CMS Releases FY 2019 Inpatient Rehabilitation Facility Final Rule

On July 31, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a final rule outlining changes on how Medicare pays inpatient rehabilitation facilities (IRFs). Below AOTA provides members with the key relevant policy changes in the final rule as we continue to analyze the implications for the provision of occupational therapy in IRFs.

Removal of Functional Independence Measure (FIM™) Instrument and Associated Function Modifiers from the IRF-Patient Assessment Instrument (PAI) and Refinements to the Case Mix Classification System

AOTA is disappointed to learn that CMS determined not to collect additional data using the FIM in the IRF setting. As background, CMS, through the IRF Quality Reporting Program (QRP), began collecting new Quality Indicator data elements in the IRF-PAI to calculate the IRF QRP quality measures. Certain elements, including elements in Section GG, collected data that overlapped with the FIM™ Instrument and associated Function Modifiers. For that reason, CMS finalized the removal of the FIM™ Instrument and associated Function Modifiers from the IRF-PAI for discharges beginning on or after October 1, 2019.

CMS also finalized the incorporation of certain Quality Indicator data elements into the IRF case-mix group (CMG) classification system for payment purposes under the IRF PPS for discharges beginning on or after October 1, 2019. AOTA believed that additional data collection for 1 more year would have been useful to ensure appropriate CMG assignment. CMS did heed the comments of AOTA and other associations regarding the use of only 1 year of data, and finalized a policy to incorporate 2 full years of data (FY 2017 and FY 2018) into their analyses used to revise the CMG definitions that will be effective beginning in FY 2020. CMS further stated that any changes to the revised CMG definitions resulting from incorporating an additional year of data (FY 2018) into the analysis will be addressed in future rulemaking. 

CMS agrees to provide additional training opportunities for IRFs on coding the Quality Indicator data items inclusive of Section GG, including in-person training, webinars, online training, and help desk assistance in preparation for the transition effective date of October 1, 2019. 

IRF Coverage Requirements Changes

CMS also finalized policy changes for the following IRF coverage criteria in response to a specific request for information in the FY 2018 Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) proposed rule: 

• Allow the rehabilitation physician to lead the interdisciplinary team meeting remotely without any additional documentation requirements
• Allow the post-admission physician evaluation to count as one of the face-to-face physician visits to increase flexibility to assess the patient during one of the three face-to-face physician visits required in the first week of the IRF admission
• Remove the admission order documentation requirement as a result of comments that doing so would reduce duplicative documentation requirements. CMS believes this requirement will continue to be appropriately addressed through enforcement of the hospital conditions of participation, as well as through the hospital admission order payment requirements, both of which IRFs need to comply with. 

The IRF coverage criteria changes listed above will be effective for all IRF discharges beginning on or after October 1, 2018. 

Further, CMS is:

• Updating the methods by which IRFs are notified of non-compliance with the requirements of the IRF QRP
• Displaying data on four assessment-based functional outcome measures in CY 2020
• Adopting an eighth factor to consider when evaluating measures for removal from the IRF Quality Reporting Program (QRP) measure set: that the costs associated with a measure outweigh the benefit of its continued use in the program.

AOTA encourages members to review the IRF PPS fact sheet. AOTA continues to analyze the IRF PPS final rule regarding the impact on occupational therapy practice as the IMPACT Act and QRP programs move forward toward implementation on different timelines. Stay tuned to the AOTA website for updates.