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UPDATE: AAPM&R Voices Physiatry’s Concerns Regarding CMS Proposed Rules

Jul 10, 2018

UPDATE: 

The Centers for Medicare and Medicaid Services (CMS) have released the Fiscal Year 2019 final rules for Inpatient Rehabilitation Facilities, Skilled Nursing Facilities, and Hospital Inpatient Prospective Payment System. Your Academy reviewed the rules and noted the final decisions on each proposal affecting physiatrists below. For more information, please see the CMS IRF Final Rule Fact SheetCMS SNF Final Rule Fact Sheet, and CMS IPPS Final Rule Fact Sheet


In April 2018, the Centers for Medicare and Medicaid Services (CMS) released its proposed payment and policy changes for fiscal year 2019. Some of the proposed changes could negatively affect physiatrists and the way they practice.

How could physiatrists be potentially affected?

The following items of the proposed rules could negatively impact physiatrists, if passed:

  • Inpatient Rehabilitation Facility (IRF) Prospective Payment System
    • Proposed Removal of the FIM™ Instrument and Associated Function Modifiers From the IRF–PAI Beginning with FY 2020 and Proposed Refinements to the Case-Mix Classification System Beginning with FY 2020: This removal might result in another set of data being used in place of FIM™, which is heavily relied upon by rehabilitation physicians.
      • Final Rule Update: Despite noting many objections from the provider community, CMS is finalizing its proposal to remove the FIM™ instrument and associated Function Modifiers from the IRF-PAI beginning in FY 2020, that is for all discharges occurring on or after October 1, 2019.
    • Proposed Changes to the Physician Supervision Requirement Beginning with FY 2019: The proposed changes could minimize the importance of face-to-face care for IRF patients and also not provide enough flexibility with scheduling visits in the first week of care.
      • Final Rule Update: CMS finalized the rule as written, noting that it is not limiting rehabilitation physicians from seeing patients more than three times in the first week of a patient’s admission but is allowing rehabilitation physicians to use their best clinical judgment regarding the frequency in which they believe patients should to be seen.
    • Proposed Changes to the Interdisciplinary Team Meeting Requirement Beginning with FY 2019: Allowing too much flexibility with this requirement could result in abuse and the minimization of the importance of face-to-face team meetings.
      • Final Rule Update: CMS finalized the rule as written, to expressly provide that the rehabilitation physician may lead the interdisciplinary meeting remotely without any additional documentation requirements beginning with FY 2019.
    • Proposed Changes to the Admission Order Documentation Requirement Beginning with FY 2019: These changes do not match the proposed changes in the IPPS proposed rule, and therefore need to be clarified.
      • Final Rule Update: CMS finalized its proposal to amend §412.606(a) to remove the admission order documentation requirement for I stays beginning with FY 2019. They did not opt to also eliminate 42CFR§412.3, which ties payment to an order being evident in the chart, as they did in the IPPS rule.
    • Proposed New Removal Factor for Previously Adopted IRF QRP Measures: This removal factor may be problematic if CMS proposes to remove a measure that clinicians or patients feel is important, but may be too costly to administer.
      • Final Rule Update: CMS finalized its proposal to add the IRF QRP measure removal Factor 8, the costs associated with a measure outweigh the benefit of its continued use in the program.
    • Proposed Policies Regarding Public Display of Measure Data for the IRF QRP: The Academy would like CMS to adopt a similar consumer testing approach for IRF QPP measures as it does for the Merit-Based Incentive Payment System (MIPS).
      • Final Rule Update: CMS is finalizing its proposal to begin publicly displaying data on the four assessment-based measures in CY 2020, or as soon thereafter as technically feasible, as proposed.
    • Solicitation of Comments Regarding Additional Changes to the Physician Supervision Requirement: Proper physiatric and rehabilitation visits require hands-on care and should not be conducted remotely. 
      • Final Rule Update: Note – this section was not a proposed rule so there is no final rule.  CMS received 22 comments in response to this solicitation
    • Solicitation of Comments Regarding Changes to the Use of Non-Physician Practitioners in Meeting the Requirements Under § 412.622(a)(3), (4), and (5): The Academy opposes expanding the role of Advanced Practice Providers (APPs) in IRFs to assume any of the activities currently requiring the involvement of a rehabilitation physician, due to the disparity between physician training and APP training.  At the same time AAPM&R acknowledges the value APPs can bring to the IRF setting, if provided with the appropriate training and oversight. 
      • Final Rule Update: Note – this section was not a proposed rule so there is no final rule.  CMS received 39 comments in response to this solicitation
  • Skilled Nursing Facilities (SNF) Prospective Payment System
    • Proposed Revisions to the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Case-Mix Classification Methodology: Medicare has proposed a new methodology for classifying SNF patients based on their condition and specific needs across five categories of care.The system, called the Patient-Driven Payment Model (PDPM) reflects a change in payment from time-based to condition-based.The Academy recognizes that under the PDPM SNFs may need to make numerous staffing and workflow changes and we have urged CMS to conduct significant educational efforts to ensure the program’s success. The Academy recommends CMS form a standing stakeholder work group to address the implementation of the PDPM.Due to the key role the physiatrist plays in the SNF, we encourage CMS to include physiatrist representation on the work group. 
      • Final Rule Update: Medicare approved its proposed new methodology for classifying SNF patients.  CMS agreed to take comments into consideration as it develops education on implementation of the new methodology. However, it did not formally approve a workgroup in the final rule.
    • Proposed Revisions to Minimum Data Set (MDS) Completion Schedule: Significant training and education will be needed to ensure SNFs are able to capture all necessary information including ICD-10-CM and PCS codes. 
      • Final Rule Update: CMS will not require ICD-10-CM coding to classify patients.  Instead, patients will, in part, be classified based on surgical procedure category.
    • Proposed Revisions to Therapy Provision Policies Under the SNF PPS: CMS proposes to limit group and concurrent therapy under the new PDPM.The Academy supports the recommendation to encourage individualized care for patients in the SNF and supports the recommended 25 percent limit on group and concurrent therapy. 
      • Final Rule Update: Approved as proposed.
    • Proposed new Measure Removal Factor for Previously Adopted SNF Quality Reporting Program (QRP) Measures: This removal factor may be problematic if CMS proposes to remove a measure that clinicians or patients feel is important.The Academy has encouraged CMS to consider the input of clinicians and patients when determining whether to remove a measure.
      • Final Rule Update: Approved as proposed.
  • Medicare Hospital Inpatient Prospective Payment System (IPPS)
    • Proposed Measure Removal Factors for the Hospital VBP Program: This removal factor may be problematic if CMS proposes to remove a measure that clinicians or patients feel is important, but may be too costly to administer. 
      • Final Rule Update: Approved as proposed.
    • Clinical Episode-Based Payment Measures: Removing 6 measures from the IQR Program could result in reverting back to the MSPB measure, which would be too broad of a measure to tie to specific existing quality metrics and wouldn’t be meaningful to clinicians.
      • Final Rule Update: CMS did not remove the 6 measures.
    • Potential Future Inclusion of the Hospital Harm-Opioid-Related Adverse Events Electronic Clinical Quality Measure (eCQM): Including this measure might discourage administration of naloxone, in favor of taking other measures.
      • Final Rule Update: CMS did not make a final decision on inclusion of this measure.

