On August 4, 2020, the Centers for Medicare and Medicaid Services (CMS) released the final rule for inpatient rehabilitation facilities (IRFs) for fiscal year (FY) 2021. The rule finalizes provisions related to payment, documentation requirements, and use of non-physician practitioners.
Provisions of this final rule are effective October 1, 2020.
Inpatient Rehabilitation Facilities Will Get a $260M Increase in Payments
CMS updates IRF payments overall by 2.8 percent, or an $260 million increase, in FY 2021. A 2-percentage point reduction will be applied to payments for IRFs that fail to meet data submission requirements.
CMS will continue to update the relative weights and average lengths of stays for various conditions within the case-mix group (CMG) system based on the latest data available. For FY 2021, the latest available data is FY 2019 IRF claims and FY 2018 IRF cost report data. The update to CMG relative weights is budget neutral and 99 percent of IRF cases are in CMGs that will experience a less than 5 percent change. The methodology for calculating IRF outlier threshold amounts will also remain the same in FY 2021. These updates are effective for discharges on and after October 1, 2020 to September 30, 2021.
CMS is not making any changes to the IRF Quality Reporting Program for FY 2021.
CMS Adopts Revised Geographic Delineations
Similar to proposals for the other post-acute care settings for FY 2021, CMS adopts updated delineations for Metropolitan Statistical Areas (MSAs), Micropolitan Statistical Areas, and Combined Statistical Areas for FY 2021. These delineations are determined by the Office of Management and Budget (OMB).
To prevent any major disruptions, CMS finalizes its transitional policy of 5-percent cap on any decreases in an IRF’s wage index for FY 2021 to allow the effects of the revised delineations to be phased in over two years. The 5 percent cap in reductions will only be applied for the first year (FY 2021) and no cap will be applied to any reductions in the wage index for the second year (FY 2022). CMS states that approximately 5 percent of IRFs will experience decreases in their area wage index values in the adoption of revised OMB delineations.
Non-Physician Practitioners Are Permitted to Perform Certain IRF Coverage Requirements
CMS finalizes part of its proposal which will allow a non-physician practitioner (NPP) to conduct face-to-face visits with patients if the IRF has determined the NPP has adequate specialized training and experience.
Previously, CMS proposed that NPPs who are determined by an IRF to have specialized training and experience in inpatient rehabilitation may perform any of the duties that are required to be performed by a rehabilitation physician. However, the final rule amends the IRF coverage requirements to allow NPPs to perform one of the three required visits in lieu of the physician in the second and later weeks of a patient’s care. Any duties taken on by an NPP must be within the practitioner’s scope of practice under applicable state law.
A physician must still review and concur with a patient’s preadmission screening, establish the overall plan of care and lead weekly interdisciplinary team meetings.
Post-Admission Physician Evaluation Documentation Requirement Is Eliminated
CMS permanently eliminates the post-admission physician evaluation documentation requirement for IRFs beginning in FY 2021. Currently, IRFs are required to conduct post-admission physician evaluation within 24 hours of admission to the IRF to confirm the IRF admission is still appropriate. CMS had temporarily waived this requirement for the duration of the COVID-19 public health emergency.
The elimination of the documentation requirement is an effort to reduce burden for rehab physicians. This change does not remove the separate requirement of a rehabilitation physician visit during the first week of a patient’s stay in the IRF.
CMS Removes Several Elements From Pre-admission Screening Documentation Requirement
CMS also finalizes its proposal to codify certain elements of the existing documentation instructions and guidance related to pre-admission screening for FY 2021.
Required elements of the pre-admission screening documentation:
- Prior level of function
- Expected level of improvement
- Expected length of time to achieve that level of improvement
- Risk for clinical complications
- Conditions that caused the need for rehabilitation
- Combinations of treatments needed
- Anticipated discharge destination
CMS removes the following elements of the pre-admission screening documentation from the Medicare Benefit Policy Manual (Ch.1. Section 110.1.1).:
- Expected frequency and duration of treatment in the IRF
- Any anticipated post-discharge treatments
- Other information relevant to the patient’s care needs
Lastly, CMS clarifies the definition of the term “week” as “7 consecutive calendar days beginning with the date of admission to the IRF.”