool

kits’’ will be developed for targeted

interventions to address common

quality issues in these facilities.

Examples of quality indicators currently

being considered for IRFs are described

below.

3. Functional Independence

The main goal of an IRF is to assist

the patient in regaining his or her prior

level of functional ability. A measure of

the quality of a rehabilitation program is

the patient’s ability to function

independently upon discharge to the

community. Using MDS–PAC data, it

will be possible to measure the percent

of all cases discharged to the

community who are functionally

independent or whose functional status

has improved at the time of discharge.

Functional independence on the MDS–

PAC would be measured using Section

E of the instrument. The information

collected in this section may be used by

staff to calculate the Activities of Daily

Living for Post-Acute Care (ADL–PAC)

Summary Scale for each patient. The

ADL–PAC computes patients’ level of

dependence on a scale from 0 (fully

independent) to 6 (fully dependent).

The scale considers level of dependence

for each of the following activities: bed

mobility, transfer between the bed and

chair, locomotion, walking in facility,

dressing upper body, dressing lower

body, eating, toilet use, transfer to toilet,

grooming and personal hygiene,

bathing, transfer to and from the tub or

shower. This information about the

patient’s levels of dependence on these

various activities of daily living on

admission, at intervals during the stay,

and at discharge will be particularly

useful to describe the patient’s progress

as a result of rehabilitation care. A

patient’s progress can be evaluated with

respect to thresholds or milestones,

developed after analysis of data

collected during rehabilitation stays

rather than based upon theoretical

assumptions. The data will also assist in

the development of quality indicators to

predict the types of patients who have

the best prognosis for improvement in

rehabilitation programs. This

information may also encourage

referrals to IRFs for patients who might

otherwise not have been referred. The

data derived from functional

information may also serve to better

match patients with program

characteristics to ‘‘fine tune’’ the

delivery of rehabilitation services.

Additional variables on the MDS–

PAC would allow the facility to

consider factors which may affect a

patient’s ability to return to his or her

previous level of functional ability or

live independently in the community.

Item E7 (stamina) helps staff predict

how much therapy the patient can

tolerate daily. This will impact the

intensity of rehabilitation to help the

patient regain functional independence.

Assessment of stamina will likely affect

a patient’s ability to function

independently once he or she is

discharged back to the community.

Items M1 (available social supports), M2

(caregiver status) and M3 (living

arrangement) will help predict the

characteristics of the community to

which the patient is being discharged in

order to make sure the environment is

optimal to the patient’s success. Finally,

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66335

item L2 (Attributes relevant to

rehabilitation) measures whether a

patient recognizes his or her limitations.

This information will be important to

determine whether the patient can

function in the community and to

determine how much help the patient

will need, without taking risks that may

cause a fall or other harmful events

when not supervised.

Indicators based on functional gain

will be useful in public reporting to

help beneficiaries make more educated

decisions about the facility from which

they choose to receive care. In addition,

Peer Review Organizations (PROs) can

use the data from successful facilities to

identify factors that are better at

assisting patients in achieving

functional independence and returning

to the community. This information can

be shared with other facilities to help

improve their success rate as well.

4. Incidence of Pressure Ulcers

Pressure ulcers (also known as

Decubitus Ulcers) are a problem in IRFs

as well as in other post-acute and acute

settings. In some situations the patient

is admitted with these ulcers. Facilities

cannot be held responsible for ulcers

which were present upon admission,

but if these ulcers increase in size or

grade, or if new ulcers develop, this can

be an indicator of poor quality of care.

Information about pressure ulcers

would be collected in section H of the

MDS–PAC. Information about bed

mobility and transfer ability (items E1a

and E1b), bladder incontinence (item

F1a), and nutritional status (item J5a

and J5b) is useful in identifying patients

at high risk for developing new pressure

ulcers. A pressure ulcer quality

indicator could be used by the facility

to institute such measures as staff

training or more attention to techniques

and equipment intended to prevent the

development of pressure ulcers (such as

frequent change of position of patients

unable to move themselves and use of

pressure relieving devices). In addition,

quality indicators at the facility and

State level can be compared to national

averages for a better understanding of a

facility’s performance relative to its

peers. Focused review will help identify

which factors are contributing to the

higher incidence of pressure ulcers.

Analysis of MDS–PAC data can also be

used to identify facilities that are

successful in resolving and treating

existing pressure ulcers. These facilities

may have effective pressure ulcer

reduction programs in place that can be

shared with other facilities that are

experiencing difficulty treating and

reducing the incidence of pressure

ulcers. Public reporting of the rate of

pressure ulcers based on quality

indicator information may help

consumers make more informed choices

when choosing a facility.

5. Falls Prevention

Falls prevention is an important

component of a rehabilitation program

and is critical to avoiding repeat

hospitalizations which, in turn, will

delay return to independence. Items in

the MDS–PAC such as D3a and D3e on

wandering and resisting care, item E9

on balance, and item H2 on dizziness

and falls, provide critical information

regarding fall risk to help facilities

identify patients who may be at risk for

falls. This indicator may also be used to

identify facilities with poorer track

records in fall avoidance. Information

about falls prevention also provides

information so that facilities serving

different types of patients can be

distinguished. PROs may also use these

data to teach facilities how to better

identify patients at risk for falls and set

up programs to reduce the incidence of

falls through such methods as low beds

or better monitoring of at-risk patients.

As illustrated by these examples,

there are several ways the quality

information gathered through the MDS–

PAC may be used. As noted, quality

indicator data does not necessarily

illustrate that a facility is providing a

lower level of care, but this information

can be useful to surveyors in targeting

facilities for closer review of their

patient care practices and facility

layout. Quality indicators can also be

used to identify facilities with best

practices. Identifying how these

facilities maintain a high-quality level of

care may provide valuable information

to assist facilities.

6. Quality Improvement

Quality assurance involves the

establishment of standards and having a

system to enforce compliance with these

standards. Quality improvement fosters

and facilitates continuous enhancement

of whatever service or product an

organization is engaged in or produces.

The JCAHO require facilities to have

quality improvement programs.

Currently, the Medicare Conditions of

Participation require hospitals to do

quality assurance, which we believe can

be supported with the information

obtained from the MDS–PAC. The

proposed change in the Medicare

Conditions of Participation for

Hospitals, proposed December 19, 1997,

would require hospitals, including IRFs,

to have quality improvement programs.

Also, we are identifying opportunities

in which PROs can use their expertise

and skill mix to provide valuable

information on quality improvement to

post-acute providers. PROs have been

working with SNFs for the past year,

and feedback from facilities has

indicated that the information shared by

the PRO in a penalty-free environment

has been valuable in helping facilities

learn how to use the MDS to identify

their own opportunities for quality

improvement. In addition, many IRFs

already have data-based quality

improvement systems addressing some

aspects of quality. PROs may build on

their experience in SNFs and on the

current experience of IRFs to become a

resource on how to use information

derived from the MDS–PAC to identify

potential quality concerns. Quality

improvement activities may include

providing each facility with information

derived from its MDS–PAC submissions

for use in self-monitoring, providing

facilities with information comparing

their performance with that of their

peers, and maintaining a clearinghouse

of ‘‘best practices’’ that can be used by

facilities to improve the quality of care

they deliver.

IRFs may also use MDS–PAC data to

generate quality indicators on their own

and use this information to help them

target specific problems within their

facility or identify areas where quality

improvement projects may be most

effective. IRFs can also use the MDS–

PAC to perform their own monitoring of

changes in quality of care within the

facility.

7. Consumer Information

We plan to use the comprehensive

quality information derived from MDS–

PAC for use in our public reporting

strategy. MDS–PAC data, after

appropriate evaluation and validation,

can be used to inform consumers about

the performance of facilities in their

area so that they can make informed

decisions when selecting a

rehabilitation facility. In addition,

information derived from MDS–PAC

and the comparable information

available in SNFs and other settings will

help us understand which patients fare

better in which types of post-acute

settings, or even within subsets of IRFs,

thus informing and shaping future longterm care quality initiatives.

As part of our efforts in designing a

monitoring system, we are soliciting

comments on whether we should also

collect data related to medications and

medication administration.

I. MDS–PAC Training and Technical

Support for IRFs

We will provide educational and

technical resources to IRFs, to support

both implementation of the MDS–PAC

66336 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

assessment instrument and the

computerization and transmission of the

MDS–PAC data. We will provide

training and technical support on the

use of the MDS–PAC by clinical staff

and on the use of MPACT software to

encode and transmit MDS–PAC data.

Although we will be providing both

initial and ongoing training and

technical support, IRFs will probably

find it advantageous to designate a staff

member as an IRF trainer, in order to

have in-house capability both to train

newly hired staff, and to have a

designated person who can serve as the

in-house resource for other staff.

We would train and support the IRFs

in the implementation of the IRF

prospective payment system and

automation of the MDS–PAC by—

• Training IRFs on MDS–PAC data set

administration;

• Answering questions on the clinical

aspects of the MDS–PAC and providing

information to IRFs on the use of the

MDS-PAC to determine CMGs;

• Providing training to State agency

staff in using MDS–PAC data for survey

activities;

• Training IRFs in interpreting

validation reports;

• Providing information relative to

hardware and software requirements;

and

• Providing support for transmission

of test data, supporting callers who

request technical assistance, providing

passwords to IRFs, and answering

questions about the computer edits and

reports.

1. Release of Information Collected

Using the MDS–PAC

In § 412.616, we propose that the IRF

and its agents must ensure the

confidentiality of the information

collected using the MDS–PAC in the

same manner as all other information in

the medical record, in accordance with

the hospital conditions of participation

at § 482.24(b)(3). The facility must

ensure that information may be released

only to authorized individuals and must

ensure that unauthorized individuals

cannot gain access to or alter patient

records. Information must be released

by the facility or its agent only in

accordance with Federal or State laws,

court orders or subpoenas. In addition,

we propose that an agent acting on

behalf of an IRF in accordance with a

written contract with that IRF may only

use the information for the purposes

specified in the contract.

We believe that this provision will

ensure that access to MDS–PAC data

(paper copy as well as electronic data)

is secured and controlled by the IRF, in

accordance with Federal and State laws.

We believe that proposed § 412.616

would provide an adequate safeguard

against the unauthorized use of a

patient’s clinical record and the

information it contains, regardless of

form or storage method. As discussed in

section III.G.1 of this preamble,

however, the confidentiality provisions

at proposed § 412.616 may be

supplemented or superseded by the

security and privacy requirements

contained in the ‘‘Standards for Privacy

of Individually Identifiable Health

Information’’ regulation (64 FR 59918)

and the ‘‘Security and Electronic

Signature Standards’’ regulation (63 FR

43242), when they are finalized.

As with other regulations that result

in the creation of a new system of

records, we are in the process of

developing a notice describing the new

system of records that is unique to

MDS–PAC. We have typically issued

notices describing new systems of

records in conjunction with the issuing

of a final rule, rather than at the

proposed rule stage. These notices,

required by the Privacy Act of 1974,

describe both the entities to whom

identifiable and non-identifiable data

can be routinely disclosed, as well as

the safeguards that will protect the

privacy and the security of the data.

While each system of records notice is

unique to the system and the data

instrument, readers interested in

understanding a recent approach are

referred to the notice of the new system

of records published June 18, 1999, (64

FR 32992) for the ‘‘Home Health Agency

Outcome and Assessment Information

Set (OASIS).’’ We would welcome

comments on issues germane to the

notice that we will develop for MDS–

PAC.

J. Patient Rights

In § 412.608, we propose that, in order

to receive payment for the Medicare IRF

services furnished, the authorized

clinician must inform the Medicare

inpatient of the following rights with

respect to the MDS–PAC assessment

prior to performing the assessment.

These rights include—

• The right to be informed of the

purpose of the MDS-PAC data

collection;

• The right to have any MDS–PAC

information that is collected remain

confidential and secure;

• The right to be informed that the

MDS–PAC information will not be

disclosed to others except for legitimate

purposes allowed by the Federal Privacy

Act and Federal and State regulations;

• The right to refuse to answer MDS–

PAC questions; and

• The right to see, review, and request

changes on the MDS–PAC assessment.

We propose requiring the IRF ensure

that a clinician documents in the

Medicare patient’s clinical record that

the patient has been informed of the

above patient rights. IRFs should note

that the above patient rights are in

addition to the patient rights specified

under the conditions of participation for

hospitals in § 482.13.

Our statements of patient rights with

regard to the MDS–PAC would also be

available via the HCFA Inpatient

Rehabilitation Facility Prospective

Payment System website. These

statements may be revised in

accordance with the Office of

Management and Budget Paperwork

Reduction Act re-approval process.

Future revisions to these statements will

be available via the HCFA Inpatient

Rehabilitation Facility Prospective

Payment System website, and in other

instructional materials that we issue.

K. Medical Review Under the IRF

Prospective Payment System

Under a discharge-based prospective

payment system IRFs might have

financial incentives to reduce the

quality and quantity of services

furnished to a patient. To monitor for

any reduction in the quality or quantity

of services IRFs furnish, medical review

may be conducted on both a random

and targeted basis. Targeting may

include claim-specific data and patterns

of case-mix upcoding, as well as the

general issues of the medical need for

the episode of care and technical

eligibility. There will be the capability

for both prepayment and post-payment

medical review that will deny claims in

total or adjust payment to the correct

case mix. Medical review will validate

MDS–PAC data items against clinical

records.

IV. Case-Mix Group Case Classification

System

A. Background

As discussed in section I.C.2. of this

preamble, section 1886(j)(2)(A) of the

Act requires the Secretary to establish a

method of classifying patients in

rehabilitation facilities within case-mix

groups. Further, the Act, as amended by

section 125 of the BBRA, requires the

Secretary to establish classes of patient

discharges of rehabilitation facilities by

functional-related groups, based on

impairment, age, comorbidities,

functional capability of the patient, and

other factors as the Secretary considers

appropriate to improve the explanatory

power of the functional independence

measure-function related groups. Under

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66337

the classification system that we are

proposing, as described at § 412.620(a),

patients would be classified into casemix groups called CMGs based on

clinical characteristics and resource

needs.

We began our efforts to establish an

appropriate classification system by

examining the FIM–FRGs, a

classification methodology developed

by Stineman et al. (1994) and extended

to incorporate comorbidities in Carter,

Relles, et al. (1997). In developing the

proposed CMGs, we updated the earlier

FIM–FRG analysis with more recent

data from calendar years 1996 and 1997

Medicare bills as well as functional

status measures from UDSmr and

Caredata.com for the same calendar

years (see Appendix A for a detailed

description of the data used to create the

CMGs). The results of using more recent

data showed that the earlier FIM–FRG

classification system continues to be an

appropriate basis to predict resource

use. Based on our analysis of the more

recent data, we are proposing a

classification system that reflects

general enhancements, including: a

refined set of rehabilitation impairment

categories; a modified set of relevant

comorbidities; groups for cases that

expire; and other types of atypical

discharges, such as short-stay cases.

B. Case-Mix Groups

1. General Description of the Case-Mix

Groups

The data elements used to construct

the proposed CMGs include

rehabilitation impairment categories

(RICs), functional status (both motor and

cognitive), age, and comorbidities. We

also used other factors to define the

CMGs that allow us to improve the

explanatory power of the groups.

Specifically, we created CMGs to

account for short-stays and expired

cases. The CMGs are based on an

analysis of the Medicare inpatient

rehabilitation cases described in

Appendix A of this proposed rule. We

separated those cases that we believe

received a typical, full course of

inpatient rehabilitation care from those

cases that may not have received a

typical, full course of inpatient

rehabilitation care such as transfer cases

and special cases that are not transfers.

As described below, (1) the analysis of

cases that receive a typical, full course

of inpatient rehabilitation care results in

the construction of 21 RICs and 92

CMGs; and (2) the analysis of special

cases that are not transfers results in the

construction of 4 CMGs for cases that

expire and 1 CMG for cases that have a

length of stay of 3 days or less. In

addition, as described in section V.B. of

this preamble, the analysis of transfer

cases results in a payment policy that is

dependent on which CMG the patient is

classified to prior to the patient’s

transfer.

2. Criteria for Establishing CMGs

We used the following criteria for

establishing specific groups within the

proposed classification system:

• Group cases that are clinically

similar. To do this, we began with the

20 RICs defined by Stineman et al.

(1997) and examined a variety of

changes that were suggested might

improve either clinical or resource

homogeneity.

• Group cases that have similar

resource needs. To do this, we used a

statistical classification method, the

Classification and Regression Trees

(CART), to partition the cases within

RICs into groups that are homogeneous

with respect to resource use and

functional impairment. Thus, each CMG

consists of cases that have similar

clinical and resource needs.

• Determine which comorbidities

affect the cost of rehabilitation cases by

RIC.

We describe in more detail the

methodology that we used to construct

the CMGs.

3. Rehabilitation Impairment Categories

The first partition in creating the

CMGs is based on the RIC of the case.

RICs are groups of codes that indicate

the primary cause of the rehabilitation

hospitalization and are clinically

homogeneous. The patient is first

grouped into a RIC based on the

impairment identified in the data

described above. Table 1D below lists

the RICs used to define and construct

the first partition of the inpatient

rehabilitation cases.

The earlier RAND research of 1994

data resulted in 20 RICs. We analyzed

RAND’s statistical analysis of 1997 data,

and that showed that the 1997 data

performed as well as the 1994 data in

predicting resource use in RICs 01

through 20 (except that the impairment

code 14.9 ‘‘Status post major multiple

fractures’’ grouped better in RIC 17). In

addition, the 1997 data indicated the

need to create a separate RIC for burn

cases.

For the majority of CMGs, the RIC

represents the first two digits of the

CMG. Thus, in Table 2D below, CMGs

0101 through 0111 are cases that are

classified to the stroke (01) RIC.

TABLE 1D.—REHABILITATION IMPAIRMENT CATEGORIES AND ASSOCIATED IMPAIRMENT GROUP CODES

Rehabilitation impairment category Associated impairment group codes

01 Stroke (Stroke) ........................................................... 01.1 Left body involvement (right brain)

01.2 Right body involvement (left brain)

01.3 Bilateral Involvement

01.4 No Paresis

01.9 Other Stroke

02 Traumatic brain injury (TBI) ........................................ 02.21 Open Injury

02.22 Closed Injury

03 Nontraumatic brain injury (NTBI) ................................ 02.1 Non-traumatic

02.9 Other Brain

04 Traumatic spinal cord (TSCI) ..................................... 04.210 Paraplegia, Unspecified

04.211 Paraplegia, Incomplete

04.212 Paraplegia, Complete

04.220 Quadriplegia, Unspecified

04.2211 Quadriplegia, Incomplete C1–4

04.2212 Quadriplegia, Incomplete C5–8

04.2221 Quadriplegia, Complete C1–4

04.2222 Quadriplegia, Complete C5–8

04.230 Other traumatic spinal cord dysfunction

66338 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

TABLE 1D.—REHABILITATION IMPAIRMENT CATEGORIES AND ASSOCIATED IMPAIRMENT GROUP CODES—Continued

Rehabilitation impairment category Associated impairment group codes

05 Nontraumatic spinal cord (NTSCI) ............................. 04.110 Paraplegia, unspecified

04.111 Paraplegia, incomplete

04.112 Paraplegia, complete

04.120 Quadriplegia, unspecified

04.1211 Quadriplegia, Incomplete C1–4

04.1212 Quadriplegia, Incomplete C5–8

04.1221 Quadriplegia, Complete C1–4

04.1222 Quadriplegia, Complete C5–8

04.130 Other non-traumatic spinal cord dysfunction

06 Neurological (Neuro) .................................................. 03.1 Multiple Sclerosis

03.2 Parkinsonism

03.3 Polyneuropathy

03.5 Cerebral Palsy

03.8 Neuromuscular Disorders

03.9 Other Neurologic

07 Fracture of LE (FracLE) ............................................. 08.11 Status post unilateral hip fracture

08.12 Status post bilateral hip fractures

08.2 Status post femur (shaft) fracture

08.3 Status post pelvic fracture

08 Replacement of LE joint (ReplLE) .............................. 08.51 Status post unilateral hip replacement

08.52 Status post bilateral hip replacements

08.61 Status post unilateral knee replacement

08.62 Status post bilateral knee replacements

08.71 Status post knee and hip replacements (same side)

08.72 Status post knee and hip replacements (different sides)

09 Other orthopedic (Ortho) ............................................ 08.9 Other orthopedic

10 Amputation, lower extremity (AMPLE) ....................... 05.3 Unilateral lower extremity above the knee (AK)

05.4 Unilateral lower extremity below the knee (BK)

05.5 Bilateral lower extremity above the knee (AK/AK)

05.6 Bilateral lower extremity above/below the knee (AK/BK)

05.7 Bilateral lower extremity below the knee (BK/BK)

11 Amputation, other (AMP–NLE) ................................... 05.1 Unilateral upper extremity above the elbow (AE)

05.2 Unilateral upper extremity below the elbow (BE)

05.9 Other amputation

12 Osteoarthritis (OsteoA) ............................................... 06.2 Osteoarthritis

13 Rheumatoid, other arthritis (RheumA) ....................... 06.1 Rheumatoid Arthritis

06.9 Other arthritis

14 Cardiac (Cardiac) ....................................................... 09 Cardiac

15 Pulmonary (Pulmonary) .............................................. 10.1 Chronic Obstructive Pulmonary Disease

10.9 Other pulmonary

16 Pain Syndrome (Pain) ................................................ 07.1 Neck pain

07.2 Back pain

07.3 Extremity pain

07.9 Other pain

17 Major multiple trauma, no brain injury or spinal cord

injury (MMT–NBSCI).

08.4 Status post major multiple fractures

14.9 Other multiple trauma

18 Major multiple trauma, with brain or spinal cord injury (MMT–BSCI).14.1 Brain and spinal cord injury

14.2 Brain and multiple fractures/amputation

14.3 Spinal cord and multiple fractures/amputation

19 Guillian Barre (GB) ..................................................... 03.4

20 Miscellaneous (Misc) .................................................. 12.1 Spina Bifida*

12.9 Other congenital

13 Other disabling impairments

15 Developmental disability

16 Debility

17.1 Infection

17.2 Neoplasms

17.31 Nutrition (endocrine/metabolic) with intubation/parenteral nutrition

17.32 Nutrition (endocrine/metabolic) without intubation/parenteral nutrition

17.4 Circulatory disorders

17.51 Respiratory disorders—Ventilator Dependent

17.52 Respiratory disorders—Non-ventilator Dependent

17.6 Terminal care

17.7 Skin disorders

17.8 Medical/Surgical complications

17.9 Other medically complex conditions

21 Burns (Burns) ............................................................. 11 Burns

* We are in the process of analyzing the effect of moving the few cases within this impairment category to one of the other spinal cord RICs

(either 05 or 04 depending upon the ‘‘fit’’).

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66339

4. Functional Status Measures and Age

After using the RIC to define the first

split among the inpatient rehabilitation

cases, we used functional status

measures and age to partition the cases

further. We describe below the

statistical methodology (Classification

and Regression Trees or CART) that we

used to incorporate a patient’s

functional status measures (motor score

and cognitive score), and age into the

construction of the proposed CMGs.

The CART methodology was used to

split the rehabilitation cases further

within each RIC. In general, CART can

be used to identify statistical

relationships among data and, using

these relationships, construct a

predictive model for organizing and

partitioning a large set of data into

smaller homogeneous groups. Further,

in constructing the proposed CMGs, we

analyzed the extent to which the

independent variables (motor score,

cognitive score, and age) help predict

the value of the dependent variable (the

log of the cost per case).

The CART methodology will ensure

that the proposed CMGs recognize that

patients with clinically distinct resource

needs are treated separately in the

classification and payment systems.

CART is an iterative process that creates

initial groups of patients then searches

for ways to split the initial groups that

may further decrease the clinical and

cost variances within a group and

increase the explanatory power of the

CMGs. (Further information regarding

this methodology can be found in the

seminal literature on CART

(Classification and Regression Trees,

Leo Breiman, Jerome Friedman, Richard

Olshen, Charles Stone, Wadsworth Inc.,

Belmont CA, 1984: pp 78–80.)

We also used a validation method to

assess the predictive accuracy of the

RICs and CMGs. Half of the 1996 and

1997 data described in Appendix A was

used initially to create the CMGs. Once

this was done, the other half of the data

was used to test or validate the

predictive accuracy of the CMGs. We

concluded that the RICs and CMGs we

are proposing are valid because the

groups performed as well using the

second half of the data as they did with

the first half. The final definitions of the

specific RICs and CMGs was based on

100 percent of the 1997 Medicare cost

data with corresponding UDSmr/COS

data.

As a result of this analysis, Table 2D

lists 92 CMGs and their respective

descriptions, including the motor and

cognitive scores and age that will be

used to classify discharges into CMGs.

As described in section II.B. of this

preamble, some CMGs may change

based on further analysis of available

data and comments we receive in

response to this proposed rule.

5. Comorbidities

We found comorbidities have major

effects on the cost of furnishing

inpatient rehabilitation care. RAND’s

previous analysis, based on 1994 data,

found that these comorbidities also

increased the cost of furnishing

inpatient rehabilitation care. A list of

the major comorbidities appears in

Appendix C of this proposed rule. A

case has to have only one of the listed

comorbidities to be classified as a case

with comorbidity. We found that the

presence of major comorbidities

multiplies the expected resource use of

a case by the same amount for each

CMG in the same RIC.

We matched frequently occurring

comorbidities to impairment categories

in order to ensure that all of the chosen

comorbidities are, in fact, relevant to the

RIC. Providing rehabilitation services to

a beneficiary with a total hip

replacement can become both more

complex and more costly if the

beneficiary also has pneumonia. By

contrast, some pulmonary diagnoses

might be determined not to have a cost

impact for beneficiaries with chronic

obstructive pulmonary disease.

We found comorbidities to affect cost

per case for some of the CMGs, but not

all. When comorbidities substantially

increased the average cost of the CMG

and were determined to be clinically

relevant, we developed CMG relative

weights adjusted for comorbidities. We

will continue to analyze the data to

determine if refinements to the list of

comorbidities in Appendix C are

necessary. Further discussion of the

effect of comorbidities is described in

section V.A.2. of this preamble.

6. Analysis of Special Cases

We analyzed payment-to-cost ratios of

special types of cases that were not

transfer cases to determine if costs could

be predicted. From this analysis, we

believe that cases that expire and cases

with a length of stay of 3 days or less

(not including transfer cases) would be

substantially ‘‘overpaid’’ if facilities

receive the full CMG payment for these

cases. To improve the explanatory

power of the groups, we added four

CMGs to account for cases that expire

and one CMG for all cases that have a

length of stay of 3 days or less (not

including transfer cases). These types of

special cases are further explained in

section V.C. of this preamble. Therefore,

the total number of proposed CMGs is

97 as shown in Table 2D.

7. Methodology To Classify Patients Into

CMGs

Data from the MDS–PAC, described in

section III of this preamble and

specified in proposed § 412.620(a)(3) of

the regulations, will be used to classify

a patient into a CMG. In Table 3D, we

have identified the specific MDS–PAC

items that must be completed in order

to classify a patient into a CMG and to

effectively implement the proposed

prospective payment system. (These

items, along with other MDS–PAC

items, will be used to administer,

monitor, and analyze possible

refinements to the proposed prospective

payment system as described in section

III of this preamble.) The MDS–PAC

items will be used to establish the motor

score, cognitive score, and age of the

patient that corresponds with a specific

CMG description.

8. Case Example To Classify a Patient

Into a CMG

The following example illustrates

how a Medicare beneficiary would be

classified to a CMG under the proposed

classification system. An 82 year old

woman has a left total hip replacement

because of osteoarthritis, and is

admitted to the IRF because of the need

for rehabilitation after the hip

replacement surgery. The beneficiary is

first classified into RIC 08: Replacement

of Left Extremity Joint with Associated

Impairment Group Code 08.51: Status

Post Unilateral Hip Replacement.

Assessment

MDS–PAC SCORE

0 Independent in eating (MDS–PAC

section E, 1g);

1 Requires set up to dress upper body

(MDS–PAC section E, 1e);

5 Requires maximum assistance to

dress lower body (MDS–PAC

section E, 1f);

1 Requires set up for grooming (MDS–

PAC section E, 1j);

2 Requires minimal assistance for bed

mobility (MDS–PAC section E, 1b);

5 Requires maximum assistance for

bed to chair transfer (MDS–PAC

section E, 1b);

5 Requires maximum assistance for

walking (MDS–PAC section E, 1d);

5 Requires maximum assistance for

toilet transfer (MDS–PAC section E,

1i);

5 Requires maximum assistance for

bathing (MDS–PAC section E, 1k);

6 Dependent shower transfer (MDS–

PAC section E, 1k);

6 Dependent stair climbing (MDS–PAC

section E, 8c); and

0 Independent bowel and bladder

sphincter control (MDS–PAC

section F, 1 and 4.

66340 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

Total MDS–PAC Motor Score: 41 This motor score places the Medicare

beneficiary in CMG 0802, which is

‘‘Replacement of lower extremity joint’’

with a motor score from 41–33. (See

footnote at the bottom of Table 2D)

TABLE 2D.—DEFINITION OF CMGS

CMG number** CMG description

0101 .................. Stroke with motor score from 29–0

0102 .................. Stroke with motor score from 34–30 and cognitive score from 27–135*

0103 .................. Stroke with motor score from 40–35 and cognitive score from 28–35*

0104 .................. Stroke with motor score from 34–30 and cognitive score from 5–26*

0105 .................. Stroke with motor score from 40–35 and cognitive score from 5–27*

0106 .................. Stroke with motor score from 45–41

0107 .................. Stroke with motor score from 49–46

0108 .................. Stroke with motor score from 55–50

0109 .................. Stroke with motor score from 78–56 and patient is 84 years old or older

0110 .................. Stroke with motor score from 60–56 and patient is 83 years old or younger

0111 .................. Stroke with motor score from 78–61 and patient is 83 years old or younger

0201 .................. Traumatic brain injury with motor score from 33–0 and cognitive score from 30–35*

0202 .................. Traumatic brain injury with motor score from 33–0 and cognitive score from 5–29*

0203 .................. Traumatic brain injury with motor score from 50–34 and cognitive score from 22–35*

0204 .................. Traumatic brain injury with motor score from 50–34 and cognitive score from 5–21*

0205 .................. Traumatic brain injury with motor score from 66–51

0206 .................. Traumatic brain injury with motor score from 78–67

0301 .................. Non-traumatic brain injury with motor score from 33–0 and cognitive score from 22–35*

0302 .................. Non-traumatic brain injury with motor score from 33–0 and cognitive score from 5–21*

0303 .................. Non-traumatic brain injury with motor score from 46–34

0304 .................. Non-traumatic brain injury with motor score from 56–47

0305 .................. Non-traumatic brain injury with motor score from 78–57

0401 .................. Traumatic spinal cord injury with motor score from 36–0

0402 .................. Traumatic spinal cord injury with motor score from 57–37

0403 .................. Traumatic spinal cord injury with motor score from 74–58

0404 .................. Traumatic spinal cord injury with motor score from 78–75

0501 .................. Non-traumatic spinal cord injury with motor score from 23–0

0502 .................. Non-traumatic spinal cord injury with motor score from 36–24

0503 .................. Non-traumatic spinal cord injury with motor score from 45–37

0504 .................. Non-traumatic spinal cord injury with motor score from 57–46

0505 .................. Non-traumatic spinal cord injury with motor score from 78–58

0601 .................. Neurological with motor score from 35–0

0602 .................. Neurological with motor score from 45–36

0603 .................. Neurological with motor score from 53–46

0604 .................. Neurological with motor score from 78–54

0701 .................. Fracture of lower extremity with motor score from 36–0

0702 .................. Fracture of lower extremity with motor score from 45–37

0703 .................. Fracture of lower extremity with motor score from 51–46

0704 .................. Fracture of lower extremity with motor score from 78–52

0801 .................. Replacement of lower extremity joint with motor score from 32–0

0802 .................. Replacement of lower extremity joint with motor score from 41–33

0803 .................. Replacement of lower extremity joint with motor score from 48–42

0804 .................. Replacement of lower extremity joint with motor score from 78–49 and cognitive score from 34–35*

0805 .................. Replacement of lower extremity joint with motor score from 55–50 and cognitive score from 5–33*

0806 .................. Replacement of lower extremity joint with motor score from 78–56 and cognitive score from 5–33*

0901 .................. Other orthopedic with motor score from 32–0

0902 .................. Other orthopedic with motor score from 44–33

0903 .................. Other orthopedic with motor score from 53–45

0904 .................. Other orthopedic with motor score from 78–54

1001 .................. Amputation, lower extremity with motor score from 38–0

1002 .................. Amputation, lower extremity with motor score from 48–39

1003 .................. Amputation, lower extremity with motor score from 78–49

1101 .................. Amputation, non-lower extremity with motor score from 30–0

1102 .................. Amputation, non-lower extremity with motor score from 44–31 and patient is 68 years old or older

1103 .................. Amputation, non-lower extremity with motor score from 44–31 and patient is 67 years old or younger

1104 .................. Amputation, non-lower extremity with motor score from 78–45

1201 .................. Osteoarthritis with motor score from 42–0 and cognitive score from 34–35*

1202 .................. Osteoarthritis with motor score from 42–0 and cognitive score from 5–33*

1203 .................. Osteoarthritis with motor score from 54–43

1204 .................. Osteoarthritis with motor score from 78–55

1301 .................. Rheumatoid, other arthritis with motor score from 30–0

1302 .................. Rheumatoid, other arthritis with motor score from 42–31

1303 .................. Rheumatoid, other arthritis with motor score from 78–43

1401 .................. Cardiac with motor score from 37–0

1402 .................. Cardiac with motor score from 50–38

1403 .................. Cardiac with motor score from 78–51

1501 .................. Pulmonary with motor score from 40–0 and patient is 78 years old or older

1502 .................. Pulmonary with motor score from 40–0 and patient is 77 years old or younger

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66341

TABLE 2D.—DEFINITION OF CMGS—Continued

CMG number** CMG description

1503 .................. Pulmonary with motor score from 63–41

1504 .................. Pulmonary with motor score from 78–64

1601 .................. Pain syndrome with motor score from 41–0 and cognitive score from 33–35*

1602 .................. Pain syndrome with motor score from 41–0 and cognitive score from 5–32*

1603 .................. Pain syndrome with motor score from 78–42

1701 .................. Major multiple trauma with brain or spinal cord injury with motor score from 48–0

1702 .................. Major multiple trauma with brain or spinal cord injury with motor score from 78–49

1801 .................. Major multiple trauma, with brain or spinal cord injury with motor score from 56–0

1802 .................. Major multiple trauma, with brain or spinal cord injury with motor score from 78–57

1901 .................. Guillian Barre with motor score from 36–0

1902 .................. Guillian Barre with motor score from 47–37

1903 .................. Guillian Barre with motor score from 78–48

2001 .................. Miscellaneous with motor score from 21–0 and patient is 59 years old or older

2002 .................. Miscellaneous with motor score from 31–22

2003 .................. Miscellaneous with motor score from 36–32

2004 .................. Miscellaneous with motor score from 21–0 and patient is 58 years old or younger

2005 .................. Miscellaneous with motor score from 43–37 and patient is 65 years old or older

2006 .................. Miscellaneous with motor score from 52–44 and patient is 65 years old or older

2007 .................. Miscellaneous with motor score from 43–37 and patient is 65 years old or younger

2008 .................. Miscellaneous with motor score from 78–53 and patient is 84 years old or older

2009 .................. Miscellaneous with motor score from 59–53 and patient is 84 years old or younger

2010 .................. Miscellaneous with motor score from 52–44 and patient is 65 years old or younger

2011 .................. Miscellaneous with motor score from 78–60 and patient is 84 years old or younger

2101 .................. Burns

5001 .................. Short-stay cases, length of stay is 3 days or fewer

5101 .................. Expired, orthopedic, short stay

5102 .................. Expired, orthopedic, not short stay

5103 .................. Expired, not orthopedic, short stay

5104 .................. Expired, not orthopedic, not short stay

*In developing this example of scoring conventions, we have displayed only the FIM motor scores as MDS–PAC scores. We have not included

the cognitive scores as MDS–PAC scores. We are currently studying the aggregation of the MDS-PAC variable into the FIM cognitive categories.

RAND, our contractor, will be performing additional analysis on the cognitive scoring conventions, and we will be including this research in the

final regulations.

**The first two digits of the CMG number from 01 to 21 correspond with a specific RIC number shown on Table 1D.

TABLE 3D.—CRITICAL MDS–PAC ITEMS

Section/item name Item number

A. ITEMS FROM THE INTERRUPTED STAY TRACKING FORM

SECTION AA. IDENTIFICATION INFORMATION:

Legal Name of Patient ............................................................................................................................................................... 1a–1d

Admission Date ......................................................................................................................................................................... 2a–2b

Social Security and Medicare Numbers .................................................................................................................................... 6a–6b

Facility Provider Number ........................................................................................................................................................... 8a–8b

Medicaid Number ...................................................................................................................................................................... 9

Gender ....................................................................................................................................................................................... 10

Birthdate .................................................................................................................................................................................... 11

Ethnicity/Race ............................................................................................................................................................................ 12a–12f

Interrupted Stay ......................................................................................................................................................................... 13a–13b

Clinician Completing Assessment ............................................................................................................................................. 14b–14f

B. ITEMS FROM THE BASIC ASSESSMENT TRACKING FORM

SECTION AA. IDENTIFICATION INFORMATION:

Legal Name of Patient ............................................................................................................................................................... 1a–1d

Admission Date ......................................................................................................................................................................... 2a–2b

Reason for Assessment ............................................................................................................................................................ 3

Assessment Reference Date ..................................................................................................................................................... 4

Discharge Status ....................................................................................................................................................................... 5a–5b*

Social Security and Medicare Numbers .................................................................................................................................... 6a–6b

Facility Provider Number ........................................................................................................................................................... 8a–8b

Medicaid Number ...................................................................................................................................................................... 9

Gender ....................................................................................................................................................................................... 10

Birthdate .................................................................................................................................................................................... 11*

Ethnicity/Race ............................................................................................................................................................................ 12a–12f

SECTION AB. ASSESSMENT ATTESTATION:

Person Completing Assessment ............................................................................................................................................... 1b–1g

66342 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

TABLE 3D.—CRITICAL MDS–PAC ITEMS—Continued

Section/item name Item number

C. ITEMS FROM COMPLETE ASSESSMENT (ASSESSMENT, READMISSION, DISCHARGE)

SECTION A. DEMOGRAPHIC/ADMISSION INFORMATION HISTORY:

Legal Name of Patient ............................................................................................................................................................... 1a–1d

Admission Date ......................................................................................................................................................................... 2a–2b

Reason for Assessment ............................................................................................................................................................ 3

Admission Status ....................................................................................................................................................................... 4

Goals for Stay ............................................................................................................................................................................ 5a–5e

Admitted From ........................................................................................................................................................................... 6

Precipitating Event Prior to Admission ...................................................................................................................................... 7

Primary and Secondary Payment Source for Stay ................................................................................................................... 8A–8B

Marital Status ............................................................................................................................................................................. 9

Language ................................................................................................................................................................................... 11

SECTION B. COGNITIVE PATTERNS:

Comatose .................................................................................................................................................................................. 1*

Memory/Recall Ability ................................................................................................................................................................ 2a–2d*

Cognitive Skills for Daily Decision Making ................................................................................................................................ 3a–3b*

Indicators of Delirium-Periodic Disorder Thinking/Awareness .................................................................................................. 4a–4f*

SECTION C. COMMUNICATION/VISUAL PATTERNS:

Modes of Communication .......................................................................................................................................................... 2a–2e*

Making Self Understood ............................................................................................................................................................ 3a–3b*

Speech Clarity ........................................................................................................................................................................... 4*

Ability to Understand Others ..................................................................................................................................................... 5a–5b*

SECTION E. FUNCTIONAL STATUS:

3 Day ADL Self-Performance .................................................................................................................................................... 1a–1l*

ADL Assist Codes ..................................................................................................................................................................... 2a–2l*

ADL Changes ............................................................................................................................................................................ 3

Devices and Aids ....................................................................................................................................................................... 6a–6j*

Walking and Stair Climbing ....................................................................................................................................................... 8a–8c*

SECTION F. BLADDER/BOWEL MANAGEMENT:

Bladder Continence ................................................................................................................................................................... 1a–1b*

Bladder Appliance ..................................................................................................................................................................... 2a–2g*

Bladder Appliance Support ........................................................................................................................................................ 3*

Bowel Continence ...................................................................................................................................................................... 4*

Bowel Appliances ...................................................................................................................................................................... 5a–5d*

Bowel Appliance Support .......................................................................................................................................................... 6*

SECTION G. DIAGNOSES:

Impairment Group ...................................................................................................................................................................... 1*

Complications/Comorbidities ..................................................................................................................................................... 5a–5d*

SECTION M. RESOURCES FOR DISCHARGE:

Living Arrangement ................................................................................................................................................................... 3a–3b (A–C)

*Must be recorded by category, variable, and item number, in order for a patient to be classified into a CMG.

9. Adjustment to the Case-Mix Groups

As described in proposed § 412.620(c)

of the regulations and as provided by

section 1886(j)(2)(c)(i) of the Act, we

adjust the CMGs periodically to reflect

changes in treatment patterns,

technology, number of discharges, and

other factors affecting the relative use of

resources.

V. Payment Rates

The IRF prospective payment system

proposed in this rule utilizes Federal

prospective payment rates across 97

distinct CMGs. The Federal payment

rates are established using a standard

payment amount (referred to as the

budget neutral conversion factor). A set

of relative payment weights which

account for the relative difference in

resource use across the CMGs is applied

to the budget neutral conversion factor,

and finally a number of facility level

and case level adjustments may apply.

The facility level adjustments include

those which account for geographic

variation in wages (wage index),

Disproportionate Share (DSH), and

location in a rural area. Case level

adjustments include those which apply

for transfer, short-stay and outlier cases,

as described later in this section.

The budget neutral conversion factor

provides the basis for determining the

CMG based Federal payment rates. It is

a standardized payment amount that is

based on average costs from a base

period and also reflects the combined

aggregate effects of the payment

weights, various facility and case level

adjustments, and other policies

discussed in this section. Consequently,

in discussing the methodology for

development of the Federal payment

rates, we begin by describing the various

adjustments and factors which serve as

the inputs used in establishing the

budget neutral conversion factor.

Accordingly, we propose to develop

prospective payments for IRFs using the

following major steps:

• Develop the CMG relative weights.

• Determine the payment

adjustments.

• Calculate the budget neutral

conversion factor minus 2 percent.

• Calculate the Federal CMG

prospective payments.

A detailed description of each step

and a discussion of our proposed

transfer policy, phase-in

implementation and other policies

follows.

A. Development of CMG Relative

Weights

1. Overview of Development of the CMG

Relative Weights

As previously stated, one of the

primary goals for the implementation of

the proposed IRF prospective payment

system is to pay each rehabilitation

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66343

facility an appropriate payment for the

efficient delivery of the care required by

its set of Medicare patients. The system

must be able to account adequately for

each facility’s case-mix in order to

ensure both fair distribution of Medicare

payments and access to adequate care

for beneficiaries whose care is provided

at a higher cost. To accomplish these

goals, payment for each case is adjusted

for case-mix.

In this payment system, under

proposed § 412.620(b)(1), relative

weights are a primary element in

accounting for the variance in cost per

discharge and resource utilization

among the payment groups. To ensure

that beneficiaries classified to each CMG

will have access to care and to

encourage efficiency, we calculate a

relative weight for each CMG that is

proportional to the resources needed by

an average inpatient rehabilitation case

in that CMG. For example, cases in a

CMG with a relative weight of 2 will on

average cost twice as much as cases in

a CMG with a weight of 1.

To calculate the relative weights, we

estimate operating (routine and

ancillary services) and capital costs

from inpatient rehabilitation facilities.

Cost-to-charge ratios for ancillary

services and per diem costs for routine

services were obtained from the most

recent available cost report data (FYs

1997, 1996, and/or 1995), charges were

obtained from calendar year 1997

Medicare bill data, and corresponding

functional measures were derived from

the UDSmr/COS data. We omit data

from rehabilitation facilities that are

classified as all-inclusive providers from

the calculation of the relative weights,

as well as from the parameters that we

use to define transfer cases, because

these facilities are paid a single,

negotiated rate per discharge and they

do not maintain a charge structure.

For ancillary services, we calculate

both operating and capital costs by

converting charges from Medicare

claims into costs using facility-specific,

cost-center specific cost-to-charge ratios

obtained from cost reports. Some

departmental cost-to-charge ratios were

missing or found to be outside a

plausible range. We replace individual

cost-to-charge ratios for all departments

except anesthesiology when the values

are either greater than 10, or less than

0.05. For anesthesiology, we replace the

cost-to-charge ratio only when the value

is greater than 10, or less than 0.01. The

replacement value that we use for these

aberrant cost-to-charge ratios is the

mean value of the cost-to-charge ratio

for the cost-center within the same type

of hospital (either freestanding or unit).

For routine services, per diem

operating and capital costs are used to

develop the relative weights. In

addition, per diem operating and capital

costs for special care services are used

to develop the relative weights. (Special

care services are furnished in intensive

care units. We note that fewer than 1

percent of rehabilitation days are spent

in intensive care units.) Per diem costs

are obtained from each facility’s

Medicare cost report data. We use per

diem costs for routine and special care

services because, unlike for ancillary

services, cost-to-charge ratios cannot be

obtained from Medicare data. To

estimate the costs for routine and

special care services included in

developing the relative weights, we sum

the product of routine cost per diem and

Medicare inpatient days and the

product of the special care per diem and

the number of Medicare special care

days.

We propose to use a hospital-specific

relative value method to calculate

relative weights. We believe this method

allows us to account for more of the

cross-facility variation in costs.

Specifically, we remove the variation in

costs across providers by converting a

facility’s cost for a case to a relative

value based on the facility’s case-mix

index. The case-mix index is the average

case weight (adjusted to eliminate the

effect of comorbidities) for cases at a

facility. Under the hospital-specific

relative value method, costs are

standardized at the facility level using

facility-specific costs. Costs are

standardized for each case by first

dividing the adjusted cost for the case

(which reflects comorbidities) by the

average adjusted cost for the facility in

which the case was treated. The average

adjusted cost represents the average

intensity of the health care services

delivered by a particular facility. The

resulting ratio is multiplied by the

facility’s own costliness (the facility’s

case-mix index) to determine the

standardized cost for the case. The casemix index accounts for the extent to

which the intensity of the services is

due to the needs of the facility’s

patients.

Because costs are standardized in this

manner, costs for a beneficiary at a

facility with high average costs are

counted as less resource intensive than

costs at a facility with low average costs.

Therefore, the adjusted cost of an

individual case more accurately reflects

actual resource use for an individual

facility. For example, a $7,000 case in a

facility with an average adjusted cost of

$10,000 reflects a higher level of relative

resource use than a $7,000 case in a

facility with the same case-mix, but an

average adjusted cost of $20,000.

We used the following basic steps to

calculate the relative weights in this

proposed rule:

The first step in calculating the CMG

weights is to estimate the effect that

comorbidities have on costs. The second

step is to adjust the cost of each

Medicare discharge (case) to reflect the

effects found in the first step. In the

third step, the adjusted costs from the

second step are used to calculate

‘‘relative adjusted weights’’ in each

CMG using the hospital-specific relative

value method described above. The final

steps are to calculate the CMG relative

weights by modifying the ‘‘relative

adjusted weight’’ with the effects of the

existence of a comorbidity and

normalize the weights to 1.

We describe each of these steps in

greater detail below.

2. Steps for Calculating the Relative

Weights

Step 1—Estimate the effect of

comorbidities on costs. In general,

comorbidities are defined as additional

medical conditions that increase the

complexity of care delivered. For

example, treatment for a beneficiary

with a total hip replacement can become

more complex if the beneficiary also has

pneumonia. Because we found

comorbidities to be significant

predictors of costs in most RICs, we

propose to calculate separate relative

weights for cases in a given CMG with

comorbidity and without comorbidity to

reflect the additional costs incurred by

cases classified with a comorbidity. We

use regression analyses to determine if

the weight for a Medicare discharge

(case) should reflect the costs of

comorbidities. Specifically, separate

regression analyses are performed for

each RIC. In the analysis, we found that

not all comorbidities have the same

effect on each RIC. Therefore, if

coefficients by RIC are positive and

significant and the comorbidity is

deemed to be clinically relevant to the

CMG, then we calculate separate

relative weights for cases with

comorbidity in Step 3 below.

Step 2—Adjust the costs of each

discharge for the effects of

comorbidities. The second step in the

calculation of the weights is to adjust

the resource use for each case to

eliminate the effect of comorbidities.

The adjusted cost (A) for a discharge,

with values x for comorbidity is:

A = cost per discharge/exp(a*x)

These adjusted cost for each discharge

are then used to calculate the relative

adjusted weight in each CMG k,wk.

66344 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

Step 3—Calculate the CMG relative

weights adjusted for comorbidities, on

an iterative basis. The process of

calculating the CMG relative weights is

iterative. First, we give an initial casemix index value of 1 to each facility.

Then, for each case, we calculate a

facility-specific relative value by

dividing the comorbidity-adjusted cost

of the case by the average comorbidityadjusted cost of all cases at the facility,

and multiplying the result by the

facility’s case-mix index. The CMGadjusted weights are then set in

proportion to the average of the facilityspecific relative values. The result is a

new case-mix index for each facility

and, therefore, new facility-specific,

relative values. The process is

continued until there is convergence

between the weights produced at

adjacent steps, for example, when the

maximum difference is less than 0.0001.

After the first iteration, statistical

outliers are defined as cases that differ

from the CMG mean by more than three

standard deviations in the log scale of

standardized cost. These outliers are

removed. Discharges that meet the

definition of a transfer case are treated

as a fraction of a case. (See discussion

of transfers in section V.B, below.) A

relative weight for each relevant

combination of CMG ‘‘with

comorbidity’’ and ‘‘without

comorbidity’’ is calculated using the

following formula:

W(k,x) = exp(a*x)wk

Where x equals 1 if the patient had one

or more comorbidities or x equals 0 if

no comorbidities were present. The

variable (wk) equals the comorbidity

adjusted weight. If the coefficient (a) is

not positive and significant as

previously discussed in Step 1, then (a)

will be set to equal 0 in the formula.

This results in exp(a*x), in the formula,

to equal 1 and the weight (W) will equal

(wk).

Step 4—Calculate the weight by

modifying the relative adjusted weight

with the effects of comorbidity and

normalizing the weights to 1.0. This step

entails calculating a relative weight for

each relevant combination of CMG and

comorbidity. In this step, we determine

the average cost per discharge for all the

cases and use that value as the divisor

to calculate the relative weights. For

example, if the average cost per

discharge across all discharges is

$12,000, then the relative weight for a

CMG with an average cost of $12,000 is

1, and the relative weight for a CMG

with an average cost per discharge of

$20,000 is 1.67. If ‘‘r’’ is the relative

adjusted weight for a case in a CMG

with a comorbidity given by:

w = k r exp(a*x),

then k is determined so that the

average value of w is 1.

Table 1E below lists the CMGs and

their respective relative weights. The

relative weights reflect the inclusion of

cases with a very short interruption

(return on day of discharge or either of

the next 2 days). As stated previously,

comorbidities were found to affect the

cost of certain CMGs, but not all. Thus,

the value for CMGs not affected by

comorbidities is the same in both the

‘‘No Comorbidity’’ and the ‘‘With

Comorbidity’’ columns. Information

obtained from the first assessment (Day

4 assessment) will be used to determine

the appropriate CMG and corresponding

payment, including existence of a

comorbidity. If a relevant comorbidity is

indicated on this assessment, payment

will be based on the relative weight

from the comorbidity column. It should

also be noted that Table 1E reflects

cognitive scores that were derived from

UDSmr/COS data.

TABLE 1E.—CMG RELATIVE WEIGHTS

CMG * Definition

(M=motor, C=cognitive, A=age)

Split by

comorbidity

Average length of stay Relative weight

No

comorbidity

With

comorbidity

No

comorbidity

With

comorbidity

0101 ....... M = 29–0 ......................................................... Y 10.4 9.6 0.6058 0.6613

0102 ....... M = 34–30 and C = 27–35 .............................. Y 12.0 11.4 0.7095 0.7746

0103 ....... M = 40–35 and C = 28–35 .............................. Y 14.3 15.2 0.8605 0.9394

0104 ....... M = 34–30 and C = 5–26 ................................ Y 14.2 16.7 0.8560 0.9344

0105 ....... M = 40–35 and C = 5–27 ................................ Y 15.9 16.7 0.9620 1.0501

0106 ....... M = 45–41 ....................................................... Y 17.7 17.2 1.0944 1.1947

0107 ....... M = 49–46 ....................................................... Y 20.1 20.7 1.2630 1.3787

0108 ....... M = 55–50 ....................................................... Y 22.7 21.2 1.4365 1.5682

0109 ....... M = 78–56 and A >= 84 .................................. Y 24.0 24.9 1.5989 1.7455

0110 ....... M = 60–56 and A <= 83 .................................. Y 25.9 23.4 1.6616 1.8139

0111 ....... M = 78–61 and A <= 83 .................................. Y 29.5 29.6 1.9626 2.1425

0201 ....... M = 33–0 and C = 30–35 ................................ N 9.4 9.4 0.5504 0.5504

0202 ....... M = 33–0 and C = 5–29 .................................. N 13.3 13.3 0.8325 0.8325

0203 ....... M = 50–34 and C = 22–35 .............................. N 16.0 16.0 0.9777 0.9777

0204 ....... M = 50–34 and C = 5–21 ................................ N 18.3 18.3 1.1640 1.1640

0205 ....... M = 66–51 ....................................................... N 22.3 22.3 1.4739 1.4739

0206 ....... M = 78–67 ....................................................... N 31.6 31.6 2.2179 2.2179

0301 ....... M = 33–0 and C = 22–35 ................................ Y 10.6 10.4 0.6399 0.7208

0302 ....... M = 33–0 and C = 5–21 .................................. Y 13.5 13.3 0.8393 0.9454

0303 ....... M = 46–34 ....................................................... Y 14.8 15.3 0.9467 1.0664

0304 ....... M = 56–47 ....................................................... Y 19.2 19.3 1.2605 1.4198

0305 ....... M = 78–57 ....................................................... Y 24.8 26.9 1.7517 1.9731

0401 ....... M = 36–0 ......................................................... Y 12.6 10.3 0.7135 0.8560

0402 ....... M = 57–37 ....................................................... Y 17.5 18.6 1.0506 1.2603

0403 ....... M = 74–58 ....................................................... Y 26.6 25.5 1.7459 2.0944

0404 ....... M = 78–75 ....................................................... Y 39.3 48.6 2.9252 3.5092

0501 ....... M = 23–0 ......................................................... Y 8.4 8.2 0.4459 0.5528

0502 ....... M = 36–24 ....................................................... Y 10.6 12.8 0.6197 0.7683

0503 ....... M = 45–37 ....................................................... Y 13.5 15.7 0.8152 1.0107

0504 ....... M = 57–46 ....................................................... Y 18.2 18.8 1.1515 1.4277

0505 ....... M = 78–58 ....................................................... Y 25.9 30.2 1.7816 2.2089

0601 ....... M = 35–0 ......................................................... Y 12.3 12.5 0.6971 0.7970

0602 ....... M = 45–36 ....................................................... Y 15.2 15.6 0.9086 1.0389

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66345

TABLE 1E.—CMG RELATIVE WEIGHTS—Continued

CMG * Definition

(M=motor, C=cognitive, A=age)

Split by

comorbidity

Average length of stay Relative weight

No

comorbidity

With

comorbidity

No

comorbidity

With

comorbidity

0603 ....... M = 53–46 ....................................................... Y 17.7 18.2 1.0833 1.2387

0604 ....... M = 78–54 ....................................................... Y 21.4 22.6 1.3375 1.5292

0701 ....... M = 36–0 ......................................................... Y 11.7 12.1 0.6525 0.7604

0702 ....... M = 45–37 ....................................................... Y 14.3 15.5 0.8337 0.9716

0703 ....... M = 51–46 ....................................................... Y 17.1 17.5 1.0129 1.1803

0704 ....... M = 78–52 ....................................................... Y 19.6 20.9 1.1794 1.3743

0801 ....... M = 32–0 ......................................................... Y 8.6 9.6 0.4822 0.5920

0802 ....... M = 41–33 ....................................................... Y 10.1 11.3 0.5984 0.7346

0803 ....... M = 48–42 ....................................................... Y 12.2 14.3 0.7464 0.9162

0804 ....... M = 78–49 and C = 34–35 .............................. Y 13.5 16.8 0.8835 1.0845

0805 ....... M = 55–50 and C = 5–33 ................................ Y 15.3 16.7 0.9540 1.1710

0806 ....... M = 78–56 and C = 5–33 ................................ Y 18.4 21.2 1.1765 1.4441

0901 ....... M = 32–0 ......................................................... Y 10.4 11.0 0.5587 0.6716

0902 ....... M = 44–33 ....................................................... Y 13.3 14.5 0.7641 0.9185

0903 ....... M = 53–45 ....................................................... Y 16.4 17.0 0.9685 1.1642

0904 ....... M = 78–54 ....................................................... Y 20.0 19.7 1.2144 1.4597

1001 ....... M = 38–0 ......................................................... Y 15.0 14.1 0.8488 0.9278

1002 ....... M = 48–39 ....................................................... Y 18.2 17.5 1.1178 1.2219

1003 ....... M = 78–49 ....................................................... Y 21.4 21.0 1.3785 1.5068

1101 ....... M = 30–0 ......................................................... Y 10.6 9.6 0.6095 0.7489

1102 ....... M = 44–31 and A >= 68 .................................. Y 13.4 13.5 0.8278 1.0171

1103 ....... M = 44–31 and A <= 67 .................................. Y 17.4 17.8 1.0894 1.3386

1104 ....... M = 78–45 ....................................................... Y 20.7 20.8 1.3232 1.6258

1201 ....... M = 42–0 and C = 34–35 ................................ Y 10.7 12.1 0.5965 0.6847

1202 ....... M = 42–0 and C = 5–33 .................................. Y 13.3 13.9 0.7181 0.8244

1203 ....... M = 54–43 ....................................................... Y 16.4 17.0 0.9181 1.0540

1204 ....... M = 78–55 ....................................................... Y 20.8 22.4 1.1492 1.3192

1301 ....... M = 30–0 ......................................................... Y 11.3 11.2 0.5927 0.6859

1302 ....... M = 42–31 ....................................................... Y 13.3 14.2 0.7116 0.8234

1303 ....... M = 78–43 ....................................................... Y 18.0 19.1 1.0450 1.2093

1401 ....... M = 37–0 ......................................................... Y 12.4 12.1 0.6511 0.7618

1402 ....... M = 50–38 ....................................................... Y 15.4 16.4 0.9006 1.0537

1403 ....... M = 78–51 ....................................................... Y 19.7 24.3 1.2689 1.4846

1501 ....... M = 40–0 and A >= 78 .................................... Y 14.0 12.7 0.7741 0.8327

1502 ....... M = 40–0 and A <= 77 .................................... Y 15.0 15.3 0.8529 0.9175

1503 ....... M = 63–41 ....................................................... Y 19.2 19.6 1.1875 1.2774

1504 ....... M = 78–64 ....................................................... Y 29.6 32.6 2.2797 2.4524

1601 ....... M = 41–0 and C = 33–35 ................................ Y 11.0 10.6 0.6151 0.7313

1602 ....... M = 41–0 and C = 5–32 .................................. Y 12.8 15.1 0.7257 0.8628

1603 ....... M = 78–42 ....................................................... Y 15.9 16.0 0.9725 1.1562

1701 ....... M = 48–0 ......................................................... Y 14.8 15.5 0.8513 1.0565

1702 ....... M = 78–49 ....................................................... Y 22.5 24.9 1.3677 1.6974

1801 ....... M = 56–0 ......................................................... N 16.7 16.7 0.9935 0.9935

1802 ....... M = 78–57 ....................................................... N 29.5 29.5 2.0563 2.0563

1901 ....... M = 36–0 ......................................................... N 11.5 11.5 0.7048 0.7048

1902 ....... M = 47–37 ....................................................... N 18.0 18.0 1.0883 1.0883

1903 ....... M = 78–48 ....................................................... N 31.4 31.4 2.0648 2.0648

2001 ....... M = 21–0 and A >= 59 .................................... Y 9.2 8.8 0.5010 0.5604

2002 ....... M = 31–22 ....................................................... Y 11.5 11.5 0.6435 0.7198

2003 ....... M = 36–32 ....................................................... Y 13.0 13.0 0.7468 0.8353

2004 ....... M = 21–0 and A <= 58 .................................... Y 13.9 11.2 0.7131 0.7977

2005 ....... M = 43–37 and A >= 65 .................................. Y 14.4 14.4 0.8549 0.9562

2006 ....... M = 52–44 and A >= 65 .................................. Y 16.5 17 1.0145 1.1348

2007 ....... M = 43–37 and A < 65 .................................... Y 16.0 15.7 0.9998 1.1183

2008 ....... M = 78–53 and A >= 84 .................................. Y 18.2 20.2 1.1359 1.2705

2009 ....... M = 59–53 and A < 84 .................................... Y 19.8 19.9 1.2481 1.3960

2010 ....... M = 52–44 and A < 65 .................................... Y 18.1 18.6 1.1570 1.2941

2011 ....... M = 78–60 and A < 84 .................................... Y 23.2 24.3 1.4898 1.6664

2101 ....... All burn cases .................................................. N 18.5 18.5 1.2863 1.2863

5001 ....... Short stay cases—LOS is 3 days or fewer ..... N 2.6 2.6 0.1908 0.1908

5101 ....... Expired orthopedic, short stay ......................... N 7.1 7.1 0.4657 0.4657

5102 ....... Expired orthopedic, not short stay .................. N 20.0 20.0 1.0777 1.0777

5103 ....... Expired not ortho, short stay ........................... N 8.4 8.4 0.5485 0.5485

5104 ....... Expired not ortho, not short stay ..................... N 25.1 25.1 1.5027 1.5027

* The first two digits of the CMG number from 01 to 21 correspond with a specific RIC number shown on Table 1D in section IV of this proposed rule.

66346 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

B. Transfer Payment Policy

1. Background

We are proposing, under § 412.624(f),

a transfer policy to provide for

payments that more accurately reflect

facility resources used and services

delivered. We believe that it is

important to minimize the inherent

incentives specifically associated with

the early transfer of patients in a

discharge-based payment system.

Without a transfer policy, we are

concerned that incentives might exist

for IRFs to discharge patients

prematurely as well as admit patients

that may not be able to endure intense

inpatient therapy services. Patients

might be transferred before receiving the

typical, full course of inpatient

rehabilitation, but the IRF would be

paid the full CMG payment rate in the

absence of a transfer policy.

Accordingly, the transfer policy that we

are proposing would reduce the full

CMG payment rate when a Medicare

beneficiary is transferred (as defined

below).

2. Statutory Background

Section 125(a)(3) of the BBRA

amended section 1886(j)(1) of the Act by

adding a new paragraph (E) that states

‘‘Construction relating to transfer

authority. ‘‘Nothing in this subsection

shall be construed as preventing the

Secretary from providing for an

adjustment to payments to take into

account the early transfer of a patient

from a rehabilitation facility to another

site of care.’’

The statute does not define ‘‘site of

care’’. ‘‘Site of care’’ could be defined as

an ‘‘institutional site’’ that includes

other rehabilitation facilities, long-term

care hospitals (as described in section

412.23(e) of the regulations), inpatient

hospitals, and nursing homes that

accept payment under Title 18 (the

Medicare program) or Title 19 (the

Medicaid program), or both. ‘‘Site of

care’’ can also be defined as a ‘‘provider

site’’ that is more encompassing and

could include home health, outpatient

rehabilitation, ‘‘day program’’ services,

as well as the ‘‘institutional sites’’ listed

above. For the purposes of our transfer

policy, we are proposing to define site

of care as an ‘‘institutional site’’,

although we are considering the option

to extend the definition of site of care

to the ‘‘provider site’’ definition.

Further, we are soliciting comments

regarding the inclusion of nursing

homes in the definition of site of care.

3. Criteria for Defining Transfer Cases

We propose that, in order for a

discharge from an IRF to be classified as

an early transfer, the length of stay for

the discharge must be less than the

average length of stay for non-transfer

cases (cases in which the patient is

discharged to the community and the

length of stay is more than 3 days) in a

given CMG (as shown in Table 1E in

this section), and the patient must be

discharged to another rehabilitation

facility, a long term care hospital, an

inpatient hospital, or a nursing home

that accepts payment under either the

Medicare program or the Medicaid

program, or both.

We believe that under a prospective

payment system, an IRF may, also, be

inclined to discharge beneficiaries

prematurely while increasing the

volume and intensity of HHA and

outpatient therapy services. We expect

that some beneficiaries may require

HHA or outpatient therapy services as a

normal progression of care after their

inpatient rehabilitation stay. However,

we are concerned that intensive use of

these therapy services could be

inappropriately used as a substitute for

several days of an intensive therapy

program in the IRF. We are analyzing

claims data to determine the extent to

which we can distinguish among

services that could be considered a

substitution of care rather than an

extension of the normal progression for

inpatient rehabilitation care and to

determine the frequency and intensity

of both HHA and outpatient therapy

services. Estimating the potential

substitution of HHA therapy services is

made more challenging because we have

just developed the HHA prospective

payment system and it is difficult to

anticipate how therapy services will be

delivered after implementation of that

system.

Accordingly, we are not proposing to

include HHA, outpatient therapy, and

‘‘day programs’’ in our transfer policy.

However, we are considering including

these services to the extent we can

distinguish when HHA and outpatient

therapy services are more intensive and

used as a substitution for inpatient

rehabilitation care. If we can determine

that the care is used as a substitution

rather than just the normal progression

of care, we believe these types of

intensive HHA and outpatient therapy

services should be included as part of

the transfer policy. Therefore, we

specifically solicit comments on this

option.

In addition, we will be developing a

monitoring system that includes

transfers or discharges from an IRF to

‘‘provider sites’’, previously referenced.

This will include transfers or discharges

from an IRF to skilled nursing facility,

long term care facilities, home health

agencies and inpatient hospitals. This

system will include discharges and

transfers from one IRF to a different IRF

including situations where the transfer

occurs between organizations of

common ownership. Although currently

it does not appear that this type of

transfer occurs frequently, further

analysis of data regarding this type of

transfer between IRFs may warrant an

adjustment to payments. Therefore, we

are specifically soliciting comments on

this monitoring system.

4. Transfer Case Payment

We believe that matching payment as

closely as possible to expected costs is

the best way to reduce opportunities for

financial considerations to affect

clinical decisions. We found a

significant correlation between the

length of a patient’s stay and the cost of

the services received. This correlation

indicates that the average length of stay

can be used as a proxy measure of a

facility’s resources needed to treat a

specific diagnosis with rehabilitation

services. Thus, a per-diem-based

payment for the number of days of care

prior to a transfer will allow us to pay

providers more appropriately for the

facility resources used and services

delivered.

We propose to compute the per-diembased payment for a transfer case as

follows: First, calculate the unadjusted

per-diem amount for each CMG (except

the short-stay CMG) by dividing the

average length of stay for non-transfer

cases (those cases discharged to the

community with a length of stay more

than 3 days) in the CMG into the

Federal prospective payment (with or

without comorbidities) for that CMG.

Next, multiply the CMG per-diem

payment from the first step by the

number of days that the beneficiary was

in the IRF prior to their transfer. The

result equals the unadjusted Federal

prospective payment for the transfer

case. See section V.D of this preamble

for specific adjustments that are

applicable to this Federal prospective

payment. We solicit comments on the

appropriateness of our proposed

methodology for computing payments

for transfer cases.

We will examine the distribution of

costs to determine if and to what extent

costs vary during the course of an

episode. If costs vary during the course

of an episode, an alternative transfer

policy could be developed to better

reflect the costs of care. The results of

this analysis will be considered as well

as the incentives inherent in an

alternative transfer payment

methodology.

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66347

C. Special Cases That Are Not Transfers

Section 1886(j)(3)(A)(v) of the Act

permits us to adjust the payment rates

by factors as the Secretary determines

are necessary to properly reflect

variations in necessary costs of

treatment among rehabilitation

facilities.

Certain cases that have stays of less

than the typical length of time and that

receive less than the full course of

rehabilitation treatment for a specific

CMG would be paid inappropriately if

the facility were to receive the full CMG

payment. Further, because of the budget

neutrality requirements, ‘‘overpayment’’

for these cases would reduce payments

for all other cases that warrant full

payment based on the rehabilitation

services actually delivered. We discuss

the special cases below in terms of the

definitions, policy rationale, and the

proposed payment methodology. The

three subsets are short-stay outliers,

cases that expire, and interrupted stays.

1. Short-Stay Outlier

We propose, under § 412.620(b)(2), to

define a short-stay outlier as a case that

has a length of stay of 3 days or fewer

(regardless of the CMG) and that does

not meet the definition of a transfer as

discussed in section V.B. of this

preamble. A short-stay may occur when

a beneficiary receives less than the full

course of rehabilitative treatment

because he or she leaves the facility

against medical advice. Another

circumstance warranting classification

as a short-stay outlier involves patients

who are admitted to rehabilitation

facilities but are unable to tolerate

intensive rehabilitative services. These

patients may be discharged home and be

readmitted once they are able to tolerate

intensive rehabilitative services (see the

interrupted stay policy in section V.C.3.

of this preamble, for further clarification

regarding length of stay criteria), or they

may be discharged and not readmitted

because they remain unable to tolerate

these services.

An incomplete assessment submitted

when the patient’s length of stay is 3

days or fewer is another example of a

short-stay case. In this situation, the

facility may not have the appropriate

information to complete the MDS–PAC

patient assessment. We believe that a

payment adjustment is necessary to

reduce incentives for facilities to

complete an assessment with

inadequate information. Further, we

believe that providing a special payment

for incomplete assessments neither

encourages facilities to submit

incomplete assessments without

obtaining the appropriate information,

nor severely penalizes providers that

occasionally may be unable, despite

good faith efforts, to complete

assessments.

Making a short-stay outlier payment

for these types of cases will allow us to

counteract the incentives inherent in a

discharge-based prospective payment

system for this pattern to emerge.

Payment-to-cost ratios for the cases

described above show that if facilities

receive a full CMG payment, they would

be ‘‘overpaid’’ for the resources they

have expended. One of the primary

objectives of the prospective payment

system is to provide incentives for

facilities to become more efficient and,

in doing so, to ensure that they can still

receive adequate and appropriate

payments. Because the rates are set to be

budget neutral minus 2 percent,

excessive payment for those cases that

do not actually entail the full course of

rehabilitative treatment would reduce

payments for cases that warrant full

payment based on the rehabilitation

services delivered. A short-stay outlier

policy would permit more equitable

payment to those facilities that manage

to increase efficiencies while still

providing the full course of

rehabilitative treatment.

We propose to pay short-stay outliers

a relative weight of 0.1908. We

computed this relative weight for shortstay outlier discharges by identifying all

cases in which the length of stay is 3

days or fewer and the discharge does

not meet the policy criteria to be

considered a transfer. The relative

weight for these cases is calculated in

the same manner discussed previously,

using the hospital-specific relative value

methodology.

However, we believe that the

considerations underlying the short-stay

policy might also apply to cases with a

length of stay greater than 3 days. More

specifically, we note that some

beneficiaries may have longer lengths of

stay, and yet may not require intensive

inpatient rehabilitative care, or may lack

the capacity to participate in an

intensive rehabilitation program.

Therefore, we are also considering a

short-stay policy that would encompass

cases with a length of stay longer than

3 days. We are in the process of further

analyzing claims data for Medicare

beneficiaries to determine the most

appropriate number of days to use in the

definition of a short-stay case. If

analysis of the data supports increasing

the number of days for the short-stay

criteria, we might adopt in the final rule

a definition covering a longer period

than the 3-day period. We specifically

solicit comments on the appropriate

time period for our short-stay criteria.

2. Cases That Expire

In general, cases that end in death

would be substantially ‘‘overpaid’’ if

facilities received the full CMG payment

for these cases; even excluding all of the

very short-stay cases with a length of

stay of 3 days or fewer, the remaining

expired cases as a whole would still be

‘‘overpaid’’. We analyzed payment-tocost ratios and found that we can

improve the accuracy of the payments if

we split expired cases into two

categories based on the RIC—one for

orthopedic cases and one for all other

types of RICs. We further find that

splitting these cases based on length of

stay also improves the accuracy of the

payment system. Therefore, we propose,

under § 412.620(b)(3), that, for expired

cases where a beneficiary dies within 3

days from admission or fewer, the case

would be classified into the short-stay

CMG. We propose that, for expired cases

with a length of stay greater than 3 days,

the case would be classified into one of

four CMGs, based on length of stay and

whether or not the discharge falls

within the orthopedic RIC. More

specifically, one group includes

orthopedic discharges with a length of

stay of more than 3 days but less than

or equal to the average length of stay for

expired cases classified within the

orthopedic RIC. The second group

includes orthopedic discharges with a

length of stay greater than the average

length of stay for expired cases

classified within the orthopedic RIC.

The third group includes nonorthopedic discharges with a length of

stay of more than 3 days but less than

or equal to the average length of stay of

expired cases that are not classified

within the orthopedic RIC. The fourth

group includes non-orthopedic

discharges with a length of stay greater

than the average length of stay of

expired cases that are not classified

within the orthopedic RIC. Relative

weights for each expired CMG are

calculated using the hospital-specific

relative value methodology discussed

previously in this preamble.

3. Interrupted Stay

We propose to define interrupted stay

cases as those involving cases in which

the beneficiary returns to the

rehabilitation facility by midnight of the

third day following a discharge. We

propose to pay one discharge payment

for these cases. The assessment from the

initial stay would be used to determine

the appropriate CMG.

D. Adjustments

Section 1886(j)(6) of the Act requires

an adjustment to the Federal

66348 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

prospective payments to account for

geographical wage variation. Section

1886(j)(3)(A)(v) of the Act confers broad

discretion on the Secretary to adjust

prospective payments ‘‘by such other

factors as the Secretary determines are

necessary to properly reflect variations

in necessary costs of treatment among

rehabilitation facilities.’’ Section

1886(j)(4) of the Act authorizes (but

does not require) the Secretary to make

specified payment adjustments

(including an adjustment for outlier

cases). In addition to the geographical

wage adjustment, we propose to adjust

payments for facilities located in rural

areas. Further, we propose to adjust

payments to reflect the percentage of

low income patients. These adjustments

and the proposed payment

methodologies are discussed below.

1. Area Wage Adjustment

Section 1886(j)(6) of the Act specifies

that payment rates under the IRF

prospective payment system must be

adjusted to account for geographic area

wage variation. The statute requires the

Secretary to adjust the labor-related

portion of the prospective payment rates

for area differences in wage levels by a

factor reflecting the relative facility

wage level in the geographic area of the

rehabilitation facility compared to the

national average wage level for these

facilities. We propose, under

§ 412.624(e)(1), to adjust the payment

rates for geographic wage variations

using the following methodology.

To account for wage differences, we

first identify the proportion of labor and

non-labor components of costs. In

general, the labor-related share is the

sum of relative importances of wages,

fringe benefits, professional fees, postal

services, labor-intensive services, and a

portion of the capital share from an

appropriate market basket. We

determine a labor-related share for

rehabilitation facilities by first

estimating the portion related to

operating costs. We use the excluded

market basket with capital to determine

the labor-related share. The excluded

market basket with capital is derived

from available cost data for facilities

including rehabilitation, long-term care,

psychiatric, cancer, and children’s

hospitals. Using the excluded hospital

market basket with capital, the laborrelated share of operating costs is 67.03

percent in fiscal year 2001. Table 2E

shows that the sum of the relative

importance for wages and salaries,

employee benefits, professional fees,

postal services and all other labor

intensive services equals 67.03 percent

for FY 2001. The labor-related share of

capital costs needs to be considered as

well. The portion of capital attributed to

labor is estimated to be 46 percent, the

same percentage used for the hospital

inpatient capital-related prospective

payment system. Because the relative

importance for capital is 9.285 percent

of the excluded hospital with capital

market basket in FY 2001, we multiply

46 percent by 9.285 percent to

determine the labor-related share for

capital costs in FY 2001, which is 4.271

percent. We add 4.271 percent for

capital costs to 67.03 percent for

operating costs to determine the total

labor-related share. Thus, the laborrelated share that we propose to use for

rehabilitation facilities in FY 2001 is

71.301 percent as shown in the Table 2E

below.