What is your Academy doing to defend physiatry?

Your Academy worked diligently to analyze the proposals and any threats to physiatry, requested comments from Academy members, developed recommendations based on the best interests of physiatrists, and submitted the following comments:

Special thanks to the following Academy volunteers for their valuable input:

  • Edward C. Burnetta, MD, FAAPMR, AAPM&R Reimbursement and Policy Review Committee Member
  • Steve M. Gnatz, MD, MHA, FAAPMR, AAPM&R Past President
  • Nneka L. Ifejika, MD, MPH, FAAPMR, AAPM&R Health Policy and Legislation Committee Chair
  • Scott R. Laker, MD, FAAPMR, AAPM&R Quality, Practice, Policy and Research Committee Chair
  • Michael F. Lupinacci, MD, FAAPMR, AAPM&R Quality, Practice, Policy and Research Committee Member
  • Annie D. Purcell, DO, FAAPMR, AAPM&R Reimbursement and Policy Review Committee Chair
  • Jiaxin Tran, MD, FAAPMR, AAPM&R Reimbursement and Policy Review Committee Member

What happens now?

Outcomes from the rules will be implemented in 2019 and 2020.

As always, your Academy will continue to closely monitor any proposed legislation and advocate on behalf of physiatrists. Stay tuned to www.aapmr.org as more information is released.