CMS Announces Fiscal 2010 Payment and Policy Updates for Inpatient Rehabilitation Facilities

The Centers for Medicare & Medicaid Services (CMS) issued a final rule that updates Inpatient Rehabilitation Facility (IRF) payment rates for fiscal 2010 and adopts a new regulatory framework that clarifies the coverage criteria, including provisions regarding patient selection and care, for IRFs that will be effective on Jan. 1, 2010. The final rule applies to more than 200 freestanding IRFs and just under 1,000 IRF units in acute care hospitals and except as otherwise specified, is effective for discharges occurring on or after Oct. 1, 2009.

The coverage criteria provisions are intended to ensure that Medicare beneficiaries who need the intensive rehabilitation services provided in IRFs continue to have access to high quality care. The Jan. 1, 2010 effective date for these provisions will allow facilities time to change their operations as needed to comply with the final regulation. The new regulatory scheme will replace the prior policies, including those contained in HCFAR 85-2-1, a 1985 ruling that was issued by CMS, then called Health Care Financing Administration. CMS plans to issue a notice in the Federal Register that will rescind HCFAR 85-2-1, effective Jan. 1, 2010. CMS also plans to draft new guidance regarding the new coverage criteria that it will place in the Medicare Benefit Policy Manual (MBPM). As amended, the MBPM will provide detailed policy guidance regarding CMS’s interpretations of the coverage criteria regulations adopted under this rule.

“The final rule we are issuing … incorporates industry best practices into CMS coverage requirements, while promoting more consistent review of the medical necessity of IRF stays for individual patients in light of their clinical needs,” Jonathan Blum, director of the CMS Center for Medicare Management said in a news release. “The policies were developed by CMS working closely with medical directors from several fiscal intermediaries and have been refined in the final rule to respond to public comments on the proposals.”

The coverage criteria provisions in the final rule establish requirements for pre-admission screening of potential IRF patients through which a facility can document a patient eligible for intensive rehabilitation services in an IRF setting, post-admission treatment planning requirements and ongoing coordination of care requirements. To eliminate confusion about the effect of the coverage criteria on IRF facility requirements, criteria facilities must meet to be paid under the IRF Prospective Payment System (IRF PPS), rather than the Inpatient Prospective Payment System (IPPS). The final rule moves the coverage criteria to a newly created section of the regulations. The coverage criteria apply to all Medicare patients in the facility without regard to whether they have one of the IRF qualifying conditions as an admitting or secondary diagnosis.

The specific coverage requirements that are adopted in the final rule included admission criteria that the patient is able and willing to actively participate in an intensive rehabilitation program and is expected to make measurable improvement in his or her functional capacity or adaptation to impairments.

The specific coverage also required that IRF services be ordered by a rehabilitation physician with specialized training and experience in rehabilitation services and be coordinated by an interdisciplinary team, including at least a registered nurse with specialized training or experience in rehabilitation; a social worker or case manager or both and a licensed or certified therapist from each therapy discipline involved in treating the patient. The rehabilitation physician would be responsible for making the final decisions regarding the patient’s treatment in the IRF.

Requirements included a post-admission evaluation to document the status of the patient after admission to the IRF and require comparison of this post-admission screen and the preadmission screening documentation. Using this information, facilities can begin developing an overall plan of care that is designed to meet the individual patient’s needs. The rule requires the maintenance of the overall plan of care in the patient’s medical record. However, in response to comments, the final rule extends the deadline for completing the overall plan of care to the end of the fourth day following the patient’s admission, rather than the proposed rule’s deadline of 72 hours. Also in response to comments, the final rule does not require the rehabilitation physician to consult with the interdisciplinary team members when developing the post-admission evaluation, although the rule encourages the rehabilitation physician to consider any available input from the interdisciplinary team members.

Requirements also included that IRFs use qualified personnel to provide required rehabilitation nursing, physical therapy, occupational therapy, speech-language pathology, social services, psychological services and prosthetic and orthotic services.

Also, it is required that the interdisciplinary team to meet weekly to review the patient’s progress and make any needed modifications to the individualized overall plan of care.

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