As we review inpatient rehabilitation facility (IRF) medical records for compliance with Centers for Medicare & Medicaid Services (CMS) requirements, we continue to see issues related to physician supervision and documentation by the rehabilitation physician to demonstrate that the care provided in the IRF is “reasonable and necessary.”

What do the regulations say?

Chapter 1, Section 110.2.4 of the Medicare Benefit Policy Manual outlines Medicare’s requirements for physician supervision of the patient in the IRF.  The regulations indicate 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. The visits must be clearly documented in the medical record and do not include the history and physical/post-admission physician evaluation, the individualized plan of care, or the interdisciplinary team meeting. 

What does that mean to the rehabilitation physician?

From a clinical perspective, the greatest risk occurs during the first seven days after admission. In addition to seeing the patient for the post-admission physician evaluation, the rehabilitation physician must still document three face-to-face visits – and the documentation in the record must show a high level of scrutiny in clinical decision-making related to the progression of the rehabilitation program, including any impact of medical issues on functional progress.

On the day of the team meeting, the physician must also see the patient face to face if he or she wants to include that visit as part of the three weekly visits.

It is not enough, however, for the rehabilitation physician to simply document a visit. The documentation in the record must demonstrate that the meeting’s purpose reflected the intent of the regulation. That means that medical and functional status were reviewed, that the care was modified appropriately to maximize the patient’s benefit from the rehabilitation stay, and that any barriers to patient progress have been addressed.

Clarifications of the Requirement

Use of mid-level practitioners

While mid-level practitioners (physician assistants, nurse practitioners, clinical nurse specialists) may participate in the care of the patient, including key components of the history and physical, “the rehabilitation physician is responsible for conducting the minimum of three face-to-face physician visits per week for the purposes of assessing the patient both medically and functionally,” the regulation reads. “This responsibility cannot be delegated to anyone other than another rehabilitation physician.”

Team conference note and the face-to-face visit

While we often seen team conference notes noting that the rehabilitation physician has also seen the patient face to face, we recommend that two separatenotes be written. This is because CMS has clarified that “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.”

Tips for Compliance

Document both functional and medical issues, anddemonstrate clinical decision-making.

Be sure that the rehabilitation physician documents functional progress in at least several areas, at least three times a week, as well as how the patient’s medical status impacts the patient’s overall progress.

Example: “Therapy notes indicate that patient is now ambulating 110 feet with front-wheeled walker but continues to have shortness of breath and a drop in O2 sats with this level of activity. Will continue measuring O2 sats during activity and modify therapy schedule to more frequent but shorter sessions each day. Per pulmonology, patient will require ongoing use of oxygen post-discharge.”  

This note demonstrates that the rehabilitation physician is managing the rehabilitation program, modifying it as appropriate to the patient’s pulmonary status, and coordinating information and services from the consultant pulmonologist.

Avoid vague terms.

Avoid statements that are vague and do not demonstrate that you have assessed the patient and all clinical information. Common phrases seen in medical records include “continue present management,” “continue therapy,” “reviewed therapy notes,” etc. These phrases typically do not provide any specific information about the patient. Rather than indicate that the “patient is doing well in therapy,” provide a statement of the current status in therapy and any additional needs.  

Example: “Ambulating 90 feet with walker and minimal assist but continues to have loss of balance during gait and ADLs that impacts overall patient safety.” Or this: “Patient having difficulty with three hours of therapy per day due to dialysis status; will modify IPOC to 15 hours per week, as patient has potential to reach rehabilitation goals with modified program.” Both of these examples show that the rehabilitation physician is applying clinical decision-making and assessment to the individual patient situation.

Use your electronic medical record (EMR) to help!

Create templates that include the key functional and medical decision-making components. If you use problem-based charting, include problems related to ADL and mobility as part of the standard template so that these items are cued each time a note is opened.

Watch out for “cut and paste” and “copy forward”

While the EMR can be a tremendous asset in ensuring that key elements are documented, it creates its own perils and pitfalls. One of those is the tendency to copy a prior note or to auto-populate certain fields. Be careful about how this is used in your IRF. If the exact same information shows up day after day in notes without any changes, you should review your process.

About the Author

Angela M. Phillips, PT, is president and chief executive officer of Images & Associates. A graduate of the University of Pennsylvania’s School of Allied Health Professions, she has over 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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