As we reach the end of the year, it’s a good time to highlight some of the common questions that continue to resurface for IRFs. This segment of our ongoing articles will summarize some of the common questions we hear and provide guidance on how IRFs can address them.
1/1/2010 and Beyond
Q: It’s 2014, why is there still so much focus on the 1/1/2010 guidelines?
A: While the regulations have been in effect for some time, the industry continues to struggle with meeting the various time frame and content requirements. This is accentuated for units in hospitals who often have to meet organization-wide policies as well as the specific requirements for IRFs. Additionally, some of the time frames are in calendar days and others are in clock hours. The requirement for hours is difficult to manage when patients are admitted at varying times of day and physicians may round earlier or later in the day.
TIME FRAME REQUIREMENTS
Q: Can you summarize the time frame requirements?
A: The current requirements are:
Preadmission Assessment Screening: Must be completed or updated no more than 48 hours prior to admission and approved by the rehabilitation physician before the patient is admitted to the IRF. (Requirement is in hours.)
Post-Admission Physician Evaluation: Must be completed after admission but within the first 24 hours of the IRF stay. (Requirement is in hours.)
Individualized Plan of Care: Must be completed by day four of the IRF stay. If the patient is admitted on Monday, December 8, the IPOC would be due no later than Thursday, December 11. (Requirement is in calendar days.)
APPROVAL OF THE PREADMISSION ASSESSMENT SCREEN
Q: If the rehab physician documents in the History and Physical or elsewhere in the medical record that he/she reviewed and approved the Preadmission Assessment Screen prior to admission, will this suffice to meet the requirement for approval of the PAS before the patient is admitted to the IRF?
A: No. This is one area where we have received very clear guidance that the approval must occur and also be documented prior to the admission.
“2. Clarification regarding the time frames for the rehabilitation physician to document his or her review and concurrence with the preadmission screening.
A rehabilitation physician must review and concur with the findings and results of the preadmission screening after the screening has been completed and prior to the IRF admission. By concurrence, we mean that the rehabilitation physician must either sign and date the original document or, if reviewing from an off-site location, sign and date a copy of the document and fax it to the IRF. This may be done either on the preadmission screening form itself or on a separate document or electronically, as long as it is done prior to the IRF admission.
We will not accept a physician review and concurrence after the patient is admitted to the IRF (i.e., it is not acceptable for the rehabilitation physician to document his or her review and concurrence on the history and physical or the post-admission physician evaluation or on any other documentation that is generated after the patient is admitted to the IRF). It is also not acceptable for the rehabilitation physician to indicate his or her review and concurrence verbally (like a verbal order) by telephone, or for another clinician (such as an Admission Liaison) to document the rehabilitation physician’s verbal review and concurrence with the preadmission screening. Verbal review and concurrence will not be accepted, even if it is followed by written review and concurrence after the IRF admission.
The rehabilitation physician’s review and concurrence must be documented by himself or herself prior to the IRF admission. Further, since this documents the decision-making of the rehabilitation physician, this review and concurrence may not be delegated to a physician extender. “[i]
TIME AND DATE VALIDATION
Q: The rehab physician dictates the History and Physical, Post-Admission Physician Evaluation, and Individualized Plan of Care but they are not signed until a later time. Will this meet the time and date requirements?
A: We believe (and have seen accepted in formal audits) that the time and date stamp from the dictation is sufficient evidence that the activity occurred within the required time frame.
IMPACT ON POLICY
Q: Is it sufficient to document the therapy plan of care as a “minimum of three hours per day” or “a minimum of 15 hours per week”?
A: No. Medicare has given us very clear guidance as to how the therapy plan(s) of care should be written and has determined that this language is not specific enough to demonstrate individualized care planning. Below are two specific clarifications from Medicare on this issue:
“ 9. Clarification regarding the meaning of the requirement to document the expected amount of therapy time “by discipline” and whether an IRF claim could be subject to denial if the expected amount of therapy time by discipline varies from one day to the next.
The expected amount of therapy time by discipline required during the IRF stay must be documented on the individualized overall plan of care. This means that the rehabilitation physician must document the amount of expected physical therapy, occupational therapy, speech-language pathology, and orthotics/prosthetics the patient is expected to need on a daily basis in the IRF. Day-by-day variation in the expected amount of therapy by discipline is acceptable as long as it reflects the unique care needs of the patient.
It is not acceptable to simply use a generalized phrase such as, “At least three hours per day, at least five days per week” on the individualized overall plan of care. This is not individualized to the unique care needs of the patient and does not indicate the expected amount of therapy by discipline. To meet the requirement, the overall plan of care must indicate the type and expected amount of physical therapy, occupational therapy, speech-language pathology, and orthotics/prosthetics needed by the patient on a daily basis. This must be unique to the individual care needs of the patient.
10. Clarification regarding the difference between the estimated length of stay and the duration of therapy treatments.
The duration of therapy treatments must be indicated by discipline, whereas the estimated length of stay is an overall number of days. For example, while the estimated length of stay for a hypothetical patient could be 21 days, the patient could require speech-language pathology treatments for days one through 10, and require orthotics/prosthetics on days 10 through 21 of the stay.”[ii]
MODES OF THERAPY MINUTES IN 2015
Q: Will the definitions for the modes of therapy for IRF be the same as those for SNF when therapy begins reporting minutes on October 1, 2015?
A: No, there are some differences in the two sets of definitions.
The finalized definitions for IRF are:
- Individual therapy is the provision of therapy services by one licensed or certified therapist (or licensed therapy assistant, under the appropriate direction of a licensed or certified therapist) to one patient at a time (this is sometimes referred to as ‘‘one-on-one’’ therapy).
- Co-treatment is the provision of therapy services by more than one licensed or certified therapist (or licensed therapy assistant, under the appropriate direction of a licensed therapist) from different therapy disciplines to one patient at the same time.
- Concurrent therapy is one licensed or certified therapist treating two patients at the same time, with each patient performing different activities.
- Group therapy is the provision of therapy services by one licensed or certified therapist (or licensed therapy assistant, under the appropriate direction of a licensed or certified therapist) treating two to six patients at the same time, with each performing the same or similar activities.
ATTENDANCE AT THE TEAM MEETING
Q: A therapist assistant provides the patient’s routine care. Can the assistant represent the appropriate therapy discipline at the team meeting?
A: While the therapist assistant can attend the meeting and participate in the discussion about the patient’s progress, this does NOT meet the requirement for attendance at the ITM. A therapist of the same discipline who is familiar with the patient must attend.
About the Author
Angela M. Phillips, PT, is president and chief executive officer of Images & Associates. A graduate of the University of Pennsylvania School of Allied Health Professions, she has more than 35 years of experience as a consultant, healthcare executive, hospital administrator, educator, and clinician. Ms. Phillips is one of the nation’s leading consultants assisting Inpatient Rehabilitation Facilities in operating effectively under the Medicare Prospective Payment System (PPS) and in addressing key issues related to compliance.
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[i] From: Follow-up to the November 12 provider training call, version 1. Posted on the CMS website at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Downloads/IRF-Training-call_version_1.pdf
[ii] From: Follow-up to the November 12 provider training call, version 1. Posted on the CMS website at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Downloads/IRF-Training-call_version_1.pdf