American Academy of Physical Medicine and Rehabilitation Position Statement on Definitions for Rehabilitation Physician and Director of Rehabilitation in Inpatient Rehabilitation Settings

The American Academy of Physical Medicine and Rehabilitation (AAPM&R) is the national medical organization representing more than 9000 physicians who are specialists in physical medicine and rehabilitation (PM&R). PM&R physicians, also known as physiatrists, treat a wide variety of medical conditions affecting the brain, spinal cord, nerves, bones, joints, ligaments, muscles, and tendons. PM&R physicians evaluate and treat injuries, illnesses, and disabilities, and are experts in designing comprehensive, patient-centered treatment plans. Physiatrists utilize cutting-edge as well as time-tested treatments to maximize function and quality of life. Physiatrists have a well-established clinical and leadership role in rehabilitation units in acute care hospitals and free standing inpatient rehabilitation hospitals (collectively referred to as inpatient rehabilitation facilities, or IRFs). By virtue of their extensive training and expertise in rehabilitation, impairment and function, physiatrists commonly serve as IRF medical directors and as the primary admitting physicians in these facilities. Appropriately, physiatrists are also typically the designated leader of the patient's multi-disciplinary rehabilitation care team in this setting. To serve in these roles, physicians must meet the qualifications specified by the Centers for Medicare and Medicaid Services (CMS) for Rehabilitation Physicians and Directors of Rehabilitation. However, as the number of freestanding and for-profit IRFs continues to increase,1 some IRFs are applying differing and conflicting interpretations of these qualifications that threaten to compromise patient care. In some cases, physicians with little to no training in rehabilitation are being allowed to fill the role of supervising and admitting physician and of medical director in IRFs. In order to guard against risk to patients and ineffective and inefficient utilization of health care resources, the AAPM&R believes that CMS should take immediate action to add clarity to the current regulatory and subregulatory definitions for a “Rehabilitation Physician” and “Director of Rehabilitation” to meet the best practices for rehabilitation care. 42 C.F.R. § 412.622,2 currently states that for an IRF claim to be paid, certain criteria need to be met, including under subsection (a)(3)(iv), which “Requires physician supervision by a rehabilitation physician, defined as a licensed physician with specialized training and experience in inpatient rehabilitation.” (emphasis added)42 C.F.R. § 412.293 further states that in order to be paid under the IRF prospective payment system rather than the general acute inpatient hospital Prospective Payment System, the IRF must have in effect certain procedures, one of which is to (e) “Have in effect a procedure to ensure that patients receive close medical supervision, as evidenced by at least 3 face-to-face visits per week by a licensed physician with specialized training and experience in inpatient rehabilitation to assess the patient both medically and functionally, as well as to modify the course of treatment as needed to maximize the patient's capacity to benefit from the rehabilitation process.” (emphasis added)The Internet Only Manual (IOM) 100-02 Medicare Benefit Policy Manual, Chapter 1,4 states, “The ‘rehabilitation physician’ need not be a salaried employee of the IRF but must be a licensed physician with specialized training and experience in rehabilitation. For ease of exposition throughout this document, this physician will be referred to as a ‘rehabilitation physician’.”(emphasis added) In the IOM 100-02 Medicare Benefit Policy Manual, Chapter 1, Section 110.2.4,4 CMS states, “A primary distinction between the IRF environment and other rehabilitation settings is the high level of physician supervision that accompanies the provision of intensive rehabilitation therapy services.” CMS adds that “the requirement for IRF physician supervision is intended to ensure that IRF patients receive more comprehensive assessments of their functional goals and progress, in light of their medical conditions, by a rehabilitation physician with the necessary training and experience to make these assessments at least 3 times per week.” (emphasis added)In section 110.2.54 of the same chapter, CMS states, “An IRF stay will only be considered reasonable and necessary if at the time of admission to the IRF the documentation in the patient's IRF medical record indicates a reasonable expectation that the complexity of the patient's nursing, medical management, and rehabilitation needs requires an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation care.” CMS indicates that “at a minimum, the interdisciplinary team must document participation by … a rehabilitation physician with specialized training and experience in rehabilitation services…” among other professionals. (emphasis added) 42 C.F.R. § 412.29(G)5 contains a definition of a director of rehabilitation which suggests that the terms “specialized training and experience” would have the meaning specified as follows“(4) Has had, after completing a one-year hospital internship, at least 2 years of training or experience in the medical-management of inpatients requiring rehabilitation services.” (emphasis added). “Definition of a ‘rehabilitation physician’: For the moment, we do not believe that we need to go further in defining a rehabilitation physician other than to say that he or she must have specialized training and experience in rehabilitation. The