In our continuing series on the technical requirements of the Jan. 1, 2010, updates to the regulations for Inpatient Rehabilitation Facilities (IRFs), this article will address the requirements for the Rehabilitation Physician. Most of these issues require that certain items are completed and documented within very specific time frames.
The rehabilitation physician has requirements in each of the following areas:
- Preadmission Assessment Screening
- Post-Admission Physician Evaluation
- Individualized Plan of Care
- Interdisciplinary Team Meetings
- Supervision of the Rehabilitation Program
Preadmission Assessment Screening
While other clinical staff may complete the Preadmission Screening Assessment (PAS), the rehabilitation physician must document that he or she has reviewed and concurs with the findings of the assessment prior to the admission to the IRF. Medicare has given several clarifications related to the approval of the PAS:
- In all cases, the concurrence must be documented BEFORE the patient is admitted to the IRF.
- Verbal review and concurrence is not acceptable even if it is followed by a written review and concurrence after the IRF admission.
- The review and concurrence must be documented by the rehabilitation physician personally and may not be delegated to a physician extender.
- A consult note completed by the rehabilitation physician can serve as the preadmission screening as long as it contains all of the required information and is written or updated within the 48 hours immediately preceding the IRF admission.
- Medicare considers “concurrence” to mean that the rehabilitation physician signs and dates the preadmission screening form or a separate document that demonstrates the review and concurrence.
Post-Admission Physician Evaluation
The Post-Admission Physician Evaluation (PAPE) must be completed with the first 24 hours of admission to the IRF. The PAPE may be combined with the history and physical exam documentation or may be a separate document and must include justification for the IRF admission. If the patient’s status has not changed, it is sufficient to write a brief note that references the preadmission screening and confirms there are no significant changes in the patient status. The PAPE must include the following elements:
- History and Physical Exam;
- A review of the patient’s prior and current medical and function conditions and comorbidities;
- A comparison of the patient’s status to what was indicated on PAS and, if there are any significant changes, an assessment of whether the patient still requires IRF services.
Medicare has clarified that if a physician extender has completed the history and physical, the rehabilitation physician is not required to repeat the history and physical but must visit the patient and complete the other required components of the PAPE within the first 24 hours after admission.
Individualized Plan of Care
The Individualized Plan of Care (IPOC) appears to be one of the most difficult areas of documentation for the rehabilitation physician. The IPOC should detail the patient’s medical prognosis as well as the interventions, functional outcomes, and discharge plans for the patient. Medicare has indicated that it is the rehabilitation physician’s responsibility to synthesize the information from individual assessments of the clinical team and to incorporate this information into a documented plan of care that is completed no later than the end of the fourth day of the IRF stay. The IPOC must include these key elements:
- Medical Prognosis;
- Anticipated interventions;
- Functional outcomes; and
- Discharge destination.
The most problematic area of the IPOC is the detailed information required related to therapy interventions. For therapy services, the plan must include the intensity of service, frequency, and duration of services. These areas must be described specifically and not include ranges or general statements. There have been a number of clarifications from Medicare related to these areas.
The intensity of therapy service is the expected amount of time by discipline that the patient will require during the IRF stay. It is not acceptable to use generic phrases like “a minimum of three hours per day, at least five times per week.” Instead, the plan should include the minutes per day of treatment. Frequency is the number of days per week and will generally be documented as five out of seven days or five days per week. In cases, where the patient has specific needs for a modified treatment program, the plan may specify that the patient will receive 15 hours or 900 minutes per week. And the duration of therapy services will differ from the expected length of stay in the IRF. For example, a patient may have an overall expected length of stay of 21 days but the therapy plan of care might include only 15 of those 21 days.
An example of more specific plan of care language that is more individualized to the patient follows: “Physical Therapy for 90 minutes per day, five out of seven days, with additional PT treatment or adjustments to treatment time as needed to achieve patient goals for a total of 15 days of treatment. Occupational Therapy for 60 minutes per day, five out of seven days, with additional treatment or adjustments to treatment time as needed to achieve patient goals for 10 days of treatment then increasing to 90 minutes per day for the final five treatment days. Speech and Language Pathology for 30 minutes per day, five out of seven days for a total of 10 days of treatment.”
Interdisciplinary Team Meetings
The rehabilitation physician is expected to lead the interdisciplinary team meeting although another individual may act as the scribe for that meeting. When the rehabilitation physician attends by phone, which is permissible, the reason the physician was not able to be physically present at the meeting should be documented along with the other detail of the discussion that occurs at the meeting.
Supervision of the Rehabilitation Program
Medicare requires close physician supervision of the patient’s care as evidenced by documented face-to-face visits from the rehabilitation physician at least three days per week throughout the patient’s stay. The goal of these visits is to assess the patient’s progress in the intensive rehabilitation program and documentation in the notes should include an assessment of the patient’s progress in that program including some statements related to functional status and progress. Medicare has clarified that these visits cannot be delegated to anyone other than another rehabilitation physician and that the PAPE cannot serve to meet the requirement for one of these visits. Additionally, there must be separate documentation of the face-to-face visits and the team meetings. If the physician completes a face-to-face visit on the same day as the team meeting, this visit should be documented in a separate entry in the medical record and should include the key components of a visit note with focus on progress in function.
Common Issues and Our Recommendations
In our experience, we have found some common trends:
- Attempts to combine the H&P, PAPE, and IPOC consistently fail to meet the requirements for the IPOC.
- We suggest combining the H&P and PAPE as the timing and content of these two documents work well together.
- We recommend development of the IPOC after the initial therapy assessments (but by day four, as required) in order to incorporate the findings of the therapy evaluations into the IPOC.
- The PAPE often lacks a comparison of the patient status at the time of the PAS with the patient status at the time of the PAPE. Discrepancies often occur in functional areas and particularly in bowel and bladder between the PAS and what we see documented in nursing notes at the time of admission.
- We recommend using a template that flags the rehabilitation physician to compare patient status; or, to make a statement that there are no significant changes.
- Barriers to goal achievement are often identified at team meetings without any documentation of the discussion of the team and changes in the plan of care to address.
- When there are barriers, appoint a key stakeholder at the conference to assure that the plan is revised or continued with documentation of how the team will address the barrier.
- While rehabilitation physicians appear to be consistently seeing patients face-to-face the required three times per week, we often find that the documentation does not include an assessment of the patient’s overall progress in the rehabilitation program.
- Avoid statements like: “Doing well in therapy.” Use “Reviewed therapy notes” and include specific statements about functional progress and care needs.
About the Author
Angela M. Phillips, PT, is President & 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 for therapy services across all venues.
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