How would the proposed rule change the Medicare Inpatient Rehabilitation Facility Coverage Requirements?

CMS is proposing to allow non-physician practitioners to perform any of the IRF coverage service and documentation duties that are currently required to be performed by a rehabilitation physician, provided that the duties are within the non-physician practitioner’s scope of practice under applicable state law.

Why is CMS making this proposal at this time?

The precise rationale is unclear, but CMS has referred to potential cost savings to the Medicare program, physician supply issues, reducing burden, and increasing access to care. The CMS decision to release the proposal in the midst of a pandemic is inexplicable.

How does CMS define non-physician practitioners (NPPs)? Does this definition include physical therapists?

CMS did not define non-physician practitioners (NPPs) in this proposed rule. However, when CMS has used the term in the past, it has not included a physical therapist. CMS’ definition has previously included a physician assistant, certified clinical nurse specialist, and a nurse practitioner.

How would the proposed rule change the Medicare Inpatient Rehabilitation Facility Documentation Requirements?

As part of their “Patients Over Paperwork” initiative, CMS is proposing additional revisions to the IRF coverage and documentation requirements to reduce hospital and clinician burden.

Post-Admission Physician Evaluation

CMS is proposing to eliminate the post-admission physician evaluation (PAPE), which is required as a condition to meet the “reasonable and necessary” coverage criteria for IRF care. CMS has already waived the requirement for a PAPE during the COVID-19 public health emergency. Therefore, for all IRF discharges beginning on or after October 1, 2020, CMS is proposing to permanently rescind the requirement to complete a PAPE.

CMS notes that if finalized, this proposal would not preclude the completion of a PAPE if the treating physician determines it is necessary. The proposed rule also would not remove one of the required rehabilitation physician visits in the first week of the patient’s stay in the IRF, which is a requirement under current regulation.

Codification of Preadmission Screening Guidance

Current IRF regulations require a comprehensive preadmission screening to be conducted within 48 hours immediately preceding the IRF admission, which must include a detailed review of the patient’s condition and medical history. The regulations do not specify elements for the preadmission screening, but the Medicare Benefit Policy Manual (MBPM) does. CMS now proposes to codify these elements in the IRF regulations.

Definition of a “Week”

CMS currently uses an intensity of therapy requirement, in part, to determine eligibility for IRF admission. This is defined as at least three hours per day, five days per week, of intensive rehabilitation therapy, or at least 15 hours within a consecutive 7-day period. CMS proposes to amend the regulatory text to replace instances of the term “week” with the term “7 consecutive day period.”

Request for Comment on Preadmission Screening Requirements

CMS includes a specific request for comment from stakeholders about potentially removing some of the preadmission screening documentation requirements. Specifically, CMS requests that stakeholders provide feedback on what aspects of the preadmission screening are most or least critical and useful for supporting the appropriateness of an IRF admission.

What other provisions are included in the proposed rule?

In addition to changes to the coverage and documentation requirements, CMS also proposes updates to the IRF payment rates. Overall, CMS estimates payments to IRFs will increase by 2.9 percent, or approximately $270 million nationwide in FY 2021. CMS is adjusting the FY 2021 IRF standard payment conversion factor for IRFs that fail to meet the quality reporting requirements.

CMS is not proposing any changes to the IRF Quality Reporting Program (QRP) for FY 2021.

View a summary of the IRF PPS FY 2021 Proposed Rule.

When does the IRF Proposed Rule take effect?

This proposed rule would likely be effective October 1, 2020, since the IRF PPS is on a fiscal year basis.

What is the Academy’s position on scope of practice expansion for advance practice provider’s (APPs)?

AAPM&R's position on the role of APPs has not changed and continues to be as follows:

• Physiatry-led, patient-centered, team-based care is the best approach to providing optimized medical rehabilitation care for patients.
• The physiatrist’s specialized, multidisciplinary training makes the PM&R physician the most qualified specialist to lead the team of medical specialists, therapists, and practitioners involved in a patient’s medical rehabilitative care. The most effective way to maximize the complementary skill sets of both physiatrists and APPs is to work in a physician-led, team-based approach.
• The Academy strongly opposes the independent practice of APPs and any other non-physician clinicians in the provision of rehabilitation care. In rehabilitation care, APPs must work closely with a physiatrist who serves in a supervisory role. The Academy is strongly opposed to training or advocating for APPs to practice independently of physiatrists.
• The Academy strongly opposes expanding the role of APPs to replace the role of rehabilitation physicians in inpatient rehabilitation settings and all practice settings due to the disparity in physician training and APP training.

View AAPM&R's position on defining a Rehabilitation Physician and Director of Rehabilitation in Inpatient Rehabilitation Settings.

Does the Academy advocate on behalf of APPs?

As an organization that represents physiatry, the Academy does not advocate on behalf of APPs for any position that would compromise our physiatrist members.