TABLE 2E.—TOTAL LABOR-RELATED

SHARE

Cost category

Relative

importance

(%) FY 2001

Wages and salaries .............. 48.895

Employee benefits ................ 10.790

Professional fees .................. 1.979

Postal services ..................... 0.245

All other labor intensive services .................................... 5.121

SUBTOTAL .................... 67.03

Labor related share of capital 4.271

TOTAL ....................... 71.301

We note that a precedent exists for

using this method to adjust for

geographic differences in costs.

Specifically, the labor-related portion

for acute care hospitals is determined

from cost report data, and is established

in conjunction with the hospital

operating market basket. We further

validated the labor-related share by

analyzing the results of the wage index

coefficient derived from the regressions.

The wage index coefficient allows us to

approximate the labor-related portion of

cost per case. The coefficient confirms

that 71.301 percent is an appropriate

labor-related share.

The labor-related portion of the

unadjusted Federal payment is

multiplied by a wage index value to

account for area wage differences. We

are proposing to use inpatient acute care

hospital wage data to compute the wage

indices. Wage data to compute IRFspecific wage indices are currently not

available. We believe that the inpatient

acute care hospital wage data reflect

wage levels similar to those of postacute care facilities, including IRFs. We

believe that IRFs and other post-acute

care facilities (such as, SNFs and HHAs)

generally compete in the same labor

market as inpatient acute care hospitals.

(Inpatient acute care hospital data is

currently being used to compute wage

indices for the SNF and HHA

prospective payment systems.)

Accordingly, we believe that inpatient

acute care hospital wage data is

appropriate to use as a basis of

computing the IRF wage index in

accordance with section 1886(j)(6) of the

Act.

The inpatient acute care hospital

wage data that we propose to use

includes the following categories of data

associated with costs paid under the

inpatient acute care hospital prospective

payment system (as well as outpatient

costs): salaries and hours from shortterm, acute care hospitals, home office

costs and hours, certain contract labor

costs and hours, and wage-related costs.

The wage data excludes the wages for

services provided by teaching

physicians, interns and residents, and

nonphysician anesthetists under

Medicare Part B, because these services

are not covered under the IRF

prospective payment system. These

wages are currently being phased out of

the hospital inpatient prospective

payment system wage index over a 5-

year period. The wage data used to

compute the FY 2000 SNF and hospital

wage indices are based on a blend of 80

percent of an average hourly wage that

includes these costs and 20 percent of

an average hourly wage that excludes

these costs. Unlike the inpatient

prospective payment system for acute

care hospitals, a transition is

unnecessary for IRF prospective

payment system because payment for

inpatient rehabilitation services has

never been based on a wage index that

includes data for these services. The

difference across geographic areas

between a wage index that uses the 80/

20 blend and a wage index that excludes

100 percent of wages for teaching

physicians, residents, and nonphysician

anesthetists is less than 2 percent on

average.

Consistent with the wage index

methodologies in other prospective

payment systems, we propose to divide

hospitals into labor market areas. For

purposes of defining labor market areas,

we are proposing to define an urban

area as a Metropolitan Statistical Area

(MSA) or New England County

Metropolitan Area (NECMA), as defined

by the Executive Office of Management

and Budget. We are proposing to define

a rural area as any area outside an urban

area. For the purposes of computing the

wage index for IRFs, the wage index

values for urban and rural areas are

determined without regard to

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66349

geographic reclassification under

section 1886(d)(8) or (d)(10) of the Act.

We are proposing to use an IRF wage

index that is based on FY 1996 inpatient

acute care hospital wage data. These

data were also used to compute the FY

2000 hospital inpatient PPS wage

indices. The FY 1997 inpatient acute

care hospital wage data was used to

develop the FY 2001 hospital wage

index, and we will consider using this

data for developing the final Federal

prospective payments.

The proposed IRF wage indices are

computed as follows:

• Compute an average hourly wage

for each urban and rural area.

• Compute a national average hourly

wage.

• Divide the average hourly wage for

each urban and rural area by the

national average hourly wage—the

result is a wage index for each urban

and rural area.

To calculate the adjusted facility

payments, the prospectively determined

Federal prospective payment is

multiplied by the labor-related

percentage (0.71301) to determine the

labor-related portion of the Federal

prospective payments. This laborrelated portion is then multiplied by the

applicable IRF wage index shown in

Table 3E for urban areas and Table 4E

for rural areas.

TABLE 3E.—WAGE INDEX URBAN

AREAS

MSA

Urban area (Constituent

counties or county

equivalents)

Wage

index

0040 .. Abilene, TX ...................... 0.8275

Taylor, TX

0060 .. Aguadilla, PR .................. 0.3859

Aguada, PR

Aguadilla, PR

Moca, PR

0080 .. Akron, OH ....................... 1.0093

Portage, OH

Summit, OH

0120 .. Albany, GA ...................... 1.6055

Dougherty, GA

Lee, GA

0160 .. Albany-SchenectadyTroy, NY.0.8751

Albany, NY

Montgomery, NY

Rensselaer, NY

Saratoga, NY

Schenectady, NY

Schoharie, NY

0200 .. Albuquerque, NM ............ 0.8366

Bernalillo, NM

Sandoval, NM

Valencia, NM

0220 .. Alexandria, LA ................. 0.7960

Rapides, LA

0240 .. Allentown-BethlehemEaston, PA.1.0226

Carbon, PA

Lehigh, PA.

TABLE 3E.—WAGE INDEX URBAN

AREAS—Continued

MSA

Urban area (Constituent

counties or county

equivalents)

Wage

index

Northampton, PA.

0280 .. Altoona, PA ..................... 0.9410

Blair, PA

0320 .. Amarillo, TX ..................... 0.8450

Potter, TX

Randall, TX

0380 .. Anchorage, AK ................ 1.3010

Anchorage, AK

0440 .. Ann Arbor, MI .................. 1.1354

Lenawee, MI

Livingston, MI

Washtenaw, MI

0450 .. Anniston,AL ..................... 0.8562

Calhoun, AL

0460 .. Appleton-OshkoshNeenah, WI.0.9018

Calumet, WI

Outagamie, WI

Winnebago, WI

0470 .. Arecibo, PR ..................... 0.4871

Arecibo, PR

Camuy, PR

Hatillo, PR

0480 .. Asheville, NC ................... 0.8969

Buncombe, NC

Madison, NC

0500 .. Athens, GA ...................... 0.9819

Clarke, GA

Madison, GA

Oconee, GA

0520 .. Atlanta, GA ...................... 1.0173

Barrow, GA

Bartow, GA

Carroll, GA

Cherokee, GA

Clayton, GA

Cobb, GA

Coweta, GA

De Kalb, GA

Douglas, GA

Fayette, GA

Forsyth, GA

Fulton, GA

Gwinnett, GA

Henry, GA

Newton, GA

Paulding, GA

Pickens, GA

Rockdale, GA

Spalding, GA

Walton, GA

0560 .. Atlantic City-Cape May ... 1.1469

Atlantic City, NJ

Cape May, NJ

0580 .. Auburn-Opelika, AL ......... 0.7718

Lee, AL

0600 .. Augusta-Aiken, GA–SC ... 0.9091

Columbia, GA

McDuffie, GA

Richmond, GA

Aiken, SC

Edgefield, SC

0640 .. Austin-San Marcos, TX ... 0.9112

Bastrop, TX

Caldwell, TX

Hays, TX

Travis, TX

Williamson, TX

0680 .. Bakersfield, CA ............... 0.9622

TABLE 3E.—WAGE INDEX URBAN

AREAS—Continued

MSA

Urban area (Constituent

counties or county

equivalents)

Wage

index

Kern, CA

0720 .. Baltimore, MD ................. 0.9614

Anne Arundel, MD

Baltimore, MD

Baltimore City, MD

Carroll, MD

Harford, MD

Howard, MD

Queen Annes, MD

0733 .. Bangor, ME ..................... 0.9696

Penobscot, ME

0743 .. Barnstable-Yarmouth, MA 1.3573

Barnstable, MA

0760 .. Baton Rouge, LA ............. 0.8782

Ascension, LA

East Baton Rouge

Livingston, LA

West Baton Rouge

0840 .. Beaumont-Port Arthur, TX 0.8715

Hardin, TX

Jefferson, TX

Orange, TX

0860 .. Bellingham, WA ............... 1.1528

Whatcom, WA

0870 .. Benton Harbor, MI ........... 0.8557

Berrien, MI

0875 .. Bergen-Passaic, NJ ........ 1.2128

Bergen, NJ

Passaic, NJ

0880 .. Billings, MT ...................... 1.0154

Yellowstone, MT

0920 .. Biloxi-GulfportPascagoula, MS.0.7960

Hancock, MS

Harrison, MS

Jackson, MS

0960 .. Binghamton, NY .............. 0.8689

Broome, NY

Tioga, NY

1000 .. Birmingham, AL ............... 0.9009

Blount, AL

Jefferson, AL

St. Clair, AL

Shelby, AL

1010 .. Bismarck, ND .................. 0.7746

Burleigh, ND

Morton, ND

1020 .. Bloomington, IN ............... 0.8694

Monroe, IN

1040 .. Bloomington-Normal, IL .. 0.9099

McLean, IL

1080 .. Boise City, ID .................. 0.9144

Ada, ID

Canyon, ID

1123 .. Boston-Worcester-Lawrence-Lowell-Brockton,

MA–NH.

1.1327

Bristol, MA

Essex, MA

Middlesex, MA

Norfolk, MA

Plymouth, MA

Suffolk, MA

Worcester, MA

Hillsborough, NH

Merrimack, NH

Rockingham, NH

Strafford, NH

1125 .. Boulder-Longmont, CO ... 1.0030

66350 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

TABLE 3E.—WAGE INDEX URBAN

AREAS—Continued

MSA

Urban area (Constituent

counties or county

equivalents)

Wage

index

Boulder, CO

1145 .. Brazoria, TX .................... 0.8616

Brazoria, TX

1150 .. Bremerton, WA ................ 1.1141

Kitsap, WA

1240 .. Brownsville-HarlingenSan Benito, TX.0.9294

Cameron, TX

1260 .. Bryan-College Station, TX 0.8601

Brazos, TX

1280 .. Buffalo-Niagara Falls, NY 0.9549

Erie, NY

Niagara, NY

1303 .. Burlington, VT ................. 1.0796

Chittenden, VT

Franklin, VT

GrandIsle, VT

1310 .. Caguas, PR ..................... 0.4596

Caguas, PR

Cayey, PR

Cidra, PR

Gurabo, PR

San Lorenzo, PR

1320 .. Canton-Massillon, OH ..... 0.8770

Carroll, OH

Stark, OH

1350 .. Casper, WY ..................... 0.9286

Natrona, WY

1360 .. Cedar Rapids, IA ............. 0.9082

Linn, IA

1400 .. Champaign-Urbana, IL .... 0.9225

Champaign, IL

1440 .. Charleston-North

Charleston, SC.

0.9073

Berkeley, SC

Charleston, SC

Dorchester, SC

1480 .. Charleston, WV ............... 0.9157

Kanawha, WV

Putnam, WV

1520 .. Charlotte-Gastonia-Rock

Hill, NC–SC.

0.9471

Cabarrus, NC

Gaston, NC

Lincoln, NC

Mecklenburg, NC

Rowan, NC

Stanly, NC

Union, NC

York, SC

1540 .. Charlottesville, VA ........... 1.0662

Albemarle, VA

Charlottesville City, VA

Fluvanna, VA

Greene, VA

1560 .. Chattanooga, TN–GA ...... 0.9824

Catoosa, GA

Dade, GA

Walker, GA

Hamilton, TN

Marion, TN

1580 .. Cheyenne, WY ................ 0.8272

Laramie, WY

1600 .. Chicago, IL ...................... 1.0889

Cook, IL

De Kalb, IL

Du Page, IL

Grundy, IL

Kane, IL

TABLE 3E.—WAGE INDEX URBAN

AREAS—Continued

MSA

Urban area (Constituent

counties or county

equivalents)

Wage

index

Kendall, IL

Lake, IL

McHenry, IL

Will, IL

1620 .. Chico-Paradise, CA ......... 1.0513

Butte, CA

1640 .. Cincinnati, OH–KY–IN ..... 0.9424

Dearborn, IN

Ohio, IN

Boone, KY

Campbell, KY

Gallatin, KY

Grant, KY

Kenton, KY

Pendleton, KY

Brown, OH

Clermont, OH

Hamilton, OH

Warren, OH

1660 .. Clarksville-Hopkinsville,

TN–KY.

0.8185

Christian, KY

Montgomery, TN

1680 .. Cleveland-Lorain-Elyria,

OH.

0.9667

Ashtabula, OH

Geauga, OH

Cuyahoga, OH

Lake, OH

Lorain, OH

Medina, OH

1720 .. Colorado Springs, CO ..... 0.9326

El Paso, CO

1740 .. Columbia MO .................. 0.9072

Boone, MO

1760 .. Columbia, SC .................. 0.9456

Lexington, SC

Richland, SC

1800 .. Columbus, GA–AL .......... 0.8529

Russell, AL

Chattanoochee, GA

Harris, GA

Muscogee, GA

1840 .. Columbus, OH ................. 0.9952

Delaware, OH

Fairfield, OH

Franklin, OH

Licking, OH

Madison, OH

Pickaway, OH

1880 .. Corpus Christi, TX ........... 0.8848

Nueces, TX

San Patricio, TX

1890 .. Corvallis, OR ................... 1.1217

Benton, OR

1900 .. Cumberland, MD–WV ..... 0.8905

Allegany MD

Mineral WV

1920 .. Dallas, TX ........................ 0.9559

Collin, TX

Dallas, TX

Denton, TX

Ellis, TX

Henderson, TX

Hunt, TX

Kaufman, TX

Rockwall, TX

1950 .. Danville, VA ..................... 0.9167

Danville City, VA

TABLE 3E.—WAGE INDEX URBAN

AREAS—Continued

MSA

Urban area (Constituent

counties or county

equivalents)

Wage

index

Pittsylvania, VA

1960 .. Davenport-Moline-Rock

Island, IA–IL.

0.8787

Scott, IA

Henry, IL

Rock Island, IL

2000 .. Dayton-Springfield, OH ... 0.9478

Clark, OH

Greene, OH

Miami, OH

Montgomery, OH

2020 .. Daytona Beach, FL ......... 0.9048

Flagler, FL

Volusia, FL

2030 .. Decatur, AL ..................... 0.8781

Lawrence, AL

Morgan, AL

2040 .. Decatur, IL ....................... 0.8380

Macon, IL

2080 .. Denver, CO ..................... 1.0202

Adams, CO

Arapahoe, CO

Denver, CO

Douglas, CO

Jefferson, CO

2120 .. Des Moines, IA ................ 0.8793

Dallas, IA

Polk, IA

Warren, IA

2160 .. Detroit, MI ........................ 1.0310

Lapeer, MI

Macomb, MI

Monroe, MI

Oakland, MI

St. Clair, MI

Wayne, MI

2180 .. Dothan, AL ...................... 0.7890

Dale, AL

Houston, AL

2190 .. Dover, DE ........................ 0.9445

Kent, DE

2200 .. Dubuque, IA .................... 0.8620

Dubuque, IA

2240 .. Duluth-Superior, MN–WI 1.0279

St. Louis, MN

Douglas, WI

2281 .. Dutchess County, NY ...... 1.0674

Dutchess, NY

2290 .. Eau Claire, WI ................. 0.9030

Chippewa, WI

Eau Claire, WI

2320 .. El Paso, TX ..................... 0.9004

El Paso, TX

2330 .. Elkhart-Goshen, IN .......... 0.9490

Elkhart, IN

2335 .. Elmira, NY ....................... 0.8634

Chemung, NY

2340 .. Enid, OK .......................... 0.8047

Garfield, OK

2360 .. Erie, PA ........................... 0.8880

Erie, PA

2400 .. Eugene-Springfield, OR .. 1.0715

Lane, OR

2440 .. Evansville-Henderson,

IN–KY.

0.8329

Posey, IN

Vanderburgh, IN

Warrick, IN

Henderson, KY

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66351

TABLE 3E.—WAGE INDEX URBAN

AREAS—Continued

MSA

Urban area (Constituent

counties or county

equivalents)

Wage

index

2520 .. Fargo-Moorhead, ND–MN 0.8721

Clay, MN

Cass, ND

2560 .. Fayetteville, NC ............... 0.8594

Cumberland, NC

2580 .. Fayetteville-SpringdaleRogers, AR.0.7768

Benton, AR

Washington, AR

2620 .. Flagstaff, AZ–UT ............. 1.0470

Coconino, AZ

Kane, UT

2640 .. Flint, MI ........................... 1.1037

Genesee, MI

2650 .. Florence, AL .................... 0.8020

Colbert, AL

Lauderdale, AL

2655 .. Florence, SC ................... 0.8668

Florence, SC

2670 .. Fort Collins-Loveland, CO 1.0335

Larimer, CO

2680 .. Ft. Lauderdale, FL ........... 1.0297

Broward, FL

2700 .. Fort Myers-Cape Cora,

FL.

0.9056

Lee, FL

2710 .. Fort Pierce-Port St. Lucie,

FL.

1.0116

Martin, FL

St. Lucie, FL

2720 .. Fort Smith, AR–OK ......... 0.7936

Crawford, AR

Sebastian, AR

Sequoyah, OK

2750 .. Fort Walton Beach, FL .... 0.8816

Okaloosa, FL

2760 .. Fort Wayne, IN ................ 0.9158

Adams, IN

Allen, IN

De Kalb, IN

Huntington, IN

Wells, IN

Whitley, IN

2800 .. Forth Worth-Arlington, TX 0.9673

Hood, TX

Johnson, TX

Parker, TX

Tarrant, TX

2840 .. Fresno, CA ...................... 1.0311

Fresno, CA

Madera, CA

2880 .. Gadsden, AL ................... 0.8791

Etowah, AL

2900 .. Gainesville, FL ................ 0.9879

Alachua, FL

2920 .. Galveston-Texas City, TX 0.9767

Galveston, TX

2960 .. Gary, IN ........................... 0.9494

Lake, IN

Porter, IN

2975 .. Glens Falls, NY ............... 0.8707

Warren, NY

Washington, NY

2980 .. Goldsboro, NC ................ 0.8432

Wayne, NC

2985 .. Grand Forks, ND–MN ..... 0.9199

Polk, MN

Grand Forks, ND

2995 .. Grand Junction, CO ........ 0.9102

TABLE 3E.—WAGE INDEX URBAN

AREAS—Continued

MSA

Urban area (Constituent

counties or county

equivalents)

Wage

index

Mesa, CO

3000 .. Grand Rapids-MuskegonHolland, MI.1.0151

Allegan, MI

Kent, MI

Muskegon, MI

Ottawa, MI

3040 .. Great Falls, MT ............... 1.0582

Cascade, MT

3060 .. Greeley, CO .................... 0.9667

Weld, CO

3080 .. Green Bay, WI ................ 0.9224

Brown, WI

3120 .. Greensboro-WinstonSalem-High Point, NC.0.9091

Alamance, NC

Davidson, NC

Davie, NC

Forsyth, NC

Guilford, NC

Randolph, NC

Stokes, NC

Yadkin, NC

3150 .. Greenville, NC ................. 0.9451

Pitt, NC

3160 .. Greenville-SpartanburgAnderson, SC.0.9264

Anderson, SC

Cherokee, SC

Greenville, SC

Pickens, SC

Spartanburg, SC

3180 .. Hagerstown, MD ............. 0.8946

Washington, MD

3200 .. Hamilton-Middletown, OH 0.9051

Butler, OH

3240 .. Harrisburg-Lebanon-Carlisle, PA.0.9749

Cumberland, PA

Dauphin, PA

Lebanon, PA

Perry, PA

3283 .. Hartford, CT .................... 1.1758

Hartford, CT

Litchfield, CT

Middlesex, CT

Tolland, CT

3285 .. Hattiesburg, MS .............. 0.7723

Forrest, MS

Lamar, MS

3290 .. Hickory-MorgantonLenoir, NC.0.9219

Alexander, NC

Burke, NC

Caldwell, NC

Catawba, NC

3320 .. Honolulu, HI .................... 1.1599

Honolulu, HI

3350 .. Houma, LA ...................... 0.7878

Lafourche, LA

Terrebonne, LA

3360 .. Houston, TX .................... 0.9405

Chambers, TX

Fort Bend, TX

Harris, TX

Liberty, TX

Montgomery, TX

Waller, TX

TABLE 3E.—WAGE INDEX URBAN

AREAS—Continued

MSA

Urban area (Constituent

counties or county

equivalents)

Wage

index

3400 .. Huntington-Ashland, WV–

KY–OH.

0.9859

Boyd, KY

Carter, KY

Greenup, KY

Lawrence, OH

Cabell, WV

Wayne, WV

3440 .. Huntsville, AL .................. 0.8926

Limestone, AL

Madison, AL

3480 .. Indianapolis, IN ............... 0.9802

Boone, IN

Hamilton, IN

Hancock, IN

Hendricks, IN

Johnson, IN

Madison, IN

Marion, IN

Morgan, IN

Shelby, IN

3500 .. Iowa City, IA .................... 0.9532

Johnson, IA

3520 .. Jackson, MI ..................... 0.8944

Jackson, MI

3560 .. Jackson, MS .................... 0.8379

Hinds, MS

Madison, MS

Rankin, MS

3580 .. Jackson, TN .................... 0.8701

Chester, TN

Madison, TN

3600 .. Jacksonville, FL ............... 0.9020

Clay, FL

Duval, FL

Nassau, FL

St. Johns, FL

3605 .. Jacksonville, NC .............. 0.7944

Onslow, NC

3610 .. Jamestown, NY ............... 0.7950

Chautaqua, NY

3620 .. Janesville-Beloit, WI ........ 0.9677

Rock, WI

3640 .. Jersey City, NJ ................ 1.1742

Hudson, NJ

3660 .. Johnson City-KingsportBristol, TN–VA.0.8949

Carter, TN

Hawkins, TN

Sullivan, TN

Unicoi, TN

Washington, TN

Bristol City, VA

Scott ,VA

Washington, VA

3680 .. Johnstown, PA ................ 0.8589

Cambria, PA

Somerset, PA

3700 .. Jonesboro, AR ................ 0.7316

Craighead, AR

3710 .. Joplin, MO ....................... 0.7766

Jasper, MO

Newton, MO

3720 .. Kalamazoo-Battlecreek,

MI.

1.0098

Calhoun, MI

Kalamazoo, MI

Van Buren, MI

3740 .. Kankakee, IL ................... 0.8699

66352 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

TABLE 3E.—WAGE INDEX URBAN

AREAS—Continued

MSA

Urban area (Constituent

counties or county

equivalents)

Wage

index

Kankakee, IL

3760 .. Kansas City, KS–MO ...... 0.9281

Johnson, KS

Leavenworth, KS

Miami, KS

Wyandotte, KS

Cass, MO

Clay, MO

Clinton, MO

Jackson, MO

Lafayette, MO

Platte, MO

Ray, MO

3800 .. Kenosha, WI .................... 0.9139

Kenosha, WI

3810 .. Killeen-Temple, TX .......... 1.0078

Bell, TX

Coryell, TX

3840 .. Knoxville, TN ................... 0.9238

Anderson, TN

Blount, TN

Knox, TN

Loudon, TN

Sevier, TN

Union, TN

3850 .. Kokomo, IN ..................... 0.9023

Howard, IN

Tipton, IN

3870 .. La Crosse, WI–MN .......... 0.9020

Houston, MN

La Crosse, WI

3880 .. Lafayette, LA ................... 0.8437

Acadia, LA

Lafayette, LA

St. Landry, LA

St. Martin, LA

3920 .. Lafayette, IN .................... 0.8913

Clinton, IN

Tippecanoe, IN

3960 .. Lake Charles, LA ............ 0.8056

Calcasieu, LA

3980 .. Lakeland-WinterHaven,

FL.

0.8919

Polk, FL

4000 .. Lancaster, PA .................. 0.9325

Lancaster, PA

4040 .. Lansing-East Lansing, MI 1.0075

Clinton, MI

Eaton, MI

Ingham, MI

4080 .. Laredo, TX ...................... 0.8421

Webb, TX

4100 .. Las Cruces, NM .............. 0.8606

DonaAna, NM

4120 .. Las Vegas, NV–AZ ......... 1.1285

Mohave, AZ

Clark, NV

Nye, NV

4150 .. Lawrence, KS .................. 0.8319

Douglas, KS

4200 .. Lawton, OK ..................... 0.9645

Comanche, OK

4243 .. Lewiston-Auburn, ME ...... 0.8962

Androscoggin ME

4280 .. Lexington, KY .................. 0.8568

Bourbon, KY

Clark, KY

Fayette, KY

Jessamine, KY

TABLE 3E.—WAGE INDEX URBAN

AREAS—Continued

MSA

Urban area (Constituent

counties or county

equivalents)

Wage

index

Madison, KY

Scott, KY

Woodford, KY

4320 .. Lima, OH ......................... 0.9010

Allen, OH

Auglaize, OH

4360 .. Lincoln, NE ...................... 0.9723

Lancaster NE

4400 .. Little Rock-North Little,

AR.

0.8708

Faulkner, AR

Lonoke, AR

Pulaski, AR

Saline, AR

4420 .. Longview-Marshall, TX .... 0.8841

Gregg, TX

Harrison, TX

Upshur, TX

4480 .. Los Angeles-Long Beach,

CA.

1.2103

Los Angeles, CA

4520 .. Louisville, KY–IN ............. 0.9415

Clark, IN

Floyd, IN

Harrison, IN

Scott, IN

Bullitt, KY

Jefferson, KY

Oldham, KY

4600 .. Lubbock, TX .................... 0.8512

Lubbock, TX

4640 .. Lynchburg, VA ................. 0.8908

Amherst, VA

Bedford City, VA

Bedford, VA

Campbell, VA

Lynchburg City, VA

4680 .. Macon, GA ...................... 0.8501

Bibb, GA

Houston, GA

Jones, GA

Peach, GA

Twiggs, GA

4720 .. Madison, WI .................... 0.9869

Dane, WI

4800 .. Mansfield, OH ................. 0.8575

Crawford, OH

Richland, OH

4840 .. Mayaguez, PR ................. 0.4729

Anasco, PR

CaboRojo, PR

Hormigueros, PR

Mayaguez, PR

Sabana Grande, PR

San German, PR.

4880 .. McAllen-Edinburg-Mission, TX.0.8208

Hidalgo, TX

4890 .. Medford-Ashland, OR ..... 1.0607

Jackson, OR

4900 .. Melbourne-Titusville-Palm

Bay, FL.

0.9405

Brevard, FL

4920 .. Memphis, TN–AR–MS .... 0.8321

Crittenden, AR

De Soto, MS

Fayette, TN

Shelby, TN

Tipton, TN

TABLE 3E.—WAGE INDEX URBAN

AREAS—Continued

MSA

Urban area (Constituent

counties or county

equivalents)

Wage

index

4940 .. Merced, CA ..................... 1.0313

Merced, CA

5000 .. Miami, FL ........................ 1.0368

Dade, FL

5015 .. Middlesex-SomersetHunterdon, NJ.1.1128

Hunterdon, NJ

Middlesex, NJ

Somerset, NJ

5080 .. Milwaukee-Waukesha, WI 0.9848

Milwaukee, WI

Ozaukee, WI

Washington, WI

Waukesha, WI

5120 .. Minneapolis-St. Paul,

MN–WI.

1.0979

Anoka, MN

Carver, MN

Chisago, MN

Dakota, MN

Hennepin, MN

Isanti, MN

Ramsey, MN

Scott, MN

Sherburne, MN

Washington, MN

Wright, MN

Pierce, WI

St. Croix, WI

5140 .. Missoula, MT ................... 0.9192

Missoula, MT

5160 .. Mobile, AL ....................... 0.8171

Baldwin, AL

Mobile, AL

5170 .. Modesto, CA ................... 1.0233

Stanislaus, CA

5190 .. Monmouth-Ocean, NJ ..... 1.1332

Monmouth, NJ

Ocean, NJ

5200 .. Monroe, LA ...................... 0.8315

Ouachita, LA

5240 .. Montgomery, AL .............. 0.7794

Autauga, AL

Elmore, AL

Montgomery, AL

5280 .. Muncie, IN ....................... 1.0533

Delaware, IN

5330 .. Myrtle Beach, SC ............ 0.8612

Horry, SC

5345 .. Naples, FL ....................... 0.9955

Collier, FL

5360 .. Nashville, TN ................... 0.9368

Cheatham, TN

Davidson, TN

Dickson, TN

Robertson, TN

Rutherford, TN

Sumner, TN

Williamson, TN

Wilson, TN

5380 .. Nassau-Suffolk, NY ......... 1.4087

Nassau, NY

Suffolk, NY

5483 .. New Haven-BridgeportStamford-WaterburyDanbury, CT.1.2260

Fairfield, CT

New Haven, CT

5523 .. New London-Norwich, CT 1.2572

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66353

TABLE 3E.—WAGE INDEX URBAN

AREAS—Continued

MSA

Urban area (Constituent

counties or county

equivalents)

Wage

index

New London, CT

5560 .. New Orleans, LA ............. 0.9140

Jefferson, LA

Orleans, LA

Plaquemines, LA

St. Bernard, LA

St. Charles, LA

St. James, LA

St. John The Baptist, LA

St. Tammany, LA

5600 .. New York, NY ................. 1.4338

Bronx, NY

Kings, NY

New York, NY

Putnam, NY

Queens, NY

Richmond, NY

Rockland, NY

Westchester, NY

5640 .. Newark, NJ ...................... 1.1729

Essex, NJ

Morris, NJ

Sussex, NJ

Union, NJ

Warren, NJ

5660 .. Newburgh, NY–PA .......... 1.1035

Orange, NY

Pike, PA

5720 .. Norfolk-Virginia BeachNewport News, VA–NC.0.8483

Currituck, NC

Chesapeake City, VA

Gloucester, VA

Hampton City, VA

Isle of Wight, VA

James City, VA

Mathews, VA

Newport News City, VA

Norfolk City, VA

Poquoson City, VA

Portsmouth City, VA

Suffolk City, VA

Virginia Beach City, VA

Williamsburg City, VA

York, VA

5775 .. Oakland, CA .................... 1.5277

Alameda, CA

Contra Costa, CA

5790 .. Ocala, FL ......................... 0.9728

Marion, FL

5800 .. Odessa-Midland, TX ....... 0.8951

Ector, TX

Midland, TX

5880 .. Oklahoma City, OK ......... 0.8551

Canadian, OK

Cleveland, OK

Logan, OK

McClain, OK

Oklahoma, OK

Pottawatomie, OK

5910 .. Olympia, WA ................... 1.1023

Thurston, WA

5920 .. Omaha, NE–IA ................ 1.0405

Pottawattamie, IA

Cass, NE

Douglas, NE

Sarpy, NE

Washington, NE

5945 .. Orange County, CA ......... 1.1720

TABLE 3E.—WAGE INDEX URBAN

AREAS—Continued

MSA

Urban area (Constituent

counties or county

equivalents)

Wage

index

Orange, CA

5960 .. Orlando, FL ..................... 0.9845

Lake, FL

Orange, FL

Osceola, FL

Seminole, FL

5990 .. Owensboro, KY ............... 0.8199

Daviess, KY

6015 .. Panama City, FL ............. 0.9277

Bay, FL

6020 .. Parkersburg-Marietta,

WV–OH.

0.8503

Washington, OH

Wood, WV

6080 .. Pensacola, FL ................. 0.8529

Escambia, FL

Santa Rosa, FL

6120 .. Peoria-Pekin, IL ............... 0.8201

Peoria, IL

Tazewell, IL

Woodford, IL

6160 .. Philadelphia, PA–NJ ....... 1.1076

Burlington, NJ

Camden, NJ

Gloucester, NJ

Salem, NJ

Bucks, PA

Chester, PA

Delaware, PA

Montgomery, PA

Philadelphia, PA

6200 .. Phoenix-Mesa, AZ ........... 0.9420

Maricopa, AZ

Pinal, AZ

6240 .. Pine Bluff, AR .................. 0.7777

Jefferson, AR

6280 .. Pittsburgh, PA ................. 0.9478

Allegheny, PA

Beaver, PA

Butler, PA

Fayette, PA

Washington, PA

Westmoreland, PA

6323 .. Pittsfield, MA ................... 1.0173

Berkshire, MA

6340 .. Pocatello, ID .................... 0.9063

Bannock, ID

6360 .. Ponce, PR ....................... 0.4970

Guayanilla, PR

Juana Diaz, PR

Penuelas, PR

Ponce, PR

Villalba, PR

Yauco, PR

6403 .. Portland, ME ................... 0.9499

Cumberland, ME

Sagadahoc, ME

York, ME

6440 .. Portland-Vancouver, OR–

WA.

1.1087

Clackamas, OR

Columbia, OR

Multnomah, OR

Washington, OR

Yamhill, OR

Clark, WA

6483 .. Providence-WarwickPawtucket, RI.1.0766

Bristol, RI

TABLE 3E.—WAGE INDEX URBAN

AREAS—Continued

MSA

Urban area (Constituent

counties or county

equivalents)

Wage

index

Kent, RI

Newport, RI

Providence, RI

Washington, RI

6520 .. Provo-Orem, UT .............. 0.9916

Utah, UT

6560 .. Pueblo, CO ...................... 0.8922

Pueblo, CO

6580 .. Punta Gorda, FL ............. 0.9620

Charlotte, FL

6600 .. Racine, WI ....................... 0.9325

Racine, WI

6640 .. Raleigh-Durham-Chapel

Hill, NC.

0.9683

Chatham, NC

Durham, NC

Franklin, NC

Johnston, NC

Orange, NC

Wake, NC

6660 .. Rapid City, SD ................ 0.8415

Pennington, SD

6680 .. Reading, PA .................... 0.9496

Berks, PA

6690 .. Redding, CA .................... 1.1376

Shasta, CA

6720 .. Reno, NV ......................... 1.0781

Washoe, NV

6740 .. Richland-KennewickPasco, WA.1.1356

Benton, WA

Franklin, WA

6760 .. Richmond-Petersburg, VA 0.9569

Charles City County, VA

Chesterfield, VA

Colonial Heights City, VA

Dinwiddie, VA

Goochland, VA

Hanover, VA

Henrico, VA

Hopewell City, VA

New Kent, VA

Petersburg City, VA

Powhatan, VA

Prince George, VA

Richmond City, VA

6780 .. Riverside-San

Bernardino, CA

1.1256

Riverside, CA

San Bernardino, CA

6800 .. Roanoke, VA ................... 0.7971

Botetourt, VA

Roanoke, VA

Roanoke City, VA

Salem City, VA

6820 .. Rochester, MN ................ 1.1619

Olmsted, MN

6840 .. Rochester, NY ................. 0.9066

Genesee, NY

Livingston, NY

Monroe, NY

Ontario, NY

Orleans, NY

Wayne, NY

6880 .. Rockford, IL ..................... 0.8885

Boone, IL

Ogle, IL

Winnebago, IL

6895 .. Rocky Mount, NC ............ 0.8837

66354 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

TABLE 3E.—WAGE INDEX URBAN

AREAS—Continued

MSA

Urban area (Constituent

counties or county

equivalents)

Wage

index

Edgecombe, NC

Nash, NC

6920 .. Sacramento, CA .............. 1.2473

El Dorado, CA

Placer, CA

Sacramento, CA

6960 .. Saginaw-Bay City-Midland, MI.0.9365

Bay, MI

Midland, MI

Saginaw, MI

6980 .. St. Cloud, MN .................. 0.9525

Benton, MN

Stearns, MN

7000 .. St. Joseph, MO ............... 0.9048

Andrews, MO

Buchanan, MO

7040 .. St. Louis, MO–IL ............. 0.8943

Clinton, IL

Jersey, IL

Madison, IL

Monroe, IL

St. Clair, IL

Franklin, MO

Jefferson, MO

Lincoln, MO

St. Charles, MO

St. Louis, MO

St. Louis City, MO

Warren, MO

Sullivan City, MO

7080 .. Salem, OR ....................... 1.0065

Marion, OR

Polk, OR

7120 .. Salinas, CA ..................... 1.4900

Monterey, CA

7160 .. Salt Lake City-Ogden, UT 0.9919

Davis, UT

Salt Lake, UT

Weber, UT

7200 .. San Angelo, TX ............... 0.7938

Tom Green, TX

7240 .. San Antonio, TX .............. 0.8429

Bexar, TX

Comal, TX

Guadalupe, TX

Wilson, TX

7320 .. San Diego, CA ................ 1.2100

San Diego, CA

7360 .. San Francisco, CA .......... 1.4287

Marin, CA

San Francisco, CA

San Mateo, CA

7400 .. San Jose, CA .................. 1.3848

Santa Clara, CA

7440 .. San Juan-Bayamon, PR 0.4698

Aguas Buenas, PR

Barceloneta, PR

Bayamon, PR

Canovanas, PR

Carolina, PR

Catano, PR

Ceiba, PR

Comerio, PR

Corozal, PR

Dorado, PR

Fajardo, PR

Florida, PR

Guaynabo, PR

TABLE 3E.—WAGE INDEX URBAN

AREAS—Continued

MSA

Urban area (Constituent

counties or county

equivalents)

Wage

index

Humacao, PR

Juncos, PR

Los Piedras, PR

Loiza, PR

Luguillo, PR

Manati, PR

Morovis, PR

Naguabo, PR

Naranjito, PR

Rio Grande, PR

San Juan, PR

Toa Alta, PR

Toa Baja, PR

Trujillo Alto, PR

Vega Alta, PR

Vega Baja, PR

Yabucoa, PR

7460 .. San Luis ObispoAtascaderoPasoRobles, CA.1.0593

San Luis Obispo, CA

7480 .. Santa Barbara-Santa

Maria-Lompoc, CA.

1.0939

Santa Barbara, CA

7485 .. Santa Cruz-Watsonville,

CA.

1.4091

Santa Cruz, CA

7490 .. Santa Fe, NM .................. 1.0511

Los Alamos, NM

Santa Fe, NM

7500 .. Santa Rosa, CA .............. 1.3172

Sonoma, CA

7510 .. Sarasota-Bradenton, FL .. 1.0022

Manatee, FL

Sarasota, FL

7520 .. Savannah, GA ................. 0.9995

Bryan, GA

Chatham, GA

Effingham, GA

7560 .. Scranton-Wilkes-BarreHazleton, PA.0.8442

Columbia, PA

Lackawanna, PA

Luzerne, PA

Wyoming, PA

7600 .. Seattle-Bellevue-Everett,

WA.

1.1376

Island, WA

King, WA

Snohomish, WA

7610 .. Sharon, PA ...................... 0.8374

Mercer, PA

7620 .. Sheboygan, WI ................ 0.8299

Sheboygan, WI

7640 .. Sherman-Denison, TX ..... 0.9439

Grayson, TX

7680 .. Shreveport-Bossier City,

LA.

0.9126

Bossier, LA

Caddo, LA

Webster, LA

7720 .. Sioux City, IA–NE ........... 0.8552

Woodbury, IA

Dakota, NE

7760 .. Sioux Falls, SD ............... 0.8813

Lincoln, SD

Minnehaha, SD

7800 .. South Bend, IN ................ 0.9732

St. Joseph, IN

TABLE 3E.—WAGE INDEX URBAN

AREAS—Continued

MSA

Urban area (Constituent

counties or county

equivalents)

Wage

index

7840 .. Spokane, WA .................. 1.0898

Spokane, WA

7880 .. Springfield, IL .................. 0.8710

Menard, IL

Sangamon, IL

7920 .. Springfield, MO ............... 0.8062

Christian, MO

Greene, MO

Webster, MO

8003 .. Springfield, MA ................ 1.0488

Hampden, MA

Hampshire, MA

8050 .. State College, PA ............ 0.9212

Centre, PA

8080 .. Steubenville-Weirton,

OH–WV.

0.8716

Jefferson, OH

Brooke, WV

Hancock, WV

8120 .. Stockton-Lodi, CA ........... 1.0571

San Joaquin, CA

8140 .. Sumter, SC ...................... 0.8335

Sumter, SC

8160 .. Syracuse, NY .................. 0.9310

Cayuga, NY

Madison, NY

Onondaga, NY

Oswego, NY

8200 .. Tacoma, WA ................... 1.1583

Pierce, WA

8240 .. Tallahassee, FL ............... 0.8529

Gadsden, FL

Leon, FL

8280 .. Tampa-St. PetersburgClearwater, FL.0.9136

Hernando, FL

Hillsborough, FL

Pasco, FL

Pinellas, FL

8320 .. Terre Haute, IN ............... 0.8614

Clay, IN

Vermillion, IN

Vigo, IN

8360 .. Texarkana, AR–TX .......... 0.8101

Miller, AR

Bowie, TX

8400 .. Toledo, OH ...................... 0.9764

Fulton, OH

Lucas, OH

Wood, OH

8440 .. Topeka, KS ..................... 0.9440

Shawnee, KS

8480 .. Trenton, NJ ..................... 1.0180

Mercer, NJ

8520 .. Tucson, AZ ...................... 0.8846

Pima, AZ

8560 .. Tulsa, OK ........................ 0.8181

Creek, OK

Osage, OK

Rogers, OK

Tulsa, OK

Wagoner, OK

8600 .. Tuscaloosa, AL ............... 0.8104

Tuscaloosa, AL

8640 .. Tyler, TX .......................... 0.9499

Smith, TX

8680 .. Utica-Rome, NY .............. 0.8370

Herkimer, NY

Oneida, NY

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66355

TABLE 3E.—WAGE INDEX URBAN

AREAS—Continued

MSA

Urban area (Constituent

counties or county

equivalents)

Wage

index

8720 .. Vallejo-Fairfield-Napa, CA 1.3503

Napa, CA

Solano, CA

8735 .. Ventura, CA ..................... 1.1603

Ventura, CA

8750 .. Victoria, TX ...................... 0.8476

Victoria, TX

8760 .. Vineland-Millville-Bridgeton, NJ.1.0640

Cumberland, NJ

8780 .. Visalia-Tulare-Porterville,

CA.

1.0533

Tulare, CA

8800 .. Waco, TX 0.8099

McLennan, TX

8840 .. Washington, DC–MD–

VA–WV.

1.1088

District of Columbia, DC

Calvert, MD

Charles, MD

Frederick, MD

Montgomery, MD

Prince Georges, MD

Alexandria City, VA

Arlington, VA

Clarke, VA

Culpepper, VA

Fairfax, VA

Fairfax City, VA

Falls Church City, VA

Fauquier, VA

Fredericksburg City, VA

King George, VA

Loudoun, VA

Manassas City, VA

Manassas Park City, VA

Prince William, VA

Spotsylvania, VA

Stafford, VA

Warren, VA

Berkeley, WV

Jefferson, WV

8920 .. Waterloo-Cedar Falls, IA 0.8597

BlackHawk, IA

8940 .. Wausau, WI ..................... 0.9556

Marathon, WI

8960 .. West Palm Beach-Boca,

FL

1.0130

Palm Beach, FL

9000 .. Wheeling, OH–WV .......... 0.7662

Belmont, OH

Marshall, WV

Ohio, WV

9040 .. Wichita, KS ...................... 0.9559

Butler, KS

Harvey, KS

Sedgwick, KS

9080 .. Wichita Falls, TX ............. 0.7743

Archer, TX

Wichita, TX

9140 .. Williamsport, PA .............. 0.8472

Lycoming, PA

9160 .. Wilmington-Newark, DE–

MD.

1.1000

New Castle, DE

Cecil, MD

9200 .. Wilmington, NC ............... 0.9818

New Hanover, NC

Brunswick, NC

TABLE 3E.—WAGE INDEX URBAN

AREAS—Continued

MSA

Urban area (Constituent

counties or county

equivalents)

Wage

index

9260 .. Yakima, WA .................... 1.0331

Yakima, WA

9270 .. Yolo, CA .......................... 0.9833

Yolo, CA

9280 .. York, PA 0.9255

York, PA

9320 .. Youngstown-Warren, OH 1.0025

Columbiana, OH

Mahoning, OH

Trumbull, OH

9340 .. Yuba City, CA ................. 1.0787

Sutter, CA

Yuba, CA

9360 .. Yuma, AZ ........................ 1.0040

Yuma, AZ

TABLE 4E.—WAGE INDEX FOR RURAL

AREAS

Nonurban area Wage

Index

Alabama .......................................... 0.7467

Alaska ............................................. 1.2175

Arizona ............................................ 0.8625

Arkansas ......................................... 0.7317

California ......................................... 1.0066

Colorado ......................................... 0.8915

Connecticut ..................................... 1.2559

Delaware ......................................... 0.9240

Florida ............................................. 0.9089

Georgia ........................................... 0.8176

Guam ..............................................

Hawaii ............................................. 1.0853

Idaho ............................................... 0.8707

Illinois .............................................. 0.8122

Indiana ............................................ 0.8493

Iowa ................................................ 0.7976

Kansas ............................................ 0.7513

Kentucky ......................................... 0.8127

Louisiana ........................................ 0.7456

Maine .............................................. 0.8679

Maryland ......................................... 0.8730

Massachusetts ................................ 1.1499

Michigan ......................................... 0.8896

Minnesota ....................................... 0.8743

Mississippi ...................................... 0.7374

Missouri .......................................... 0.7802

Montana .......................................... 0.8479

Nebraska ........................................ 0.8024

Nevada ........................................... 0.9197

New Hampshire .............................. 0.9827

New Jersey 1 ...................................

New Mexico .................................... 0.8472

New York ........................................ 0.8604

North Carolina ................................ 0.8378

North Dakota .................................. 0.7662

Ohio ................................................ 0.8746

Oklahoma ....................................... 0.7332

Oregon ............................................ 0.9966

Pennsylvania .................................. 0.8559

Puerto Rico ..................................... 0.4299

Rhode Island 1 ................................

South Carolina ................................ 0.8353

South Dakota .................................. 0.7625

Tennessee ...................................... 0.7738

Texas .............................................. 0.7545

Utah ................................................ 0.8998

TABLE 4E.—WAGE INDEX FOR RURAL

AREAS—Continued

Nonurban area Wage

Index

Vermont .......................................... 0.9518

Virginia ............................................ 0.7991

Virgin Islands ..................................

Washington ..................................... 1.0548

West Virginia .................................. 0.8116

Wisconsin ....................................... 0.8838

Wyoming ......................................... 0.8955

1All counties within the State are classified

urban.

The resulting wage-adjusted laborrelated portion is added to the nonlabor

related portion, resulting in a wageadjusted payment. The following

example illustrates how a Medicare

fiscal intermediary would calculate the

Adjusted Facility Federal prospective

payment for inpatient rehabilitation

facility services with a hypothetical

Federal prospective payment of $10,000

for services provided in the

rehabilitation facility located in

Heartland, USA. The rehabilitation

wage index value for facilities located in

Heartland, USA is 1.0234. The laborrelated portion (71.301 percent) of the

Federal prospective payment is

$7130.10=($10,000*71.301 percent), and

the nonlabor related portion (28.699

percent) of the Federal prospective

payment is $2869.90=($10,000*28.699

percent). Therefore, the wage-adjusted

payment calculation, rounded to the

nearest dollar is as follows:

$10,167=($7130.10*1.0234) + $2,869.90

2. General Specifications to Determine

Other Adjustments

As indicated earlier, section

1886(j)(3)(A)(v) of the Act confers broad

authority on the Secretary to adjust

prospective payments ‘‘by such other

factors as the Secretary determines are

necessary to properly reflect variations

in necessary costs of treatment among

rehabilitation facilities’’. To determine

whether other payment adjustments are

warranted for the IRF prospective

payment system, we conducted

extensive regression analysis of the

relationship between IRF costs

(including both operating and capital

costs per case) and several factors that

may affect costs. The appropriateness of

potential payment adjustments are

based on both cost effects estimated by

regression analysis and other factors,

including simulated payments that we

discuss in section VIII.B.2. of this

preamble.

Our analyses included 624 facilities

for which cost and case-mix data were

available. We estimated costs for each

case by multiplying facility specific,

66356 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

cost-center specific cost-to-charge ratios

by charges. Cost-to-charge ratios were

obtained from FYs 1995, 1996, and/or

1997 cost report data and charges were

obtained from the calendar years 1996

and 1997 Medicare claims data. The

cost per case is calculated by summing

all costs and dividing by the number of

equivalent full cases. When we had cost

per case data for both years, the number

of cases and total costs are combined for

both years. We accounted for the

difference in the year by adjusting the

1996 cost per case by the case-weighted

average change in cost per case between

1996 and 1997. Using the data from both

years should provide more stability in

the payment adjustments than would

using data for a single year. When data

for only one year are available, we use

the costs and number of equivalent

cases for that year.

Multivariate regression analysis is a

standard way to examine facility cost

variation and analyze potential payment

adjustments. We looked at two standard

models: (1) Fully specified explanatory

models to examine the impact of all

relevant factors that might potentially

affect facility cost per case; and (2)

payment models that examine the

impacts of those factors specifically

used to determine payment rates. The

general specification for the multivariate regression is that the estimated

average cost per case (the dependent

variable) at the facility can be explained

or predicted by several independent

variables, including the case-mix index,

the wage index for the facility, and a

vector of additional explanatory

variables that affect a facility’s cost per

case, such as its teaching program or the

proportion of low-income patients. The

case-mix index is the average of the

CMG weights derived by the hospitalspecific relative value method for each

facility. Transfer cases are given a

partial weight based on the ratio of the

length of stay for the transfer to the

average length of stay for nontransfer

cases. Using the regression coefficients,

we then simulated payments and

calculated payment-to-cost ratios for

different classes of hospitals, for specific

combinations of payment policies.

We use payment variables from the

hospital inpatient prospective payment

system, including disproportionate

share patient percentage, both capital

and operating teaching variables

(resident-to-average daily census and

resident-to-bed ratios, respectively) as

well as the teaching variable (residentto-adjusted average daily census ratio)

used in the analyses for the hospital

outpatient prospective payment system,

and variables to account for location in

a rural or large urban area. A discussion

of the major payment variables and our

findings appears below.

3. Adjustments for Rural Location

We examined costs per case for both

large urban and rural facilities. In the

regression models, both explanatory and

payment, the variable for rural facilities

was positive and significant (p<0.05).

The standardized cost per case for rural

hospitals is 15 percent higher than the

national average. On average, rural

facilities tend to have fewer cases, a

longer length of stay, and a higher

average cost per case. The difference in

costs becomes more evident when the

average cost per case is standardized for

the case-mix index and the wage index.

In the regression models, large urban

facilities were not significantly different

from other urban facilities. We propose,

under § 412.624(e)(3), to adjust for rural

facilities by multiplying the payment by

1.1589. This adjustment was determined

by using the coefficients derived from

the regressions.

4. Adjustments for Indirect Teaching

Costs

Facilities with major teaching

programs tend to be located in large

urban areas and have more cases, a

higher case-mix and a higher proportion

of low-income patients. We found that

when only the payment variables that

might warrant an adjustment (that is,

DSH or rural/urban status, rather than

for-profit/not for profit) under the

prospective payment system are used in

the regression models, the indirect

teaching cost variable is not significant.

We looked at different specifications for

the teaching variable. We used a

resident-to-average daily census ratio

and a resident-to-bed ratio that we based

on the estimated number of residents

assigned to the inpatient area of the

rehabilitation facility. We also used a

resident-to-adjusted average daily

census ratio based on the total number

of residents at the hospital complex and

outpatient as well as inpatient volume.

We also looked for a teaching threshold.

In all our payment regressions, the

teaching variable was not significant.

Therefore, we are not proposing an

adjustment for indirect teaching costs.

5. Adjustments for Disproportionate

Share of Low-Income Patients

We assessed the appropriateness of

adjustments for facilities serving a

disproportionate share of low income

patients. We limited our analysis to the

effects of serving low-income patients

on costs per case, rather than a subsidy

for uncompensated care.

We evaluated a facility-level

adjustment that takes into account both

the percentage of Medicare patients who

are on Supplemental Security Income

and the percentage of Medicaid patients

who are not entitled to Medicare. As a

facility’s percentage of low income

patients increases, there is an

incremental increase in the facility’s

cost. This suggests that additional

payments are appropriate. We propose

to use the same measure of

disproportionate patient percentage

currently used for the acute care

hospital inpatient prospective payment

system. Payments for each facility

would be adjusted to reflect the

facility’s disproportionate share

percentage.

Section 4403(b) of the BBA requires

HCFA to develop a Report to the

Congress containing a formula for

determining additional payment

amounts to hospitals under section

1886(d)(5)(F) of the Act. In determining

the formula, the Secretary must:

• Establish a single threshold for

costs incurred by hospitals serving lowincome patients.

• Consider the costs incurred in

furnishing hospital services to

individuals who are entitled to benefits

under Part A of Medicare and who

receive Supplemental Security Income

benefits under Title XVI.

• Consider the costs incurred in

furnishing hospital services to

individuals who receive medical

assistance under the State plan under

the Medicare program and are not

entitled to benefits under Part A of

Medicare.

Further, MedPAC recommends

including the costs of uncompensated

care in calculating low-income shares

and using the same formula to distribute

payments to all facilities covered by

prospective payments. In light of

HCFA’s current study of a new payment

formula for determining adjustments for

hospitals serving low income patients

and MedPAC’s recommendations, we

will consider these study results and

other information as it becomes

available and potentially refine the DSH

adjustment in the future so that we

ensure that facilities are paid in the

most consistent and equitable manner

possible. At this time, we propose,

under § 412.624(e)(2), to adjust each

rehabilitation facility payment by the

following formula to account for the

cost of furnishing care to low income

patients: ((.0001+DSH) raised to the

power of .0905)/(.0001 raised to the

power of .0905));

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66357

Where DSH = Medicare SSI Days

care Days

 + Medicaid, Non-Medicare Days

Total Medi Total Days

6. Adjustments for Alaska and Hawaii

Section 1886(j)(4)(B) provides that the

Secretary is authorized but not required

to take into account the unique

circumstances of IRFs located in Alaska

and Hawaii. There are currently three

IRFs in Hawaii and one in Alaska.

However, we have cost and case-mix

data for only one of the facilities in

Hawaii (982 cases) and the facility in

Alaska (117 cases). In the absence of a

cost-of-living adjustment, our

simulations indicate that the facility in

Hawaii may profit and the facility in

Alaska may experience a loss. Due to

the small number of cases, analyses of

the simulation results are inconclusive

regarding whether a cost-of-living

adjustment would improve payment

equity for these facilities. Therefore, we

are not proposing an adjustment for

rehabilitation facilities located in Alaska

and Hawaii.

7. Adjustments for Cost Outliers

Section 1886(j)(4) of the Act specifies

that the Secretary is authorized, but not

required, to provide for additional

payments for outlier cases. Further,

section 1886(j)(4)(A)(iii) of the Act

specifies that the total amount of the

additional payments cannot be

projected to exceed 5 percent of the total

payments in a given year. Providing

additional payments for costs that are

beyond facilities’ control can strongly

improve the accuracy of the IRF

prospective payment system in

determining resource costs at the patient

and facility level. In general, outlier

payments reduce the financial risk

which would otherwise be substantial

because of the relatively small size of

many rehabilitation facilities. These

additional payments reduce the

financial losses caused by treating

patients who require more costly care

and, therefore, will reduce the

incentives to under serve these patients.

We considered various outlier policy

options. Specifically, we examined

outlier policies using 3, 4, and 5 percent

of the total estimated payments. In order

to determine the most appropriate

outlier policy, we analyzed the extent to

which the various options reduce

financial risk, reduce incentives to

underserve costly beneficiaries, and

improve the overall fairness of the

system. We believe an outlier policy of

3 percent will allow us to achieve a

balance of the above stated goals.

Additional increments of outlier

payments reduce risk by successively

smaller amounts. Further, additional

amounts of outlier payments are funded

by prospectively reducing the nonoutlier payment rates in a budget

neutral manner. Therefore, we propose

an outlier policy of 3 percent of total

estimated payments because we believe

this option optimizes the extent to

which we can protect vulnerable

facilities, while still providing adequate

payment for all other cases.

We propose, under § 412.624(e)(4), to

make outlier payments for discharges

whose estimated cost exceeds an

adjusted threshold amount ($7,066

multiplied by the facility’s adjustments)

plus the adjusted CMG payment. Both

the loss threshold and the CMG

payment amount are adjusted for wages,

rural location, and disproportionate

share. The estimated cost of a case will

be calculated by multiplying an overall

facility-specific cost-to-charge ratio by

the charge. Based on analysis of

payment-to-cost ratios for outlier cases,

and consistent with the marginal cost

factor used under section 1886(d) of the

Act, we propose to pay outlier cases 80

percent of the difference between the

estimated cost of the case and the

outlier threshold (the sum of the CMG

payment and the loss amount of $7,066,

as adjusted). The outlier threshold was

calculated by simulating aggregate

payments with and without an outlier

policy, and applying an iterative process

to determine a threshold that would

result in outlier payments being equal to

3 percent of total payments under the

simulation.

E. Calculation of the Budget Neutral

Conversion Factor Minus Two Percent

1. Overview of Development of the

Budget Neutral Conversion Factor

Section 1886(j)(3)(B) of the Act and

proposed § 412.624(d) of the regulations

specify that, for prospective payment

units during FYs 2001 and 2002, the

amount of total payments, including any

payment adjustments under sections

1886(j)(4) and (6) of the Act, shall be

projected to equal 98 percent of the

amount of payments that would have

been made during these fiscal years for

operating and capital costs of

rehabilitation facilities had section

1886(j) not been enacted.

We propose, under § 412.624(c)(1), to

calculate the budget neutral conversion

factor using the following steps:

Step 1—Update the latest cost report

data to the midpoint of the year 2001.

Step 2—Estimate total payments

under the current payment system.

Step 3—Calculate the average

weighted payment per discharge

amount under the current payment

system.

Step 4—Estimate new payments

under the proposed payment system

without a budget neutral adjustment.

Step 5—Determine the budget neutral

conversion factor.

2. Steps for Developing the Budget

Neutral Conversion Minus 2 Percent

• Data Sources

The data sources that we propose

under § 412.624(a)(1) to construct the

budget neutral adjustment factor

include the cost report data from FYs

1995, 1996, and 1997, a list obtained

from the fiscal intermediaries of facilityspecific target amounts applicable for

providers that applied to rebase their

target amount in fiscal year 1998, and

calendar year 1996 and 1997 Medicare

claims with corresponding UDSmr or

COS data. We used data from 508

facilities to calculate the budget neutral

conversion factor. These facilities

represent those providers for which we

had cost report data available from FYs

1995, 1996, and 1997. We used the 3

years cost report data to trend the data

to the midpoint of the year 2001 based

on the facilities’ historical relationship

of costs and target amounts. The FY

1995 cost report data was used to

determine the update to be used for FY

1999, the FY 1996 cost report data was

used to determine the update to be used

for FY 2000, and the FY 1997 cost report

data was used to determine the update

to be used for FY 2001. We were unable

to calculate payment under the current

payment system for some inpatient

rehabilitation facilities because cost

report data were unavailable. We will

attempt to obtain the most recent

payment amounts for these facilities

through their Medicare fiscal

intermediary and we will consider using

this data to construct the payment rates

for the final rule. We will also examine

the extent to which certain facilities,

such as new facilities, are not included

in the construction of the budget neutral

conversion factor and consider the

appropriateness of an adjustment to

better reflect total estimated payments

for IRFs.

Step 1—Update the latest cost report

data to the midpoint of the year 2001.

Section 1886(j)(3)(A)(i) of the Act and

proposed § 412.624(b) of the regulations

66358 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

specify that the per-payment-unit

amount is to be updated to the midpoint

of the fiscal year 2000, using the

weighted average of the applicable

percentage increases provided under

Section 1886(b)(3)(B)(ii) of the Act. The

statute allows us more discretion in

determining an appropriate

methodology to update from the year

2000 to 2001. We propose, under

§ 412.624(c)(2), to update from the

midpoint of the year 2000 to the

midpoint of the year 2001 using the

same methodology provided under

Section 1886(b)(3)(B)(ii). We determine

the appropriate update factor for each

facility by using one of the four

methodologies described below:

• For facilities with costs that equal

or exceed their target amounts by 10

percent or more for the most recent cost

reporting period for which information

is available, the update factor is the

market basket percentage increase; or

• For facilities that exceed their target

by less than 10 percent, the update

factor would be equal to the market

basket minus .25 percentage points for

each percentage point by which

operating costs are less than 10 percent

over the target (but in no case less than

0); or

• For facilities that are at or below

their target but exceed two-thirds of the

target amount, the update factor is the

market basket minus 2.5 percentage

points (but in no case less than 0); or

• For facilities that do not exceed

two-thirds of their target amount, the

update factor is 0 percent.

Step 2—Estimate total payments

under the current payment system.

Operating payments are calculated

using the following methodology:

Step 2a—We determine the facilityspecific target amount, subject to the

applicable cap on the target amounts for

rehabilitation facilities. There are two

national caps on the target amounts for

rehabilitation facilities. We used the cap

amounts published in the July 30, 1999

Federal Register. For older facilities

certified before October 1, 1997, the

applicable cap amount for FY 2000 is

$14,654 for the labor-related share

adjusted by the appropriate geographic

wage index and added to $4,169 for the

nonlabor-related share. For newer

facilities certified on or after October 1,

1997, the cap amount applicable for FY

2000 is $12,574 for the labor-related

share adjusted by the appropriate

geographic wage index and added to

$4,999 for the nonlabor-related share.

These target amounts are then inflated

to the midpoint of the year 2001 by

applying the excluded hospital

operating market basket.

Step 2b—We calculate the lower of

the results of step 2a.

• The facility-specific target amount

(including application of the cap) times

the Medicare discharges (the ceiling) or;

• The facility average operating cost

per case times Medicare discharges.

Payment for operating costs are

determined by using one of the

following methods:

• For facilities whose operating costs

are lower than or equal to the ceiling,

payment would be the lower of either

the operating cost plus 15 percent of the

difference between the operating cost

and the ceiling or the operating costs

plus 2 percent of the ceiling; or

• For facilities whose operating costs

are more than 110 percent of the ceiling,

payment would be the lower of either

the ceiling multiplied by 1.10 or half of

the difference between the 110 percent

of the ceiling and the operating costs.

• For facilities whose operating costs

are greater than the ceiling but less than

110 percent of the ceiling, payment

would be the ceiling.

Step 2c—After operating payments

are computed, we determine capital

payments. Section 4412 of the BBA

amended section 1886(g) of the Act by

reducing capital payments that would

otherwise be made for rehabilitation

facilities. Payments for capital costs are

made on a reasonable cost basis. The

BBA mandated the reduction of capital

payments by 15 percent. Therefore, we

reduce capital payments for inpatient

rehabilitation facilities or units by

multiplying the costs by .85.

Step 2d—The next step in

determining total payments under the

current payment system is to add

operating and capital payments. Section

1886(j)(1)(A) of the Act specifies that the

IRF prospective payment system will

include both operating and capital costs.

Once appropriate payments for

operating costs are determined

(including bonus and penalty payments

as appropriate), and after reductions are

made for capital payments, we would

add the operating costs and the reduced

capital costs together.

Step 2e—The statute provides for the

Secretary to adjust the rates so that the

amount of total payments under this

section are projected to equal 98 percent

of the payments that would have been

paid under this section in the absence

of this new payment methodology.

Payments made for cost reporting

periods beginning on or after the

implementation of this prospective

payment system through FY 2002 are

based on both the facility-specific

payment and the Federal prospective

payment that we propose in this

regulation. Therefore under proposed

§ 412.624(d)(2), we reduce total

estimated payments calculated under

the current payment system to ensure

that the 98 percent budget neutrality

provision is applicable to all payments.

In addition, total estimated payments

are adjusted to reflect the estimated

proportion of additional outlier

payments, under proposed

§ 412.624(d)(1) and for coding and

classification changes under proposed

§ 412.624(d)(3). These payments are the

proposed numerator of the equation

used to calculate the budget neutral

adjustment.

Step 3—Calculate the average

weighted payment per discharge

amount under the current payment

system. Once total payments are

calculated under the current payment

system, an average per discharge

payment amount weighted by the

number of Medicare discharges under

the current payment system can be

calculated. This is done by first

determining the average payment per

discharge amount under the current

payment system for each facility. Cost

report data are used to calculate each

facility’s average payment per discharge

by dividing the number of discharges

into the total payments. The next step

is to determine the weighted average per

discharge payment amount. To calculate

this amount, we multiply the number of

discharges from the Medicare bills (with

corresponding UDSmr/COS data) by

each facility’s average payment per

discharge amount. We then sum the

amounts for all facilities and divide by

the total number of discharges from the

Medicare bills (with corresponding

UDSmr/COS data) to derive an average

payment per discharge amount that is

weighted by the number of Medicare

discharges.

Step 4—Estimate payments under the

proposed payment system without a

budget neutral adjustment. Payments

under the proposed payment system are

then simulated without a budget neutral

adjustment. To do this, we multiply the

following: each facility’s case-mix

index, the number of discharges from

the Medicare bills (with corresponding

UDSmr/COS data), the appropriate wage

index, the rural adjustment (if

applicable), an appropriate

disproportionate share adjustment, and

the weighted average per discharge

payment amount computed in Step 3.

Total payments for each facility are then

added together. This total is the

denominator in the calculation of the

budget neutral adjustment.

Step 5—Determine the budget neutral

conversion factor. The denominator of

the budget neutral adjustment equation

is the total estimated payments for the

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66359

proposed prospective payment system

without a budget neutral adjustment

(the total amount calculated in Step 4).

The budget neutral adjustment is

calculated by dividing total reduced

payments under the current payment

system (the total amount calculated in

Step 2) by estimated payments for the

proposed prospective payment system.

The resulting budget neutral adjustment

is then multiplied by the average

weighted per discharge payment

amount under the current payment

system to derive the budget neutral

conversion factor.

Because we do not have UDSmr and

COS data for all rehabilitation facilities,

for the final rule we will further analyze

the extent to which the data used to

construct the budget neutral conversion

factor accurately reflect the relationship

between case-mix and cost. We are

considering the use of weighted

averages to more fully account for those

types of facilities that may be underrepresented with the given data.

Once the budget neutral conversion

factor is calculated, the factor is further

adjusted to include a behavioral offset.

As previously stated, to calculate the

budget neutral conversion factor, we

had to estimate what would have been

paid under the current payment system.

However, due to the incentives for

premature discharge inherent in the

new payment system, we expect that

differences in the utilization of these

services might result. In the case of the

proposed payment system, discharges to

other settings of care may take place

earlier than under the current payment

system. This would result in lower

payments under the current payment

system for this care, which must be

taken into account when computing

budget neutral payment rates.

Accounting for this effect through an

adjustment is commonly known as a

behavioral offset. The budget neutral

conversion factor with a behavioral

offset is $6,024. This represents a .64

percent (that is, sixty four hundredths of

one percent) reduction in the budget

neutral conversion factor otherwise

calculated under the methodology

described in the preceding pages. In

determining this adjustment, we

assumed that the IRFs would regain 15

percent of potential losses and augment

payment increases by 5 percent through

transfers occurring at or beyond the

mean length of stay associated with

CMG or home health care at any point.

F. Development of the Federal

Prospective Payment

Once the relative weights for each

CMG and the budget neutral conversion

factor are calculated, the Federal

prospective payments can be

determined. Under proposed

§ 412.624(c)(4), these CMG payments are

calculated by multiplying the budget

neutral conversion factor by each of the

CMG relative weights. The equation is

as follows:

Federal Prospective Payment = CMG

Relative Weight * Budget Neutral

Conversion Factor

Table 5E displays the CMGs and the

corresponding Federal prospective

payments.

TABLE 5E.—FEDERAL PROSPECTIVE

PAYMENTS

CMG Without

comorbidities

With

comorbidities

0101 ............... $3,649.34 $3,983.67

0102 ............... 4,274.03 4,666.19

0103 ............... 5,183.65 5,658.95

0104 ............... 5,156.54 5,628.83

0105 ............... 5,795.09 6,325.80

0106 ............... 6,592.67 7,196.87

0107 ............... 7,608.31 8,305.29

0108 ............... 8,653.48 9,446.84

0109 ............... 9,631.77 10,514.89

0110 ............... 10,009.48 10,926.93

0111 ............... 11,822.70 12,906.42

0201 ............... 3,315.61 3,315.61

0202 ............... 5,014.98 5,014.98

0203 ............... 5,889.66 5,889.66

0204 ............... 7,011.94 7,011.94

0205 ............... 8,878.77 8,878.77

0206 ............... 13,360.63 13,360.63

0301 ............... 3,854.76 4,342.10

0302 ............... 5,055.94 5,695.09

0303 ............... 5,702.92 6,423.99

0304 ............... 7,593.25 8,552.88

0305 ............... 10,552.24 11,885.95

0401 ............... 4,298.12 5,156.54

0402 ............... 6,328.81 7,592.05

0403 ............... 10,517.30 12,616.67

0404 ............... 17,621.40 21,139.42

0501 ............... 2,686.10 3,330.07

0502 ............... 3,733.07 4,628.24

0503 ............... 4,910.76 6,088.46

0504 ............... 6,936.64 8,600.46

0505 ............... 10,732.36 13,306.41

0601 ............... 4,199.33 4,801.13

0602 ............... 5,473.41 6,258.33

0603 ............... 6,525.80 7,461.93

0604 ............... 8,057.10 9,211.90

0701 ............... 3,930.66 4,580.65

0702 ............... 5,022.21 5,852.92

0703 ............... 6,101.71 7,110.13

0704 ............... 7,104.71 8,278.78

0801 ............... 2,904.77 3,566.21

0802 ............... 3,604.76 4,425.23

0803 ............... 4,496.31 5,519.19

0804 ............... 5,322.20 6,533.03

0805 ............... 5,746.90 7,054.10

0806 ............... 7,087.24 8,699.26

0901 ............... 3,365.61 4,045.72

0902 ............... 4,602.94 5,533.04

0903 ............... 5,834.24 7,013.14

0904 ............... 7,315.55 8,793.23

1001 ............... 5,113.17 5,589.07

1002 ............... 6,733.63 7,360.73

1003 ............... 8,304.08 9,076.96

1101 ............... 3,671.63 4,511.37

1102 ............... 4,986.67 6,127.01

TABLE 5E.—FEDERAL PROSPECTIVE

PAYMENTS—Continued

CMG Without

comorbidities

With

comorbidities

1103 ............... 6,562.55 8,063.73

1104 ............... 7,970.96 9,793.82

1201 ............... 3,593.32 4,124.63

1202 ............... 4,325.83 4,966.19

1203 ............... 5,530.63 6,349.30

1204 ............... 6,922.78 7,946.86

1301 ............... 3,570.42 4,131.86

1302 ............... 4,286.68 4,960.16

1303 ............... 6,295.08 7,284.82

1401 ............... 3,922.23 4,589.08

1402 ............... 5,425.21 6,347.49

1403 ............... 7,643.85 8,943.23

1501 ............... 4,663.18 5,016.18

1502 ............... 5,137.87 5,527.02

1503 ............... 7,153.50 7,695.06

1504 ............... 13,732.91 14,773.26

1601 ............... 3,705.36 4,405.35

1602 ............... 4,371.62 5,197.51

1603 ............... 5,858.34 6,964.95

1701 ............... 5,128.23 6,364.36

1702 ............... 8,239.02 10,225.14

1801 ............... 5,984.84 5,984.84

1802 ............... 12,387.15 12,387.15

1901 ............... 4,245.72 4,245.72

1902 ............... 6,555.92 6,555.92

1903 ............... 12,438.36 12,438.36

2001 ............... 3,018.02 3,375.85

2002 ............... 3,876.44 4,336.08

2003 ............... 4,498.72 5,031.85

2004 ............... 4,295.71 4,805.34

2005 ............... 5,149.92 5,760.15

2006 ............... 6,111.35 6,836.04

2007 ............... 6,022.80 6,736.64

2008 ............... 6,842.66 7,653.49

2009 ............... 7,518.55 8,409.50

2010 ............... 6,969.77 7,795.66

2011 ............... 8,974.56 10,038.39

2101 ............... 7,748.67 7,748.67

5001 ............... 1,149.38 1,149.38

5101 ............... 2,805.38 2,805.38

5102 ............... 6,492.06 6,492.06

5103 ............... 3,304.16 3,304.16

5104 ............... 9,052.26 9,052.26

G. Examples of Computing the Adjusted

Facility Prospective Payments

The Federal prospective payments,

described above, will be adjusted to

account for geographic wage variation,

disproportionate share and, if

applicable, facilities located in rural

areas.

To illustrate the methodology that we

propose to use for adjusting the Federal

prospective payments, we provide the

following example. One beneficiary is in

rehabilitation facility A and another

beneficiary is in rehabilitation facility B.

Rehabilitation facility A has a

disproportionate share adjustment of

1.0648, a wage index of 0.987, and is

located in a rural area. Rehabilitation

facility B has a disproportionate share

amount of 1.1337, a wage index of

1.234, and is located in an urban area.

Both Medicare beneficiaries are

classified to CMG 0111 (without

66360 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

comorbidity). This CMG represents a

stroke with motor scores in the 78–61

range and the patient is 83 years old or

younger. To calculate the facility’s total

adjusted Federal prospective payment,

we compute the wage adjusted Federal

prospective payment and multiply the

result by: the appropriate

disproportionate share adjustment, and

the rural adjustment (if applicable).

Table 6E illustrates the components of

the adjusted payment calculation.

TABLE 6E.—EXAMPLES OF COMPUTING A FACILITY’S FEDERAL PROSPECTIVE PAYMENT

Facility A

Federal Prospective Payment (From Table 5E) .............................................................................. $11,822.70 $11,822.70

Labor Share (From Table 2E) ......................................................................................................... × .71301 × .71301

Labor Portion of Federal Payment .................................................................................................. = $8,429.70 = $8,429.70

Wage Index (From Tables 3E or 4E) .............................................................................................. × 0.987 × 1.234

Wage Adjusted Amount ................................................................................................................... $8,320.12 $10,402.25

Non-Labor Amount ........................................................................................................................... + $3,393.00 + $3,393.00

Wage Adjusted Federal Payment .................................................................................................... = $11,713.11 = $13,795.25

Rural Adjustment ............................................................................................................................. × 1.1589 × 1.0000

Subtotal ..................................................................................................................................... = $13,574.33 = $13,795.25

DSH Adjustment .............................................................................................................................. × 1.0648 × 1.1337

Total Adjusted Federal Prospective Payment .......................................................................... $14,453.94 $15,639.68

Thus, the adjusted payment for

facility A will be $14,453.64 and the

adjusted payment for facility B will be

$15,639.68.

H. Computing Total Payments

As described in proposed § 412.626,

for cost reporting periods beginning on

or after April 1, 2001 and before October

1, 2001, payments will be based on 662⁄3

percent of the facility specific payment

and 331⁄3 percent of the IRF adjusted

facility Federal prospective payment.

The facility specific payment is the

amount the facility would have been

paid if the prospective payment system

had not been implemented. Medicare

fiscal intermediaries will continue to

compute the facility specific payment

amount according to § 412.22(b) of the

regulations and sections 1886(d) and (g)

of the Act.

I. Method of Payment

A beneficiary will be classified into a

CMG based on data obtained during the

initial MDS–PAC assessment. The CMG

will determine the Federal prospective

payment the IRF will receive for the

Medicare-covered Part-A services the

IRF furnished during the Medicare

beneficiary’s episode of care. However,

we are proposing, under § 412.632(a),

that the payment be based on the

submission of a discharge bill. This will

allow us to account for the occurrence

of an event during the stay which would

result in a reclassification to one of the

five special CMGs (for cases that expire

or have a very short length of stay) or

an adjustment to the payment to reflect

an early transfer and determine if the

case qualifies for an outlier payment.

