Removal of the requirement, if adopted, becomes effective FY 2020.

Our early review of the document and accompanying fact sheets has identified a number of provisions of interest to inpatient rehabilitation facility (IRF) providers. One of the key provisions, the removal of the Functional Independence Measure (FIMTM) Instrument and associated Functional Modifiers from the inpatient rehabilitation facility patient assessment instrument (IRF-PAI), has been anticipated by the industry since the implementation of overlapping quality measures.  The proposed rule establishes an implementation date for FY 2020 for this provision and it would be effective for discharges on or after Oct. 1, 2019.

Other key provisions of the proposed rule include the following and would be effective for FY 2019 beginning Oct. 1, 2018:

  • Allows the post-admission physician evaluation to count as one of the face to face visits
  • Allows the rehabilitation physician to conduct the team meeting remotely without any additional documentation requirements
  • Removes the IRF specific admission order requirement in an effort to reduce duplicative documentation requirements
  • Removes Quality Indicators NQF #1716 related to Methicillin-Resistant Staphylococcus Aureus and NQF#0680 related to Patient Influenza Vaccinations from the required data collection.
  • Updates the Federal Prospective Payment Rates for FY 2019

The following provisions would also be effective for FY 2020 beginning Oct. 1, 2019.

  • Removes the FIMTM from the IRF-PAI and incorporates certain data elements from the Quality Indicators section of the IRF-PAI into the case-mix classification system to assign patients to a Case Mix Group (CMG)

For IRF’s, long over-burdened by with the technical components of documentation, the proposed revisions are welcome relief. 

Several key components of the proposed rule are addressed here, however, we urge IRFs to take advantage of the opportunity to comment on potential changes and/or refinements to the 60 percent rule.


Post-admission Physician Evaluation to Count as One of The Face-to-Face Visits

  • The current rehabilitation physician supervision requirements and associated clarifications have required three face-to-face visits by a rehabilitation physician each week during the patient’s stay and prior clarifications have noted that the Post-Admission Physician Evaluation (PAPE) was not counted as one of those visits.
  • The updated provision would allow the IRF to count the PAPE as one of the required visits and give the rehabilitation physician some flexibility to determine how to more efficiently and effectively supervise the patients care.


Allows the Rehabilitation Physician to Conduct the Team Meeting Remotely Without Any Additional Documentation Requirements

  • While prior provisions have allowed the rehabilitation physician to conduct the team meeting remotely, specific documentation was required related to electronic methods of participation. This requirement would be removed.
  • The proposed provisions, however, do not remove the documentation requirements for other team members attending via remote access.


Removes the IRF Specific Admission Order

  • The proposed provisions remove the admission order language from the IRF rules as they are duplicative of those required by hospital conditions.
  • This change does not eliminate the requirement for admission orders and the IRF must still obtain these orders at admission and have them signed prior to discharge in order to meet the overall conditions of payment.

FY 2020 Removes the FIMTM from the IRF-PAI

  • Probably the most note-worthy provision in the proposed rule, the removal of the FIMTM data requirements for FY 2020 – that is all admissions on or after Oct. 1, 2019 – will have a significant impact on IRF documentation and scoring workloads. The duplicative processes to collect similar data that has distinct scoring differences have been a challenge for IRFs since the implementation of new functional measures into the Quality Indicator set.  This proposed change will significantly reduce workload in that area but will require organizations to make some significant changes in documentation template and work processes to make the shift.
  • With the removal of these data elements, CMS has proposed to incorporate the current Quality Indicator data into the CMG classification system. The proposed rule includes a detailed discussion of how the updated CMGs would be calculated.

Updates the Federal Prospective Payment Rates for FY 2019

  • Consistent with prior years, the regulations update the CMG payment rates including adjustments to the relative weights and average length of stay values for individual CMGs as well as adjustments to the wage index and labor-related share amounts for calculating the individual IRFs payment for a given CMG.
  • CMS estimates an overall increase in IRF PPS payments of .9% which is very similar to that provided in FY 2018. Under the proposed rule, the standard payment conversion rate will increase from $15,838 in FY 2018 to $16,020 in 2019. 


The Bottom Line

The proposed changes for FY 2019 reflect some positive changes related to reduction in paperwork for IRFs and, if finalized, will provide some easing of that work load. 

Once again, IRFs should actively participate in responding to the request for information that is included in this proposed ruling.

The proposed rule is now available for public inspection and is expected to be published on May 8, 2018.  In the proposed rule released on April 27, 2018, Centers for Medicare and Medicaid Services (CMS) included changes in payment policies as well as updates to the payment rates for IRFs.

The proposed rule also included a Request for Information from stakeholders related to sharing of healthcare information between providers.

Comments on the proposed rule and the request for information are due June 26, 2018.

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