In this third article in our series on meeting the January 2010 Medicare technical requirements for inpatient rehabilitation facilities (IRFs), we will discuss the requirements for the post-admission physician evaluation (PAPE). First, however, here is a quick summary of the first two articles in order to ensure that our readers are on the same page and that we have clarified any confusion from the previous article.
In our first article, we clarified the time frames in “clock” hours versus “days” for the required activities:
Those forms of documentation required to indicate clock hours include a) the preadmission screening (PAS), which must be completed and/or updated within the 48 hours immediately preceding admission to the IRF; and b) the PAPE, which must be completed within 24 hours after admission. Those forms of documentation required to indicate days include a) the individualized plan of care, which must be completed no later than day four of the IRF stay; and b) the team meeting, which must be held once every seven days during the IRF stay.
In our second article, we discussed the key requirements of the preadmission screening, including the required time frame for completion as noted above, the requirement for a narrative assessment by the clinician completing the assessment, and the requirement for the physician to agree and/or disagree, sign, date and time the document within the 48 hours immediately prior to the patient’s actual admission to the IRF.
As with many of the other technical requirements, there are both time frame requirements and content requirements for the PAPE. The time frame, as noted above, is within 24 hours immediately following admission to the IRF. Since this requirement is listed in clock hours, it has been problematic for IRFs when the rehabilitation physician makes his or her rounds at different times of the day. Organizations must develop systems for communicating to the physicians the actual time of admission of the patient in order to assure that the PAPE is completed, documented and signed within the 24-hour time frame immediately after admission.
The overall time requirements are shown in Figure 1.
Additionally, organizations must verify that the admission date and time on the patient face sheet is accurate and clearly matches the actual time of admission.
Because the purpose of the PAPE is to document the patient’s status upon admission, compare it to the patient’s status in the preadmission assessment and begin development of the patient’s expected course of treatment. The PAPE also must include specific content items in order to meet regulatory requirements. One of the most problematic areas in compliance is the comparison of the patient status upon admission to the IRF to the status report on the preadmission screening. The PAPE should include a specific statement related to this review. We recommend that the rehab physician actually make an assessment statement to cover this requirement. For example:
- If the patient condition is unchanged from the preadmission screening: “I have examined the patient and find that his/her functional status, medical condition and appropriateness for IRF admission are essentially unchanged from those described in the preadmission screening.”
- If the patient condition has changed but the patient is still appropriate for IRF admission: “I have examined the patient and find that his/her functional status and/or medical status has improved/declined as noted above (be sure H&P and PAPE documentation includes specifics, or state the changes here); however, patient continues to meet the requirements for an IRF stay and has ongoing needs for IRF and potential for significant practical improvement.”
- If the patient condition has changed and the patient is no longer appropriate for IRF admission: “I have examined the patient and find that his/her functional and medical status have improved/declined to a level where patient is no longer appropriate for IRF services. Discharge planning will be initiated immediately.”
The PAPE may be included in the history and physical, or it may be a separate document in the medical record. When the information is included in the history and physical, we recommend that the pertinent items be grouped under a heading titled “post-admission physician evaluation” to demonstrate clearly what information indicates that the requirements have been met.
Medicare allows for a resident or physician extender to complete the history and physical provided that the rehabilitation physician visits the patient and completes the other required elements of the PAPE within the 24 hours immediately following IRF admission.
The required elements include a documented history and physical exam, any relevant changes that have occurred since the preadmission screening, a review of the patient’s prior and current medical conditions, a review of the patient’s prior and current functional status, and documentation of co-morbid conditions that impact the IRF stay.
At times, the rehabilitation physician completes a full consult immediately prior to patient admission to the IRF. While a post-admission physician evaluation is required to be completed for all IRF admissions, regardless of how recently prior to the admission the patient was evaluated, the rehabilitation physician may use information from the referring hospital’s evaluation when completing the post-admission physician evaluation. In these cases, the rehabilitation physician must update any information necessary to ensure that the information is current and accurate. This can be accomplished by performing a brief history and physical and/or PAPE that references the previous evaluation and confirms that the patient’s status has not changed (or clearly describes any changes that have occurred in the interim). The history and physical and PAPE may not be completed prior to admission to the IRF, regardless of how recently the patient has been evaluated.
About the Author
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 over 35 years of experience as a consultant, healthcare executive, hospital administrator, educator and clinician. Ms. Phillips is one of the nation’s leading consultants assisting acute rehabilitation units and hospitals in operating effectively under the Medicare Prospective Payment System (PPS) and in address key issues related to compliance.
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