Accordingly, the CMG and other

information to determine if an

adjustment to the payment is necessary

will be recorded by the IRF on the

beneficiary’s discharge bill and

submitted to its Medicare fiscal

intermediary for processing. The

payment made represents payment in

full, under proposed § 412.622(b), for

inpatient operating and capital costs,

but not for the costs of an approved

medical education program, bad debts,

or other costs not paid for under the

proposed IRF prospective payment

system.

Under the current payment system,

(1) An IRF may be paid using the

periodic interim payment (PIP) method

described in § 413.64(h) of the

regulations, (2) rehabilitation units are

paid under the PIP method if the

hospital of which they are a part is paid

under § 412.116(b), and (3) IRFs may be

eligible to receive accelerated payments

as described in § 413.64(g) or for

rehabilitation units under § 412.116(f).

We presently see no reason to

discontinue administratively our

existing policy of allowing the PIP and

accelerated payment methods under the

prospective payment system for

qualified IRFs, though we may choose to

evaluate its continuing need in the

future. Therefore, we are proposing to

permit the continued availability of PIP

and accelerated payments for services of

IRFs paid under the prospective

payment system at proposed paragraphs

(b) and (e) of § 412.632 of the

regulations.

For those services paid under the PIP

method, the amount is based on

estimated prospective payments for the

year rather than on estimated cost

reimbursement. An IRF receiving

prospective payments, whether or not it

received a PIP prior to receiving

prospective payments, may receive a

PIP if it meets the requirements in

§ 412.632 and receives approval by its

intermediary. Likewise, if an

intermediary determines that an IRF

which received a PIP prior to receiving

prospective payments is no longer

entitled to receive a PIP, it will remove

the IRF from the PIP method. As

provided in § 412.632, intermediary

approval of a PIP is conditioned upon

the intermediary’s best judgment as to

whether payment can be made under

the PIP method without undue risk of

its resulting in an overpayment to the

provider.

Excluded from the PIP amount are

outlier payments that are paid in final

upon the submission of a discharge bill.

In addition, Part A costs that are not

paid for under the IRF prospective

payment system, including Medicare

bad debts and costs of an approved

educational program, will be subject to

the interim payment provisions of the

regulations at § 413.64.

Under the prospective payment

system, if an IRF is not paid under the

PIP method it may qualify to receive an

accelerated payment. Under § 412.632,

the IRF must be experiencing financial

difficulties due to a delay by the

intermediary in making payment to the

IRF or there is a temporary delay in the

IRF’s preparation and submittal of bills

to the intermediary beyond its normal

billing cycle because of an exceptional

situation. A request for an accelerated

payment must be made by the IRF and

approved by the intermediary and

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HCFA. The amount of an accelerated

payment is computed as a percentage of

the net payment for unbilled or unpaid

covered services. Recoupment of an

accelerated payment is made as bills are

processed or by direct payment by the

IRF.

J. Update to the Adjusted Facility

Federal Prospective Payment

Under section 1886(j)(3)(C) of the Act

and under proposed § 412.624(c)(3)(ii)

of the regulations, future updates to the

adjusted facility Federal prospective

payments (budget neutral conversion

factor) will include the use of an

increase factor based on an appropriate

percentage increase in a market basket

of goods and services comprising

services for which payment is made

under the proposed IRF prospective

payment system. This increase factor

may be the market basket percentage

increase described in section

1886(b)(3)(B)(iii) of the Act. A

description of IRF market basket that we

propose to use in developing an

increase factor under section

1886(j)(3)(C) is found in Appendix D of

this proposed rule.

VI. Provisions of the Proposed Rule

We are proposing to make a number

of revisions to the regulations in order

to implement the prospective payment

system for inpatient rehabilitation

facilities. We are proposing to make

conforming changes in 42 CFR parts 412

and 413. We are proposing to establish

a new subpart P in part 412,

‘‘Prospective Payment for Inpatient

Rehabilitation Facilities’’. This subpart

would implement section 1886(j) of the

Act, which provides for the

implementation of a prospective

payment system for inpatient

rehabilitation facilities. This subpart

would set forth the framework for the

inpatient rehabilitation facility

prospective payment system, including

the methodology used for the

development of the payment rates and

related rules. These revisions and others

are discussed in detail below.

Section 412.1 Scope of Part

We are proposing to revise § 412.1 by

redesignating paragraph (a) as paragraph

(a)(1) and adding a paragraph (a)(2) that

specifies that this part implements

section 1886(j) of the Act by establishing

a prospective payment system for the

inpatient operating and capital costs of

inpatient hospital services provided to

Medicare beneficiaries by a

rehabilitation hospital or rehabilitation

unit for cost reporting periods beginning

on or after April 1, 2001. As a result of

our proposed changes to § 412.1, we

would make a number of conforming

changes to various sections of the

regulations text. These changes include

adding references to the inpatient

hospital prospective payment systems

as described in § 412.1(a)(1).

Currently, § 412.1(b) ‘‘Summary of

content’’ describes the content of each

subpart in part 412. To make this

paragraph more user friendly, we would

restructure the paragraph by dividing it

into 12 subparagraphs. In addition, we

would add references to

§ 412.1(a)(1)(where appropriate) and

add a new subparagraph (b)(12) that

summarizes the content of the new

subpart P.

Section 412.20 Hospital Services to the

Prospective Payment Systems

We propose to revise § 412.20 by

revising paragraph (a) to add a reference

to inpatient hospital prospective

payment system, redesignating

paragraph (b) as paragraph (c), and

adding a new paragraph (b). Section

412.20(b) would specify that effective

for all cost reporting periods beginning

on or after April 1, 2001, the services

furnished by an inpatient rehabilitation

hospital or rehabilitation unit specified

in § 412.604 are paid for under the

prospective payment system described

in subpart P. We would also add a

reference to § 412.1(a)(1) to the

introductory text of § 412.20(c).

Section 412.22 Excluded Hospitals

and Hospital Units: General Rules

We propose to revise §§ 412.22(a), (b),

(e), and (h)(2) to add references to

§ 412.1(a)(1) or § 412.20 (b).

Section 412.23 Retroactive

Adjustments for Incorrectly Excluded

Hospital Units

We propose to revise the introductory

text of §§ 412.23 and 412.23(b)(2) to add

references to § 412.1(a)(1) and (a)(2). We

propose to revise the introductory text

of paragraph (b) to add references to

§ 412.1(a)(1) and (a)(2). We proposed to

revise paragraphs (b)(8) and (b)(9) to

specify that in order to be classified as

a rehabilitation hospital a patient

assessment instrument must be

completed in accordance with § 412.606

for each Medicare patient admitted or

discharged on or after April 1, 2001.

Section 412.25 Excluded Hospital

Units: Common Requirements

We propose to revise §§ 412.25(a) and

(e)(2) to add references to § 412.1(a)(1).

Section 412.29 Excluded

Rehabilitation Units: Additional

Requirements

We propose to revise the introductory

text of § 412.29 to add a reference to

§ 412.1(a)(1) and (a)(2).

Section 412.116 Method of Payments

We propose to restructure and revise

paragraph (a) by creating paragraphs

(a)(1) and (a)(2). New paragraph (a)(2)

would be revised to specify that

payments for inpatient hospital services

furnished by an excluded psychiatric or

rehabilitation unit (not paid under the

provisions of subpart P of this part) are

made as described in § 413.64(a), (c), (d)

and (e) of this chapter. We also propose

to add a new paragraph (a)(3) that

specifies how payments for inpatient

hospital services are made to a qualified

IRF.

Section 412.130 Retroactive

Adjustments for Incorrectly Excluded

Hospital Units

We would revise paragraphs (a)(1)

and (a)(2) to add references to

§§ 412.1(a)(1) and (a)(2). In addition,

§ 412.130 (a)(1) and (a)(2) would be

revised to specify that for cost reporting

periods on or after October 1, 1991,

rehabilitation hospitals and units that

were excluded from the prospective

payment systems specified in

§ 412.1(a)(1) or paid under the inpatient

rehabilitation prospective payment

system, as a new rehabilitation hospital

or unit will have its payments adjusted

if the inpatient population actually

treated in the hospital during the cost

reporting period did not meet the

requirements of § 412.23(b)(2). In

§ 412.130(b), we would add the

provisions that specify that the

intermediary adjusts the payment to the

hospitals described in paragraph (a) of

this section for cost reporting periods

beginning on or after April 1, 2001 as

follows:

• The intermediary calculates the

difference between the amounts actually

paid under subpart P of this part during

the cost reporting period for which the

hospital, unit, or beds were first

classified as a new hospital, new unit,

or newly added beds under subpart B of

this part, and the amount that would

have been paid under the prospective

payment systems described in

§ 412.1(a)(1) for services furnished

during that period.

• The intermediary makes a

retroactive adjustment for the difference

between the amount paid to the hospital

under subpart P of this part and the

amount that would have been paid

under the prospective payment systems

described in § 412.1(a)(1).

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Subpart P Prospective Payment for

Inpatient Rehabilitation Hospitals and

Rehabilitation Units

We propose to reserve subparts N and

O, and add a new subpart P.

Section 412.600 Basis and Scope of

the Subpart

We are proposing to add a new

§ 412.600. Section 412.600(a) provides

for the implementation of a prospective

payment system for inpatient

rehabilitation facilities. In § 412.600(b),

we would specify that this subpart sets

forth the framework for the prospective

payment system, including the

methodology used for the development

of payment rates and associated

adjustments, the application of a

transition phase, and related rules for

inpatient rehabilitation facilities for cost

reporting periods beginning on or after

April 1, 2001.

Section 412.602 Definitions

In § 412.602, we are proposing the

following definitions for purposes of

this new subpart:

• Assessment reference date;

• Authorized clinician;

• Discharge;

• Encode;

• Functional-related groups;

• Interrupted stay;

• MDS–PAC;

• Outlier payment;

• Rural area

• Transfer; and

• Urban area.

Section 412.604 Conditions for

Payment Under the Prospective

Payment System for Inpatient

Rehabilitation Facilities

In proposed § 412.604(a), we would

specify that IRFs must meet the

following general requirements to

receive payment under the IRF

prospective payment system:

• The IRF must meet the conditions

of this section;

• If the IRF fails to comply with the

provisions of the section then we can—

• Withhold (in full or in part) or

reduce payment to the IRF; or

• Classify the IRF as an inpatient

hospital subject to the inpatient hospital

prospective payment system.

In proposed paragraph (b), we would

specify that an IRF must meet the

rehabilitation hospital or rehabilitation

unit classification criteria set forth in

§§ 412.22, 412.23(b) and 412.30 for

exclusion from the inpatient hospital

prospective payment system. In

addition, we propose to specify that

qualifying IRFs are subject to the

payment provisions for the IRF

prospective payment system.

Proposed paragraph (c) would specify

that the IRF must complete a patient

assessment instrument for each

Medicare patient admitted or discharged

on or after April 1, 2001.

Proposed paragraph (d) would specify

the prohibited and permitted charges

that can be imposed on Medicare

beneficiaries. In proposed paragraph

(d)(1), we would specify that an IRF

may not charge a beneficiary for any

services for which payment is made by

Medicare, even if the IRF’s costs are

greater than the amount the facility is

paid under the IRF prospective payment

system. In addition, proposed paragraph

(d)(2) would specify that an IRF

receiving payment for a covered stay

may charge the Medicare beneficiary or

other person for only the applicable

deductible and coinsurance amounts

under §§ 409.82, 409.83, and 409.87.

Proposed paragraph (e) would specify

the following provisions for furnishing

IRF services directly or under

arrangements:

• Applicable payments made under

the IRF prospective payment system are

in full for all inpatient hospital services

(as defined in § 409.10) other than

physicians’ services to individual

patients (as specified in § 415.102(a))

which are reimbursable on a reasonable

cost basis.

• Payment is not made to a provider

or supplier other than the IRF, except

for physicians’ services reimbursable

under § 405.550(b) and the services of

an anesthetist employed by a physician

reimbursable under § 415.102(a).

• The IRF must furnish all necessary

covered services to the Medicare

beneficiary directly or under

arrangements (as defined in § 409.3).

Lastly, proposed paragraph (f) would

specify that IRFs must meet the

recordkeeping and cost reporting

requirements of §§ 413.20 and 413.24.

Section 412.606 Patient Assessments

In proposed § 412.606, we set forth

the requirements regarding patient

assessment. Proposed § 412.606(a)

would specify that at the time each

Medicare patient is admitted the facility

must have physician orders for the

patient’s care during his or her

hospitalization. Proposed § 412.606(b)

would specify that MDS–PAC is the

instrument used to assess Medicare

inpatients who are admitted on or after

April 1, 2001, or were admitted before

April 1, 2001, and are still inpatients as

of April 1, 2001. In proposed

§ 412.606(c), we would specify that an

inpatient rehabilitation facility’s

authorized clinician must perform a

comprehensive, accurate, standardized,

and reproducible assessment of each

Medicare inpatient using the MDS–PAC.

This assessment must be in accordance

with the assessment schedule. A

clinician must record appropriate and

applicable data accurately and

completely for each MDS–PAC item.

The assessment process must include

direct patient observation and

communication with the patient; and

when appropriate and to the extent

feasible, patient data from the patient’s

physician(s), family, friends, the

patient’s clinical record and other

sources. The authorized clinician must

sign the MDS–PAC attesting to its

completion and accuracy.

Section 412.608 Patients’ Rights

Regarding MDS–PAC Data Collection

Proposed § 412.608 specifies patient

rights regarding MDS–PAC data

collection. In proposed paragraph (a) we

would specify the rights that a Medicare

inpatient must be informed of by the

IRF authorized clinician before an

assessment can be performed. Proposed

paragraph (b) would require the

authorized clinician to document in the

Medicare inpatient’s clinical record that

the patient was informed of the rights

listed in paragraph (a). Proposed

paragraph (c) specifies that the patient

rights included in this section are in

addition to the patient rights specified

under the conditions of participation for

hospitals in § 482.13.

Section 412.610 Assessment Schedule

In proposed § 412.610, we would

specify the following:

• The start of the assessment

schedule day count.

• The determination of the

assessment reference date.

• The date when an MDS–PAC

assessment reference is late.

• MDS–PAC completion and

encoding dates.

• The accuracy of the MDS–PAC data.

• The length of time that an IRF has

to retain MDS–PAC patient data sets.

Section 412.612 Coordination of MDS–

PAC Data Collection

We proposed to add a new § 412.612.

Paragraph (a) of this section would

specify the responsibilities of the IRF’s

authorized clinician. Section 412.612(b)

states that the IRF’s authorized clinician

must certify the accuracy and

completion date of the MDS–PAC

assessment by signing and dating the

appropriate lines of section AB of the

MDS–PAC. Proposed paragraph (c)

specifies the signature requirements for

any clinician who contributes data for

an MDS–PAC item. Proposed paragraph

(d) specifies the penalty for falsification

of a patient assessment.

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Section 412.614 Transmission of

MDS–PAC Data

Proposed § 412.614 specifies the

requirements for transmittal of MDS–

PAC data that include the following:

• The format for submitting data.

• How the data is to be submitted.

• The timeframe for submitting data.

• The penalties for late transmission

of data.

Section 412.616 Release of

Information Collected Using the MDS–

PAC

In proposed § 412.616, we specify that

the IRF and its agents must ensure the

confidentiality of the information

collected using the MDS–PAC in the

same manner as all other information in

the medical record, in accordance with

the hospital conditions of participation

at § 482.24(b)(3). An IRF may release

patient-identifiable information to an

agent of the IRF only in accordance with

a written contract under which the

agent agrees not to use or disclose the

information except for the purpose

specified in the contract and only to the

extent that the IRF itself is permitted to

so under § 412.616(a).

Section 412.618 Interrupted Stay

In proposed § 412.618 (a), we specify

that for purposes of the MDS–PAC

assessment process, if a Medicare

inpatient has an interrupted stay then

the following applies:

• The initial case-mix group

classification from the ‘‘initial’’ (Day 4)

MDS–PAC assessment remains in effect.

• The required scheduled MDS–PAC

Day 11, Day 30, Day 60, and discharge

assessments must be performed.

• The authorized clinician must

record the interrupted stay data on the

interrupted stay tracking form of the

MDS–PAC.

• The recorded and encoded

interrupted stay data must be

transmitted to the HCFA MDS–PAC

system within 7 calendar days of the

date that the Medicare patient returns to

IRF. In proposed paragraph (d), we

specify the revised assessment schedule.

Proposed paragraph (d)(1) specifies that

if the interrupted stay occurs before the

Day 4 assessment, the assessment

reference dates, completion dates,

encoding dates, and data transmission

for the Day 4 and Day 11 MDS–PAC

assessments are advanced by the same

number of calendar days as the length

of the Medicare patient’s interrupted

stay. Proposed paragraphs (d)(2), (d)(3)

and (d)(4), specify the provisions under

which the Day 11, Day 30, and Day 60

are advanced in the same manner.

Section 412.620 Patient Classification

System

Proposed § 412.620 specifies the

classification methodology, weighting

factors, and case-mix adjustments as

they relate to the patient classification

system.

Section 412.622 Basis of Payment

Proposed § 412.622(a), we would

specify that under the prospective

payment system, IRFs received a

predetermined amount per discharge for

inpatient services furnished to Medicare

beneficiaries. This paragraph also

specifies the basis for the amount of

payment under the prospective system.

Proposed § 412.622(b) specifies that

payments made under the prospective

payment system represent payment in

full for inpatient operating and capital

costs associated with services furnished

in an IRF, but not for the costs of an

approved medical education program.

Paragraph (b) also specifies the

additional payments that an IRFs

receive.

Section 412.624 Methodology for

Calculating the Prospective Payment

Rates

This proposed section specifies the

methodology for calculating the

prospective payment rates for IRFs. The

items specified in this section are as

follows:

• Proposed paragraph (a) specifies the

data used to calculate the prospective

payment rates;

• Proposed paragraph (b) specifies the

methodology for calculating the Federal

per discharge payment rates that

includes—

• Determination of the per discharge

payment rate; and

• Adjustments to the data.

• Proposed paragraph (c) specifies

how the Federal prospective payment

rates for IRFs will be determined. This

includes the general rules, the update

per discharge, the computation of the

budget neutral conversion factor and the

determination of the Federal

prospective payment rate for each casemix group.

• Proposed paragraph (d) specifies

the adjustments to the budget neutral

conversion factor. The adjustments

include the following: (1) outlier

payments; (2) budget neutrality; and (3)

coding and classification changes.

• Proposed paragraph (e) specifies the

calculation of the adjusted Federal

prospective payment is computed for

each discharge on the basis of the

Federal prospective payment rate

determined in paragraph (c) of this

section and adjusted to account for area

wage levels, payments for outliers,

transfers, and other appropriate factors.

Section 412.626 Transition Period

Proposed § 412.626(a) specifies the

duration of the transition period to IRF

prospective payment system. It also

specifies that IRFs will receive a

payment that is comprised of a blend of

the adjusted facility Federal prospective

payment and the facility-specific

payment. Proposed paragraph (b)

specifies how the facility-specific

payment is calculated.

Section 412.628 Publication of the

Federal Prospective Payment Rates

Proposed § 412.628 specifies that we

will publish information pertaining to

the IRF prospective payment system

effective for each fiscal year in the

Federal Register. In addition, it

specifies that the information regarding

the IRF prospective payment system

will be published on or before August

1 prior to the beginning of each fiscal

year.

Section 412.630 Limitation on Review

Proposed § 412.630 specifies that

administrative or judicial review under

sections 1869 or 1878 of the Act, or

otherwise, is prohibited with regard to

the establishment of the methodology to

classify a patient into the case-mix

groups and the associated weighting

factors, the unadjusted Federal per

discharge payment rates, additional

payments for outliers and special

payments, and the area wage index.

Section 412.632 Method of Payment

Under the Inpatient Rehabilitation

Facility Prospective Payment System

Proposed § 412.632 specifies the

method of payment under the inpatient

rehabilitation facility prospective

payment system. This section specifies

the following:

• General rule for receiving payment,

including exceptions;

• The requirements for periodic

interim payments that include—

• Criteria for receiving periodic

interim payments;

• Frequency of payments; and

• Termination of periodic interim

payments;

• Interim payment for Medicare bad

debts and for Part A costs not paid

under the prospective payment system.

• Outlier payments.

• The requirements for accelerated

payments that include—

• General rule regarding request for

accelerated payments;

• Approval of request for accelerated

payments;

• Amount of the accelerated payment;

and

66364 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

• Recovery of the accelerated

payment.

Section 413.1 Introduction

We propose to revised § 413.1(d)(ii) to

remove the reference to rehabilitation

hospitals and units. We also propose to

add a new § 413.1(d)(iv) that specifies

that for cost reporting periods beginning

on or before April 1, 2001, payment to

rehabilitation hospitals and units that

are excluded under subpart B of part

412 of this subchapter from the

prospective payment system is on a

reasonable cost basis in accordance with

the provisions of § 413.40. In addition,

we propose to add a new § 413.1(d)(v)

that specifies that for cost reporting

periods on or after April 1, 2001,

payment to rehabilitation hospitals and

units (as described in § 412.604) is

based on the prospectively determined

rates under the provisions of subpart P

of part 412.

Section 413.40 Ceiling on the Rate of

Increase in Hospital Costs

Section 413.40(a)(2)(i) specifies the

types of facilities to which the ceiling

on the rate of increase in hospital

inpatient costs is not applicable. We

propose to add a new paragraph

§ 413.40(a)(2)(i)(C) to specify that for

cost reporting periods beginning on or

after October 1, 2002, § 413.40 is not

applicable to rehabilitation hospitals

and rehabilitation units that meet the

conditions for payment under § 412.604

and are paid under the prospective

payment system for inpatient hospital

services in accordance with section

1886(j) and subpart P of part 412.

We propose to revise § 413.40(a)(2)(ii)

and to add (a)(2)(iii) to specify the cost

reporting periods under which

rehabilitation hospitals and units that

are excluded from the prospective

payment system specified in

§ 412.1(a)(1) meet the terms of this

section

Section 413.64 Payment to Providers:

Specific Rules

We propose to revise § 413.64 to

include hospitals paid under the IRF

prospective payment system and add a

reference to § 412.1(a)(1).

VII. Response to Comments

Because of the large number of items

of correspondence we normally receive

on Federal Register documents

published for comment, we are not able

to acknowledge or respond to them

individually. We will consider all

comments we receive by the date and

time specified in the ‘‘DATES’’ section

of this preamble, and we will respond

to the comments in the preamble to the

final rule.

VIII. Regulatory Impact Analysis

Section 804(2) of title 5, United States

Code (as added by section 251 of Public

Law 104–121), specifies that a ‘‘major

rule’’ is any rule that the Office of

Management and Budget finds is likely

to result in—

• An annual effect on the economy of

$100 million or more;

• A major increase in costs or prices

for consumers, individual industries,

Federal, State, or local government

agencies, or geographic regions; or

• Significant adverse effects on

competition, employment, investment

productivity, innovation, or on the

ability of United States-based

enterprises to compete with foreign

based enterprises in domestic and

export markets.

We have examined the impacts of this

proposed rule as required by Executive

Order (EO) 12866, the Unfunded

Mandates Reform Act of 1995 (Public

Law 104–4), the Regulatory Flexibility

Act (RFA) (Public Law 96–354), and EO

13132 (Federalism). Executive Order

12866 directs agencies to assess all costs

and benefits of available regulatory

alternatives and, if regulation is

necessary, to select regulatory

approaches that maximize net benefits

(including potential economic,

environmental, public health and safety

effects, distributive impacts, and

equity). A regulatory impact analysis

(RIA) must be prepared for major rules

with economically significant effects

($100 million or more annually). This

proposed regulation would be a major

rule because the aggregate amount of

savings is estimated to be 1.54 billion

dollars over 7 years.

The RFA requires agencies to analyze

options for regulatory relief of small

entities. For purposes of the RFA,

businesses include small businesses,

non-profit organizations and

governmental agencies. Most hospitals

and most other providers and suppliers

are small entities, either by nonprofit

status or by having revenues of $5

million or less annually. Intermediaries

and carriers are not considered to be

small entities. Individuals and States are

not included in the definition of a small

entity.

Section 202 of the Unfunded

Mandates Reform Act of 1995 also

requires that agencies assess anticipated

costs and benefits before issuing any

rule that may result in an expenditure

in any one year by State, local, or Tribal

governments, in the aggregate, or by the

private sector, of at least $100 million.

This rule will not have an effect on the

governments mentioned nor will it

affect private sector costs, rather, the

proposed rule will affect Medicare

payments.

In addition, we examined this rule in

accordance with Executive Order 13132

and determined that this proposed rule

would not have any negative impact on

the rights, roles, or responsibilities of

State, local, or Tribal governments.

Section 1102(b) of the Act requires us

to prepare a regulatory impact analysis

for any proposed rule that may have a

significant impact on the operations of

a substantial number of small rural

hospitals. This analysis must conform to

the provisions of section 604 of the

RFA. For purposes of section 1102(b) of

the Act, we define a small rural hospital

as a hospital that is located outside of

a Metropolitan Statistical Area and has

fewer than 50 beds.

For these reasons, we are preparing

analyses under the RFA and section

1102(b) of the Act because we

determine, and we certify, that this

proposed rule would have a significant

economic impact on a substantial

number of small entities or a significant

impact on the operations of a substantial

number of small rural hospitals. As

discussed earlier in this preamble, we

propose to adjust payments for facilities

located in rural areas. Therefore, the

impacts shown below reflect the

adjustments that are designed to

minimize or eliminate the negative

impact that the prospective payment

system would otherwise have on rural

facilities.

A. Background

This proposed rule sets forth the

prospective payments to be used to

determine payments under the Medicare

program for inpatient rehabilitation

facilities.

While section 1886(j) of the Act

specifies the basic methodology of

constructing a case-mix adjusted

prospective payment system, the statute

does allow us some discretion in

designing the key elements of the

system, and we had some opportunity to

consider alternatives for these elements.

These include the patient assessment

instrument, the patient classification

methodology based on functionalrelated groups, and adjustments to the

prospective payments. These elements,

and alternatives that we considered,

were discussed in detail earlier in the

preamble of this proposed rule.

B. Anticipated Effects of This Proposed

Rule

We discuss the impact of this

proposed rule in terms of its fiscal

impact on the budget and in terms of its

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66365

impact on providers. The estimated

fiscal impact is discussed first.

1. Budgetary Impact

Under section 1886(j)(3)(B) of the Act,

payment rates set forth in this proposed

rule must be set at levels such that total

payments under this prospective

payment system are projected to equal

98 percent of the amount that would

have been paid for operating and capital

costs if this prospective payment system

had not been implemented. The

provision to implement the IRF

prospective payment system is projected

to save the Medicare program $1.54

billion over 7 years, as follows:

$60 million for FY 2001

$200 million for FY 2002

$220 million for FY 2003

$240 million for FY 2004

$250 million for FY 2005

$270 million for FY 2006

$300 million for FY 2007

2. Impacts on Providers

In order to understand the impact of

the new prospective payment system on

different categories of facilities, it is

necessary to compare estimated

payments under the current payment

system (current payments) to estimated

payments under the proposed

prospective payment system (proposed

prospective payments). To estimate the

impacts among the various classes of

providers it is imperative that current

payments and proposed prospective

payments contain similar inputs. More

specifically, we simulate proposed

prospective payments only for those

providers that we are able to calculate

current payment. Further, we calculate

current payment only for those

providers that we are able to simulate

proposed prospective payments.

As previously stated in section V. of

this preamble, we have both case-mix

and cost data for 624 rehabilitation

facilities. Data from these facilities were

used to analyze the appropriateness of

various adjustments to the Federal

unadjusted payment rates. However, for

the impact analyses shown in the

following tables, we simulate payments

for 505 facilities. These impacts reflect

the estimated losses/gains among the

various classifications of providers for

FY 2001. The methodology used to

update the data to the midpoint of FY

2001, necessitated the use of historical

cost report data to determine the

relationship of the facilities’ costs and

target amount. Thus, the number of

providers reflects only those providers

for which we had cost report data

available from FYs 1995, 1996, and 1997

(see discussion in section V.E.1. of this

proposed rule).

3. Calculation of Current Payments

To calculate current payments, cost

report data is trended forward from the

midpoint of the cost reporting period to

the midpoint of FY 2001 using the

methodology set forth in section V. of

this preamble. To estimate current

payments, we calculate operating

payments for each rehabilitation facility

in accordance with section 1886(b).

Further, we compute capital payments

by reducing reasonable costs by 15

percent, consistent with section

1886(g)(4) of the Act, as added by

section 4412 of the BBA. To determine

each facility’s average per discharge

payment amount under the current

payment system, operating and capital

payments are added together, and then

the total payment is divided by the

number of Medicare discharges from the

cost reports. Total payments for each

facility are then computed by

multiplying the number of discharges

from the Medicare bills (with

corresponding UDSmr/COS data) by the

average per discharge payment amount.

4. Calculation of Proposed Prospective

Payments

To estimate payments under the

proposed prospective payment system,

we multiply each facility’s case-mix

index by the facility’s number of

Medicare discharges, the budget neutral

conversion factor, the applicable wage

index, a disproportionate share

adjustment, and a rural adjustment, (if

applicable). The specific adjustments

follow:

• The wage adjustment is calculated

as (.2897 + (.7103 × Wage Index)),

• The disproportionate share

adjustment is calculated as:

(( .0001 + Disproportionate Share)

raised to the power of .0905)/(.0001

raised to the power of .0905)),

• The rural adjustment, if applicable,

is calculated by multiplying payments

by 1.1589.

After the proposed Federal rate

payments are calculated for each

facility, the appropriate percentages of

the current payments and the proposed

Federal rate payments are blended

together to determine the appropriate

amount for the first three years of

implementation of the IRF prospective

payment system. Specifically, for cost

reporting periods beginning on or after

implementation of the prospective

payment system through FY 2001 we

combine 662⁄3 percent of the current

payment amount with 331⁄3 percent of

the proposed Federal rate payment

amount. For cost reporting periods

beginning in FY 2002, we combine 331⁄3

percent of the current payment amount

with 662⁄3 percent of the proposed

Federal rate payment amount. For cost

reporting periods beginning in FY 2003,

we show the impacts of the fully

phased-in IRF prospective payment

amount. All payment simulations reflect

data trended to the midpoint FY 2001.

These data were not trended out to the

midpoint of FYs 2002 or 2003.

Tables 1G, 2G, and 3G illustrate the

aggregate impact of the proposed

payment system among various

classifications of facilities. The first

column, Facility Classifications,

identifies the type of facility. The

second column identifies the number of

cases. The third column lists the

number of facilities of each

classification type, and the fourth

column is the ratio of proposed

prospective payments to current

payments. The impacts reflect the

adjustments that we propose, including

the specific geographic wage

adjustment, the adjustment for rural

facilities (if applicable), and a

disproportionate share adjustment for

all facilities.

TABLE 1G.—IMPACTS REFLECTING 1⁄3 OF PROPOSED PROSPECTIVE PAYMENTS PLUS 2⁄3 OF CURRENT PAYMENTS

Facility classifications Number of

cases

Number of

Facilities

Proposed payment to current payment

ratio

All Facilities .................................................................................................................................. 167390 505 0.98

Geographic Location

Large Urban ................................................................................................................................. 69344 218 0.98

Other Urban ................................................................................................................................. 88232 238 0.98

66366 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

TABLE 1G.—IMPACTS REFLECTING 1⁄3 OF PROPOSED PROSPECTIVE PAYMENTS PLUS 2⁄3 OF CURRENT PAYMENTS—

Continued

Facility classifications Number of

cases

Number of

Facilities

Proposed payment to current payment

ratio

Rural ............................................................................................................................................ 9814 49 1.00

Region

New England ............................................................................................................................... 15320 37 0.98

Middle Atlantic ............................................................................................................................. 24937 46 0.98

South Atlantic ............................................................................................................................... 34845 79 0.99

East North Central ....................................................................................................................... 33018 120 0.98

East South Central ...................................................................................................................... 12344 26 1.00

West North Central ...................................................................................................................... 9175 44 0.98

West South Central ..................................................................................................................... 22995 73 0.95

Mountain ...................................................................................................................................... 5659 25 0.96

Pacific .......................................................................................................................................... 9097 55 0.99

Urban by Region

Urban—New England .................................................................................................................. 15202 36 0.98

Urban—Middle Atlantic ................................................................................................................ 24351 43 0.98

Urban—South Atlantic ................................................................................................................. 31314 72 1.00

Urban—East North Central .......................................................................................................... 30993 108 0.98

Urban—East South Central ......................................................................................................... 11849 24 0.99

Urban—West North Central ......................................................................................................... 7979 36 0.98

Urban—West South Central ........................................................................................................ 21929 64 0.95

Urban—Mountain ......................................................................................................................... 5349 22 0.96

Urban—Pacific ............................................................................................................................. 8610 51 0.99

Rural by Region

Rural—New England ................................................................................................................... 118 1 1.01

Rural—Middle Atlantic ................................................................................................................. 586 3 1.01

Rural—South Atlantic .................................................................................................................. 3531 7 0.99

Rural—East North Central ........................................................................................................... 2025 12 1.03

Rural—East South Central .......................................................................................................... 495 2 1.09

Rural—West North Central .......................................................................................................... 1196 8 0.98

Rural—West South Central ......................................................................................................... 1066 9 0.96

Rural—Mountain .......................................................................................................................... 310 3 1.02

Rural—Pacific .............................................................................................................................. 487 4 0.97

Type and Size of Facility

Unit of acute hospital ................................................................................................................... 101518 398 0.99

Average Daily Census < 10 ................................................................................................. 12962 102 0.98

Average Daily Census 10–24 ............................................................................................... 51783 211 0.99

Average Daily Census > 24 ................................................................................................. 36773 85 0.99

Freestanding hospital .................................................................................................................. 65872 107 0.96

Average Daily Census less than 25 ..................................................................................... 3527 18 0.96

Average Daily Census 25–50 ............................................................................................... 19248 40 0.97

Average Daily Census greater than 50 ................................................................................ 43097 49 0.96

Disproportionate Share

Disproportionate share less than 10% ........................................................................................ 76374 197 0.98

Disproportionate share 10%–19% ............................................................................................... 56138 190 0.99

Disproportionate share 20%–29% ............................................................................................... 13308 58 0.98

Disproportionate share greater than 29% ................................................................................... 7191 32 0.99

Missing ......................................................................................................................................... 14379 28 0.97

Teaching Status

Non-Teaching .............................................................................................................................. 132437 407 0.98

Resident to ADC less than 10% .................................................................................................. 26377 67 0.98

Resident to ADC 10%–19% ........................................................................................................ 7309 20 0.97

Resident to ADC greater than 19% ............................................................................................. 1267 11 0.97

Alaska/Hawaii .............................................................................................................................. 1099 2 0.99

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66367

TABLE 2G.—IMPACTS REFLECTING 2⁄3 OF PROPOSED PROSPECTIVE PAYMENTS PLUS 1⁄3 OF CURRENT PAYMENTS

Facility classifications Number of

cases

Number of facilities

Proposed payment to current payment

ratio

All Facilities .................................................................................................................................. 167390 505 0.98

Geographic Location

Large Urban ................................................................................................................................. 69344 218 0.99

Other Urban ................................................................................................................................. 88232 238 0.97

Rural ............................................................................................................................................ 9814 49 1.01

Region

New England ............................................................................................................................... 15320 37 0.98

Middle Atlantic ............................................................................................................................. 24937 46 0.97

South Atlantic ............................................................................................................................... 34845 79 1.01

East North Central ....................................................................................................................... 33018 120 0.98

East South Central ...................................................................................................................... 12344 26 1.01

West North Central ...................................................................................................................... 9175 44 0.98

West South Central ..................................................................................................................... 22995 73 0.93

Mountain ...................................................................................................................................... 5659 25 0.94

Pacific .......................................................................................................................................... 9097 55 0.99

Urban by Region

Urban—New England .................................................................................................................. 15202 36 0.98

Urban—Middle Atlantic ................................................................................................................ 24351 43 0.97

Urban—South Atlantic ................................................................................................................. 31314 72 1.01

Urban—East North Central .......................................................................................................... 30993 108 0.98

Urban—East South Central ......................................................................................................... 11849 24 1.01

Urban—West North Central ......................................................................................................... 7979 36 0.99

Urban—West South Central ........................................................................................................ 21929 64 0.93

Urban—Mountain ......................................................................................................................... 5349 22 0.93

Urban—Pacific ............................................................................................................................. 8610 51 0.99

Rural by Region

Rural—New England ................................................................................................................... 118 1 1.04

Rural—Middle Atlantic ................................................................................................................. 586 3 1.03

Rural—South Atlantic .................................................................................................................. 3531 7 1.00

Rural—East North Central ........................................................................................................... 2025 12 1.08

Rural—East South Central .......................................................................................................... 495 2 1.20

Rural—West North Central .......................................................................................................... 1196 8 0.97

Rural—West South Central ......................................................................................................... 1066 9 0.95

Rural—Mountain .......................................................................................................................... 310 3 1.06

Rural—Pacific .............................................................................................................................. 487 4 0.96

Type and Size of Facility

Unit of acute hospital ................................................................................................................... 101518 398 1.00

Average Daily Census < 10 ................................................................................................. 12962 102 0.99

Average Daily Census 10–24 ............................................................................................... 51783 211 1.00

Average Daily Census > 24 ................................................................................................. 36773 85 1.00

Freestanding hospital .................................................................................................................. 65872 107 0.95

Average Daily Census less than 25 ..................................................................................... 3527 18 0.93

Average Daily Census 25–50 ............................................................................................... 19248 40 0.95

Average Daily Census greater than 50 ................................................................................ 43097 49 0.95

Disproportionate Share

Disproportionate share less than 10% ........................................................................................ 76374 197 0.97

Disproportionate share 10%–19% ............................................................................................... 56138 190 0.99

Disproportionate share 20%–29% ............................................................................................... 13308 58 0.98

Disproportionate share greater than 29% ................................................................................... 7191 32 1.01

Missing ......................................................................................................................................... 14379 28 0.96

Teaching Status

Non-Teaching .............................................................................................................................. 132437 407 0.98

Resident to ADC less than 10% .................................................................................................. 26377 67 0.99

Resident to ADC 10%–19% ........................................................................................................ 7309 20 0.96

Resident to ADC greater than 19% ............................................................................................. 1267 11 0.95

Alaska/Hawaii .............................................................................................................................. 1099 2 1.00

66368 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

TABLE 3G.—IMPACTS REFLECTING THE FULLY PHASED-IN PROSPECTIVE PAYMENTS

Facility classifications Number of

cases

Number of facilities

Proposed payment to current payment

ratio

All Facilities .................................................................................................................................. 167390 505 0.98

Geographic Location

Large Urban ................................................................................................................................. 69344 218 0.99

Other Urban ................................................................................................................................. 88232 238 0.97

Rural ............................................................................................................................................ 9814 49 1.03

Region

New England ............................................................................................................................... 15320 37 0.98

Middle Atlantic ............................................................................................................................. 24937 46 0.97

South Atlantic ............................................................................................................................... 34845 79 1.02

East North Central ....................................................................................................................... 33018 120 0.99

East South Central ...................................................................................................................... 12344 26 1.03

West North Central ...................................................................................................................... 9175 44 0.99

West South Central ..................................................................................................................... 22995 73 0.90

Mountain ...................................................................................................................................... 5659 25 0.92

Pacific .......................................................................................................................................... 9097 55 1.00

Urban by Region

Urban—New England .................................................................................................................. 15202 36 0.98

Urban—Middle Atlantic ................................................................................................................ 24351 43 0.97

Urban—South Atlantic ................................................................................................................. 31314 72 1.03

Urban—East North Central .......................................................................................................... 30993 108 0.98

Urban—East South Central ......................................................................................................... 11849 24 1.02

Urban—West North Central ......................................................................................................... 7979 36 0.99

Urban—West South Central ........................................................................................................ 21929 64 0.90

Urban—Mountain ......................................................................................................................... 5349 22 0.91

Urban—Pacific ............................................................................................................................. 8610 51 1.00

Rural by Region

Rural—New England ................................................................................................................... 118 1 1.07

Rural—Middle Atlantic ................................................................................................................. 586 3 1.06

Rural—South Atlantic .................................................................................................................. 3531 7 1.01

Rural—East North Central ........................................................................................................... 2025 12 1.13

Rural—East South Central .......................................................................................................... 495 2 1.31

Rural—West North Central .......................................................................................................... 1196 8 0.97

Rural—West South Central ......................................................................................................... 1066 9 0.93

Rural—Mountain .......................................................................................................................... 310 3 1.10

Rural—Pacific .............................................................................................................................. 487 4 0.96

Type and Size of Facility

Unit of acute hospital ................................................................................................................... 101518 398 1.01

Average Daily Census < 10 ................................................................................................. 12962 102 0.99

Average Daily Census 10–24 ............................................................................................... 51783 211 1.02

Average Daily Census > 24 ................................................................................................. 36773 85 1.02

Freestanding hospital .................................................................................................................. 65872 107 0.93

Average Daily Census less than 25 ..................................................................................... 3527 18 0.91

Average Daily Census 25–50 ............................................................................................... 19248 40 0.94

Average Daily Census greater than 50 ................................................................................ 43097 49 0.93

Disproportionate Share

Disproportionate share less than 10% ........................................................................................ 76374 197 0.97

Disproportionate share 10%–19% ............................................................................................... 56138 190 1.00

Disproportionate share 20%–29% ............................................................................................... 13308 58 0.98

Disproportionate share greater than 29% ................................................................................... 7191 32 1.03

Missing ......................................................................................................................................... 14379 28 0.94

Teaching Status

Non-Teaching .............................................................................................................................. 132437 407 0.98

Resident to ADC less than 10% .................................................................................................. 26377 67 0.99

Resident to ADC 10%–19% ........................................................................................................ 7309 20 0.95

Resident to ADC greater than 19% ............................................................................................. 1267 11 0.94

Alaska/Hawaii .............................................................................................................................. 1099 2 1.00

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66369

5. Costs Associated With The MDS-PAC

We propose that all IRFs furnishing

Medicare-covered Part A services assess

their Medicare patients using the

standardized data set known as the

MDS–PAC. Costs associated with MDS–

PAC data collection and data reporting

are related to both personnel and

equipment. These two classes of costs

include the costs associated with using

the MDS–PAC to assess patients (MDS–

PAC data collection costs), the IRF’s

costs to start the MDS–PAC process, and

the IRF’s ongoing costs after the MDS–

PAC process has been initiated. It

should be noted that many of the

components of the costs associated with

initiation of the MDS–PAC process and

the IRF’s ongoing costs are the same.

a. MDS–PAC Data Collection Costs

In calculating the cost to perform an

MDS–PAC assessment we made the

following assumptions: (1) That

physicians, registered nurses,

occupational therapists, or physical

therapists are the only clinicians with

the training to complete all, or the vast

majority, of the MDS–PAC items. Other

clinicians may contribute data to

complete some MDS–PAC items. (2)

That a physician would not record the

data for all or most of the MDS–PAC

items. We believe that the majority of

the items would be completed by

registered nurses, occupational

therapists, or physical therapists.

We then applied the above

assumptions to the following data:

• According to the Occupational

Outlook Handbook of the Bureau of

Labor Statistics, U.S. Department of

Labor, the median earnings of registered

nurses in 1998 were $40,690. That is

equivalent to a median hourly wage of

$19.56. ($40,690/52 weeks = $782.50/

week. $782.50/40 hours = $19.5625).

• According to the Occupational

Outlook Handbook of the Bureau of

Labor Statistics, U.S. Department of

Labor, the median earnings of

occupational therapists in 1998 were

$48,230. That is equivalent to a median

hourly wage of $23.19. ($48,230/52

weeks = $927.50. $927.50/40 hours =

$23.1875).

• According to the Occupational

Outlook Handbook of the Bureau of

Labor Statistics, U.S. Department of

Labor, the median earnings of physical

therapists in 1998 were $56,600. That is

equivalent to a median hourly wage of

$27.21. ($56,600/52 weeks = $1088.46/

week. $1088.46/40 hours = $27.2115).

• According to the Occupational

Outlook Handbook of the Bureau of

Labor Statistics, U.S. Department of

Labor, the median earnings of dietitians

and nutritionists in 1998 were $35,020.

That is equivalent to a median hourly

wage of $16.84. ($35,020/52 weeks =

$673.46/week. $673.46/40 hours =

$16.8365).

• According to the Occupational

Outlook Handbook of the Bureau of

Labor Statistics, U.S. Department of

Labor, the median earnings of social

workers in 1998 were $30,590. That is

equivalent to a median hourly wage of

$14.71. ($30,590/52 weeks = $588.27/

week. $588.27/40 hours = $14.7067).

• According to the Occupational

Outlook Handbook of the Bureau of

Labor Statistics, U.S. Department of

Labor, the median earnings of speechlanguage pathologists and audiologists

in 1998 were $43,080. That is equivalent

to a median hourly wage of $20.71.

($43,080/52 weeks = $828.46/week.

$828.46/40 hours = $20.7115).

• IRF staff familiar with the MDS–

PAC that was the product of our pilot

and field testing required a median of 85

minutes to complete an initial intake

assessment.

• IRF staff familiar with the MDS–

PAC that was the product of our pilot

and field testing required a median of 48

minutes to complete an update

assessment.

• According to one external source

IRF staff familiar with the UDSmr FIM

required a median of 20 minutes to

complete the initial FIM instrument.

• According to another external

source IRF staff familiar with the FIM

required a range of 30 to 45 minutes to

complete the FIM instrument. It was not

specified if this was the UDSmr or COS

instrument. Also, although it was not

specified, we believe that this range of

time was the time to complete an initial

FIM assessment.

• It should be noted that the

information from both external sources

concerning the length of time it takes to

complete the FIM instrument has not

been verified.

• Our data indicates that in 1997

there were 359,032 IRF admissions and

1,123 IRFs. Therefore, there were an

average of 319.70 admissions per IRF.

Based on the above data and

assumptions, and depending on the type

of clinician that completes all, or the

vast majority, of the MDS–PAC items,

the range of the incremental average

cost difference per year per IRF to

complete the initial MDS–PAC when

compared to the initial FIM is

illustrated in Table 4G below. In

addition, considering the hourly wage

rates specified above it would make no

difference in cost if a dietitian or social

worker completed all or most of the

MDS–PAC items, and only a slight

difference at the low end of the range if

a speech-language pathologist

completed all or most of the MDS–PAC

items.

TABLE 4G.—RANGE OF INCREMENTAL COST—COMPARISON OF THE INITIAL MDS–PAC TO THE INITIAL FIM

Range of hourly wages per clinician

Minimum incremental

time of 40 minutes—

range of Incremental

Cost per IRF per year

Maximum incremental

time of 65 minutes—

range of incremental

cost per IRF per year

$19.56 (R.N.) ........................................................................................................................... $4,169.02 $6,774.61

23.19 (O.T.) ............................................................................................................................. 4,942.72 8,031.86

27.21 (P.T.) .............................................................................................................................. 5,799.54 9,424.18

We believe that the FIM data are

inconclusive, and we have several

concerns and observations regarding the

data. The data from both external

sources were collected from a survey of

a sample of IRFs. We do not know the

size of one of the samples, and if either

sample is representative of all IRFs. We

do not know if the data are estimates of

time or controlled measurements of

time. Nor do we know the details of the

survey method that was used to collect

the data. The data may be biased at the

source where the data was collected,

that is, the sources of the data may be

reflecting institutionalized biases when

reporting their data. In addition, the

data was reported by organizations with

vested interests in the FIM, and they

may have used a different approach

than the one we used in estimating

completion time of an assessment

instrument. For example, we do not

know whether they measured only the

time necessary to enter information on

the FIM form or also included—(1) the

time it took to obtain information from

66370 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

the patient and/or clinical record; (2)

the time it took to actually assess the

patient; and (3) the time it took

clinicians before filling out the FIM to

apply clinical judgment, or to consult

with other clinicians, or to examine the

clinical record regarding their

assessment observations. In addition,

unlike the MDS–PAC estimates, the

information from both external sources

was survey information, instead of a

controlled study. For the above reasons,

when we conduct a test of the UDSmr,

COS, and the MDS–PAC instruments we

will include in the test measurements of

the time it takes to complete each one.

Previously in this preamble we state

that testing indicated that IRF staff

familiar with the MDS–PAC can

complete an update MDS–PAC in a

median of 48 minutes. SNF staff familiar

with the MDS–PAC can complete an

update MDS–PAC in a median of 45

minutes.

Although we are proposing to require

more items to be collected on an update

assessment, the update assessment still

requires less data collection than an

initial assessment. Table 7C (found in

section II of this preamble), entitled

‘‘MDS–PAC Items Required by Type of

Assessment,’’ listed the items that we

propose be collected on the Day 4

(admission), update (Day 11, Day 30,

Day 60), and the discharge assessments.

Counting the items in each column

gives a simple total of the items required

on each type of assessment. The update

assessment requires that 85.2 percent of

the items on the initial assessment be

addressed on the update assessment.

The discharge assessment requires that

87.5 percent of the items on the initial

assessment be addressed on the

discharge assessment. Consequently, we

believe that the time required by IRF

staff to complete an update MDS–PAC

assessment is likely more than 48

minutes but less than the time it takes

to complete the initial MDS–PAC

assessment. We do not have data that

specifically states the time it takes to

complete a patient’s discharge FIM,

which, in essence, is the patient’s

update FIM. Therefore, we cannot

currently compare MDS–PAC update or

discharge assessment completion times

to FIM update or discharge assessment

completion times.

Most patients would require a Day 11

update assessment, because our data

indicates that the mean length of stay is

15.81 days and the median length of

stay is 14 days. Patients would also

require a discharge assessment. But our

data indicates that less than 9 percent of

patients would require a Day 30

assessment, and less than 1⁄2 of one

percent of patients would require a Day

60 assessment.

b. Start-Up Costs

The IRF’s costs to start the MDS–PAC

process consists of material costs and

personnel costs. Our data indicates that

in 1997 there were 1,123 IRFs. As

presented in detail in Table 5G below

entitled ‘‘MDS–PAC IRF Start-up Costs’’

we estimate that the costs for all IRFs to

start the MDS–PAC process, excluding

the MDS–PAC data collection costs

discussed above, to be approximately

$5,121,722 to $5,247,498, which is

equal to approximately $4,561 to $4,673

per IRF.

The costs presented below are based

on the profile of an average IRF, because

certain costs are constant regardless of

the size of the IRF. For both start-up

costs and on-going costs, cost estimates

are based on an assumption that IRFs

would perform the encoding and

transmission functions themselves.

TABLE 5G.—MDS–PAC IRF START-UP COSTS

Task/equipment Hours per

IRF

Cost per

IRF

Estimated

number of

staff per

IRF to be

trained

Total per

IRF

National

costs

Hard drive, printer, RAM,

MODEM, Internet Browser.

$0 a $0 a None

Training on MDS–PAC data

collection at initial assessment, update assessment,

discharge assessment, and

data auditing.

16 PT b

$27/hr

OT b

$23/hr

RN b

$20/hr

1 c PT d

$432

OT e

$368

RN f

$320

$359,360–

$485,136 g

12 $23/hr (average cost of the 3 disciplines)9 h $2,484 i $2,789,532 j

Data Entry (encoding/transmission) training.5.5 $12.50/hr k 1 $68.75 l $77,206.25 m

Data Entry .............................. 96 n $1,200 o $1,200 $1,347,600 p

Data Entry Audits q ................ $38 r $38 $42,674 s

Data Transmissions—Staff

time.

Running the data edit check

program @ 20 minutes per

month and actual transmission by staff @ 40 minutes per month.

1 $150 t $150 $168,450 u

Systems Maintenance ........... $100 $100 $112,300

Supplies ................................. $200 $200 $224,600

Total ................................ $5,121,722–

$5,247,498

aWe believe that all IRFs have the computer capability to process the MDS–PAC-related software.

bThese are the 1998 median hourly wages for these occupations based on the US Dept. of Labor, Bureau of Labor Statistics, Occupational

Outlook Handbook, 2000–2001 Edition. We are providing a range of median hourly wages as the IRFs must determine the discipline specific clinician they will send to training. cWe expect the IRF to send a lead clinician to a HCFA sponsored training session and then that lead clinician would train the other IRF clinicians. d 16 × $27. e 16 × $23.

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66371

f 16 × $20. g 1,123 × $320 to 1,123 × $432. hThis number represents the average number of clinicians per IRF that would require training. These clinicians would be trained in their facility. i 12 hrs × $23/hr × 9 staff=$2,484.

j 1,123 × $2,484. kWe estimate that the hourly wage for data entry personnel is $12.50 per hour.

l 5.5 hrs × $12.50. m 1,123 × $68.75. nThe average total of admissions per year per IRF is a approximately 320. We estimate that on average approximately 91 percent of IRF admissions will require 3 assessments. Approximately 9 percent of IRF admissions will require 4 assessments. This time includes data review and

entry of 3 min. per assessment for up-front review & another 3 min. of post data entry review for a total of 6 min. 6 minutes × 291=1746 minutes/

60=29.1 hrs × 3=87.3. 6 minutes × 29=174 minutes/60=2.9 hrs × 3=8.7 hrs. 87.3 + 8.7=96 hrs. oWe estimate an hourly rate for data entry costs of $12.50. 96 hrs × $12.50=$1200. p 1,123 × $1200. qWe estimate a 15 minute monthly data entry audit for quality assurance purposes.

r $12.50 hr/4 × 12 months=$37.50 per year. s 1,123 × $38. t 1 hr × 12 (mos.) × $12.50/hr. u 1,123 × $150.

Note: We anticipate that the IRFs will designate a lead licensed clinician to attend all training. That lead clinician would then provide training to

other IRF staff.

(1) Computer Hardware and Software

Because we will supply to the IRFs

free of charge the MDS–PAC software

that performs the MDS–PAC process

electronic functions, the IRFs will incur

no software costs. We believe that IRFs

possess the computer hardware

capability to handle the MDS–PAC

computerization, data transmission, and

grouper software requirements. Our

belief is based upon indications that—

(1) Approximately 99 percent of

hospital inpatient claims currently are

submitted electronically; (2) close to 100

percent of IRFs submit their cost reports

electronically; and (3) approximately 55

percent of IRFs submit FIMs

electronically. Although we will supply

the MPACT software, IRFs may incur

costs, which we are not able to estimate,

associated with making changes to their

information management systems to

incorporate the MPACT software.

Therefore, we are specifically soliciting

comments regarding MDS–PAC

computerization issues.

IRFs have the option of purchasing

data collection software that can be used

to support other clinical or operational

needs (for example, care planning,

quality assurance, or billing) or other

regulatory requirements for reporting

patient information. However, we are

developing an MDS–PAC data system

(that is, MPACT) that would be

available to IRFs at no charge through

our website. MPACT would allow users

to computerize their MDS–PAC

assessment data and transmit the data in

a HCFA-standard format to the HCFA

MDS–PAC system. Therefore, IRFs that

plan to use MPACT will need Internet

access and a dial-up Internet Service

Provider account in order to be able to

download and install MPACT into their

computer system. We believe that all

IRFs currently have the capability to

access the Internet. However, we are

specifically soliciting comments from

any IRFs that do not possess Internet

access capability, in order for us to

consider if we should make MPACT

available to these facilities by some

other means.

(2) Training

IRF staff will require training in

performing MDS–PAC assessments,

encoding assessments, preparing MDS–

PAC data for electronic submission, and

actually transmitting the data. We

believe that the initial training of IRF

personnel would require about 75.5

hours of staff time. We estimate training

to cost an IRF approximately $1,242 for

training of clinical staff, based on an

average hourly payroll rate of $23 for

licensed clinical staff. We estimate

training to cost an IRF approximately

$69 for training data entry staff, based

on an average hourly payroll rate of

$12.50 for data entry staff.

(3) Data Entry

IRFs have flexibility in choosing the

data entry software used to computerize

the MDS–PAC data, but the software

must, at a minimum, perform the

MPACT functions. In addition, when

IRFs are performing data entry functions

themselves, or contracting for the

performance of these functions, the IRFs

must ensure that performance of data

entry complies with our requirement for

safeguarding the confidentiality of

clinical records.

IRFs must collect and transmit MDS–

PAC data to the HCFA MDS–PAC

system in accordance with the

assessment schedule and transmission

requirements specified elsewhere in this

preamble. The data may be entered by

an IRF staff member from a paper

document completed by a licensed

clinical staff member, or by a data entry

operator under contract to the IRF to key

in data. IRFs must allow time for data

validation, preparation of data for

transmission, and correction of returned

records that failed checks by the HCFA

MDS–PAC system. We estimate that an

average IRF will incur a cost of an

hourly rate for data entry of $12.50. This

cost includes data review and entry, as

well as a (recommended) 15 minute

monthly data entry audit for quality

assurance purposes.

(4) Data Transmission

MDS–PAC data would be transmitted

to the HCFA MDS–PAC system. This

system is similar to the ones that HHAs

use to report OASIS data and that SNFs

use to report MDS 2.0 data. IRF staff

must also manage the data transmission

function, correct transmission problems,

and manage report logs and validation

reports transmitted by the HCFA MDS–

PAC system. We estimate that it will

take about one additional hour of staff

time to perform data transmission

related tasks each month, including

running a data edit check program. This

staff time will cost an average-sized IRF

about $150 per year based on an hourly

rate of $12.50. IRFs will be able to

transmit the MDS–PAC data using the

toll-free MDCN line.

(5) Systems Maintenance

There are costs associated with

normal maintenance related to

computer equipment, such as the

replacement of disk drives or memory

chips. Typically, this maintenance is

provided through warranty agreements

with the original equipment

manufacturer, system retailer, or a firm

that provides computer support. These

maintenance costs are estimated to

average no more than $100 per year IRF.

(6) Supplies

Supplies necessary for collection and

transmission of data, including forms,

diskettes, computer paper, and toner,

will vary according to the size of the

IRF, the number of patients served, and

the number of assessments conducted.

66372 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

We anticipate that an average IRF with

approximately $200 in costs for

supplies.

c. Ongoing Costs

We wanted to differentiate between

one-time start-up costs for the IRF and

costs we believe the IRFs will incur on

a regular, yearly basis. Therefore, Table

6G entitled ‘‘Agency Ongoing Costs’’

include only data that we consider will

be a repeated cost to the IRF.

TABLE 6G.—MDS–PAC IRF ONGOING COSTS

Task/equipment

Hours

per

IRF

Cost per

IRF

Estimated

number of

staff

Total per IRF National

costs

Data Entry .................................................................................................................

Data Entry Audit(d) ...................................................................................................

96a $1,200b

$38e 1

$1,200

$38

$1,347,600c

$42,674f

Data Transmissions—Staff time Running the data edit check program @ 20 minutes per month and actual transmission by staff @ 40 minutes per month.1 $150g $150 $168,450h

Systems Maintenance .............................................................................................. $100 $100 $112,300

Supplies .................................................................................................................... $200 $200 $224,600

Annual Training:

Clinical ............................................................................................................... 12 $20–27/

hri

1 $240–$324j $269,520–

$363,852k

Data Entry .......................................................................................................... 12 12.50/hrl 1 $150m $168,450n

Clinicalo .............................................................................................................. 2 $20–27/

hr.

9 $360–$486 $404,280–

$545,778

Total .......................................................................................................................... $2,737,874–

$2,973,704

aThe average total of admissions per year per IRF is approximately 320. We estimate that on average approximately 91 percent of IRF admissions will require 3 assessments. Approximately 9 percent of IRF admissions will require 4 assessments. This time includes data review and

entry of 3 min. per assessment for up-front review & another 3 min. of post data entry review for a total of 6 min. 6 minutes × 291=1746 minutes/

60=29.1 hrs × 3=87.3. 6 minutes × 29=174 minutes/60=2.9 hrs × 3=8.7 hrs. 87.3 + 8.7=96 hrs. bWe estimate an hourly rate for data entry costs of $12.50. 96 hrs × $12.50=$1,200. c 1,123 × $1,200. dWe estimate a 15 minute monthly data entry audit for quality assurance purposes.

e $12.50 hr/4 × 12 months=$37.50 per year. f 1,123 × $38. g 1 hr × 12 (mos.) × $12.50/hr. h 1,123 × $150. iBased on the 1998 U.S. Dept. of Labor, Bureau of Labor Statistics, Occupational Outlook Handbook, 2000–2001 Edition, the median hourly

wage for an RN is $20, $23 for an OT, and $27 for a PT. We are providing a range of median hourly wages as the IRFs must determine the discipline specific clinician they will send to training. We expect that the IRF will send one discipline specific clinician to a HCFA sponsored training

session and then that individual would train the other IRF clinicians.

j 12 hours × $20 to 12 hours × $27. k 1,123 × $240 to 1,123 × $324. lWe estimate that the hourly wage for data entry personnel is $12.50 per hour.

m 12 hours × $12.50. n 1,123 × $150. oThis entry represents the average annual cost of IRF in-house training for the MDS–PAC.

Our data indicates that in 1997 there were 1,123 IRFs. Therefore, we estimate annual ongoing costs for an averagesized IRF, excluding MDS–PAC data collection costs discussed previously, to be approximately $2,438 to $2,648.

d. Conclusion

As discussed in detail above, IRFs will incur costs associated with the MDS–PAC process. Table 7G below is

a further analysis of these costs.

TABLE 7G.—MDS–PAC COST PER CASE

[Based on IRFs currently completing a FIM instrument]

Percent of MDS–

PAC items

completed

Maximum incremental clinician

(physical therapist) cost per IRF

(from table 4G)

Total incremental

maximum cost per

IRF (Col. 2 times

Col. 3)

Average maximum

incremental cost

per case (Col. 4

divided by 320 average admissions

per IRF)

Col. 1 Col. 2 Col. 3 Col. 4 Col. 5

Assessment Type:

Initial ................................................................................. 100.00 $9,424.18 $9,424.18 $29.45

Update .............................................................................. 1 85.20 9,424.18 8,029.40 25.09

Discharge .......................................................................... 2 87.50 9,424.18 8,246.16 25.77

Average Estimated Cost to Complete MDS–PAC .................. .............................. .............................. 25,699.74 80.31

Estimated Maximum MDS–PAC Start-up Cost per IRF 3 ........ .............................. .............................. 4,673.00 14.60

Total Estimated Maximum first year Cost ............................... .............................. .............................. 30,372.74 94.91

1Assumes the time to complete each MDS–PAC item weighted equally at 1.000.

2Same as footnote 1.

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66373

3This amount is based on the maximum costs shown in Table 5G divided by 1,123 IRFs. This amount will decline after the first year of implementation to reflect the ongoing costs shown in Table 6G.

We assessed the relationship between

the estimated cost of completing the

MDS–PAC with an estimate of the

average cost of one RIC. For analysis we

used RIC 7: Hip Fractures. This RIC has

an estimated average cost of $9,848

(based upon secondary analysis of data

from 1996 and 1997 MEDPAR and cost

reports). We compared the assumed cost

for completing the initial, update and

discharge assessments using the MDS–

PAC. We found that the average

maximum incremental cost per case of

completing the MDS–PAC for one year,

assuming the completion of three

assessments represents approximately

0.008 per cent of the cost of the

estimated average cost of RIC 7. We

used a single RIC for comparison

because there is a large variation of cost

across RICs. We believe that the

estimated costs of completing the MDS–

PAC are well justified when considered

within the context of the statutory

requirement and the methodology

needed to implement the IRF

prospective payment system, the

probability that the MDS–PAC process

will lead to increased quality of care for

IRF patients, as well as the potential

uses of the automated data by the IRFs

themselves, the States, fiscal

intermediaries, and HCFA. Our cost

estimates may actually overstate

anticipated costs, because they do not

take into account cost-savings that IRFs

may achieve by improving their

management information systems, as

well as potential improvements in the

quality of patients’ clinical care

resulting from improved care planning

under the MDS–PAC assessment

process.

C. Alternatives Considered

We propose to use the MDS–PAC as

the patient assessment instrument

instead of the patient assessment

instruments marketed by UDSmr or

COS. These other patient assessment

instruments are used by approximately

56 percent of the IRFs. But these patient

assessment instruments are not as

precise in assessing patients as the

MDS–PAC, because they do not collect

as much detailed data as the MDS–PAC.

For example, the MDS–PAC provides a

better description of a patient’s

cognitive functioning (the processing of

empirical factual concepts) than these

other assessment instruments. The

MDS–PAC is also better at assessing a

patient’s mood and behavior patterns,

measures of a patient’s emotional and

psychological status. Nor do these other

assessment instruments allow for

collecting patient assessment data in

sufficient detail to allow us to develop

the IRF quality of care monitoring

system that we need. In addition, we

believe that neither of these other

patient assessment instruments permits

a comparison of patients across different

settings of post-acute care as

recommended by MedPAC.

In constructing our proposed

assessment schedule we decided not to

use the patient assessment schedules

associated with the patient assessment

instruments marketed by UDSmr or

COS. These other patient assessment

instruments are used to assess patients

only upon admission and discharge. We

believe that the data provided by our

update assessments would yield the

type of structured data that we can use

to monitor the quality of treatment being

furnished. We also propose not to use

the FIM items exactly as they are

contained in the patient assessment

instruments of UDSmr or COS, or the

MDS–PAC with the FIM payment items

pasted in exactly as contained in the

patient assessment instruments of

UDSmr or COS. These two approaches

were not selected as they would not

support HCFA’s long-term quality

monitoring strategy nor the goal to

establish a common core post-acute care

assessment instrument. In addition, we

propose not to collect only the

assessment items that would be used to

generate a case-mix group determined

payment rate, because these few items

do not provide the scope of information

needed to monitor access to care,

quality of care, and to determine if

future adjustments to the payment

system are needed.

However, as we discussed earlier in

the preamble, the process for arriving at

the number of elements on the MDS–

PAC was based on a consensus of

clinical expert panels, which focused on

the scope of elements necessary to

support both quality monitoring and

payment. Similarly, our proposed

assessment schedule, including the

number of assessments performed, was

designed to meet both payment and

quality monitoring objectives of the

MDS–PAC. Alternatives to the

approaches we have proposed in this

rule could include either a reduction in

the number of elements on the

instrument or in the number of

assessments performed while

maintaining the MDS–PAC’s ability to

facilitate both payment and

comprehensive quality monitoring. We

are specifically requesting comments on

these facets of the patient assessment

methodology.

In accordance with the provisions of

Executive Order 12866 this regulation

was reviewed by the Office of

Management and Budget.

IX. Collection of Information

Requirements

Under the Paperwork Reduction Act

of 1995 (PRA), we are required to

provide 60-day notice in the Federal

Register and solicit public comment

before a collection of information

requirement is submitted to the Office of

Management and Budget (OMB) for

review and approval. In order to fairly

evaluate whether an information

collection should be approved by OMB,

section 3506 (c)(2)(A) of the PRA

requires that we solicit comment on the

following issues:

• The need for the information

collection and its usefulness in carrying

out the proper functions of our agency.

• The accuracy of our estimate of the

information collection burden.

• The quality, utility, and clarity of

the information to be collected.

• Recommendations to minimize the

information collection burden on the

affected public, including automated

collection techniques.

We are soliciting public comment on

each of these issues for the sections that

contain information collection

requirements (ICRs).

Section 412.23 Excluded Hospitals:

Classifications

• Paragraph (b)(2) requires that,

except in the case of a newly

participating hospital seeking

classification under this paragraph as a

rehabilitation hospital for its first 12-

month cost reporting period, as

described in paragraph (b)(8) of this

section, the entity show that during its

most recent 12-month cost reporting

period it served an inpatient population

of whom at least 75 percent required

intensive rehabilitative services for

treatment of one or more specified

conditions.

• Paragraph (b)(8) requires that a

hospital seeking classification under

this paragraph as a rehabilitation

hospital, for the first 12-months cost

reporting period that occurs after it

becomes a Medicare participating

hospital, may provide a written

certification that the inpatient

population it intends to serve meets the

requirements of paragraph (b)(2) of this

66374 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

section, instead of showing that it has

treated this population during its most

recent 12-month cost reporting period.

The information collection

requirements of these two paragraphs of

this section are currently approved

under OMB approval number 0938–

0358 (Psychiatric Unit Criteria Work

Sheet, Rehabilitation Hospital Criteria

Work Sheet, Rehabilitation Unit Criteria

Work Sheet) through November 30,

2000. The proposed changes to the

information collection requirements in

these two paragraphs are clarifying

changes.

Section 412.116 Method of Payment

Under 412.116 (b), Periodic interim

payments, a hospital that meets the

criteria in § 413.65(h) of this chapter

may request in writing to receive

periodic interim payments as described

in this paragraph.

The burden associated with this

provision is the time it takes a hospital

to write its request for periodic interim

payments. We estimate that 34 facilities

would request these payments and that

it would take each 1 hour to write and

mail its request.

Sections 412.606 Patient Assessment

and 412.610(c) Assessment Schedule

• Paragraph (a) of § 412.606 requires

that at the time each Medicare patient

is admitted the facility must have

physician orders for the patient’s

immediate care.

This requirement is subject to the

PRA. However, we believe that the

burden associated with it is exempt as

defined in 5 CFR 1320.3(b)(2), because

the time, effort, and financial resources

necessary to comply with the

requirement are incurred by persons in

the normal course of their activities.

• Paragraph (c) of § 412.606,

Comprehensive assessments, requires

that an IRF clinician initially and

periodically perform a comprehensive,

accurate, standardized, and

reproducible assessment of each

Medicare patient using the MDS–PAC as

the patient assessment instrument and

that the assessment process must

include—

• Direct patient observation and

communication with the patient; and

• When appropriate and to the extent

feasible, patient data from the patient’s

physician(s), family, friends, and the

patient’s clinical record and other

sources.

• Section 412.610(c), Assessment

reference dates, requires assessments

upon admission (Day 4); Day 11, Day 30,

and Day 60; upon discharge or when the

patient stops receiving part A benefits.

In 1997, there were approxiamtely

359,000 admissions to IRFs and there

are 1,123 facilities, averaging 320

admissions annually. We estimate that it

would take 85 minutes for the initial

assessment and at least 48 minutes for

each subsequent assessment.

Under these proposed rules, all

Medicare beneficiaries would be

assessed two times: upon admission and

upon discharge. Sixty-six percent would

be assessed on the 11th day as well.

Fewer than 9 percent of Medicare

beneficiaries in IRFs would also be

assessed at 30 days. Fewer than 1⁄2 of a

percent would require an assessment at

60 days.

Below is a chart showing burden.

Type of assessment

Estimated time for

completion

(in minutes)

Hours per year

per facility

(in hours)

Hours per year

nationwide

(in hours)

Admission (Day 4) ..................................................................................................... 85 453 508,719

Day 11 ....................................................................................................................... 48 169 189,787

Day 30 ....................................................................................................................... 48 23 25,829

Day 60 ....................................................................................................................... 48 1 1,123

Discharge ................................................................................................................... 48 256 287,488

Total/Facility (5 assessment) .............................................................................. .............................. 902 1,012,946

The total ongoing annual burden for

all facilities for five assessments would

be 902 hours × 1,123 or 1,012,946 hours.

We are also including training in our

burden estimates: 16 hours to train the

lead clinician and 12 hours to train the

other clinicians (an average of 9). This

totals 121,284 nationally for a one-time

burden. We also estimate an on-going

burden for training of 14 hours per IRF

per year (15,722 nationally).

Section 412.608 Patient Rights

Regarding MDS–PAC Data Collection.

Under paragraph (a) of this section,

before performing an assessment of a

Medicare inpatient using the MDS–PAC,

an IRF clinician must inform the

Medicare inpatient of the following

patient rights:

• The right to be informed of the

purpose of the MDS–PAC data

collection;

• The right to have the MDS–PAC

information collected kept confidential

and secure;

• The right to be informed that the

MDS–PAC information will not be

disclosed to others, except for legitimate

purposes allowed by the Federal Privacy

Act and Federal and State regulations;

• The right to refuse to answer MDS–

PAC questions; and

• The right to see, review, and request

changes on his or her MDS–PAC

assessment.

Under paragraph (b) of this section,

the IRF must ensure that the authorized

clinician document in the patient’s

clinical record that the patient was

informed of the patient rights specified

in paragraph (a) of this section.

In accordance with paragraph (c) of

this section, the patient rights specified

in paragraph (a) of this section are in

addition to the patient rights specified

under the conditions of participation for

hospitals in § 482.13.

We anticipate adding the burden of

disclosure to IRF patients and

documenting that disclosure to the

burden in § 412.13 on hospitals

furnishing a patient rights statements.

The hospitals would be able to easily

give both statements to patients upon

admission, along with other required

notifications. The burden for the general

patient rights statement has not yet been

approved but is under development. We

have estimated that it would take each

hospital 5 minutes to disclose the

general hospital statement to each

patient on admission. The disclosure of

the IRF patients’ rights statement would

increase that time by an estimated 2

minutes.

Section 412.610 Assessment Schedule

Paragraph (g), MDS–PAC record

retention, of this section requires that an

IRF maintain all MDS–PAC patient data

sets completed within the previous 5

years in a paper format in the patient’s

clinical record or in an electronic

computer file that the inpatient

rehabilitation facility can easily obtain.

We estimate that, for facilities that

choose to file a paper copy, it would

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66375

take the facility 5 minutes to print out,

or copy, each assessment and file it in

the patient’s record. On average, each

facility would need to obtain a copy of

and file 882 assessments per year,

equaling 74 hours. We cannot estimate

how many facilities would choose to file

paper copies. However, we are assuming

that most facilities would choose to

retain the assessments in an electronic

format, which would not add to the

paperwork burden. We request

comments on the accuracy of this

assumption concerning how many

facilities will comply by retaining an

electronic version.

Section 412.612 Coordination of MDS–

PAC Data Collection.

Paragraph (b), Certification, of this

section requires that the authorized

clinician who has done at least part of

the assessment certify the accuracy and

completion date by signing and dating

the appropriate lines of section AB of

the MDS–PAC.

We estimate that it would take the

authorized clinician approximately 10

minutes per assessment to determine to

his or her satisfaction that the

assessment is complete and to so certify.

Eight hundred eighty-two assessments

would equal 147 hours per year per

facility, and 165,081 hours nationally.

Paragraph (c) of this section requires

that any clinical who contributes data

for an MDS–PAC item sign and date the

appropriate lines of the MDS–PAC.

Under the definition of information in

5 CFR 1320.3(h)(1), ‘‘information’’ does

not include such items as affidavits,

oaths, affirmations, certifications,

consents or acknowledgments, provided

that they do not entail any burden other

than that necessary to identify the

respondent, the date, and the

respondent’s address. We believe that

the signatures required by § 412.610(c)

are acknowledgments identifying the

signers (as persons furnishing a service)

and are not information.

Section 412.614 Transmission of

MDS–PAC Data

Paragraph (a), Data format, of this

section requires that each IRF encode

and transmit data—

• Using the computer program(s)

available from HCFA; or

• Using a computer program(s) that

conforms to the HCFA standard

electronic record layout, data

specifications, and data dictionary,

includes the required MDS–PAC data

set, and meets other HCFA

specifications.

In accordance with paragraph (b),

How to transmit data, of this section,

each IRF must—

• Electronically transmit complete

and encoded MDS–PAC data for each

Medicare inpatient to the HCFA MDS–

PAC system in accordance with the data

format specified in paragraph (a) of this

section; and

• Transmit data using electronic

communications software that provides

a direct telephone connection from the

IRF to the HCFA MDS–PAC system.

IRFs would have to collect and

transmit MDS–PAC data to the HCFA

MDS—PAC system. The data may be

entered by a IRF staff member from a

paper document completed by a

licensed clinical staff member, or by a

data entry operator under contract to the

IRF to key in data. IRFs would have to

allow time for data validation,

preparation of data for transmission,

and correction of returned records that

failed checks by the HCFA MDS–PAC

system.

We estimate that an average IRF with

320 admissions per year will require 3

minutes for data review and entry per

assessment for up-front review and

another 3 minutes for data entry review

for a total of 6 minutes. The burden of

transmitting the data is contained in

that 6 minutes. The yearly burden

would be 96 hours per facility. (This

burden also includes recommended 15

minute monthly data entry audit for

quality assurance purposes.)

