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A brewing problem, or simply an area for clarification for IRFs?

During what was expected to be a plain vanilla review of the Inpatient Rehabilitation Facility Prospective Payment Systems (IRF-PPS) Coverage Requirements and Updates from the FY 2019 Final Rule, the Centers for Medicare & Medicaid Services (CMS) made a remark that has set the IRF world abuzz.

In the question-and-answer portion of the Medicare Learning Network call on Nov. 15, a CMS staffer reportedly responded to a listener’s question related to counting minutes of therapy provided by a therapy student with guidance that these minutes would not count, regardless of the level of supervision.

To our knowledge, this is the first clarification CMS has given related to the use of students in the IRF setting, and it has set off our phones and email inboxes.

What Do We Know About This Issue?
Medicare has clearly defined “qualified personnel” in the Code of Federal Regulations (CFR) as therapists and assistants with specific qualifications that are listed in the Regulations. There has been little clarification regarding the use of students or interns in the inpatient hospital environment. Most of the language related to use of students in therapy settings has centered around “billing” for services in the outpatient arena – and here, the language has been very prescriptive to not allow it for billing.

Section 230 of Chapter 15 of the Medicare Benefit Policy Manual provides some guidance:

B. Therapy Students
1. General

Only the services of the therapist can be billed and paid under Medicare Part B. The services performed by a student are not reimbursed even if provided under “line of sight” supervision of the therapist; however, the presence of the student “in the room” does not make the service unbillable. Pay for the direct (one-to-one) patient contact services of the physician or therapist provided to Medicare Part B patients. Group therapy services performed by a therapist or physician may be billed when a student is also present “in the room”.

Therapists may bill and be paid for the provision of services in the following scenarios:

  • The qualified practitioner is present and in the room for the entire session. The student participates in the delivery of services when the qualified practitioner is directing the service, making the skilled judgment, and is responsible for the assessment and treatment.
  • The qualified practitioner is present in the room guiding the student in service delivery when the therapy student and the therapy assistant student are participating in the provision of services, and the practitioner is not engaged in treating another patient or doing other tasks at the same time.
  • The qualified practitioner is responsible for the services and as such, signs all documentation. (A student may, of course, also sign but it is not necessary since the Part B payment is for the clinician’s service, not for the student’s services).

Of note, this information relates to Medicare Part B and not Medicare Part A services.

What is more helpful to us, however, is Section 230, Part 3:

3. Services Provided Under Part A and Part B
The payment methodologies for Part A and B therapy services rendered by a student are different. Under the MPFS (Medicare Part B), Medicare pays for services provided by physicians and practitioners that are specifically authorized by statute. Students do not meet the definition of practitioners under Medicare Part B. Under SNF PPS, payments are based upon the case mix or Resource Utilization Group (RUG) category that describes the patient. In the rehabilitation groups, the number of therapy minutes delivered to the patient determines the RUG category. Payment levels for each category are based upon the costs of caring for patients in each group rather than providing specific payment for each therapy service as is done in Medicare Part B.

While the Manual does not specifically reference IRF services, it addresses the use of minutes in Part A settings in which minutes of therapy are tied to burden of care – much the same as in the IRF. There are detailed clarifications that allow minutes of therapy provided by students in the Part A Skilled Nursing Facility (SNF) setting to be counted as the intensity listed on the Minimum Data Set (MDS). We have found no similar documentation that specifically addresses the IRF setting, which is also a Part A environment.

How Do We Respond to The Information Provided in This Response?
Due to the response to this question, it is a certainty that the therapy professional associations – the American Physical Therapy Association (APTA), American Occupational Therapy Association (AOTA), and the American Speech and Hearing Association (ASHA) – will be working with CMS on the issue, and it’s likely that a clarification will be forthcoming. We’ll keep you informed as this issue evolves.

Also, remember that CMS staff are well-versed in regulatory issues, but there is a myriad of nuances to these matters, and information presented at training programs is not intended to set policy.

So, What Now?
In light of the new spotlight on this topic, IRFs should review their practices to determine the proportion of student minutes in their treatment programs and the level of supervision provided to those students, as well as the amount of treatment time provided by therapists and assistants. Regardless of past interpretations, organizations need to be aware of their current utilization and practices in order to quickly meet any clarification requirements as they develop.

What’s the Bottom Line?
The bottom line is that we don’t have a clear answer for our readers at this point. We’re closely watching this issue and will keep you updated as information becomes available.


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Angela Phillips, PT

Angela M. Phillips, PT, is President & Chief Executive Officer of Images & Associates. A graduate of the University of Pennsylvania, School of Allied Health Professions, she has almost 45 years of experience as a consultant, healthcare executive, hospital administrator, educator, and clinician. Ms. Phillips is one of the nation’s leading consultants assisting Inpatient Rehabilitation Facilities in operating effectively under the Medicare Prospective Payment System (PPS) and in addressing key issues related to compliance.

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