March 9, 2020

On March 3, your Academy met with Centers for Medicare Services (CMS) staff to discuss several issues pertaining to physiatry paperwork burdens and burnout. AAPM&R was represented by Drs. Nneka Ifejika and Darryl Kaelin.

The meeting focused on issues pertaining to inpatient claims denials based on technical or documentation errors and the activities that resident physicians may perform in Inpatient Rehabilitation Facilities (IRFs) as compared to other hospital settings. AAPM&R made several proposals to address inpatient denials:

1. Provide additional flexibility for arbitrary time requirements, especially on holidays and weekends, by adjusting CMS regulations with two small changes.The first being to establish time-related requirements in days, rather than hours to avoid arbitrary cut-off periods during the workday. The second by offering greater flexibility for documentation timeframes during weekends and holidays.
2. Eliminate denials for de minimis omissions in the medical record when medical necessity is clearly demonstrated by amending the IRF regulations with a statement that claims will not be denied due to a minor or non-material technical deficiency.
3. Streamline redundant documentation requirements to improve efficiency and allow more time spent treating patients, rather than proving that patients deserve treatment. Physiatrists are perpetually burdened by voluminous and redundant documentation requirements that are sometimes clinically irrelevant. Between the Pre-Admission Screening, Post-Admission Physician Evaluation (PAPE), and Individual Plan of Care (IPOC), physiatrists are required to recite the same information several times to prove a patient belongs in IRF care, whereas Acute Care Hospitals simply require a History and Physical.

In addition to burden caused by inpatient denials and documentation burden, we discussed burden on physiatrists working in IRFs because some IRFs have interpreted CMS’s vague guideline that a “rehabilitation physician” must complete certain tasks, including the PAPE, three minimum face-to-face visits, and developing the patient’s IPOC means that a resident cannot help with these tasks. Not only does this vague requirement keep residents from learning in IRF settings, but the responsibility of this extensive paperwork falls entirely on to the physiatrist. As such, we asked CMS to clarify that rehabilitation physicians and resident physicians may participate in these tasks.

AAPM&R had already discussed these issues with CMS through several meetings and letters over the last year, but felt it important to reintroduce these issues as continuing AAPM&R priorities and with the hopes that CMS may consider addressing them in the upcoming proposed CY 2021 Inpatient Rehabilitation Facility Prospective Payment System rule. For more information, please read our 2020 Inpatient Denials Letter.