Other Data Transmission Functions

In addition to the burden of managing

the data transmission function, IRF staff

will have to correct transmission

problems and manage report logs and

validation reports transmitted by the

HCFA MDS–PAC system. We estimate

that it will take about one additional

hour of staff time to perform data

transmission related tasks each month,

including running a data edit check

program.

We estimate that it will require a onetime burden of 5.5 hours per hospital to

train the personnel to be able to

complete data transmission tasks. With

1,123 facilities, the national burden

would be 6177 hours.

Section 412.616 Release of

Information Collected Using the MDS–

PAC

Under paragraph (b) of this section, a

facility may release information that is

patient-identifiable to an agent only in

accordance with a written contract

under which the agent agrees not to use

or disclose the information except for

the purposes specified in the contract

and to the extent the facility itself is

permitted to do so under § 412.616(a).

The burden associated with this ICR

is the time required to include the

necessary information in the contract.

While this ICR is subject to the PRA, we

believe the burden associated with it is

exempt as defined in 5 CFR 1320.3(b)(2)

because the time, effort, and financial

resources necessary to comply with the

requirement would be incurred by

persons in the normal course of their

activities.

Section 412.618 Interrupted Stay

Paragraph (a) of this section requires

that if a patient has an interrupted stay

the facility must record interrupted stay

data on the MDS–PAC interrupted stay

tracking form.

We currently have no data on the

incidence of interrupted stays. We

estimate, however, that it would take no

more than 5 minutes to complete a form.

We request comments on the burden

that completion of this form might

impose.

Submission to OMB

We have submitted a copy of this

proposed rule to OMB for its review of

the information collection requirements

in §§ 412.23, 412.29, 412.116, and

412.606 through 412.618. These

requirements are not effective until they

have been approved by OMB.

If you have any comments on any of

these information collection and record

keeping requirements, please mail the

original and 3 copies directly to the

following:

Health Care Financing Administration,

Office of Information Services,

Standards and Security Group,

Division of HCFA Enterprise

Standards, Room N2–14–26, 7500

Security Boulevard, Baltimore, MD

21244–1850, Attn: Julie Brown

HCFA–1069–P.

and,

Office of Information and Regulatory

Affairs, Office of Management and

Budget, Room 10235, New Executive

Office Building, Washington, DC

20503, Attn: Allison Eydt, HCFA Desk

Officer.

List of Subjects

42 CFR Part 412

Administrative practice and

procedure, Health facilities, Medicare,

Puerto Rico, Reporting and

recordkeeping requirements.

42 CFR Part 413

Health facilities, Kidney diseases,

Medicare, Puerto Rico, Reporting and

recordkeeping requirements.

For the reasons set forth in the

preamble, 42 CFR chapter IV is

proposed to be amended as follows:

66376 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

PART 412—PROSPECTIVE PAYMENT

SYSTEMS FOR INPATIENT HOSPITAL

SERVICES

A. Part 412 is amended as set forth

below:

1. The authority citation for part 412

continues to read as follows:

Authority: Secs. 1102 and 1871 of the

Social Security Act (42 U.S.C. 1302 and

1395hh).

Subpart A—General Provisions

2. Section § 412.1 is revised to read as

follows:

§ 412.1 Scope of part.

(a) Purpose. (1) This part implements

sections 1886(d) and (g) of the Act by

establishing a prospective payment

system for the operating costs of

inpatient hospital services furnished to

Medicare beneficiaries in cost reporting

periods beginning on or after October 1,

1983 and a prospective payment system

for the capital-related costs of inpatient

hospital services furnished to Medicare

beneficiaries in cost reporting periods

beginning on or after October 1, 1991.

Under these prospective payment

systems, payment for the operating and

capital-related costs of inpatient

hospital services furnished by hospitals

subject to the systems (generally, shortterm, acute-care hospitals) is made on

the basis of prospectively determined

rates and applied on a per discharge

basis. Payment for other costs related to

inpatient hospital services (organ

acquisition costs incurred by hospitals

with approved organ transplantation

centers, the costs of qualified

nonphysician anesthetist’s services, as

described in § 412.113(c), and direct

costs of approved nursing and allied

health educational programs) is made

on a reasonable cost basis. Payment for

the direct costs of graduate medical

education is made on a per resident

amount basis in accordance with

§ 413.86 of this chapter. Additional

payments are made for outlier cases, bad

debts, indirect medical education costs,

and for serving a disproportionate share

of low-income patients. Under either

prospective payment system, a hospital

may keep the difference between its

prospective payment rate and its

operating or capital-related costs

incurred in furnishing inpatient

services, and the hospital is at risk for

inpatient operating or inpatient capitalrelated costs that exceed its payment

rate.

(2) This part implements section

1886(j) of the Act by establishing a

prospective payment system for the

inpatient operating and capital costs of

inpatient hospital services furnished to

Medicare beneficiaries by a

rehabilitation hospital or rehabilitation

unit that meets the conditions of

§ 412.604.

(b) Summary of content. (1) This

subpart describes the basis of payment

for inpatient hospital services under the

prospective payment systems specified

in paragraph (a)(1) of this section and

sets forth the general basis of these

systems.

(2) Subpart B sets forth the

classifications of hospitals that are

included in and excluded from the

prospective payment systems specified

in paragraph (a)(1) of this section, and

sets forth requirements governing the

inclusion or exclusion of hospitals in

the systems as a result of changes in

their classification.

(3) Subpart C sets forth certain

conditions that must be met for a

hospital to receive payment under the

prospective payment systems specified

in paragraph (a)(1) of this section.

(4) Subpart D sets forth the basic

methodology by which prospective

payment rates for inpatient operating

costs are determined under the

prospective payment system specified

in paragraph (a)(1) of this section.

(5) Subpart E describes the transition

rate-setting methods that are used to

determine transition payment rates for

inpatient operating costs during the first

4 years of the prospective payment

system specified in paragraph (a)(1) of

this section.

(6) Subpart F sets forth the

methodology for determining payments

for outlier cases under the prospective

payment system specified in paragraph

(a)(1) of this section.

(7) Subpart G sets forth rules for

special treatment of certain facilities

under the prospective payment system

specified in paragraph (a)(1) of this

section for inpatient operating costs.

(8) Subpart H describes the types,

amounts, and methods of payment to

hospitals under the prospective

payment system specified in paragraph

(a)(1) of this section for inpatient

operating costs.

(9) Subpart K describes how the

prospective payment system specified

in paragraph (a)(1) of this section for

inpatient operating costs is

implemented for hospitals located in

Puerto Rico.

(10) Subpart L sets forth the

procedures and criteria concerning

applications from hospitals to the

Medicare Geographic Classification

Review Board for geographic

redesignation under the prospective

payment systems specified in paragraph

(a)(1) of this section.

(11) Subpart M describes how the

prospective payment system specified

in paragraph (a)(1) of this section for

inpatient capital-related costs is

implemented effective with reporting

periods beginning on or after October 1,

1991.

(12) Subpart P describes the

prospective payment system specified

in paragraph (a)(2) of this section for

rehabilitation hospitals and

rehabilitation units and sets forth the

general methodology for paying for the

operating and capital costs of inpatient

hospital services furnished by

rehabilitation hospitals and

rehabilitation units effective with cost

reporting periods beginning on or after

April 1, 2001.

Subpart B—Hospital Services Subject

to and Excluded From the Prospective

Payment Systems for Inpatient

Operating Costs and Inpatient CapitalRelated Costs

3. Section 412.20 is amended by:

A. Revising paragraph (a).

B. Redesignating paragraph (b) as

paragraph (c).

C. Adding a new paragraph (b).

D. Revising the introductory text of

the redesignated paragraph (c).

§ 412.20 Hospital services subject to the

prospective payment systems.

(a) Except for services described in

paragraphs (b) and (c) of this section, all

covered inpatient hospital services

furnished to beneficiaries during subject

cost reporting periods are paid under

the prospective payment systems

specified in § 412.1(a)(1).

(b) Effective for cost reporting periods

beginning on or after April 1, 2001,

covered inpatient hospital services

furnished to Medicare beneficiaries by a

rehabilitation hospital or rehabilitation

unit that meet the conditions of

§ 412.604 are paid under the prospective

payment system described in subpart P

of this part.

(c) Inpatient hospital services will not

be paid under the prospective payment

systems specified in § 412.1(a)(1) under

any of the following circumstances:

* * * * *

4. Section 412.22 is amended by:

A. Revising paragraphs (a) and (b).

B. Revising the introductory text of

paragraph (e).

C. Revising the introductory text of

paragraph (h)(2).

§ 412.22 Excluded hospitals and hospital

units: General rules.

(a) Criteria. Subject to the criteria set

forth in paragraph (e) of this section, a

hospital is excluded from the

prospective payment systems specified

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in § 412.1(a)(1) of this part if it meets the

criteria for one or more of the excluded

classifications described in § 412.23.

(b) Cost reimbursement. Except for

those hospitals specified in paragraph

(c) of this section and § 412.20(b), all

excluded hospitals (and excluded

hospital units, as described in §§ 412.23

through 412.29) are reimbursed under

the cost reimbursement rules set forth in

part 413 of this subchapter, and are

subject to the ceiling on the rate of

hospital cost increases described in

§ 413.40 of this subchapter.

* * * * *

(e) Hospitals within hospitals. Except

as provided in paragraph (f) of this

section, for cost reporting periods

beginning on or after October 1, 1997, a

hospital that occupies space in a

building also used by another hospital,

or in one or more entire buildings

located on the same campus as

buildings used by another hospital,

must meet the following criteria in order

to be excluded from the prospective

payment systems specified in

§ 412.1(a)(1):

* * * * *

(h) Satellite facilities. ***

(2) Except as provided in paragraph

(h)(3) of this section, effective for cost

reporting periods beginning on or after

October 1, 1999, a hospital that has a

satellite facility must meet the following

criteria in order to be excluded from the

prospective payment systems specified

in § 412.1(a)(1) for any period:

* * * * *

5. Section 412.23 is amended by:

A. Revising the introductory text.

B. Revising the introductory text of

paragraph (b).

C. Revising paragraphs (b)(2)

introductory text, (b)(8), and (b)(9).

§ 412.23 Excluded hospitals:

Classifications.

Hospitals that meet the requirements

for the classifications set forth in this

section are not reimbursed under the

prospective payment systems specified

in § 412.1(a)(1):

* * * * *

(b) Rehabilitation hospitals. A

rehabilitation hospital must meet the

following requirements to be excluded

from the prospective payment systems

specified in § 412.1(a)(1) and to be paid

under the prospective payment system

specified in § 412.1(a)(2):

* * * * *

(2) Except in the case of a newly

participating hospital seeking

classification under this paragraph as a

rehabilitation hospital for its first 12-

month cost reporting period, as

described in paragraph (b)(8) of this

section, show that during its most recent

12-month cost reporting period, it

served an inpatient population of whom

at least 75 percent required intensive

rehabilitative services for treatment of

one or more of the following conditions:

* * * * *

(8) A hospital that seeks classification

under this paragraph as a rehabilitation

hospital for the first full 12-month cost

reporting period that occurs after it

becomes a Medicare-participating

hospital may provide a written

certification that the inpatient

population it intends to serve meets the

requirements of paragraph (b)(2) of this

section, instead of showing that it has

treated that population during its most

recent 12-month cost reporting period.

The written certification is also effective

for any cost reporting period of not less

than one month and not more than 11

months occurring between the date the

hospital began participating in Medicare

and the start of the hospital’s regular 12-

month cost reporting period.

(9) For cost reporting periods

beginning on or after October 1, 1991, if

a hospital is excluded from the

prospective payment systems specified

in § 412.1(a)(1) or is paid under the

prospective payment system specified

in § 412.1(a)(2) for a cost reporting

period under paragraph (b)(8) of this

section, but the inpatient population it

actually treated during that period does

not meet the requirements of paragraph

(b)(2) of this section, HCFA adjusts

payments to the hospital retroactively in

accordance with the provisions in

§ 412.130.

* * * * *

6. In § 412.25, paragraph (a)

introductory text and paragraph (e)(2)

introductory text are revised to read as

follows:

§ 412.25 Excluded hospital units: Common

requirements.

(a) Basis for exclusion. In order to be

excluded from the prospective payment

systems specified in § 412.1(a)(1), a

psychiatric or rehabilitation unit must

meet the following requirements.

* * * * *

(e) Satellite facilities. ***

(2) Except as provided in paragraph

(e)(3) of this section, effective for cost

reporting periods beginning on or after

October 1, 1999, a hospital unit that

establishes a satellite facility must meet

the following requirements in order to

be excluded from the prospective

payment systems specified in

§ 412.1(a)(1) for any period:

* * * * *

7. In § 412.29, the introductory text is

revised to read as follows:

§ 412.29 Excluded rehabilitation units:

Additional requirements.

In order to be excluded from the

prospective payment systems described

in § 412.1(a)(1) and to be paid under the

prospective payment system specified

in § 412.1(a)(2), a rehabilitation unit

must meet the following requirements:

* * * * *

Subpart H—Payments to Hospitals

Under the Prospective Payment

Systems

8. In § 412.116, paragraph (a) is

revised to read as follows:

§ 412.116 Method of payment.

(a) General rule. (1) Unless the

provisions of paragraphs (b) and (c) of

this section apply, hospitals are paid for

hospital inpatient operating costs and

capital-related costs for each discharge

based on the submission of a discharge

bill.

(2) Payments for inpatient hospital

services furnished by an excluded

psychiatric unit of a hospital (or by an

excluded rehabilitation unit of a

hospital for cost reporting periods

beginning before April 1, 2001) are

made as described in § 413.64(a), (c),

(d), and (e) of this chapter.

(3) For cost reporting periods

beginning on or after April 1, 2001,

payments for inpatient hospital services

furnished by a rehabilitation hospital or

a rehabilitation unit that meets the

conditions of § 412.604 are made as

described in § 412.632.

* * * * *

9. In § 412.130, paragraphs (a)(1),

(a)(2), and (b) are revised to read as

follows:

§ 412.130 Retroactive adjustments for

incorrectly excluded hospitals and units.

(a) Hospitals for which adjustment is

made. ***

(1) A hospital that was excluded from

the prospective payment systems

specified in § 412.1(a)(1) or paid under

the prospective payment system

specified in § 412.1(a)(2), as a new

rehabilitation hospital for a cost

reporting period beginning on or after

October 1, 1991 based on a certification

under § 412.23(b)(8) of this part

regarding the inpatient population the

hospital planned to treat during that

cost reporting period, if the inpatient

population actually treated in the

hospital during that cost reporting

period did not meet the requirements of

§ 412.23(b)(2).

(2) A hospital that has a unit excluded

from the prospective payment systems

specified in § 412.1(a)(1) or paid under

the prospective payment system

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specified in § 412.1(a)(2), as a new

rehabilitation unit for a cost reporting

period beginning on or after October 1,

1991, based on a certification under

§ 412.30(a) regarding the inpatient

population the hospital planned to treat

in that unit during the period, if the

inpatient population actually treated in

the unit during that cost reporting

period did not meet the requirements of

§ 412.23(b)(2).

* * * * *

(b) Adjustment of payment. (1) For

cost reporting periods beginning before

April 1, 2001, the intermediary adjusts

the payment to the hospitals described

in paragraph (a) of this section as

follows:

(i) The intermediary calculates the

difference between the amounts actually

paid during the cost reporting period for

which the hospital, unit, or beds were

first excluded as a new hospital, new

unit, or newly added beds under

subpart B of this part, and the amount

that would have been paid under the

prospective payment systems specified

in § 412.1(a)(1) for services furnished

during that period.

(ii) The intermediary makes a

retroactive adjustment for the difference

between the amount paid to the hospital

based on the exclusion and the amount

that would have been paid under the

prospective payment systems specified

in § 412.1(a)(1).

(2) For cost reporting periods

beginning on or after April 1, 2001, the

intermediary adjusts the payment to the

hospitals described in paragraph (a) of

this section as follows:

(i) The intermediary calculates the

difference between the amounts actually

paid under subpart P of this part during

the cost reporting period for which the

hospital, unit, or beds were first

classified as a new hospital, new unit,

or newly added beds under subpart B of

this part, and the amount that would

have been paid under the prospective

payment systems specified in

§ 412.1(a)(1) for services furnished

during that period.

(ii) The intermediary makes a

retroactive adjustment for the difference

between the amount paid to the hospital

under subpart P of this part and the

amount that would have been paid

under the prospective payment systems

specified in § 412.1(a)(1).

Subparts N and O—[Reserved]

10. Subparts N and O are added and

reserved.

11. A new subpart P, consisting of

§§ 412.600, 412.602, 412.604, 412.606,

412.608, 412.610, 412.612, 412.614,

412.616, 412.618, 412.620, 412.622,

412.624, 412.626, 412.628, 412.630, and

412.632 is added to read as follows:

Subpart P—Prospective Payment for

Inpatient Rehabilitation Hospitals and

Rehabilitation Units

Sec.

412.600 Basis and scope of subpart.

412.602 Definitions.

412.604 Conditions for payment under the

prospective payment system for

inpatient rehabilitation facilities.

412.606 Patient assessment.

412.608 Patient rights regarding MDS–PAC

data collection.

412.610 Assessment schedule.

412.612 Coordination of MDS–PAC data

collection.

412.614 Transmission of MDS–PAC data.

412.616 Release of information collected

using the MDS–PAC.

412.618 Interrupted stay.

412.620 Patient classification system.

412.622 Basis of payment.

412.624 Methodology for calculating the

Federal prospective payment rates.

412.626 Transition period.

412.628 Publication of the Federal

prospective payment rates.

412.630 Limitation on review.

412.632 Method of payment under the

inpatient rehabilitation facility

prospective payment system.

Subpart P—Prospective Payment for

Inpatient Rehabilitation Hospitals and

Rehabilitation Units

§ 412.600 Basis and scope of subpart.

(a) Basis. This subpart implements

section 1886(j) of the Act, which

provides for the implementation of a

prospective payment system for

inpatient rehabilitation hospitals and

rehabilitation units (in this subpart

referred to as ‘‘inpatient rehabilitation

facilities’’).

(b) Scope. This subpart sets forth the

framework for the prospective payment

system for inpatient rehabilitation

facilities, including the methodology

used for the development of payment

rates and associated adjustments, the

application of a transition phase, and

related rules. Under this system, for cost

reporting periods beginning on or after

April 1, 2001, payment for the operating

and capital costs of inpatient hospital

services furnished by inpatient

rehabilitation facilities is made on the

basis of prospectively determined rates

and applied on a per discharge basis.

§ 412.602 Definitions.

As used in this subpart—

Assessment reference date means the

specific calendar day in the MDS–PAC

assessment process that sets the

designated endpoint of the common 3

day patient observation period, with

most MDS–PAC assessment items

usually referring back in time from this

endpoint.

Authorized clinician means one of the

following clinicians:

(1) An occupational therapist who

meets the qualifications specified in

§ 482.56(a)(2) of this chapter.

(2) A physical therapist who meets

the qualifications specified in

§ 482.56(a)(2) of this chapter.

(3) A physician who is a doctor of

medicine or osteopathy and is licensed

to practice medicine and surgery by the

State in which the function or action is

performed.

(4) A registered nurse as defined in

§ 484.4 of this chapter.

Discharge A Medicare patient in a

inpatient rehabilitation facility is

considered discharged when—

(1) The patient is formally released; or

(2) The patient dies in the inpatient

rehabilitation facility.

Encode means entering data items

into the fields of the computerized

MDS–PAC software program.

Functional-related groups refers to the

distinct groups under which inpatients

are classified using proxy measurements

of inpatient rehabilitation relative

resource usage.

Interrupted stay means the period

during which a Medicare inpatient is

discharged from the inpatient

rehabilitation facility and returns to the

same inpatient rehabilitation facility

within 3 consecutive calendar days. The

3 consecutive calendar days begin with

the day of discharge.

MDS–PAC stands for the Minimum

Data Set for Post Acute Care, a patient

clinical assessment instrument.

Outlier payment means an additional

payment beyond the standard Federal

prospective payment for cases with

unusually high costs.

Rural area means an area as defined

in § 412.62(f)(1)(iii).

Transfer means the release of a

Medicare inpatient from an inpatient

rehabilitation facility to another

inpatient rehabilitation facility, a shortterm, acute-care prospective payment

hospital, a long-term care hospital as

described in § 412.23(e), or a nursing

home that qualifies to receive Medicare

or Medicaid payments.

Urban area means an area as defined

in § 412.62(f)(1)(ii).

§ 412.604 Conditions for payment under

the prospective payment system for

inpatient rehabilitation facilities.

(a) General requirements. (1) An

inpatient rehabilitation facility must

meet the conditions of this section to

receive payment under the prospective

payment system described in this

subpart for inpatient hospital services

furnished to Medicare beneficiaries.

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(2) If an inpatient rehabilitation

facility fails to comply fully with these

conditions with respect to inpatient

hospital services furnished to one or

more Medicare beneficiaries, HCFA

may, as appropriate—

(i) Withhold (in full or in part) or

reduce Medicare payment to the

inpatient rehabilitation facility until the

facility provides adequate assurances of

compliance; or

(ii) Classify the inpatient

rehabilitation facility as an inpatient

hospital that is subject to the conditions

of subpart C of this part and is paid

under the prospective payment systems

specified in § 412.1(a)(1).

(b) Inpatient rehabilitation facilities

subject to the prospective payment

system. An inpatient rehabilitation

facility must meet the criteria to be

classified as a rehabilitation hospital or

rehabilitation unit set forth in

§§ 412.23(b), 412.25, and 412.29 for

exclusion from the inpatient hospital

prospective payment systems specified

in § 412.1(a)(1).

(c) Completion of patient assessment

instrument. For each Medicare patient

admitted or discharged on or after April

1, 2001, the inpatient rehabilitation

facility must complete a patient

assessment instrument in accordance

with § 412.606.

(d) Limitation on charges to

beneficiaries. (1) Prohibited charges.

Except as provided in paragraph (d)(2)

of this section, an inpatient

rehabilitation facility may not charge a

beneficiary for any services for which

payment is made by Medicare, even if

the facility’s costs of furnishing services

to that beneficiary are greater than the

amount the facility is paid under the

prospective payment system.

(2) Permitted charges. An inpatient

rehabilitation facility receiving payment

under this subpart for a covered hospital

stay (that is, a stay that includes at least

one covered day) may charge the

Medicare beneficiary or other person

only for the applicable deductible and

coinsurance amounts under §§ 409.82,

409.83, and 409.87 of this subchapter.

(e) Furnishing of inpatient hospital

services directly or under arrangement.

(1) The applicable payments made

under this subpart are payment in full

for all inpatient hospital services, as

defined in § 409.10 of this chapter, other

than physicians’ services to individual

patients reimbursable on a reasonable

cost basis (in accordance with the

criteria of § 415.102(a) of this

subchapter).

(2) HCFA does not pay any provider

or supplier other than the inpatient

rehabilitation facility for services

furnished to a Medicare beneficiary who

is an inpatient, except for physicians’

services reimbursable under

§ 405.550(b) of this chapter and services

of an anesthetist employed by a

physician reimbursable under

§ 415.102(a) of this subchapter.

(3) The inpatient rehabilitation

facility must furnish all necessary

covered services to the Medicare

beneficiary either directly or under

arrangements (as defined in § 409.3 of

this subchapter).

(f) Reporting and recordkeeping

requirements. All inpatient

rehabilitation facilities participating in

the prospective payment system under

this subpart must meet the

recordkeeping and cost reporting

requirements of §§ 413.20 and 413.24 of

this subchapter.

§ 412.606 Patient assessment.

(a) Admission orders. At the time that

each Medicare patient is admitted, the

inpatient rehabilitation facility must

have physician orders for the patient’s

care during the time the patient is

hospitalized.

(b) Patient assessment instrument. An

inpatient rehabilitation facility must use

the MDS–PAC instrument to assess

Medicare inpatients who—

(1) Are admitted on or after April 1,

2001; or

(2) Were admitted before April 1,

2001, and are still inpatients as of April

1, 2001.

(c) Comprehensive assessments. (1)

An inpatient rehabilitation facility’s

authorized clinician must perform a

comprehensive, accurate, standardized,

and reproducible assessment of each

Medicare inpatient using the MDS–PAC

as part of his or her patient assessment

in accordance with the schedule

described in § 412.610.

(2) A clinician employed or

contracted by an inpatient rehabilitation

facility must record appropriate and

applicable data accurately and

completely for each MDS–PAC item.

(3) The assessment process must

include—

(i) Direct patient observation and

communication with the patient; and

(ii) When appropriate and to the

extent feasible, patient data from the

patient’s physician(s), family, friends,

the patient’s clinical record, and other

sources.

(4) The authorized clinician, must

sign the MDS–PAC attesting to its

completion and accuracy.

§ 412.608 Patient rights regarding MDS–

PAC data collection.

(a) Before performing an assessment

using the MDS–PAC, an authorized

clinician must inform the Medicare

inpatient of the following patient rights:

(1) The right to be informed of the

purpose of the MDS–PAC data

collection;

(2) The right to have the MDS–PAC

information collected be kept

confidential and secure;

(3) The right to be informed that the

MDS–PAC information will not be

disclosed to others, except for legitimate

purposes allowed by the Federal Privacy

Act and Federal and State regulations;

(4) The right to refuse to answer

MDS–PAC questions; and

(5) The right to see, review, and

request changes on his or her MDS–PAC

assessment.

(b) The inpatient rehabilitation

facility must ensure that an authorized

clinician documents in the Medicare

inpatient’s clinical record that the

patient was informed of the patient

rights specified in paragraph (a) of this

section.

(c) The patient rights specified in

paragraph (a) of this section are in

addition to the patient rights specified

under the conditions of participation for

hospitals in § 482.13 of this chapter.

§ 412.610 Assessment schedule.

(a) General. For each Medicare

inpatient an inpatient rehabilitation

facility must submit MDS–PAC

assessment data that covers a time

period that is in accordance with the

assessment schedule specified in

paragraph (c) of this section.

(b) Starting the assessment schedule

day count. The first day that the

inpatient is furnished Medicare-covered

services during his or her current

inpatient rehabilitation facility hospital

stay is counted as day one of the MDS–

PAC assessment schedule.

(c) Assessment reference dates. With

respect to the patient’s current

hospitalization, an inpatient

rehabilitation facility must indicate on

the MDS–PAC one of the following

assessment reference dates:

(1) Day 4 MDS–PAC assessment. For

the assessment that covers calendar

days 1 through 3 of the patient’s current

hospitalization, the date that is the 3rd

calendar day after the patient started

being furnished Medicare-covered Part

A services.

(2) Day 11 MDS–PAC assessment. For

the assessment that covers calendar

days 8 through 10 of the patient’s

current hospitalization, the date that is

the 10th calendar day after the patient

started being furnished Medicarecovered Part A services.

(3) Day 30 MDS–PAC assessment. For

the assessment that covers calendar

days 28 through 30 of the patient’s

current hospitalization, the date that is

the 30th calendar day after the patient

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started being furnished Medicarecovered Part A services.

(4) Day 60 MDS–PAC assessment. For

the assessment that covers calendar

days 58 through 60 of the patient’s

current hospitalization, the date that is

the 60th calendar day after the patient

started being furnished Medicarecovered Part A services.

(5) Discontinuation of Medicarecovered Part A services assessment. For

the assessment that is completed when

the inpatient is not discharged from the

inpatient rehabilitation facility but stops

receiving Medicare-covered Part A

services, the actual date that the

inpatient stops receiving Medicarecovered Part A services.

(6) Discharge assessment. For the

assessment that is completed when the

Medicare inpatient is discharged from

the inpatient rehabilitation facility, the

actual date of discharge from the

inpatient rehabilitation facility.

(d) Late MDS–PAC assessment

reference date. If the MDS–PAC

assessment reference date is entered

later than the assessment reference date

specified in paragraph (c)(1) of this

section, the MDS–PAC assessment

reference date is considered late.

(1) If the MDS–PAC assessment

reference date is late by 10 calendar

days or fewer, the inpatient

rehabilitation facility receives a

payment rate that is 25 percent less than

the payment rate associated with a casemix group.

(2) If the MDS–PAC assessment

reference date is late by more than 10

calendar days, the inpatient

rehabilitation facility receives no

payment.

(e) Completion and encoding dates.

(1) The Day 4, Day 11, Day 30, and Day

60 MDS–PAC assessments must be

completed 1 calendar day after the

MDS–PAC assessment reference date

that is recorded on the MDS–PAC.

(2) The discharge MDS–PAC

assessment must be completed on the

5th calendar day in the period

beginning with the MDS–PAC

assessment reference date.

(3) All MDS–PAC assessments must

be encoded by the 7th calendar day in

the period beginning with the MDS–

PAC completion date that is recorded on

the MDS–PAC.

(f) Accuracy of the MDS–PAC data.

The encoded MDS–PAC assessment

data must accurately reflect the patient’s

clinical status at the time of the MDS–

PAC assessment.

(g) MDS–PAC record retention. An

inpatient rehabilitation facility must

maintain all MDS–PAC patient data sets

completed within the previous 5 years

in a paper format in the patient’s

clinical record or in an electronic

computer file that the inpatient

rehabilitation facility can easily obtain.

§ 412.612 Coordination of MDS–PAC data

collection.

(a) Responsibilities of the authorized

clinician. An inpatient rehabilitation

facility’s authorized clinician who has

participated in performing an MDS–

PAC patient assessment must have

responsibility for—

(1) The accuracy and thoroughness of

the patient’s MDS–PAC assessment; and

(2) The accuracy of the date inserted

in the attestation section of the MDS–

PAC.

(b) Certification. An inpatient

rehabilitation facility’s authorized

clinician must certify the accuracy and

completion date of the MDS–PAC

assessment by signing and dating the

appropriate lines of the MDS–PAC.

(c) Signatures. Any clinician who

contributes data for an MDS–PAC item

must sign and date the appropriate lines

of the MDS–PAC.

(d) Penalty for falsification. (1) Under

Medicare an individual who knowingly

and willfully—

(i) Certifies a material and false

statement in a patient assessment is

subject to a civil money penalty of not

more than $1,000 for each assessment;

or

(ii) Causes another individual to

certify a material and false statement in

a patient assessment is subject to a civil

money penalty of not more than $5,000

for each assessment.

(2) Clinical disagreement does not

constitute a material and false

statement.

§ 412.614 Transmission of MDS–PAC data.

(a) Data format. The inpatient

rehabilitation facility must encode and

transmit data for each Medicare

inpatient—

(1) Using the computerized version of

the MDS–PAC available from HCFA; or

(2) Using a computer program(s) that

conforms to the HCFA standard

electronic record layout, data

specifications, and data dictionary,

includes the required MDS–PAC data

set, and meets other HCFA

specifications.

(b) How to transmit data. The

inpatient rehabilitation facility must—

(1) Electronically transmit complete

and encoded MDS–PAC data for each

Medicare inpatient to the HCFA MDS–

PAC system in accordance with the data

format specified in paragraph (a) of this

section; and

(2) Transmit data using electronic

communications software that provides

a direct telephone connection from the

inpatient rehabilitation facility to the

HCFA MDS–PAC system.

(c) Transmission dates. All MDS–PAC

assessments must be transmitted to

HCFA MDS–PAC system by the 7th

calendar day in the period beginning

with the last permitted MDS–PAC

encoding date.

(d) Late transmission penalty. (1)

HCFA assesses a penalty when an

inpatient rehabilitation facility does not

transmit the required MDS–PAC data to

the HCFA MDS–PAC system in

accordance with the transmission

timeframe in paragraph (c) of this

section.

(2) If the actual MDS–PAC

transmission date is later than the

transmission date specified in paragraph

(a) of this section the MDS–PAC data is

considered late.

(i) If the MDS–PAC transmission date

is late by 10 calendar days or fewer, the

inpatient rehabilitation facility receives

a payment rate that is 25 percent less

than the payment rate associated with a

case-mix group.

(ii) If the MDS–PAC transmission date

is late by more than 10 calendar days,

the inpatient rehabilitation facility

receives no payment.

§ 412.616 Release of information collected

using the MDS–PAC.

(a) General. An inpatient

rehabilitation facility may release

information from the MDS–PAC only as

specified in § 482.24(b)(3) of this

chapter.

(b) Release to the inpatient

rehabilitation facility’s agent. An

inpatient rehabilitation facility may

release information that is patientidentifiable to an agent only in

accordance with a written contract

under which the agent agrees not to use

or disclose the information except for

the purposes specified in the contract

and only to the extent the facility itself

is permitted to do so under paragraph

(a) of this section.

§ 412.618 Interrupted stay.

For purposes of the MDS–PAC

assessment process, if a Medicare

patient has an interrupted stay the

following applies:

(a) Assessment requirements. (1) The

initial case-mix group classification

from the Day 4 MDS–PAC assessment

remains in effect (that is, no new Day 4

MDS–PAC assessment is performed).

(2) The required scheduled MDS–PAC

Day 11, Day 30, and Day 60 assessments

must be performed.

(3) When the patient is discharged, a

discharge MDS–PAC assessment must

be performed.

(b) Recording and encoding of data.

The authorized clinician must record

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the interrupted stay data on the

interrupted stay tracking form of the

MDS–PAC.

(c) Transmission of data. The data

recorded on the interrupted stay

tracking form must be transmitted to the

HCFA MDS–PAC system within 7

calendar days of the date that the

Medicare patient returns to the inpatient

rehabilitation facility.

(d) Revised assessment schedule. (1) If

the interrupted stay occurs before the

Day 4 assessment, the assessment

reference dates, completion dates,

encoding dates, and data transmission

dates for the Day 4 and Day 11 MDS–

PAC assessments are advanced by the

same number of calendar days as the

length of the patient’s interrupted stay.

(2) If the interrupted stay occurs after

the Day 4 assessment and before the Day

11 assessment, then the assessment

reference date, completion date,

encoding date, and data transmission

date for the Day 11 MDS–PAC

assessment are advanced by the same

number of calendar days as the length

of the patient’s interrupted stay.

(3) If the interrupted stay occurs after

the Day 11 and before the Day 30

assessment, then the assessment

reference date, completion date,

encoding date, and data transmission

date for the Day 30 MDS–PAC

assessment are advanced by the same

number of calendar days as the length

of the patient’s interrupted stay.

(4) If the interrupted stay occurs after

the Day 30 and before the Day 60

assessment then the assessment

reference date, completion date,

encoding date, and data transmission

date for the Day 60 MDS–PAC

assessment are advanced by the same

number of calendar days as the length

of the patient’s interrupted stay.

§ 412.620 Patient classification system.

(a) Classification methodology. (1) A

patient classification system is used to

classify patients in inpatient

rehabilitation facilities into mutually

exclusive case-mix groups.

(2) For the purposes of this subpart,

case-mix groups are classes of Medicare

patient discharges by functional-related

groups that are based on a patient’s

impairment, age, comorbidities,

functional capabilities, and other factors

that may improve the ability of the

functional-related groups to estimate

variations in resource use.

(3) Data from Day 4 assessments

under § 412.610(c)(1) are used to

classify a Medicare patient into an

appropriate case-mix group.

(b) Weighting factors. (1) General. An

appropriate weight is assigned to each

case-mix group that measures the

relative difference in facility resource

intensity among the various case-mix

groups.

(2) Short-stay outliers. HCFA will

determine a weighting factor or factors

for patients that are discharged and not

transferred within a number of days

from admission as specified by HCFA.

(3) Patients who expire. HCFA will

determine a weighting factor or factors

for patients who expire within a number

of days from admission as specified by

HCFA.

(c) Revision of case-mix group

classifications and weighting factors.

HCFA may periodically adjust the casemix groups and weighting factors to

reflect changes in—

(1) Treatment patterns;

(2) Technology;

(3) Number of discharges; and

(4) Other factors affecting the relative

use of resources.

§ 412.622 Basis of payment.

(a) Method of payment. (1) Under the

prospective payment system, inpatient

rehabilitation facilities receive a

predetermined amount per discharge for

inpatient services furnished to Medicare

beneficiaries.

(2) The amount of payment under the

prospective payment system is based on

the Federal payment rate, including

adjustments described in § 412.624 and,

during a transition period, on a blend of

the Federal payment rate and the

facility-specific payment rate described

in § 412.626.

(b) Payment in full. (1) The payment

made under this subpart represents

payment in full (subject to applicable

deductibles and coinsurance as

described in subpart G of part 409 of

this subchapter) for inpatient operating

and capital costs associated with

furnishing Medicare covered services in

an inpatient rehabilitation facility, but

not for the cost of an approved medical

education program described in

§§ 413.85 and 413.86 of this chapter.

(2) In addition to payments based on

prospective payment rates, inpatient

rehabilitation facilities receive

payments for the following—

(i) Bad debts of Medicare

beneficiaries, as provided in § 413.80 of

this chapter, and

(ii) A payment amount per unit for

blood clotting factor provided to

Medicare inpatients who have

hemophilia.

§ 412.624 Methodology for calculating the

Federal prospective payment rates.

(a) Data used. To calculate the

prospective payment rates for inpatient

hospital services furnished by inpatient

rehabilitation facilities HCFA uses—

(1) The most recent Medicare data

available, as of the date of establishing

the inpatient rehabilitation facility

prospective payment system, used to

estimate payments for inpatient

operating and capital costs made under

part 413 under this subchapter;

(2) An appropriate wage index to

adjust for area wage differences;

(3) An increase factor to adjust for the

most recent estimate of increases in the

prices of an appropriate market basket

of goods and services included in

covered inpatient rehabilitation

services; and

(4) Patient assessment data described

in § 412.606 and other data that account

for the relative resource utilization of

different patient types.

(b) Determining the average costs per

discharge for fiscal year 2000. HCFA

determines the average inpatient

operating and capital costs per

discharge for which payment is made to

each inpatient rehabilitation facility

using the available data under

paragraph (a)(1) of this section. The cost

per discharge is adjusted to fiscal year

2000 by an increase factor, described in

paragraph (a)(3) of this section, under

the update methodology described in

section 1886(b)(3)(B)(ii) of the Act for

each year through the midpoint of fiscal

year 2000.

(c) Determining the Federal

prospective payment rates—(1) General.

The Federal prospective payment rates

will be established using a standard

payment amount referred to as the

budget neutral conversion factor. The

budget neutral conversion factor is a

standardized payment amount based on

average costs from a base year which

reflects the combined aggregate effects

of the weighting factors, various facility

and case level adjustments and other

adjustments.

(2) Update the cost per discharge. (i)

HCFA applies the increase factor

described in paragraph (a)(3) of this

section to the facility’s cost per

discharge determined under paragraph

(b) of this section to compute the cost

per discharge for fiscal year 2001. Based

on the updated cost per discharge,

HCFA estimates the payments that

would have been made to the facility for

fiscal year 2001 under part 413 of this

chapter without regard to the

prospective payment system

implemented under this subpart.

(ii) HCFA applies the increase factor

described in paragraph (a)(3) of this

section to the facility’s fiscal year 2001

cost per discharge determined under

paragraph (c)(2)(i) of this section to

compute the cost per discharge for fiscal

year 2002. Based on the updated cost

per discharge, HCFA estimates the

66382 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

payments that would have been made to

the facility for fiscal year 2002 under

part 413 of this chapter without regard

to the prospective payment system

implemented under this subpart.

(3) Computation of the budget neutral

conversion factor. The budget neutral

conversion factor is computed as

follows:

(i) For fiscal years 2001 and 2002.

Based on the updated costs per

discharge and estimated payments for

fiscal years 2001 and 2002 determined

in paragraphs (c)(2)(i) and (c)(2)(ii) of

this section, HCFA computes a budget

neutral conversion factor for fiscal years

2001 and 2002, as specified by HCFA,

that reflects, as appropriate, the

adjustments described in paragraph (d)

of this section.

(ii) For fiscal years after 2002. The

budget neutral conversion factor for

fiscal years after 2002 will be the

standardized payments for the previous

fiscal year updated by the increase

factor described in paragraph (a)(3) of

this section including adjustments,

described in paragraph (d) of this

section, as appropriate.

(4) Determining the Federal

prospective payment rate for each casemix group. The Federal prospective

payment rates for each case-mix group

is the product of the weighting factors

described in § 412.620(b) and the budget

neutral conversion factor described in

paragraph (c)(3) of this section.

(d) Adjustments to the budget neutral

conversion factor. The budget neutral

conversion factor described in

paragraph (c)(3) of this section will be

adjusted for—

(1) Outlier payments. HCFA

determines a reduction factor equal to

the estimated proportion of additional

outlier payments described in paragraph

(e)(4) of this section.

(2) Budget neutrality. HCFA adjusts

the Federal prospective payment rates

for fiscal years 2001 and 2002 so that

aggregate payments under the

prospective payment system are

estimated to equal 98 percent of the

amount that would have been made to

inpatient rehabilitation facilities under

part 413 of this subchapter without

regard to the prospective payment

system implemented under this subpart.

(3) Coding and classification changes.

HCFA adjusts the budget neutral

conversion factor for a given year if

HCFA determines that revisions in casemix classifications or weighting factors

for a previous fiscal year (or estimates

that such revisions for a future fiscal

year) did result in (or would otherwise

result in) a change in aggregate

payments that are a result of changes in

the coding or classification of patients

that do not reflect real changes in casemix.

(e) Calculation of the adjusted Federal

prospective payment. For each

discharge, an inpatient rehabilitation

facility’s Federal prospective payment is

computed on the basis of the Federal

prospective payment rate determined

under paragraph (c) of this section. A

facility’s Federal prospective payment

rate will be adjusted, as appropriate, to

account for area wage levels, payments

for outliers and transfers, and for other

factors as follows:

(1) Adjustment for area wage levels.

The labor portion of a facility’s Federal

prospective payment is adjusted to

account for geographical differences in

the area wage levels using an

appropriate wage index. The application

of the wage index is made on the basis

of the location of the facility in an urban

or rural area as defined in § 412.602.

(2) Adjustments for low income

patients. HCFA adjusts the Federal

prospective payment, on a facility basis,

for the proportion of low income

patients that receive inpatient

rehabilitation services as determined by

HCFA.

(3) Adjustments for rural areas. HCFA

adjusts the Federal prospective payment

by a factor, as specified by HCFA, to

account for the higher costs per patient

in facilities located in rural areas as

defined in § 412.602.

(4) Adjustment for high cost outliers.

HCFA provides for an additional

payment to a facility if its estimated

costs for a patient exceeds a fixed dollar

amount (adjusted for area wage levels,

and factors to account for treating low

income patients and for rural locations)

as specified by HCFA. The additional

payment equals 80 percent of the

difference between the estimated cost of

the patient and the sum of the adjusted

Federal prospective payment computed

under this section and the adjusted

fixed dollar amount.

(5) Adjustments related to the MDS–

PAC. An adjustment to a facility’s

Federal prospective payment amount for

a given discharge will be made if—

(i) The assessment reference date

identified on the MDS–PAC as

described in § 412.610(d) is late; and

(ii) The transmission of MDS–PAC

data as described in § 412.614(d) is late.

(f) Special payment provision for

patients that are transferred. (1) A

facility’s Federal prospective payment

will be adjusted to account for a

discharge of a patient who—

(i) Is transferred from the inpatient

rehabilitation facility to another site of

care,; and

(ii) Stays in the facility for a number

of days that is less than the average

length of stay for non-transfer cases in

the case-mix group to which the patient

is classified.

(2) HCFA calculates the adjusted

Federal prospective payment for

patients who are transferred in the

following manner:

(i) By dividing the Federal

prospective payment by the average

length of stay for non-transfer cases in

the case-mix group to which the patient

is classified to equal the payment per

day.

(ii) By multiplying the payment per

day under paragraph (f)(2)(i) of this

section by the number of days the

patient stayed in the facility prior to

being discharged to equal the

unadjusted payment amount.

(iii) By applying the adjustments

described in paragraphs (e)(1), (e)(2),

and (e)(3) of this section to the

unadjusted payment amount

determined in paragraph (f)(2)(ii) of this

section.

§ 412.626 Transition period.

(a) Duration of transition period and

proportions of the blended transition

rate. (1) For cost reporting periods

beginning on or after April 1, 2001

through fiscal year 2002, inpatient

rehabilitation facilities receive a

payment comprised of a blend of the

adjusted Federal prospective payment,

as determined in § 412.624(e) or

§ 412.624(f) and, a facility-specific

payment as determined in paragraph (b)

of this section.

(i) For cost reporting periods

beginning on or after April 1, 2001 and

before fiscal year 2002, payment is

based on 662⁄3 percent of the facilityspecific payment and 331⁄3 percent of

the adjusted Federal prospective

payment.

(ii) For cost reporting periods

beginning in fiscal year 2002, payment

is based on 331⁄3 percent of the facilityspecific payment and 662⁄3 percent of

the adjusted Federal prospective

payment.

(2) For cost reporting periods

beginning with fiscal year 2003 and

after, payment is based entirely on the

adjusted Federal prospective payment.

(b) Calculation of the facility-specific

payment. The facility-specific payment

is equal to the payment for each cost

reporting period in the transition period

that would have been made without

regard to this subpart. The facility’s

Medicare fiscal intermediary calculates

the facility-specific payment for

inpatient operating costs and capital

costs in accordance with part 413 of this

chapter.

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66383

§ 412.628 Publication of the Federal

prospective payment rates.

HCFA publishes information

pertaining to the inpatient rehabilitation

facility prospective payment system

effective for each fiscal year in the

Federal Register. This information

includes the unadjusted Federal

payment rates, the patient classification

system and associated weighting factors,

and a description of the methodology

and data used to calculate the payment

rates. This information is published on

or before August 1 prior to the

beginning of each fiscal year.

§ 412.630 Limitation on review.

Administrative or judicial review

under sections 1869 or 1878 of the Act,

or otherwise, is prohibited with regard

to the establishment of the methodology

to classify a patient into the case-mix

groups and the associated weighting

factors, the unadjusted Federal per

discharge payment rates, additional

payments for outliers and special

payments, and the area wage index.

§ 412.632 Method of payment under the

inpatient rehabilitation facility prospective

payment system.

(a) General rule. Subject to the

exceptions in paragraphs (b) and (c) of

this section, inpatient rehabilitation

facilities receive payment under this

subpart for inpatient operating costs and

capital costs for each discharge only

following submission of a discharge bill.

(b) Periodic interim payments. (1)

Criteria for receiving periodic interim

payments. (i) An inpatient rehabilitation

facility receiving payment under this

subpart may receive periodic interim

payments (PIP) for Part A services under

the PIP method subject to the provisions

of § 413.64(h) of this subchapter.

(ii) To be approved for PIP, the

inpatient rehabilitation facility must

meet the qualifying requirements in

§ 413.64(h)(3) of this subchapter.

(iii) Payments to a rehabilitation unit

are made under the same method of

payment as the hospital of which it is

a part as described in § 412.116.

(iv) As provided in § 413.64(h)(5) of

this chapter, intermediary approval is

conditioned upon the intermediary’s

best judgment as to whether payment

can be made under the PIP method

without undue risk of its resulting in an

overpayment to the provider.

(2) Frequency of payment. For

facilities approved for PIP, the

intermediary estimates the inpatient

rehabilitation facility’s Federal

prospective payments net of estimated

beneficiary deductibles and coinsurance

and makes biweekly payments equal to

1⁄26 of the total estimated amount of

payment for the year. If the inpatient

rehabilitation facility has payment

experience under the prospective

payment system, the intermediary

estimates PIP based on that payment

experience, adjusted for projected

changes supported by substantiated

information for the current year. Each

payment is made 2 weeks after the end

of a biweekly period of service as

described in § 413.64(h)(6) of this

subchapter. The interim payments are

reviewed at least twice during the

reporting period and adjusted if

necessary. Fewer reviews may be

necessary if an inpatient rehabilitation

facility receives interim payments for

less than a full reporting period. These

payments are subject to final settlement.

(3) Termination of PIP—(i) Request by

the inpatient rehabilitation facility.

Subject to paragraph (b)(1)(iii) of this

section, an inpatient rehabilitation

facility receiving PIP may convert to

receiving prospective payments on a

non-PIP basis at any time.

(ii) Removal by the intermediary. An

intermediary terminates PIP if the

inpatient rehabilitation facility no

longer meets the requirements of

§ 413.64(h) of this chapter.

(c) Interim payments for Medicare bad

debts and for Part A costs not paid

under the prospective payment system.

For Medicare bad debts and for costs of

an approved education program and

other costs paid outside the prospective

payment system, the intermediary

determines the interim payments by

estimating the reimbursable amount for

the year based on the previous year’s

experience, adjusted for projected

changes supported by substantiated

information for the current year, and

makes biweekly payments equal to 1⁄26

of the total estimated amount. Each

payment is made 2 weeks after the end

of a biweekly period of service as

described in § 413.64(h)(6) of this

chapter. The interim payments are

reviewed at least twice during the

reporting period and adjusted if

necessary. Fewer reviews may be

necessary if an inpatient rehabilitation

facility receives interim payments for

less than a full reporting period. These

payments are subject to final cost

settlement.

(d) Outlier payments. Additional

payments for outliers are not made on

an interim basis. The outlier payments

are made based on the submission of a

discharge bill and represent final

payment.

(e) Accelerated payments—(1)

General rule. Upon request, an

accelerated payment may be made to an

inpatient rehabilitation facility that is

receiving payment under this subpart

and is not receiving PIP under

paragraph (b) of this section if the

inpatient rehabilitation facility is

experiencing financial difficulties

because of the following:

(i) There is a delay by the

intermediary in making payment to the

inpatient rehabilitation facility.

(ii) Due to an exceptional situation,

there is a temporary delay in the

inpatient rehabilitation facility’s

preparation and submittal of bills to the

intermediary beyond its normal billing

cycle.

(2) Approval of payment. An inpatient

rehabilitation facility’s request for an

accelerated payment must be approved

by the intermediary and HCFA.

(3) Amount of payment. The amount

of the accelerated payment is computed

as a percentage of the net payment for

unbilled or unpaid covered services.

(4) Recovery of payment. Recovery of

the accelerated payment is made by

recoupment as inpatient rehabilitation

facility bills are processed or by direct

payment by the inpatient rehabilitation

facility.

B. Part 413 is amended as set forth

below:

PART 413—PRINCIPLES OF

REASONABLE COST

REIMBURSEMENT; PAYMENT FOR

END-STAGE RENAL DISEASE

SERVICES; PROSPECTIVELY

DETERMINED PAYMENT FOR

SKILLED NURSING FACILITIES

1. The authority citation for part 413

is revised to read as follows:

Authority: Secs. 1102, 1812(d), 1814(b),

1815, 1833(a), (i) and (n), 1861(v), 1871,

1881, 1883, and 1886 of the Social Security

Act (42 U.S.C. 1302, 1395f(b), 1395g, 1395l,

1395l(a), (i) and (n), 1395x(v), 1395hh,

1395rr, 1395tt, and 1395ww).

Subpart A—Introduction and General

Rules

2. Section 413.1 is amended by:

A. Revising paragraph (d)(2)(ii).

B. Adding paragraphs (d)(2)(iv) and

(d)(2)(v).

§ 413.1 Introduction.

* * * * *

(d) * * *

(2) * * *

(ii) Payment to children’s, psychiatric,

and long-term hospitals (as well as

separate psychiatric units (distinct

parts) of short-term general hospitals),

that are excluded from the prospective

payment systems under subpart B of

part 412 of this subchapter, and

hospitals outside the 50 States and the

District of Columbia is on a reasonable

66384 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

cost basis, subject to the provisions of

§ 413.40.

* * * * *

(iv) For cost reporting periods

beginning before April 1, 2001, payment

to rehabilitation hospitals (as well as

separate rehabilitation units (distinct

parts) of short-term general hospitals),

that are excluded under subpart B of

part 412 of this subchapter from the

prospective payment systems is on a

reasonable cost basis, subject to the

provisions of § 413.40.

(v) For cost reporting periods

beginning on or after April 1, 2001,

payment to rehabilitation hospitals (as

well as separate rehabilitation units

(distinct parts) of short-term general

hospitals) that meet the conditions of

§ 412.604 of this chapter is based on

prospectively determined rates under

subpart P of part 412 of this subchapter.

* * * * *

Subpart C—Limits on Cost

Reimbursement

3. Section 413.40 is amended by:

A. Republishing the introductory text

of paragraph (a)(2)(i).

B. Adding a new paragraph

(a)(2)(i)(C).

C. Revising paragraph (a)(2)(ii).

D. Adding paragraph (a)(2)(iii).

§ 413.40 Ceiling on the rate of increase in

hospital inpatient costs.

(a) Introduction. ***

(2) Applicability. (i) This section is

not applicable to—

* * * * *

(C) Rehabilitation hospitals and

rehabilitation units that are paid under

the prospective payment system for

inpatient hospital services in

accordance with section 1886(j) of the

Act and subpart P of part 412 of this

subchapter for cost reporting periods

beginning on or after October 1, 2002.

(ii) For cost reporting periods

beginning on or after October 1, 1983,

this section applies to—

(A) Hospitals excluded from the

prospective payment systems described

in § 412.1(a)(1) of this subchapter; and

(B) Psychiatric and rehabilitation

units excluded from the prospective

payment systems, as described in

§ 412.1(a)(1) of this chapter and in

accordance with §§ 412.25 through

412.30 of this chapter, except as limited

by paragraph (a)(2)(iii) of this section

with respect to rehabilitation hospitals

and rehabilitation units specified in

§§ 412.23(b), 412.27, and 412.29 of this

subchapter.

(iii) For cost reporting periods

beginning on or after October 1, 1983

and before April 1, 2001, this section

applies to rehabilitation hospitals and

rehabilitation units that are excluded

from the prospective payment systems

described in § 412.1(a)(1) of this

subchapter.

* * * * *

Subpart E—Payments to Providers

4. In § 413.64 paragraph (h)(2)(i) is

revised to read as follows:

§ 413.64 Payment to providers: Specific

rules.

* * * * *

(h) Periodic interim payment method

of reimbursement—***

(2) * * *

(i) Part A inpatient services furnished

in hospitals that are excluded from the

prospective payment systems, described

in § 412.1(a)(1) of this chapter, under

subpart B of part 412 of this chapter or

are paid under the prospective payment

system described in subpart P of part

412 of this chapter.

* * * * *

(Catalog of Federal Domestic Assistance

Program No. 93.778, Medical Assistance

Program)

Dated: September 18, 2000.

Nancy-Ann Min DeParle,

Administrator, Health Care Financing

Administration.

Dated: September 29, 2000.

Donna E. Shalala,

Secretary.

Note: The following appendices will not

appear in the Code of Federal Regulations.

Appendix A—Technical Discussion of

Cases and Providers Used in RAND

Analysis

This Appendix explains the methodology

used to create the data file used to develop

the proposed IRF prospective payment

system. A general description of the process

to create this data file is contained in section

II of this proposed rule. RAND has performed

the following analysis to match UDSmr, COS,

and HCFA data files.

Table A shows that for 1996 and 1997, the

MEDPAR files had over 12 million records

per year. We are interested in a subset of

these records: cases paid by Medicare as

rehabilitation stays that were exempt from

the acute care hospital PPS.

TABLE A.—NUMBER OF MEDPAR

CASES AND FACILITIES

Calendar year No. of

cases

No. of

facilities

1996 .......................... 12,231,275 6,339

1997 .......................... 12,263,463 6,257

Table B shows total 1996 and 1997

rehabilitation stays by type of provider (freestanding rehabilitation facility versus

excluded unit of an acute care hospital). This

was the ‘‘sampling’’ frame. In order to

describe the IRF prospective payment system

case-mix, RAND attached information from

FIM instruments to each record in this frame,

thereby obtaining ‘‘complete’’ records. To the

extent that RAND was unable to add

information to some records, it was

important to know both how to and whether

to weight the complete records so they would

reflect the composition of the frame.

TABLE B.—NUMBER OF REHABILITATION MEDPAR CASES AND FACILITIES

Calendar year/type No. of

cases

No. of

facilities

1996:

Excluded unit ........... 229,193 877

Free-standing .......... 114,933 204

Total ..................... 344,126 1,081

1997:

Excluded unit ........... 240,491 911

Free-standing .......... 118,541 212

Total ..................... 359,032 1,123

Note: Free-standing facilities have characters 3–6 of the Medicare provider number in

the range 3025–3099. Patients receiving rehabilitation care in excluded units of acute care

hospitals have a ‘‘provider code’’ of T in their

MEDPAR records.

Table C shows the number of facilities and

the number of UDSmr and COS records for

calendar years 1996 and 1997.

TABLE C.—NUMBER OF UDSMR/COS

RECORDS AND FACILITIES

Calendar

year Source No. ofrecords

No. of

facilities

1996 ......... UDSmr ..... 225,069 533

COS ......... 44,478 159

1997 ......... UDSmr ..... 258,915 595

COS ......... 67,350 164

Matching MEDPAR and UDSmr/COS

Facilities

The first step in the matching process is to

link MEDPAR facilities to UDSmr/COS

facilities. For each of these combinations,

RAND counted the number of exact matches

of MEDPAR and UDSmr/COS records based

on admission date, discharge date, and zip

code. Table D summarizes the results of this

stage of the linking process. The number of

facilities represented in our UDSmr/COS

datasets is slightly more than half of all IRFs.

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66385

TABLE D.—NUMBERS OF UDSMR/COS FACILITIES LINKED TO MEDPAR FACILITIES

Calendar year/source MEDPAR

Unique 1

MEDPAR

Multiple 2

NonRehab 3 Total

1996:

UDSmr ............................................................................................................................................... 501 10 22 533

COS ................................................................................................................................................... 67 8 84 159

1997:

UDSmr ............................................................................................................................................... 557 15 23 595

COS ................................................................................................................................................... 68 18 78 164

1 UDSmr/COS IRFs that appear to have a single MEDPAR provider.

2 UDSmr/COS IRFs that appear to have more than one MEDPAR provider.

3 UDSmr/COS IRFs that appear to be SNFs or long term care hospitals.

The UDSmr/COS data do not contain the

Medicare beneficiary identifier, and therefore

it was necessary to use a probabilistic

matching algorithm based on characteristics

of the beneficiary and the hospitalization.

The matching was accomplished in a series

of four steps:

(1) Identify match variables;

(2) Recode certain UDSmr/COS variables to

be consistent with MEDPAR, create

additional records for UDSmr interrupted

stays, and eliminate duplicate cases;

(3) Run a match algorithm to link UDSmr/

COS and MEDPAR records; and

(4) Choose a single MEDPAR case if it

matches multiple UDSmr or COS cases.

Step 1: Identify Match Variables

A further search for matches only within

the provider number and facility identifier

pairings was performed. For free-standing

facilities, an attempt was made to match all

MEDPAR records to a UDSmr record.

For MEDPAR, in addition to facility

identity, 6 variables were used to link the

records: Admission date, discharge date, zip

code, age at admission, sex, and race. For

UDSmr/COS, the same information in a

slightly recoded form was available (for

example, birth date). An indicator of whether

Medicare was the primary payor was used to

determine how to set certain parameters for

the matching algorithm.

Step 2: Create Additional UDSmr/COS Files

COS’s coding of interrupted stays is similar

to Medicare’s: One record per rehabilitation

episode; therefore, these records did not

require any additional processing. UDSmr,

however, codes multiple stays via a series of

‘‘transfer/return’’ dates on a single UDSmr

record. To facilitate matching UDSmr and

MEDPAR records, multiple records for

interrupted stays were created with

admission and discharge dates corresponding

to the beginning and ending of each stay. The

additional records were then given the same

chance of matching MEDPAR records as any

non-interrupted stay. For both UDSmr and

COS files, there were some duplicate cases.

Table E shows the number of records

present at the various stages of processing.

The last column shows the number of cases

that would be matched to MEDPAR.

TABLE E.—NUMBER OF UDSMR/COS RECORDS AT VARIOUS STAGES OF PROCESSING

Calendar year/source

No. of records

Original After

expansion

After

duplicate

elimination

1996:

UDSmr .............................................................................................................................................. 225,069 232,076 231,003

COS .................................................................................................................................................. 44,478 44,478 44,375

1997:

UDSmr .............................................................................................................................................. 258,915 267,444 266,288

COS .................................................................................................................................................. 67,350 67,350 67,082

Step 3: Match Discharges from MEDPAR and

UDSmr/CareData

A match algorithm similar to the one used

in Carter, Relles, et al. (1997) was run

assuming that links are imperfect—any

variable can be in error. A scoring function

is developed, based on Bayes’ Theorem,

which gives the odds of a match based on

how consistent variables tend to be for true

matching and non-matching cases. A score of

2.00 or above has a high probability of

identifying a match. The match statistics

reported below assume that cutoff.

Step 4: Choose a Single MEDPAR Case for

Multiple UDSmr/COS Matches

While the matching was unique within a

facility/provider pair, some MEDPAR

providers were paired with different

facilities, as shown in Table F. Also, some

UDSmr and COS facilities were the same: 6

overlaps in 1996, 7 in 1997.

TABLE F.—MEDPAR FACILITIES

PAIRED WITH MULTIPLE FACILITIES

Source Calendar

year

No. of

facilities

UDSmr ...................... 1996 5

UDSmr ...................... 1997 8

COS .......................... 1996 5

COS .......................... 1997 10

First, MEDPAR duplicate links were

eliminated within each file, and then

duplicate links were eliminated between

UDSmr and COS files all within the same

years. In all cases, the highest scores were

kept. Table G provides results for cutoff score

2.0.

66386 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

TABLE G.—NUMBER OF LINKED RECORDS AFTER DUPLICATION ELIMINATION

Calendar year/source

No. of Records, Cutoff Source ≥2.0

Multiple

paired

providers

(a)

Total

records

Duplicates

eliminated

(b)

Overlap

eliminated

(c)

1996:

UDSmr ...................................................................................................................... 5 163,509 162,850 162,692

COS .......................................................................................................................... 5 27,664 27,630 26,197

1997:

UDSmr ...................................................................................................................... 8 185,567 184,431 183,960

COS .......................................................................................................................... 10 42,219 41,980 38,722

Note: (a) Number of MEDPAR providers paired with more than one UDSmr/COS facility. (b) Multiple pairings can link the same MEDPAR

record to more than one UDSmr/COS case. This step eliminates those multiple links, keeping the link with the highest match score. (c) the same

MEDPAR provider might show up in both UDSmr and COS, again allowing the same MEDPAR record to match more than one UDSmr/COS

case.

Quality of the Match

There are two aspects to evaluating the

quality of the match. The first is whether we

actually matched all of the cases. To evaluate

this, we computed match rates for each of our

populations: UDSmr, COS, and MEDPAR.

The second aspect is the representativeness

of the match for the entire population. To

evaluate this, we compared patient and

facility characteristics to both linked and full

population, and considered whether some

form of weighting would make those

populations look sufficiently the same.

Match Rates

Table H suggests overall match rates in

these UDSmr/COS facilities for the eligible

RPPS population to be almost 90 percent.

This was slightly higher than expected—the

Carter, Relles, et al. (1997) match rates were

about 86 percent.

TABLE H.—MEDPAR MATCH RATES, PROVIDERS WITH A FULL YEAR OF DATA

Source Calendar

year

MEDPAR

cases

Matched

cases

Percent

matched

UDSmr ............................................................................................................................. 1996 155,502 136,056 87.5

UDSmr ............................................................................................................................. 1997 175,807 156,520 89.0

COS ................................................................................................................................. 1996 7,157 6,354 88.8

COS ................................................................................................................................. 1997 36,774 33,549 91.2

Note: Tabulations are for patients eligible for IRFPPS.

The UDSmr/COS.com files contain many cases not paid by Medicare, but the files provide an indication of whether Medicare

is the primary payer. Restricting our attention to just these cases, we obtain the percentages shown in Table I.

TABLE I.—UDSMR/COS MATCH RATES FOR MEDICARE AS THE PRIMARY PAYER

Source Calendar

year

UDS/COS

cases

Matched

cases

Percent

matched

UDSmr ............................................................................................................................. 1996 160,125 153,926 96.1

UDSmr ............................................................................................................................. 1997 179,179 171,885 95.9

COS ................................................................................................................................. 1996 28,767 26,857 93.4

COS ................................................................................................................................. 1997 44,172 41,168 93.2

Note: UDSmr/COS cases matching any Medicare case.

These match rates are also slightly higher

than reported in Carter and Relles (1997),

where a 93.7 percent rate was achieved for

1994 UDSmr data. We consider these match

rates to be acceptable, within the limitations

of information available.

Representativeness of Linked MEDPAR

For analytical purposes, lack of

representativeness is most important for

characteristics that are related to outcomes

we are trying to model. For example, if costs

for treating a patient in free-standing

facilities differed from costs in excluded

units of acute care hospitals, we would

consider re-weighting the sample of linked

cases to adjust our total cost estimates.

Representativeness of Linked MEDPAR

Hospital Characteristics

This section addresses the extent to which

the facilities present in the UDSmr/COS file

are representative of the set of all facilities

that provide inpatient rehabilitation care to

Medicare beneficiaries, and the extent to

which UDSmr/COS patients are

representative of all Medicare IRFPPSeligible patients. This analysis reflects the

effects of the partial-year sample available for

some UDSmr/COS facilities as well as the

sampling of MEDPAR facilities. The

MEDPAR records contain data from over

1,000 IRFs in each year. Table J divides these

facilities into free-standing rehabilitation

facilities (free-standing rehab) and excluded

rehabilitation units of acute-care hospitals

(excluded units). It presents the number of

facilities in the linked MEDPAR sample,

along with the total MEDPAR counts of

rehabilitation patients at these facilities.

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66387

TABLE J.—COMPARISON OF NUMBER OF UDSMR/COS AND MEDPAR REHABILITATION FACILITIES, BY TYPE

Type of facility

1996 1997

UDS/COS1 Total

MEDPAR 2

Percent

UDS/COS UDS/COS1 TotalMEDPAR 2

Percent

UDS/COS

Number of rehab facilities:

Free-standing rehab ................................................. 130 204 64 142 212 67

Excluded unit ............................................................ 435 877 50 489 911 54

Total ...................................................................... 565 1,081 42 631 1,123 56

Number of rehab patients:

Free-standing rehab ................................................. 86,301 114,933 75 94,327 118,541 80

Excluded unit ............................................................ 130,623 229,193 57 150,787 240,491 63

Total ...................................................................... 216,924 344,126 63 245,114 359,032 68

1 Hospitals with at least one linked MEDPAR/UDSmr/COS rehabilitation record.

2Total (matched and unmatched) rehabilitation cases.

As shown in Table J, UDSmr/COS slightly

over-represents free-standing rehabilitation

facilities and slightly under-represents

excluded units. The table also indicates

UDSmr/COS’s tendency to include larger

facilities. In 1997, UDSmr/COS facilities

represented 47 percent of the facilities, but

served almost 70 percent of all MEDPAR IRF

cases. Based on data found in the table, in

1997, UDSmr/COS free-standing facilities

had an average of 792 patients, 532 more

than other-MEDPAR free-standing facilities,

and UDSmr/COS excluded units had an

average of 365 patients, 185 more than otherMEDPAR excluded units.

Table K shows the distribution of UDSmr/

COS IRFs by size. This shows both that freestanding facilities are larger than excluded

units, and that UDSmr/COS IRFs tend to be

larger than other MEDPAR facilities within

type of facility.

TABLE K.—COMPARISON OF SIZES OF UDSMR/COS AND MEDPAR FACILITIES, BY TYPE OF FACILITY

No. of MEDPAR patients

1996 1997

Free-standing Excluded Unit Free-standing Excluded Unit

UDS/

COS

Other

MEDPAR

UDS/

COS

Other

MEDPAR

UDS/

COS

Other

MEDPAR

UDS/

COS

Other

MEDPAR

1–100 ............................................................... 2 23 30 97 4 24 33 105

101–200 ........................................................... 14 9 139 140 14 7 143 126

201–300 ........................................................... 14 2 105 102 11 5 123 103

301–400 ........................................................... 14 10 59 48 17 9 65 40

401–500 ........................................................... 8 8 38 27 12 7 52 29

501–1000 ......................................................... 56 16 58 26 59 15 67 18

1001–2000 ....................................................... 20 6 6 2 24 3 6 1

2001–3000 ....................................................... 1 0 0 0 0 0 0 0

3001–4000 ....................................................... 1 0 0 0 1 0 0 0

Total .......................................................... 130 74 435 442 142 70 489 422

Table L shows that there are some UDSmr/COS facilities in each region, although the southeast and mountain States appear

to be slightly under represented.

TABLE L.—NUMBER AND PERCENTAGE OF MEDPAR REHABILITATION CASES FOR UDSMR/COS SAMPLE HOSPITALS, BY

STATE

State

1996 1997

Total Percent

UDS/COS

Total Percent

UDS/COS UDS/COS MEDPAR UDS/COS MEDPAR

AL ..................................................................................... 7,135 7,839 91 8,338 8,654 96

AK .................................................................................... 136 247 55 153 302 51

AR .................................................................................... 2,829 6,581 43 3,338 6,973 48

AZ ..................................................................................... 2,261 3,672 62 2,334 4,084 57

CA .................................................................................... 8,108 15,294 53 7,899 15,559 51

CO .................................................................................... 1,306 4,757 27 2,786 4,263 65

CT .................................................................................... 1,521 2,217 69 2,024 2,290 88

DC .................................................................................... 133 1,097 12 104 996 10

DE .................................................................................... 1,061 1,399 76 985 1,361 72

FL ..................................................................................... 17,143 23,021 74 18,734 23,630 79

GA .................................................................................... 6,115 9,615 64 7,014 10,716 65

66388 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

TABLE L.—NUMBER AND PERCENTAGE OF MEDPAR REHABILITATION CASES FOR UDSMR/COS SAMPLE HOSPITALS, BY

STATE—Continued

State

1996 1997

Total Percent

UDS/COS

Total Percent

UDS/COS UDS/COS MEDPAR UDS/COS MEDPAR

HI ...................................................................................... 1,087 1,087 100 1,016 1,016 100

IA ...................................................................................... 1,264 1,264 100 1,404 1,404 100

ID ...................................................................................... 1,781 1,829 97 1,773 1,807 98

IL ...................................................................................... 8,044 14,953 54 9,191 14,894 62

IN ...................................................................................... 5,330 8,943 60 5,349 8,884 60

KS .................................................................................... 874 3,224 27 786 3,333 24

KY .................................................................................... 3,859 5,198 74 4,083 5,201 79

LA ..................................................................................... 3,338 9,206 36 5,071 10,061 50

MA .................................................................................... 4,532 8,765 52 5,748 8,631 67

MD .................................................................................... 667 867 77 574 715 80

ME .................................................................................... 130 1,255 10 1,047 1,460 72

MI ..................................................................................... 13,470 16,523 82 14,090 17,255 82

MN .................................................................................... 1,115 2,048 54 1,554 2,112 74

MO ................................................................................... 3,349 9,788 34 4,414 10,513 42

MS .................................................................................... 1,701 1,968 86 1,747 2,021 86

MT .................................................................................... 878 878 100 766 766 100

NC .................................................................................... 6,325 7,123 89 7,752 8,771 88

ND .................................................................................... 1,564 1,821 86 1,356 1,636 83

NE .................................................................................... 1,094 1,195 92 1,008 1,107 91

NH .................................................................................... 1,320 2,310 57 1,442 2,505 58

NJ ..................................................................................... 10,010 11,234 89 10,637 11,083 96

NM .................................................................................... 364 1,283 28 452 1,277 35

NV .................................................................................... 0 2,230 0 0 2,303 0

NY .................................................................................... 7,905 21,431 37 11,618 22,875 51

OH .................................................................................... 8,992 11,837 76 10,175 13,888 73

OK .................................................................................... 3,238 6,356 51 4,100 6,949 59

OR .................................................................................... 824 1,179 70 728 1,184 61

PA .................................................................................... 23,437 36,989 63 24,806 35,700 69

RI ...................................................................................... 1,379 2,247 61 1,517 2,307 66

SC .................................................................................... 3,758 4,536 83 4,200 4,878 86

SD .................................................................................... 1,684 2,096 80 1,702 2,101 81

TN .................................................................................... 7,574 10,731 71 8,477 11,917 71

TX ..................................................................................... 19,498 33,619 58 22,551 36,616 62

UT .................................................................................... 369 858 43 610 984 62

VA .................................................................................... 4,924 6,738 73 5,628 7,235 78

VT ..................................................................................... 446 603 74 412 567 73

WA ................................................................................... 3,726 3,753 99 3,584 3,608 99

WI ..................................................................................... 5,741 6,591 87 6,201 6,690 93

WV ................................................................................... 3,480 3,497 100 3,553 3,574 99

WY ................................................................................... 105 334 31 283 376 75

Total .......................................................................... 216,924 344,126 63 245,114 359,032 68

Representativeness of Patient and Stay Characteristics

Table M compares demographic characteristics of all Medicare rehabilitation patients with the matched UDSmr/COS sample. Of

all the characteristics examined, the UDSmr/COS sample of discharges appears very similar.

TABLE M.—PATIENT CHARACTERISTICS FOR MEDPAR REHABILITATION INPATIENTS, BY UDSMR/COS STATUS

Patient characteristic

1996 1997

UDS/COS Other

MEDPAR

Total

MEDPAR UDS/COS OtherMEDPAR

Total

MEDPAR

Sample Size ..................................................................... 171,626 172,500 344,126 206,032 153,000 359,032

Average Age .................................................................... 75.4 75.6 75.5 75.4 75.6 75.5

Age 0–50 .......................................................................... 2.6% 2.8% 2.7% 2.8% 3.0% 2.8%

Age 51–60 ........................................................................ 3.1% 3.1% 3.1% 3.2% 3.2% 3.2%

Age 61–70 ........................................................................ 20.1% 19.3% 19.7% 19.5% 18.9% 19.2%

Age 71–80 ........................................................................ 44.2% 42.8% 43.5% 43.9% 42.8% 43.4%

Age 81–90 ........................................................................ 26.9% 28.1% 27.5% 27.4% 28.2% 27.7%

Age 91+ ........................................................................... 3.2% 3.9% 3.5% 3.2% 4.0% 3.6%

Male ................................................................................. 37.9% 37.3% 37.6% 38.0% 37.6% 37.8%

White ................................................................................ 86.7% 85.8% 86.3% 86.6% 85.3% 86.1%

Black ................................................................................ 9.8% 10.6% 10.2% 10.1% 10.9% 10.4%

In-hospital death .............................................................. 0.2% 0.6% 0.4% 0.3% 0.7% 0.4%

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66389

Table N compares resources used for linked UDSmr/COS stays with those for other Medicare rehabilitation patients. Average length

of stay for UDSmr/COS cases is the same as for non-UDSmr/COS patients. However, for cases in free-standing hospitals, UDSmr/

COS stays consume fewer resources: LOS and total charges are about 10 percent less.

TABLE N.—COMPARISON OF RESOURCE USE FOR MEDICARE REHABILITATION INPATIENTS, BY UDSMR/COS STATUS

Hospitalization characteristic

1996 1997

UDS/COS Other

MEDPAR

Total

MEDPAR UDS/COS OtherMEDPAR

Total

MEDPAR

All hospitals:

Sample size ...................................... 171,626 172,500 344,126 206,032 153,000 359,032

Length of Stay (days) ....................... 16.20 16.20 16.20 15.70 15.70 15.70

Daily therapy charges ....................... $360.00 $351.00 $355.00 $379.00 $368.00 $374.00

Total therapy charges ....................... $5,960.00 $5,829.00 $5,894.00 $6,064.00 $5,924.00 $6,004.00

Total charges .................................... $18,013.00 $18,790.00 $18,403.00 $18,348.00 $19,287.00 $18,748.00

Freestanding hospitals:

Sample size ...................................... 65,349 49,584 114,933 82,393 36,148 118,541

Length of Stay (days) ....................... 18.0 18.9 18.4 17.8 19.2 18.2

Daily therapy charges ....................... $360.00 $387.00 $371.00 $384.00 $406.00 $391.00

Total therapy charges ....................... $6,652.00 $7,605.00 $7,063.00 $7,002.00 $8,064.00 $7,325.00

Total charges .................................... $19,443.00 $21,214.00 $20,207.00 $20,202.00 $22,541.00 $20,915.00

Note: UDSmr/COS case totals count matched cases, hence differ from Table J which counts matched and unmatched cases.