responsibility is on the IRF to ensure that the rehabilitation physician(s) who are making the admission decisions and treating the patients have the necessary training and experience. If we later find that this is becoming a problem and we need to further define the qualifications, we will consider revising our policy accordingly.” Despite the fact that CMS provides clear rationale for the need to have a licensed physician with specialized training and experience in rehabilitation services as the supervising physician in IRFs, the Agency has persisted in maintaining definitions for Rehabilitation Physician and Director of Rehabilitation that are far too broad. “(2) Director of inpatient psychiatric services: Medical staff. Inpatient psychiatric services must be under the supervision of a clinical director, service chief, or equivalent who is qualified to provide the leadership required for an intensive treatment program. The number and qualifications of doctors of medicine and osteopathy must be adequate to provide essential psychiatric services. “(i) The clinical director, service chief, or equivalent must meet the training and experience requirements for examination by the American Board of Psychiatry and Neurology or the American Osteopathic Board of Neurology and Psychiatry.” (emphasis added). The above specificity regarding training and experience ensures that patients are appropriately assessed for their complex psychiatric conditions and receive the specialized care they need in a psychiatric unit. This approach provides an important precedent for qualifications that should be required for Rehabilitation Physicians and Directors of Rehabilitation in IRFs. Rehabilitation Physician: Physiatrist, defined as a licensed physician (M.D. or D.O.) who has completed a Physical Medicine and Rehabilitation (PM&R) residency accredited by the Accreditation Council for Graduate Medical Education (ACGME), the American Osteopathic Association (AOA), or the Royal College of Physicians and Surgeons of Canada (RCPSC) and meets the training and experience requirements for examination by the American Board of Physical Medicine and Rehabilitation or the American Osteopathic Board of Physical Medicine and Rehabilitation. “Physical medicine and rehabilitation is the medical specialty which focuses on the diagnoses, evaluation, and management of persons of all ages with physical and/or cognitive impairments, disabilities, and functional limitations.” Residents must demonstrate competence in the evaluation and management of patients with physical and/or cognitive impairments, disabilities, and functional limitations, including: “Residents must have direct and complete responsibility for the rehabilitative management of patients on the inpatient physical medicine and rehabilitation service. The inpatient experience should be at least 12 months in Physical Medicine and Rehabilitation. Each resident assigned to an acute inpatient rehabilitation service should be responsible for a minimum of six physical medicine and rehabilitation inpatients. Each resident assigned to an acute inpatient rehabilitation service should not be responsible for more than 14 physical medicine and rehabilitation inpatients. Residents should care for an average daily patient load of eight patients over the 12-month inpatient experience. Residents should have inpatient rounds to evaluate patients with faculty members at least five times per week.” This AAPM&R Position Statement is intended to provide general information to physiatrists and is designed to complement advocacy efforts with payers and policymakers at the federal, state and regional levels. The statement should never be relied on as a substitute for proper assessment with respect to the specific circumstances of each case a physiatrist encounters and the needs of each patient. This AAPM&R statement has been prepared with regard to the information available at the time of its publication. Each physiatrist must have access to timely relevant information, research or other material which may have been published or become available subsequently. The Position Statement on Definitions for Rehabilitation Physician and Director of Rehabilitation in Inpatient Rehabilitation Settings was crafted by the American Academy of Physical Medicine and Rehabilitation (AAPM&R) Quality, Practice, Policy and Research (QPPR) Committee. The Board of Governors approved the Position Statement in December 2018. This document did not undergo standard Journal peer review.Members of the QPPR Committee and authors of the Position Statement are:Scott R. Laker, MD, ChairWilliam A. Adair, III, MDThiru M. Annaswamy, MD, MALawrence W. Frank, MDMichael Hatzakis, Jr., MDSusan L. Hubbell, MDNneka L. Ifejika, MD, MPHCindy B. Ivanhoe, MDValerie A. Jones, MDMichael F. Lupinacci, MDAnnie D. Purcell, DOChristopher J. Standaert, MDMelanie A. Dolak, MHA, Staff Liaison The Position Statement on Definitions for Rehabilitation Physician and Director of Rehabilitation in Inpatient Rehabilitation Settings was crafted by the American Academy of Physical Medicine and Rehabilitation (AAPM&R) Quality, Practice, Policy and Research (QPPR) Committee. The Board of Governors approved the Position Statement in December 2018. This document did not undergo standard Journal peer review. Members of the QPPR Committee and authors of the Position Statement are: Scott R. Laker, MD, Chair William A. Adair, III, MD Thiru M. Annaswamy, MD, MA Lawrence W. Frank, MD Michael Hatzakis, Jr., MD Susan L. Hubbell, MD Nneka L. Ifejika, MD, MPH Cindy B. Ivanhoe, MD Valerie A. Jones, MD Michael F. Lupinacci, MD Annie D. Purcell, DO Christopher J. Standaert, MD Melanie A. Dolak, MHA, Staff Liaison