[Blog Series] IRF Regulations Part 2: Coverage Requirements for the Fiscal Year 2021

by Armi Hernandez, Consultant on September 23, 2020

In “[Blog Series] IRF Regulations Part 1: 1135 Waiver Highlights,” we discussed the changes that were implemented with the 1135 waiver and how these changes were affecting Inpatient Rehabilitation Facilities (IRFs). In Part 2, we will discuss the coverage requirements for the fiscal year (FY) 2021.

On August 4, 2020, the Centers for Medicare & Medicaid Services (CMS) released the IRF Prospective Payment System (PPS) final rule for FY 2021. On August 10, 2020, in the Federal Register 48424, Volume 85, Number 154, published the Final Rule. These changes will go in effect on October 1, 2020.




Post-Admission Physician Evaluation (PAPE)

One of the current IRF coverage requirements is to complete the PAPE within the first 24 hours of the patient's admission to the IRF. Due to the COVID-19 public health emergency (PHE), the requirement is temporarily waived. CMS concluded the PAPE covers much of the same information included in the patient's Pre-Admission Screening (PAS) and Individualized Plan of Care (IPOC). The Code of Federal Regulations (CFR), Title 42, Chapter IV, will be amended to remove §412.622(a)(4)(ii), the PAPE documentation provision, for IRF discharges beginning on or after October 1, 2020. The PAPE would no longer be an IRF coverage requirement; however, the PAPE requirement change does not prevent an IRF from continuing with the best practice of evaluating the patient within the first 24 hours of admission, if the patient's condition warrants a timely evaluation.

Flexibility for Physicians

The IRF coverage requirements will be amended for FY 2021 to allow non-physician practitioners (NPPs) to perform specific duties that are currently required to be performed by a rehabilitation physician. NPPs are physician assistants, clinical nurse specialists, and nurse practitioners, who have specialized training and experience in inpatient rehabilitation as determined by the IRF, if state and local laws permit it. In the final rule, the NPPs may perform one of the three required face-to-face visits instead of the rehabilitation physician beginning in the second and later weeks of a patient's IRF stay. The rehabilitation physicians will continue to have the flexibility to see the patient on three or more occasions per week and must complete the three visits in the first week.

Note that CMS did not change the rehabilitation physician requirements to review and concur with the patient's PAS, establish and implement the IPOC, and lead the weekly interdisciplinary team conferences.

Definition of a Week

For purposes of the IRF coverage requirements, CMS has clarified the definition of a week. The word calendar was added to "seven consecutive calendar days beginning with the date of admission to the IRF.” The term “at least fifteen hours of intensive therapy within a seven consecutive day period” was revised to “at least fifteen hours of intensive therapy within a calendar week.”  The intention is to avoid confusion that a week might represent Monday through Friday or any seven consecutive days for example. The week starts the day of admission.

Other updates include the change of the IRF PPS payment rates by 2.4% and applying the two-percentage point reduction (i.e., penalty) to the FY 2021 IRF increase factor for IRF providers that fail to meet the Quality Reporting Program (QRP) requirements.

The IRF claim is only considered by CMS to be reasonable and necessary if it meets all the IRF coverage requirements. Non-compliance with these coverage requirements may result in an IRF claim denial. For the past few years, the changes that CMS has implemented had lessened the administrative burden on both IRF providers and Medicare Administrative Contractors (MACs). Regulatory changes result from the “Patients Over Paperwork” initiative launched by CMS in 2017 as a response to an executive order from President Trump to reduce red tape and administrative paperwork.

LW Consulting, Inc. (LWCI) has developed a 13-Part General Inpatient Rehabilitation Facility Training Series that details the IRF coverage requirements. For information, visit the LWCI Store.

If you have any questions or would like an external review of a sample of your records completed during the COVID-19 parameters, LWCI will be glad to assist.


For more information, contact Jim Wright, Director by calling 717-213-3128 or email JWright@lw-consult.com.

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Topics: Compliance