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CMS Relaxes IRF Coverage Requirements

Payment Matters

CMS's final FY 2021 inpatient rehabilitation facility (IRF) prospective payment system rule went into effect for discharges occurring on or after October 1, 2020. The rule amends certain coverage and documentation requirements, as discussed below.

Post-Admission Physician Evaluation (PAPE)

In an effort to reduce medical record documentation that it believes is no longer necessary, CMS has removed the PAPE coverage requirement. Pursuant to this requirement, a rehabilitation physician had to complete an evaluation within 24 hours following admission, documenting the patient's status on admission. CMS has determined that this is no longer necessary as IRFs are making appropriate admissions using the preadmission screening requirement already in place and the PAPE is duplicative of that screening. The agency removed the PAPE requirement during the COVID-19 Public Health Emergency (PHE) and is now making that coverage change permanent. The requirement is being removed both from the applicable regulatory text at 42 C.F.R. § 412.622(a) and the Medicare Benefit Policy Manual (MBPM) provision at chapter 1, section 110.1.2. CMS notes that removal of this requirement does not remove one of the three required visits by the rehabilitation physician in the first week of the patient's stay in the IRF, as required by section 412.6222(a)(33)(iv).

Preadmission Screening

Both the applicable regulations at 42 C.F.R. § 412.622 and the MBPM, chapter 1, section 110.1.1 require, as a condition of IRF coverage, that all IRF patients receive a preadmission screening by a licensed or certified clinician within 48 hours immediately preceding the IRF admission. However, the regulations lacked certain specificity related to the preadmission screening that appeared in the manual. The newly adopted rules have incorporated the following preadmission screening requirements that formerly appeared only in the manual:

  • The detailed and comprehensive review of each patient's condition and medical history must include "the patient's level of function prior to the event or condition that led to the patient's need for intensive rehabilitation therapy, expected level of improvement, and the expected length of time necessary to achieve that level of improvement; an evaluation of the patient's risk of clinical complications; the conditions that caused the need for rehabilitation; the treatments needed (that is, physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics; and anticipated discharge destination."
  • Review and concurrence by a rehabilitation physician with the preadmission screening must occur prior to admission.

Definition of a "Week"

There are several IRF provisions that have weekly requirements, e.g., three face-to-face visits per week by a rehabilitation physician and three hours of intensive therapy per day at least five days a week or fifteen hours per week. CMS notes that questions have arisen regarding whether "week" means any seven days or a Monday through Sunday period. The new regulations clarify that week means any seven consecutive calendar days beginning with the date of the IRF admission.

Face-to-Face Visits

A longstanding IRF coverage requirement has been that a rehabilitation physician must perform three face-to-face visits per week with each IRF patient. A rehabilitation physician is defined by regulation as a licensed physician with specialized training and experience in inpatient rehabilitation. Over the last several years, CMS has sought feedback on whether certain services that must be completed by rehabilitation physicians, such as the PAPE and the face-to-face visits, could be adequately performed by non-physician practitioners (NPPs).

After consideration, CMS revised only one requirement to allow performance by a NPP instead of a rehabilitation physician: NPPs may perform one of the three weekly required face-to-face visits beginning the second week of an IRF stay. The NPP must be determined by the IRF to have specialized training and experience in inpatient rehabilitation and the face-to-face duties must be consistent with the NPP's scope of practice under applicable state law. CMS is continuing the requirements that a rehabilitation physician review and concur with the preadmission screening for the IRF admission, establish and implement the overall plan of care, and lead the weekly interdisciplinary team conferences.

For further information, please contact any member of the Baker Donelson Reimbursement Team.

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