Inpatient Rehabilitation Facility Review Choice Demonstration Billing Guidance

In accordance with 42 CFR § 412.622(a)(3)1, in order for an Inpatient Rehabilitation Facility (IRF) claim to be considered reasonable and necessary under section 1862(a)(1) of the Act, there must be a reasonable expectation that the patient meets all of the following requirements at the time of the patient's admission to the IRF, as defined in the IRF RCD Operational Guide (PDF). 

Note: The IRF completes an assessment of the patient, and this code comes from the PAI (patient assessment instrument) the provider uses. Prior to any service coverage by Medicare a facility must: 

1. Be eligible for a defined Medicare benefit category;
2. Be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member; and
3. Meet all other applicable Medicare statutory and regulatory requirements

The following revenue code, type of bill, provider type, and Case Mix Group (CMG) codes are subject to complex medical review for the demonstration:

Important: IRF claims for Veteran Affairs, Indian Health Services, Part A/B rebilling, demand bills submitted with condition code 20, no-pay bills submitted with condition code 21, and all Part A and Part B demonstrations are not part of this demonstration. 

Additional Resources

• Data Entry and Calculation Steps for the Inpatient Rehabilitation Facility 
• Medicare Benefit Policy Manual, Pub. 100-02, Chapter 1, Section 110 (PDF) 
• Web Pricer