Information is effective as of May 15, 2020

What patients may an IRF unit treat during this public health emergency (PHE) that would normally not be permitted?

• CMS has granted several waivers that allow treatment of a patient in an IRF unit that might otherwise not have been permissible. CMS is waiving requirements to allow acute care hospitals to house acute care inpatients in excluded distinct part units, such as excluded distinct part unit IRFs, where the distinct part unit’s beds are appropriate for acute care inpatients. The Inpatient Prospective Payment System (IPPS) hospital should bill for the care and annotate the patient’s medical record to indicate the patient is an acute care inpatient being housed in the excluded unit because of capacity issues related to the disaster or emergency.
• In addition, CMS has waived 42 C.F.R. 412.622(a)(3)(ii) for all IRFs. This regulation requires that IRF patients be expected to participate in and benefit from 3-hours of therapy per day or 15-hours per week. Therefore, IRF units can admit patients that may not be able to tolerate or benefit from 3-hours per day or 15-hours per week of therapy (but meet all other intensity of therapy coverage requirements).

What patients may a freestanding IRF treat during this public health emergency (PHE) that would normally not be permitted? 

• ​CMS is now permitting freestanding IRFs to admit acute-care patients and bill under the IRF PPS, without having to meet the IRF coverage or classification requirements for “surge patients.” There are several important conditions and nuances to this change, including that this can only be used by freestanding IRFs in areas under a certain surge status, and only for patients admitted to assist with capacity at acute-care hospitals. You can read more about all of the conditions here.  These flexibilities would remain in place for the duration of the patient’s stay in the IRF.
• Under another option, CMS is also permitting acute-care hospitals to treat patients at external locations (the “Hospitals without Walls” policy), including freestanding IRFs. The acute-care hospital must continue to exercise sufficient control and responsibility over the hospital resources used to treat the patient in the external location in these scenarios. This control and responsibility standard is intended to be consistent with its current policy for when a hospital arranges diagnostic or therapeutic services for a patient at an off-site location (referred to as providing services “Under Arrangement.”).
• For all other patients, CMS has waived 42 C.F.R. 412.622(a)(3)(ii), which requires that IRF patients be expected to participate in and benefit from 3-hours of therapy per day or 15-hours per week. Therefore, IRFs can admit patients that meet all other coverage requirements, but may not be able to tolerate or benefit from 3-hours per day or 15-hours per week of therapy.

Which patients still must receive 3-hours of therapy per day or 15-hours per week?

• The waiver of 42 C.F.R. 412.622(a)(3)(ii) applies to all patients treated in IRFs during the PHE.

How do we document for patients who do not need or receive the 3-hours of therapy per day or 15-hours per week?

• CMS has affirmed that no additional documentation is needed for these patients. However, CMS expects freestanding IRFs who are admitting acute-care “surge patients,” as described above, to document that they are doing so. In addition, these freestanding IRFs admitting “surge patients” must append the “DS” modifier to the end of the IRF’s unique patient identifier number (used to identify the patient’s medical record in the IRF) to identify patients who are being treated in a freestanding IRF hospital solely to alleviate acute-care inpatient bed capacity. These freestanding IRFs must append the “DDS” rather than the “DS” modifier if also wishing to exclude the patient from the 60 percent rule calculation.

What other flexibilities can we utilize for our rehabilitation patients that are billed under the IRF PPS during this public health emergency?

• For patients that do not fall under the “surge patients” flexibility described above for freestanding IRFs, there are a number of other flexibilities that are permitted for both unit and freestanding IRFs. CMS is has waived the post-admission physician evaluation (PAPE) for all patients. Rehabilitation visits and interdisciplinary team meetings can be conducted remotely. Patients can also be excluded from the 60 percent rule calculation if admitted “solely to respond to the emergency.”

Can we forgo the post-admission physician evaluations (PAPEs) for all patients during this PHE?

