Inpatient Rehabilitation Facilities Required Documentation

Published 03/24/2022

An Inpatient Rehabilitation Facility (IRF) is designed to provide intensive rehabilitation therapy within a resource-intensive hospital environment for patients who, due to the complexity of their medical, nursing and rehabilitation needs, require and can reasonably be expected to benefit from an inpatient stay and an interdisciplinary approach to the delivery of rehabilitation care.

Specific medical record documentation, at the time of an IRF admission, must support a reasonable expectation that the patient needs multiple intensive therapies, one of which must be physical or occupational therapy. The patient must be able to actively participate in, and benefit significantly from, the intensive rehabilitation therapy program, and requires supervision by a rehabilitation physician to assess and modify the course of treatment as needed to maximize the benefit from the rehabilitation process.

Medical Necessity
For IRF care to be considered reasonable and necessary, the documentation in the patient’s IRF medical record must demonstrate a reasonable expectation that the criteria below were met at the time of admission to the IRF. Admission orders must be generated by a physician at the time of admission; any licensed physician may generate the admission order. Physician extenders, working in collaboration with the physician, may also generate the admission order. These admission orders must be retained in the patient’s IRF medical record. For admission, the patient must:

  • Require active and ongoing intervention of multiple therapy disciplines Physical Therapy (PT), Occupational Therapy (OT), Speech-Language Pathology (SLP), or prosthetics/orthotics, at least one of which must be PT or OT
  • Require an intensive rehabilitation therapy program, generally consisting of three (3) hours of therapy per day at least five days per week; or, in certain well-documented cases, at least 15 hours of intensive rehabilitation therapy within a seven-consecutive day period, beginning with the date of admission
  • Reasonably be expected to actively participate in, and benefit significantly from, the intensive rehabilitation therapy program. The patient’s condition and functional status are such that the patient can reasonably be expected to make measurable improvement, expected to be made within a prescribed period of time, and as a result of the intensive rehabilitation therapy program, that will be of practical value to improve the patient’s functional capacity or adaptation to impairments.
  • During the first week of the patient’s IRF stay, the rehabilitation physician is required to visit the patient a minimum of three times to ensure that the patient’s plan of care is fully established and optimized to the patient’s care needs within the IRF
    • During the following weeks of care, CMS will continue to require a minimum of three rehabilitation physician visits per week, but will allow nonphysician practitioners (who is determined by the IRF to have specialized training and experience in inpatient rehabilitation) to independently conduct one of these three minimum required visits per week
  • Require an intensive and coordinated interdisciplinary team approach to the delivery of rehabilitative care
     

The Pre-Admission Screening should be completed within 48 hours prior to the IRF admission and should include the following:

  • Patient’s prior level of function (prior to the event that caused the need for intensive rehabilitation therapy)
  • The IRF rehabilitation physician must review and document concurrence of PAS prior to IRF admission
  • Detailed justification for admission Patient’s expected level of improvement
  • Expected length of stay needed to achieve that level of improvement
  • The risk(s) for clinical complications
  • The conditions that caused the need for rehabilitation
  • The combinations of treatments needed in the IRF
  • Expected frequency and duration of treatment in the IRF
  • The anticipated discharge destination from the IRF, any anticipated post-discharge treatments, and other information relevant to the patient’s care needs

Post-Admission Physical Exam and Evaluation (PAPE)
The post-admission physician evaluation documentation requirement, previously required pursuant to 42 CFR § 412.622(a)(4)(ii), was removed in the FY 2021 IRF PPS Final Rule (85 FR 48424). However, the history and physical is still required under the Conditions of Participation at 42 CFR § 482.24(c)(4)(i)(A).

Required Individualized Overall Plan of Care
The individualized overall plan of care must:

  • Be completed by the rehabilitation physician within the first four (4) days of the IRF admission
  • Support medical necessity of admission
  • Detail the patient’s medical prognosis and anticipated interventions (PT, OT, SLP and prosthetic/orthotic therapies) required during the IRF stay, include expected intensity (number of hours per day), expected frequency (number of days per week) and expected duration (number of total days during IRF stay)
  • Detail functional outcomes
  • Detail discharge destination from the IRF stay

Required Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI)
The IRF-PAI gathers data to determine the payment for each Medicare Part A FFS patient admitted to an IRF. The IRF-PAI form must be included in the patient’s IRF medical record in either electronic or paper format. Information in the IRF-PAI must correspond with all information in the patient’s IRF medical record. The IRF-PAI must be dated, timed and authenticated in the written or electronic form. One signature (attached in some way to the IRF-PAI, either in a cover page or handwritten somewhere on the form) from the person who completed (or transmitted) the IRF-PAI is sufficient.

Interdisciplinary Team (IDT) and Meetings
While a patient is being treated at an IRF, there should be a weekly Interdisciplinary Team (IDT) meeting that is led by the rehabilitation physician, who is responsible for making the final decisions regarding the patient’s treatment in the IRF. The physician must document concurrence with all decisions made by the interdisciplinary team. Documentation must include the name and professional designation of each interdisciplinary team member in attendance. During these weekly meetings, you should address: 

  • The patient’s progress towards the rehabilitation goals
  • Consider possible resolutions to any problems that could impede progress towards the goals
  • Reassess the validity of the rehabilitation goals previously established
  • Monitor and revise the treatment plan, as needed

Documentation from these meetings should also be included when submitting your claim. The following must be present during an IDT meeting:

  • 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)
  • A licensed or certified therapist from each therapy discipline involved in treating the patient

Credentials

  • The rehabilitation physician should be licensed with specialized training and experience in rehabilitation
  • The physician must be approved to work in the facility
  • When submitting claim information please submit the physician’s credentials to support that the physician has had specialized training and experience in rehabilitation

Responding to ADRs 

  • Be aware of the ADR date and the need to submit medical records within 45 days of the ADR date as this is time sensitive. No response to the ADR will result in the claim being denied.
  • Submit the medical records as soon as the ADR is received
  • Return the medical records to the address on the ADR letter. Be sure to include the appropriate mail code. This ensures that your responses are promptly routed to the Medical Review Department. If submitting documentation to the CERT Contractor, please include the Bar-coded Scan Coversheet with each medical record. To ensure CERT receives the documentation quickly, please submit the requested information directly to the CERT Contractor.
  • Gather all of the information needed for the claim and submit it all at one time
  • Attach a copy of the ADR request to each individual claim

Appeals
You have 120 days from the date of the initial determination. Do not resubmit the claim. The decision for denial was based upon review of medical records; therefore, claims for these services may not be resubmitted for payment. Please visit our website at www.palmettogba.com for more information about appealing your medically reviewed claim.

Educational References and Resources