Appendix B: Variables Suggested for Exclusion from the MDS–PAC Instrument During the pilot and field testings of versions 7–9 of the MDS–PAC, a number of assessors (Registered Nurses, Physical Therapists,

or Occupational Therapists) were asked to rate which items on the MDS–PAC they would suggest dropping. Based on these findings,

the MDS–PAC no longer includes 104 items that were originally field tested in Version 8 of the instrument. The table below describes

the percentage of assessors by facility type (rehabilitation hospital or skilled nursing facility) who recommended dropping each of

the MDS–PAC items displayed in the table. The table is broken down by the type of facility in which the assessor was employed.

The items in the table below are the majority of the items that are now in the version of the MDS–PAC found in Appendix BB.

TABLE 1.—PERCENT OF ASSESSORS BY THE TYPE OF FACILITY WHO RECOMMENDED REMOVAL OF MDS–PAC ITEMS

MDS–PAC item No. MDS–PAC item

Percent of assessors by facility-type

who recommended removal of specific

MDS–PAC items

Rehabilitation

hospitals

Skilled nursing

facilities

A1A .............................................. First Name ......................................................................................... 0 8.3

A1B .............................................. Middle Initial ...................................................................................... 0 8.3

A1C .............................................. Last Name ......................................................................................... 0 8.3

A1D .............................................. Jr/Sr ................................................................................................... 0 8.3

A3 ................................................. Reason for Assessment .................................................................... 5.9 2.0

A5A .............................................. Medical Stabilization ......................................................................... 5.8 10.0

A5B .............................................. Rehab/Functional Improvement ........................................................ 4.7 4.0

A5C .............................................. Recuperation ..................................................................................... 12.8 18.0

A5D .............................................. Monitor to Avoid Clinical Complication ............................................. 9.2 6.0

A5E .............................................. Palliative Care ................................................................................... 18.6 6.0

A6 ................................................. Admitted from .................................................................................... 6.5 4.8

A7A .............................................. Time of Onset of Precipitating Event ................................................ 15.4 33.3

A7B .............................................. Reason Most Recent Acute Care Hospitalization ............................ 8.6 10.0

A8A .............................................. Primary Payment Source for Stay .................................................... 2.3 4.0

A8B .............................................. Secondary Payment Source for Stay ............................................... 5.7 8.2

A9 ................................................. Marital Status .................................................................................... 4.7 4.2

AA10 ............................................ Gender .............................................................................................. 0 2.0

AA11 ............................................ Birthdate ............................................................................................ 0 8.3

AA12A .......................................... American Indian/Alaskan Native ....................................................... 12.0 16.7

AA12B .......................................... Asian ................................................................................................. 12.0 16.7

AA12C .......................................... Black or African-American ................................................................ 12.0 16.7

AA12D .......................................... Native Hawaiian or Other Pacific Islander ........................................ 12.0 16.7

AA12E .......................................... White ................................................................................................. 12.0 16.7

AA12F .......................................... Hispanic or Latino ............................................................................. 15.4 16.7

AA13 ............................................ Date of Reentry ................................................................................. 12.9 14.3

A10 ............................................... Education .......................................................................................... 10.3 6.0

A11A ............................................ Primary Language ............................................................................. 1.2 2.0

A11B ............................................ Other Language ................................................................................ 2.4 2.0

A12 ............................................... Dominant Hand ................................................................................. 9.2 50.0

A13 ............................................... Mental Health History ........................................................................ 12.3 4.9

A14 ............................................... Conditions Related to MR/DD Status ............................................... 12.5 25.0

A15A ............................................ Legal Guardian .................................................................................. 7.5 5.0

A15B ............................................ Other Legal Oversight ....................................................................... 7.5 5.0

A15C ............................................ Durable Power of Attorney/Health .................................................... 7.5 5.0

A15D ............................................ Patient Responsible for Self ............................................................. 7.5 5.0

66390 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

TABLE 1.—PERCENT OF ASSESSORS BY THE TYPE OF FACILITY WHO RECOMMENDED REMOVAL OF MDS–PAC ITEMS—

Continued

MDS–PAC item No. MDS–PAC item

Percent of assessors by facility-type

who recommended removal of specific

MDS–PAC items

Rehabilitation

hospitals

Skilled nursing

facilities

A16A ............................................ Living Will .......................................................................................... 11.5 2.0

A16B ............................................ Do Not Resuscitate ........................................................................... 13.8 0

A16C ............................................ Do Not Hospitalize ............................................................................ 16.1 4.1

A16D ............................................ Other Treatment Restrictions ............................................................ 13.8 2.0

A16E ............................................ None of the above ............................................................................ 12.6 2.0

AA2A ............................................ Date of Entry ..................................................................................... 3.1 0

AA4 .............................................. Assessment Reference Date ............................................................ 0 0

AA6A ............................................ Social Security # ............................................................................... 3.4 0

AA6B ............................................ Medicare # ........................................................................................ 0 0

AA7 .............................................. Medical Record &num ....................................................................... 2.3 0

AA8A ............................................ State # ............................................................................................... 6.9 2.0

AA8B ............................................ Federal # ........................................................................................... 4.7 0

AA9 .............................................. Medicaid # ......................................................................................... 1.2 0

B1 ................................................. Comatose .......................................................................................... 14.8 0

B2A .............................................. Short-term Memory Ok ..................................................................... 0 2.0

B2B .............................................. Long-term Memory Ok ...................................................................... 0 2.0

B2C .............................................. Situational Memory Ok ...................................................................... 8.2 0

B2D .............................................. Procedural Memory Ok ..................................................................... 5.9 0

B3A .............................................. Decisions Regarding Tasks of Daily Life .......................................... 2.3 0

B3B .............................................. Status Compared to 30 Days Ago .................................................... 6.9 24.5

B4A .............................................. Easily Distracted ............................................................................... 5.7 0

B4B .............................................. Periods of Altered Perception ........................................................... 5.7 2.0

B4C .............................................. Episodes of Disorganized Speech .................................................... 5.7 4.1

B4D .............................................. Periods of Restlessness ................................................................... 5.7 2.0

B4E .............................................. Periods of Lethargy ........................................................................... 6.1 0

B4F .............................................. Mental Function Varies over Course of Day .................................... 7.4 0

C1 ................................................ Hearing .............................................................................................. 3.4 0

C2A .............................................. Hearing Aid ....................................................................................... 4.5 0

C2B .............................................. Lip Reading ....................................................................................... 4.9 0

C2C .............................................. Signs/Gestures/Jokes ....................................................................... 5.7 0

C2D .............................................. Message to Express Needs .............................................................. 4.5 0

C2E .............................................. None of the Above ............................................................................ 4.5 0

C3A .............................................. Expressing Information Content ........................................................ 1.1 22.4

C3B .............................................. Status Compared to 30 Days Ago .................................................... 8.0 2.0

C2 ................................................ Speech Clarity ................................................................................... 0 0

C5A .............................................. Verbal Content .................................................................................. 0 0

C5B .............................................. Status Compared to 30 Days Ago .................................................... 7.0 22.4

C6A .............................................. See in Adequate Light W/Glasses .................................................... 1.2 0

C6B .............................................. More Impaired in Vision .................................................................... 7.4 22.5

D1A .............................................. Patient Made Negative Statements .................................................. 3.8 0

D1B .............................................. Persistent Anger W/Self or Others ................................................... 3.8 0

D1C .............................................. Expressions of Unrealistic Fears ...................................................... 11.5 0

D1D .............................................. Repetitive Anxious Complaints ......................................................... 7.7 0

D1E .............................................. Repetitive Health Complaints ............................................................ 11.5 0

D1F .............................................. Sad, Pained, Facial Expressions ...................................................... 7.7 0

D1G .............................................. Crying, Tearfulness ........................................................................... 3.8 0

D1H .............................................. Repetitive Physical Movements ........................................................ 11.5 0

D1IS ............................................. Insomnia/change in Sleep Patterns .................................................. 3.8 0

D1J ............................................... W/draw from Activities of Interest ..................................................... 11.5 0

D1K .............................................. Reduced Social Interaction ............................................................... 7.7 0

D2 ................................................ Mood Persistence ............................................................................. 4.8 5.0

D3A .............................................. Wandering—Freq .............................................................................. 3.4 0

D3B .............................................. Verbal Abuse Behavior—Freq .......................................................... 4.6 0

D3C .............................................. Physical Abuse Behavior—Freq ....................................................... 3.4 2.1

D3D .............................................. Social Inappropriate Behavior—Freq ................................................ 3.4 2.1

D3E .............................................. Resists Care—Freq ........................................................................... 3.4 0

E10AA .......................................... Leg—Joint ......................................................................................... 4.7 4.2

E10AB .......................................... Voluntary Motor Control Leg ............................................................. 5.1 2.6

E10AC .......................................... Intact Touch Leg ............................................................................... 7.6 10.3

E10BA .......................................... Arm-Joint ........................................................................................... 4.7 4.2

E10BB .......................................... Voluntary Motor Control Arm ............................................................ 5.1 2.6

E10BC .......................................... Intact Touch Arm ............................................................................... 7.6 10.3

E10CA .......................................... Trunk & Neck—Joint ......................................................................... 7.0 4.2

E10CB .......................................... Vol. Motor Control—Trunk & Arm ..................................................... 7.6 2.6

E10CC ......................................... Intact Touch Trunk & Arm ................................................................. 8.9 10.3

E1A .............................................. Bed Mobility—3 Days ........................................................................ 2.4 0

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66391

TABLE 1.—PERCENT OF ASSESSORS BY THE TYPE OF FACILITY WHO RECOMMENDED REMOVAL OF MDS–PAC ITEMS—

Continued

MDS–PAC item No. MDS–PAC item

Percent of assessors by facility-type

who recommended removal of specific

MDS–PAC items

Rehabilitation

hospitals

Skilled nursing

facilities

E1B .............................................. Transfer Bed/Chair—3 Days ............................................................. 2.4 2.0

E1C .............................................. Locomotion—3 Days ......................................................................... 2.4 2.0

E1D .............................................. Walk in Corridor—3 Days ................................................................. 4.7 4.1

E1E .............................................. Dressing Upper Body—3 Days ......................................................... 2.4 0

E1F .............................................. Dressing Lower Body—3 Days ......................................................... 2.4 0

E1G .............................................. Eating—3 Days ................................................................................. 2.4 0

E1H .............................................. Toilet Use—3 Days ........................................................................... 2.4 0

E1I ................................................ Transfer Toilet—3 Days .................................................................... 2.3 4.1

E1J ............................................... Personal Hygiene—3 Days ............................................................... 2.3 0

E1K .............................................. Bathing—3 Days ............................................................................... 2.4 0

E1L ............................................... Transfer Tub/shower—3 Days .......................................................... 4.7 4.1

E3 ................................................. ADL Areas Now More Impaired ........................................................ 4.0 16.7

E4A .............................................. Meal Preparation—Now .................................................................... 4.5 23.4

E4C .............................................. Phone Use—Now .............................................................................. 10.2 25.5

E4D .............................................. Medication Management—Now ........................................................ 4.5 31.9

E4E .............................................. Stairs—Now ...................................................................................... 4.5 23.4

E4F .............................................. Car Transfer—Now ........................................................................... 5.7 23.4

E5 ................................................. IADL Areas Now More Impaired ....................................................... 3.8 16.7

E6A .............................................. Cane/Crutch ...................................................................................... 0 0

E6B .............................................. Walker ............................................................................................... 2.3 0

E6C .............................................. Wheeled—Not Motorized .................................................................. 2.5 0

E6D .............................................. Adaptive Eating Utensil ..................................................................... 0 9.1

E6E .............................................. Mechanical Lift .................................................................................. 3.4 2.2

E6F .............................................. Orthotics/Prosthesis .......................................................................... 0 18.2

E6G .............................................. Postural Support ............................................................................... 3.4 2.2

E6H .............................................. Slide Board ........................................................................................ 3.4 2.2

E6I ................................................ Other Adaptive Device ...................................................................... 2.3 2.2

E6J ............................................... None of Above .................................................................................. 2.5 2.7

E7A .............................................. Hours of Physical Activity—past 24 Hrs ........................................... 6.5 45.0

E7B .............................................. Hours of Physical Activity—30 Days Ago ......................................... 29.4 50.0

E8A .............................................. Distance Walk W/o Sit Down—Consistently ..................................... 4.6 6.3

E8B .............................................. Walking Support Provided ................................................................ 11.1 25.6

E9A .............................................. Moved from Seated to Standing ....................................................... 8.0 2.1

E9B .............................................. Turned Around Face Opposite Direction .......................................... 14.8 8.3

F1A .............................................. Control of Urinary Bladder ................................................................ 0 0

F1B .............................................. Continence Compared to 30 Days Ago ............................................ 4.5 22.4

F2A .............................................. External Catheter .............................................................................. 1.1 0

F2B .............................................. Indwelling Catheter ........................................................................... 2.3 4.1

F2C .............................................. Intermittent Cath ................................................................................ 2.5 0

F2F ............................................... Pads, Briefs ....................................................................................... 3.7 0

F4 ................................................. Bowel Continence ............................................................................. 1.1 2.0

F5 ................................................. Bowel Appliances .............................................................................. 2.5 0

G2A .............................................. Diabetes Mellitus ............................................................................... 0 8.3

G2AA ........................................... A Multiple Sclerosis ........................................................................... 0 8.3

G2AB ........................................... Parkinson’s Disease .......................................................................... 0 8.3

G2AC ........................................... Quadriplegia ...................................................................................... 0 8.3

G2AD ........................................... Seizure Disorder ............................................................................... 0 8.3

G2AE ........................................... Spinal Cord Dysfunction—Nontraumatic .......................................... 0 8.3

G2AF ............................................ Spinal Cord Dysfunction—Traumatic ................................................ 0 8.3

G2AG ........................................... Stroke ................................................................................................ 0 8.3

G2AH ........................................... Anxiety Disorder ................................................................................ 0 8.3

G2AI ............................................. Depression ........................................................................................ 0 8.3

G2AJ ............................................ Other Psychiatric Disorder ................................................................ 0 8.3

G2AK ........................................... Asthma .............................................................................................. 0 8.3

G2AL ............................................ COPD ................................................................................................ 0 8.3

G2AM ........................................... Emphysema ...................................................................................... 0 8.3

G2AN ........................................... Cancer ............................................................................................... 4.2 8.3

G2AO ........................................... Post Surgery—Non Orthopedic ........................................................ 4.2 8.3

G2AP ........................................... Renal Failure ..................................................................................... 0 8.3

G2AQ ........................................... None of Above .................................................................................. 0 8.3

G2B .............................................. Hypothyroidism .................................................................................. 0 8.3

G2C .............................................. Cardiac Arrhythmias .......................................................................... 0 8.3

G2D .............................................. Congestive Heart Failure .................................................................. 0 8.3

G2E .............................................. Coronary Artery Disease ................................................................... 0 8.3

G2F .............................................. Deep Vein Thrombosis ..................................................................... 0 8.3

G2G ............................................. Hypertension ..................................................................................... 0 8.3

66392 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

TABLE 1.—PERCENT OF ASSESSORS BY THE TYPE OF FACILITY WHO RECOMMENDED REMOVAL OF MDS–PAC ITEMS—

Continued

MDS–PAC item No. MDS–PAC item

Percent of assessors by facility-type

who recommended removal of specific

MDS–PAC items

Rehabilitation

hospitals

Skilled nursing

facilities

G2H .............................................. Hypotension ...................................................................................... 0 8.3

G2I ............................................... Peripheral Vascular Disease ............................................................. 0 8.3

G2J .............................................. Post Acute MI .................................................................................... 0 8.3

G2K .............................................. Post Heart Surgery ........................................................................... 0 8.3

G2L .............................................. Pulmonary Embolism ........................................................................ 0 8.3

G2M ............................................. Pulmonary Failure ............................................................................. 0 8.3

G2N .............................................. Other Cardiovascular Disease .......................................................... 0 8.3

G2O ............................................. Fracture—Hip .................................................................................... 0 8.3

G2P .............................................. Fracture—Lower Extremity ............................................................... 0 8.3

G2Q ............................................. Fracture(s)—Other ............................................................................ 0 8.3

G2R .............................................. Osteoarthritis ..................................................................................... 0 8.3

G2S .............................................. Osteoporosis ..................................................................................... 0 8.3

G2T .............................................. Rheumatoid Arthritis .......................................................................... 0 8.3

G2U .............................................. Alzheimer’s Disease .......................................................................... 0 8.3

G2V .............................................. Aphasia or Apraxia ............................................................................ 0 8.3

G2W ............................................. Cerebral Palsy ................................................................................... 0 8.3

G2X .............................................. Dementia Other than Alzheimer’s ..................................................... 0 8.3

G2Y .............................................. Hemiplegia/Hemiparesis ................................................................... 0 8.3

G3A .............................................. Antibiotic Resistant Infection ............................................................. 0 2.0

G3B .............................................. Cellulitis ............................................................................................. 0 2.5

G3C .............................................. Hepatitis ............................................................................................ 1.2 2.0

G3D .............................................. HIV/AIDS ........................................................................................... 1.2 2.0

G3E .............................................. Pneumonia ........................................................................................ 0 2.0

G3F .............................................. Osteomyelitis ..................................................................................... 0 2.0

G3G ............................................. Septicemia ......................................................................................... 1.2 2.0

G3H .............................................. Staphylococcus Infection .................................................................. 1.2 4.1

G3I ............................................... Tuberculosis (Active) ......................................................................... 1.2 2.0

G3J .............................................. Urinary Tract Infection ....................................................................... 0 2.0

G3K .............................................. Wound Infection ................................................................................ 0 2.0

G3L .............................................. None of Above .................................................................................. 0 2.0

G4AA ........................................... ICD–9–CM Diagnosis Code #1 ......................................................... 10.8 4.2

G4AB ........................................... ICD–9–CM Code #1 .......................................................................... 8.4 4.2

G4BA ........................................... ICD–9–CM Diagnosis Code #2 ......................................................... 10.8 4.2

G4BB ........................................... ICD–9–CM Code #2 .......................................................................... 8.4 4.2

G4CA ........................................... ICD–9–CM Diagnosis Code #3 ......................................................... 11.0 4.2

G4CB ........................................... ICD–9–CM Code #3 .......................................................................... 8.5 4.2

G4DA ........................................... ICD–9–CM Diagnosis Code #4 ......................................................... 11.0 4.2

G4DB ........................................... ICD–9–CM Code #4 .......................................................................... 8.5 4.2

G4EA ........................................... ICD–9–CM Diagnosis Code #5 ......................................................... 12.2 4.2

G4EB ........................................... ICD–9–CM Code #5 .......................................................................... 9.8 4.2

H1 ................................................ Vital Signs ......................................................................................... 4.6 12.5

H2A .............................................. Dizziness/Vertigo/Lightheaded .......................................................... 1.1 0

H2B .............................................. Fell in past 7 Days ............................................................................ 1.1 4.1

H2C .............................................. Fell in past 8 to 180 Days ................................................................. 7.7 0

H3D .............................................. Advanced Cardiac Failure ................................................................. 9.1 10.2

H2E .............................................. Chest Pain/Pressure on Exertion ...................................................... 1.1 2.0

H2F .............................................. Chest Pain/Pressure at Rest ............................................................ 1.1 2.0

H2G .............................................. Edema—Generalized ........................................................................ 1.1 2.0

H2H .............................................. Edema—Localized ............................................................................ 2.3 2.0

H2I ............................................... Edema—pitting .................................................................................. 3.4 2.1

H2J ............................................... Impaired Aerobic Capacity ................................................................ 3.4 2.0

H2K .............................................. Constipation ...................................................................................... 1.1 0

H2L .............................................. Dehydrated ........................................................................................ 3.4 0

H2M ............................................. Diarrhea ............................................................................................. 1.1 0

H2N .............................................. Internal Bleeding ............................................................................... 3.8 0

H2O .............................................. Recurrent Nausea/Vomiting .............................................................. 2.3 0

H2P .............................................. Refuse/Inability to Take Liquids Orally ............................................. 6.8 0

H2R .............................................. Fever ................................................................................................. 4.5 0

H2S .............................................. Hemi-neglect ..................................................................................... 4.5 0

H2T .............................................. Cachexia (Severe Malnutrition) ......................................................... 6.8 0

H2U .............................................. Morbid Obesity .................................................................................. 3.4 0

H2V .............................................. End-stage Disease ............................................................................ 4.5 0

H2W ............................................. None of Above .................................................................................. 0 0

H3A .............................................. Inability to Lie Flat—Loss of Breath .................................................. 2.3 0

H3B .............................................. Shortness of Breath—Exertion ......................................................... 3.4 0

H3C .............................................. Shortness of Breath—Rest ............................................................... 3.4 0

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66393

TABLE 1.—PERCENT OF ASSESSORS BY THE TYPE OF FACILITY WHO RECOMMENDED REMOVAL OF MDS–PAC ITEMS—

Continued

MDS–PAC item No. MDS–PAC item

Percent of assessors by facility-type

who recommended removal of specific

MDS–PAC items

Rehabilitation

hospitals

Skilled nursing

facilities

H3D .............................................. Oxygen Saturation ............................................................................ 3.4 2.0

H3E .............................................. Diff Cough/clearing Airway ................................................................ 3.4 0

H3F .............................................. Recurrent Aspiration ......................................................................... 2.3 0

H3G .............................................. Recurrent Aspiration Infection ........................................................... 4.9 0

H3H .............................................. None of Above .................................................................................. 3.5 0

H4A .............................................. Highest Pressure Ulcer Stage .......................................................... 2.3 0

H4B .............................................. # of Current Pressure Ulcers ............................................................ 2.4 0

H4C .............................................. Length Multiplied by Width ................................................................ 4.7 12.2

H4D .............................................. Exudate Amount ................................................................................ 4.7 12.2

H4E .............................................. Predominant Tissue .......................................................................... 4.7 12.2

H4F .............................................. Total Push Score .............................................................................. 4.7 10.4

H5A .............................................. # of Stasis Ulcers .............................................................................. 3.4 0

H5B .............................................. # of Surgical Wounds ........................................................................ 3.4 0

H5C .............................................. Ulcer Resolved/Healed ..................................................................... 8.4 6.1

H6A .............................................. Burns ................................................................................................. 2.3 2.0

H6B .............................................. Open Lesions Excluding Foot ........................................................... 2.3 0

H6C .............................................. Rashes .............................................................................................. 1.1 0

H6D .............................................. Skin Tears or Cuts ............................................................................ 1.1 0

H6E .............................................. None of Above .................................................................................. 1.1 0

I1A ................................................ Freq Patient Complains of Pain ........................................................ 0 0

I1B ................................................ Intensity of Pain ................................................................................ 0 0

I1C ............................................... Current Pain Status ........................................................................... 7.3 26.8

J1A ............................................... Chewing Problem .............................................................................. 1.2 0

J1B ............................................... Dental Problems ................................................................................ 1.2 0

J2 ................................................. Swallowing ........................................................................................ 1.2 0

J3A ............................................... Height in Inches ................................................................................ 5.8 0

J3B ............................................... Weight in Pounds .............................................................................. 7.0 0

J4A ............................................... Weight Loss ...................................................................................... 8.1 4.2

J4B ............................................... Weight Gain ...................................................................................... 8.2 4.2

J5A ............................................... Total Calories .................................................................................... 3.5 0

J5B ............................................... Fluid Intake ........................................................................................ 4.6 0

K1A .............................................. Total # Physician Visits ..................................................................... 21.6 22.4

K1B .............................................. # Times Phys/nurse Practitioner Called to Bedside ......................... 17.2 40.0

K1C .............................................. # Nurse Practitioner Visits ................................................................ 20.7 27.1

K1D .............................................. # Phys Asst Visits ............................................................................. 20.7 29.2

K1E .............................................. # New or Changed Orders ................................................................ 14.9 22.4

K2AA ............................................ Diabetic Management ....................................................................... 3.5 8.3

K2AB ............................................ At Dis—insulin Management ............................................................. 7.7 33.3

K2BA ............................................ Injections ........................................................................................... 7.7 8.3

K2BB ............................................ Injections at Discharge ...................................................................... 8.3 20.0

K2CA ............................................ IV Antibiotics/meds ............................................................................ 7.7 8.3

K2CB ............................................ At Dis—Iv Antibiotics/meds ............................................................... 7.7 33.3

K2DA ............................................ Application of Dressings ................................................................... 7.7 8.3

K2DB ............................................ Application of Dressings at Dis. ........................................................ 8.3 20.0

K2EA ............................................ Application of Ointments ................................................................... 7.7 8.3

K2EB ............................................ At Dis—Application of Ointments ...................................................... 7.7 33.3

K2GA ........................................... Nutrition/dehydration Intervention ..................................................... 7.7 8.3

K2GB ........................................... At Dis—nutrition/hydration Intervention ............................................ 7.7 33.3

K2HA ............................................ Pressure Relieving Bed/Chair ........................................................... 3.8 8.3

K2HB ............................................ At Dis—Pressure Relieving Bed/Chair ............................................. 7.7 33.3

K2IA ............................................. Turning and Repositioning ................................................................ 3.8 8.3

K2IB ............................................. At Dis—Turning and Repositioning ................................................... 7.7 33.3

K2JA ............................................ Ulcer Care ......................................................................................... 7.7 8.3

K2JB ............................................ At Discharge—Ulcer Care ................................................................. 7.7 33.3

K2KA ............................................ Wound Care—Surgical ..................................................................... 7.7 8.3

K2KB ............................................ At Dis—Wound Care Surgical .......................................................... 7.7 33.3

K2LA ............................................ Bladder Training ................................................................................ 3.8 8.3

K2LB ............................................ At Dis—Bladder Training .................................................................. 8.3 20.0

K2MA ........................................... Scheduled Toileting ........................................................................... 3.8 8.3

K2MB ........................................... At Dis—Scheduled Toileting ............................................................. 8.3 20.0

K2NA ............................................ Bowel Program .................................................................................. 3.8 8.3

K2NB ............................................ At Dis—Bowel Program .................................................................... 8.3 20.0

K2OA ........................................... Cardiac Monitoring/Rehab ................................................................ 11.5 8.3

K2OB ........................................... At Dis—Cardiac Monitoring ............................................................... 7.7 33.3

K2PA ............................................ Cast(s) ............................................................................................... 11.5 8.3

K2PB ............................................ At Dis—Cast(s) ................................................................................. 7.7 33.3

66394 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

TABLE 1.—PERCENT OF ASSESSORS BY THE TYPE OF FACILITY WHO RECOMMENDED REMOVAL OF MDS–PAC ITEMS—

Continued

MDS–PAC item No. MDS–PAC item

Percent of assessors by facility-type

who recommended removal of specific

MDS–PAC items

Rehabilitation

hospitals

Skilled nursing

facilities

K2QA ........................................... Continuous Positive Airway Pressure ............................................... 11.5 8.3

K2QB ........................................... At Dis—Continuous Positive Airway Pressure ................................. 9.0 33.3

K2RA ............................................ Drains ................................................................................................ 3.8 0

K2RB ............................................ At Dis—Drains ................................................................................... 7.7 31.7

K2SA ............................................ Dialysis .............................................................................................. 0 0

K2SB ............................................ At Dis—Dialysis ................................................................................. 4.2 16.7

K2TA ............................................ Enteral Tube Feeding ....................................................................... 0 0

K2TB ............................................ At Dis—Enteral Tube Feeding .......................................................... 6.5 31.7

K2UA ............................................ IV Line—Central ................................................................................ 3.8 0

K2UB ............................................ At Dis—Central Iv Line ..................................................................... 7.7 31.7

K2VA ............................................ IV Line—Peripheral ........................................................................... 3.8 0

K2VB ............................................ At Dis—Peripheral Iv Line ................................................................. 7.7 31.7

K2WA ........................................... Ng Feeding Tube .............................................................................. 0 0

K2WB ........................................... At Dis—NG Feeding Tube ................................................................ 6.4 31.7

K2XA ............................................ Oxygen .............................................................................................. 0 0

K2XB ............................................ At Dis—Oxygen ................................................................................. 6.4 31.7

K2YA ............................................ Pain Management—Other than Drugs ............................................. 7.7 0

K2YB ............................................ At Dis—Pain Management ................................................................ 7.7 31.7

K2ZA ............................................ Suctioning—Oral ............................................................................... 0 0

K2ZB ............................................ At Dis—Suctioning—Oral .................................................................. 7.7 31.7

K2AAA ......................................... Suctioning—Tracheal ........................................................................ 0 0

K2AAB ......................................... At Dis—Suctioning Tracheal ............................................................. 7.7 31.7

K2ABA ......................................... Tracheostomy Care ........................................................................... 0 0

K2ABB ......................................... At Dis—Tracheostomy Care ............................................................. 6.4 31.7

K2ACA ......................................... Transfusion(s) ................................................................................... 7.7 0

K2ACB ......................................... At Dis—Transfusion(s) ...................................................................... 7.7 31.7

K2ADA ......................................... Ventilator or Respirator ..................................................................... 7.7 0

K2ADB ......................................... At Dis—Vent. Or Resp. ..................................................................... 9.0 31.7

K2AEA ......................................... Ventilator Weaning ............................................................................ 7.7 0

K2AEB ......................................... At Dis—Ventilator Weaning .............................................................. 9.0 31.7

K2AFA .......................................... Train Family to Assist Patient ........................................................... 3.8 0

K2AFB .......................................... At Dis-Train Family to Assist Patient ................................................ 6.4 31.7

K2AGA ......................................... Training in Health Maint .................................................................... 3.8 0

K2AGB ......................................... At Dis—Pat Train Skills Required after Discharge ........................... 6.4 31.7

K2AHA ......................................... Design and Implementation .............................................................. 3.8 0

K2AHB ......................................... At Dis—Social Service Design .......................................................... 7.7 31.7

K3AIA ........................................... None of Above .................................................................................. 0 0

K3AIB ........................................... At Dis—None of Above ..................................................................... 7.7 31.7

K3A .............................................. Range of Motion—Passive ............................................................... 4.5 8.2

K3B .............................................. Range of Motion—Active .................................................................. 4.5 8.2

K3C .............................................. Splint/Orthotic Assistance ................................................................. 4.5 8.2

K3D .............................................. Bed Mobility ....................................................................................... 4.5 8.2

K3E .............................................. Bladder/Bowel ................................................................................... 3.4 8.2

K3F .............................................. Transfer ............................................................................................. 4.5 8.2

K3G .............................................. Walking .............................................................................................. 4.5 8.2

K3H .............................................. Dressing or Grooming ....................................................................... 3.4 8.2

K3I ................................................ Eating or Swallowing ......................................................................... 3.4 8.2

K3K .............................................. Communication ................................................................................. 3.4 8.2

K4AA ............................................ Speech—Days Ordered .................................................................... 16.0 26.2

K4AB ............................................ Speech—Days Delivered .................................................................. 2.4 4.8

K4AC ............................................ Speech—Min Delivered .................................................................... 3.7 2.4

K4AD ............................................ Post Dis—Speech ............................................................................. 4.0 18.0

K4BA ............................................ Ot—Days Ordered ............................................................................ 17.3 26.2

K4BB ............................................ Ot—Days Delivered .......................................................................... 2.4 4.8

K4BC ............................................ Ot—Min Delivered ............................................................................. 2.5 2.4

K4BD ............................................ Post Dis—Ot ..................................................................................... 5.3 18.2

K4CA ............................................ Pt—Days Ordered ............................................................................. 17.3 26.2

K4CB ............................................ Pt—Days Delivered ........................................................................... 1.2 4.8

K4CC ........................................... Pt—Min Delivered ............................................................................. 3.7 2.4

K4CD ........................................... Pt—Post Dis—Pt ............................................................................... 5.3 18.2

K4DA ............................................ Resp. Therapy—Days Ordered ........................................................ 16.0 26.2

K4DB ............................................ Resp. Therapy—Days Delievered .................................................... 2.4 4.8

K4DC ........................................... Resp. Therapy—Min. Delivered ........................................................ 3.7 2.4

K4DD ........................................... Post Dis—Resp.Therapy ................................................................... 4.0 18.2

K4EA ............................................ Psych Therapy—Days Ordered ........................................................ 18.5 26.2

K4EB ............................................ Psych Therapy—Days Delivered ...................................................... 3.7 4.8

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66395

TABLE 1.—PERCENT OF ASSESSORS BY THE TYPE OF FACILITY WHO RECOMMENDED REMOVAL OF MDS–PAC ITEMS—

Continued

MDS–PAC item No. MDS–PAC item

Percent of assessors by facility-type

who recommended removal of specific

MDS–PAC items

Rehabilitation

hospitals

Skilled nursing

facilities

K4EC ............................................ Psych Therapy—Min Delivered ........................................................ 3.7 2.4

K4ED ............................................ Post Dis—Psych Therapy ................................................................. 6.7 18.2

K4FA ............................................ Therapeutic Recreation—Days Ordered ........................................... 18.7 24.2

K3FB ............................................ Therapeutic Recreation—Days Delivered ......................................... 1.3 3.0

K3FC ............................................ Therapeutic Recreation—Min Delivered ........................................... 5.3 0

K3FD ............................................ Post Dis—Therapeutic Recreation .................................................... 6.7 18.2

K5A .............................................. Full Bed Rails on Both Sides ............................................................ 5.1 0

K5B .............................................. Other Types of Side Rails Used ....................................................... 6.4 4.9

K5C .............................................. Trunk Restraint .................................................................................. 6.4 0

K5D .............................................. Chair Prevents Rising ....................................................................... 7.7 2.4

L1A ............................................... Bed Mobility/Transfer ........................................................................ 6.9 10.2

L1B ............................................... Dressing ............................................................................................ 6.9 10.2

L1C .............................................. Eating ................................................................................................ 6.9 10.2

L1D .............................................. Locomotion ........................................................................................ 6.9 10.2

L1F ............................................... Medication Managment ..................................................................... 6.8 14.3

L1G .............................................. Pain Management ............................................................................. 6.8 10.2

L2A ............................................... Believe Is Capable of Incr Indep. ..................................................... 5.7 10.4

L2B ............................................... Unable to Recognize New Limits ...................................................... 8.0 10.4

L2C .............................................. Fails to Initiate/Continue Adls ........................................................... 9.2 10.4

L3A ............................................... Functional Status—Last 3 Days ....................................................... 9.2 12.2

L3B ............................................... Health Status—Last 3 Days .............................................................. 9.3 12.2

L4 ................................................. Estimated Length of Stay .................................................................. 2.3 6.0

M1A .............................................. Emotional Support ............................................................................. 0 8.3

M1B .............................................. Intermit Phys Support—less than Daily ............................................ 0 8.3

M1C ............................................. Intermit Phys Support—Daily ............................................................ 0 8.3

M1D ............................................. Full Time Physical Support ............................................................... 0 8.3

M1E .............................................. All or Most of Nec Transportation ..................................................... 0 9.1

M2A .............................................. Family Overwhelmed by Pat. Illness ................................................ 4.2 16.7

M2B .............................................. Family Relationship Require Great Deal of Staff Time .................... 4.2 8.3

M3AA ........................................... Type of Residence—Pre ................................................................... 2.3 10.2

M3AB ........................................... Type of Residence—Discharge ........................................................ 0 10.0

M3AC ........................................... Temp. Type of Residence ................................................................. 5.0 12.5

M3BA ........................................... Lived With—Pre ................................................................................ 2.5 10.6

M3BB ........................................... Live With—Disch ............................................................................... 0 10.4

M3BC ........................................... Temp Live(d) With ............................................................................. 5.3 13.2

N1C .............................................. Date Assessment Coord Signed ....................................................... 0 0

BILLING CODE 4120–03–P

66396 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66397

66398 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66399

66400 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66401

66402 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66403

BILLING CODE 4120–03–P

66404 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

Appendix BBB—Item-by-Item Guide to

the Minimum Data Set for Post Acute

Care (MDS–PAC)

1.1 Required Assessments and Associated

Forms

The following rules apply to HCFA’s MDS–

PAC to be used by rehabilitation hospitals

and rehabilitation units in acute care

hospitals.

The content of the MDS–PAC patient

assessment instrument is recorded on the

following required forms:

The Minimum Data Set-Post Acute (MDS–

PAC) is designed to be used for admission

assessments, reassessments, and discharge

assessments. These forms contain Section AA

(Identification Information) through M

(Resources for Discharge). There are three

separate forms which are entitled ‘‘Basic

Assessment Tracking Form’’, ‘‘Interrupted

Stay Tracking Form’’, and ‘‘Full Assessment

Form’’. Whenever an item is on all three

forms, there will be no distinguishing

notation. However, if an item(s) is (are) to be

asked only on a particular form, there will be

a statement in the ‘‘coding’’ section.

1.2 Overview to the Item-by-Item Guide to

MDS–PAC

This Manual is to be used in conjunction

with the MDS–PAC forms.

It provides information to facilitate

completion of an accurate and uniform

patient assessment. Item-by-item instructions

focus on:

• The intent of items included on the

MDS–PAC.

• Supplemental definitions and

instructions for completing MDS–PAC items.

• Reminders of which MDS–PAC items

require a different observation and

information about the patient other than the

standard 3-day observation period.

• Sources of information to be consulted in

completing specific MDS–PAC items.

• Examples to illustrate MDS–PAC coding

responses.

1.3 How Can This Manual Be Used?

Use this manual alongside the MDS–PAC

forms, keeping the forms in front of you at

all times. The MDS–PAC form itself contains

a wealth of information. Learn to rely on it

as a resource for many of the definitions and

procedural instructions necessary for proper

assessment. The amplifying information in

this manual should facilitate successful use

of the MDS–PAC forms.

Coding Conventions

• Dates—Where recording month, day, and

year, enter two digits for the month and the

day, but four digits for the year. For example,

the third day of January in the year 1999 is

recorded as:

• The standard no-information code is

either a ‘‘circled’’ dash or an ‘‘NA’’. This

code indicates that all available sources of

information have been exhausted; that is the

information is not available, and despite

exhaustive probing, it remains unavailable.

The use of NA code is very limited. For

example, ‘‘NA’’ cannot be used in Section E.

If an activity has not occurred in the last 3

days, a code of ‘‘8’’ must be used.

• NONE OF THE ABOVE is a response

item to several items (for example., G3,

Infections, box l). Check this item where

none of the responses apply; it should not be

used to signify lack of information about the

item.

• ‘‘Skip’’ Patterns—There are a few

instances where scoring on one item will

govern how scoring is completed for one or

more additional items. The instructions

direct the assessor to ‘‘skip’’ over the next

item (or several items) and go on to another

(for example, B1, Comatose, directs the

assessor to ‘‘skip’’ to Section E. if B1 is

answered ‘‘1’’—Yes’’. The intervening items

from B2–D3 would not be scored. If B1 was

recorded as ‘‘0’’—‘‘No’’, then the assessor

would continue with item B2.).

A useful technique for visually checking

the proper use of the ‘‘skip’’ pattern

instructions is to circle the ‘‘skip’’

instructions before going to the next

appropriate item.

• The ‘‘8’’ code is for use in Section E.,

Functional Status. The use of this code is

limited to situations where the ADL activity

was not performed and therefore an objective

assessment of the resident’s performance is

not possible. Its primary use is with bedbound residents who neither transferred from

bed nor moved between locations over the

entire 3 day period of observation.

The items from the MDS–PAC forms are

presented in a sequential basis in this

manual. Each item is accompanied by a

statement of intent (rationale for assessment),

definitions, assessment processes, and coding

instructions. Many items are accompanied by

patient examples to illustrate coding

concepts.

The chart that follows summarizes the

recommended approach to assist you in

becoming familiar with the MDS–PAC. The

initial time investment in this multi-step

review process will have a major payback on

the quality of your patient assessments using

the MDS–PAC.

Carefully review these item-by-item

instructions. The time-frame of the

assessment, the processes, the coding options

and items have been developed to reflect the

needs of post-acute patients.

Recommended Approach for Becoming

Familiar With the MDS–PAC

(A) First, review the MDS–PAC forms.

• Notice how sections are organized and

where information is to be recorded.

• Work through one section at a time.

• Examine item definitions and response

categories.

• Review procedural instructions, time

frames, and general coding conventions. Note

that the assessment reflects activities over the

last 3 days unless otherwise indicated.

• Are the definitions and instructions

clear? Do they differ from current practice at

your facility? What areas require further

clarification?

• Complete the MDS–PAC assessment for

a patient at your facility. Draw only on your

knowledge of this individual. Enter the

appropriate codes on the MDS–PAC form.

Where your review could benefit from

additional information, make note of that

fact. Where might you secure additional

information?

(B) Complete the initial pass through this

manual.

• Go on to this step only after first

reviewing the MDS–PAC form and trying to

complete as many items as possible for a

patient known to you.

• As you read this manual, clarify

questions that arose as you used the MDS–

PAC for the first time to assess a patient. Note

sections of this manual that help to clarify

coding and procedural questions you may

have had.

• Once again, read the instructions that

apply to a single section of the MDS–PAC.

Make sure you understand this information

before going on to another section. Review

the test case you completed. Would you still

code it the same way? It will take time to go

through all this material. Do it slowly. Do not

rush. Work through the Manual one section

at a time.

• Are you surprised by any MDS–PAC

definitions, instructions, or case examples?

For example, do you understand how to code

ADLs? Or Mood?

• Do any definitions or instructions differ

from what you thought you learned when

you reviewed the MDS–PAC form?

• Would you now complete your initial

case differently?

• Are there definitions or instructions that

differ from current practice patterns in your

facility?

• Make notations next to any section(s) of

this Manual you have questions about.

In a second pass through this manual,

focus on issues that were more difficult or

problematic in the first pass.

• Further familiarize yourself with

definitions and procedures that differ from

current practice patterns or seem to raise

questions.

• Reread each of the case examples

presented throughout this chapter.

• (D) The third pass through this manual

will provide you with another opportunity to

review the material in this manual.

• (E) Future use of information in this

manual:

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66405

• Keep this manual at hand during the

assessment process.

• Where necessary, review the intent of

each item in question.

• This manual is a source of information.

Use it to increase the accuracy of your

assessments.

1.4 What Is the Standard Format Used in

This Manual?

To facilitate completion of the MDS–PAC

assessment and to ensure consistent

interpretation of items, this manual presents

the following types of information for many

(but not all) items:

Intent: Reason(s) for including the item (or

set of items) in the MDS–PAC, including

discussions of how the information will be

used by clinical staff to identify patient

problems and develop the plan of care.

Definition: Explanation of key terms.

Process: Sources of information and

methods for determining the correct response

for an item. Sources include:

• Patient interview, observation, and

examination.

• Clinical records, facility records,

transmittal records (at admission), physician

orders, laboratory data, medication records,

treatment sheets, flow sheets (for example,

vital signs, weights, intake and output), care

plans, and any similar documents in the

facility record system.

• Discussion with multidisciplinary

facility staff—licensed and nonlicensed staff

caregivers.

• Discussion with the patient’s family,

particularly during the admission assessment

period, when available.

• Attending physician.

Coding: Proper method of recording each

response, with explanations of individual

response categories.

1.5 Item-by-Item Instructions for the MDS–

PAC Forms

The item-by-item instructions follow the

sequence of items on the HCFA MDS–PAC.

This will facilitate your use of this guide as

a reference tool.

Basic Assessment Tracking Form

Section AA. Identification Information

Intent: This section provides the key

information to uniquely identify each patient

as well as the reason for assessment.

1. Legal Name of Patient

Definition: Legal name in the clinical

record. This must be the same as the patient’s

Medicare record legal name.

Coding: Use printed letters. Enter in the

following order:

a. First Name.

b. Middle initial (leave blank if no middle

name).

c. Last/Family Name.

d. Suffix—meaning Jr., Sr., III, etc.

2. Admission Date

a. Date the stay began.

Intent and Definition: For the current

precipitating event/problem, this is the date

when the patient first became a rehabilitation

patient in your facility.

It is possible that a patient in a

rehabilitative phase of care may be

discharged from the rehabilitation facility

and then admitted to an acute care hospital

or unit. Admissions and ‘‘bed-hold’’ policies

vary in different settings. A rehabilitation

facility may choose to follow a facility

specific policy and ‘‘close’’ the medical

record of a patient that has an overnight stay

in an acute care hospital, or to keep the chart

‘‘open’’ during this period of time. However,

to be in compliance with Medicare

regulations, if a patient has an overnight stay

in an acute care hospital or unit, then for

Medicare payment purposes the

rehabilitation facility must discharge the

patient.

For the purpose of the MDS–PAC, enter the

date the person was first admitted to receive

rehabilitative care for the current

precipitating event/problem. This admission

date should correspond with the admission

date used by the billing office to initially

begin this stay.

Process: Review the clinical record. If it is

unclear on what date the stay for the current

precipitating event/problem began, clarify

with the admissions/business or medical

record departments.

Coding: For a one digit month or day, place

a zero in the box. For example: July 1, 2000,

should be entered as follows:

b. Date Medicare-covered Part A stay

began.

Intent and Definition: For the current

precipitating event/problem, this is the date

of the current stay when the patient first

started receiving Medicare-covered Part-A

services in your facility. Complete this date

only if this date is different than the date in

item AA2A ‘‘Date the stay began.’’

It is possible that a patient in a

rehabilitative phase of care may be

discharged from the rehabilitation facility

and then admitted to an acute care hospital

or unit. Admissions and ‘‘bed-hold’’ policies

vary in different settings. A rehabilitation

facility may choose to follow a facility

specific policy and ‘‘close’’ the medical

record of a patient that has an overnight stay

in an acute care hospital, or to keep the chart

‘‘open’’ during this period of time. However,

to be in compliance with Medicare

regulations, if a patient has an overnight stay

in an acute care hospital or unit, then for

Medicare payment purposes the

rehabilitation facility must discharge the

patient.

For the purpose of the MDS–PAC, enter the

date the patient first started to be furnished

Medicare-covered Part A services in your

rehabilitation facility for the current

precipitating event/problem. This date

should correspond with the date used by the

billing office to initially start billing

Medicare for this stay.

Process: Review the clinical record. If it is

unclear what date the person first started

being furnished Medicare-covered Part A

services for the current stay and for the

current precipitating event/problem, clarify

with the admissions/business or medical

record departments.

Coding: For a one digit month or day, place

a zero in the first box. For example: July 1,

2000, should be entered as follows:

3. Reason for Assessment

Intent and Definition: To document the key

reason for completing the MDS–PAC

assessment.

Process: Calculate the length of time the

patient has been receiving Medicare-covered

Part A services during the current stay. Then

determine the type of assessment for which

the data must be collected and recorded on

the MDS–PAC.

Coding: Code for appropriate assessment.

1. Admission assessment (covers first 3

days)—Completed on day 4.

2. Reassessment—Completed on day 11.

3. Reassessment—Completed on day 31.

4. Reassessment—Completed on day 61.

5. Discharge assessment—After the

assessment reference date for the discharge

MDS–PAC assessment is determined, the

completion date for the discharge MDS–PAC

assessment must be set. The completion date

66406 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

for the discharge MDS–PAC assessment must

be the fifth calendar day following the

discharge MDS–PAC assessment reference

date. To count the 5 calendar days following

the discharge MDS–PAC assessment

reference date count the discharge MDS–PAC

assessment reference date as day 1 of the 5

calendar days. For example, if the MDS–PAC

assessment reference date is May 1, 2000,

then the MDS–PAC completion date would

be May 5, 2000.

The following tables illustrate the

relationship between the type of MDS–PAC

assessment (the Day 4, Day 11, Day 30, Day

60, and discharge assessment), and the

observation time period, the assessment

reference date, and the MDS–PAC

completion date. In addition, for each type of

MDS–PAC assessment the tables depict the

associated encoding date and by when the

data for that type of assessment must be

transmitted.

TABLE 1.—MDS–PAC ASSESSMENT SCHEDULE AND ASSOCIATED DATES

MDS–PAC

assessment type

Hospitalization

time period and

observation time

period

MDS–PAC assessment reference date

MDS–PAC must

be completed by:

Hospitalization

episode covered

by this

assessment:

MDS–PAC must

be encoded by:

MDS–PAC must

be transmitted by:

Day 4 .................... First 3 Days ......... Day 3 ................... Day 4 ................... Entire Hospitalization Time Period.Day 10 ................. Day 16.

Day 11 .................. Days 8 to 10 ........ Day 10 ................. Day 11 ................. .............................. Day 17 ................. Day 23.

Day 30 .................. Days 28 to 30 ...... Day 30 ................. Day 31 ................. .............................. Day 37 ................. Day 43.

Day 60 .................. Days 58 to 60 ...... Day 60 ................. Day 61 ................. .............................. Day 67 ................. Day 73.

Table 1 above represents the generic assessment schedule and other associated MDS–PAC dates. The term ‘‘day’’ refers to the

number of calendar days during the patient’s current hospitalization that the patient has been hospitalized as a Medicare Part-A

patient.

Table 2 below is an example of how Table 1 would be applied using actual calendar dates. In Table 2 it is assumed that the

patient was admitted on April 3, 2001.

TABLE 2.—EXAMPLE APPLYING THE MDS–PAC ASSESSMENT SCHEDULE AND ASSOCIATED DATES

MDS–PAC assessment type Hospitalization time period and observation time period

MDS–PAC

assessment

reference

date

MDS–PAC

must be

completed

by:

MDS–PAC

must be

encoded by:

MDS–PAC

must be

transmitted

by:

Day 4 ........................................................ First 3 Days .............................................. 4/5/01 4/6/01 4/12/01 4/18/01

Day 11 ...................................................... Days 8 to 10 ............................................. 4/12/01 4/13/01 4/19/01 4/25/01

Day 30 ...................................................... Days 28 to 30 ........................................... 5/2/01 5/3/01 5/9/01 5/15/01

Day 60 ...................................................... Days 58 to 60 ........................................... 6/1/01 6/2/01 6/8/01 6/14/01

TABLE 3.—EXAMPLE APPLYING THE MDS–PAC DISCHARGE ASSESSMENT DATES

MDS–PAC assessment type Discharge

date*

MDS–PAC

assessment

reference

date

MDS–PAC

must Be

completed

on:

MDS–PAC

must be encoded by:

MDS–PAC

must be

transmitted

by:

Discharge Assessment ............................................................................ 5/1/00 5/1/00 5/5/00 5/11/00 5/17/00

* This is either when the first of the following occurs: (1) The day the patient is discharged from the IRF, or (2) the day the patient ceases receiving Medicare-covered Part-A inpatient rehabilitation services.

4. Assessment Reference Date

Intent: To establish a common reference

point for all staff participating in the patient’s

assessment. Although staff members may

work on completing a patient’s MDS–PAC on

different days (for example, begin entering

demographics on day 1 of admission, and

complete functional assessment on day 3),

establishment of the assessment reference

date ensures the commonality of the

assessment period. It starts the ‘‘clock’’ so

that all assessment items refer to the patient’s

status, treatment regimen, and resource

utilization during the same period of time.

Many items require the ‘‘counting’’ of the

number of treatments, visits, or procedures,

making a common temporal reference point

crucial for accuracy.

Definition: This is the last day in the MDS–

PAC assessment process, that is, the last day

of the 3-day MDS–PAC observation period. It

is the designated endpoint of the observation

period. In order to gain accurate information

for the interdisciplinary team, it is essential

for everyone to focus on the same time period

(that is, for most items, this day and the two

that preceded it.) It is from this date that all

time references are measured. For a discharge

assessment, including an unexpected

discharge, see the explanation under

‘‘Process’’ below.

For instance, if an item indicates ‘‘in the

past 3 days’’ this 3 day period is calculated

from the last day of the MDS–PAC

observation period (that is, the third day and

the two days that preceded it.)

Process: Refer to item AA2—‘‘Admission

Date’’. The date entered in AA2b or if no date

is entered in AA2b then the date entered in

AA2a must be used to calculate the

assessment reference date that must be used

for the Day 4, Day 11, Day 30, or Day 60

assessments. The assessment reference date

for the discharge assessment is the day when

one of either of these two events occurs first:

(1) The day the patient is discharged from the

IRF, or (2) the day the patient ceases

receiving Medicare-covered Part-A inpatient

rehabilitation services. The MDS–PAC

discharge assessment process is started only

at the first point in time either of these events

occur. There may be cases when a patient

ceases receiving inpatient rehabilitation

Medicare-covered services, but is not

discharged from the IRF.

Coding: Beginning with the left-most box

enter the month, day, and year of the

assessment reference date. Do not leave any

boxes blank. If the month or day contains

only a single digit, place a ‘‘0’’ in the first

box. For example: July 3, 2000, should be

entered as follows:

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66407

5. Discharge Status

a. Last day of stay.

Intent and Definition: To establish the date

when either of these two events occurs first:

(1) The individual is discharged as an

inpatient from the IRF and physically leaves

the facility, or (2) the patient ceases receiving

Medicare-covered Part-A inpatient

rehabilitation services whether or not the

patient physically leaves the facility.

Process: Consult the physician’s orders. In

cases when the patient is discharged

‘‘Against Medical Advice’’ (AMA) refer to the

documentation in the clinical record progress

notes and the physician’s orders.

Coding: Beginning with the left-most box

enter the month, day, and year of discharge.

Do not leave any boxes blank. If the month

or day contains only a single digit, place a

‘‘0’’ in the first box. For example July 26,

2000, should be entered as:

b. If discharged, status at discharge.

Intent: The intent of this item is to

determine the patient’s status upon

discharge.

Definition: This is the patient’s clinical and

rehabilitation program status at discharge.

Process: Consult with members of the

interdisciplinary team. Examine the

documentation in the patient’s clinical

record. Talk to the patient and family if

necessary.

Coding

0. Rehabilitation program complete for this

stay and return not anticipated.

1. Patient left, against medical advice, prior

to completion of plan of care.

2. Acute problem, discharge to acute

hospital.

3. Patient died.

6. Social Security and Medicare Numbers

Intent: To record patient identifier

numbers.

Process: Review the patient’s medical

record face sheet (usually at the front of the

chart). To ensure accuracy, review a copy of

the patient’s Social Security (SS) card and

Medicare card, if possible. In rare cases, the

patient will have neither a Social Security

number nor a Medicare number. When this

occurs, another type of identification number

may be used (for example, a railroad

insurance number).

Coding: Begin printing one number per box

starting with the left-most box. Recheck each

number to be sure you have entered the digits

in the correct order.

a. Enter the Social Security number as

specified in the medical record or on the

Social Security card.

b. Enter the Medicare number as indicated

in the medical record. However, if the patient

does not have a Medicare number but instead

has a comparable railroad insurance number,

then enter that number in these boxes and

indicate that this is not a Medicare number

by placing the letter ‘‘C’’ in first box of the

‘‘b’’ boxes.

7. Medical Record Number

Definition: A patient’s identification

number designated by the facility.

Process: Review the patient’s medical

record ‘‘face sheet’’ (usually at the front of

the chart) for the medical record number. If

the number is missing, obtain the number

from the facility’s Medical Records

Department.

Coding: Begin printing one number per box

starting with the left-most box. Recheck the

number to be sure you have entered the digits

in the correct order.

8. Facility Provider Number

Intent: To record the facility identifier

numbers.

Definition: The identification numbers

assigned to health care facilities by the

Medicare and Medicaid programs. Some

facilities will have only a Federal (Medicare)

identification number; others will have

Federal (Medicare) and State (Medicaid)

identification numbers. ‘‘Medicaid only’’

facilities have a Federal as well as a State

number. The Medicaid Federal number has a

‘‘letter’’ in the third box.

Process: Obtain the facility’s Medicare and

Medicaid numbers from the facility’s

business office. Once you have these

numbers, they apply to all patients of that

facility.

Coding: Begin printing one number per box

starting with the left-most box. Recheck each

number to be sure you have entered the digits

in the correct order. Remember, there must

be at least one provider number indicated,

and there may be two, one for the state, one

for the federal.

9. Medicaid Number

Intent: An identifying number for tracking

purposes.

Process: Review the patient’s medical

record face sheet (usually at the front of the

chart). Review a copy of the patient’s

Medicaid card to ensure accuracy, if possible.

Coding: Begin printing one number per box

starting with the left-most box. Recheck the

number to be sure you have entered the digits

in the correct order.

• If the Medicaid application is pending,

place a ‘‘+’’ in the first box.

• If the patient does not receive Medicaid

benefits, place an ‘‘N’’ in the first box.

10. Gender

Coding

1. Male.

2. Female.

11. Birthdate

Coding: Beginning with the left-most box

enter the month, day, and year of birth. If you

do not know the patient’s full birthdate you

may enter a partial birthdate, but the partial

birthdate must at least include the patient’s

year of birth. If the month or day contains

only a single digit, place a ‘‘0’’ in the first

box. For example: January 2, 1918 should be

entered as:

Note: It’s not unheard of to mistakenly

enter today’s date in this location. Make sure

you have entered the date of birth.

12. Ethnicity/Race

Intent: The documentation of ethnicity and

race per nationally established standards.

Process: Ask the patient and/or family

member what best describes their race and

ethnic background.

Coding: Check all that apply.

66408 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

Ethnicity

a. Hispanic or Latino.

Race

b. American Indian/Alaskan Native.

c. Asian.

d. Black or African American.

e. Native Hawaiian or other Pacific

Islander.

f. White.

13. Interrupted Stay

Note: This item only appears on the

interrupted stay tracking form.

Intent and Definition: To track patients that

have an interruption in their stay. An

interrupted stay is one in which a patient is

discharged from a rehabilitation facility and

returns to the same rehabilitation facility in

3 calendar days or less. For purposes of the

MDS–PAC assessment process, if a patient

has an interrupted stay, then—(1) No new

Day 4 MDS–PAC assessment would be

performed; and (2) The required scheduled

MDS–PAC update assessments must still be

performed. Note: A patient that returns to the

same rehabilitation facility more than 3

calendar days after being discharged is

considered a ‘‘new’’ patient in terms of the

MDS–PAC assessment schedule process.

In counting the 3 calendar day time period

to determine the length of the interrupted

stay, the first day of the start of the

interrupted stay is counted as ‘‘day 1,’’ with

midnight of that day serving as the end of

that calendar day. The next 2 calendar days

that immediately follow would be days two

and three. If the patient returns to the

rehabilitation facility by midnight of the

third calendar day, then it would be

determined that the patient had an

interrupted stay of 3 calendar days or less.

a. Date/time departed from the

rehabilitation unit/hospital.

Process: Consult the clinical record, talk to

physician and nursing staff.

Coding: If the patient has not had an

interrupted stay, the boxes will remain blank.

Otherwise, use all boxes. For a one-digit

month or day, place a zero in the first box.

July 31, 2000, should be entered as follows:

A time of 9:15 am should be entered as

follows:

b. Date/time returned to the rehabilitation

unit/hospital.

Process: Review the clinical record. If dates

are unclear or unavailable, ask the

admissions office or medical record

department.

Coding: If patient has not had an

interrupted stay, leave the boxes blank.

Otherwise, use all the boxes. For a onedigit month or day, place a zero in the first

box.

August 2, 2000, should be entered as

follows:

A time of 2:30 pm should be entered as

follows:

14. Clinician Completing Assessment

Note: This item only appears on the

interrupted stay tracking form. This is NOT

the same as Section AB ‘‘Assessment

Attestation’’.

Intent: To ensure that the data recorded on

the Interrupted Stay Tracking Form is

accurate and submitted to the HCFA MDS–

PAC system within 7 calendar days of the

date recorded in item AA13b. The date

recorded in item AA13b is ‘‘day 1’’ when

starting to count the 7 calendar days in order

to determine the 7 calendar day time period.

Definition: The clinician who signs item

AA14a must be a physician, registered nurse,

physical therapist, or occupational therapist.

Process: As necessary examine the clinical

record, and consult with other members of

the interdisciplinary care team to obtain the

data needed prior to completing this item.

Coding: After signing your name print your

name at AA14b to AA14e. Indicate your

credentials in the box at AA14f.

Section AB. Assessment Attestation

1. Person Completing the Assessment

Intent and Definition: A licensed clinician

who is a physician, registered nurse, physical

therapist, or occupational therapist must sign

and certify that—(1) The assessment is

complete; and (2) The data recorded for the

assessment items are to the best of his or her

belief accurately recorded and accurately

depict the patient’s clinical status.

Process: Examine the MDS–PAC to

determine if according to the instructions

that the required data for each item has been

accurately recorded.

Coding: The physician, registered nurse,

physical therapist, or occupational therapist

signs his/her name on line AB1a. The date

that he or she signed the assessment as

complete and accurate is entered in the boxes

of AB1g and his/her name must be printed

on the line that starts at AB1b. In the box for

item AB1f enter the code number that

identifies the type of licensed clinician

signing item AB1a.

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66409

2. Signatures of Staff Completing Part of the

Assessment

Intent: Each individual who completes a

portion of the assessment must sign and

certify to the accuracy of the items he or she

has completed.

Coding: On lines AB2a–AB2f each person

who has completed any MDS–PAC item signs

their name, writes their credentials, indicates

what section(s) or item(s) he or she

completed, and writes the date of his or her

signature.

Section A. Demographic/Admission

Information History

Intent: This section provides the key

information to uniquely identify each patient

as well as the reason for assessment.

1. Legal Name of Patient

Definition: Legal name in the clinical

record. This must be the same as the patient’s

Medicare record legal name.

Coding: Use printed letters. Enter in the

following order:

a. First Name.

b. Middle initial (leave blank if no middle

name).

c. Last/Family Name.

d. Suffix—meaning Jr., Sr., III, etc.

2. Admission Date

a. Date the stay began.

Intent and Definition: For the current

precipitating event/problem, this is the date

when the patient first became a rehabilitation

patient in your facility.

It is possible that a patient in a

rehabilitative phase of care may be

discharged from the rehabilitation facility

and then admitted to an acute care hospital

or unit. Admissions and ‘‘bed-hold’’ policies

vary in different settings. A rehabilitation

facility may choose to follow a facility

specific policy and ‘‘close’’ the medical

record of a patient that has an overnight stay

in an acute care hospital, or to keep the chart

‘‘open’’ during this period of time. However,

to be in compliance with Medicare

regulations, if a patient has an overnight stay

in an acute care hospital or unit, then for

Medicare payment purposes the

rehabilitation facility must discharge the

patient.

For the purpose of the MDS–PAC, enter the

date the person was first admitted to receive

rehabilitative care for the current

precipitating event/problem. This admission

date should correspond with the admission

date used by the billing office to initially

begin this stay.

Process: Review the clinical record. If it is

unclear what date the stay for the current

precipitating event/problem began, clarify

with the admissions/ business or medical

record departments.

Coding: For a one digit month or day, place

a zero in the box. For example: July 1, 2000,

should be entered as follows:

b. Date Medicare-covered Part-A stay

began.

Intent and Definition: For the current

precipitating event/problem, this is the date

of the current stay when the patient first

started receiving Medicare-covered Part-A

services in your facility. Complete this date

only if this date is different than the date in

item A2a ‘‘Date the stay began.’’

It is possible that a patient in a

rehabilitative phase of care may be

discharged from the rehabilitation facility

and then admitted to an acute care hospital

or unit. Admissions and ‘‘bed-hold’’ policies

vary in different settings. A rehabilitation

facility may choose to follow a facility

specific policy and ‘‘close’’ the medical

record of a patient that has an overnight stay

in an acute care hospital, or to keep the chart

‘‘open’’ during this period of time. However,

to be in compliance with Medicare

regulations, if a patient has an overnight stay

in an acute care hospital or unit, then for

Medicare payment purposes the

rehabilitation facility must discharge the

patient.

For the purpose of the MDS–PAC, enter the

date the patient first started to be furnished

Medicare-covered Part-A services in your

rehabilitation facility for the current

precipitating event/problem. This date

should correspond with the date used by the

billing office to initially start billing

Medicare for this stay.

Process: Review the clinical record. If it is

unclear what date the person first started

being furnished Medicare-covered Part A

services for the current stay and for the

current precipitating event/problem, clarify

with the admissions/ business or medical

record departments.

Coding: For a one digit month or day, place

a zero in the first box. For example: July 1,

2000, should be entered as follows:

3. Reason for Assessment

Intent and Definition: To document the key

reason for completing the MDS–PAC

assessment.

Process: Calculate the length of time the

patient has been receiving Medicare-covered

Part-A services during the current stay. Then

determine the type of assessment for which

the data must be collected and recorded on

the MDS–PAC.

Coding: Code for appropriate assessment.

1. Admission assessment (covers first 3

days)—Completed on day 4.

2. Reassessment—Completed on day 11.

3. Reassessment—Completed on day 31.

4. Reassessment—Completed on day 61.

5. Discharge assessment—After the

assessment reference date for the discharge

MDS–PAC assessment is determined, the

completion date for the discharge MDS–PAC

assessment must be set. The completion date

for the discharge MDS–PAC assessment must

be the fifth calendar day following the

discharge MDS–PAC assessment reference

date. To count the 5 calendar days following

the discharge MDS–PAC assessment

reference date count the discharge MDS–PAC

assessment reference date as day 1 of the 5

calendar days. For example, if the MDS–PAC

assessment reference date is May 1, 2000,

then the MDS–PAC completion date would

be May 5, 2000.

The following tables illustrate the

relationship between the type of MDS–PAC

assessment (the Day 4, Day 11, Day 30, Day

60, and discharge assessment), and the

observation time period, the assessment

reference date, and the MDS–PAC

completion date. In addition, for each type of

MDS–PAC assessment the tables depict the

associated encoding date and by when the

data for that type of assessment must be

transmitted.

66410 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

TABLE 1.—MDS–PAC ASSESSMENT SCHEDULE AND ASSOCIATED DATES

MDS–PAC

assessment type

Hospitalization

time period and

observation time

period

MDS–PAC assessment

reference date

MDS–PAC must

be completed on:

Hospitalization

episode covered

by this

assessment:

MDS–PAC must

be encoded by:

MDS–PAC must

be transmitted by:

Day 4 .................... First 3 Days ......... Day 3 ................... Day 4 ................... Entire Hospitalization Time Period.Day 10 ................. Day 16.

Day 11 .................. Days 8 to 10 ........ Day 10 ................. Day 11 ................. .............................. Day 17 ................. Day 23.

Day 30 .................. Days 28 to 30 ...... Day 30 ................. Day 31 ................. .............................. Day 37 ................. Day 43.

Day 60 .................. Days 58 to 60 ...... Day 60 ................. Day 61 ................. .............................. Day 67 ................. Day 73.

Table 1 above represents the generic

assessment schedule and other associated

MDS—PAC dates. The term ‘‘day’’ refers to

the number of calendar days during the

patient’s current hospitalization that the

patient has been hospitalized as a Medicare

Part A patient.

Table 2 below is an example of how Table

1 would be applied using actual calendar

dates. In Table 2 it is assumed that the

patient was admitted on April 3, 2001.

TABLE 2.—EXAMPLE APPLYING THE MDS–PAC ASSESSMENT SCHEDULE AND ASSOCIATED DATES

MDS–PAC assessment type Hospitalization time period and observation time period

MDS–PAC

assessment

reference

date

MDS–PAC

must be

completed

by:

MDS–PAC

must be

encoded by:

MDS–PAC

must be

transmitted

by:

Day 4 ........................................................ First 3 Days .............................................. 04/05/01 04/06/01 04/12/01 04/18/01

Day 11 ...................................................... Days 8 to 10 ............................................. 04/12/01 04/13/01 04/19/01 04/25/01

Day 30 ...................................................... Days 28 to 30 ........................................... 05/02/01 05/03/01 05/09/01 05/15/01

Day 60 ...................................................... Days 58 to 60 ........................................... 06/01/01 06/02/01 06/08/01 06/14/01

TABLE 3.—EXAMPLE APPLYING THE MDS–PAC DISCHARGE ASSESSMENT DATES

MDS–PAC assessment type Discharge

date

MDS–PAC

assessment

reference

date

MDS–PAC

must be

completed

by:

MDS–PAC

must be encoded by:

MDS–PAC

must be

transmitted

by:

Discharge Assessment ............................................................................ 5/01/00 5/01/00 5/05/00 5/11/00 5/17/00

* This is either when the first of the following occurs: (1) The day the patient is discharged from the IRF, or (2) the day the patient ceases receiving Medicare-covered Part-A inpatient rehabilitation services.

4. Admission Status

Intent: The purpose of this item is to

determine if the patient has been previously

admitted for rehabilitation of this problem.

Process: Talk to the patient and family if

necessary. Review the medical record to

determine what type of facility this patient

has been admitted from.

Coding: Place the number of the most

appropriate code in the box.

0. First admission to inpatient

rehabilitation services.

1. Readmission to rehabilitation but not

directly from other rehabilitation.

2. Readmission directly from other

rehabilitation.

5. Goals for Stay

Intent: To document the expected

outcomes of the patient’s post acute care stay.

It is possible and common to have more than

one goal for the stay.

Definition: a. Medical stabilization—

Patient’s condition is unstable and requires

frequent medical and nursing monitoring (for

example, vital signs; drug levels; laboratory

evaluation) and interventions (for example,

titrating drug dosages; transfusions) in an

effort to achieve a steady state/program of

care.

b. Rehabilitation/Functional

Improvement—Care is directed towards the

attainment of baseline (or prior to the

precipitating event) level of function in a

selected area or areas, for example, activities

of daily living, instrumental activities of

daily living, cognitive status, communication

status, or psychosocial functioning.

c. Recuperation—Care directed towards

recovery from an illness by regaining health

or strength. Often includes patient or family

caregiver teaching to prepare for different

level of care (for example, medication

management; energy conservation; ostomy

care).

d. Monitoring to avoid clinical

complication—For a medically stable patient,

care directed at systematic monitoring of the

patient’s condition through observation (that

is, clinical signs and symptoms) and

measurement of physical parameters (that is,

lab values; respiratory function tests) with

the intent of preventing complications

associated with the patient’s clinical

condition.

e. Palliative care—A primary goal of care

is to provide comfort and quality of life

through the prevention and control of

symptoms near the end of life. Palliative care

often includes active treatment of associated

conditions in an effort to promote a sense of

well-being at the end of life (for example,

antidepressant drugs/psychotherapy for

depression; physical therapy as an adjunct to

pain management and prevention of pressure

ulcers; nutritional counseling).

Coding: Code each possible goal with one

of the following responses, as appropriate:

0. No.

1. Yes.

6. Admitted From (At admission date A2)

Intent: To facilitate care planning by

documenting the place from which the

patient was admitted to the facility on the

date recorded in item A2.

Definition: 1. Private home—Any house or

condominium in the community whether

owned by the patient or another person. Also

included in this category are retirement

communities, and independent housing for

the elderly or disabled.

2. Private apartment—Any apartment in

the community whether owned by the

patient or another person.

3. Rented room—A rented room in a

private house, boarding house, or hotel.

4. Board and care/group home—A noninstitutional community residential setting

that integrates a shared living environment

with varying degrees of supportive services

of the following types: supervision, home

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66411

health, homemaker, personal care, meal

service, transportation, etc.

5. Assisted living—A housing option for

older adults who need some assistance with

activities of daily living (ADLs) but do not

require 24-hour nursing care.

6. Homeless shelter—A community-based

shelter for individuals who do not have a

place to reside.

7. Transitional living—A community based

supervised setting where individuals are

taught skills so that they can live

independently in the community.

8. Long term care facility (nursing home)—

A licensed health facility that provides 24-

hour skilled or intermediate nursing care.

9. Post acute care SNF—Facility (or

designated beds within a SNF) dedicated to

the care of patients with intense

rehabilitative or clinically complex needs.

Most patients are admitted to the post acute

care facility from an acute hospital, or

rehabilitation hospital. These patients will

have a short, intense stay in the post acute

care SNF.

10. Acute care hospital (not rehabilitation

unit)—A facility licensed as an acute care

hospital which focuses primarily on the

diagnosis and treatment of acute medical

(and in some cases psychiatric) disorders.

11. Rehabilitation unit (in acute care

hospital)—A unit within an acute care

hospital that focuses on the acute

rehabilitation of individuals who have been

functionally affected by disease or injury.

12. Rehabilitation hospital—A facility

licensed as a rehabilitation hospital that

focuses on the physical rehabilitation of

individuals who have been functionally

affected by disease or injury.

13. Long term care hospital—A facility

licensed as a long-term care hospital.

Included are hospitals that focus on the

management of clinically complex patients,

chronic medical needs, chronic disease, etc.

(includes chronic disease hospitals, and long

term acute care hospitals).

14. Psychiatric hospital/unit—A facility

licensed as a psychiatric hospital or unit

which focuses on the diagnosis and treatment

of psychiatric disorders.

15. MR/DD facility (exclude group home)—

A facility which specializes in the

management and rehabilitation of

individuals with mental retardation or

developmental disorders. Examples include

mental retardation or developmental

disabilities facility (including MR/DD

institutions) and intermediate care facilities

for the mentally retarded (ICF/MRs).

16. Other hospital—Any other hospital not

categorized above (may include in-patient

hospice programs).

17. Outpatient surgery center—A standalone or hospital-affiliated outpatient surgery

center designated to provide perioperative

care (no inpatient beds). Includes same-day

surgery units.

18. Other—Any other setting not

categorized above.

Process: Review the medical record. If

unavailable in medical record, ask patient or

family.

Coding: Choose only one answer and enter

the appropriate code in the box provided.

7. Precipitating Event Prior to Admission

a. Time of onset of the precipitating event

or problem that directly preceded admission

into this facility (time from admission date—

item A2).

Intent: This item seeks to provide the care

team with some perspective on the event that

caused the admission.

Process: Review medical record for history

of the event or problem using admission date

to the facility (item A2) as a reference point.

If necessary, clarify with patient or family.

Coding: Enter the number that best

represents the time period in which the

precipitating event occurred. This

information is obtained only on admission,

but must be coded and submitted to the

HCFA MDS–PAC system for each subsequent

(for example, the Day 11) assessment.

0. Within last week.

1. Within last 8–14 days.

2. 15–30 days ago.

3. 31–60 days ago.

4. More than 60 days ago.

b. Date of admission of most recent acute

care hospitalization (within last 90 days).

Intent: This item (in addition to the next)

gives perspective on the amount of time the

patient spent in the hospital. If there was NO

hospitalization in the last 90 days, leave this

section blank and move on to item A8.

Process: Review the medical record.

Hospital discharge summaries are the most

efficient means to gather this information, if

available. If unavailable, consult with patient

or family.

Code: Enter the date of admission to the

hospital in space provided. For a one-digit

month or day, place a zero in the first box.

For example: February 3, 1999, should be

entered as:

c. Reason for most recent acute care

hospitalization (within last 90 days).

Definition: Hospitalization—The patient

was formally admitted to an acute care

hospital by a physician as an inpatient with

an overnight stay. This category does not

include day surgery or outpatient services.

New problem—A condition that is

distinctly different or unrelated to any

previously identified disease or condition of

the patient.

Exacerbation—Recurrence or aggravation

of symptoms or increase in the severity of a

previously identified disease or condition.

Process: Review medical record. If

necessary, clarify with patient or family.

Coding: Using the following codes, enter

the number that best represents the reason

the patient was most recently hospitalized.

0. Not Hospitalized at any time in last 90

days.

1. New problem.

2. Exacerbation.

3. Both (New Problem and Exacerbation).

8. Primary and Secondary Payment Sources

for Stay (Per diem)

Intent: To document the payment source(s)

that covers the daily per diem services for

this post acute stay.

Definition: Per diem—Room, board,

nursing services and other services included

in the routine daily charge.

Process: Consult with the business or

billing office to review current payment

sources. Do not rely exclusively on

information recorded in the patient’s medical

record (usually the face sheet at the front of

the chart) as the patient’s clinical condition

may trigger different sources of payment

during the stay. It’s important to capture all

methods of payment; usually business offices

track such information.

Coding: Using the following list, enter the

code which best indicates the primary and

secondary payment sources in the

appropriate boxes. In Column A, code for the

primary payment source for the stay. In

Column B, code for the secondary payment

source for the stay.

Note: The code for Column B can’t be the

same as the code in Column A.

0. None—no insurance coverage, no private

pay.

