(Medicare Benefit Policy Manual)

Interdisciplinary services are those provided by a treatment team in which all of its members participate in a coordinated effort to benefit the patient and the patients significant others and caregivers. Interdisciplinary services, by definition, cannot be provided by only one discipline.  Though individual members of the interdisciplinary team work within their own scopes of practice, each professional is also expected to coordinate his or her efforts with team members of other specialties, as well as with the patient and the patients significant others and caregivers.  The purpose of the interdisciplinary team is to foster frequent, structured, and documented communication among disciplines to establish, prioritize, and achieve treatment goals.   In accordance with the requirements at 42 CFR 412.622(a)(5), at a minimum, the interdisciplinary team must document participation by professionals from each of the following disciplines (each of whom must have current knowledge of the patient as documented in the medical record at the IRF):    A rehabilitation physician who is determined by the IRF to have specialized training and experience in inpatient  rehabilitation;    A registered nurse with specialized training or experience in rehabilitation;    A social worker or a case manager (or both); and    A licensed or certified therapist from each therapy discipline involved in treating the patient.   The interdisciplinary team must be led by a rehabilitation physician either in person or remotely via a mode of communication such as video or telephone conferencing, who is responsible for making the final decisions regarding the patients treatment in the IRF. This physician must document concurrence with all decisions ma de by the interdisciplinary team at each meeting.   The periodic team conferences held a minimum of once per weekmust focus on:   Assessing the individual's progress towards the rehabilitation goals;    Considering possible resolutions to any problems tha t could impede progress towards the goals;    Reassessing the validity of the rehabilitation goals previously established; and    Monitoring and revising the treatment plan, as needed.   A team conference may be formal or informal; however, a review by t he various team members of each other's notes does not constitute a team conference. It is expected that all treating professionals from the required disciplines will be at every meeting or, in the infrequent case of an absence, be represented by another p erson of the same discipline who has current knowledge of the patient. Documentation of each team conference should generally include the names and professional designations of the participants in the team conference.  Signatures from participants of the i nterdisciplinary team meeting are not required other than the rehabilitation physicians concurrence as noted above. The occurrence of the team conferences and the decisions made during such conferences, such as those concerning discharge planning and the need for any adjustment in goals or in the prescribed treatment program, must be recorded in the patients medical record in the IRF. The focus of the review of this requirement will be on the accuracy and quality of the information and decision- making, not on the internal processes used by the IRF in conducting the team conferences.     110.2.6  IRF Waivers and Flexibilities During the Public Health Emergency for the COVID -19 Pandemic  (Rev. 10892; Issued: 08-06- 21; Effective: 11 -08-21; Implementation: 11-08-21)   Inpatient Rehabilitation Facility (IRF) Flexibilities Issued on March 30, 2020  On March 30, 2020, CMS issued the interim final rule Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency (CMS -1744-IFC).  This interim final rule removed the IRF post-admission physician evaluation requirement in 42 CFR  412.622(a)(4)(ii) for all Medicare Part A fee-for-service beneficiaries during the public health emergency (PHE) specified in 42 CFR 400.200.  Thus, contractors shall not require documentation of post-admission physician evaluations in the IRF medical records for Medicare Part A fee-for- service beneficiaries during the PHE. As discussed in Section 110.1.2, CMS subsequently removed the post-admission physician evaluation documentation requirement entirely beginning with FY 2021 (e.g., for all IRF discharges beginning on or after October 1, 2020).  This interim final rule also revises the physician supervision requirement in 42 CFR  412.622(a)(3)(iv) and  412.29(e) to permit physician visits in the IRF required under these provisions to be conducted via telehealth to safeguard the health and safety of Medicare beneficiaries and the rehabilitation physicians treating them during the P HE.  Contractors shall allow rehabilitation physicians to use telehealth services as defined in section 1834(m)(4)(F) of the Act to conduct the required 3 physician visits per week during the PHE for the COVID-19 pandemic.  IRF Flexibilities Issued on Apri l 30, 2020   On April 30, 2020, CMS issued the interim final rule Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program (CMS-5531-IFC).  This interim final rule, codified at 42 CFR  412.622(a)(3)(ii), waives the IRF 3-hour rule in accordance with section 3711(a) of the CARES Act.  