• Yes, the PAPE is not required for any patients during the PHE. CMS has clarified that this waiver does not preclude an IRF patient from being evaluated by a rehabilitation physician within the first 24 hours of admission if the IRF believes that the patient’s condition warrants such an evaluation.

Can all of the required weekly rehabilitation physician visits be conducted via telehealth, or just for certain patients or hospitals?

• CMS is permitting all of the required rehabilitation physician visits to be conducted via telehealth during this public health emergency, though CMS encourages these visits to be performed face-to-face when safe/practical.

Can we provide therapy services via telehealth or other means where the therapist is not in the room with the patient in the IRF?

• CMS has not provided any specific guidance on providing therapy via telehealth or other alternative means for patients in an IRF. However, there is no longer a minimum hours-based threshold of therapy that must be provided by the IRF due to the waiver of 42 C.F.R. 412.622(a)(3)(ii).

Can team conferences be conducted/attended virtually by all members, and if so, do special documentation requirements apply?

• CMS has stated affirmatively that it is appropriate for IRFs to conduct team meetings remotely during this PHE. CMS did not provide any instructions for special documentation.

Do I need to continue to include a pre-admission screening and individualized overall plan of care for all patients?

• Except for those patients that qualify as “surge patients” for freestanding IRFs, CMS has not waived any requirements pertaining to the pre-admission screening or individualized overall plan of care.

Is the 60% rule still in place during the COVID-19 public health emergency declaration?

• Both IRF units and freestanding IRFs may exclude patients from the 60% rule calculation if the patient is admitted “solely to respond to the emergency and the patient’s medical record identifies the patient as such.”  IRFs should use the “D” modifier when excluding patients from the hospital’s 60 percent rule calculation because the patient was admitted “solely to respond to the emergency.”

Can we treat our IRF unit patient in the acute-care portion of the hospital (outside of the IRF unit)?

• CMS is permitting hospitals with excluded distinct part inpatient rehabilitation units that, as a result of a disaster or emergency, need to treat patients in an acute care bed. The hospital should continue to bill for inpatient rehabilitation services under the inpatient rehabilitation facility prospective payment system for these patients and annotate the medical record to indicate the patient is a rehabilitation inpatient being cared for in an acute care bed because of capacity or other exigent circumstances related to the disaster or emergency. This waiver may be utilized where the hospital’s acute care beds are appropriate for providing care to rehabilitation patients and such patients continue to receive intensive rehabilitation services. CMS has stated that the patient may remain in the same bed as was used during the acute-care portion of the patient’s stay in the hospital (such that the patient does not need to be physically relocated). 

Can an IRF expand its number of beds beyond its current or licensed amount during this PHE?

• The number of licensed beds a hospital is permitted to operate is usually a state or local rule. Under 42 C.F.R. 412.29(c)(2), an IRF unit or IRF hospital is permitted to increase its bed size once during a cost reporting period. Thus, the IRF unit would be allowed to increase its bed capacity once during the public health emergency. Providers should be aware there are several requirements and implications related to the adding of new beds, as detailed at the referenced regulation. This includes requiring the new beds comply with all applicable State Certificate of Need and State licensure laws, as well as receiving advanced written approval from the appropriate CMS regional office, among other things. In addition, there may be state or local restrictions the provider must comply with.  

Do hospitals need to apply to use these waivers or notify CMS they intend to use them?

• No, the blanket waivers are available to all IRFs for the duration of the PHE and they do not need to apply to use them or notify CMS in advance. However, hospitals should ensure changes do not violate any state or local rules that are still in effect, and comply with all coding/modifier rules issued by CMS. 

What disaster relief (DR) condition codes need to be added to claims during the public health emergency? Would it be appropriate to add DR codes to all claims during the public health emergency or should it only be applied to individual cases that have utilized one of the waiver allowances?