1. Medicare.

2. Medicaid.

3. CHAMPUS.

4. Department of Veterans Affairs.

5. Managed Care/HMO—Medicare.

6. Managed Care/HMO—non-Medicare.

7. Private insurance.

8. Private pay—self or family pays,

includes private pay by patient or family.

9. Worker’s Compensation.

10. Other payment—examples include

Commission for the Blind, Alzheimer’s

Association.

9. Marital Status

Process: Ask patient or family member.

Coding: Choose the code that best

describes the patient’s current marital status.

If the patient is in a ‘‘Common Law’’

marriage, enter code ‘‘2’’, Married. Common

Law marriage—a couple who have been cohabitating and who consider themselves as

being married, even though not legally

married.

1. Never married.

2. Married.

66412 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

3. Widowed.

4. Separated.

5. Divorced.

10. Education (Highest Level Completed)

Intent: To record the highest level of

education the patient attained. Knowing this

information is useful for assessment (for

example, interpreting cognitive patterns or

language skills), care planning (for example,

deciding how to focus a planned recovery

program), and planning for patient education

in self-care skills.

Definition: The highest level of education

attained.

1. No schooling: Patient/family state that

patient received no formal schooling at all.

2. 8th grade or less: Patient attended school

through 8th grade level or less.

3. 9th–11th grade: Patient completed

school at 9th, 10th, or 11th grade.

4. High School: Patient obtained high

school diploma—completed school through

the twelfth grade or GED.

5. Technical or Trade School: Include

schooling in which the patient received a

non-degree certificate in any technical

occupation or trade (for example, carpentry,

plumbing, acupuncture, baking, secretarial,

practical/vocational nursing, computer

programming, etc.).

6. Some College: Includes completion of

some college courses at a junior (community)

college, associate’s degree, or incomplete

bachelor’s degree.

7. Bachelor’s degree: Includes any

undergraduate bachelor’s level college

degree.

8. Graduate Degree: Master’s degree or

higher (M.S., Ph.D., M.D., J.D., etc.).

Note: If assessor has been unsuccessful in

determining educational information, the

assessor may use a ‘‘dash’’ symbol to indicate

information not available.

Process: Ask the patient or family. If a part

of your facility’s standard intake record,

review the patient’s record.

Coding: Code for the best response. For

MR/DD patients who have received special

education services, code ‘‘2’’ (8th grade/less).

11. Language

Definition: (a.) Primary language—The

language the patient primarily speaks or

understands. If patient is unable to speak at

the present time, code for language familiar

to patient prior to the precipitating event.

Process: Determine patient’s primary

language by asking the patient or family. If

a part of your facility’s standard intake

record, review the patient’s record.

Coding: Given the choices provided,

indicate what the patient identifies as their

primary language.

0. English.

1. Spanish.

2. French.

3. Other, specify in A11b.

(b.) If the patient’s primary language is

other than English, Spanish, or French, enter

3 for Other in item A11a, and print the

primary language in item A11b beginning in

the left-most box.

12. Dominant Hand

Intent: To document which hand the

patient considers to be the ‘‘dominant’’ hand.

Knowing the patient’s ‘‘handedness’’ can

facilitate rehabilitation and assist in the

detection of neurological and functional

diagnoses.

Definition: The dominant hand describes

what is usually referred to as ‘‘handedness’’

and reflects the area of the brain that is most

dominant.

Process: Ask patient, family, or therapy

staff.

Coding: Indicate which hand the

individual has considered to be dominant

since childhood. If an individual feels that

both hands are equal (ambidextrous), enter

code ‘‘3’’, unable to determine. Also use code

‘‘3’’ if you are unable to obtain this

information from the patient, family or

medical record.

If Right handed, code ‘‘1’’.

If Left handed, code ‘‘2’’.

If Unable to determine, code ‘‘3’’.

13. Mental Health History

Intent: To document a primary or

secondary diagnosis of psychiatric illness or

developmental disability.

Definition: Patient has one of the

following:

• A schizophrenic, mood, paranoid, panic

or other severe anxiety disorder; somatoform

disorder, personality disorder; other

psychotic disorder; or another mental

disorder that may lead to chronic disability;

but

• Not a primary diagnosis of dementia,

including Alzheimer’s disease or a related

disorder, or a non-primary diagnosis of

dementia unless the primary diagnosis is a

major mental disorder;

AND

• The disorder results in functional

limitations in major life activities that would

be appropriate within the past 3 to 6 months

for the individual’s developmental stage;

AND

• The treatment history indicates that the

individual has experienced either: (a)

Psychiatric treatment more intensive than

outpatient care more than once in the past 2

years (for example, partial hospitalization or

inpatient hospitalization); or (b) within the

last 2 years due to the mental disorder,

experienced an episode of significant

disruption to the normal living situation, for

which formal supportive services were

required to maintain functioning at home, or

in a residential treatment environment, or

which resulted in intervention by housing or

law enforcement officials.

Process: Review the patient’s record only.

For a ‘‘Yes’’ response to be entered, there

must be written documentation (that is,

verbal reports from the patient or patient’s

family are not sufficient).

Coding: Enter ‘‘0’’ for No or ‘‘1’’ for Yes.

0. No.

1. Yes.

14. Conditions Related to MR/DD Status

(Mental Retardation/Developmental

Disabilities)

Intent: To document presence of mental

retardation or developmental disabilities

with and without organic conditions.

Process: Review the patient’s record only.

Condition must be documented in the

clinical record. Examples of organic

conditions related to MR/DD are rubella,

prenatal infection, congenital syphilis,

maternal intoxication, mechanical injury at

birth, prenatal hypoxia, neuronal lipid

storage diseases, phenylketonuria (PKU),

neurofibromatosis, microcephalus,

macroencephaly, meningomyelocele,

congenital hydrocephalus, etc.

Coding: If organic condition is present,

check if condition is related to MR/DD status

present before age 22. When age of onset is

not specified, assume that the condition

meets this criterion AND is likely to continue

indefinitely.

1. Not applicable—No MR/DD.

2. MR/DD with no organic condition.

3. MR/DD with organic condition.

15. Responsibility/Legal Guardian

Intent: To record who has responsibility for

participating in decisions about the patient’s

health care, treatment, financial affairs, and

legal affairs. Depending on the patient’s

condition, multiple options may apply. For

example, a patient with moderate dementia

may be competent to make decisions in

certain areas, although in other areas a family

member will assume decision-making

responsibility. Or a patient may have

executed a limited power of attorney to

someone responsible only for legal affairs.

Definition: a. Legal guardian—Someone

who has been appointed after a court hearing

and is authorized to make decisions for the

patient, including giving and withholding

consent for medical treatment. Once

appointed, the decision-making authority of

the guardian may be revoked only by another

court hearing.

b. Other legal oversight—Use this category

for any other program in your State whereby

someone other than the patient participates

in or makes decisions about the patient’s

health care and treatment.

c. Durable power of attorney/health care—

Documentation that someone other than the

patient is legally responsible for health care

decisions if the patient becomes unable to

make decisions. This document may also

provide guidelines for the agent or proxy

decision-maker, and may include

instructions concerning the patient’s wishes

for care. Unlike a guardianship, durable

power of attorney/health care proxy terms

can be revoked by the patient at any time.

d. Patient responsible for self—Patient

retains responsibility for decisions. In the

absence of guardianship or legal documents

indicating that decision-making has been

delegated to others, always assume that the

patient is the responsible party.

e. NONE OF THE ABOVE.

Process: Legal oversight such as

guardianship, durable power of attorney, and

living wills are generally governed by state

law. The descriptions provided here are for

general information only. Refer to the law in

your State and to the facility’s legal counsel,

as appropriate, for additional clarification.

Consult the patient and the patient’s

family. Review records. Where the legal

oversight or guardianship is court ordered, a

copy of the legal document must be included

in the patient’s record in order for the item

to be checked on the MDS–PAC form.

Coding: Check all that apply.

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16. Advance Directives

Intent: To document the existence of any

legal directives to guide the health care team

in making treatment decisions, whether made

by the patient him/herself or a legal proxy.

This documentation must be in the medical

record to be considered current and binding.

The absence of pre-existing directives for the

patient provides an opportunity for a

discussion by the clinical team with the

patient and family regarding the patient’s

wishes. Any discrepancies between the

patient’s current stated wishes and what is

said in legal documents in the patient’s file

should be resolved immediately.

Definition: a. Living will—A document

specifying the patient’s preferences regarding

measures used to prolong life when there is

a terminal prognosis.

b. Do not resuscitate—In the event of

respiratory or cardiac failure, the patient,

family or legal guardian has directed that no

cardiopulmonary resuscitation (CPR) or other

life-saving methods will be used to attempt

to restore the patient’s respiratory or

circulatory function.

c. Do not hospitalize—A document

specifying that the patient is not to be

hospitalized even after developing a medical

condition that usually requires

hospitalization.

d. Treatment restrictions—The patient or

responsible party (family or legal guardian)

does not wish the patient to receive certain

medical treatments. Examples include, but

are not limited to: blood transfusion,

tracheotomy, respiratory intubation, and

restraints. Such restrictions may not be

appropriate to treatments given for palliative

reasons (for example, reducing pain or

distressing physical symptoms such as

nausea or vomiting). In these cases, the

directive should be reviewed with the

responsible party. Treatment restrictions

could also include:

• Feeding restrictions—The patient or

responsible party (family or legal guardian)

does not wish the patient to be fed by

artificial means (for example, tube,

intravenous nutrition) if unable to be

nourished by oral means.

• Medication restrictions—The patient or

responsible party (family or legal guardian)

does not wish the patient to receive lifesustaining medications (for example,

antibiotics, chemotherapy).

e. NONE OF THE ABOVE.

Process: You will need to familiarize

yourself with the legal status of each type of

directive in your State. In some states only

a health care proxy is formally recognized;

other jurisdictions allow for the formulation

of living wills and the appointment of

individuals with durable power of attorney

for health care decisions. Facilities should

develop a policy regarding documents drawn

in other states, respecting them as important

expressions of the patient’s wishes until their

legal status is determined.

Review the patient’s record for

documentation of the patient’s advance

directives. Documentation must be available

in the record for a directive to be considered

current and binding.

Some patients at the time of admission

may be unable to participate in decisionmaking. Staff should make a reasonable

attempt to determine whether the new

patient has ever created an advance directive

(for example, ask family members, check

with the primary physician). Lacking any

directive, treatment decisions will likely be

made in concert with the patient’s closest

family members or, in their absence or in

case of conflict, through legal guardianship

proceedings.

Coding: The following comments provide

further guidance on how to code these

directives. You will also need to consider

State law, legal interpretations, and facility

policy.

• The patient (or proxy) should always be

involved in the discussion to ensure

informed decision-making. If the patient’s

preference is known and the attending

physician is aware of the preference, but the

preference is not recorded in the record,

check the MDS–PAC item only after the

preference has been documented.

• If the patient’s preference is in areas that

require supporting orders by the attending

physician (for example, do not resuscitate, do

not hospitalize, feeding restrictions, other

treatment restrictions), check the MDS–PAC

item only if the document has been recorded

or after the physician provides the necessary

order. Where a physician’s current order is

recorded but patient’s or proxy’s preference

is not indicated, discuss with the patient’s

physician and check the MDS–PAC item only

after documentation confirming that the

patient’s or proxy’s wishes have been entered

into the record.

• If your facility has a standard protocol

for withholding particular treatments from all

patients (for example, no facility staff

member may resuscitate or perform CPR on

any patient; facility does not use feeding

tubes), check the MDS–PAC item only if the

advanced directive is the individual

preference of the patient (or legal proxy),

regardless of the facility’s policy or protocol.

Coding: Check all that apply. If none of the

directives are verified by documentation in

the medical records, check NONE OF

ABOVE.

Section B. Cognitive Patterns

Intent: To assess the patient’s ability to

think coherently, remember and organize

thoughts into actions, including daily selfcare activities. These items focus on the

patient’s functional performance, including

demonstration of ability to remember recent

and past events, to perform key decision

making skills. This information can

significantly contribute to the development

of a post acute plan of care, including the

discharge plan.

Questions about cognitive function and

memory can be threatening or sensitive for

some patients. Some may react defensively or

get agitated and emotional if unable to

remember or answer the questions. These are

not uncommon reactions to ‘‘performance

anxiety’’ and feelings of being exposed,

embarrassed, or frustrated if the patient is

aware that he or she cannot respond

cogently. It is important to recognize these

feelings and to be as supportive as possible.

It is important to establish an environment

that enables the patient to function at their

optimal level. The first few days of admission

to a post acute setting can be overwhelming.

Be sure to interview the patient in a private,

quiet area (for example, limit distractions and

interruptions as much as possible), and not

in the presence of other patients or family,

unless the patient would prefer that they

stay. Using a non-judgmental approach to

questioning will help create a needed sense

of trust between the assessor and the patient.

Clarify and validate your findings with the

patient’s family or other clinicians as needed.

This input is especially important for those

patients with limited communication skills

or language barriers.

Engage the patient in general conversation

to help establish rapport.

• Actively listen and observe for clues to

help you structure your assessment.

Remember that repetitiveness, inattention,

rambling speech, defensiveness, or agitation

may be challenging to deal with during an

interview, but they provide important

information about cognitive function.

• Be open, supportive, and reassuring

during your conversation with the patient

(for example, ‘‘Do you sometimes have

trouble remembering things? Tell me what

happens. We will try to help you’’).

If the patient becomes really agitated,

sympathetically respond to his or her feelings

of agitation and STOP discussing cognitive

function. The information-gathering process

does not need to be completed in one sitting

during the three-day observation/assessment

period but may be ongoing during the entire

assessment period. Say to the agitated

patient, for example, ‘‘Let’s talk about

something else now,’’ or ‘‘We don’t need to

talk about that now. We can do it later’’.

Observe the patient’s cognitive performance

over the next few hours and days and come

back to ask more questions when he or she

is feeling more comfortable.

1. Comatose

Intent: To record whether the patient’s

clinical record includes a documented

neurological diagnosis of coma or persistent

vegetative state.

Process: Review medical record for

documentation.

Coding: Enter the appropriate number in

the box.

If the patient has been diagnosed as

comatose or in a persistent vegetative state,

code ‘‘1’’ (Yes) and Skip to Section E. If the

patient is not comatose, or is semi-comatose,

code ‘‘0’’ (No) and proceed to the next item

(B2).

2. Memory/Recall Ability

Intent: To determine a patient’s ability to

remember recent and past events (that is,

short-term, long-term, situational and

procedural memory).

Process: a. Short-term memory OK: Ask the

patient to describe a recent event that both

of you have had the opportunity to remember

(you should be able to validate that patient’s

memory with your knowledge of such

events). Examples include what the patient

had for breakfast, when the last pain

medication dosage was received, (you can

validate the patient’s recollection with

information from the medical record). For

persons with verbal communication deficits,

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non-verbal responses are acceptable (for

example, when asked how many children

visited today, they can correctly tap out a

response of the appropriate number). If there

is no positive indication of memory ability,

code ‘‘1’’, Memory problem.

b. Long-term memory OK: Engage in

conversation about past events that are

meaningful to the patient (for example,

family, hospitalization, work experience).

Ask questions for which you can validate the

answers (from your review of the medical

record, general knowledge, the patient’s

family). For patients with limited

communication skills, ask family members

about their perception of the patient’s

memory. If the patient demonstrates

difficulty remembering key events of long

ago, code ‘‘1’’, Memory problem.

c. Situational memory OK: This item refers

to two abilities that can be demonstrated by

the patient within the facility: (1) The

patient’s ability to recognize the names and

faces of staff whom they frequently

encounter, AND (2) the patient’s ability to

remember the location of places regularly

visited (for example, bedroom, meal room/

dining area, activity room, therapy room).

IMPORTANT: For coding purposes, the

patient must demonstrate positive abilities in

BOTH types of situations to be coded as ‘‘0’’,

Memory OK. If she/he demonstrates

difficulty in one or both areas code as ‘‘1’’,

Memory problem.

• Recognize staff names and faces—The

patient distinguishes staff caregivers from

family members, strangers, visitors, and other

patients. It is not necessary that the patient

remembers all staff members’ names, but to

recognize them as staff caregivers (that is,

nurse, therapist) vs. others.

• Remember the location of places

regularly visited—The patient is able to

locate or recognize key areas of the facility

that they frequent regularly. It is not

necessary for the patient to know his/her

room number but he/she should be able to

find the way to his room, recognize the

purposes of particular rooms, etc.

d. Procedural Memory OK: This MDS–PAC

item refers to the ability to perform

sequential activities. Dressing is an example

of such a task as it requires multiple steps to

complete the entire task. The patient must be

able to perform or remember to perform all

or most all of the steps in order to be scored

a ‘‘0’’ Memory O.K. If the patient

demonstrates difficulty in two or more steps,

code as ‘‘1’’ Memory Problem.

Coding: For each type of memory:

Code ‘‘0’’ in the box provided, if memory

OK.

Code ‘‘1’’ in the box provided, if memory

problem is demonstrated.

3. Cognitive Skills for Daily Decision Making

Intent: To record the patient’s ability and

actual performance in making every day

decisions about tasks or activities of daily

living. This item is especially important for

assessment and care planning for 2 reasons:

(1) The information can alert health care

providers to new changes (decline or

improvement) in the patient’s cognitive

function, and (2) the information can alert

staff to a discrepancy between a patient’s

capacity for decision-making and their

current level of performance, which may

indicate that caregivers or family may be

inadvertently fostering the patient’s

dependence. It may have an impact on the

course of treatment outcomes and discharge

plan.

For persons who have been acutely ill, it

is important to determine the patient’s

‘‘baseline’’ cognitive skills from some point

prior to the current admission (Note: this

instrument uses a time period prior to the

assessment reference date [item AA4]), as

well as his/her current skills (Note: the last

3 days, and the time immediately prior to

precipitating event), so that the clinician can

make a comparison for diagnostic and care

planning purposes. Even slight deviations

(decline) from baseline may be secondary to

a variety of causes including: (1) The

outcome of a recent acute event (for example,

a primary neurological event such as a CVA;

post anesthesia), (2) an evolving acute illness

or exacerbation of disease (for example,

infection; congestive heart failure;

dehydration; drug effects or interactions;

depression), or (3) a progression of a chronic

neurological condition (for example,

Alzheimer’s disease; Huntington’s disease).

Detecting change is the first step in

determining whether the change is due to a

remediable condition or chronic decline.

Likewise, follow-up measurements can

provide an indication of success of treatment

programs, prognosis for independent living,

etc.

(a) Making decisions regarding tasks of

daily life.

Process: This assessment should be

conducted through conversation with direct

care staff, a review of the clinical record

(chart), in addition to personally observing

and interacting with the patient [Note—this

personal interaction can occur in the course

of regular ongoing care activities; or it can be

a part of a planned MDS–PAC interview/

observation where a series of issues are

reviewed—cognition, mood, ADLs,

activities]. Your inquiry should focus on

whether the patient is actively making

choices, plans, and decisions, and not

whether staff believe the patient might be

capable of doing so. Remember, the intent of

this item is to record what the patient is

doing (performance). Where a health care

provider or family member takes decisionmaking responsibilities away from the

patient regarding tasks of everyday living or

the patient does not participate in decisionmaking (which may happen when patients

take on the ‘‘sick’’ role), consider the patient

to have impaired performance in decision

making. In this case document how they

function now rather than your supposition of

their capacity to function. Consult with

family and health care providers where

necessary to clarify patient decision making.

Coding: Enter the number that most

accurately characterizes the patient’s

cognitive performance in making decisions

regarding the tasks of daily life over the last

three days.

0. Independent—The patient’s decisions in

planning and executing daily routines and

making decisions were consistent,

reasonable, safe, and organized reflecting

lifestyle, culture, values.

1. Modified Independence—The patient

was organized in daily routines and made

safe decisions in familiar situations, but

experienced some difficulty in decisionmaking when faced with new tasks or

situations.

2. Minimally Impaired—For the most part,

the patient was organized in daily routines

and made safe decisions, but in specific

situations the patient demonstrated poor

decision-making skills requiring directions or

cues or supervision at those times.

3. Moderately Impaired—The patient

demonstrated poor decision making skills

that could place his/her safety at risk. The

patient needs reminders, cues and

supervision in planning, organizing,

correcting, and carrying out daily routines.

Cues and supervision are required at all

times.

4. Severely Impaired—The patient’s

decision making was severely impaired: the

patient never (or rarely) makes decisions.

(b) Is now more impaired in decision

making than prior to precipitating event

(item A7a).

Intent: To record whether the patient is

now more impaired than she/he was at a

specified period in time prior to the

precipitating event (that is, the current score

to item B3a is higher that it would have been

prior to the precipitating event).

Process: Through patient interview, family

reports, or review of earlier clinical record,

compare the patient’s current skills in daily

decision making with their skills

immediately prior to the precipitating event

[Item A7a].

Coding: Enter the number corresponding to

the most appropriate response.

0. No or unsure.

1. Yes, more impaired today.

4. Indicators of Delirium—Periodic

Disordered Thinking/Awareness

Intent: To assess and record behavioral

signs that may indicate that delirium is

present. The characteristics of delirium are

usually manifested behaviorally, and

therefore can be observed. For example,

disordered thinking, a typical characteristic

of delirium, may be first observed as

rambling, irrelevant, or incoherent speech.

Other typical behaviors are described in the

definitions below.

Many acute conditions (for example,

infections; congestive heart failure) and

treatment (for example, polypharmacy;

anesthesia; anticholinergic drugs) can have a

deleterious effect on cognitive performance

and the development of delirium,

particularly in persons with the following

risk factors: over age 80 years, prior history

of cognitive impairment, recent hip fractures,

complex medical conditions and drug

regimens, recent hospitalization, and history

or signs/symptoms of depression. The

incidence rate of delirium among acute care

hospital patients is as high as 41% and often

occurs by day 2 through 6 of the

hospitalization. Approximately 48–96% of

patients continue to have some behavioral

and cognitive symptoms by discharge. With

the shortening of hospital stays, and the shift

towards earlier discharge to post acute

environments it is crucial for clinicians to

identify and monitor for behavioral

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66415

manifestations of delirium for two reasons:

(1) to identify new or worsening signs that

herald the onset of a treatable acute

condition, and (2) to document the

progression of changes over time for

discharge planning.

Definition: a. Easily distracted—(for

example, has difficulty paying attention, does

not complete tasks or conversations without

getting sidetracked)

b. Periods of altered perception or

awareness of surroundings—(for example,

moves lips or talks to someone not present;

believes he/she is somewhere else; confuses

night and day)

c. Episodes of disorganized speech—(for

example, speech is incoherent, nonsensical,

irrelevant, rambling from subject to subject;

loses train of thought)

d. Periods of restlessness—(for example,

fidgeting or picking at skin, clothing,

napkins, etc.; frequently changing positions;

repetitive physical movements or calling out)

e. Periods of lethargy—(for example,

sluggishness, staring into space; difficult to

arouse; little body movement)

f. Mental function varies over the course of

the day—(for example, alertness and

behaviors vary during the course of the day,

sometimes better, sometimes worse;

sometimes present, sometimes not)

Process: Observe patient and interview

staff.

Coding: Code for the patient’s behavior in

the last seven days regardless of what you

believe the cause to be—focus on when the

manifested behavior first occurred. Accurate

assessment requires conversations with staff

and family who have direct knowledge of

patient’s behavior over this time.

0. Behavior not present.

1. Behavior present, not of recent onset.

2. Behavior present over last 7 days

appears different from the patient’s usual

functioning (for example, new onset or

worsening).

Section C. Communication/Vision Patterns

Intent: To document the patient’s sensory

function (for example, ability to hear and see

with assistive devices, if used, and/or

environmental adjustments, if necessary) and

ability to understand and communicate with

others.

Communication—There are many possible

causes for communication problems

experienced by elderly and post acute

patients. Some can be attributed to the aging

process; others are associated with

progressive physical and neurological

disorders. Usually the communication

problem is caused by more than one factor.

For example, a patient might have aphasia as

well as long standing hearing loss; or he

might have dementia with word finding

difficulties and a hearing loss. The patient’s

physical, emotional, and social situation may

also complicate communication problems.

Additionally, a noisy or isolating

environment can inhibit opportunities for

effective communication.

Deficits in ability to make one’s self

understood (expressive communication

deficits) can include reduced voice volume

and difficulty in producing sounds, or

difficulty in finding the right word, making

sentences, writing, and gesturing. Deficits in

one’s ability to understand (receptive

communication deficits) can involve declines

in hearing, comprehension (spoken or

written), or recognition of facial expressions.

Vision—Visual limitations or difficulties

may be related to the aging process as well

as to diseases common in aged and

chronically ill persons (for example,

cataracts, glaucoma, macular degeneration,

diabetic retinopathy, neurologic diseases). It

is important to identify visual impairment.

Some conditions may be treatable and

reversible; others, though not reversible, may

be managed by interventions aimed at

maintaining or improving the patient’s

residual visual abilities. In the post acute

setting, identifying and addressing visual

impairment is an important part of preparing

the patient for tasks related to self-care upon

potential discharge to a more independent

care setting (for example, reading medication

and food labels; safely negotiating a living

environment; using the stove).

1. Hearing

Intent: To evaluate the patient’s ability to

hear (with hearing appliance, if used, and/or

environmental adjustments, if necessary)

during the last 3-day period. Identifying

impairments early in the post acute stay can

facilitate the development of necessary

adaptions for discharge. Often the

environment can have an impact on the

patient’s ability to hear and must be

considered in the assessment.

Process: If the patient has an adaptive

hearing device/aid/appliance, evaluate

hearing ability with the working device in

place. Interview the patient (ask about

hearing function) and observe for hearing

function during your verbal interactions. Use

a variety of observations to make your

assessment (for example, one-on-one vs.

group situations). Always be mindful of

environmental factors that may influence

your assessment (for example, call bells;

vacuum cleaners; suctioning equipment;

roommate’s conversations; outside noises,

etc.). If necessary to clarify exact hearing

level, consult with the patient’s family,

primary caregivers, or speech or hearing

specialists.

Be alert to what you have to do to

communicate with the patient. For example,

if you have to speak more clearly, use a

louder tone, speak more slowly, or use more

gestures, or if the patient needs to see your

face to know what you are saying, or if you

have to take the patient to a more quiet area

to conduct the interview—all of these are

cues that there is a hearing problem, and

should be indicated in coding this section.

Coding: Enter the number that corresponds

to the most correct response.

0. Hears adequately—The patient hears all

normal conversational speech, social

interaction, including when using the phone,

and watching TV.

1. Minimal difficulty—The patient hears

speech at conversational levels but has

difficulty hearing when the environment is

not quiet or when he/she is in group

situations. Background noise affects hearing.

2. Hears in special situations only—The

patient is hearing deficient but compensates

and hears better when the speaker increases

volume, adjusts his voice tone, and/or speaks

distinctly; or the patient can hear only when

the speaker’s face is clearly visible.

3. Highly impaired/absence of useful

hearing—The patient hears only some sounds

and frequently fails to respond even when

speaker adjusts tone and volume, speaks

slowly and distinctly, or is positioned faceto-face with the patient. There is no

comprehension of conversational speech,

even when the speaker makes maximum

adjustments.

2. Modes of Communication

Intent: To record the types of

communication techniques (for example,

alternative verbal or non-verbal techniques)

used by the patient to make his or her needs

or wishes known.

Definition: a. Hearing aid—An apparatus

used by those with impaired hearing for

amplifying sound.

b. Lip reading—Understanding spoken

word by means of visualization of the

speaker’s mouth and lips.

c. Signs/gestures/sounds—This category

includes non-verbal expressions used by the

patient to communicate with others.

• Actions may include pointing to words,

objects, people; facial expressions; using

physical gestures such as nodding head twice

for ‘‘yes’’ and once for ‘‘no’’ or squeezing

another’s hand in the same manner.

• Sounds may include grunting, banging,

ringing a bell, etc.

d. Writing messages to express or clarify

needs—Patient writes notes to communicate

with others.

e. NONE OF THE ABOVE.

Process: Interact with the patient and

observe for any reliance on non-verbal

expression (physical gestures, such as

pointing to objects), either in one-on-one

communication or in group situations.

Consult with the direct care staff from all

shifts. For patient with limited

communication skills, have staff ask patient’s

family if there are additional effective means

of communication.

Coding: Check the boxes for each method

used by the patient to communicate his or

her needs. If the patient does not use any of

the listed items, check NONE OF THE

ABOVE.

3. Making Self Understood (Expression)

Intent: To document the patient’s ability to

express or communicate requests, needs,

opinions, urgent problems, and social

conversation, whether in speech, writing,

sign language, or a combination of these. In

order to monitor the patient’s progress, the

assessment reflects the patient’s status at 2

points in time: over the last 3 days, and

immediately prior to the precipitating event

(A7a).

(a) Expressing information content—

however able.

Process: Interact with the patient. Observe

and listen to the patient’s efforts to

communicate with you using the assistive

devices/modes of expression they would

normally use to communicate. Consult with

the primary caregivers (over all shifts), and

speech-language pathologist, if possible, who

will be able to report on observations of

patient’s interactions with others in different

66416 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

settings (for example, one-on-one, groups)

and different circumstances (for example,

when calm, when agitated) and different

times of day. If direct care staff are uncertain

and you require further clarification, consult

with family members who frequently visit

the patient (if such a person is present).

Coding: Enter the number corresponding to

the patient’s ability to make self understood

over the last 3 days.

0. Understood—The patient expresses

ideas clearly, without difficulty.

1. Usually Understood—The patient may

have difficulty expressing ideas (finding

words or finishing thoughts) but is able to

make him/herself understood if the listener

is patient and gives him/her time to express

himself. Little or no prompting required by

the listener.

2. Often Understood—The patient has

difficulty finding the right words or finishing

thoughts, resulting in delayed or incomplete

responses. The patient usually requires some

prompting/cuing by the listener to complete

or clarify the message (make self understood).

3. Sometimes Understood—The patient has

limited ability, but expresses simple,

concrete requests regarding at least basic

needs that would be generally understood

(for example, food, drink, sleep, toilet, pain).

4. Rarely or Never Understood—The

patient is not able to communicate

effectively. At best, this communication is

such that it required staff to interpret the

meaning of highly individual, patientspecific sounds or body language (for

example, indicated presence of pain or need

to use the toilet).

(b) Is now more impaired in making self

understood by others than was prior to

precipitating event (item A7a).

Process: Through patient interview, family

reports, or review of earlier clinical record

compare patient’s current ability to make self

understood (last 3 days) with their ability

prior to the precipitating event [Item A7a]).

Coding: Enter the number corresponding to

the most appropriate response.

0. No, or unsure.

1. Yes, more impaired today.

4. Speech Clarity

Intent: To document the quality/

intelligibility of the patient’s speech (not the

content or appropriateness).

Definition: Speech—the expression of

articulate words.

Process: Throughout the course of the

assessment the patient will have many

opportunities to talk with you. Listen to the

clarity of speech. To assess speech quality

over the last 3 days also confer with primary

caregivers.

Coding: Enter the number corresponding to

the response which best describes the clarity

and quality of the patient’s speech in the last

3 days.

0. Clear speech—utters distinct, intelligible

words.

1. Unclear speech—utters slurred or

mumbled words.

2. No speech—absence of spoken words.

5. Ability to Understand Others

(Comprehension)

Intent: To describe the patient’s ability to

comprehend information whether

communicated to the patient orally, in

writing, or in sign language or Braille. This

item measures not only the patient’s ability

to hear messages but also to process and

understand language. In order to monitor the

patient’s progress, the assessment reflects the

patient’s status at 2 points in time: the last

3 days, and immediately prior to a more

distant precipitating event (A7a).

(a) Understanding verbal information

content (however able) with hearing

appliance, if used.

Process: Assess the patient using whatever

assistive devices/methods (for example,

hearing aids) that the patient would usually

use in communicating with others. Interact

with the patient. Throughout the assessment

process and at other times observe the patient

and determine his/her ability to comprehend

your questions and statements. Try to

observe the patient’s interactions with others,

in different situations and times of day.

Consult with primary staff caregivers (over

all shifts), and speech-language pathologist

(if present) to clarify patient understanding at

different times and in different settings. If

direct care staff are uncertain and you require

further clarification, consult with family

member who frequently visits the patient (if

such person is present).

Coding: Enter the number corresponding to

the patient’s ability to comprehend

(understand others) over the last 3 days.

0. Understands—The patient clearly

comprehends the speaker’s message(s) and

demonstrates this understanding through

words or actions/behaviors.

1. Usually Understands—The patient may

miss some part or intent of the message but

comprehends most of it. The patient may

have periodic difficulties integrating

information but generally demonstrates

comprehension, by responding in words or

actions. Little or no prompting required.

2. Often Understands—The patient may

miss some part or intent of the message.

When the messenger(s) (staff or family)

rephrase or simplify the message(s) or use

gestures, and specifically inquires as to the

patient’s understanding of what is being

communicated, the patient’s comprehension

is enhanced. This type of prompting occurs

often.

3. Sometimes Understands—The patient

demonstrates frequent difficulties integrating

information and responds adequately only to

simple and direct questions or directions/

cues (for example, one-step commands such

as ‘‘close your eyes’’)

4. Rarely/Never Understands—The patient

demonstrates very limited ability to

understand communication. Based on the

patient’s verbal and nonverbal responses,

staff have difficulty determining whether the

patient comprehends messages, or the patient

can hear sounds but does not understand

messages.

(b) Is now more impaired in understanding

others than was prior to precipitating event

(Item A7a).

Process: Through patient interview, family

reports, or review of earlier clinical record

compare patient’s current ability to

understand others (last 3 days) with their

ability immediately prior to the precipitating

event [Item A7a].

Coding: Enter the number corresponding to

the most appropriate response.

0. No or unsure.

1. Yes, more impaired today.

6. Vision

Intent: To evaluate the patient’s ability to

see close objects in adequate lighting, using

the patient’s customary visual appliances for

close vision (for example, glasses; contact

lenses; magnifying glass). Adequate lighting

is defined as the amount of light that is

sufficient or comfortable for a person with

normal vision.

Process: • Ask the patient about his or her

visual abilities for close vision (for example,

to see newsprint, menus, greeting cards), use

of glasses, contact lenses, etc.

• To validate the patient’s reported vision,

ask the patient to look at regular-size print in

a book or newspaper using whatever visual

appliance he or she customarily uses for

close vision (for example, glasses, magnifying

glass). Then ask the patient to read a few

words aloud, starting with larger headlines

and ending with the finest, smallest print.

• Be sensitive to the fact that some patients

are not literate or are unable to read English.

In such cases, ask the patient to read aloud

individual letters of different size print or

numbers, such as dates or page numbers, or

to name items in small pictures.

• If the patient is unable to communicate

or follow your directions for testing vision,

observe the patient’s eye movements to see

if his or her eyes seem to follow movement

and objects. Though these are gross

measurements of visual acuity, they may

assist you in assessing whether the patient

has any visual ability.

(a) Ability to see in adequate light and with

glasses, if used.

Coding: Enter the code that best describes

the patient’s visual ability given adequate

light and use of his/her customary visual

aids.

0. Adequate—The patient sees fine detail,

including regular print in newspapers/books.

1. Impaired—The patient sees large print,

but not regular print in newspapers/books.

2. Moderately Impaired—The patient has

limited vision, is not able to see newspaper

headlines, but can identify objects in his or

her environment.

3. Highly Impaired—The patient’s ability

to identify objects in his or her environment

is in question, but eye movements appear to

follow objects (for example, people walking

by).

Note: Many patients with severe cognitive

impairment are unable to participate in

vision screening because they are unable to

follow directions or are unable to tell you

what they see. However, many such patients

appear to ‘‘track’’ or follow moving objects in

their environment with their eyes. For

patients who appear to do this, use code ‘‘3’’,

Highly Impaired. Even though these are gross

measures, with our current limited

technology, this is the best general

assessment you can do under the

circumstances.

4. Severely Impaired—The patient has no

vision; reports seeing only light or colors, but

eyes do not appear to follow objects (for

example, people walking by).

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66417

(b) Is now more impaired in vision than

was prior to precipitating event (Item A7a).

0. No or unsure.

1. Yes, more impaired today.

Section D. Mood and Behavior Patterns

Mood distress is a serious condition that is

associated with significant morbidity and

mortality. It may be precipitated by acute

illness, loss of independence (whether

temporary or permanent), a new diagnosis

(possibly terminal), pain, effects of

medications, etc. Although changes in mood

and behavior can happen to anyone, persons

at particular risk for disorders such as

depression are those with prior history of

mood disorders, mild to moderate cognitive

impairment, pain, and unstable health

conditions. Many clinicians and patients

perceive changes in mood and behavior to be

normal, expected reactions to crisis (for

example, deteriorating health). Although

such reactions are common, it is crucial to

identify the particular signs of distress, assess

the frequency of their occurrence, and

determine whether they are easily altered.

Then clinicians can develop an appropriate

treatment plan based on the impact of the

mood or behavioral indicators on the

patient’s quality of life and well-being, ability

to participate in the post acute treatment and

discharge plans, etc.

1. Indicators of Depression, Anxiety, Sad

Mood

Intent: To record the frequency of

indicators observed in the last 3 days,

irrespective of the assumed cause of the

indicator (behavior).

Definition: Feelings of psychic distress

may be expressed directly by the patient who

is depressed, anxious, or sad. However,

direct statements such as ‘‘I’m so depressed’’

are often rare; signs must be often ‘‘teased’’

out by clinicians through observation and

interview. Distress may be more commonly

expressed in the following ways:

VERBAL EXPRESSIONS OF DISTRESS

a. Patient made negative statements—for

example, ‘‘Nothing matters; Would rather be

dead than live this way; What’s the use; Let

me die.’’

b. Persistent anger with self or others—for

example, easily annoyed, anger at presence

in post acute care, anger at care received.

c. Expressions of what appear to be

unrealistic fears—for example, fear of being

abandoned, left alone, being with others,

afraid of nighttime.

d. Repetitive anxious complaints/concerns

(non-health related)—for example,

persistently seeks attention/reassurance

regarding therapy or others’ schedules,

meals, laundry, clothing, relationship issues,

when family will visit.

e. Repetitive health complaints—for

example, persistently seeks medical

attention, obsessive concern with body

functions, obsessive concern with vital signs.

Distress may also be expressed nonverbally and identified through observation

of the patient in the following areas during

usual daily routines:

SAD, APATHETIC ANXIOUS APPEARANCE

f. Sad, pained, worried facial expressions—

for example, furrowed brows.

g. Crying, tearfulness.

h. Repetitive physical movements—for

example, pacing, hand wringing, restlessness,

fidgeting, picking.

SLEEP CYCLE ISSUES

Distress can also be manifested in

disturbed sleep patterns.

i. Insomnia/change in usual sleep

patterns—for example, difficulty falling

asleep, fewer or more hours of sleep than

usual, waking up too early and unable to fall

back to sleep.

LOSS OF INTEREST

These items refer to a change in the

patient’s usual pattern of behavior.

j. Withdrawal from activities of interest—

for example, no interest in long standing

activities or being with family/friends.

k. Reduced social interaction—for

example, less talkative, more isolated.

Process: Initiate a conversation with the

patient, being cognizant of earlier statements

by (or observations of) the patient. Some

patients are more verbal about their feelings

than others and will either tell someone

about their distress, or tell someone only

when asked directly how they feel. For

patients who verbalize their feelings, ask how

long these conditions have been present.

Other patients may be unable to articulate

their feelings (that is, cannot find the words

to describe how they feel, or lack insight or

cognitive capacity). Observe the patient

carefully for any indicator, both at the time

of the planned assessment and in any direct

contacts you may have with the patient

during the three days covered by this

assessment. Consult with direct-care staff

over all shifts, if possible, or other clinicians

who work with the patient, or family who

have direct knowledge of the patient’s typical

and current behavior. Relevant information

may also be found in the clinical record,

although this can vary.

Coding: For each indicator apply one of the

following codes based on interactions with

and observations of the patient in the last 3

days. Remember, code regardless of what you

believe the cause to be.

0. Indicator not exhibited in last 3 days.

1. Exhibited on 1–2 of last 3 days.

2. Exhibited on each of last 3 days.

2. Mood Persistence

Intent: To identify if one or more indicators

of depressed, sad or anxious mood [Item D1]

were easily altered by attempts to ‘‘cheer

up’’, console, or reassure the patient over the

last three days.

Process: The information on which to base

this judgement is gathered as part of the

conversations, observation, and record

reviews for D1 (the individual indicators of

mood state). The key factor here is the need

to assess whether (when aggregated across

the several mood indicators) the patient

cannot be easily consoled, reassured or

cheered up.

Coding: One or more indicators of

depressed, sad or anxious mood were not

easily altered by attempts to cheer up,

console, or reassure the patient over last 3

days.

0. No mood indicators or always easily

altered.

1. Partially altered or easily altered on only

some occasions.

2. All aspects of mood not easily altered.

3. Behavioral Symptoms

Intent: To identify the frequency of

behavioral symptoms over the last 3 days that

cause distress to the patient, or are

distressing or disruptive to other patients or

staff members. Such behaviors include those

that are potentially harmful to the patient, or

disruptive in the environment, even if staff

or other patients appear to understand or

have adjusted to them (for example, ‘‘Mrs. R.

doesn’t mean anything by calling out. She

does it because she’s confused right now.’’)

Behavioral symptoms can be associated

with an acute illness, a change in medication,

or simply a response to or change in the

environment. Acknowledging and

documenting behavioral symptoms provides

a basis for further evaluation, care planning,

and delivery of consistent, appropriate care.

Note: Documentation of the patient’s

behavioral status in the medical record may

not be accurate, valid, or complete, and it is

not intended to be the only source of

information. (See Process below). However,

once the frequency and alterability of

behavioral symptoms is determined,

subsequent documentation should more

accurately reflect the patient’s status and

response to interventions.

Definition: a. Wandering—Locomotion

with no discernible, rational purpose. A

wandering patient may be oblivious to his or

her physical or safety needs. Wandering

behavior should be differentiated from

purposeful movement (for example, a hungry

person moving about the unit in search of

food). Wandering may be manifested by

walking or by wheelchair use.

Do not include pacing back and forth as

wandering behavior. If it occurs, it should be

documented in Item D1h, ‘‘Repetitive

physical movements’’.

b. Verbally Abusive Behavioral

Symptoms—Other patients or staff were

threatened, screamed at, or cursed at.

c. Physically Abusive Behavioral

Symptoms—Other patients or staff were hit,

shoved, scratched, or sexually abused.

d. Socially Inappropriate/Disruptive

Behavioral Symptoms—Includes disruptive

sounds, excessive noise, screams, selfabusive acts, sexual behavior or disrobing in

public, smearing or throwing food or feces,

hoarding, rummaging through others’

belongings.

e. Resists care—Resists taking medications/

injections, ADL assistance, help with eating,

or changes in position. This category does

not include instances where the patient has

made an informed choice not to follow a

course of care (for example, patient has

exercised his or her right to refuse treatment,

and reacts negatively if staff try to reinstate

treatment).

Signs of resistance may be verbal or

physical (for example, verbally refusing care,

pushing caregiver away, scratching

caregiver). These behaviors are not

necessarily positive or negative, and their

presence should prompt further investigation

of their cause (for example, fear of pain, fear

of falling, poor comprehension, anger, poor

66418 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

relationships, eagerness for greater

participation in care decisions, past

experience with medication errors and

unacceptable care, desire to modify care

being provided).

Process: Take an objective view of the

patient’s behavioral symptoms. The coding

for this item focuses on the patient’s actions,

not intent. It is often difficult to determine

the meaning behind a particular behavioral

symptom. Therefore, it is important to record

all behavioral symptoms. The fact that staff

have become used to the behavior and

minimize the patient’s presumed intent (‘‘He

doesn’t really mean to hurt anyone. He’s just

frightened.’’) is not pertinent to this coding.

Does the patient manifest the behavioral

symptom or not?

Observe the patient and how he/she

responds to caregiver attempts to deliver care

to him or her. Consult with staff who provide

direct care on all three shifts. A symptomatic

behavior may be present and might not be

seen because it occurs during intimate care

on another shift. Therefore, it is especially

important to solicit input from direct

caregivers (including nurse assistants) who

have contact with the patient.

Simply relying on written notes in the

patient record is not sufficient. You must be

alert to the possibility that staff might not

think to report a behavioral symptom if it is

part of the unit norm (for example, staff are

working with severely cognitively and

functionally impaired patients (for example,

in a head trauma unit) and are used to

patients’ wandering, noisiness, etc.). Focus

staff attention on what has been the

individual patient’s actual behavior over the

last three days. Finally, although it may not

be complete, review the clinical record for

documentation of behaviors you may not

have seen, nor staff reported. When such a

note is found, review the patient’s status with

staff. Is the note correct? Is it within the

appropriate time frame of the record?

Coding: Behavioral symptom frequency in

last 3 days.

Record the frequency of behavioral

symptoms manifested by the patient across

all three shifts.

Code ‘‘0’’ if the described behavioral

symptom was not exhibited in last three

days. This code applies to patients who have

never exhibited the behavioral symptom or

those who have previously exhibited the

symptom but now no longer exhibit it,

including those whose behavioral symptoms

are fully managed by psychotropic drugs, or

a behavior-management program. For

example: A ‘‘wandering’’ patient who has not

wandered in the last three days because he

was restricted to bedrest and had a private

duty nurse attending to him would be coded

‘‘0’’—Behavioral symptom not exhibited in

last three days.

Code ‘‘1’’ if the described behavioral

symptom occurred on 1 day.

Code ‘‘2’’ if the described behavioral

symptom occurred on 2 days.

Code ‘‘3’’ if the described behavioral

symptom occurred daily or more frequently

(that is, multiple times each day) in the last

3 days.

Section E. Functional Status

Patients in post-acute care settings will

have acute (and often chronic) illnesses, and

they will be subject to a variety of factors that

can severely impact self-sufficiency. For

example, cognitive deficits can limit a

person’s ability or willingness to initiate or

participate in self-care or constrict

understanding of the tasks required to

complete the ADLs. A wide range of physical

and neurological illnesses can adversely

affect physical factors important to self-care

such as stamina, muscle tone, balance, and

bone strength. Side effects of medications

and other treatments can also contribute to

needless loss of self-sufficiency.

Individualized plans of care can be

successfully developed only when the

patient’s self-performance has been

accurately assessed, including the amount

and type of support being provided to the

patient by others.

For patients in post acute settings, the

focus of the admission assessment is twofold:

(1) to determine baseline functional

performance levels, and (2) to determine if

these levels have recently changed. This

information will then be used as a basis for

developing a plan of care (for example,

targeted rehabilitation and other services)

with the goal of leading the patient to an

expeditious and coordinated discharge to

home or a lower level of care.

1. Activities of Daily Living (ADL) SelfPerformance Summary (Over Last Three

Days)

Intent: To record a summary of the

patient’s self-care performance in activities of

daily living (that is, what the patient actually

did for himself or herself or how much verbal

or physical help was required by staff

members) during the last three days. This

requires a review of all ADL activities over

this period.

Definition: ADL SELF–PERFORMANCE—

Measures what the patient actually did (not

what he or she might be capable of doing)

within each ADL category over all shifts for

all episodes over the last three days

according to a performance-based scale.

a. Bed Mobility—How patient moves to

and from a lying position, turns side to side,

and positions the body while in bed.

b. Transfer—Bed/Chair—How patient

moves between surfaces-that is, to/from bed,

chair, wheelchair standing position. This

definition excludes movement to/from bath

or toilet, which is coded under Transfer

Toilet (item E1i) and Transfer Tub/Shower

(item E1l).

c. Locomotion—How patient moves

between locations in his/her room and

adjacent corridor on the same floor. If in

wheelchair, locomotion is defined as selfsufficiency once in the chair.

d. Walk in Facility—How patient walks in

different areas of the facility. For a patient

who uses a wheelchair exclusively, this

would be coded as ‘‘8’’ (Activity did not

occur).

e. Dressing Upper Body—How patient

dresses and undresses (street clothes,

underwear) above the waist. Includes

prostheses, orthotics, fasteners, pullovers,

etc.

f. Dressing Lower Body—How patient

dresses and undresses (street clothes,

underwear) from the waist down. Includes

prostheses, orthotics (for example, antiembolic stockings), belts, pants, skirt, shoes

and fasteners.

g. Eating—How patient eats and drinks

(regardless of skill). Includes intake or

nourishment by other means (for example,

tube feeding, total parenteral nutrition).

h. Toilet Use—How patient uses the toilet

room (or commode, bed pan, urinal), adjusts

clothes before and after using toilet, manages

perineal hygiene, changes pad, manages

ostomy or catheter. (EXCLUDE transfer to

toilet which is coded under item E1i,

Transfer Toilet).

i. Transfer Toilet—How patient moves on

and off toilet or commode or bedpan.

j. Grooming/Personal Hygiene—How

patient maintains personal hygiene,

including combing hair, brushing teeth,

shaving, applying makeup; and washing/

drying face and hands (EXCLUDE baths and

showers which are coded in item E1k,

Bathing).

k. Bathing—How patient takes full-body

bath/shower or sponge bath (EXCLUDE

washing of back and hair and TRANSFER

[which is coded in item E1l, Transfer Tub/

Shower]). Includes how each part of body is

bathed: arms, upper and lower legs, chest,

abdomen, perineal area. Note: For this item

and item E1l below, you must code for most

dependent episode.

l. Transfer Tub/Shower—How patient

transfers in/out of tub/shower. Code for most

dependent episode.

Process: In order to promote the highest

level of functioning among patients, clinical

staff must first identify what the patient

actually does for himself or herself, noting

when assistance is received and clarifying

the types of assistance provided (verbal

cuing, physical support, etc.)

A patient’s ADL self-performance may vary

from day to day, shift to shift, or within

shifts. There are many possible reasons for

these variations, including mood, medical

condition, relationship issues (for example,

willing to perform for a nurse assistant he or

she likes), medications and changes in

underlying functional capacity. The

responsibility of the person completing the

assessment is to capture the total picture of

the patient’s ADL self-performance over the

3-day period, 24 hours a day—that is, not

only how the evaluating clinician sees the

patient, but how the patient performs on

other shifts as well.

In order to accomplish this, you will need

to know about the multiple episodes of the

activity over the last 3-days—for example,

how the patient dressed and undressed the

upper body yesterday, the day before

yesterday, and the day before that. To gather

this information, there are two obvious sets

of people to talk with—the patient and direct

care staff—and when you have these

conversations, be sure to plan to discuss all

ADLs (get the total picture)—that is, if

possible, talk with the patient and direct care

staff on all three shifts (including weekends)

and review documentation used to

communicate with staff across shifts.

Ask questions pertaining to all aspects of

the ADL activity definitions. For example,

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66419

when discussing Bed Mobility with a nurse

assistant, be sure to inquire specifically how

the patient moves to and from a lying

position, how the patient turns from side to

side, and how the patient positions himself

or herself while in bed. A patient can be

independent in one aspect of Bed Mobility

yet require extensive assistance in another

aspect. Be sure to consider each activity

definition fully.

The wording used in each coding option is

intended to reflect real-world situations,

where slight variations are common. Where

variations occur, the coding ensures that the

patient is not assigned to an excessively

independent or dependent category. For

example, by definition, codes 0, 1, 2, and 3

(Independent, Set up Help only, Supervision,

Minimal Assistance) permit one or two

exceptions for the provision of heavier care.

This is clinically useful and increases the

likelihood that staff will code ADL SelfPerformance items consistently and

accurately.

The following chart provides general

guidelines for recording accurate ADL SelfPerformance.

Guidelines for Assessing (Item E1) ADL SelfPerformance (Last 3 Days)

• The coding options for E1 record the

patient’s actual level of involvement in selfcare and the type and amount of support

actually received during the last three days—

requiring that you have knowledge of all

episodes of each of the ADLs (or as near as

possible to all episodes).

• Do not record your assessment of the

patient’s capacity for involvement in selfcare—that is, what you believe the patient

might be able to do for himself or herself

based on demonstrated skills or physical

attributes. An assessment of functional

prognosis is covered in Item L1 (Functional

Improvement Goals by Discharge).

• Do not record the type and level of

assistance that the patient ‘‘should’’ be

receiving according to the written plan of

care. The type and level of assistance actually

provided may be quite different from what is

indicated in the plan. Record what is actually

happening.

• Engage direct care staff from all shifts

who have cared for the patient over the last

three days in discussions regarding the

patient’s ADL functional performance.

Remind staff that the focus is on the last

three days only. To clarify your own

understanding and observations about each

ADL activity (bed mobility, locomotion,

transfer, etc.), ask probing questions,

beginning with the general and proceeding to

the more specific.

• When you are uncertain that the patient

could perform the activity as described or

conversely where you wonder why the

patient is not more independent, observe a

regularly scheduled session where this

activity is carried out (for example, eating a

meal, dressing in the morning). Observation

will both help you to validate reported

behaviors and will be useful as you go

forward to care planning.

Here is a typical conversation between the

RN and a nurse assistant regarding a patient’s

Bed Mobility assessment:

R.N. ‘‘Describe to me how Mrs. L positions

herself in bed. By that I mean, once she is

in bed, how does she move from sitting up

to lying down, lying down to sitting up,

turning side to side, and positioning

herself?’’

N.A. ‘‘She can lay down and sit up by

herself, but I help her turn on her side.’’

R.N. ‘‘She lays down and sits up without any

verbal instructions or physical help?’’

N.A. ‘‘No, I have to remind her to use her

trapeze every time. But once I tell her how

to do things, she can do it herself.’’ se

supervision

R.N. ‘‘How do you help her turn side to

side?’’

N.A. ‘‘She can help turn herself by grabbing

onto her siderail. I tell her what to do. But

she needs me to lift her bottom and guide

her legs into a good position.’’

R.N. ‘‘Do you lift her by yourself or does

someone help you?’’

N.A. ‘‘I do it by myself.’’

R.N. ‘‘How many times during the last three

days did you give this type of help?’’

N.A. ‘‘Every time she was turned.’’

Provided that ADL function in Bed

Mobility was similar on all shifts, Mrs. L

would receive an ADL Self-Performance (in

the last three days) Code of ‘‘4’’.

Now review the first two exchanges in the

conversation between the RN and the nurse

assistant. If the RN did not probe further, he

or she would not have received enough

information to make an accurate assessment

of either the patient’s skills or the nurse

assistant’s actual workload, or whether the

current plan of care was being implemented.

Coding: For each ADL category, code the

appropriate response for the patient’s actual

performance during the last three days.

Consider the patient’s performance during all

shifts, as function may vary. For example, for

eating, a patient may receive 3 meals per day

and two supplemental feedings. Thus, over 3

days, there would have been 15 feeding

episodes. It is this performance experience

that forms the basis for scoring item E1g.

0. Independent—No help, or set up or staff

oversight/supervision –OR–help, setup or

supervision provided only 1 or 2 times

during period (with any task or subtask). [See

examples of Setup Help in the box following

these coding options.]

1. Setup Help Only—Article or device

provided or placed within reach of patient 3

or more times. [See examples of Setup Help

in the box following these coding options.]

2. Supervision—Oversight, encouragement,

or cuing provided 3 or more times during

period–OR–Supervision (1 or more times)

plus physical assistance provided only 1 or

2 times during period (for a total of 3 or more

episodes of help or supervision).

3. Minimal Assistance (Limited

Assistance)—Patient highly involved in

activity; received physical help in guided

maneuvering of limbs or other non-weight

bearing assistance 3 or more times –OR–

Combination of non-weight bearing help with

more help provided only 1 or 2 times during

period (for a total of 3 or more episodes of

physical help).

4. Moderate Assistance (Extensive

Assistance)—Patient performed part of

activity on own (50% or more of subtasks)

BUT help of the following type(s) was

provided 3 or more times:

• Weight-bearing support (for example,

holding weight of one or both lower limbs,

trunk).

• Full staff performance of a task (some of

time) or discrete subtask.

5. Maximal Assistance—Patient involved

but completed less than 50% of subtasks on

own (includes 2 + person assist), received

weight bearing help or full performance of

certain subtasks 3 or more times.

6. Total Assistance (Total Dependence)—

Full staff performance of the activity during

the entire period.

8. Activity Did Not Occur—During the last

three days, the ADL activity was not

performed by the patient or staff. In other

words, the specific activity did not occur at

all.

For example: A patient who was restricted

to bed for the entire three day period and was

never transferred from the bed would receive

a code of ‘‘8’’ for Transfer (Item E1b).

However, do not confuse a patient who is

totally dependent in an ADL activity (Code

6—Total Dependence) with the activity itself

not occurring. For example: A patient who

receives tube feedings and no food or fluids

by mouth is engaged in eating (receiving

nourishment), and must be evaluated under

the Eating category for his or her level of

assistance in the process. A patient who is

highly involved in giving himself a tube

feeding is not totally dependent and should

be coded as a ‘‘3.’’

Note: Each of these ADL Self-Performance

scoring categories is exclusive. There is no

overlap between categories. Changing from

one self-performance category to another

demands an increase or decrease in the

number of times that help is provided.

There will be times when there is no one

type or level of assistance provided to the

patient 3 or more times during a three-day

period. However the sum total of support of

various types will be provided three or more

times. In this case, code for the least

dependent self-performance category where

the patient received that level or more

dependent support 3 or more times during

the 3 day period. Please review the following

example for clarification of this principle.

Examples of Setup Help

• For bed mobility—Handing the patient

the bar on a trapeze apparatus.

• For transfer—Giving the patient a

transfer board or locking/unlocking the

wheels on a wheelchair for a safe transfer.

• For locomotion.

Walking—Handing the patient a walker or

cane.

Wheeling—Locking/unlocking the brakes

on the wheelchair or adjusting the foot

pedals to facilitate foot motion while

wheeling.

• For dressing—Retrieving clothes from

closet and laying out on the patient’s bed;

handing the patient a shirt; retrieving a

prosthesis or orthotic.

• For eating—Cutting meat and opening

containers at meals; giving one food category

at a time.

• For toilet use—Handing the patient a

bedpan or placing articles necessary for

changing ostomy appliance within reach.

66420 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

• For personal hygiene—Providing a wash

basin and grooming articles.

• For bathing—Placing bathing articles at

tub side within the patient’s reach; handing

the patient a towel upon completion of the

bath.

2. ADL Assist Codes

Intent: To identify and document the level

of weight bearing ADL assistance provided to

the patient over the last 3 days.

Definition: a. Bed mobility—How patient

moves to and from lying position, turns side

to side, and positions body while in bed.

b. Transfer bed/chair—How patient moves

between surfaces-to or from: bed, chair,

wheelchair, standing position (Exclude to or

from bath or toilet).

c. Locomotion—How patient moves

between locations in his/her room and

adjacent corridor on the same floor. If in

wheelchair, how the patient moves once in

the wheelchair.

d. Walk in facility—How the patient walks

in room, corridor, or other place in the

facility.

e. Dressing upper body—How the patient

dresses and undresses (street clothes,

underwear) above the waist, includes

prostheses, orthotics, fasteners, pullovers,

etc.

f. Dressing lower body—How the patient

dresses and undresses (street clothes,

underwear) from the waist down, includes

prostheses, orthotics, belts, pants, skirts,

shoes, and fasteners.

g. Eating—How the patient eats and drinks

(regardless of skill) includes intake of

nourishment by other means (for example,

tube feeding, total parenteral nutrition).

h. Toilet use—How patient uses the toilet

room (or commode, bedpan, urinal), cleanses

self after toilet use or incontinent episode(s),

changes pad, manages ostomy or catheter,

adjusts clothes (Exclude transfer to toilet).

i. Transfer/Toilet—How patient moves on

and off toilet or commode

j. Grooming/Personal hygiene—How the

patient maintains personal hygiene,

including combing hair, brushing teeth,

shaving, applying makeup, washing and

drying face, and hands (Excludes baths and

showers).

k. Bathing—How patient takes full body

bath or shower or sponge bath (Exclude

washing of back and hair and transfer).

Includes how each part of the body is bathed:

arms, upper and lower legs, chest, abdomen,

perineal area.

l. Transfer tub/shower—How the patient

transfers in and out of the tub or shower.

Coding: Code for the most help in the last

3 days.

0. Neither code applies.

1. Weight bearing support with 1 limb (arm

or leg).

2. 2+ person physical assist.

3. ADL Changes

Intent: In this item the assessor compares

the patient’s current ADL function to self

performance prior to the precipitating event

item A7a.

Definition: a. The number of ADL areas

(listed under E1) in which the patient is now

more impaired in self performance than was

prior to the precipitating event (A7a)

determines the appropriate coding.

b. The number of ADL areas (from E1

above) in which patient was independent

prior to precipitating event (item A7a).

Coding: Place the appropriate number of

ADL areas in box a and box b.

4. Instrumental Activities of Daily Living

(IADLs)

Intent: The intent of these items is to

examine the areas of function that are most

commonly associated with independent

living.

Process: The patient is to be questioned

directly about his or her capacity to perform

the usual activities around the home or

community in the last 24 hours of a 3-day

assessment period. If the patient performed

or contributed to the performance of the

IADL task during this period (meal

preparation, medication management, etc)

this performance should be considered when

coding. However, be aware that a patient’s

partial involvement in an activity in the last

24 hours may not necessarily express that

patient’s full capacity to perform the task.

For example: A patient may have

performed part of the medication

management with assistance from staff. Staff

assistance may have been provided because

medication containers are different than what

the patient was used to at home. The patient

states that within the last 24 hours, he or she

could have performed the medication task if

he or she had been in his or her own home.

In fact, the patient had been independent

prior to admission, and there have been no

cognitive or functional changes that might

cause you to call the patient’s judgement into

question. The assessor would code E4d as

‘‘0’’ Independent.

In talking to the patient, you are both

involved in a process of speculation about

IADL activities that did not occur at the

facility, leading to the assessor’s active

coding decision.

Definition: a. Meal preparation—How

meals are prepared (for example, planning

meals, assembling ingredients, cooking,

setting out food and utensils.)

b. Managing finances—Paying for

newspaper or TV service, using the cafeteria.

c. Phone Use—How telephone calls are

made or received (using assistive devices

such as large numbers on the telephone,

voice amplification as needed.)

d. Medication Management—How

medications are managed (for example,

remembering to take medications, opening

bottles, taking correct dosage of pills, filling

syringe, giving injections, applying

ointments.)

e. Stairs—How moves up and down stairs

(for example, one flight of steps, using

handrails as needed.)

f. Car Transfer—How patient moves in and

out of a car. Includes opening door, sitting,

and rising from seat.

Coding: CAPACITY TO PERFORM

INSTRUMENTAL ACTIVITIES OF DAILY

LIVING—If patient had been required to

carry out the activity as independently as

possible, SPECULATE AND CODE for what

you would consider the patient’s capacity

(ability) would have been to perform the

activity in the last 24 hours of the 3-day

assessment period.

0. Independent—Would have required no

help, setup or supervision.

1. Setup Help Only—Would have required

help that would have been limited to

providing or placing an article/device within

reach of the patient; all other tasks would

have been performed by the patient on his or

her own.

2. Supervision—Would have required

oversight, encouragement or cuing.

3. Limited Assistance—On some

occasion(s) could have done on own, other

times would have required help.

4. Moderate Assistance—While patient

could have been involved, would have

required presence of helper at all times, and

would have performed 50% or more of

subtasks on own.

5. Maximal Assistance—While patient

could have been involved, would have

required presence of helper at all times, and

would have performed less than 50% of all

subtasks on own.

6. Total Dependence—Full performance of

the activity by other person would have been

required at all times (no residual capacity

exists).

5. IADL Areas Now More Limited

Intent: In this item the assessor compares

the patient’s current capacity to perform

IADLs to self performance with IADLs prior

to the precipitating event (Item A7a).

Process: Compare all the IADL capacity self

performance area codes (for Items E4a–f) to

the patient’s function prior to the

precipitating event. Determine the overall

number of IADL areas that the patient is now

more limited in.

Coding: Code for the most appropriate

category.

0. None.

1. Some (1–3 IADL areas).

2. All or most (4–6 IADL areas).

6. Devices/Aids

Intent: To record the type of appliances,

aids, or assistive devices the patient used

over the last 3 days.

Definition: Locomotion Devices

a. Cane/crutch—A cane is a slender stick

held in the hand and used for support during

walking. Includes 3 or 4 prong canes. A

crutch is a device for aiding a patient with

walking. Usually it is a long staff with

padded crescent-shaped portion at the top

that is placed under the armpit.

b. Walker—A mobile device used to assist

a patient with walking. Usually consists of a

stable platform made of metal tubing that the

patient grasps while taking a step. The

patient then moves the walker forward and

makes another step. Also check this item in

those instances where the patient walks with

a wheelchair or Meri-Walker for support. [For

Meri-Walkers, if the patient is standing most

of the time in the Meri-Walker and using it

as a walker, code as a walker—if the patient

sits in the Meri-Walker most of the time—

code it as a wheelchair.]

c. Wheelchair/scooter—Includes use of a

hand-propelled wheelchair as well as

motorized chair or scooter, includes

wheeling self and being wheeled by others.

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66421

Other Aids

d. Adaptive eating utensil—A device that

is specially designed to help the patient be

independent in eating. Some examples are,

built-up spoon, rocker knife, plate guard,

special mug.

e. Mechanical lift—A mechanical device

such as a Hoyer lift, used to lift a patient.

f. Orthotics/prosthesis—An orthotic is a

device added to the upper or lower

extremities to stabilize or immobilize present

deformity, protect against injury, or assist

with function (for example, arm sling, finger

splint). A prosthesis is a replacement of a

missing body part by an artificial substitute,

such as an artificial extremity. A device of a

natural function.

g. Postural support (while sitting)—A

device (pads, pillows, boards) used to

maintain the patient’s position while in a

chair or wheelchair.

h. Slide Board—A flat surfaced board

(usually polished to a smooth finish) used to

help a patient transfer from bed to chair or

chair to bed.

i. Other Adaptive Devices—Include

assistive/adaptive devices such as trapezes,

braces.

j. NONE OF THE ABOVE.

Process: Observe, interview patient or staff.

Coding: Check all that apply.

7. Stamina

Intent: Moderate physical activity in

connection with activities of everyday life or

chosen activities can help to keep patients fit

in many ways. Below a certain threshold of

activity, functional decline may be

accelerated. Activities can include domestic

IADLs (for example, light housework), or

chosen physical activities (for example,

recreation, going out to shop or walk).

It is necessary to understand if the patient

is motivated, what the patient’s needs may

be, what barriers need to be overcome, and

whether health education is needed.

Many people are interested in maintaining

health. They usually know that lifestyle

practices may be important, but they often

need concrete information about how

important their own life style is for health

maintenance. For example, the patient may

understand questions on walking and eating,

but may not be willing to take corrective

action.

Definition: Hours of physical activity at

two points in time—examples of physical

activity include exercise, therapy sessions,

walking, house cleaning, grocery shopping:

(A) in last 24 hours and (B) immediately

prior to precipitating event (A7a).

Process: Talk to the patient and family

members if required. In assessing patient selfinvolvement, confirm patient stamina

estimates. Talk to staff. Determine

performance in last 24 hours and prior to

precipitating event (Item A7a) and code

accordingly.

Coding: Note—Item E7 has two coding

columns, Column A and Column B.

0. None.

1. Less than one hour per day.

2. 1 to 2 hours per day.

3. 2+ to 3 hours per day.

4. 3+ to 4 hours per day.

5. More than 4 hours per day.

8. Walking and Stair Climbing

Intent: Walking is a crucial activity when

considering a discharge back to the

community. The interdisciplinary team

members need current information about the

patient’s walking ability. This knowledge

will help the team in devising an accurate

service delivery and care plan resulting in an

expeditious and coordinated discharge home.

CODE for walking or stair climbing episode

that represents the most consistent pattern

over the last 24 hours of the 3-day assessment

period (includes episodes during therapy,

activities, etc.)

Process: Observe the patient and interview

staff.

Coding: a. Farthest distance walked

without sitting down.

0. 150+ feet.

1. 51–149 feet.

2. 25–50 feet.

3. 10–24 feet.

4. Less than 10 feet.

8. ACTIVITY DID NOT OCCUR.

b. Walking support provided.

0. None.

1. Set up help only.

2. Supervision.

3. One person physical assistance.

4. Two+ person physical assistance.

8. ACTIVITY DID NOT OCCUR.

c. Stair climbing.

Intent: This item gives an indication of the

patients stamina as measured by stairclimbing activity.

Process: Talk with the patient and family

member if necessary. Consult with therapy

staff who have observed or assisted the

patient in stair climbing activity in the last

24 hours.

Definition: A full flight of stairs consists of

12–14 stairs (steps). A partial flight of stairs

consists of 4 to 6 stairs (steps).

Coding: Code for the most dependent

episode of stair climbing activity when the

activity attempted in the last 24 hours. Note:

There are only three possible codes when the

patient does 4–6 stairs (steps) only (code—2,

5, 6).

0. Complete Independence—Up and down

full flight of stairs with NEITHER physical

help NOR support device.

1. Modified Independence—Up and down

full flight of stairs with NO physical help and

any of following:

Use of one or more supportive devices

(support devices includes the required use of

hand rails).

OR Use of an appliance (that is, cane,

brace, prosthesis, walker).

OR Excessive time to climb the stairs (3 or

more times normal).

2. Supervision—Up/down full flight of

stairs with supervision or cuing–OR–up and

down partial flight with NO physical help

(device may or may not be used).

3. Minimal Assistance—Contact guard/

steadying/assistance to go up/down full flight

of stairs.

4. Moderate Assistance—Some weight

bearing help to go up/down full flights of

stairs, patient does most on own.

5. Maximal Assistance—Patient had

limited involvement in going up/down full

flight of stairs, staff perform more than 50%

of effort–OR–receives physical help on

partial flight of stairs.

6. Total Assistance—Did not go up/down

4–6 stairs (OR has 2-person assist) OR totally

dependent.

8. Activity did not occur in last 24 hours.

9. Balance Related to Transitions

Intent: Balance is a key component of a

patient’s ability to transfer from standing to

seated position and from seated to standing

position. Problems with stability involve

provision of support (either staff member or

device) to ensure a safe transfer. It is

important to assess a person’s ability to

balance in order that interventions (strength

training exercises, safety awareness,

restorative nursing, nursing-based

rehabilitation) can be implemented to

prevent injuries and foster increased

independence in the patient.

Process: Over the last 24 hours, assess how

the patient: transfers from seated to standing

position, or turns and faces the opposite

direction. Because this assessment is to be

based on the most dependent episode over

the last 24 hours, base both on your own

observations and reports of staff.

Definition: a. Moved from seated to

standing position.

b. (While standing) turned around and

faced the opposite direction.

Coding: Code for the most dependent in

the last 24 hours.

0. Smooth transition; stabilizes without

assistance.

1. Transition not smooth, but able to

stabilize without assistance.

2. Transition not smooth, unable to

stabilize without assistance.

8. ACTIVITY DID NOT OCCUR.

10. Neuro-musculo-skeletal Impairment

Process: Review the patient’s record for

documentation of impairment of this type.

An obvious example of a patient with this

problem is someone who is comatose. Other

patients at high risk include those with

quadriplegia, paraplegia, hemiplegia or

hemiparesis, peripheral vascular disease and

neurological disorders. In the absence of

documentation in the clinical record,

sensation can be tested in the following way:

• To test for pain, use a new safety pin or

wooden ‘‘orange stick’’ (usually used for nail

care). Always dispose of the pin or stick after

each use to prevent contamination.

• Do not use pins with agitated or restless

patients. Abrupt movements can cause

injury.

• Ask the patient to close his or her eyes.

If the patient cannot keep his or her eyes

closed or cannot follow directions to close

eyes, block what you are doing (in local areas

of legs and feet) from view with a cupped

hand or towel.

• Lightly press the pointed end of the pin

or stick against the patient’s skin. Do not

press hard enough to cause pain, injury, or

break in the skin. Use the pointed and blunt

ends of the pin or stick alternately to test

sensations on the patient’s arms, trunk, and

legs. Ask the patient to report if the sensation

is ‘‘sharp’’ or ‘‘dull.’’

• Compare the sensations in symmetrical

areas on both sides of the body.

• If the patient is unable to feel the

sensation, or cannot differentiate sharp from

dull, the area is considered desensitized to

pain sensation.

66422 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

• For patients who are unable to make

themselves understood or who have

difficulty understanding your directions, rely

on their facial expressions (for example,

wincing, grimacing, surprise), body motions

(for example, pulling the limb away, pushing

the examiner) or sounds (for example,

‘‘Ouch!’’) to determine if they can feel pain.

Definition: a. Leg (hip, knee, ankle, foot).

b. Arm (shoulder, elbow, wrist, hand).

c. Trunk and neck.

Coding: Code for the most limited in the

last 24 hours.

A. Joint mobility/range of motion at joints

listed (code for most impaired joint).

0. No impairment.

1. Impairment on one side.

2. Impairment on both sides.

B. Voluntary motor control (active,

coordinated, purposeful movement—code for

most dependent joint).

0. No loss.

1. Partial loss on one side.

2. Partial loss both sides.

3. Full loss one side.

4. Full loss both sides.

C. Intact touch/sensation on extremity

(tactile sense) (Use same codes as E10B).

0. No loss.

1. Partial loss on one side.

2. Partial loss both sides.

3. Full loss one side.

4. Full loss both sides.

Section F. Bowel/Bladder Management

1. Bladder Continence

Intent: To describe the patient’s pattern of

bladder continence (control) over the last 7–

14 days, and to compare current continence

status to status prior to the current event

which precipitated this post-acute stage. This

information is key in care planning for

incontinence.

Definition: Bladder Continence—Refers to

control of urinary bladder function. This item

describes the patient’s bladder continence

pattern even with scheduled toileting plans,

continence training programs, or appliances.

It does not refer to the patient’s ability to

toilet self—for example, a patient can receive

extensive assistance in toileting and yet be

continent, perhaps as a result of staff help.

The patient’s self-performance in toilet use is

recorded in Item E1h.

Process: Complete your review in the

following order. Remember to consider

continence patterns over the last 7–14 day

period, 24 hours a day, including weekends.

(1) Review the patient’s clinical record and

any urinary elimination (bladder) flow sheets

(if available).

(2) Validate the accuracy of written records

with the patient. Make sure that your

discussions are held in private. Control of

bladder function is a sensitive subject,

particularly for patients that are struggling to

maintain control. Many people with poor

control problems will try to hide their

problems out of embarrassment or fear of

retribution. Others will not report the

problem to staff because they mistakenly

believe that incontinence is a natural part of

aging or certain disease processes and that

nothing can be done to reverse the problem.

Despite these common reactions to

incontinence, many patients are relieved

when a health care professional shows

enough concern to ask about the nature of the

problem in a sensitive, straightforward

manner.

(3) Validate continence patterns with

people who know the patient well (for

example, primary family member of a newly

admitted patient, or direct care staff).

(4) When the information you have

received is inconsistent and particularly if

the staff report incontinence that is not

reported by the patient, review for physical

indications that the patient is in fact

incontinent. This could include being

present at scheduled toileting intervals,

observing clothing, bed clothes, etc.

a. Control of urinary bladder function—(if

patient dribbles, volume insufficient to soak

through undergarments).

Coding: Choose the response that best

reflects the patient’s level of bladder

continence in the last 7–14 days.

Code for the patient’s actual bladder

continence pattern—that is, the frequency

with which the patient is wet and dry during

the 7–14 day assessment period. Do not

record the level of control the patient might

have achieved under optimal circumstances.

For bladder continence the difference

between a ‘‘5’’ (Frequently Incontinent) and

a ‘‘6’’ (Incontinent) is determined by the

presence (‘‘5’’) or absence (‘‘6’’) of any

bladder control.

0. Continent—Complete control; does not

use any type of catheter or other urinary

collection device.

1. Continent with Catheter—Complete

control with any use of any type of catheter

or urinary collection device that does not

leak urine.

2. Biweekly Incontinence—Incontinent

episodes less than once a week (that is, once

in last 2 weeks).

3. Weekly Incontinence—Incontinent

episodes once a week.

4. Occasionally Incontinent—Incontinent

episodes 2 or more times a week, but not

daily.

5. Frequently Incontinent—Tended to be

incontinent daily, but some control present

(that is, on day shift).

