Changes in Centers for Medicare and Medicaid Services (CMS) Documentation Requirements

Lisa Werner, MBA, MS, SLP Director of Consulting Services, Fleming-AOD, Inc.

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).

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

• Identify any relevant changes that may have occurred since the pre-admission screening • Provide guidance as to whether it is safe to initiate the patient’s therapy program • Support the medical necessity of the IRF admission • Include a documented history and physical (H&P) exam, and a review of the patient’s prior and current medical and functional conditions and comorbidities Each provider has a hospital policy or bylaws that require an H&P. The policy likely states the amount of time the clinician has to complete and sign the H&P, and what it should include. Changes in the CMS requirements do not impact those policies. Make sure that your physicians understand the need to comply with hospital policy regardless of recent changes to CMS requirements. The information typically included by the physician in the H&P is instrumental in providing direction to clinicians on how best to care for patients.

The H&P contains the substance of the functional and medical plan of care. It may appear that the relaxed PAPE requirements do not address changes in the patient’s status between preadmission screening and admission, or provide guidance on whether it is safe to initiate the therapy program. However, these elements are implicit in the physician’s H&P. Therefore, the only thing removed (without compromising the quality of care or patient safety) is a timeframe that a CMS auditor could use against you in a chart review.

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AMRPA: Working Together To Preserve Access To Medical Rehabilitation AMRPA: Working Together to Preserve Access to Medical Rehabilitation Maggie Ramirez · VP of Membership Services · 347-573-3732 · mramirez@amrpa.org Elizabeth Katsion, AMRPA Member Services Coordinator, ekatsion@amrpa.org, 202-207-1102.