• The “DR”, “D”, or “E” codes do not need to be applied to patients under the waiver required by section 3711(a) of the CARES Act, as this waives the intensity of therapy requirement for all IRF patients during the public health emergency. However, for the other blanket waivers, including the 60 percent rule blanket waiver, specific coding rules apply. The IRF must include an identifier code at the end of the patient’s medical record hospital identifier number (the hospital record locator number that the IRF uses to identify the hospital record for that individual patient) to indicate that that patient is being treated under one or more of those blanket waivers. The IRF should also document this somehow in the patient’s medical record at the IRF.
• For freestanding IRFs admitting “surge patients,” as described above, the hospital must append the following modifiers to the end of the IRF’s unique patient identifier number (used to identify the patient’s medical record in the IRF):
  • D”: When excluding patients from the hospital’s 60 percent rule calculation because the patient was admitted “solely to respond to the emergency.”
  • “DS”: When utilizing any of the flexibilities provided by CMS’ recent interim final rules that allow freestanding IRFs to forgo IRF coverage or classification rules for acute-care surge patients (e.g., pre-admission screening, individualized overall plan of care requirements)
  • “DDS”: When utilizing both the aforementioned 60 percent rule flexibility and the coverage or classification requirement flexibilities.

Do I still need to submit items for IRF Quality Reporting Program (QRP) requirements?

• Submission of QRP items are optional for October 1, 2019 – December 31, 2019 (Q4) and January 1, 2020 – June 30, 2020 (Q1-Q2).  However, IRFs must continue to submit items that are used for payment in order to receive Medicare payments. CMS is not waiving patient assessment requirements that relate to payment of claims.  Therefore, IRFs must continue to submit IRF-PAI assessments to ensure requirements are met for claims matching purposes. Nonetheless, CMS is granting an exception to the QRP reporting requirements that would normally result in a penalty for the Annual Payment Update (APU) and will not be implementing that penalty for the mentioned quarters.

We are having trouble placing patients ready for discharge in sub-acute settings. Can we “discharge” the patient and provide sub-acute care until another suitable placement is available?

• CMS has issued a waiver to permit hospitals to provide “swing-bed” capacity for sub-acute care, with special payment and coverage rules that apply to these patients. The waiver excluded LTCHs, but is silent on IRFs. AMRPA is seeking further clarification from CMS on this matter. Per CMS, an FAQ document on this policy will be available shortly (per May 14^th CMS “Office Hours” call).

Is CMS considering creating a new rehabilitation classification category for COVID-19 patients so these patients will be 60 percent rule compliant?  

• CMS has not said it is considering adding a new classification category for COVID-19 patients, but AMRPA is aware of concerns about future 60 percent rule compliance and is exploring how best to address this concern.

Has CMS delayed implementation of the IRF PAI v. 4.0 currently scheduled to go into effect on October 1, 2020?

• Yes, CMS has delayed the IRF PAI V.4.0 until at least October 2021, as well as the SPADES and QRP measures that were planned to be incorporated in the IRF PAI v.4.0. CMS plans to release the drafts of the new IRF PAI version “shortly after the COVID-19 PHE ends to provide ample time for training and any vendor programming.”

Has prior authorization for Medicare Advantage plans been suspended?

• CMS has recommended, but not required, that plans suspend prior authorization. Many plans have done so. If you need assistance finding information about a specific plans position, please contact the AMRPA staff.

In a state where all/most of Medicaid is provided through Managed Care Organizations (MCOs), do the Medicaid 1135 waivers that specifically say “fee-for-service” also apply to the managed Medicaid?

• The state Medicaid agency will need to determine if the 1135 waivers for fee-for-service will also apply to managed care. To determine if the waivers apply to managed care in your state, check with your state-specific Medicaid agency.

CMS announced it was waiving the “detailed regulatory requirements” related to discharge planning that normally apply to hospitals.  Does this waiver extend to IRFs?

• CMS has not clarified this point to date.  AMRPA continues to request guidance from CMS on this issue.