CESIG, PTASIG and NCCE Statement Regarding IRF and CMS

This is a follow-up communication on the issue of Medicare regulations related to use of students in Inpatient Rehab Facilities. Please share this with academic and clinical stakeholders, including those in academic and clinical administration.

This message was developed jointly by the ACAPT National Consortium of Clinical Educators (NCCE) and the APTE Clinical Education and Physical Therapist Assistant Educators Special Interest Groups (CESIG and PTAESIG). We are sharing this with academic and clinical stakeholders and ask for your assistance in disseminating it to those involved in academic and clinical education-particularly administrators and others in the clinic that we may not easily reach.

Here is a summary of what we know so far:

  • On a November 15, 2018 Medicare Learning Network webinar entitled, "Inpatient Rehab Facilities (IRF) Payment and Coverage Policies: FY 2019 Final Rule," hosted by the Centers for Medicare & Medicaid Services (CMS), a number of questions were posed to CMS officials about whether student services can count towards the three-hour rule/intensity of therapy services requirement in the IRF setting.

  • On November 20, the leaders of the NCCE, CESIG and PTAESIG had a conference call with APTA Education and Regulatory Affairs staff. The purpose of the call was to get insight into the current Medicare regulations as they relate to students in Inpatient Rehab Facilities (IRF) and the circumstances under which the issue of billing for student services and treatment by students was raised in the CMS webinar on 11/15.

These are the key points we learned in this conference call with APTA:

  • The Medicare Conditions of Participation (CoPs) for Hospitals (Acute Care Hospitals and IRFs) do not recognize therapy students as qualified practitioners.

  • The CoPs are the requirements that hospitals must meet in order to participate in the Medicare and Medicaid programs. The CoPs are intended to protect patient health and safety and to ensure that high quality care is provided to all patients.

  • Student treatment does not count toward the minutes/hours of care in IRF; only the services of the qualified practitioner are billable.

  • The regulation applicable to who is qualified to provide therapy services in hospitals has been in effect for quite some time.

  • Because CMS has received questions on the ability to use therapy students in IRFs, the CMS spokesperson raised the issue on the webinar, choosing to address it during the question and answer portion of the November 15 call.

  • When they raised this issue, it led to many other questions about specific scenarios related to supervision and student involvement. The CMS representative clarified that students are not qualified providers of skilled rehabilitation services. The CMS representative did not offer additional details on student supervision requirements that allow students to participate in clinical education and training.

  • The regulations apply to acute hospitals as well, but the billing issue is different because it is bundled and not billed directly.

  • We do not believe it is CMS's intention to prohibit training of students; therefore, we are hopeful they will be engaged and committed to working with the therapy professions.

  • A meeting between CMS, APTA, AOTA and ASHA is pending in the near future.

  • The transcript from the CMS webinar will be available approximately 2 weeks after the webinar (on or about November 29), and APTA will provide the link to it in a future communication. This written confirmation of statements made by CMS officials will validate their intent and policy interpretation. For general information about the call, please click here.

  • Should individuals have specific questions regarding the use of therapy students in inpatient rehabilitation facilities, they can email CMS at: IRFCoverage@cms.hhs.gov

We have identified the relevant regulations and pasted them as an addendum to the bottom of this message.

We have known for a long time that Medicare does not consider students to be qualified practitioners. Many of you will remember that we dealt with a similar Medicare regulation in clinical education several years ago with Medicare B. Essentially, the Medicare B regulations allow the student to be in the room and involved, but the therapist is directing all care, is not engaged in anything else, and is present for the whole session. The presence of the student in the room does not make the service unbillable, nor does documentation by a student. We do not know whether this current discussion will land in a similar place, but we should be reassured that CMS understands the importance of training health professionals and is working with the professional associations.

Until we have more information, we recommend that clinics and CIs use their best judgment on how to involve students in patient care based on the language in the regulations. Documentation by students should indicate that a licensed physical therapist or assistant was present during all patient care.

We have set up a Discussion Board on the ACAPT website. It is not password protected, so please share the link. The purpose of the discussion board is to identify questions and concerns and to share comments and potential strategies. Participation can be anonymous if the individual chooses, but we do encourage individuals to identify themselves and/or their role to provide context. We will monitor the discussion board and consult with experts as necessary to resolve questions.

Donna Applebaum, PT, DPT, MS

NCCE Chair

Carol Beckel, PT, PhD

CESIG Academic co-Chair

Jay Lamble, PT, DPT, MS, OCS, NCS

CESIG Clinical co-Chair

Kathrine A. Giffin, PTA, MS Ed


Addendum: These are the relevant regulations and the link to each:

42 CFR 482.56: Condition of Participation for Hospitals: Rehabilitation Services, which states that PT, OT, and SLP services must be provided by qualified therapists or assistants as defined in Part 484. It also mentions the provision of care and personnel qualifications must meet the requirements of 409.17. https://www.ecfr.gov/cgi-bin/text-idx?SID=701c600508ebd3d4596d82be385f4710&mc=true&node=se42.5.482_156&rgn=div8

42 CFR 484.115: Condition of Participation: Personnel Qualifications: Outlines the qualifications of therapists and assistants being referenced by 42 CFR 482.56 and 42 CFR 409.17. https://www.ecfr.gov/cgi-bin/text-idx?SID=5d0e26127b202b6434791c979c6f3269&mc=true&node=se42.5.484_1115&rgn=div8

42 CFR 409.17: Hospital Insurance Benefits: Inpatient Hospital Services and Inpatient Critical Access Hospital Services: Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services: States that PT, OT, and SLP services must be provided by therapists or assistants who meet the requirements specified in part 484. https://www.ecfr.gov/cgi-bin/text-idx?SID=701c600508ebd3d4596d82be385f4710&mc=true&node=se42.2.409_117&rgn=div8

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