Danielle C. Gordet, JD, MPH, CHC, (dgordet@gmail.com) is a Director of Compliance in the Office of Compliance & Ethics, at Jackson Health System, in Miami, FL.
An inpatient rehabilitation facility (IRF) must meet specific coverage criteria for care to be considered reasonable and necessary.[1] Failure to meet the IRF coverage criteria may result in denial of a claim. Because the IRF coverage criteria had not been updated since January 1, 2010, the Centers for Medicare & Medicaid Services (CMS) realized that changes were needed to maximize the quality of care provided to IRF patients.[2] Therefore, beginning fiscal year 2019 (for all IRF discharges on or after October 1, 2018), CMS implemented revisions to the IRF coverage criteria in an effort to “allow providers and physicians to focus the majority of their time treating patients rather than completing paperwork.”[3]
These revisions were published on August 6, 2018, as part of CMS’s IRF Prospective Payment System final rule (IRF final rule). The changes were aimed at alleviating the administrative burden placed on IRFs.[4] This article will outline the revisions to the IRF final rule regarding coverage requirements and will provide recommendations to help you ensure compliance at your IRF.
Physician supervision
IRF coverage criteria require that at the time of the patient’s admission to the IRF, there must be a reasonable expectation that the patient “requires physician supervision by a rehabilitation physician.” To satisfy this requirement, the rehabilitation physician must conduct at least three face-to-face visits with the patient per week throughout the patient’s stay in the IRF.[5] These face-to-face visits must be documented in the patient’s medical record.[6] , [7]
The purpose of the physician supervision requirement is “to ensure that the patient’s medical and functional statuses are being continuously monitored as the patient’s overall plan of care is being carried out.”[8] CMS believes that the physician supervision requirement’s purpose is different from that of the post-admission physician evaluation (PAPE), which must be completed by a rehabilitation physician within 24 hours of the patient’s admission to the IRF and be retained in the patient’s medical record.[9] The purpose of the PAPE “is to document (in the IRF medical record) the patient’s status on admission, identify any relevant changes that may have occurred since the preadmission screening, and provide the rehabilitation physician with the necessary information to begin development of the patient’s overall plan of care.”[10]
CMS has reiterated its belief that the physician supervision requirement and the PAPE are two different types of assessments; however, in the IRF final rule, CMS modified the physician supervision requirement to allow the PAPE to count as one of the face-to-face physician visits.[11] This revision will allow the rehabilitation physician “the flexibility to assess the patient and conduct the post-admission physician evaluation during one of the three face-to-face physician visits required in the first week of the IRF admission.”[12] It should be noted that this revision is not meant to limit rehabilitation physicians from seeing patients more than three times in the first week of the patient’s IRF stay.[13]
CMS expects “that each rehabilitation physician will exercise his or her best clinical judgement to determine the need and frequency of rehabilitation physician visits for a given patient.” Interestingly, CMS estimates that only about half of IRFs will actually adopt this new policy, because many rehabilitation physicians visit patients more than the minimum three times per week.[14]
Recommendation: Provide education to the providers at your facility to ensure that they understand the requirements for PAPEs and physician supervision, including the importance of adequate documentation in the medical record. Physicians must remember that the PAPE requirement remains unchanged; however, by adequately completing and documenting the PAPE, a physician is only required to have two additional face-to-face visits with the patient in the first week of the patient’s admission to the IRF.[15]
