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”.
EXAMPLES:
Therapists may bill and be paid for the provision of services in the following scenarios:
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.
The phased elimination of Medicare’s Inpatient-Only List (IPOL) represents more than a regulatory change that will impact utilization review and the surgical authorization process; it
In my travels to hospitals across the country and time spent in emergency rooms shadowing the critical work of social workers, I’ve seen firsthand the
Please log in to your account to comment on this article.
Expert presenters Kathy Pride, RHIT, CPC, CCS-P, CPMA, and Brandi Russell, RHIA, CCS, COC, CPMA, break down complex fracture care coding rules, walk through correct modifier application (-25, -57, 54, 55), and clarify sequencing for initial and subsequent encounters. Attendees will gain the practical knowledge needed to submit clean claims, ensure compliance, and stay one step ahead of payer audits in 2026.
Accurately determining the principal diagnosis is critical for compliant billing, appropriate reimbursement, and valid quality reporting — yet it remains one of the most subjective and error-prone areas in inpatient coding. In this expert-led session, Cheryl Ericson, RN, MS, CCDS, CDIP, demystifies the complexities of principal diagnosis assignment, bridging the gap between coding rules and clinical reality. Learn how to strengthen your organization’s coding accuracy, reduce denials, and ensure your documentation supports true medical necessity.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
Sepsis remains one of the most frequently denied and contested diagnoses, creating costly revenue loss and compliance risks. In this webcast, Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, provides practical, real-world strategies to align documentation with coding guidelines, reconcile Sepsis-2 and Sepsis-3 definitions, and apply compliant queries. You’ll learn how to identify and address documentation gaps, strengthen provider engagement, and defend diagnoses against payer scrutiny—equipping you to protect reimbursement, improve SOI/ROM capture, and reduce audit vulnerability in this high-risk area.
Stay ahead of the 2026-2027 audit surge with “Top 10 Audit Targets for 2026-2027 for Hospitals & Physicians: Protect Your Revenue,” a high-impact webcast led by Michael Calahan, PA, MBA. This concise session gives hospitals and physicians clear insight into the most likely federal audit targets, such as E/M services, split/shared and critical care, observation and admissions, device credits, and Two-Midnight Rule changes, and shows how to tighten documentation, coding, and internal processes to reduce denials, recoupments, and penalties. Attendees walk away with practical best practices to protect revenue, strengthen compliance, and better prepare their teams for inevitable audits.
As AI reshapes healthcare compliance, the risk of biased outputs and opaque decision-making grows. This webcast, led by Frank Cohen, delivers a practical Four-Pillar Governance Framework—Transparency, Accountability, Fairness, and Explainability—to help you govern AI-driven claim auditing with confidence. Learn how to identify and mitigate bias, implement robust human oversight, and document defensible AI review processes that regulators and auditors will accept. Discover concrete remedies, from rotation protocols to uncertainty scoring, and actionable steps to evaluate vendors before contracts are signed. In a regulatory landscape that moves faster than ever, gain the tools to stay compliant, defend your processes, and reduce liability while maintaining operational effectiveness.
Get clear, practical answers to Medicare’s most confusing regulations. Join Dr. Ronald Hirsch as he breaks down real-world compliance challenges and shares guidance your team can apply right away.
Federal auditors are zeroing in on Inpatient Rehabilitation Facility (IRF) and hospital rehab unit services, with OIG and CERT audits leading to millions in penalties—often due to documentation and administrative errors, not quality of care. Join compliance expert Michael Calahan, PA, MBA, to learn the five clinical “pillars” of IRF-PPS admissions, key documentation requirements, and real-life case lessons to help protect your revenue.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