6. Incontinent—Has inadequate control of

bladder, multiple daily episodes all or almost

all of the time.

8. DID NOT OCCUR—No urine output

from bladder.

b. Is now more impaired in bladder

incontinence then was prior to precipitating

event (item A7a).

Coding: 0. No, or unsure.

1. Yes, more impaired today.

2. Bladder Appliance.

Definition: a. External catheter (condom

catheter)—A urinary collection appliance

worn over the penis.

b. Indwelling catheter—A catheter that is

maintained within the bladder for the

purpose of continuous drainage of urine.

This item includes catheters inserted through

the urethra or via supra-pubic incision.

c. Intermittent catheterization—A catheter

that is used periodically for draining urine

from the bladder. This type of catheter is

usually removed immediately after the

bladder has been emptied. Includes

intermittent catheterization whether

performed by a licensed professional or by

the patient. Catheterization may occur as

one-time event (for example, to obtain a

sterile specimen) or as part of a bladder

emptying program (for example, every shift

in a patient with an underactive or a

contractile bladder muscle).

d. Medications for control—medications

administered to the patient for the purpose

of improving control of the bladder.

e. Ostomy—Any type of ostomy of the

urinary tract.

f. Pads, briefs—Any type of absorbent

disposable or reusable undergarment or item,

whether worn by the patient (for example,

diaper, adult brief) or placed on the bed or

chair for protection from incontinence. Does

not include the routine use of pads when a

patient is never or rarely incontinent.

g. Urinals, bedpan—A urinal is a container

into which a patient urinates. A bedpan is a

pan-shaped device placed under a patient for

collecting urine (and feces)

Process: Consult with the nursing staff and

the patient. Be sure to ask about any items

that are usually hidden from view because

they are worn under street clothing (for

example, pads or briefs). If necessary, check

the clinical record.

Coding: Code for the last 24 hours.

0. No.

1. Yes.

3. Bladder Appliance Support

Intent: This item is designed to identify the

type of assistance or support a patient needs

in order to use any of the bladder appliances

listed in F2.

Coding: Code for the level of bladder

appliance support provided to the patient in

the last 24 hours.

0. No appliances (in item F2).

1. Use of appliances, did not require help

or supervision.

2. Use of appliances, required supervision

or set up.

3. Minimal contact assistance (light touch

only).

4. Moderate assistance—patient able to do

50% or more of subtasks involved in using

equipment.

5. Maximal assistance—patient able to do

25–49% of all subtasks involved in using

equipment.

6. Total dependence—patient requires

assistance in all subtasks involved in using

bladder equipment.

4. Bowel Continence

Process: The assessment for bowel

continence should be completed

simultaneously with the bladder continence

review. This will thus include a review of the

patient’s clinical record and any bowel

records (if available). Validate the accuracy of

written records with the patient. Make sure

that your discussions are held in private.

Control of bowel function is a sensitive issue.

Be sure to ask about the nature of the

problem in a sensitive, straightforward

manner.

• Validate continence patterns with people

who know the patient well (for example,

primary family member of newly admitted

patient, direct care staff).

• Remember to consider continence

patterns over the last 7–14 day period, 24

hours a day, including weekends.

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66423

Coding: Code for bowel continence over

the last 7–14 days.

0. Continent—Complete control, does not

use ostomy device.

1. Continent with Ostomy—Complete

control with use of ostomy device that does

not leak stool.

2. Biweekly Incontinence—Incontinent

episodes less than once a week (that is, once

in last two weeks).

3. Weekly Incontinence—Incontinent

episodes once a week.

4. Occasionally Incontinent—2 to 3 times

a week.

5. Frequently Incontinent—4+ times a

week but not all of the time.

6. Incontinent—All of the time.

8.DID NOT OCCUR—No bowel movement

during the entire 14-day assessment period.

5. Bowel Appliances

Definition: a. Bedpan—A bedpan is a panshaped device placed under a patient for

collecting feces (and urine).

b. Enema—Introduction of solutions into

the rectum and colon in order to stimulate

bowel activity and to cause emptying of the

lower intestine.

c. Medication for control—Medications

administered to the patient for the pupose of

improving control of the bowels. These

medications can include laxatives, stool

softeners, stimulants as well as anti-diarrheal

preparations.

d. Ostomy—Any type of ostomy of the

gastrointestinal tract.

Coding: Code for use of bowel appliances

for the last 3 days.

0. No.

1. Yes.

6. Bowel Appliance Support

Intent: This item is designed to identify the

type of assistance or support a patient needs

in order to use any of the bowel appliances

listed in F5.

Coding: Code for the level of bowel

appliance support provided to the patient in

the last 24 hours.

0. No appliances (in item F5).

1. Use of appliances, did not require help

or supervision.

2. Use of appliances, required supervision

or set up.

3. Minimal contact assistance (light touch

only).

4. Moderate assistance—patient able to do

50 percent or more of subtasks involved in

using equipment.

5. Maximal assistance—patient able to do

25–49 percent of all subtasks involved in

using equipment.

6. Total dependence—patient requires

assistance in all subtasks involved in using

bowel equipment.

Section G. Diagnoses

1. Impairment Group

Intent: This item identifies the Impairment

Group that best describes the primary reason

for admission to the rehabilitation program.

Process: Consult with attending physician.

Coding: Each Impairment Group has been

assigned a two-digit ID number, a decimal

point, and a unique number (from one to four

digits) for the subgroups. Code for the major

diagnostic category of the patient by selecting

the Impairment Group which best describes

the condition requiring admission to

rehabilitation. Then select a subgroup, if

appropriate. Code as specifically as possible.

REHABILITATION IMPAIRMENT CATEGORIES AND ASSOCIATED IMPAIRMENT GROUP CODES

Rehabilitation impairment category Associated impairment group codes

01 Stroke (Stroke) .................................................................. 01.1 Left body involvement (right brain).

01.2 Right body involvement (left brain).

01.3 Bilateral Involvement.

01.4 No Paresis.

01.9 Other Stroke.

02 Traumatic brain injury (TBI) .............................................. 02.21 Open Injury.

02.22 Closed Injury.

03 Nontraumatic brain injury (NTBI) ...................................... 02.1 Non-traumatic.

02.9 Other Brain.

04 04 Traumatic spinal cord (TSCI) ...................................... 04.210 Paraplegia, Unspecified.

04.211 Paraplegia, Incomplete.

04.212 Paraplegia, Complete.

04.220 Quadriplegia, Unspecified.

04.2211 Quadriplegia, Incomplete C1–4.

04.2212 Quadriplegia, Incomplete C5–8.

04.2221 Quadriplegia, Complete C1–4.

04.2222 Quadriplegia, Complete C5–8.

04.230 Other traumatic spinal cord dysfunction.

05 Nontraumatic spinal cord (NTSCI) ................................... 04.110 Paraplegia, unspecified.

04.111 Paraplegia, incomplete.

04.112 Paraplegia, complete.

04.120 Quadriplegia, unspecified.

04.1211 Quadriplegia, Incomplete C1–4.

04.1212 Quadriplegia, Incomplete C5–8.

04.1221 Quadriplegia, Complete C1–4.

04.1222 Quadriplegia, Complete C5–8.

04.130 Other non-traumatic spinal cord dysfunction.

06 Neurological (Neuro) ......................................................... 03.1 Multiple Sclerosis.

03.2 Parkinsonism.

03.3 Polyneuropathy.

03.5 Cerebral Palsy.

03.8 Neuromuscular Disorders.

03.9 Other Neurologic.

07 Fracture of LE (FracLE) .................................................... 08.11 Status post unilateral hip fracture.

08.12 Status post bilateral hip fractures.

08.2 Status post femur (shaft) fracture.

08.3 Status post pelvic fracture.

08 Replacement of LE joint (ReplLE) .................................... 08.51 Status post unilateral hip replacement.

08.52 Status post bilateral hip replacements.

08.61 Status post unilateral knee replacement.

08.62 Status post bilateral knee replacements.

08.71 Status post knee and hip replacements (same side).

08.72 Status post knee and hip replacements (different sides).

08 Other orthopedic (Ortho) .................................................. 08.9 Other orthopedic.

66424 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

REHABILITATION IMPAIRMENT CATEGORIES AND ASSOCIATED IMPAIRMENT GROUP CODES—Continued

Rehabilitation impairment category Associated impairment group codes

10 Amputation, lower extremity (AMPLE) ............................. 05.3 Unilateral lower extremity above the knee (AK).

05.4 Unilateral lower extremity below the knee (BK).

05.5 Bilateral lower extremity above the knee (AK/AK).

05.6 Bilateral lower extremity above/below the knee (AK/BK).

05.7 Bilateral lower extremity below the knee (BK/BK).

11 Amputation, other (AMP–NLE) ......................................... 05.1 Unilateral upper extremity above the elbow (AE).

05.2 Unilateral upper extremity below the elbow (BE).

05.9 Other amputation.

12 Osteoarthritis (OsteoA) ..................................................... 06.2 Osteoarthritis.

13 Rheumatoid, other arthritis (RheumA) .............................. 06.1 Rheumatoid Arthritis.

06.9 Other arthritis.

14 Cardiac (Cardiac) .............................................................. 09 Cardiac.

15 Pulmonary (Pulmonary) .................................................... 10.1 Chronic Obstructive Pulmonary Disease.

10.9 Other pulmonary.

16 Pain Syndrome (Pain) ...................................................... 07.1 Neck pain.

07.2 Back pain.

07.3 Extremity pain.

07.9 Other pain.

17 Major multiple trauma, no brain injury or spinal cord injury (MMT–NBSCI).08.4 Status post major multiple fractures.

14.9 Other multiple trauma.

18 Major multiple trauma, with brain or spinal cord injury

(MMT–BSCI).

14.1 Brain and spinal cord injury.

14.2 Brain and multiple fractures/amputation.

14.3 Spinal cord and multiple fractures/amputation.

19 Guillian Barre (FB) ............................................................ 03.4.

20 Miscellaneous (Misc) ........................................................ *12.1 Spina Bifida.

12.9 Other congenital.

13 Other disabling impairments.

15 Developmental disability.

16 Debility.

17 Infection.

17.2 Neoplasms.

17.31 Nutrition (endocrine/metabolic) with intubation/parenteral nutrition.

17.32 Nutrition (endocrine/metabolic) without intubation/parenteral nutrition.

17.4 Circulatory disorders.

17.51 Respiratory disorders—Ventilator Dependent.

17.52 Respiratory disorders—Non-ventilator Dependent.

17.6 Terminal care.

17.7 Skin disorders.

17.8 Medical/Surgical complications.

17.9 Other medically complex conditions.

21 Burn (Burns) ..................................................................... 11 Burns.

We are in the process of anayzing the effect of moving the few cases within this impairment category to one of the other spinal cord RICs (either 05 or 04 depending upon the ‘‘fit’’).

2. Other Diseases

Intent: To document the presence of

diseases that have an impact or potential

impact on the patient’s overall function

(physical, cognitive, mood and behavioral),

treatment or discharge plans.

Definition: ENDOCRINE

a. Diabetes Mellitus 250.00—Any of several

metabolic disorders characterized by

abnormal insulin secretion and elevated

blood glucose levels. Category includes

insulin-dependent diabetes mellitus (IDDM)

as well as other types (for example, noninsulin dependent diabetes mellitus

[NIDDM], adult onset diabetes mellitus

[AODM], gestational diabetes, and diabetes

associated with particular conditions or

medications).

b. Hypothyroidism 244.9—Under-activity

of the thyroid gland (insufficiency of thyroid

hormone) resulting in a decrease in the basal

metabolic rate.

HEART/CIRCULATION

c. Cardiac arrhythmias 427.9—A

disturbance in the cardiac electrical

conduction system resulting in irregularities

in heart rate and rhythm.

d. Congestive heart failure 428.0—A

dysfunction that occurs when cardiac output

is insufficient to meet the person’s metabolic

demands.

e. Coronary artery disease (CAD) 746.85—

A narrowing of one or more of the coronary

arteries by atherosclerotic plaque or vascular

spasm; results in a decrease in oxygenated

blood flow (ischemia) to the heart. Usually

associated with angina.

f. Deep vein thrombosis 451.1—A

condition in which a blood clot (thrombus)

is formed in the deeper/larger veins, usually

in the lower extremities.

g. Hypertension 401.9—A persistent

elevation of systolic or arterial blood

pressure. This category includes primary

(essential) and secondary hypertension.

h. Hypotension 458.9—An absolute

systolic blood pressure value of less than 90

mm Hg (or a decline of 20 mm Hg or greater

in systolic blood pressure from the person’s

usual baseline, or a decline of 10 mm Hg or

greater in diastolic blood pressure from the

person’s usual baseline). This category also

includes orthostatic hypotension (a reduction

≥ 20 mm Hg in systolic blood pressure upon

standing).

i. Peripheral vascular disease (arteries)

443.9—A variety of syndromes that result in

decreased blood flow in the peripheral

arterial vessels, usually of the lower

extremities. This category includes

arteriosclerosis obliterans, small vessel

syndrome, Raynaud’s phenomenon, arterial

aneurysms (for example, thoracic, abdominal,

popliteal), and temporal arteritis. Do not

include deep vein thrombosis in this

category; if present, use item G2f.

j. Post Acute MI (within 30 days) 410.92—

The immediate period following the necrosis

of myocardial tissue resulting from

obstruction of a coronary artery.

k. Post heart surgery (for example, valve,

CABG) V45.81—Cardiovascular surgery such

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66425

as percutaneous transluminal coronary

angioplasty (PTCA), coronary artery bypass

graft (CABG), valve replacement,

percutaneous balloon valvuloplasty.

l. Pulmonary embolism 415.1—Obstruction

of one or more of the pulmonary arteries by

a thrombus (blood clot).

m. Pulmonary failure 518.8—Failure of the

respiratory system to meet oxygenation needs

(severe hypoxemia).

n. Other cardiovascular disease 429.2—

Any other cardiac diagnosis not coded

elsewhere in Section G (for example, valvular

heart disease).

MUSCULOSKELETAL

o. Fracture—hip V43.64—Hip fracture (for

example, femoral neck; intertrochanteric;

subcapital) that has been repaired via

surgical arthroplasty or internal fixation.

Category also includes fractures treated with

traction that may have involved the surgical

placement of pins. Also includes surgical hip

replacement (for example, total or

hemiarthroplasty) following fracture of the

hip (for example, femoral neck;

intertrochanteric; subcapital fractures, etc).

Hips stabilized via open reduction and

internal fixation (ORIF) with pins or screws

would be included in this item.

p. Fracture—lower extremity 812.40—Any

fracture of the lower extremity, other than

hip fracture. Includes surgically and nonsurgically treated fractures. Category does not

include pathological fractures of the lower

extremity; if the patient has a diagnosis of

pathologic bone fracture of the lower

extremity, code item G4.

q. Fracture(s)—other 829.0—Any other

fracture type or location not captured in

Section G.

r. Osteoarthritis 715.90—A progressive

degenerative disease of joint cartilage and

bone characterized by joint pain; may be

accompanied by joint deformity and

limitation of movement.

s. Osteoporosis 733.00—A metabolic bone

disorder characterized by a loss of bone

density resulting in weakened bones and

susceptibility to fractures.

t. Rheumatoid Arthritis 714.0—A

progressive degenerative joint disease

characterized by recurrent inflammation of

synovial tissue and joint deformities.

NEUROLOGICAL

u. Alzheimer’s disease 331.0—A

degenerative and progressive dementia that is

diagnosed by ruling out other dementias and

physiological reasons for the dementia.

v. Aphasia or Apraxia (784.3, 784.69)—

Symptoms of neurological defects

characterized by a difficulty or inability to

express thoughts (in speech or writing) or

comprehend language (aphasia), or a

difficulty/inability to carry out purposeful

movements or use objects properly due to a

failure to identify them or understand their

meaning (apraxia).

w. Cerebral Palsy 343.9—A group of

nonprogressive muscular and motor

disorders secondary to a neurological defect

or trauma at birth.

x. Dementia other than Alzheimer’s disease

290.0—Includes diagnosis of organic brain

syndrome (OBS) or Chronic Brain Syndrome

(CBS), senile dementia, multi-infarct

dementia, and dementia related to other

neurological diseases other than Alzheimer’s

Disease (for example., Picks, CreutzfeldJacob, Huntington’s Disease).

y. Hemiplegia/hemiparesis left side

342.90—Paralysis/partial paralysis

(temporary or permanent impairment of

sensation, function, motion) of both limbs on

left side of the body. Usually caused by

cerebral hemorrhage, thrombosis, embolism,

or tumor. There must be a diagnosis of

hemiplegia or hemiparesis in the resident’s

record.

z. Hemiplegia/hemiparesis right side

342.90—Paralysis/partial paralysis

(temporary or permanent impairment of

sensation, function, motion) of both limbs on

right side of body. Usually caused by cerebral

hemorrhage, thrombosis, embolism, or tumor.

There must be a diagnosis of hemiplegia or

hemiparesis in the resident’s record.

aa. Multiple sclerosis 340—A progressive

central nervous system disease characterized

by demyelination in brain and spinal cord

resulting in various neurological symptoms

(for example, paresthesias; motor disorders;

diplopia or blindness; urinary incontinence);

usually involves recurrent exacerbations and

remissions.

ab. Parkinson’s Disease 332.0—A

progressive disease affecting the centers of

the brain responsible for control and

regulation of movement.

ac. Quadriplegia 344.00–344.09—Paralysis

(temporary or permanent impairment of

sensation, function, motion) of all four limbs.

Usually caused by cerebral hemorrhage,

thrombosis, embolism, tumor, or spinal cord

injury. There must be a diagnosis of

quadriplegia in the patient’s record.

ad. Seizure Disorder 780.39—Disorder of

cerebral function characterized by sudden

attacks of altered consciousness, sensory

changes, motor activity, or inappropriate

behavior. May be focal (localized) or

generalized.

ae. Spinal cord dysfunction—nontraumatic 336.9—A non-traumatic disorder

affecting the spinal cord (for example,

neoplasm; abscess; hematoma; neurologic

manifestations of pernicious anemia; spina

bifida); may be associated with pain, sensory

impairment, abnormal reflexes, motor

dysfunction.

af. Spinal cord dysfunction—traumatic

952.9—Alteration of neurological function

(for example, motor, sensory, reflexes)

secondary to compression or laceration of the

spinal cord.

ag. Stroke (CVA) 436—A vascular insult to

the brain that may be caused by intracranial

bleeding, stenosis, thrombosis, infarcts, or

emboli; may result in permanent neurological

and physical dysfunction.

PSYCHIATRIC/MOOD

ah. Anxiety Disorder 300.00—A disorder

characterized by prominent symptoms of

anxiety or phobic avoidance. This category

includes generalized anxiety disorder, panic

disorder, phobias, obsessive-compulsive

disorder, post-traumatic stress disorder, acute

distress disorder, and other anxiety disorders

(for example, due to general medical

condition; substance-induced).

ai. Depression 311—A mood disorder often

characterized by a depressed mood (for

example, feels sad or empty; appears tearful),

decreased ability to think or concentrate, loss

of interest or pleasure in usual activities,

insomnia or hypersomnia, loss of energy,

change in appetite, feelings of hopelessness

or worthlessness or guilt. May include

thoughts of death or suicide.

aj. Other psychiatric disorders 300.9—

Other diagnosed psychiatric disorders not

coded elsewhere on this assessment (for

example, psychotic disorders, such as

anorexia, bulimia; eating disorders).

PULMONARY

ak. Asthma 493.9—Intermittent periods of

wheezing and dyspnea as a result of variable

and recurring airway obstruction.

al. COPD 496—A group of conditions

resulting in generalized airway obstruction

(particularly the small airways) associated

with varying combinations of asthma,

chronic bronchitis, and emphysema. May

also be called COLD (chronic obstructive

lung disease). This category also includes

chronic restrictive lung diseases such as

asbestosis.

Note: Do not code asthma or emphysema

in this category if either of these are the

patient’s definitive diagnoses. If asthma only

is present, code in item G2ak. If emphysema

only is present, code in item G2am.

am. Emphysema 492.8—A specific chronic

obstructive pulmonary disease which is

characterized by destructive changes in the

alveoli which reduce the surface area for gas

exchange.

OTHER

an.Cancer 199.1—A diagnosis of a

carcinoma characterized by a localized

malignant tumor or abnormal cell growth that

has not spread to other areas or systems of

the body. This category also includes

metastatic cancer—a diagnosis of a

carcinoma characterized by a malignant

tumor or abnormal cell growth that has

spread to other areas or systems of the body.

ao. Post surgery-non-orthopedic, noncardiac V50.9—Status post any surgical

procedure not noted in Section G.

ap. Renal Failure 586—Derangement and

insufficiency of renal excretory and

regulatory function. This category includes

acute (ARF) and chronic renal failure (CRF).

aq. NONE OF THE ABOVE

Process: Review patient’s current medical

record (including current physician

treatment orders and nursing care plans),

referral information and hospital discharge

summary. If the patient was admitted from an

acute care or rehabilitation hospital, the

discharge forms often list diagnoses and

corresponding ICD–9–CM codes that were

current during the hospital stay. If these

diagnoses are still present, record them using

the appropriate code to categorize the nature

of the patient’s treatment regimen.

There will be times when a particular

diagnosis will not be documented in the

medical record. If that is the case, accept

statements by the patient that seem to have

clinical validity, consult with the physician

for confirmation, and initiate necessary

physician documentation.

For example: If a new patient reports that

he or she had a severe depression and was

66426 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

seeing a private psychiatrist in the

community, this information may not have

been documented in records accompanying

the patient from an acute care hospital to the

post acute setting.

Physician involvement in this part of the

assessment process would be beneficial. The

physician can be asked to review the items

in Section G at the time of visit closest to the

scheduled MDS–PAC assessment. Use this

scheduled visit as an opportunity to ensure

that ‘‘active’’ diagnoses are noted and

‘‘inactive’’ diagnoses are appropriately

designated. This is also an important

opportunity to share the entire assessment

with the physician. It is the responsibility of

clinical staff to solicit physician input.

Inaccurate or missed diagnoses can be a

serious impediment to care planning. Thus,

share this section of the assessment with the

physician and ask for his or her input.

Full physician review of the most recent

assessment or ongoing input into the

assessment currently being completed can be

very useful to overall care planning. For the

physician, the assessment completed by

clinical staff can provide insights that would

have otherwise not been possible. For

clinical staff, the informed comments of the

physician may suggest new avenues of

inquiry, or help to confirm existing

observations, or suggest the need for

additional consultation and follow-up.

Record a diagnosis only if the disease is

being treated or monitored; or has a

relationship to current ADL status, cognitive

status, behavior status, medical treatment,

nursing monitoring, or risk of death. For

example, do not place a code for item G2g

(hypertension) if one episode occurred

several years ago unless the hypertension is

either currently being controlled with drug

therapy, diet, biofeedback, etc., or is being

regularly monitored for recurrence. Likewise

gallbladder surgery that occurred 15 years

ago would not be recorded in item G2ao (Post

surgery—non-orthopedic, non-cardiac)

unless it had a relationship to the patient’s

current health status.

Coding: Record all documented diagnoses

in the appropriate category. Do not record

any conditions that have been resolved and

no longer affect the patient’s functional status

or care plan—leave the box blank. For each

item that is present enter the most

appropriate code to describe the patient’s

documented diagnosis.

[Blank] Not present.

1. Other primary diagnosis/diagnoses for

current stay (not primary impairment). These

are the diagnoses used to support and justify

services being provided.

2. Diagnosis present, patient is receiving

active treatment (for example, drug therapy;

therapeutic rehabilitation services; laboratory

monitoring); other medical or skilled nursing

intervention (for example, wound care; IV

antibiotics; suctioning).

3. Diagnosis present, patient monitored but

condition is not being actively treated.

If none of the conditions in Section G2

apply, check NONE OF ABOVE (G2aq). If

you have more detailed information available

in the clinical record for a more definitive

diagnosis than is provided in the list in

Section G2, record the general diagnosis in

Section G2 and then enter the more detailed

diagnosis (with ICD–9–CM code) under

Section G4.

3. Infections

Intent: To document the presence of

infections that have an impact or potential

impact on the patient’s overall function

(physical, cognitive, mood and behavioral),

treatment and/or discharge plans.

a. Antibiotic resistant infection—any

infection in which the bacteria have

developed a resistance to the effective actions

of an antibiotic (for example, Methicillin

resistant staphylococcus aureus [MRSA

041.11], Vancomycin-resistant enterococcus

[VRE 041.9]).

b. Cellulitis 682.9—inflammation of

cellular or connective tissue, spreading as in

erysipelas. The process of inflammation

spreading throughout the tissue is called

cellulitis.

c. Hepatitis 070.9—an inflammatory

process in the liver usually caused by viral

infection. This category includes acute and

chronic viral hepatitis.

d. HIV/AIDS 042—Code this item only if—

(A) there is supporting documentation in the

medical record of (1) a positive blood test

result for the Human Immunodeficiency

Virus (HIV), or (2) a diagnosis of Acquired

Immuno-deficiency Syndrome (AIDS), or (3)

a diagnosis of AIDS-related complex (ARC);

or (B) if the patient (or surrogate decisionmaker) informs you of the presence of any of

these diagnoses.

e. Pneumonia 486—an acute bacterial or

viral infection of the lungs.

f. Osteomyelitis 730.2—an infection of

bone, usually caused by bacteria or other

pathogens. This category also includes

infection of a surgically-implanted

prosthesis.

g. Septicemia 038.9—clinical

manifestations of bacterial infection of the

circulatory system (bacteremia) associated

with inadequate tissue perfusion

(hypotension, renal failure and risk of death).

h. Staphylococcus infection (other than

item ‘‘G3a’’ above) 041.10—any infection

identified as staphylococcus by culture that

is not considered to be resistant to antibiotic

treatment.

i. Tuberculosis (active) 011.90—Diagnosis

of active tuberculosis as evidenced by

symptoms and/or currently receiving drug

therapy (for example, isoniazid (INH),

ethambutol, rifampin, cycloserine). Includes

patients who have converted to PPD positive

tuberculin status and are receiving drug

treatment.

j. Urinary Tract Infection 599.0—includes

chronic and acute symptomatic infection.

Code only if there is supporting

documentation or significant laboratory

findings in the medical record, or the patient

is currently being treated or evaluated for a

UTI.

k. Wound Infection (958.3, 998.59, 136.9)—

Category includes documentation of

infection(s) of any type of wound (for

example, surgical; traumatic; pressure ulcer)

of any part of the body. Note: Report of

wound culture may or may not be present in

the medical record; diagnosis may be based

on presence of drainage, erythema, edema,

etc. around wound site.

l. NONE OF THE ABOVE.

Process: Review patient’s medical record.

Coding: Record all documented diagnoses

of infection(s) in the appropriate category. Do

not record any conditions that have been

resolved and no longer affect the patient’s

functional status or care plan—leave the box

blank. For each item that is present enter the

most appropriate code to describe the

patient’s documented diagnosis.

[Blank] Not present.

1. Other primary diagnosis/diagnoses for

current stay. These are the diagnoses used to

support and justify services being provided.

2. Diagnosis present, patient is receiving

active treatment (drug therapy; therapeutic

rehabilitation services; laboratory

monitoring; other medical or skilled nursing

intervention (for example, wound care; IV

antibiotics; suctioning; respiratory therapy).

3. Diagnosis present, patient monitored but

condition is not being actively treated.

If none of the conditions in Section G3

apply, check NONE OF ABOVE (G3l). If you

have more detailed information available in

the clinical record for a more definitive

diagnosis than is provided in the list in

Section G3, record the general diagnosis in

Section G3 and then enter the more detailed

diagnosis (with ICD–9–CM code) under

Section G4.

For example: If the medical record states

that the patient has ‘‘Pneumocystis carinii

pneumonia’’ record the nature of this

diagnosis in item G3e (Pneumonia) and then

record the more specific diagnosis and ICD–

9–CM code in Section G4.

4. Other Current or More Detailed Diagnoses

and ICD–9 Codes

Intent: To identify and document

conditions not listed in Items G1, G2 and G3

that have an impact or potential impact on

the patient’s current ADL status, mood and

behavioral status, medical treatments,

nursing monitoring, therapeutic

rehabilitation, discharge plan or risk of death.

Also, to record more specific designations for

general disease categories listed in Sections

G2 and G3.

Process: Review patient’s current medical

record, referral information and hospital

discharge summary.

Coding: If the patient does not have any

other or more detailed diagnoses

documented, leave the boxes blank.

Enter the description of the diagnoses on

the lines provided. For each diagnosis

complete the following:

Write in diagnosis in lines ‘‘a’’ through

‘‘e’’.

Column A: enter the ICD–9–CM code for

the diagnosis in the boxes, AND

Column B: enter the code (from the

following codes) that best characterizes the

diagnosis.

1. Other primary diagnosis/diagnoses for

current stay (not primary impairment). These

are the diagnoses used to support and justify

services being provided.

2. Diagnosis present, patient is receiving

active treatment (for example, drug therapy;

therapeutic rehabilitation services; laboratory

monitoring); other medical or skilled nursing

intervention (for example, wound care; IV

antibiotics; suctioning).

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66427

3. Diagnosis present, patient monitored but

condition is not being actively treated.

Any new diagnosis at reassessment or

discharge is to be recorded in G4.

5. Complications/Comorbidities

Intent: To identify and document

comorbidities that may effect the patient’s

functional status or health.

Definition: ‘‘Complications, comorbid

conditions, and high-risk medical disorders

may occur with any Impairment Group when

the occurrence delays or compromises

rehabilitation by:

Existing prior to the rehabilitation

program.

Occurring or existing during the

rehabilitation program.

Causing subject transfer to acute care.

Causing subject death during the

rehabilitation program’’ (Uniform Data

System for Medical Rehabilitation, Guide for

the Uniform Data Set for Medical

Rehabilitation-Version 5.1, Appendix A:

UDSmr Policy Regarding ICD–9 Coding, p.

A19.) NOTE: HCFA has excluded from the

definition of comorbidities the recording of

diagnoses by Rehabilitation Impairment

Category. For example, stroke is not a

comorbidity for the stroke Rehabilitation

Impairment Category, cardiac is not a

comorbidity for the cardiac Rehabilitation

Impairment Category. The ‘‘Rehabilitation

Impairment Categories and Associated

Impairment Group Codes’’ were discussed

previously in this guide.

Process: Review the patient’s medical

record, referral information, hospital

discharge summary, and consult with other

clinical staff.

Coding: For the comorbidities to enter in

lines G5a thru G5d including the ICD–9–CM

codes refer to ‘‘Appendix C: List of

Comorbidities’’ which is one of the

appendixes of this proposed rule. If no

comorbid condition exists write in the words

‘‘No comorbid condition’’ once and enter

‘‘0000.00’’ in the associated boxes.

Section H. Medical Complexities

Intent: To record clinical signs, symptoms,

and conditions that affect or could affect the

patient’s health, functional, and psychosocial

status and to identify risk factors for illness,

accidents, and functional decline. Such

factors need to be considered for treatment,

rehabilitation, and discharge planning.

Definition: Medical complexities—include

a number of indicators which help clinicians

and others form a picture of the clinical

intensity and level of service the patient

receives in the post acute setting.

1. Vital Signs

Intent: To record the status of the patient’s

vital signs (that is, pulse; blood pressure;

respiratory rate; temperature).

Definition: Abnormal vital signs—see

ranges in box below.

Process: To interpret whether vital signs

are within the range of ‘‘normal’’ usually

requires an evaluation of several

measurements rather than relying on a single

value at one point in time. Therefore, review

the results from the evaluation of the

patient’s vital signs over the past three days.

In addition to reviewing vital signs, review

the patient’s clinical record, specifically,

vital signs ‘‘flow sheets’’, and physician or

nursing documentation in the medical

record, referral sheet, or discharge summary.

Coding: Code for the ‘‘most abnormal’’ set

of vital signs over the last 3 days.

0. All vital signs were normal/standard

(that is, when compared to standard values).

1. Vital signs abnormal, but not on all days

during assessment period.

2. Vital signs consistently abnormal (on all

days).

2. Problem Conditions

Intent: To record clinical signs, symptoms,

and conditions that affect or could affect the

patient’s health, functional, and psychosocial

status and to identify risk factors for illness,

accidents, and functional decline. Such

factors need to be considered for treatment,

rehabilitation, and discharge planning.

Process: Gather information from a variety

of sources. Begin by reviewing the discharge

referral record and current medical record,

including laboratory data, consultation

reports, and nursing observations. This will

be the primary source of information. Check

that it is complete by soliciting input from all

members of the interdisciplinary team,

including direct care providers (for example,

certified nurse assistants). Finally, in your

scheduled contact with the patient to assess

other areas, interview, observe, and examine

the patient to ensure nothing has been

overlooked. Remember, you are reviewing

problem conditions that have been present in

the last 3 days.

Definition: FALLS/BALANCE

a. Dizziness/vertigo/lightheadedness—The

patient has experienced the sensation of

unsteadiness, that he or she is ‘‘turning’’, or

that the surroundings are whirling/spinning

around; or if the patient complained

specifically of dizziness/vertigo/or

lightheadedness in the last 3 days.

b. Fell (since admission or last

assessment)—Patient/family reports or

medical record or discharge summary

indicates the patient fell since admission or

since last assessment.

c. Fell in 180 days prior to admission—

Patient/family reports or medical record or

discharge summary indicates the patient fell

in the 180 days prior to admission.

CARDIAC/PULMONARY

d. Advanced cardiac failure (ejection

fraction <25 percent)—Check if EITHER

documented cardiac disease with significant

decrease in cardiac output (for example,

documented ejection fraction <25 percent) in

last 60 days OR diastolic dysfunction, as

indicated by repeated episodes of heart

failure with a normal ejection fraction).

e. Chest pain/pressure on exertion—The

patient experiences any type of pain in the

chest (or radiating to arm or jaw pain), which

may be described as burning, pressure,

stabbing, or discomfort, etc. associated with

physical exertion.

f. Chest pain/pressure at rest—The patient

experiences any type of pain in the chest (or

radiating to arm or jaw pain), which may be

described as burning, pressure, stabbing, or

discomfort, etc. that starts spontaneously and

without physical exertion (at rest).

g. Edema-generalized—Generalized

abnormal pooling or accumulation of fluid in

tissues throughout the body (not limited to

specific site).

h. Edema-localized—Abnormal pooling or

accumulation of fluid in specific tissues (for

example, pedal edema; lymphedema of upper

extremity).

i. Edema-pitting—Abnormal pooling or

accumulation of fluid in tissues. Assessed by

pressing the patient’s skin firmly with the

thumb for at least five seconds behind the

medial malleolus, dorsum of the foot, or over

the shin. If present, a ‘‘thumb print’’ will

remain over the area of edema.

j. Impaired aerobic capacity/endurance

(tires easily, poor task endurance)—A

symptom characterized by a limited ability to

sustain a period of exercise or exertion due

to decreased cardiac or respiratory function

(may be as a result of disease or

deconditioning).

FLUID STATUS—It is often difficult to

recognize when a frail, ill person is

experiencing fluid overload that could

precipitate congestive heart failure, or

alternatively dehydration. Ways to monitor

the problem, particularly in patients who are

unable to recognize or report the common

symptoms of fluid variation, are as follows:

k. Constipation—The patient passes two or

fewer bowel movements per week, or strains

more than one out of four times when having

a bowel movement.

l. Dehydrated: output exceeds input (for

example, BUN/creatinine ratio >25)—check

this item if the patient’s laboratory results

reveal a blood urea nitrogen (BUN) to

creatinine ratio greater than 25 OR if the

patient has 2 or more of the following

indicators.

• Patient’s fluid intake is less than 2500 ml

of fluids daily (water or liquids in beverages,

water in food/supplements/parenteral

nutrition, IV fluids).

• Patient has clinical signs of dehydration

(for example, dry mucous membranes,

decrease in skin elasticity).

• Patient’s fluid loss exceeds the amount

of fluids he or she takes in (for example, loss

from vomiting, fever, diarrhea that exceeds

fluid replacement)—review the Input and

Output record;

m. Diarrhea—Frequent elimination of

watery stools from any etiology (for example,

diet, viral or bacterial infection).

n. Internal bleeding—Includes

gastrointestinal and other types of intestinal

bleeding. Bleeding may be frank (such as

bright red blood) or occult (such as guaiac

positive stools); any documented bleeding as

diagnosed by GI evaluation or any evidence

of current bleeding through rectal exam or

guaiac testing. Could also include: hematuria

(blood in urine); hemoptysis (coughing up

blood); or severe epistaxis (nosebleed), etc.

present over the last 3 days that did not

spontaneously resolve or that occurred more

than once.

o. Recurrent nausea/vomiting—Patient

reports recurrent (more than one episode)

sensations of having to vomit or actual

regurgitation of stomach contents; code

regardless of etiology (for example, drug side

effect or toxicity; influenza; anxiety;

obstruction; reaction to particular odors or

sights).

66428 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

p. Refusal/inability to take liquids orally—

Patient either rejects intake of fluids (for

example, liquids, jello, sorbets, etc.) as a

conscious decision or pushes them away, OR

has a physical condition that inhibits intake

of oral liquids (for example, nausea/vomiting;

dysphagia; severe candidiasis of oral mucosa,

etc.).

OTHER

q. Delusions/Hallucinations—Delusions

are fixed, false beliefs not shared by others

that the patient holds even when there is

obvious proof or evidence to the contrary (for

example, belief he or she is terminally ill;

belief that spouse is having an affair; belief

that food served by the hospital/facility is

poisoned).

Hallucinations are false perceptions that

occur in the absence of any real stimuli. A

hallucination may be auditory (for example,

hearing voices), visual (for example, seeing

people, animals), tactile (for example, feeling

bugs crawling over skin), olfactory (for

example, smelling fumes), or gustatory (for

example, having strange tastes).

r. Fever—Rectal temperatures above

100°Fahrenheit (38°Celsius) are considered

significant. Many frail patients have normally

low rectal baseline temperatures (for

example, 96°). A fever is present when the

patient’s temperature (°F) is 2.4 degrees

greater than the baseline temperature.

s. Hemi-neglect (inattention to one side)—

For example, patient denies that their left

arm belongs to them, shaves only on one side

of face, ignores items to their left.

t. Cachexia (severe malnutrition)—A

condition of undernutrition and wasting that

may occur in a variety of chronic diseases

and malignancies.

u. Morbid Obesity—According to a

National Institute of Health consensus panel,

a body weight that is double (twice) the

‘‘ideal’’ body weight of standard heightweight tables OR 100 pounds (45 g)

overweight.

Extremely obese persons are at great risk of

serious disorders, including diabetes,

hypertension, osteoarthritis, impairment in

psychosocial well-being, and death from

cardiovascular disease. (Refer to the latest

(1983) Metropolitan Life Insurance Company

standard height-weight table below to

identify ideal/desirable body weights).

HEIGHT AND WEIGHT TABLE FOR WOMEN

Height (in feet and inches) Small frame Medium frame Large frame

4′10′′ ............................................................................................................................................. 102–111 109–121 118–131

4′11′′ ............................................................................................................................................. 103–113 111–123 120–134

5′0′′ ............................................................................................................................................... 104–115 113–126 122–137

5′1′′ ............................................................................................................................................... 106–118 115–129 125–140

5′2′′ ............................................................................................................................................... 108–121 118–132 128–143

5′3′′ ............................................................................................................................................... 111–124 121–135 131–147

5′4′′ ............................................................................................................................................... 114–127 124–138 134–151

5′5′′ ............................................................................................................................................... 117–130 127–141 137–155

5′6′′ ............................................................................................................................................... 120–133 130–144 140–159

5′7′′ ............................................................................................................................................... 123–136 133–147 143–163

5′8′′ ............................................................................................................................................... 126–139 136–150 146–167

5′9′′ ............................................................................................................................................... 129–142 139–153 149–170

5′10′′ ............................................................................................................................................. 132–145 142–156 152–173

5′11′′ ............................................................................................................................................. 135–148 145–159 155–176

6′0′′ ............................................................................................................................................... 138–151 148–162 158–179

HEIGHT AND WEIGHT TABLE FOR MEN

Height (in feet and inches) Small frame Medium frame Large frame

5′2′′ ............................................................................................................................................... 128–134 131–141 138–150

5′3′′ ............................................................................................................................................... 130–136 133–143 140–153

5′4′′ ............................................................................................................................................... 132–138 135–145 142–156

5′5′′ ............................................................................................................................................... 134–140 137–148 144–160

5′6′′ ............................................................................................................................................... 136–142 139–151 146–164

5′7′′ ............................................................................................................................................... 138–145 142–154 149–168

5′8′′ ............................................................................................................................................... 140–148 145–157 152–172

5′9′′ ............................................................................................................................................... 142–151 148–160 155–176

5′10′′ ............................................................................................................................................. 144–154 151–163 158–180

5′11′′ ............................................................................................................................................. 146–157 154–166 161–184

6′0′′ ............................................................................................................................................... 149–160 157–170 164–188

6′1′′ ............................................................................................................................................... 152–164 160–174 168–192

6′2′′ ............................................................................................................................................... 155–168 164–178 172–197

6′3′′ ............................................................................................................................................... 158–172 167–182 176–202

6′4′′ ............................................................................................................................................... 162–176 171–187 181–207

v. End-stage disease, life expectancy of 6 or

fewer months—The intent of this item is to

heighten staff awareness of the potential

terminal nature of the patient’s condition so

that an appropriate course of care can be

developed. In one’s best clinical judgement,

the patient in the final (end) stage of a

disease process (for example, COPD;

malignancy; cardiac disease; Alzheimer’s

disease, etc.) and has only six or fewer

months to live. Although it is often difficult

to make such a prognosis, this judgement

should be substantiated by a physician and

the presence of a deteriorating clinical

course.

w. NONE OF THE ABOVE—The patient

has not experienced any of the above

conditions.

Coding: Check all problems present in the

last three days, unless other time frames are

indicated. If none apply, check NONE OF

THE ABOVE.

3. Respiratory Conditions

Intent: To identify and record signs,

symptoms or conditions of respiratory

distress that could have a direct or indirect

affect on the patient’s ability to function,

participate in rehabilitation and on the

patient’s plan of care, including discharge.

More than one condition may apply.

Definition: a. Inability to lie flat due to

shortness of breath—In the last 3 days the

patient reported feeling ‘‘breathless’’ or short

of breath (dyspneic), or has been observed to

be short of breath, while lying supine;

requires more than one pillow or has the

head of the bed mechanically raised in order

to breathe more comfortably.

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66429

b. Shortness of breath with exertion—In

the last 3 days the patient has reported

becoming ‘‘breathless’’ or short of breath

(dyspneic), or has been observed to be short

of breath, even with mild exertion such as

taking a bath, transferring from bed to chair,

toileting.

c. Shortness of breath at rest—In the last

three days the patient reported feeling

‘‘breathless’’ or short of breath (dyspneic), or

was observed being short of breath, at rest

(for example, sitting, talking).

d. Oxygen saturation < 90 percent—In the

last 3 days the patient’s oxygen saturation

level (obtained by oximeter) was less than 90

percent (either while receiving or not

receiving oxygen therapy).

e. Difficulty coughing and clearing airway

secretions—In the last 3 days the patient

reports or has been observed to be unable to

cough effectively to expel respiratory

secretions (for example, secondary to

weakness, pain) or is unable to mobilize

secretions or sputum from mouth (for

example, secondary to dysphagia or pain) or

tracheostomy (for example, secondary to

viscosity of sputum; inability to physically

remove secretions from tracheostomy

entrance). Examples might include a post

abdominal surgery patient unable to cough

due to incisional pain, or a comatose patient

that required suctioning to manage

secretions.

f. Recurrent aspiration—In the last 3 days

a patient with a history of at least one or

more episodes of aspiration (inspiration) of

fluids/food/secretions, etc. into lungs,

exhibits clinical signs and symptoms of

another episode. Recurrence often occurs in

patients with swallowing difficulties or who

receive tube feedings (that is esophageal

reflux of stomach contents). Clinical

indicators include productive cough,

shortness of breath, wheezing. It is not

necessary that there be X-ray evidence of

lung aspiration for this item to be checked.

g. Recurrent Respiratory Infection—In the

last 3 days patient with a history of

respiratory infection (for example.,

pneumonia; bronchitis) with evidence of a

recurrence (for example, prior infection not

resolved with medical intervention; infection

has been experienced multiple times).

h. NONE OF THE ABOVE—In the last 3

days none of the above conditions were

present.

Process: Interview and observe the patient.

Review the patient’s medical record,

including consultation reports by a

respiratory therapist and laboratory data such

as arterial blood gases (ABG’s), as indicated.

Coding: Check all conditions that were

present in the last three days. If no

conditions apply, check NONE OF THE

ABOVE.

4. Pressure Ulcers

Intent: To identify and document the

presence, stage and number of pressure

ulcers, and, if present, record the

characteristics (that is the size, exudate, and

predominant tissue) of the ulcer(s).

Definition: Pressure Ulcer—Any lesion

caused by unrelieved pressure resulting in

damage of underlying tissue. Pressure ulcers

usually occur over bony prominences and are

graded or staged to classify the degree of

tissue damage observed (Agency for Health

Care Policy Research, 1992).

Pressure Ulcer Stage—The following

pressure ulcer staging definitions are

consistent with the recommendations of the

Agency for Health Care Policy Research

(AHCPR, 1992) and the National Pressure

Ulcer Advisory Panel (NPUAP, 1989). A

shorter version of these definitions appear on

the form as coding options for Items H4a

(highest current pressure ulcer stage).

a. Highest current pressure ulcer stage.

0. No pressure ulcer.

1. (Stage 1) Any area of persistent skin

redness.

2. (Stage 2) Partial loss of skin layers.

3. (Stage 3) Deep craters in the skin.

4. (Stage 4) Breaks in skin exposing muscle

or bone.

5. Not stageable (necrotic eschar

predominant, no prior staging available).

PUSH (Pressure Ulcer Healing Scale)

Score—A tool to monitor pressure ulcer

healing over time. The PUSH Score is

measured by assessing wound size, amount

of exudate, and characteristics of

predominant tissue. The PUSH is used in

Items 4c through 4f.

(a) Highest current pressure ulcer stage.

Intent: In conjunction with other items, to

facilitate the monitoring of pressure ulcer

healing or worsening over time.

Process: Examine the patient for pressure

ulcers and determine pressure ulcer stage.

Without a full body inspection, an ulcer can

be missed. If the patient has more than one

ulcer, determine which ulcer has the highest

(worst) ulcer stage. This type of information

may be found in referral records (including

discharge summaries), clinical progress

notes, flow sheets, or patient care plans.

Review these records to determine the

highest ulcer ever achieved for any ulcer the

patient currently has.

Coding: Record the highest (worst) current

pressure ulcer stage. If the predominant

tissue of the ulcer is necrotic eschar,

prohibiting accurate staging, code ‘‘5’’, Not

Stageable (necrotic eschar predominant; no

prior staging available). If the patient has no

pressure ulcers, record ‘‘0’’ (No pressure

ulcers) in the box provided.

(b) Number of current pressure ulcers.

Process: Examine the patient for pressure

ulcers. Without a full body inspection, an

ulcer can be missed. COUNT the number of

pressure ulcers.

Coding: Record the number of pressure

ulcers, including ulcers that cannot be

accurately staged (that is, if the predominant

tissue of the ulcer is necrotic eschar). If the

patient has no pressure ulcers, record ‘‘0’’

(No pressure ulcers) in the box provided.

(c–f) PUSH Scale (Items c through f).

The next four items (c through f) represent

the PUSH Scale 3.0 developed by the

National Pressure Ulcer Advisory Panel

(NPUAP, 1998) to monitor pressure ulcer

healing over time. For purposes of this

assessment there are three important things

to remember for this section:

• The PUSH Scale (items ‘‘c’’ through ‘‘f’’)

can only be calculated for ulcers of Stage 2

and higher OR for ulcers where necrotic

eschar is the predominant tissue. If highest

pressure ulcer stage is ‘‘0’’ or ‘‘1’’, enter code

of ‘‘0’’ in c, d, e, and f.

• Select the LARGEST ulcer. Note: The

largest ulcer may not necessarily be the ulcer

with the highest ulcer stage.

• Although the PUSH Scale was designed

to evaluate the healing of a pressure ulcer, its

use in this assessment is to provide a

‘‘snapshot’’ of the status for the largest ulcer

present at the time of the assessment. When

tracked over time, we can know the highest

PUSH score that characterizes the patient’s

pressure ulcer status.

(c) Length multiplied by width (open

wound surface area).

Materials: You will need a centimeter ruler

to measure the surface area of an open

wound. Although it’s not necessary, it is also

helpful to use a calculator for multiplying

ulcer measurements to calculate the total

open wound surface area.

Process: • Using a centimeter ruler,

measure the greatest length (head to toe) and

the greatest width (side to side) of the ulcer

margins (for example, the edges of the

‘‘open’’ areas). If necrotic eschar is the

predominant tissue and the ulcer is not

‘‘open’’, measure from edge to edge of the

eschar.

• Multiply these two measurements

(length x width) to obtain an estimate of the

surface area in square centimeters (cm2). Do

not guess! Always use a centimeter ruler and

always use the same method each time the

ulcer is measured.

Coding: Record the number that

corresponds to the largest pressure ulcer’s

open wound surface area using the following

codes:

0. 0 cm2.

1. <0.3 cm2.

2. 0.3–0.6 cm2.

3. 0.7–1.0 cm2.

4. 1.1–2.0 cm2.

5. 2.1–3.0 cm2.

6. 3.1–4.0 cm2.

7. 4.1–8.0 cm2.

8. 8.1–12.0 cm2.

9. 12.1–24.0 cm2.

10. >24 cm2.

(d) Exudate amount.

Process: Estimate the amount of exudate

(drainage) present after removal of the

dressing and before applying any topical

agent to the ulcer for the selected (largest)

pressure ulcer.

Coding: Record the response that best

estimates the amount of exudate (drainage).

0. None.

1. Light.

2. Moderate.

3. Heavy.

(e) Tissue Type.

Process: Inspect the selected (largest)

pressure ulcer and note the tissue that

occupies the majority of the ulcer bed. Divide

the ulcer bed into four imaginary quadrants,

each representing about 1⁄4 of the original

ulcer surface. Estimate the portion or amount

of each tissue type on the ulcer. Determine

the predominant tissue type on the ulcer.

Coding: Record the response that describes

the most predominant tissue type.

0. Closed/Resurfaced—The wound is

completely covered with epithelium (new

skin).

1. Epithelial Tissue—For superficial ulcers,

new pink or shiny tissue (skin) that grows in

66430 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

from the edges or as islands on the ulcer

surface.

2. Granulation Tissue—Pink or beefy red

tissue with a shiny, moist, granular

appearance.

3. Slough—Yellow or white tissue that

adheres to the ulcer bed in strings or thick

clumps/or is mucinous.

4. Necrotic tissue (eschar)—Black, brown

or tan tissue that adheres firmly to the wound

bed or ulcer edges and may be either firmer

or softer than surrounding skin.

(f) Total PUSH (Pressure Ulcer Healing

Scale) Score.

Process: Add up the scores from Items H4c

(open wound surface area) + H4d (exudate

amount) + H4e (tissue type). This sum

represents the total PUSH Score.

Coding: Record the number that represents

the Total PUSH Score in the box provided.

5. Other Skin Integrity

(a) Number of stasis ulcers (in the last 24

hours).

Definition: Stasis ulcer—An open lesion,

usually of the ankle or lower third of the

lower extremities, caused by chronic venous

stasis or insufficiency. In the medical record

one may also find this type of ulcer referred

to as a ‘‘venous ulcer’’ or ulcer related to

peripheral vascular disease (PVD).

Process: Examine the patient and review

the clinical record. COUNT the number of

stasis ulcers present in the last 24 hours.

Coding: Record the number of stasis ulcers

in the box provided. If there are no stasis

ulcers, code a ‘‘0’’ in the box.

(b) Number of surgical wounds (in the last

24 hours).

Definition: Surgical wounds—Includes

healing and non-healing, open or recently

closed (since onset of precipitating event in

A7a) surgical incisions, skin grafts or

drainage sites on any part of the body. This

category does not include healed surgical

sites or stomas.

Process: Examine the patient’s body and

COUNT the number of surgical wounds

present in the last 24 hours.

Coding: Record the number of surgical

wounds in the box provided. If there are no

surgical wounds, code a ‘‘0’’ in the box.

(c) Ulcer resolved or healed in last 90 days.

Definition: Ulcer—For this item, the term

ulcer refers to ANY lesion caused by pressure

(that is, pressure ulcer; bedsore; decubitus

ulcer) or venous stasis/insufficiency (that is,

stasis ulcer).

Process: Review the patient’s clinical

record over the last 90 days for

documentation of the presence of a pressure

or stasis ulcer that has been healed (that is,

closed/resurfaced; new tissue entirely covers

the wound). Validate findings by examining

the patient’s body.

Coding: Record the most appropriate

response to indicate that the patient had an

ulcer that was resolved or healed in the last

90 days. If the patient did not have an ulcer

that resolved in the last 90 days, use a code

of ‘‘0’’ in the box. Note: The patient may still

have other ulcers in various stages of healing.

0. No, or never had ulcer.

1. Yes.

6. Other Skin Problems or Lesions Present

Intent: To document the presence of skin

problems other than ulcers or surgical

wounds, and conditions that are risk factors

for more serious problems.

Definition: a. Burns (second or third

degree)—Includes burns from any cause (for

example, heat, electricity, chemicals,

radiation, or gases) that affects skin deeper

than the epidermis or outermost layer of skin.

This category does not include first degree

burns (changes in skin color only).

b. Open lesions other than rashes, cuts (for

example, cancer lesions, ulcers)—Any open

area of the skin unrelated to pressure, venous

stasis, surgery, trauma or rashes.

c. Rashes—Includes inflammation or

eruption of the skin that may include change

in color, spotting, blistering, etc. and

symptoms such as itching, burning, or pain.

Record rashes from any cause (for example,

eczema, heat, drugs, bacteria, fungus, viruses

[such as herpes zoster, chicken pox],

parasites [such as scabies, lice], contact with

irritating substances such as urine or

detergents, allergies, etc.). Intertrigo refers to

rashes (dermatitis) within skin folds.

d. Skin tears or cuts (other than surgery)—

Any traumatic break in the skin penetrating

to subcutaneous tissue not caused by surgical

puncture or incision. Examples include

lacerations, punctures wounds, etc.

e. NONE OF THE ABOVE.

Review the patient’s record for

documentation of impairment of this type.

An obvious example of a patient with this

problem is someone who is comatose. Other

patients at high risk include those with

quadriplegia, paraplegia, hemiplegia or

hemiparesis, peripheral vascular disease and

neurological disorders.

Process: Ask the patient if he or she has

any problem areas. Ask the nurse assistant

and examine the patient. Review the patient’s

record. You are assessing for skin problem

areas present over the last 24 hours.

Coding: Check all that apply for the last 24

hours. If there is no evidence of such

problems in the last 24 hours, check NONE

OF THE ABOVE.

Section I. Pain Symptoms

Intent: The intent of this section is to

identify other health conditions that have an

impact on the patient’s quality of life, health

risks, and plan of care, including the

discharge plan.

1. Pain Symptoms

Intent: To evaluate and record the

presence, frequency and intensity of pain and

how it is managed. Pain can impact the

patient in many ways, including affecting his

or her ability to meet established goals. It is

essential that pain is assessed and an

effective pain management plan put in place

in order to optimize the patient’s recovery

and quality of life. Items I1a through I1b refer

to pain in the last 3 days. In item I1c, how

the patient’s current perception of pain

compares to pain status prior to precipitating

event (item A7a). For care planning purposes

these items can be used to determine the

characteristics of the patient’s pain and to

monitor his or her response to pain

management interventions.

Definition: Pain—pain refers to any type of

physical pain or discomfort in any part of the

body. Pain may be localized to one area, or

may be more generalized. It may be acute or

chronic, continuous or intermittent (comes

and goes), or occur at rest or with movement.

The pain experience is very subjective; pain

is whatever the patient says it is. If the

patient complains of pain, record that pain is

present.

Pain assessment may depend on the

observation of others (that is, cues), either

because the patient does not complain, or is

unable to verbalize or describe symptoms.

Process: This evaluation is based solely on

the patient’s perception of pain, or in cases

where the patient has limited ability to

communicate, staff’s interpretation of

behaviors that might indicate pain. Ask the

patient to categorize the highest level of pain

they have experienced over each time period.

Ask the patient if he or she has

experienced any pain or discomfort in the

last three days and ask him/her to describe

it. If the patient states he or she has pain, take

his or her word for it. Pain is a subjective

experience.

Observe the patient for indicators of pain.

Observation is particularly important in

patients who are unable to communicate

their experiences of pain. Indicators may

include moaning, crying, and other

vocalizations; wincing or frowning and other

facial expressions; or body posture such as

guarding/protecting an area of the body, lying

very still or decreasing usual activities (to

prevent pain from occurring).

In severely cognitively impaired patients,

the pain experience is particularly difficult to

discern. For example, in patients who cannot

verbalize that they are feeling pain,

discomfort may be manifested by behaviors

such as calling out for help, pained facial

expressions, refusing to eat, or striking out at

a nurse assistant who tries to move them or

touch a body part. Although such behaviors

may not be solely indicative of pain, code for

the frequency and intensity of symptoms if

in your best clinical judgement it is possible

that the behavior could be caused by the

patient experiencing pain.

Ask nurse assistants and therapists who

work with the patient if the patient had

complaints or indicators of pain the last three

days.

Coding: For each of the following items

(I1a through I1b) code for the HIGHEST

LEVEL OF PAIN the patient experienced in

the last three days, even while receiving

treatments.

a. FREQUENCY—Measures how often the

patient experiences pain (reports or shows

evidence of pain).

Codes: 0. No pain.

1. Pain less than daily.

2. Daily—single shift.

3. Daily—multiple shifts.

b. INTENSITY ‘‘ Measures the level of pain

as the patient perceives it (described or

manifested by the patient). Use the following

scale to indicate the level of pain

experienced:

Codes: 0. No pain.

1. Mild pain—Although the patient

experiences some (‘‘a little’’) pain he or she

is usually able to carry on with daily

routines, socialization, or sleep.

2. Moderate pain—Patient experiences ‘‘a

medium’’ amount of pain.

3. Severe pain—Patient experiences

intense pain.

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66431

4. Times when pain is horrible or

excruciating—Worst possible pain the person

can imagine.

c. CURRENT PAIN STATUS as compared

to pain status prior to precipitating event

item (A7a). Patient’s experience of pain NOW

as compared to pain status prior to

precipitating event. Note: If the patient has

no pain now and no pain prior to

precipitating event (item A7a), code ‘‘0’’,

same.

Coding: 0. Same.

1. Better.

2. Worse.

8. UNKNOWN—The patient is unable to

describe how the pain compares OR there is

no available information in the clinical

record or via family or professional

caregivers.

Section J. Oral/Nutritional Status

1. Oral Problems

Intent: To record any oral or nutritional

problems in the last 3 days.

Definition: a. Chewing Problem—Inability

to chew regular food easily and without pain

or difficulties, regardless of cause (for

example, poor mastication, immobile jaw,

recent oral surgery, temporomandibular joint

pain, decreased sensation/motor control).

b. Dental Problem—Upon exam and

interview of the patient, problems with teeth

are identified (for example, ill—fitting or lack

of dentures, painful tooth, poor dental

hygiene).

Process: Examine and interview the

patient—this is the crucial part of the

process, without this examination, oral

problems often go undetected. Review

clinical records. Talk to the nurse assistants

who have recently helped the patient with

his/her ADL’s.

Coding: Record the most appropriate

response in the box provided. Code ‘‘0’’ for

No and ‘‘1’’ for Yes.

2. Swallowing

Intent: The ability to swallow safely can be

affected by many disease processes and

functional decline. Alterations in one’s

ability to swallow can result in choking and

aspiration, both of which can cause

morbidity and mortality. Often patients with

swallowing difficulties require altered

consistencies of food and fluids OR may not

be able to ingest nutrition by mouth. This

item details the diet consistencies and

modifications in place to address swallowing

difficulties.

Process: Observe patient. Review the

patient’s clinical record, including MD,

dietitian and Speech Language Pathology

notes if applicable.

Coding: Using the codes provided, indicate

which item best describes the dietary

prescriptions to address swallowing

difficulties.

0. Normal—Safe and efficient swallowing

of all diet consistencies.

1. Requires diet modification to swallow

solid foods (mechanical diet or able to ingest

specific foods only).

2. Requires modification to swallow solid

foods and liquids (puree, thickened liquids).

3. Combined oral and tube feeding [tube

feeding (via NGT, GT, JT), and some oral

intake]

4. No oral intake (NPO)

3. Height and Weight

Intent: To establish a height and weight in

order to monitor nutrition and hydration

status over time, to establish a baseline to

monitor changes in weight over time.

Process: Base weight on the most recent

measure in the last 3 days. Utilize your

facility’s standard of practice to ensure

consistency in measuring weights (for

example, in a.m. after voiding, before

breakfast, with shoes off and in night

clothes).

Coding: Record in ‘‘box a.’’—Height in

inches and in ‘‘box b’’—Weight in pounds.

4. Weight Change

Intent: To assess any presence of weight

loss or gain.

Process: Review clinical record, weight

records, and dietary notes to assess weight

history. Since patient may have only been in

your facility a few days, it may be difficult

to obtain accurate factual information. Utilize

patient and family interview to determine

appropriate coding.

a. Weight Loss.

Definition:Weight loss in percentages (for

example, 5 percent or more in last 30 days).

Process: New admission ‘‘ Ask the patient

or family about weight changes over the last

30 days. Consult physician, review transfer

documentation and compare with admission

weight. Calculate weight loss in percentages

during the specified time periods.

Current patient ‘‘ Review the clinical

records and compare current weight with

weights of 30 days ago. Calculate weight loss

in percentages during the specified time

periods.

Coding: 0. No or unknown.

1. Yes, planned loss.

2. Yes, unplanned loss.

b. Weight Gain.

Definition: Weight gain in percentages (for

example, 5 percent or more in last 30 days).

Process: New admissions—Ask the patient

or family about weight changes over the last

30 days. Consult physician, review transfer

documentation and compare with admission

weight. Calculate weight gain during the

specified time periods.

Current weight ‘‘ Review the clinical

records and compare current weight with

weights of 30 days ago. Calculate weight gain

during the specified time periods.

Coding: 0. No or unknown.

1. Yes, planned gain.

2. Yes, unplanned gain.

5. Parenteral or Enteral Intake

Intent: To record the proportion of all

calories received, and the average fluid

intake, through parenteral or tube feeding in

the last 3 days.

a. The proportion of total calories the

patient received through parenteral or tube

feedings in last 3 days.

Definition:Proportion of total calories

received—the proportion of all calories

ingested during the last 3 days that the

patient actually received (not just ordered) by

parenteral or tube feedings. Determined by

calorie count.

Process: Review clinical record,

particularly the intake flow sheets. Consult

with the dietitian who can derive a calorie

count received from parenteral or tube

feedings.

Coding: Code for the best response. If the

patient took no food or fluids by parenteral

or tube feedings, or took just sips of fluid,

code ‘‘0’’ (None).

0. None.

1. 1 percent to 25 percent.

2. 26 percent to 50 percent.

3. 51 percent to 75 percent.

4. 76 percent to 100 percent.

b. Average fluid intake per day by IV or

tube in last 3 days.

Definition: Average fluid intake per day by

IV or tube in last 3 days refers to the actual

amount of fluid the patient received by these

modes (not the amount ordered).

Process: Review the Intake and Output

record from the last 3 days. Add up the total

amount of fluid received each day by IV and/

or tube feedings only. Divide the total fluid

intake during this time by 3. This will give

you the average of fluid intake per day.

Coding: Code for the average number of

cc’s of fluid the patient received per day by

IV or tube in last 3 days.

Codes: 0. None.

1. to 500 cc/day.

2. 501 to 1000 cc/day.

3. 1001 to 1500 cc/day.

4. 1501 to 2000 cc/day.

5. 2001 or more cc/day.

Section K. Procedures/Services

Intent: To document the service,

treatments, procedures and devices the

patient received over the last 3 days.

1. Clinical Visits and Orders

Intent: To document the number of

physician, nurse practitioner, and physician

assistant visits in which the patient was

examined and notes written, as well as the

number of order changes in the last 3 days.

Process: Review the medical record,

including physician, nurse practitioner, and

physician assistant orders over the last 3

days. See specific processes under each of

the following definitions:

Definition: a. Total number of physician

visits (by attending, consultant, etc.) in

which the patient was examined and MD

notes written—This category also includes

any primary care or consulting osteopath,

podiatrist or dentist. Review the medical

record and add up the total number of

physician visits the patient had in the last

three days. Count only those where the

patient was actually seen and examined/

assessed by the physician as indicated by

physician notes specifically indicating

findings/results of the examination.

Examination/assessment may be a partial or

full exam that occurs at the facility or

physician’s office/clinic. This category does

not include exams conducted in an

emergency room.

b. Number of times physician or nurse

practitioner called to bedside for emergency

(for example, cardiorespiratory arrest,

hemorrhaging, to evaluate change in

condition)—Once again the physician

category also includes bedside visits for

emergencies by MD, osteopath, podiatrist, or

dentist.

c. Number of nurse practitioner (NP) visits

in which patient examined and notes

66432 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

written—Review the medical record and add

up the total number of NP visits the patient

had in the last 3 days. Count only those

where the patient was actually seen and

examined/assessed as indicated by NP notes

specifically indicating findings/results of the

examination.

d. Number of physician assistant (PA)

visits in which patient examined and notes

written—Review the medical record and add

up the total number of PA visits the patient

had in the last 3 days. Count only those

where the patient was actually seen and

examined/assessed as indicated by PA notes

specifically indicating findings/results of the

examination.

e. Number of new or changed orders—

Includes written, telephone, fax, or

consultation orders for new or altered

treatment. Does NOT include admission

orders, return admission orders or renewal

orders without changes. Does include orders

for lab tests. Review the physician order

sheet in the medical record and add up the

total amount of new or changed orders by

M.D., osteopath, podiatrist, dentist, NP or

PA.

Coding: For each clinical visit or order,

record how often it was provided to the

patient in the last 3 days.

2. Treatments and Services

Intent: To document the following:

• Column A—over the last 3 days, code for

treatment frequency [either daily (Code 3) or

less than daily (Code 2) or ordered, not yet

implemented (Code 1)].

• Column B—Record whether patient will

receive service after discharge.

Process: Column A—Review patient’s plan

of care with the primary caregiver, and

review the current medical record, referral

information and hospital discharge summary.

Use the following coding instructions to

indicate how often each of these services was

provided in the last 3 days. Note: These

treatments and services must either be

ordered by a physician or performed by a

licensed professional and documented

appropriately.

Column B—This column is to be

completed ONLY at the discharge assessment

(Item AA3 = 5). Review the patient’s plan of

care with the primary caregiver, and review

the current medical record. Use the coding

instructions for Column B (below) to indicate

whether the patient will receive the service/

treatment after discharge.

Coding: Column A—For each treatment or

service indicate how often it was provided to

the patient in the last 3 days. If none of these

treatments were provided, check NONE OF

ABOVE (Item K2aiA, located in the bottom

right hand corner of Section K2, Treatments

and Services). For any activity that did not

occur, or was not ordered, leave the box next

to that item blank. Code for most intense

treatment on any one day using the following

codes:

[Leave blank] if treatment did not occur,

not ordered.

Code ‘‘1’’ If the treatment was ordered, but

has not yet been implemented.

Code ‘‘2’’ If the treatment occurred less

than daily.

Code ‘‘3’’ If the treatment occurred daily.

Column B—For each treatment or service

(‘‘a’’ through ‘‘ah’’) indicate whether the

patient will receive it after discharge. Leave

‘‘Blank’’ for No, Code ‘‘1’’ for Yes. This

information is obtained on a Discharge

Assessment only.

Definition: MEDICATION RELATED

a. Diabetic management—Involves a

variety of activities centered around

stabilization of blood sugar, including

determining sliding scale insulin dosages,

and blood sugar monitoring. In order to use

codes 1–3 in Column A, there must be

documentation of changes in type of insulin,

insulin dosing, or reports/documentation of

blood sugar levels.

b. Injections—Subcutaneous,

intramuscular, or intradermal injections of

any type of medication, antigen, or vaccine.

Although antigens and vaccines are

considered ‘‘biologicals’’ and not medication

per se, it is important to track when they are

given in order to monitor for systemic

reactions. This category does not include

intravenous fluids or medications. If the

patient received IV medications, record in

Item K2c. (If the patient received IV fluids,

record in Item J5b).

c. IV antibiotics/medications—

Administration of antibiotics or other

medications by means of infusion therapy.

Includes any drug or biological (for example,

contrast material) given by intravenous push

or drip through a central or peripheral port.

Does not include a saline or heparin flush to

keep a heparin lock patent, or IV fluids

without medication.

SKIN TREATMENT

d. Application of dressing—Includes dry

gauze dressings, dressings moistened with

saline or other solutions, transparent

dressings, hydrogel dressings, and dressings

with hydrocolloid or hydroactive particles.

e. Application of ointments, topical

medications—Includes ointments or

medications used to treat a skin condition

(for example, cortisone, antifungal

preparations, chemotherapeutic agents, etc.).

This definition does not include ointments

used to treat non-skin conditions (for

example, nitropaste for chest pain).

f. Debridement (chemical or surgical)—

Chemical debridement is the process of

removing dirt or dead tissue from a wound

or burn using chemical agents or dressing

change products to promote wound healing.

Surgical debridement is the process of

surgically removing dirt or dead tissue from

a wound or burn to promote wound healing.

g. Nutritional/hydration intervention to

manage skin problems—Any nutritional

intervention whose purpose is to promote

wound healing (for example, high protein

drinks, TPN/PPN).

h. Pressure relieving bed/chair—Pressure

relieving devices for the bed include air

fluidized, low airloss therapy beds, flotation,

water, or bubble mattress or pad placed on

the bed. Do not include egg crate mattresses

in this category. Pressure relieving devices

for the chair include gel, air (for example,

Roho) or other cushioning placed on a chair

or wheelchair. Do not include egg crate

cushions in this category.

i. Turning and repositioning—Includes a

continuous, consistent program for changing

the patient’s position and realigning the

body.

j. Ulcer Care—Includes any intervention

for treating an ulcer at any ulcer stage.

Examples include use of dressings, chemical

or surgical debridement, wound irrigations,

and hydrotherapy.

k. Wound care (surgical)—Includes any

intervention for treating or protecting any

type of surgical wound. Examples of care

include topical cleansing, wound irrigation,

application of microbial ointments, dressings

of any type, suture removal, and warm soaks

or heat application.

MANAGEMENT OF HEALTH PROBLEMS

l. Bladder training—A planned program

aimed at assessing and treating bladder

incontinence.

m. Scheduled toileting—A plan whereby

staff members at scheduled times either take

the patient to the toilet room, or give the

patient a urinal, or remind the patient to go

to the toilet. Includes habit training or

prompted voiding.

n. Bowel program—A planned program

aimed at treating bowel incontinence. A

bowel program also includes a program of

planned bowel elimination as with patients

with spinal cord injury.

o. Cardiac monitoring/Rehabilitation—

Cardiac monitoring includes electrical

surveillance of heart rates and patterns either

through EKG or telemetry. Rehabilitation is a

formalized program focusing on regaining

function and endurance that has been limited

by either a chronic or acute cardiac disease.

p. Cast(s)—A device used to immobilize

limbs or joints to promote healing or as a

treatment for various musculoskeletal

problems.

q. Continuous or bi-level positive airway

pressure (CPAP or BiPAP)—Assistive

breathing device which provides the patient

with a continuous flow of air throughout the

breathing cycle.

r. Drains (cutaneous drains and other

drains)—A heavy gauged tube used to

remove air, fluid, or exudate from a body

cavity or wound (exclude chest tubes).

s. Dialysis (includes hemodialysis and

peritoneal dialysis)—Hemodialysis is a

method for removing unwanted byproducts

from the blood of patients with renal

insufficiency or failure through the use of a

machine (dialyzer). Peritoneal dialysis

(CAPD) is a method of removing unwanted

by-products from the body through the

instillation of dialysate into the peritoneal

cavity and using the abdominal wall as a

filter.

t. Enteral Feeding Tube—Any tube inserted

into the gastrointestinal tract for the purpose

of nutrition, hydration, or medication

administration. (This includes, jejunostomy,

gastrostomy, and PEG tubes).

u. IV line-Central—A catheter which is

placed in the more ‘‘central’’ veins such as

subclavian, jugular, or superior vena cava, for

the purpose of monitoring, and

administration of medications and fluids.

This item includes the insertion,

discontinuation, and maintenance of this IV

line, including dressing changes, evaluation

for patency, assessment for adverse effects

(for example, infection), and flushes.

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66433

v. IV line-peripheral—A catheter which is

placed in a peripheral vein (usually hand or

arm) for administration of medications and

fluids. This item includes the insertion,

discontinuation, and maintenance of this IV

line, including dressing changes, evaluation

for patency, assessment for adverse effects

(for example, infiltration; infection; cellulitis)

and flushes.

w. NG feeding tube—A tube inserted

through the nose and extending into the

stomach.

x. Oxygen—Either the intermittent or

continuous use of oxygen to support,

promote or maintain vital functions and

comfort.

y. Pain management other than drugs—

Any documented non-pharmaceutical

intervention designed to decrease or alleviate

pain. Examples may include (but are not

limited to) acupuncture, relaxation therapy,

hypnosis, TENS therapy.

z. Suctioning-oral/nasopharyngeal—

Removing secretions or other matter from the

respiratory system through the mouth or

nose.

aa. Suctioning-tracheal—Removing

secretions or other matter from the

respiratory system through a tracheostomy.

ab. Tracheostomy care—The process of

maintaining a clean and functioning

tracheostomy, includes assessing the

surrounding skin, changing dressing around

tracheostomy tube, cleaning and changing

inner cannula, monitoring cuff pressures, and

securing the tracheostomy tube.

ac. Transfusion(s)—Giving whole blood or

blood component (for example, red blood

cells) to replace blood loss through injury,

surgery, or disease.

ad. Ventilator or respirator—Assures

adequate ventilation in patients who are, or

who may become, unable to support their

own respiration. Includes any type of

electrically or pneumatically powered closed

system mechanical ventilatory support

devices.

ae. Ventilator weaning—Any patient who

was in the process of being weaned off the

ventilator or respirator in the last 3 days

should be coded under this definition.

OTHER

af. Family training in assistance to patient

in health measures or skills required after

return to the community—Any documented

family teaching to support the patient’s

discharge home. Examples include, but are

not limited to, observing for signs of

declining health (for example, hypoglycemia;

cognitive change; new or worsening urinary

incontinence); administering medications;

observing for drug side effects or adverse

drug reactions; providing ostomy care or

dressing changes; coaching strength training

exercises; assisting in transferring and

locomotion; providing appropriate verbal/

physical cues for feeding; how to label

closets and drawers so patient can retrieve

clothes; application of behavioral

management techniques; when to report

change or request assistance.

ag. Patient training in health maintenance

or skills required after return to community—

Any documented patient teaching to support

the patient’s discharge home. Examples

include, but are not limited to, recognizing

and reporting signs of declining health (for

example, hypoglycemia; cognitive change;

new or worsening urinary incontinence); selfadministration of medications; recognizing

and reporting drug side effects or adverse

drug reaction; recording adherence to

strength training exercises; self-ostomy care;

how the Lifeline emergency response system

works; how to access help in an emergency.

ah. Design and implementation of

discharge plan—Discharge plan developed by

the interdisciplinary team; includes making

the necessary arrangements and contacts

with community services.

ai. NONE OF THE ABOVE—Code if the

patient has received NONE of the treatments

or services above.

3. Nursing Practice or Restorative Care

Intent: To determine the extent to which

the patient receives nursing rehabilitation or

restorative services from other than

specialized therapy staff (for example,

occupational therapist, physical therapist,

etc.). Rehabilitative or restorative care refers

to nursing interventions that promote the

patient’s ability to adapt and adjust to living

as independently and safely as is possible.

