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Printed Date: 9/22/2015
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.
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:
The Pre-Admission Screening should be done 48 hours prior to the IRF admission and should include the following:
Post-Admission Physical Exam and Evaluation (PAPE) must be done within 24 hours of the IRF admission and should include the following:
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:
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:
Documentation from these meetings should also be included when submitting your claim
Responding to ADRs (no response is an error)
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
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Last Updated: 03/08/2019