While we’ve addressed this titular issue in prior articles, it is one of the most common issues about which we receive questions from the field in our consulting practice.
Chapter 1, Section 110.2.4 of the Medicare Benefit Policy Manual outlines Medicare’s requirements for physician supervision of the patient in the inpatient rehabilitation facility (IRF). The regulations note that “close physician involvement in the patient’s care is demonstrated by documented face-to-face visits from a rehabilitation physician or other licensed treating physician with specialized training and experience in rehabilitation at least three days per week throughout the patient’s IRF stay.” These visits are meant to assess the patient from both a medical and functional perspective, and to adjust treatment based on that assessment. These visits must be clearly documented in the medical record by the rehabilitation physician.
The regulation appears clear enough, so why the mystery? The confusion appears to relate to what constitutes an actual face-to-face visit and what does not.
What Doesn’t Count?
Medicare has provided specific clarifications indicating that neither the post-admission physician evaluation (PAPE) nor the interdisciplinary team meeting note serve to meet the face-to-face visit requirement.
While there has been no specific language that includes the history and physical (H&P) in that guidance, we believe that the H&P is considered part of the content requirements of the PAPE and thus does not meet the broader face-to-face requirement. In a detailed clarification related to the PAPE, Medicare has indicated that “the post-admission physician evaluation documents the patient’s status on admission and provides the rehabilitation physician with the necessary information to begin development of the patient’s overall plan of care.”
“The ongoing rehabilitation physician visits ensure that the patient’s medical status and functional status are being continuously monitored as the patient’s overall plan of care is being carried out, so that the patient can ultimately achieve his or her highest functional recovery. One of the requirements of the minimum three rehabilitation physician visits per week is to assess the patient’s functional goals and progress in light of the patient’s medical conditions,” the Medicare guidance continues. “We do not believe that a rehabilitation physician can do a meaningful assessment of the patient’s progress in light of the intensive rehabilitation therapy program before the patient has received at least one full day’s worth of intensive rehabilitation therapy.”
When asked for clarification of whether the rehabilitation physician’s interdisciplinary team conference note could serve as one of the minimum required three rehabilitation physician face-to-face visits per week, CMS responded: “No. The new IRF coverage requirements specify that there must be documentation of weekly interdisciplinary team meetings throughout the patient’s stay in the IRF and separate documentation of at least three face-to-face rehabilitation physician visits per week for the purpose of assessing the patient, both medically and functionally. These requirements cannot be combined.”
While some physicians indicate a separate face-to-face visit in the same note that records information from the team conference, we recommend that our clients avoid this practice and instead require the rehabilitation physician to document the team meeting information in a separate note from the face-to-face visit note. Because the two events occur at different times of the day, the notes would then clearly demonstrate separate date/time stamps and support the face-to-face encounter as a separate event.
The individualized plan of care (IPOC) itself does not require a patient visit, and we believe it should not be considered a face-to-face visit. The Medicare Benefit Policy Manual notes that “information from the preadmission screening and the post-admission physician evaluation, together with other information garnered from the assessments of all therapy disciplines involved in treating the patient and other pertinent clinicians, will be synthesized by a rehabilitation physician to support a documented overall plan of care, including an estimated length of stay. The overall plan of care must detail the patient’s medical prognosis and the anticipated interventions, functional outcomes, and discharge destination from the IRF stay, thereby supporting the medical necessity of the admission. “
The plan itself is frequently documented in a separate template within the medical record, and it pulls together information from preadmission and early IRF assessments. This information must be completed by day four of the IRF admission. At times, this template is combined with or located within other documents – the history and physical, the team conference note, and in some organizations, within a daily visit note, for example.
While is highly likely that a face-to-face visit will be completed on the same day that the IPOC is recorded, there has been no specific Medicare clarification related to the IPOC and the face-to-face requirements. For this reason, we advise IRFs to create a separate note detailing the elements of the face-to-face visit.
Face-to-Face Note Content
The Medicare Benefits Manual describes the purpose of the face-to-face visits as “to assess the patient both medically and functionally (with an emphasis on the important interactions between the patient’s medical and functional goals and progress), as well as to modify the course of treatment as needed to maximize the patient’s capacity to benefit from the rehabilitation process.” As with any physician evaluation and management service, we would expect to see some level of examination, assessment, coordination, and treatment planning, and when completing our own audits of documentation, we’d look for the following components:
- An examination of the patient’s status, including what is going on medically and functionally. Did the rehabilitation physician report status of medical issues, a physical exam, and a statement related to current function?
- Assessment of the interplay between patient functional progress and the patient’s medical status and issues. For example, if a patient is making poor functional progress related to medical issues and management, did the physician address those issues?
- When other physicians are also involved in the care of the patient, does the rehabilitation physician note test results, consultant recommendations, and the impact on rehabilitation?
- When appropriate, is the plan modified consistent with the assessment findings?
Midlevel Practitioners and the Face-to-Face Note
When clarification was requested in this area, Medicare responded: “We have been asked whether a physician extender could conduct these visits, and the answer is no. They must be conducted by a licensed physician. Physician extenders generally work under the direction of a physician and can perform certain tasks as delegated by a physician, but the level of assessment we are expecting from the three physician visits outlined in this requirement is specifically to ensure that IRF patients receive more comprehensive assessments of their functional goals and progress in light of their medical conditions by a rehabilitation physician with the necessary training and experience to make these assessments.”
While we believe that rehabilitation physicians may utilize mid-level practitioners within the IRF, it is clear that the services provided by the mid-level would not count as meeting the face-to-face requirement.
Our advice: to consider the visit as a physician face-to-face encounter, the note must clearly demonstrate that the physician performed sufficient services to meet the requirements for a split visit under physician billing, and that the portion of the evaluation and maintenance service performed and documented by the physician must be substantive, which includes part or all the history, exam, or medical decision-making.