This concept actively focuses on achieving

and maintaining optimal physical, mental,

and psychosocial functioning.

Skill practice in such activities as walking

and mobility, dressing and grooming, eating

and swallowing, transferring, amputation

care, and communication can improve or

maintain function in physical abilities and

ADLs and prevent further impairment.

Definition: Rehabilitation/restorative

care—Included are nursing interventions that

assist or promote the patient’s ability to

attain his or her maximum functional

potential. This item does not include

procedures or techniques carried out by or

under the direction of qualified therapists, as

identified in item K4. In addition, to be

included in this section, a rehabilitation or

restorative practice must meet all of the

following additional criteria:

• Measurable objectives and interventions

must be documented in the care plan and in

the clinical record.

• Evidence of periodic evaluation by

licensed nurse must be present in the clinical

record.

• Nurse assistants/aides must be trained in

the techniques that promote patient

involvement in the activity.

• These activities are carried out or

supervised by members of the nursing staff.

Sometimes under licensed nurse supervision,

other staff and volunteers will be assigned to

work with specific patients.

• This category does not include exercise

groups with more than four patients per

supervising helper or caregiver.

Definition: a. Range of motion (passive)—

The extent to which, or the limits between

which, a part of the body can be passively

moved around a fixed point, or joint. Passive

range of motion exercise is a program of

movements to maintain flexibility and useful

motion in the joints of the body.

b. Range of motion (active)—Exercises

performed by a patient, with cuing or

supervision by staff, that are planned,

scheduled, and documented in the clinical

record.

c. Splint or orthotic assistance—Assistance

can be of 2 types: (1) where staff provide

verbal and physical guidance and direction

that teaches the patient how to apply,

manipulate, and care for an orthotic device

or splint, or (2) where staff have a scheduled

program of applying and removing a splint or

brace, assess the patient’s skin and

circulation under the device, and reposition

the limb in correct alignment. These sessions

are planned, scheduled, and documented in

the clinical record.

Training and skill practice—Activities

including repetition, physical or verbal

cuing, and task segmentation provided by

any staff member or volunteer under the

supervision of a licensed nurse.

d. Bed mobility—Activities used to

improve or maintain the patient’s selfperformance in moving to and from a lying

position, turning side to side, and positioning

him or herself in bed.

e. Bladder/Bowel—Activities used to

improve or maintain the patient’s selfperformance in bladder and bowel

evacuation (includes ostomy care).

f. Transfer—Activities used to improve or

maintain the patient’s self-performance in

moving between surfaces or planes either

with or without assistive devices.

g. Walking—Activities used to improve or

maintain the patient’s self-performance in

walking, with or without assistive devices.

h. Dressing or grooming—Activities used to

improve or maintain the patient’s selfperformance in dressing and undressing,

bathing and washing, and performing other

personal hygiene tasks.

i. Eating or swallowing—Activities used to

improve or maintain the patient’s selfperformance in feeding oneself food and

fluids, or activities used to improve or

maintain the patient’s ability to ingest

nutrition and hydration by mouth.

j. Amputation/prosthesis care—Activities

used to improve or maintain the patient’s

self-performance in putting on and removing

a prosthesis, caring for the prosthesis, and

providing appropriate hygiene at the site

where the prosthesis attaches to the body (for

example, leg stump or eye socket).

k. Communication—Activities used to

improve or maintain the patient’s selfperformance in using newly acquired

functional communication skills or assisting

the patient in using residual communication

skills and adaptive devices.

Process: Review the clinical record and the

current care plan. Consult with facility staff.

Look for rehabilitation, restorative care

schedule, assignment, and implementation

record sheet on the nursing unit.

Coding: For the last three days, enter the

number of days on which the technique,

procedure, or activity was practiced for a

total of at least 15 minutes during each day

(24-hour period). The 15 minutes does not

have to occur all at once. Remember that

persons with dementia learn skills best

through repetition that occurs multiple times

per day. Review for each activity throughout

the 24-hour period. Enter zero ‘‘0’’ if none,

or if the service was provided for less than

15 minutes per day in the last 3 days.

66434 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

4. Therapy Services

This item involves therapies that occurred

after admission to the facility and meet the

following criteria: (1) were ordered by a

physician, (2) were performed by a qualified

therapist (that is, one who meets state

credentialing requirements) OR (3) were

performed by therapy assistant under the

direction of the therapist.

The therapy treatment may occur either

inside or outside the facility. Includes only

therapies based on a therapist’s assessment

and treatment plan that is documented in the

patient’s clinical record.

Intent: To record the (A) total number of

days treatment was ordered in the last 3 days,

(B) number of days administered (for 15

minutes or more), (C) total number of

minutes each of the following therapies was

provided in the last 3 days (or ordered if days

administered =0 and days ordered >0), and

(D) whether the patient will receive the

service after discharge. Note: In order for

therapy minutes to be recorded in the most

precise 15 minute increment, either the

physician’s order or the therapist’s plan of

care must indicate minutes of therapy

ordered by the physician or recommended in

the therapist’s plan of care.

Definition: a. Speech-language pathology,

audiology services—Services that are

provided by a qualified speech-language

pathologist.

b. Occupational therapy—Therapy services

that are provided or directly supervised by a

qualified occupational therapist. A qualified

occupational therapy assistant may provide

therapy but not supervise others (aides or

volunteers) giving therapy. Include services

provided by a qualified occupational therapy

assistant who is employed by (or under

contract to) the facility only if he or she is

under the direction of a qualified

occupational therapist.

c. Physical therapy—Therapy services that

are provided or directly supervised by a

qualified physical therapist. A qualified

physical therapy assistant may provide

therapy but not supervise others (aides or

volunteers) giving therapy. Include service

provided by a qualified physical therapy

assistant who is employed by (or under

contract to) the facility only if he or she is

under the direction of a qualified physical

therapist.

d. Respiratory therapy—Included are

coughing, deep breathing, administration of

heated nebulizers, aerosol treatments, and

mechanical ventilation, etc., which must be

provided by a qualified professional (that is,

trained nurse, respiratory therapist). This

item does not include use of hand-held

medication dispensers. Count only the time

that the qualified professional spends with

the patient. For high intensity respiratory

patients who receive 24° respiratory care,

have a discussion with the therapist to get an

estimate of the actual amount of time spent

at the bedside providing care.

e. Psychological therapy by any licensed

mental health professional—Therapy given

by any licensed mental health professional,

such as a psychiatrist, psychologist,

psychiatric nurse, or psychiatric social

worker.

f. Therapeutic recreation—Therapy ordered

by a physician that provides therapeutic

stimulation beyond the general activity

program in a facility. The physician’s order

must include a statement of frequency,

duration and scope of the treatment. Such

therapy must be provided by a state licensed

or nationally certified Therapeutic Recreation

Specialist or Therapeutic Recreation

Assistant. The Therapeutic Recreation

Assistant must work under the direction of

a Therapeutic Recreation Specialist.

Process: Review the patient’s clinical

record and consult with each of the qualified

therapists.

Coding: For Boxes (Columns) A, B and C

count only post-admission therapies (given

in or outside the facility).

Column A: Days ordered—In the first

column, enter the number (#) of days the

treatment was ordered during the last three

days. Enter ‘‘0’’ if none. Maximum code is

‘‘3’’.

Column B: Days administered—In the

second column, enter the number (#) of days

the therapy was administered for at least 15

minutes or more in the last three days. Enter

‘‘0’’ if none. Maximum code is ‘‘3’’.

Column C: Minutes delivered—In the third

column, enter the total number (#) of minutes

the particular therapy was provided in the

last 3 days. The time should include only the

actual treatment time (not time waiting,

writing reports, or conducting an evaluation).

Enter total number of minutes ordered if days

administered (K4B) = 0 and days ordered

(K4A) > 0. Enter ‘‘0’’ if the therapy was not

ordered or administered. [Note—Enter

cumulative time over all 3 days even when

total time on a day (or days) was less than

15 minutes].

Column D: Post Discharge Therapy—Code

at discharge assessment only (A3=5). Record

whether the patient will receive the therapy

service after discharge. Code ‘‘0’’ for No, or

‘‘1’’ for Yes. This information is obtained on

a Discharge Assessment only.

5. Devices and Restraints

Intent: To record the frequency, over the

last three days, with which the patient was

restrained by any of the devices listed below

at any time during the day or night.

Definition: This category includes the use

of any device (for example, physical or

mechanical device, material, or equipment

attached or adjacent to the patient’s body)

that the patient cannot easily remove and

that restricts freedom of movement or normal

access to his or her body. If device is used

as an ‘‘enabler,’’ you still must code device

in this item.

a. Full bed rails—Full rails may be one or

more rails along both sides of the patient’s

bed that block three-quarters to the whole

length of the mattress from top to bottom.

This definition also includes beds with one

side placed against the wall (prohibiting the

patient from entering and exiting on that

side) and the other side blocked by a full rail

(one or more rails). A veil screen (used in

pediatric units) or veil bed is included in this

category.

b. Other types of side rails used (for

example, one-side half rail, one-side full rail,

two-sided half rails).

c. Trunk restraint—Includes any device or

equipment or material that the patient cannot

easily remove (for example, vest or waist

restraint).

d. Chair prevents rising—Any type of chair

with locked lap board or chair that places

patient in a recumbent position that restricts

rising or a chair that is soft and low to the

floor (for example, bean bag chair). Includes

‘‘comfort cushions’’ (for example, lap buddy),

‘‘merry walkers.’’

Process: Check the patient’s clinical

records and restraint device flow sheets.

Consult nursing staff. Observe the patient.

Coding: For each device type, enter the

code that best describes the pattern of

restraint or device use for the last 3 days:

0. Not used in last three days

1. Used, but used less than daily in last

three days

2. Daily use—night only in the last three

days

3. Daily use—days only in the last three

days

4. Night and day use, but not constant use

in the last three days

5. Constant use for full 24 hours (with

periodic release) during the last three days

Section L. Functional Prognosis

Intent: A major goal of post acute care is

to rehabilitate the patient to a level of

function and health that enables return to the

patient’s previous living arrangement or, if

not appropriate, to the most independent

living arrangement possible. Developing

plans of care to achieve this goal and prepare

for post-discharge needs requires (1)

establishing individualized goals in specific

areas of function and health, (2) estimating

the degree to which the patient will improve,

(3) evaluating the patient’s and family’s

individual needs, values, motivation for

participation in rehabilitation, and (4)

estimating the rate of patient change (and

goal achievement) and length of stay. This

section asks the interdisciplinary team to

take this information and make some

predictions on rehabilitation prognosis.

These predictions are essential in planning

services needed during the stay as well as

upon discharge.

1. Functional Improvement Goals

Intent: This section looks at some key

functional areas, and asks staff to make a

prediction whether the patient will meet

these goals in the indicated time frame.

Definition: ADLs

a. Bed mobility/transfer—Goals that

involve how patient moves to and from a

lying position, turns side to side, and

positions body while in bed. Also includes

goals involving how patient moves between

surfaces—to or from: bed, chair, wheelchair.

b. Dressing—Goals that involve how the

patient dresses and undresses (street clothes

and underwear) including prostheses,

orthotics, fasteners, pullovers, belts, pants,

skirts, and shoes.

c. Eating—Goals centering on how the

patient eats and drinks (regardless of skill).

This includes intake of nourishment by other

means (for example, tube feeding, total

parenteral nutrition).

d. Locomotion—Goals involving how the

patient moves between locations in his/her

room and adjacent corridor on the same floor.

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66435

If patient uses a wheelchair, the goals would

involve how the patient moves once the

patient is in the wheelchair.

e. Toileting—Goals that involve how the

patient uses the toilet room (or commode,

urinal, bedpan), cleanses himself/herself after

toilet use or incontinent episode(s), changes

pads, manages ostomy or catheter, and

adjusts clothes. This item does include goals

centering on transfers on and off the toilet or

commode.

OTHER

f. Medication Management—Goals

involving how the patient manages

medications ( remembering to take

medications, opening bottles, taking correct

drug dosages, filling syringe, giving

injections, applying ointments).

g. Pain Control—Goals involving the

control (cessation or mitigation) of pain by

the patient. Pain control goals could involve

both pharmacologic and non-pharmacologic

interventions.

h. Managing Finances—In the inpatient

environment this includes goals involving

financial activities such as paying for the

newspaper, paying for TV service. When

considering home discharge, this item

involves paying bills, managing checking

account, or bank account.

Process: Using your best clinical judgment,

code each of these functional areas using the

scale described below. A review of the

physician orders, notes and plans of care

would be essential in this process to confirm

what goals have been established.

Coding: Choose the response that best

reflects the clinical staff’s prognosis for goal

attainment in each of the specified areas in

the last 24 hours. Code for the most

aggressive goal in each area. For admission

assessment and reassessment, code for

clinical staff expectations of patient goals in

the areas listed below by time of discharge.

For discharge assessments, code for staff

expectation of patient functional goal in the

post discharge period.

0. No goal exists—There is currently no

goal in the patient’s plan of care that aims to

improve or maintain the patient’s current

functional performance or health (in the area

specified) in the area indicated.

1. Goal—improvement, full recovery to

premorbid status anticipated—Goals for

improvement in the area specified have been

set, and clinical staff project that the patient

will improve to the level of function or

health (in the area specified) that he or she

experienced prior to the precipitating event

(Item A7a).

2. Goal—improvement, partial recovery

anticipated—Goals for improvement in the

specified area have been set, but given the

patient’s current status and availability of

services within the expected length of stay,

clinical staff project that the patient will not

improve to the level of function or health (in

the area specified) he or she experienced

prior to the precipitating event (Item A7a).

3. Goal—improvement, recovery

uncertain—Goals for improvement in the

specified area have been set, but given the

patient’s current health, functional or

emotional status, clinical staff are unable to

determine if the patient will partially or fully

return to the level of function or health (in

the specified area) he or she experienced

prior to the precipitating event (Item A7a).

4. Goal—maintenance, prevention of

further decline—Goals for maintenance

(preservation) of function or health in the

specified area have been set, and clinical staff

project that the patient will meet

maintenance goals as evidenced by NO

further deterioration in function or health (in

the area specified).

2. Attributes Relevant to Rehabilitation

Intent: The intent of this section is to

measure the patient’s and his or her family’s

motivation to participate in the rehabilitation

program and goals. This is essential to

establish the patient and the patient’s

support system’s participation in the

established plan of care. When conflicts

arise, the plan of care needs to be modified

to reflect efforts to resolve these conflicts. For

example, if the patient is in the post-acute

setting for rehabilitation after a stroke, but is

‘‘refusing rehabilitation,’’ this issue becomes

the primary issue to deal with rather than the

fact that the patient’s mobility is limited.

Definition: a. Patient believes he/she is

capable of increased independence—The

patient states that he/she has the capacity to

improve or be more independent (albeit with

therapeutic support) or demonstrates this

belief by actively participating in

rehabilitative programming.

b. Patient unable to recognize new

limitations—The patient lacks insight into

the level of his/her altered function; may use

poor judgement, thereby placing self at safety

risk; may resist participation in therapeutic

programming aimed at improving function or

compensating for deficits.

c. Patient fails to initiate or to continue to

carry out ADLs (once initiated) for which he/

she has some demonstrated capability—The

patient refrains from participating in self-care

in one or more ADL areas in which he/she

has shown self-care abilities.

Process: Interview the patient. Get a sense

of what his/her goals are from this post-acute

admission. Also discuss what the patient’s

family or support person’s perceptions are.

Observe the patient’s behavior and

participation in plan of care. Are there

differences in the Care Plan goals established

by the team and the patient’s and family’s

goals?

Coding: Indicate ‘‘0’’ for No, ‘‘1’’ for Yes,

or ‘‘8’’ for Unknown in the box

corresponding to each item, indicating that

they have been observed, verbalized or

documented in the last 3 days.

3. Change Over the Last 3 Days

Intent: To evaluate and predict the rate in

which the patient will progress toward his or

her established goals.

Process: Obtain information via review of

the medical record, staff and patient

interview.

Definition: a. Change in overall functional

status over last 3 days.

b. Change in overall health status over last

3 days.

Coding: From the following codes, choose

the response that best reflects your best

clinical judgement of the patient’s rate of

overall functional and health status change

over the last 3 days.

0. Improved.

1. About the same as at admission (or last

assessment if this is not an admission

assessment).

2. Worse.

4. Estimated Length of Stay From Date of

Admission

Intent: It is essential to put a time frame

around established goals in the plan of care.

The guiding time frame in this process is the

anticipated length of stay. This is established

based on a number of factors including but

not limited to, diagnosis, functional ability

and prognosis, medical complications,

support systems, patient motivation, and

anticipated living arrangement and payor

source. All this information must be taken

into consideration when making a prediction.

Process: Use a chart review, patient/

support system interview, or obtain

interdisciplinary clinical input to code for

the anticipated length of stay.

Coding: Starting from (and including) the

date entered in AA2b or if AA2b is blank

AA2a (Admission Date), using your best

clinical judgement, determine the patient’s

expected length of stay in the current setting

prior to returning to a community setting.

Choose the response that best reflects the

anticipated time frame.

0. 1–6 days.

1. 7–13 days.

2. 14—30 days.

3. 31—90 days.

4. 91 or more days.

5. Discharge to community not expected—

It is anticipated that the patient will never

return to the community, even if they are

transferred to another facility. This category

also includes patients who are expected to

die during this admission.

6. Expected discharge will be to another

health care setting prior to return to

community—Examples include transfer to

nursing facility with eventual discharge to

the community.

Section M. Resources for Discharge

Intent: In this section some key elements

related to discharge planning are addressed.

Before formulating a discharge plan, the

resources available to support the patient’s

discharge home should be evaluated based

on the patient’s current needs. In conjunction

with previous sections of the assessment,

these items lay the ground work for

developing a realistic discharge/transition

plan.

1. Available Social Supports

Intent: To identify the availability of family

or friends to provide support during the postacute phase and after discharge.

Process: Information should be obtained

through patient/family interview and through

medical record review. Determine if there is

any indication that family or close friends are

present and available. Privately employed

caregivers would not be coded in this item.

Definition: a. Emotional Support—The

provision of encouragement, comfort,

attentive listening.

b. Intermittent physical support with ADLs

or IADLs—less than daily—The provision of

‘‘hands on’’ assistance to the patient with

personal care, transfers, mobility, or doing

66436 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

housework, shopping etc, on a less than daily

basis.

c. Intermittent physical support with ADLs

or IADLs—daily—The provision of ‘‘hands

on’’ assistance to the patient with personal

care, transfers, mobility, or doing housework,

shopping etc., on a daily basis (for example,

once a day), but not full time.

d. Full time physical support (as needed)

with ADLs or IADLs—The provision of

‘‘hands on’’ assistance to the patient with

personal care, transfers, mobility, or doing

housework, shopping etc., on a daily basis

full time.

e. All or most of necessary transportation—

Includes providing transportation by driving

patient in a car (or other motorized vehicle)

OR accompanying patient using bus, subway,

or other public transportation.

Coding: Ask if one or more family

members/close friends are willing and able to

provide support after discharge. Enter the

most appropriate response next to the type of

support. Enter ‘‘0’’ for No, ‘‘1’’ for Possibly

yes, and ‘‘2’’ for Definitely Yes.

2. Caregiver Status

Intent: The following items identify issues

with the patient’s family or informal

caregivers in preparation for discharge.

Often, when a family member needs postacute care, the entire family is affected. It is

important to determine how the caregiver(s)

is coping, whether he/she requires additional

supports, or if he/she is willing and able to

provide the patient with extended care in

their home.

Process: Interview the patient and family/

caregiver, as well as staff who are closely

involved with the patient’s care. Review

medical record, including Social Service

notes.

Coding: Enter a ‘‘0’’ for ‘‘No’’, and a ‘‘1’’

for ‘‘Yes’’ in the box next to each statement

that applies to the patient and their care

givers/family.

0. No.

1. Yes.

a. Family (or close friend) overwhelmed by

patient’s illness.

b. Family relationship(s) require unusual

amounts of staff time.

3. Living Arrangement

Intent: The intent of this item is to

establish the permanent living arrangement

both prior to admission [A] and that which

is expected after discharge [B]. If the initial

arrangement expected at discharge is

different than column M3B—code in column

C for Temporary Discharge arrangement (A3

= 5).

Process: Obtain information through

patient and family interview. Medical record

review may also be helpful.

Definition: a. Type of residence.

0. Unknown.

1. Private home—Any house or

condominium in the community whether

owned by the patient or another person. Also

included in this category are retirement

communities, and independent housing for

the elderly or disabled.

2. Private apartment—Any apartment in

the community whether owned by the

patient or another person.

3. Rented Room—A rented room either part

of a private house or a boarding room

establishment.

4. Board and Care/assisted living/group

home—An alternative housing option which

integrates shared living environment with

some degree of supportive services such as

home health services, personal care, meal

service, transportation.

5. Homeless (with or without shelter)—

Person does not have a residence—lives out

on streets, woods, etc. or uses a community

based shelter for individuals who do not

have a residential address.

6. Long Term Care Facility (nursing

home)—A residence that provides 24-hour

skilled or intermediate nursing care.

7. Post Acute Care SNF—Facility (or

designated beds within a SNF) dedicated to

the care of patients with intense

rehabilitative or clinically complex needs.

Most patients are admitted to the post acute

care facility from an acute hospital, or

rehabilitation hospital. These patients will

have a short, intense stay in the post acute

care SNF.

8. Hospice—An interdisciplinary program

of palliative care and support services that

addresses the physical, social, spiritual, and

financial needs of terminally ill patients and

their families.

9. Acute unit/hospital—A facility licensed

as an acute care hospital or unit. Patients in

acute care may receive comprehensive and

complex diagnostic services, treatments, and

surgery.

10. Other—Any other setting not

categorized above.

b. Live(d) with.

0. Unknown.

1. Alone—Living with a pet is coded as

living alone.

2. Spouse only—If patient is living as

married (common law marriage) with another

person, use this code.

3. Spouse and others—husband or wife,

and other family members, friends, boarders.

4. Child—Lives with child, no spouse

present.

5. Other relative(s)—Not spouse or

children.

6. Friends.

7. Group setting—An alternative housing

option which integrates a shared living

environment with some degree of supportive

services such as home health services,

personal care, meal service, transportation.

8. Personal Care Attendant—A health care

worker either hired by an agency or the

patient himself. This worker is trained to

provide the patient with help in ADL’s and

other types of assistance.

9. Other—Any other living arrangement

not categorized above.

Process: Review the medical record.

Consult the patient and family. This is meant

to measure permanent placement. If a patient

is going to be discharged to a skilled nursing

facility for a short period of time, and then

discharged back to their home, the

permanent living arrangement would be

either 1 or 2 depending on home service

arrangements.

Coding: a. Type of residence—

• In Column A—indicate the type of

residence where the patient permanently

resided prior to admission.

• In Column B—indicate the type of

residence where the patient is expected to

permanently reside after discharge.

• In Column C—indicate the type of

residence where the patient is expected to

temporarily reside initially after discharge.

Code this item only if this arrangement is

different than that coded in Column B.

b. Lived with—

• In Column A—indicate with whom the

patient permanently resided prior to

admission.

• In Column B—indicate with whom the

patient is expected to permanently reside

after discharge.

• In Column C—indicate with whom the

patient is expected to temporarily reside

initially after discharge. Code this item only

if this arrangement is different than that

coded in Column B.

Appendix C: List of Comorbidities

ICD9 code

No. Abbreviated code title

011 .............. Pulmonary tuberculosis*

011.0 ........... TB of lung, infiltrative

011.00 ......... TB lung infiltr-unspec

011.01 ......... TB lung infiltr-no exam

011.02 ......... TB lung infiltr-exm unkn

011.03 ......... TB lung infiltr-micro DX

011.04 ......... TB lung infiltr-cult DX

011.05 ......... TB lung infiltr-histo DX

011.06 ......... TB lung infiltr-oth test

011.1 ........... TB of lung, nodular

011.10 ......... TB lung nodular-unspec

011.11 ......... TB lung nodular-no exam

011.12 ......... TB lung nodul-exam unkn

011.13 ......... TB lung nodular-micro DX

011.14 ......... TB lung nodular-cult DX

011.15 ......... TB lung nodular-histo DX

011.16 ......... TB lung nodular-oth test

011.2 ........... TB of lung w cavitation

011.20 ......... TB lung w cavity-unspec

011.21 ......... TB lung w cavity-no exam

011.22 ......... TB lung cavity-exam unkn

011.23 ......... TB lung w cavit-micro DX

011.24 ......... TB lung w cavity-cult DX

011.25 ......... TB lung w cavit-histo DX

011.26 ......... TB lung w cavit-oth test

011.3 ........... Tuberculosis of bronchus

011.30 ......... TB of bronchus-unspec

011.31 ......... TB of bronchus-no exam

011.32 ......... TB of bronchus-exam unkn

011.33 ......... TB of bronchus-micro DX

011.34 ......... TB of bronchus-cult DX

011.35 ......... TB of bronchus-histo DX

011.36 ......... TB of bronchus-oth test

011.4 ........... TB fibrosis of lung

011.40 ......... TB lung fibrosis-unspec

011.41 ......... TB lung fibrosis-no exam

011.42 ......... TB lung fibros-exam unkn

011.43 ......... TB lung fibros-micro DX

011.44 ......... TB lung fibrosis-cult DX

011.45 ......... TB lung fibros-histo DX

011.46 ......... TB lung fibros-oth test

011.5 ........... TB bronchiectasis

011.50 ......... TB bronchiectasis-unspec

011.51 ......... TB bronchiect-no exam

011.52 ......... TB bronchiect-exam unkn

011.53 ......... TB bronchiect-micro DX

011.54 ......... TB bronchiect-cult DX

011.55 ......... TB bronchiect-histo DX

011.56 ......... TB bronchiect-oth test

011.6 ........... Tuberculous pneumonia

011.60 ......... TB pneumonia-unspec

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66437

ICD9 code

No. Abbreviated code title

011.61 ......... TB pneumonia-no exam

011.62 ......... TB pneumonia-exam unkn

011.63 ......... TB pneumonia-micro DX

011.64 ......... TB pneumonia-cult DX

011.65 ......... TB pneumonia-histo DX

011.66 ......... TB pneumonia-oth test

011.7 ........... Tuberculous pneumothorax

011.70 ......... TB pneumothorax-unspec

011.71 ......... TB pneumothorax-no exam

011.72 ......... TB pneumothorx-exam unkn

011.73 ......... TB pneumothorax-micro DX

011.74 ......... TB pneumothorax-cult DX

011.75 ......... TB pneumothorax-histo DX

011.76 ......... TB pneumothorax-oth test

011.8 ........... Pulmonary TB nec

011.80 ......... Pulmonary TB nec-unspec

011.81 ......... Pulmonary TB nec-no exam

011.82 ......... Pulmon TB nec-exam unkn

011.83 ......... Pulmon TB nec-micro DX

011.84 ......... Pulmon TB nec-cult DX

011.85 ......... Pulmon TB nec-histo DX

011.86 ......... Pulmon TB nec-oth test

011.9 ........... Pulmonary TB nos

011.90 ......... Pulmonary TB nos-unspec

011.91 ......... Pulmonary TB nos-no exam

011.92 ......... Pulmon TB nos-exam unkn

011.93 ......... Pulmon TB nos-micro DX

011.94 ......... Pulmon TB nos-cult DX

011.95 ......... Pulmon TB nos-histo DX

011.96 ......... Pulmon TB nos-oth test

012 .............. Other respiratory TB*

012.0 ........... Tuberculous pleurisy

012.00 ......... TB pleurisy-unspec

012.01 ......... TB pleurisy-no exam

012.2 ........... TB pleurisy-exam unkn

012.3 ........... TB pleurisy-micro DX

012.04 ......... TB pleurisy-cult DX

012.5 ........... TB pleurisy-histolog DX

012.6 ........... TB pleurisy-oth test

012.1 ........... TB thoracic lymph nodes

012.10 ......... TB thoracic nodes-unspec

012.11 ......... TB thorax node-no exam

012.12 ......... TB thorax node-exam unkn

012.13 ......... TB thorax node-micro DX

012.14 ......... TB thorax node-cult DX

012.15 ......... TB thorax node-histo DX

012.16 ......... TB thorax node-oth test

012.2 ........... Isolated trach/bronch TB

012.20 ......... Isol tracheal TB-unspec

012.21 ......... Isol tracheal TB-no exam

012.22 ......... Isol trach TB-exam unkn

012.23 ......... Isolat trach TB-micro DX

012.24 ......... Isol tracheal TB-cult DX

012.25 ......... Isolat trach TB-histo DX

012.26 ......... Isolat trach TB-oth test

012.3 ........... Tuberculous laryngitis

012.30 ......... TB laryngitis-unspec

012.31 ......... TB laryngitis-no exam

012.32 ......... TB laryngitis-exam unkn

012.33 ......... TB laryngitis-micro DX

012.34 ......... TB laryngitis-cult DX

012.35 ......... TB laryngitis-histo DX

012.36 ......... TB laryngitis-oth test

012.8 ........... Respiratory TB nec

012.80 ......... Resp TB nec-unspec

012.81 ......... Resp TB nec-no exam

012.82 ......... Resp TB nec-exam unkn

012.83 ......... Resp TB nec-micro DX

012.84 ......... Resp TB nec-cult DX

012.85 ......... Resp TB nec-histo DX

012.86 ......... Resp TB nec-oth test

013 .............. CNS tuberculosis*

013.0 ........... Tuberculous meningitis

ICD9 code

No. Abbreviated code title

013.00 ......... TB meningitis-unspec

013.01 ......... TB meningitis-no exam

013.02 ......... TB meningitis-exam unkn

013.03 ......... TB meningitis-micro DX

013.04 ......... TB meningitis-cult DX

013.05 ......... TB meningitis-histo DX

013.06 ......... TB meningitis-oth test

013.1 ........... Tuberculoma of Meninges

013.10 ......... Tubrclma meninges-unspec

013.11 ......... Tubrclma mening-no exam

013.12 ......... Tubrclma menin-exam unkn

013.13 ......... Tubrclma mening-micro DX

013.14 ......... Tubrclma mening-cult DX

013.15 ......... Tubrclma mening-histo DX

013.16 ......... Tubrclma mening-oth test

013.2 ........... Tuberculoma of brain

013.20 ......... Tuberculoma brain-unspec

013.21 ......... Tubrcloma brain-no exam

013.22 ......... Tubrclma brain-exam unkn

013.23 ......... Tubrcloma brain-micro DX

013.24 ......... Tubrcloma brain-cult DX

013.25 ......... Tubrcloma brain-histo DX

013.26 ......... Tubrcloma brain-oth test

013.3 ........... TB abscess of brain

013.30 ......... TB brain abscess-unspec

013.31 ......... TB brain abscess-no exam

013.32 ......... TB brain absc-exam unkn

013.33 ......... TB brain absc-micro DX

013.34 ......... TB brain abscess-cult DX

013.35 ......... TB brain absc-histo DX

013.36 ......... TB brain absc-oth test

013.4 ........... Tuberculoma spinal cord

013.40 ......... Tubrclma sp cord-unspec

013.41 ......... Tubrclma sp cord-no exam

013.42 ......... Tubrclma sp cd-exam unkn

013.43 ......... Tubrclma sp crd-micro DX

013.44 ......... Tubrclma sp cord-cult DX

013.45 ......... Tubrclma sp crd-histo DX

013.46 ......... Tubrclma sp crd-oth test

013.5 ........... TB abscess spinal cord

013.50 ......... TB sp crd abscess-unspec

013.51 ......... TB sp crd absc-no exam

013.52 ......... TB sp crd absc-exam unkn

013.53 ......... TB sp crd absc-micro DX

013.54 ......... TB sp crd absc-cult DX

013.55 ......... TB sp crd absc-histo DX

013.56 ......... TB sp crd absc-oth test

013.6 ........... TB encephalitis/myelitis

013.60 ......... TB encephalitis-unspec

013.61 ......... TB encephalitis-no exam

013.62 ......... TB encephalit-exam unkn

013.63 ......... TB encephalitis-micro DX

013.64 ......... TB encephalitis-cult DX

013.65 ......... TB encephalitis-histo DX

013.66 ......... TB encephalitis-oth test

013.8 ........... CNS tuberculosis nec

013.80 ......... CNS tb nec-unspec

013.81 ......... CNS tb nec-no exam

013.82 ......... CNS tb nec-exam unkn

013.83 ......... CNS tb nec-micro DX

013.84 ......... CNS tb nec-cult DX

013.85 ......... CNS tb nec-histo DX

013.86 ......... CNS tb nec-oth test

013.9 ........... CNS tuberculosis nos

013.90 ......... CNS tb nos-unspec

013.91 ......... CNS tb nos-no exam

013.92 ......... CNS tb nos-exam unkn

013.93 ......... CNS tb nos-micro DX

013.94 ......... CNS tb nos-cult DX

013.95 ......... CNS tb nos-histo DX

013.96 ......... CNS tb nos-oth test

014 .............. Intestinal tb*

014.0 ........... tuberculous peritonitis

ICD9 code

No. Abbreviated code title

014.00 ......... TB peritonitis-unspec

014.01 ......... TB peritonitis-no exam

014.02 ......... TB peritonitis-exam unkn

014.03 ......... TB peritonitis-micro DX

014.04 ......... TB peritonitis-cult DX

014.05 ......... TB peritonitis-histo DX

014.06 ......... TB peritonitis-oth test

014.8 ........... Intestinal tb nec

014.80 ......... Intestinal tb nec-unspec

014.81 ......... Intestin tb nec-no exam

014.82 ......... Intest tb nec-exam unkn

014.83 ......... Intestin tb nec-micro DX

014.84 ......... Intestin tb nec-cult DX

014.85 ......... Intestin tb nec-histo DX

014.86 ......... Intestin tb nec-oth test

015 .............. TB of bone and joint*

015.0 ........... TB of vertebral column

015.00 ......... TB of vertebra-unspec

015.01 ......... TB of vertebra-no exam

015.02 ......... TB of vertebra-exam unkn

015.03 ......... TB of vertebra-micro DX

015.04 ......... TB of vertebra-cult DX

015.05 ......... TB of vertebra-histo DX

015.06 ......... TB of vertebra-oth test

015.1 ........... TB of hip

015.10 ......... TB of hip-unspec

015.11 ......... TB of hip-no exam

015.12 ......... TB of hip-exam unkn

015.13 ......... TB of hip-micro DX

015.14 ......... TB of hip-cult DX

015.15 ......... TB of hip-histo DX

015.16 ......... TB of hip-oth test

015.2 ........... TB of knee

015.20 ......... TB of knee-unspec

015.21 ......... TB of knee-no exam

015.22 ......... TB of knee-exam unkn

015.23 ......... TB of knee-micro DX

015.24 ......... TB of knee-cult DX

015.25 ......... TB of knee-histo DX

015.26 ......... TB of knee-oth test

015.5 ........... TB of limb bones

015.50 ......... TB of limb bones-unspec

015.51 ......... TB limb bones-no exam

015.52 ......... TB limb bones-exam unkn

015.53 ......... TB limb bones-micro EX

015.54 ......... TB limb bones-cult DX

015.55 ......... TB limb bones-histo DX

015.56 ......... TB Limb bones-oth test

015.6 ........... TB of mastoid

015.60 ......... TB of mastoid-unspec

015.61 ......... TB of mastoid-no exam

015.62 ......... TB of mastoid-exam unkn

015.63 ......... TB of mastoid-micro DX

015.64 ......... TB of mastoid-cult DX

015.65 ......... TB of mastoid-histo DX

015.66 ......... TB of mastoid-oth test

015.7 ........... TB of bone nec

015.70 ......... TB of bone nec-unspec

015.71 ......... TB of bone nec-no exam

015.72 ......... TB of bone nec-exam unkn

015.73 ......... TB of bone nec-micro DX

015.74 ......... TB of bone nec-cult DX

015.75 ......... TB of bone nec-histo DX

015.76 ......... TB of bone nec-oth test

015.8 ........... TB of joint nec

015.80 ......... TB of joint nec-unspec

015.81 ......... TB of joint nec-no exam

015.82 ......... TB joint nec-exam unkn

015.83 ......... TB of joint nec-micro DX

015.84 ......... TB of joint nec-cult DX

015.85 ......... TB of joint nec-histo DX

015.86 ......... TB of joint nec-oth test

015.9 ........... TB of bone & joint nos

66438 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

ICD9 code

No. Abbreviated code title

015.90 ......... TB bone/joint nos-unspec

015.91 ......... TB bone/jt nos-no exam

015.92 ......... TB bone/jt nos-exam unkn

015.93 ......... TB bone/jt nos-micro DX

015.94 ......... TB bone/jt nos-cult DX

015.95 ......... TB bone/jt nos-histo DX

015.96 ......... TB bone/jt nos-oth test

016 .............. Genitourinary TB*

016.0 ........... TB of kidney

016.00 ......... TB of kidney-unspec

016.01 ......... TB of kidney-no exam

016.02 ......... TB of kidney-exam unkn

016.03 ......... TB of kidney-micro DX

016.04 ......... TB of kidney-cult DX

016.05 ......... TB of kidney-histo DX

016.06 ......... TB of kidney-oth Test

016.1 ........... TB of bladder*

106.10 ......... TB of bladder-unspec

016.11 ......... TB of bladder-no exam

016.12 ......... TB of bladder-exam unkn

016.13 ......... TB of bladder-micro DX

016.14 ......... TB of bladder-cult DX

016.15 ......... TB of bladder-histo DX

016.16 ......... TB of bladder-oth test

106.2 ........... TB of ureter

016.20 ......... TB of ureter-unspec

016.21 ......... TB of ureter-no exam

016.22 ......... TB of ureter-exam unkn

016.23 ......... TB of ureter-micro DX

016.24 ......... TB of ureter-cult DX

016.25 ......... TB of ureter-histo DX

016.26 ......... TB of ureter-oth test

016.3 ........... TB of urinary organ nec

016.30 ......... TB urinary nec-unspec

016.31 ......... TB urinary nec-no exam

016.32 ......... TB urinary nec-exam unkn

016.33 ......... TB urinary nec-micro DX

016.34 ......... TB urinary nec-cult DX

016.35 ......... TB urinary nec-histo DX

016.36 ......... TB urinary nec-oth test

016.4 ........... TB of epididymis

016.40 ......... TB epididymis-unspec

016.41 ......... TB epididymis-no exam

016.42 ......... TB epididymis-exam unkn

016.43 ......... TB epididymis-micro DX

016.44 ......... TB epididymis-cult DX

016.45 ......... TB epididymis-histo DX

016.46 ......... TB epididymis-oth test

016.5 ........... TB male genital org nec

016.50 ......... TB male genit nec-unspec

016.51 ......... TB male gen nec-no exam

016.52 ......... TB male gen nec-ex unkn

016.53 ......... TB male gen nec-micro DX

016.54 ......... TB male gen nec-cult DX

016.55 ......... TB male gen nec-histo DX

016.56 ......... TB male gen nec-oth test

016.6 ........... TB of ovary and tube

016.60 ......... TB ovary & tube-unspec

016.61 ......... TB ovary & tube-no exam

016.62 ......... TB ovary/tube-exam unkn

016.63 ......... TB ovary & tube-micro DX

016.64 ......... TB ovary & tube-cult DX

016.65 ......... TB ovary & tube-histo DX

016.66 ......... TB ovary & tube-oth test

016.7 ........... TB female genit org nec

016.70 ......... TB female gen nec-unspec

016.71 ......... TB fem gen nec-no exam

016.72 ......... TB fem gen nec-exam unkn

016.73 ......... TB fem gen nec-micro DX

016.74 ......... TB fem gen nec-cult DX

016.75 ......... TB fem gen nec-histo DX

016.76 ......... TB fem gen nec-oth test

016.9 ........... Genitourinary TB nos

ICD9 code

No. Abbreviated code title

016.90 ......... GU TB nos-unspec

016.91 ......... GU TB nos-no exam

016.92 ......... GU TB nos-exam unkn

016.93 ......... GU TB nos-micro DX

016.94 ......... GU TB nos-cult DX

016.95 ......... GU TB nos-histo DX

016.96 ......... GU TB nos-oth test

017 .............. Tuberculosis nec*

017.0 ........... TB skin & subcutaneous

017.00 ......... TB skin/subcutan-unspec

017.01 ......... TB skin/subcut-no exam

017.02 ......... TB skin/subcut-exam unkn

017.03 ......... TB skin/subcut-micro DX

017.04 ......... TB skin/subcut-cult DX

017.05 ......... TB skin/subcut-histo DX

017.06 ......... TB skin/subcut-oth Test

017.1 ........... Erythema nodosum in TB

017.10 ......... Erythema nodos TB-unspec

017.11 ......... Erythem nodos TB-no exam

017.12 ......... Erythem nod TB-exam unkn

017.13 ......... Erythem nod TB-micro DX

017.14 ......... Erythem nodos TB-cult DX

017.15 ......... Erythem nod TB-histo DX

017.16 ......... Erythem nod TB-oth test

017.2 ........... TB of periph lymph node

017.20 ......... TB periph lymph-unspec

017.21 ......... TB periph lymph-no exam

017.22 ......... TB periph lymph-exam unk

017.23 ......... TB periph lymph-micro DX

017.24 ......... TB periph lymph-cult DX

017.25 ......... TB periph lymph-histo DX

017.26 ......... TB periph lymph-oth test

017.3 ........... TB of eye

017.30 ......... TB of eye-unspec

017.31 ......... TB of eye-no exam

017.32 ......... TB of eye-exam unkn

017.33 ......... TB of eye-micro DX

017.34 ......... TB of eye-cult DX

017.35 ......... TB of eye-histo DX

017.36 ......... TB of eye-oth test

107.4 ........... TB of ear

017.40 ......... TB of ear-unspec

017.41 ......... TB of ear-no exam

017.42 ......... TB of ear-exam unkn

017.43 ......... TB of ear-micro DX

017.44 ......... TB of ear-cult DX

017.45 ......... TB of ear-histo DX

017.46 ......... TB of ear-oth test

017.5 ........... TB of thyroid gland

017.50 ......... TB of thyroid-unspec

017.51 ......... TB of thyroid-no exam

017.52 ......... TB of thyroid-exam unkn

017.53 ......... TB of thyroid-micro DX

017.54 ......... TB of thyroid-cult DX

017.55 ......... TB of thyroid-histo DX

017.56 ......... TB of thyroid-oth test

017.6 ........... TB of adrenal gland

017.60 ......... TB of adrenal-unspec

017.61 ......... TB of adrenal-no exam

017.62 ......... TB of adrenal-exam unkn

017.63 ......... TB of adrenal-micro DX

017.64 ......... TB of adrenal-cult DX

017.65 ......... TB of adrenal-histo DX

017.66 ......... TB of adrenal-oth test

017.7 ........... TB of spleen

017.70 ......... TB of spleen-unspec

017.71 ......... TB of spleen-no exam

017.72 ......... TB of spleen-exam unkn

017.73 ......... TB of spleen-micro DX

017.74 ......... TB of spleen-cult DX

017.75 ......... TB of spleen-histo DX

017.76 ......... TB of spleen-oth test

017.8 ........... TB of esophagus

ICD9 code

No. Abbreviated code title

017.80 ......... TB esophagus-unspec

017.81 ......... TB esophagus-no exam

017.82 ......... TB esophagus-exam unkn

017.83 ......... TB esophagus-micro DX

017.84 ......... TB esophagus-cult DX

017.85 ......... TB esophagus-histo DX

017.86 ......... TB esophagus-oth test

017.9 ........... TB of organ nec

017.90 ......... TB of organ nec-unspec

017.91 ......... TB of organ nec-no exam

017.92 ......... TB organ nec-exam unkn

017.93 ......... TB of organ nec-micro DX

017.94 ......... TB of organ nec-cult DX

017.95 ......... TB of organ nec-histo DX

017.96 ......... TB of organ nec-oth test

018 .............. Miliary tuberculosis*

018.0 ........... Acute miliary TB

018.00 ......... Acute miliary TB-unspec

018.01 ......... Acute miliary TB-no exam

018.02 ......... AC miliary TB-exam unkn

018.03 ......... AC miliary TB-micro DX

018.04 ......... Acute miliary TB-cult DX

018.05 ......... AC miliary TB-histo DX

018.06 ......... AC miliary TB-oth test

018.8 ........... Miliary TB nec

018.80 ......... Miliary TB nec-unspec

018.81 ......... Miliary TB nec-no exam

018.82 ......... Miliary TB nec-exam unkn

018.83 ......... Miliary TB nec-micro DX

018.84 ......... Miliary TB nec-cult DX

018.85 ......... Miliary TB nec-histo DX

018.86 ......... Miliary TB nec-oth test

018.9 ........... Miliary tuberculosis nos

018.90 ......... Miliary TB nos-unspec

018.91 ......... Miliary TB nos-no exam

018.92 ......... Miliary TB nos-exam unkn

018.93 ......... Miliary TB nos-micro DX

018.94 ......... Miliary TB nos-cult DX

018.95 ......... Miliary TB nos-histo DX

018.96 ......... Miliary TB nos-oth test

027.0 ........... Listeriosis

027.1 ........... Erysipelothrix infection

027.2 ........... Pasteurellosis

027.8 ........... Zoonotic bact dis nec

027.9 ........... Zoonotic bact dis nos

036.0 ........... Meningococcal meningitis

036.2 ........... Meningococcemia

036.3 ........... Meningococc adrenal synd

036.40 ......... Meningococc carditis nos

036.42 ......... Meningococc endocarditis

036.43 ......... Meningococc myocarditis

037 .............. Tetanus

038.0 ........... Streptococcal septicemia

038.1 ........... Staphylococc septicemia

038.10 ......... Staphylcocc septicem nos

038.11 ......... Staph aureus septicemia

038.19 ......... Staphylcocc septicem nec

038.2 ........... Pneumococcal septicemia

038.3 ........... Anaerobic septicemia

038.4 ........... Gram-neg septicemia nec

038.40 ......... Gram-neg septicemia nos

038.41 ......... H. influenae septicemia

038.42 ......... E coli septicemia

038.43 ......... Pseudomonas septicemia

038.44 ......... Serratia septicemia

038.49 ......... Gram-neg septicemia nec

038.8 ........... Septicemia nec

038.9 ........... Septicemia nos

042 .............. Human immuno virus dis

052.0 ........... Postvaricella encephalit

052.1 ........... Varicella pneumonitis

053.0 ........... Herpes zoster meningitis

054.3 ........... Herpetic encephalitis

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66439

ICD9 code

No. Abbreviated code title

054.5 ........... Herpetic septicemia

054.72 ......... H Simplex meningitis

054.79 ......... H Simplex Complicat nec

055.0 ........... Postmeasles Encephalitis

055.1 ........... Postmeasles Pneumonia

070.20 ......... Hpt B acte coma wo dlta

070.21 ......... Hpt B acte coma w dlta

070.22 ......... Hpt B chrn coma wo dlta

070.23 ......... Hpt B chrn coma w dlta

070.41 ......... Hpt C acute w hepat coma

070.42 ......... Hpt DLT wo b w hpt coma

070.43 ......... Hpt E w hepat coma

070.44 ......... Chrnc hpt C w hepat coma

070.49 ......... Oth vrl hepat w hpt coma

070.06 ......... Viral hepat nos w coma

072.1 ........... Mumps meningitis

072.2 ........... Mumps encephalitis

072.3 ........... Mumps pancreatitis

079.5 ........... Retrovirus

090.42 ......... Congen syph meningitis

093.20 ......... Syphil endocarditis nos

093.82 ......... Syphilitic myocarditis

094.2 ........... Syphilitic meningitis

094.87 ......... Syph rupt cereb aneurysm

098.89 ......... Gonococcal inf site nec

112.4 ........... Candidiasis of lung

112.5 ........... Disseminated candidiasis

112.81 ......... Candidal endocarditis

112.83 ......... Candidal meningitis

114.2 ........... Coccidioidal meningitis

115 .............. Histoplasmosis*

115.1 ........... Histoplasma capsulatum

115.00 ......... Histoplasma capsulat nos

115.01 ......... Histoplasm capsul mening

115.02 ......... Histoplasm capsul retina

115.03 ......... Histoplasm caps pericard

115.04 ......... Histoplasm caps endocard

115.05 ......... Histoplasm caps pneumon

115.09 ......... Histoplasma capsulat nec

115.1 ........... Histoplasma duboisii

115.10 ......... Histoplasma duboisii nos

115.11 ......... Histoplasm dubois mening

115.12 ......... Histoplasm dubois retina

115.13 ......... Histoplasm dub pericard

115.14 ......... Histoplasm dub endocard

115.15 ......... Histoplasm dub pneumonia

115.19 ......... Histoplasma duboisii nec

115.9 ........... Histoplasmosis, unspec

115.90 ......... Histoplasmosis nos

115.91 ......... Histoplasmosis meningit

115.92 ......... Histoplasmosis retinitis

115.93 ......... Histoplasmosis pericard

115.94 ......... Histoplasmosis endocard

115.95 ......... Histoplasmosis pneumonia

115.99 ......... Histoplasmosis nec

130.0 ........... Toxoplasm meningoenceph

130.3 ........... Toxoplasma myocarditis

130.4 ........... Toxoplasma pneumonitis

136.3 ........... Pneumocystosis

204.00 ......... Act lym leuk w/o rmsion

205.00 ......... Act myl leuk w/o rmsion

206.00 ......... Act mono leuk w/o rmsion

207.00 ......... Act erth/erylk w/o rmson

208.00 ......... Act leuk uns cl w/o rmsn

260 .............. Kwashiorkor

261 .............. Nutritional marasmus

262 .............. Oth severe malnutrition

277.00 ......... Cystic fibros w/o ileus

277.01 ......... Cystic fibrosis w ileus

286.0 ........... Cong factor viii diord

286.1 ........... Cong factor ix disorder

286.6 ........... Defibrination syndrome

320.0 ........... Hemophilus meningitis

ICD9 code

No. Abbreviated code title

320.1 ........... Pneumococcal meningitis

320.2 ........... Streptococcal meningitis

320.3 ........... Staphylococc meningitis

320.7 ........... Mening in oth bact dis

320.81 ......... Anaerobic meningitis

320.82 ......... Mningts gram-neg bct nec

320.89 ......... Meningitis oth spcf bact

320.9 ........... Bacterial meningitis nos

321.0 ........... Cryptococcal meningitis

321.1 ........... Mening in oth fungal dis

321.4 ........... Meningit d/t sarcoidosis

321.8 ........... Mening in oth nonbac dis

324.0 ........... Intracranial abscess

324.1 ........... Intraspinal abscess

324.9 ........... CNS abscess nos

345.11 ......... Gen CNV epil w intr epil

345.3 ........... Grand mal status

348.1 ........... Anoxic brain damage

376.01 ......... Orbital cellulitis

376.02 ......... Orbital periostitis

376.03 ......... Orbital osteomyelitis

398.0 ........... Rheumatic myocarditis

403.01 ......... Mal hyp ren w renal fail

404.01 ......... Mal hyper hrt/ren w chf

404.03 ......... Mal hyp hrt/ren w chf&rf

410.01 ......... Ami anterolateral, init

410.11 ......... Ami anterior wall, init

410.21 ......... Ami inferolateral, init

410.31 ......... Ami inferopost, initial

410.41 ......... Ami inferior wall, init

410.51 ......... Ami lateral nec, initial

410.61 ......... True post infarct, init

410.71 ......... Subendo infarct, initial

410.81 ......... Ami nec, initial

410.91 ......... Ami nos, initial

415.1 ........... Pulmon embolism/infarct

415.11 ......... Iatrogen pulm emb/infarc

415.19 ......... Pulm embol/infarct nec

421.0 ........... AC/subac bact endocard

421.1 ........... AC endocardit in oth dis

421.9 ........... AC/subac endocardit nos

422.0 ........... AC myocardit in oth dis

422.90 ......... Acute myocarditis nos

422.91 ......... Idiopathic myocarditis

422.92 ......... Septic myocarditis

422.93 ......... Toxic myocarditis

422.99 ......... Acute myocarditis nec

427.41 ......... Ventricular fibrillation

427.5 ........... Cardiac arrest

430 .............. Subarachnoid hemorrhage

431 .............. Intracerebral hemorrhage

432.0 ........... Nontraum extradural hem

432.1 ........... Subdural hemorrhage

433.01 ......... OCL bslr art w infrct

433.11 ......... OCL crtd art w infrct

433.21 ......... OCL vrtb art w infrct

433.31 ......... OCL mlt bi art w infrct

433.81 ......... OCL spcf art w infrct

433.91 ......... OCL art nos w infrct

434.01 ......... CRBL thrmbs w infrct

434.11 ......... CRBL emblsm w infrct

434.91 ......... CRBL art ocl nos w infrc

436 .............. CVA

440.23 ......... ATH ext ntv art ulcrtion

440.24 ......... ATH ext ntv art gngrene

441.0 ........... Dissecting aneurysm

441.00 ......... DSCT of aorta unsp site

441.01 ......... DSCT of thoracic aorta

441.02 ......... DSCT of abdominal aorta

441.03 ......... DSCT of thoracoabd aorta

441.1 ........... RUPTUR thoracic aneurysm

441.3 ........... RUPT abd aortic aneurysm

441.5 ........... RUPT aortic aneurysm nos

ICD9 code

No. Abbreviated code title

441.6 ........... Thoracoabd aneurysm rupt

446.3 ........... Lethal midline granuloma

451.89 ......... Thrombophlebitis nec

452 .............. Portal vein thrombosis

453 .............. OTH venous thrombosis*

453.0 ........... BUDD-Chiari syndrome

453.1 ........... Thrombophlebitis migrans

453.2 ........... Vena cava thrombosis

453.3 ........... Renal vein thrombosis

464.11 ......... AC tracheitis w obstruct

464.21 ......... AC laryngotrach w obstr

464.31 ......... AC epiglottitis w obstr

466.1 ........... Acute bronchiolitis

480.0 ........... Adenoviral pneumonia

480.1 ........... RESP syncyt viral pneum

480.2 ........... Parinfluenza viral pneum

480.8 ........... Viral pneumonia nec

480.9 ........... Viral pneumonia nos

481 .............. Pneumococcal pneumonia

482 .............. Oth bacterial pneumonia*

482.0 ........... K. pneumoniae pneumonia

482.1 ........... Pseudomonal pneumonia

482.2 ........... H.influenzae pneumonia

482.3 ........... Streptococcal pneumonia

482.30 ......... Streptococcal pneumn nos

482.31 ......... Pneumonia strptococcus A

482.32 ......... Pneumonia strptococcus B

482.39 ......... Pneumonia oth strep

482.4 ........... Staphylococcal pneumonia

482.40 ......... Staphylococcal pneu nos

482.41 ......... Staph aureus pneumonia

482.49 ......... Staph pneumonia nec

482.8 ........... Bacterial pneumonia nec

482.81 ......... Pneumonia anaerobes

482.82 ......... Pneumonia e coli

482.83 ......... Pneumo oth grm-neg bact

482.84 ......... Legionnaires’ disease

482.89 ......... Pneumonia oth spcf bact

482.9 ........... Bacterial pneumonia nos

483 .............. Pneumonia: organism nec*

483.0 ........... Pneu mycplsm pneumoniae

483.1 ........... Pneumonia d/t chlamydia

483.8 ........... Pneumon oth spec orgnsm

484 .............. Pneum in oth infec dis*

484.1 ........... Pneum w cytomeg incl dis

484.3 ........... Pneumonia in whoop cough

484.5 ........... Pneumonia in anthrax

484.6 ........... Pneum in aspergillosis

484.7 ........... Pneum in oth sys mycoses

484.8 ........... Pneum in infect dis nec

485 .............. Bronchopneumonia org nos

486 .............. Pneumonia, organism nos

487 .............. Influenza*

487.0 ........... Influenza with pneumonia

506.0 ........... Fum/vapor bronc/pneumon

506.1 ........... Fum/vapor ac pulm edema

507.0 ........... Food/vomit pneumonitis

507.1 ........... Oil/essence pneumonitis

507.8 ........... Solid/liq pneumonit nec

510.0 ........... Empyema with fistula

510.9 ........... Empyema w/o fistula

511.1 ........... Bact pleur/effus not tb

513.0 ........... Abscess of lung

513.1 ........... Abscess of mediastinum

514 .............. Pulm congest/hypostasis

515 .............. Postinflam pulm fibrosis

518.3 ........... Pulmonary eosinophilia

518.5 ........... Post traum pulm insuffic

518.81 ......... Acute respiratry failure

519.2 ........... Mediastinitis

528.3 ........... Cellulitis/abscess mouth

530.4 ........... Perforation of esophagus

530.82 ......... Esophageal hemorrhage

66440 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

ICD9 code

No. Abbreviated code title

531.00 ......... AC stomach ulcer w hem

531.01 ......... AC stomac ulc w hem-obst

531.10 ......... AC stomach ulcer w perf

531.11 ......... AC stom ulc w perf-obst

531.20 ......... AC stomac ulc w hem/perf

531.21 ......... AC stom ulc hem/perf-obs

531.40 ......... CHR stomach ulc w hem

531.41 ......... CHR stom ulc w hem-obstr

531.50 ......... CHR stomach ulcer w perf

531.51 ......... CHR stom ulc w perf-obst

531.60 ......... CHR stomach ulc hem/perf

531.61 ......... CHR stom ulc hem/perf-ob

532.00 ......... AC duodenal ulcer w hem

532.01 ......... AC duoden ulc w hem-obst

532.10 ......... AC duodenal ulcer w perf

532.11 ......... AC duoden ulc perf-obstr

532.20 ......... AC duoden ulc w hem/perf

532.21 ......... AC duod ulc hem/perf-obs

532.40 ......... CHR duoden ulcer w hem

532.41 ......... CHR duoden ulc hem-obstr

532.50 ......... CHR duoden ulcer w perf

532.51 ......... CHR duoden ulc perf-obst

532.60 ......... CHR duoden ulc hem/perf

532.61 ......... CHR duod ulc hem/perf-ob

533.00 ......... AC peptic ulcer w hemorr

533.01 ......... AC peptic ulc w hem-obst

533.10 ......... AC peptic ulcer w perfor

533.11 ......... AC peptic ulc w perf-obs

533.20 ......... AC peptic ulc w hem/perf

533.21 ......... AC pept ulc hem/perf-obs

533.40 ......... CHR peptic ulcer w hem

533.41 ......... CHR peptic ulc w hem-obs

533.50 ......... CHR peptic ulcer w perf

533.51 ......... CHR peptic ulc perf-obst

533.60 ......... CHR pept ulc w hem/perf

533.61 ......... CHR pept ulc hem/perf-ob

534.00 ......... AC marginal ulcer w hem

534.01 ......... AC margin ulc w hem-obst

534.10 ......... AC marginal ulcer w perf

534.11 ......... AC margin ulc w perf-obs

534.20 ......... AC margin ulc w hem/perf

534.21 ......... AC marg ulc hem/perf-obs

534.40 ......... CHR marginal ulcer w hem

534.41 ......... CHR margin ulc w hem-obs

534.50 ......... CHR marginal ulc w perf

534.51 ......... CHR margin ulc perf-obst

534.60 ......... CHR margin ulc hem/perf

534.61 ......... CHR marg ulc hem/perf-ob

535.01 ......... Acute gastritis w hmrhg

535.11 ......... ATRPH gastritis w hmrhg

535.21 ......... GSTR Mcsl Hyprt w hmrg

535.31 ......... ALCHL Gstritis w hmrhg

535.41 ......... OTH SPF Gastrt w hmrhg

535.51 ......... GSTR/DDNTS NOS w hmrhg

535.61 ......... Duodenitis w hmrhg

537.4 ........... Gastric/Duodenal fistula

537.83 ......... Angio Stm/dudn w hmrhg

540.0 ........... AC Append w peritonitis

557.0 ........... AC VASC insuff intestine

562.02 ......... DVRTCLO SML Int w hmrhg

562.03 ......... DVRTCLI SML Int w hmrhg

562.12 ......... DVRTCLO colon w hmrhg

562.13 ......... DVRTCLI colon w hmrhg

567.0 ........... Peritonitis in infec dis

567.1 ........... Pneumococcal peritonitis

567.2 ........... Suppurat peritonitis nec

567.8 ........... Peritonitis nec

567.9 ........... Peritonitis nos

569.60 ......... Colstomy/enter comp nos

569.61 ......... Colosty/enterost infectn

569.69 ......... Colstmy/enteros comp nec

569.83 ......... Perforation of intestine

569.85 ......... Angio intes w hmrhg

ICD9 code

No. Abbreviated code title

570 .............. Acute necrosis of liver

572.0 ........... Abscess of liver

572.4 ........... Hepatorenal syndrome

573.4 ........... Hepatic infarction

575.4 ........... Perforation gallbladder

576.3 ........... Perforation of bile duct

577.2 ........... Pancreat cyst/pseudocyst

579.3 ........... Intest postop nonabsorb

580.0 ........... AC proliferat nephritis

580.4 ........... AC rapidly progr nephrit

580.81 ......... AC nephritis in oth dis

580.89 ......... Acute nephritis nec

580.9 ........... Acute nephritis nos

583.4 ........... Rapidly prog nephrit nos

584.5 ........... Lower nephron nephrosis

584.6 ........... AC renal fail, cort necr

584.7 ........... AC ren fail, medull necr

584.8 ........... AC renal failure nec

584.9 ........... Acute renal failure nos

590.2 ........... Renal/perirenal abscess

596.6 ........... Bladder rupt, nontraum

659.30 ......... Septicemia in labor-unsp

659.31 ......... Septicem in labor-deliv

665.00 ......... Prelabor rupt uter-unsp

665.01 ......... Prelabor rupt uterus-del

665.03 ......... Prelab rupt uter-antepar

665.10 ......... Rupture uterus nos-unsp

665.11 ......... Rupture uterus nos-deliv

669.10 ......... Obstetric shock-unspec

669.11 ......... Obstetric shock-deliver

669.12 ......... Obstet shock-deliv w p/p

669.13 ......... Obstetric shock-antepar

669.14 ......... Obstetric shock-postpart

669.30 ......... AC ren fail w deliv-unsp

669.32 ......... AC ren fail-deliv w p/p

669.34 ......... AC renal failure-postpar

673.00 ......... OB air embolism-unspec

673.01 ......... OB air embolism-deliver

673.02 ......... OB air embol-deliv w p/p

673.03 ......... OB air embolism-antepart

673.04 ......... OB air embolism-postpart

673.10 ......... Amniotic embolism-unspec

673.11 ......... Amniotic embolism-deliv

673.12 ......... Amniot embol-deliv w p/p

673.13 ......... Amniotic embol-antepart

673.14 ......... Amniotic embol-postpart

673.20 ......... OB pulm embol nos-unspec

673.22 ......... Pulm embol nos-del w p/p

673.23 ......... Pulm embol nos-antepart

673.24 ......... Pulm embol nos-postpart

673.30 ......... OB pyemic embol-unspec

673.31 ......... OB pyemic embol-deliver

673.32 ......... OB pyem embol-del w p/p

673.33 ......... OB pyemic embol-antepart

673.34 ......... OB pyemic embol-postpart

673.80 ......... OB pulmon embol nec-unsp

673.81 ......... Pulmon embol nec-deliver

673.82 ......... Pulm embol nec-del w p/p

673.83 ......... Pulmon embol nec-antepar

673.84 ......... Pulmon embol nec-postpar

674.00 ......... Puerp cerebvasc dis-unsp

682 .............. Other cellulitis/abscess*

682.0 ........... Cellulitis of face

682.1 ........... Cellulitis of neck

682.22 ......... Cellulitis of trunk

682.3 ........... Cellulitis of arm

682.4 ........... Cellulitis of hand

682.5 ........... Cellulitis of buttock

682.6 ........... Cellulitis of leg

682.7 ........... Cellulitis of foot

682.8 ........... Cellulitis, site nec

765.01 ......... Extreme immatur <500G

765.02 ......... Extreme immatur 500–749G

ICD9 code

No. Abbreviated code title

765.03 ......... Extreme immatur 750–999G

781.7 ........... Tetany

785.51 ......... Cardiogenic shock

785.59 ......... Shock w/o trauma nec

799.1 ........... Respiratory arrest

958.0 ........... Air embolism

958.1 ........... Fat embolism

958.5 ........... Traumatic anuria

996.02 ......... Malfunc prosth hrt valve

996.61 ......... React-cardiac dev/graft

996.62 ......... React-oth vasc dev/graft

996.63 ......... React-nerv sys dev/graft

996.64 ......... React-indwell urin cath

996.66 ......... React-inter joint prost

996.67 ......... React-oth int ortho dev

996.69 ......... React-int pros devic nec

997.62 ......... Infection amputat stump

998.0 ........... Postoperative shock

998.3 ........... Postop wound disruption

998.5 ........... Postoperative infection

998.6 ........... Persist postop fistula

999.1 ........... Air embol comp med care

V440 ............ Tracheostomy status

V451 ............ Renal dialysis status

V461 ............ Dependence on respirator

* Denotes this is a category rather than a

code.

Appendix D—The IRF Market Basket

Section 1886(j)(3)(C) of the Act requires the

Secretary to establish an increase factor (for

purposes of setting prospective payment

system rates) based on a market basket index.

The proposed market basket includes both

operating and capital costs of rehabilitation

facilities (that is, freestanding rehabilitation

hospitals and rehabilitation hospital units).

The index currently used for operating costs

for rehabilitation facilities is the excluded

hospital market basket. This market basket is

based on 1992 cost report data and includes

Medicare participating rehabilitation, long

term care, psychiatric, cancer, and children’s

hospitals. Since freestanding rehabilitation

hospitals are a component of the excluded

hospital market basket, this index most

closely reflects the cost shares of

rehabilitation facilities. Because the excluded

hospital market basket only includes

operating costs, we are proposing to use the

excluded hospital market basket with the

addition of a capital portion to the index. We

provide a brief explanation of the

methodology used to develop our proposed

index for rehabilitation facilities. We refer to

this index as the excluded hospital (with

capital) market basket. In the following

discussion we describe: the methodology

used to determine the operating portion of

the market basket, the methodology used to

determine the capital portion of the market

basket, and additional analyses that help

support the extent to which rehabilitation

cost shares are reflected in the market basket

that we are proposing.

The operating portion of the excluded

hospital market basket consists of major cost

categories and their respective weights. The

major cost categories include wages, benefits,

drugs, and a residual. The weights for the

major cost categories are developed from the

Medicare cost reports for FY 1992. The cost

Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules 66441

report data used includes those hospitals

excluded from the inpatient hospital

prospective payment system where the

Medicare average length of stay is within 15

percent (higher or lower) of the total facility

average length of stay. Limiting the sample in

this way provides a more accurate reflection

of the structure of costs for Medicare. The

detailed cost categories are derived from the

Asset and Expenditure Survey, 1992 Census

of Service Industries, by the Bureau of the

Census, Economics and Statistics

Administration, U.S. Department of

Commerce. This is used in conjunction with

the 1992 Input-Output Tables published by

the Bureau of Economic Analysis, U.S.

Department of Commerce. A more detailed

description of the development of this index

can be found in our final rule, Medicare

Program; Changes to the Hospital Inpatient

Prospective Payment Systems and Fiscal

Year 1998 Rates; published in the Federal

Register at 62 FR 45965–45996, on August

29, 1997.

As previously stated, the market basket we

are proposing needs to reflect both operating

and capital costs. Capital costs include

depreciation, interest, and other capitalrelated costs. The cost categories for the

capital portion of the market basket that we

are proposing is developed in a similar

manner as those for the inpatient hospital

prospective payment system capital input

price index, which is explained in the

August 30, 1996 Federal Register. We

calculated weights for capital costs, using the

same set of Medicare cost reports used to

develop the operating share for excluded

hospitals. The resulting capital weight for the

1992 base year is 9.080 percent.

Because capital is consumed over time,

depreciation and interest costs in the current

year reflect both current and previous capital

purchases. We use vintage weighting of

current and previous capital price changes to

capture this effect. Vintage weighting, which

is explained in the August 30, 1996 Federal

Register (61 FR 46197 through 46203), is the

process of weighting price changes for

individual years in proportion to that year’s

share of total purchases still being consumed.

In order to vintage weight the capital

portion of the index as described above, the

average useful life of both assets and debt

instruments (for example, a loan, bond, or

promissory note) needs to be developed. For

depreciation expenses, the useful life of fixed

and movable assets is calculated from the

Medicare cost reports for excluded hospitals,

including freestanding rehabilitation

hospitals. The average useful life for fixed

assets is 21 years and the average useful life

for movable assets is 13 years. For interest

expenses, we use the same useful life of debt

instruments used in the hospital prospective

payment system capital input price index.

We believe that this useful life is appropriate,

because it reflects the average useful life of

hospital issuances of commercial and

municipal bonds from all hospitals,

including rehabilitation facilities. The

average useful life of interest expense is

determined to be 22 years. After the useful

life is determined, a set of weights is

calculated by determining the average

proportion of depreciation or interest

expense incurred during any given year

during the useful life. This information is

developed using the Medicare cost reports.

These calculations are the same as those

described for the inpatient hospital

prospective payment system capital input

price index in the August 30, 1996 Federal

Register. The price proxies for each of the

capital cost categories are the same as those

used for the inpatient hospital prospective

payment system capital input price index.

The cost categories, price proxies, and baseyear fiscal year 1992 weights for the excluded

hospital (with capital) market basket are

presented in Table 1. The vintage weights for

the index are presented in Table 2.

TABLE 1.—HCFA EXCLUDED HOSPITAL INPUT PRICE INDEX WITH CAPITAL (FY 1992) STRUCTURE AND WEIGHTS

Cost category Price/wage variable

Weights (%)

Base-year:

1992

TOTAL ......................................................................................... .................................................................................................... 100.000

Compensation ............................................................................. .................................................................................................... 57.935

Wages and Salaries ............................................................ HCFA Prospective payment system Occupational .................... 47.417

Employee Benefits ............................................................... HCFA Prospective payment system .......................................... 10.519

Professional fees: Non-Medical .................................................. ECI—Compensation: Prof. & Tech ............................................ 1.908

Utilities ......................................................................................... .................................................................................................... 1.523

Electricity .............................................................................. WPI—Commercial Electric Power ............................................. 0.916

Fuel Oil, Coal, etc ................................................................ WPI—Commercial Natural Gas ................................................. 0.365

Water and Sewerage ........................................................... CPI–U—Water & Sewage .......................................................... 0.243

Professional Liability Insurance .................................................. HCFA—Prof. Liab. Prem ........................................................... 0.983

All Other Products and Services ................................................ .................................................................................................... 28.572

All Other Products ............................................................... .................................................................................................... 22.027

Pharmaceuticals ........................................................... WPI—Prescription Drugs ........................................................... 2.791

Food: Direct Purchase .................................................. WPI—Processed Foods ............................................................. 2.155

Food: Contract Service ................................................. CPI–U—Food Away fr. Home .................................................... 0.998

Chemicals ..................................................................... WPI—Industrial Chemicals ........................................................ 3.413

Medical Instruments ..................................................... WPI—Med. Inst. & Equip ........................................................... 2.868

Photographic Supplies .................................................. WPI—Photo Supplies ................................................................ 0.364

Rubber and Plastics ..................................................... WPI—Rub. & Plast. Products .................................................... 4.423

Paper Products ............................................................. WPI—Convert. Paper and Paperboard ..................................... 1.984

Apparel ......................................................................... WPI—Apparel ............................................................................ 0.809

Machinery and Equipment ............................................ WPI—Mach. & Equipment ......................................................... 0.193

Miscellaneous Products ................................................ WPI—Finished Goods ............................................................... 2.029

All Other Services ................................................................ .................................................................................................... 6.544

Telephone ..................................................................... CPI–U—Telephone Services ..................................................... 0.574

Postage ......................................................................... CPI–U—Postage ........................................................................ 0.268

All Other: Labor Intensive ............................................. ECI—Compensation: Service Workers ...................................... 4.945

All Other: Non-Labor Intensive ..................................... CPI–U—All Items (Urban) .......................................................... 0.757

Capital-Related Costs ................................................................. .................................................................................................... 9.080

Depreciation ......................................................................... .................................................................................................... 5.611

Fixed Assets ................................................................. Boeckh-Institutional Construction: 21 year useful life ............... 3.570

Movable Equipment ...................................................... WPI—Machinery & Equipment: 13 year useful life ................... 2.041

Interest Costs ....................................................................... .................................................................................................... 3.212

Non-profit ...................................................................... Avg. Yield Municipal Bonds: 22 year useful life ........................ 2.730

For-profit ....................................................................... Avg, Yield AAA Bonds: 22 year useful life ................................ 0.482

Other Capital-Related Costs ................................................ CPI–U—Residential Rent .......................................................... 0.257

* The wage and benefit proxies are a blend of 10 employment cost indices (ECI). A detailed discussion of the price proxies can be found in the

August 30, 1996 FEDERAL REGISTER final rule.

66442 Federal Register / Vol. 65, No. 214 / Friday, November 3, 2000 / Proposed Rules

TABLE 2.—HCFA EXCLUDED HOSPITAL INPUT PRICE INDEX WITH CAPITAL (FY 1992) VINTAGE WEIGHTS

Year Fixed assets

(21 year weights)

Movable assets

(13 year weights)

Interest:

capital-related

(22 year weights)

1 ........................................................................................................................... 0.0201 0.0454 0.0071

2 ........................................................................................................................... 0.0225 0.0505 0.0082

3 ........................................................................................................................... 0.0225 0.0562 0.0100

4 ........................................................................................................................... 0.0285 0.0620 0.0119

5 ........................................................................................................................... 0.0301 0.0660 0.0139

6 ........................................................................................................................... 0.0321 0.0710 0.0161

7 ........................................................................................................................... 0.0336 0.0764 0.0185

8 ........................................................................................................................... 0.0353 0.0804 0.0207

9 ........................................................................................................................... 0.0391 0.0860 0.0244

10 ......................................................................................................................... 0.0431 0.0923 0.0291

11 ......................................................................................................................... 0.0474 0.0987 0.0350

12 ......................................................................................................................... 0.0513 0.1047 0.0409

13 ......................................................................................................................... 0.0538 0.1104 0.0474

14 ......................................................................................................................... 0.0561 ................................ 0.0525

15 ......................................................................................................................... 0.0600 ................................ 0.0590

16 ......................................................................................................................... 0.0628 ................................ 0.0670

17 ......................................................................................................................... 0.0658 ................................ 0.0742

18 ......................................................................................................................... 0.0695 ................................ 0.0809

19 ......................................................................................................................... 0.0720 ................................ 0.0875

20 ......................................................................................................................... 0.0748 ................................ 0.0931

21 ......................................................................................................................... 0.0769 ................................ 0.0993

22 ......................................................................................................................... ................................ ................................ 0.1034

Total ..................................................................................................................... 1.0000 1.0000 1.0000

We further analyzed the extent to which the

weights in the excluded hospital (with

capital) market basket that we are proposing

reflects the cost weights in rehabilitation

hospitals; particularly since more than 50

percent of excluded hospitals are psychiatric

hospitals. For this purpose, we conducted an

analysis comparing the cost weights of

rehabilitation hospitals to the cost weights

for excluded hospitals. We analyzed the

variations of major costs, such as wages,

drugs, and capital for rehabilitation and

excluded hospitals. This analysis showed

that while these weights differed slightly

between rehabilitation hospitals and

excluded hospitals, the difference is very

small. When these weights are substituted

into the market basket structure for

sensitivity analysis, the effect is never more

than 0.2 percentage points in any given year.

This difference is less than the 0.25

percentage point criteria that determines

whether a forecast error adjustment under the

inpatient hospital prospective payment

system is warranted. We conducted this

analysis in both the base year (FY 1992), and

for the most recent set of cost reports (FY

1997) to determine if the difference in

weights changed over time. Again, the

differences were very small. Based on this

analysis, we concluded that using the

excluded hospital (with capital) market

basket for the IRF prospective payment

system will provide a reasonable measure of

the price changes facing rehabilitation

hospitals. We request comments on any other

data sources that may be available to provide

detailed cost category information on

rehabilitation hospitals, or on data sources

for cost categories in rehabilitation units.

[FR Doc. 00–27646 Filed 11–2–00; 8:45 am]

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