AHIMA Comments on Proposed Changes to the Medicare Prospective Payment System (PPS) for Inpatient Rehabilitation Facilities (IRFs) for fiscal year 2006

July 13, 2005

Mark McClellan, MD, PhD
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1290-P
PO Box 8010
Baltimore, Maryland 21244-8010

Dear Dr. McClellan:

The purpose of this letter is to comment on the Centers for Medicare & Medicaid Services' (CMS') proposed changes to the Medicare Prospective Payment System (PPS) for Inpatient Rehabilitation Facilities (IRFs) for fiscal year 2006, as published in the May 25, 2005 Federal Register. The American Health Information Management Association (AHIMA) is a professional association representing 50,000 educated health information management (HIM) professionals who work throughout the healthcare industry. HIM professionals serve the healthcare industry and the public by managing, analyzing, and utilizing data and records vital for patient care and making it accessible to healthcare providers and appropriate researchers when it is needed most.

Managing the records for health care has been a role for HIM professionals for over seventy-five years, and AHIMA members are now working diligently to ensure that we soon have standard, interoperable electronic health records to improve the quality and safety of patient care. Currently we are working on a variety of projects with the Health Level Seven (HL7), the Office of the Coordinator for Health Information Technology (ONCHIT), and other groups to ensure that in the future electronic health records (EHRs) will provide the same complete and accurate record, only in an environment that will permit better health and safety than in the paper environment.

I: Background

I-D: Quality of Care in IRFs (70FR30191)

We fully support CMS' efforts to promote and improve the continuity and quality of healthcare through the use of interoperable electronic health record (EHR) systems and standardized data. Moving from paper-based records and systems to electronic health records and systems offers significant benefits to the healthcare consumer, provider and payer such as reduction in medical errors, improved use of resources, accelerated diffusion of knowledge, and increased consumer involvement in their care. Post-acute care providers, like the rest of the health care community, face significant challenges in moving towards an EHR. In addition to the daunting challenges posed by technical obstacles, fiscal resources and staff capacity to implement and maintain fully electronic health records are huge hurdles in an industry known for reimbursement and staffing issues. In addition to using electronic information exchange to improve communication between hospitals and IRFs, we believe it is also important to include physician practices in this process. Federal incentives are needed to accelerate the adoption of interoperable electronic health records and achieve the goals of improved quality, safety, and coordination among healthcare providers.

II-B: Proposed Refinements to the Patient Classification System - Proposed Changes to the Existing List of Tier Comorbidities

II-B-1: Proposed Changes to Remove Codes That Are Not Positively Related to Treatment Costs (70FR30194)

Code V46.1 is listed in the proposed list of codes to be removed from the tier list (Table 1 on page 30195). Since this code is a subcategory, is the intent to remove both codes in this subcategory, V46.11 (Dependence on respirator, status) and V46.12 (Encounter for respirator dependence during power failure), or just one of these codes?

Also in the proposed list of codes to be removed from the tier list, the "Condition" column designates code 356.4, idiopathic progressive polyneuropathy, as a type of meningitis and encephalitis. However, code 356.4 does not describe a condition that is related to meningitis or encephalitis. Is the "Condition" column incorrect, or is the wrong code listed in the table?

Why aren't ICD-9-CM codes 250.91 and 250.92 listed in Table 1? It is not clear why all of the 250.9x codes wouldn't be removed from the tier list, rather than just codes 250.90 and 250.93. Code 250.90 represents type II or unspecified type, not stated as uncontrolled, and code 250.93 represents type I, uncontrolled. It would seem as though the counterparts to these codes (type I, not stated as uncontrolled and type II or unspecified type, uncontrolled) should be listed as well.

Also, codes 250.90 and 250.93 are described in this table as "non-renal complications of diabetes." These codes actually describe diabetes with unspecified complications, meaning that it is known the patient has a diabetic complication, but the specific type of complication is unknown. Since the type of complication is not specified, the complication could be renal or non-renal. Codes 250.90-250.93 are very infrequently used, since the medical record documentation doesn't generally indicate that the patient has a diabetic complication without identifying the type. If diabetes is documented and there is no mention of any complication whatsoever, the correct codes would be 250.00-250.03.

We are concerned about the proposed removal of the codes for status amputation (V49.75, V49.76, V49.7) from the tier list. If an amputee fractures a hip, his amputation status significantly complicates his care and thus impacts treatment cost. While some of this complexity may be picked up by other data elements, the patient's amputation status helps to more fully explain the higher cost of care.


We appreciate the opportunity to comment on the proposed modifications to the Medicare IRF PPS program for fiscal year 2006. If AHIMA can provide any further information, or if there are any questions or concerns with regard to this letter and its recommendations, please contact either Sue Bowman, RHIA, CCS, AHIMA's director of coding policy and compliance at (312) 233-1115 or sue.bowman@ahima.org, or myself at (202) 659-9440 or dan.rode@ahima.org.


Dan Rode, MBA, FHFMA
Vice President, Policy and Government Relations

cc: Sue Bowman, RHIA, CCS