ATRA Policy Alert
Phase Two of Three

The Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) comments are due to HCFA no later than January 2, 2001. ATRA's final comments are being reviewed by the ATRA Legislative Counsel and will be released on Wednesday, December 20, 2000. Until then, the following information is provided to the ATRA member and recreational therapy professional for information and preparation of letter writing.

Overview of Proposed Regulations for IRF PPS

l IRF PPS will be implemented as of April 1, 2001 depending upon the facility's cost reporting period. To qualify, facilities must meet current definitions for a rehabilitation hospital or rehabilitation unit.

l IRF PPS restructures the payment system for inpatient rehabilitation facilities. It does not revise the quality of care regulations (i.e. rehabilitation screening criteria and the three hour rule or the definitions of active treatment).

l In an April 5, 2000 written correspondence from the Health Care Financing Administration (HCFA), ATRA received an affirmation of the role of recreational therapy in inpatient rehabilitation facilities
- There is nothing in the regulations that would specifically exclude coverage of recreational therapy.
- There is specific language that allows coverage of other services beyond occupational and physical therapy.
- Utilization and coverage of recreational therapy services is based on individual medical judgment.

l IRF PPS currently establishes the Minimum Data Set Post Acute Care (MDS PAC) as the primary data collection instrument.

- The MDS PAC does include therapeutic recreation as a therapy service under Section K. Procedures/Services, 4. Therapy Services.
- The MDS PAC includes over 400 data elements, however only 134 are needed for the classification into the payment system. The other elements are included to support HCFA's efforts to coordinate all post acute care among Medicare beneficiaries.

l The patient classification system will be based on the Functional Independence Measure-Functional Related Groups (FIM-FRGs) in a newly established Case Mix Groups or CMGs. There are 97 CMGs based on 21 rehabilitation impairment categories (RICs).

l Each CMG has assigned relative weights, established for a variety of factors including rehabilitation impairment categories, functional status, co-morbidities and age and potential facility adjustments.

l The payment unit is "per discharge" based and will correspond to the pre-determined amount per CMG.

l The MDS PAC assessment process is a collaborative one, including the expertise of many professionals for individual items. There are no restrictions on professional designation for the completion of most items of the MDS PAC1.

l The MDS PAC collects information for the future monitoring of care via quality indicators and comparison between inpatient rehabilitation, home health, and skilled nursing settings.

1There is an exception to this for items AA14 and AB1 of the MDS-PAC, which is addressed in the ATRA ACTION response to HCFA.

ATRA Talking Points (in preparation for comments to HCFA)

l The MDS PAC directly excludes the qualified recreational therapist, a certified therapeutic recreation specialist (CTRS), from serving as a "qualified clinician" in the attestation sections AA14 and AB1 of the instrument. ATRA fully supports the inclusion of a qualified recreational therapist as a qualified clinician to complete the attestation sections AA14 and AB1 of the MDS PAC.

l The MDS PAC "Section K. Procedures/Services #4. Therapy Services" includes a variety of definitions for qualified therapists that are contradictory. ATRA recommends these definitions be consistent with accepted standards of practice for each professional discipline.

l The MDS PAC recognition of "therapeutic recreation" is not consistent with the Skilled Nursing Facility PPS definitions or the MDS 2.0 recognition of "recreational therapy". ATRA recommends the revision to "recreational therapy" be made to reflect consistency in current federal regulations, and other voluntary accreditation standards.

l The MDS PAC defines therapeutic recreation or recreational therapy as "therapy ordered by a physician that provides therapeutic stimulation beyond the general activity program in a facility." ATRA believes this language is not reflective of current recreational therapy practice in rehabilitation settings and recommends revision to "Therapy ordered by a physician that restores, remediates, or rehabilitates in order to improve functioning and independence as well as reduce or eliminate the effects of illness or disability…"

l The MDS PAC defines the qualified provider of recreational therapy as "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". Due to recent changes in the national certification program, ATRA recommends this language be revised to "a state licensed or nationally certified Therapeutic Recreation Specialist. A qualified therapeutic recreation assistant may provide therapy but not supervise others (aides or volunteers) giving therapy. The Therapeutic Recreation Assistant must work under the direction of a Therapeutic Recreation Specialist".

l ATRA recommends the total revisions of Section K. Procedures/Services, #4. Therapy Services, read:

f. Recreational therapy - Therapy ordered by a physician that restores, remediates, or rehabilitates in order to improve functioning and independence as well as reduce or eliminate the effects of illness or disability. A state licensed or nationally certified Therapeutic Recreation Specialist must provide such therapy. A qualified therapeutic recreation assistant may provide therapy but not supervise others (aides or volunteers) giving therapy. The Therapeutic Recreation Assistant must work under the direction of a Therapeutic Recreation Specialist".

l The MDS PAC is a lengthy and labor consuming instrument. The inclusion of over 400 data elements versus the 134 elements necessary for patient classification seems administratively unnecessary. ATRA recommends the MDS PAC be revisited, compared with the successful FIM assessment and correlated to include only those items necessary for patient classification.

l The MDS PAC has not been tested for reliability and validity and HCFA has not released results of the research evaluating the MDS PAC classification to the FIM assessment. ATRA supports a payment system that minimizes the administrative burden and improves efficiency in classifying patients for payment determination.

l The MDS PAC is significantly different from the FIM assessment including a reversed rating scale and different definitions to determine the level of a patient's independence. As others suggest, the rating scales and definitions must be brought into consistent measurement with the FIM assessment.

l HCFA solicited comments regarding the mid-stay assessment on day 11. ATRA recommends an assessment at day 11 would be unnecessary in a per episode payment system and only add to the labor-intensive data collection methods.

l HCFA solicited comments regarding the application of the transfer policy to home care or outpatient rehabilitation services. ATRA opposes the extension of the transfer policy to home health and outpatient rehabilitation services as may inflate length of stays and promote inefficient utilization of rehabilitation alternatives.

ATRA will release final positions, a draft letter to HCFA and final legal comments following review by the ATRA Legislative Counsel and legal team review on Wednesday, December 20, 2000. Please be prepared for recreational therapists response to HCFA regarding these proposed regulations.

Phase One - HCFA Response - December 8, 2000

Phase Two - ATRA Policy Alert - December 15, 2000

Phase Three - ATRA Final Positions - December 20, 2000