Changes in Centers for Medicare and Medicaid Services (CMS) Documentation Requirements
When the FY21 Inpatient Rehabilitation Facility (IRF) Prospective Payment System Final Rule went into effect on October 1, 2020, it included changes to some documentation elements that were once required for Medicare patients. These changes impact the pre-admission screening and the post-admission physician evaluation (PAPE).
Lisa Werner, MBA, MS, SLP Director of Consulting Services, Fleming-AOD, Inc.
The pre-admission screening, completed by a licensed clinician approved by the facility’s medical director, includes an array of required items. A standard document is not required, so providers may use their own form or one that is available through an electronic medical record vendor or eRehabData®. There are specific items to document to ensure that medical necessity is established, thus indicating the patient’s stay was reasonable and necessary. These elements include: • Patient’s prior level of function (prior to the event or condition that led to the patient’s need for intensive rehabilitation therapy) • Expected level of improvement • Expected length of time required to reach that level of improvement • Evaluation of the patient’s risk for clinical complications • Conditions that caused the need for rehabilitation • Combination of treatments needed (one of which must be physical or occupational therapy) • Anticipated discharge destination The items eliminated from the list of requirements include expected frequency and duration of therapy services, anticipated post-discharge needs, and other information relevant to the care needs of the patient. CMS no longer requires the rehabilitation physician to complete the Post-Admission Physician Evaluation (PAPE). The PAPE was required within 24 hours of the patient’s arrival to the inpatient rehabilitation unit or hospital. The PAPE document required that the provider: • Document the patient’s status on admission to the IRF • Compare it to that noted in the pre-admission screening documentation • Begin development of the patient’s expected course of treatment that will be completed with input from all interdisciplinary team members in the overall plan of care
AMRPA Magazine / December 2020 13
