IRF Errors & Documentation Requirements
CGS and CMS continue to focus on lowering the Comprehensive Error Rate Testing (CERT) claim payment error rate. Inpatient Rehabilitation Facility (IRF) coverage requirements represent a top ranked problem area for improper payments because the medical record documentation submitted doesn't support IRF care as reasonable and necessary according to Medicare's regulations.
IRF Errors
We identified these common IRF documentation errors:
- No response to request for documentation
- Medical necessity:
- The beneficiary didn't need multiple therapy disciplines.
- The medical records didn't support that the beneficiary had intensive rehabilitative therapy needs following discharge from the hospital.
- On admission, the beneficiary was minimum assist in most areas.
- The beneficiary shouldn't have been expected to appropriately participate due to cognitive deficits.
- The medical records didn't support that the beneficiary could reasonably be expected to actively participate in, and benefit from, an intensive rehabilitation therapy program. The beneficiary wasn't able to ambulate and required maximal assistance for all mobility tasks and cognition.
- Insufficient documentation:
- Missing pre-admission screening to support IRF admission.
- Inadequate interdisciplinary team meeting notes.
- Missing physician's signature of concurrence with team conference meeting notes.
IRF Coverage Requirements
An IRF is a hospital, or part of a hospital, that provides an intensive rehabilitation program to inpatients and skilled nursing care to inpatients on a 24-hour basis under the supervision of a doctor and a registered professional nurse.
Patients are expected to participate in, and benefit from, the care and treatment received in an IRF. The patient must also require multiple therapy disciplines with at least one of the therapy services consisting of physical or occupational therapy. A patient who only needs one type of therapy is not appropriate for IRF admission. If a patient is unable to actively participate in the IRF intensive rehabilitative program, consider another setting that will meet the patient's needs. Patients should be stable at the time of the IRF admission.
The intensity of rehabilitation therapy services provided in an IRF is a primary distinction between an IRF and other rehabilitation settings. For this reason, the patient's medical record must include documentation to indicate a reasonable expectation that at the time of admission, the patient required the intensive services uniquely provided in IRFs.
IRFs provide intensive rehabilitation services using an interdisciplinary team approach in a hospital environment.
It is a reasonable expectation that the patient will benefit from intensive rehabilitation in an inpatient hospital environment and an interdisciplinary team approach to the delivery of rehabilitation care.
Admission to an IRF is appropriate for patients with complex nursing, medical management and rehabilitative needs.
IRF Criteria
IRF care is considered reasonable and necessary when documentation in the patient's medical record demonstrates a reasonable expectation that the following criteria are met:
- Requires active and ongoing intervention of multiple therapy disciplines: physical therapy (PT), occupational therapy (OT), speech language pathology (SLP), or prosthetics/orthotics, one of which is PT or OT.
- Requires an intensive rehabilitation therapy program. The generally accepted standard of care is one-on-one therapy, generally consisting of 3 hours per day, 5 days per week. In certain well-documented cases, this intensive rehabilitation might consist of at least 15 hours of therapy within a 7 consecutive day period, beginning with the date of admission to the IRF.
- Required therapy treatment must begin within 36 hours from midnight of the day of admission to the IRF. Group therapy is acceptable but may not constitute most of the therapy. Justification for the use of group therapies must be documented in the medical record.
- Reasonably be expected to actively participate in, and benefit significantly from, the intensive 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, and because of the intensive rehabilitation therapy program, which will be of practical value to improve the patient's functional capacity or adaptation to impairments.
- Requires physician supervision by a rehabilitation physician or other licensed treating physician with specialized training and experience in rehabilitation. There must be face-to-face visits at least 3 days per week, beginning with the first week throughout the patient's IRF stay. Note: Beginning the second week of admission to the IRF, a non-physician practitioner may conduct 1 of the 3 required face-to-face visits per week.
- Requires intensive and coordinated interdisciplinary team approach to foster frequent, structured, and documented communication among disciplines to establish, prioritize, and achieve treatment goals.
Documentation Requirements
Determination of whether an IRF admission is reasonable and necessary must be based on an assessment of each individual's care needs documented in the medical records.
The documentation in the patient's medical record must justify the IRF stay. It must demonstrate that the patient is making functional improvements that are ongoing, sustainable, and of practical value, as measured against the patient's condition at the start of treatment.
The patient's medical record must contain the following documentation:
- Admission orders generated by a licensed rehabilitation physician at the time of admission.
- Admission orders should generally be retained in the patient's medical record at the IRF.
- Preadmission screening (PAS) completed within 48 hours prior to admission.
- The PAS documentation must justify that the patient requires, will benefit from, and is able to actively participate in intensive rehabilitation therapy.
- A licensed or certified clinician can conduct the PAS, but the rehabilitation physician must sign and date the screening before the patient is admitted.
