Providers are hopeful that some of the COVID-19 blanket waivers that reduce their burden or expand telehealth services will become permanent, and one wish has tentatively been granted: the 2021 proposed inpatient rehabilitation facility (IRF) prospective payment system regulation would end the requirement for post-admission physician evaluations.
“We do believe that removing the post-admission physician evaluation would reduce administrative and paperwork burden for both IRF providers and” Medicare administrative contractors, CMS said in the regulation, which was published in the Federal Register on April 21. If this provision of the regulation is finalized before the public health emergency ends, rehabilitation physicians may never resume post-admission evaluations. Post-admission evaluations were waived in the April 6 interim final rule, Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency.
The permanent end to post-admission evaluations is one of several changes in the IRF proposed regulation that would help IRFs avoid Medicare denials of the entire stay because of noncompliance with one of the coverage and documentation requirements. For example, a licensed clinician must complete a preadmission screening of patients within 48 hours of admission, and a rehabilitation physician must confirm the admission is appropriate by performing a post-admission evaluation within 24 hours of the patient’s IRF admission.
“The current requirements on IRFs are extremely time and people specific, which leaves room for many potential errors,” said attorney Danielle Gordet, with Akerman LLP in Miami, Florida.
It makes perfect sense to relieve IRFs of the post-admission history and physical because the patient was evaluated fewer than 48 hours before admission, “and it would be unlikely the patient’s condition would change that drastically in such a short period of time,” said Ronald Hirsch, M.D., vice president of R1 RCM. “It also addresses the reality that CMS realizes there should not be denials because of minor infractions of rules where there would be no clinical consequences.” There also are hints of relief to come with the preadmission screening, Gordet said. CMS asked stakeholders for feedback on the aspects of preadmission screening they think “are most or least critical and useful for supporting the appropriateness of an IRF admission.”
Meanwhile, CMS proposed to codify that “the rehab physician should review and concur with the preadmission screening before the patient is admitted,” Gordet said. “This requirement is already detailed in the Medicare Benefit Policy Manual, but CMS hopes this revision to the regulation will add clarity by having all preadmission documentation requirements in one place."
That also may change. The proposed regulation would allow advanced practice providers (APPs), who the regulation calls nonphysician practitioners, to perform the same services as rehabilitation physicians—within their scope of practice under state law and with specialized training and experience in inpatient rehabilitation, she said. “They are proposing to allow APPs to complete the IRF coverage requirements for the three face-to-face visits a week, preadmission screenings, overall plan of care and team meetings,” Gordet said. For now, APPs may complete the preadmission screening, as long as a rehab physician reviews it and documents concurrence with the findings and results, she said. But the proposal would allow an IRF to put the entire process in an APP’s hands.