As a result o f the 3 -hour rule waiver, contractors shall not review Medicare Part A fee-for-service beneficiaries admitted to IRFs during the PHE specified in section 1135(g)(1)(B) of the Social Security Act for compliance with 42 CFR  412.622(a)(3)(ii).  That is, M edicare Part A fee-for-service beneficiaries admitted to IRFs during the PHE do not need to receive at least 15 hours of intensive rehabilitation therapy per week.  This waiver applies to all patients admitted to IRFs during the PHE.  This interim final ru le also modifies the IRF coverage and classification requirements in 42 CFR  412.29(d), (e), (h), and (i) and  412.622(a)(3)(i), (iii)  (iv), (4), and (5) for the public health emergency (PHE) during the COVID-19 pandemic, when all of the following criteria are satisfied at the time of admission to the IRF:   Patient is admitted to a freestanding IRF solely to alleviate acute care hospital bed capacity issues, and   IRF is located in a state (or region, as applicable) that is experiencing a surge during the Public Health Emergency, as defined in 42 CFR  400.200.   The regulation at 42 CFR  412.622(c), as amended by the April 30, 2020 interim final rule, specifies that a state (or region, as applicable) that is experiencing a surge refers to a state regi on that is in Phase 1 of the presidential Guidelines for Opening Up America Again (( https://www.whitehouse.gov/openingamerica/), specifically, a state (or region, as applicable)  that satisfies all of the following, as determined by applicable state and local officials:  1.  All vulnerable individuals continue to shelter in place.  2.  Individuals continue social distancing.  3.  Individuals avoid socializing in groups of more than 10.  4.  Non- essential trave l is minimized.  5.  Visits to senior living facilities and hospitals are prohibited.  6.  Schools and organized youth activities remain closed.   The evolution of the Phase 1 criteria listed above are most likely to be clearly articulated by a states governor.  Further, contractors will need to be aware that there may not be a clearly posted phase for a state or community that aligns with the presidential Guidelines for Opening Up America Again cited at 42 CFR  412.622(c).   Some of the criteria are likely to  be in place across a number of phases, particularly the criteria in (i), (ii), and (iii).  An example of a more complicated criteria to apply is (iv).  Non- essential travel can still be minimized, even after stay at home orders are lifted in an area to al low for additional access to health care services or to allow for additional commerce (such as manufacturing) to improve the overall economic circumstances of a region or state. There may also be circumstances where beach regions, which can provide more ability for social distancing, of a state are reopening whereas more concentrated population centers remain with higher restrictions.  Thus, contractors should apply the standard regionally, as applicable.  Furthermore, schools and organized youth activities  may be closed simply because of the time of year (for instance, during the summer months).   Additionally, contractors should recognize that, in some cases, states or regions can move to Phase 2 or Phase 3 of the plan and then return to Phase 1 if they experience another surge in cases.   In the April 30, 2020 interim final rule, CMS instructed freestanding IRFs to add the letters DS to the end of their unique hospital patient identification numbers (the numbers that identify the patients medical records in the IRF) to identify patients who are being treated in a freestanding IRF hospital solely to alleviate inpatient bed capacity in a state that is experiencing a surge during the PHE for the COVID -19 pandemic. The modifier will be used to identify those p atients for whom the requirements in 42 CFR  412.622(a)(3)(i), (iii), (iv), (4) and (5) do not apply.  Thus, contractors shall not review freestanding IRF patient medical records that have DS at the end of their unique hospital patient identifier numbers for meeting any of the following requirements:    Needing at least 2 forms of therapy (one of which must be physical or occupational therapy,    Being sufficiently stable to tolerate the IRF intensive rehabilitation therapy program,    Requiring close medical supervision by a rehabilitation physician, as demonstrated by at least 3 rehabilitation physician visits per week,    Having a preadmission screening,    Having an individualized overall plan of care, or    Having an interdisciplinary approach to care, including weekly interdisciplinary team meetings.   In addition, as noted at 85 FR 27573 contractors shall not include freestanding IRF patient medical records that have DS at the end of their unique hospital patient identifier numbers when reviewing whether the IRF meets the following coverage requirements:     Has in effect a preadmission screening procedure,    Has in effect a procedure for ensuring that patients receive close medical supervision by a physician,    Has a plan of treatment for each patient, or    Uses an interdisciplinary approach to care.   Contractors shall allow freestanding IRFs to be paid at the usual IRF prospective payment amounts for these patients.