- Required elements include:
- Prior level of function (prior to the event or condition that led to the patient's need for intensive rehabilitation therapy).
- Expected level of improvement.
- Expected length of time necessary to achieve that level of improvement (i.e., estimated length of stay).
- Evaluation of the patient's risk for clinical complications.
- Conditions or comorbidities that caused the need for rehabilitation.
- Treatments needed (i.e., PT, OT, SLP or prosthetics/orthotics).
- Anticipated discharge destination.
- The rehabilitation physician must also review and document concurrence with the preadmission screening before the patient is admitted to the IRF.
- Individualized overall plan of care (IPOC) completed within 4 days of the IRF admission.
- The IPOC should generally detail the patient's medical prognosis and anticipated interventions, functional outcomes, and discharge destination from the IRF stay.
- The rehabilitation physician is responsible for developing the IPOC with input from the interdisciplinary team.
- The IPOC documents the following:
- Expected intensity (i.e., number of hours per day).
- Frequency (i.e., number of days per week).
- Duration (i.e., total number of days during the IRF stay the patient requires PT, OT, SLP or prosthetics/orthotics).
- Interdisciplinary team (IDT) approach to care with IDT meetings held a minimum of once per week.
- Must include the rehabilitation physician, a registered nurse with specialized training in rehabilitation, a social worker or case manager (or both), and a licensed or certified therapist from each discipline involved in treating the patient.
- Must be led by a rehabilitation physician (either in person or remotely) who documents concurrence with all decisions made at each meeting.
- The IDT meeting should focus on:
- Assessing the individual's progress toward the rehabilitation goal.
- Considering possible resolutions to any problems that could impede progress toward the goals.
- Reassessing the validity of the rehabilitation goals previously established.
- Monitoring and revising the treatment plan, as needed.
- Medical necessity documentation:
- Therapy evaluation/skilled notes.
- May include history and physical, IPOC, skilled notes, IDT notes, admission orders, etc.
- Should support the patient required active and ongoing therapeutic intervention of multiple therapy disciplines (PT, OT, SLP or prosthetics/orthotics), one of which is PT or OT.
- Supports the patient requires an intensive therapy program (per industry standards, generally at least 3 hours of therapy per day at least 5 days per week).
- Must show therapy services began within 36 hours from midnight of the day of admission to the IRF; therapy evaluations are generally considered to constitute the beginning of the required therapy services and should generally be included in the total daily/weekly.
- Should demonstrate the patient is reasonably expected to actively participate in, and benefit significantly from, an intensive rehabilitation therapy program.
- Supports the medical supervision requirement (i.e., the rehabilitation physician conducted the initial face-to-face visit(s) required at least 3 days per week throughout the patient's IRF stay). Note: Beginning with the second week, a non-physician practitioner with specialized training determined by the IRF may conduct 1 or 3 of the required face-to-face visits.
- IRF Patient Assessment Instrument (IRF-PAI) must correspond with all information in the patient's medical record.
- Per requirements, the IRF-PAI forms should generally be included in the patient's medical record at the IRF (in either electronic or paper format).
- Dated, timed, and authenticated by the person responsible for providing or evaluating services provided.
- Signature of the person who completed and/or transmitted the IRF-PAI form.
- Discharge dates (should match the discharge dates on the IRF claim).
- Clarification when conducting concurrent and group therapy sessions.
- See the CMS IRF-PAI webpage for the current form and instructions.
- Per requirements, the IRF-PAI forms should generally be included in the patient's medical record at the IRF (in either electronic or paper format).
- History & Physical (H&P)
Note: The FY 2021 IRF PPS Final Rule (85 FR 48424) removed the post-admission physician evaluation (PAPE) documentation requirement. However, the H&P is still required under the Conditions of Participation.
The H&P must contain all required elements and be completed within the first 24 hours of admission to the IRF.
- The H&P should contain:
- Patient's prior level of functioning.
- Current medical and functioning.
- Any relevant changes that may have occurred since preadmission.
- Information that supports the medical necessity for admission to an IRF.
The H&P serves as the basis for developing the plan of care. The ongoing visits ensure the patient's medical and functional status are continuously monitored and the plan of care is carried out.
References
- CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 1, section 110
- CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 15, sections 220 & 230
- CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 3, section 140.1.1
- Medicare Provider Compliance Tips CMS MLN Educational Tool
- 42 CFR §412.622 – Basis of payment
- 42 CFR §412.29 – Classification criteria for payment under the inpatient rehabilitation facility prospective payment system
- 42 CFR §412.600 – Prospective Payment for Inpatient Rehabilitation Hospitals and Rehabilitation Units
- 42 CFR §482.24 – Condition of participation: Medical record services