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 and demonstrate measurable improvement; 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.

The biggest error rate of claim denials are due to the lack of documentation, no documentation, credentials for the physician not being present and not meeting medical necessity. Below are some of the ways to help prevent the mentioned details.

Helpful Hint: Create a checklist to use as an accuracy tool for your facility, to assure that the appropriate documentation is sent in as well as checking for medical necessity. This useful tool can help decrease and/or prevent these denials from occurring and can be used as an educational tool for your staff.

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 following criteria 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)
  • Require physician supervision by a rehabilitation physician, with face-to-face visits at least three (3) days per week to assess the patient both medically and functionally and to modify the course of treatment as needed
  • Require an intensive and coordinated interdisciplinary team approach to the delivery of rehabilitative care

The Pre-Admission Screening should be done 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 rehabilitation)
  • Patient’s expected level of improvement
  • Expected length of time 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) must be done within 24 hours of the IRF admission and should include the following:

  • History and physical that includes all of the required elements for the post-admission physician evaluation and that is done by a rehabilitation physician within the first 24 hours of the IRF admission meets the requirement for the post‐admission physician evaluation
  • Must identify any relevant changes that have occurred since the preadmission screening
  • Must include a documented history and physical exam, and a review of the patient’s prior and current medical and functional conditions and comorbidities
  • The post-admission physician evaluation (like all entries in the medical record) must be dated, timed and authenticated, in written or electronic form, by the person responsible for providing or evaluating the service provided

The PAPE must be completed by a physician with specialized education and training in rehabilitation medicine and the post-admission physician evaluation cannot serve as one of the three required rehabilitation physician face-to-face visits in the first week.

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

  • Be completed within the first four (4) days of the IRF admission (may be completed at the same time as the post-admission physician evaluation, as long as all required elements are included)
  • 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.

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
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 (no response is an error)

  • 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
  • Submit the medical records as soon as the ADR is received
  • Monitor the status of your claims in Direct Data Entry (DDE) and begin gathering the medical records as soon as the claim goes to the location of SB6001
  • Return the medical records to the address on the ADR letter. Be sure to include the appropriate mail code or station number. This ensures that your responses are promptly routed to the Medical Review Department.
  • 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
If you appeal the CERT decision and the appeals reviewer contacts you, you have 10 days to respond and submit any additional documentation to support the appeal. If the provider does not respond or submit the requested documentation then the appeal will be processed with the original documents that were submitted along with the documentation received from the CERT contractor.

Educational References and Resources

  • Inpatient Rehabilitation Facility (IRF) Medical Review Changes MLN Matters Article (PDF, 239 KB)
  • Inpatient Rehabilitation Therapy Services: Complying with Documentation Requirements Fact Sheet (PDF, 814 KB)
  • Chapter 1, Section 110, of the Medicare Benefit Policy Manual (PDF, 589 KB)

Contact Palmetto GBA JJ Part A Medicare

Provider Contact Center: 877-567-7271

Email JJ Part A

Contact a specific JJ Part A department


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