01-025 Inpatient Rehabilitation Facility (IRF) Notification of Medical Review

 Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Part A Inpatient Rehabilitation Facility (IRF) stays billed on dates of service from January 1, 2018 through December 31, 2018. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

Inpatient rehabilitation hospitals and rehabilitation units of acute-care hospitals are collectively known as IRFs. IRFs provide intensive rehabilitation therapy in a resource-intensive inpatient hospital environment for patients who, because of the complexity of their nursing, medical management, and rehabilitation needs, require and can reasonably be expected to benefit from an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation care (the Medicare Benefit Policy Manual, Publication 100-02, Chapter 1, §110).

In a recent 2018 Office of Inspector General (OIG) report, titled “Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements” (A-01-15-00500), the OIG found that for many IRF’s, medical record documentation did not support that IRF care was reasonable and necessary in accordance with Medicare’s requirements.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical review activities on claims to determine if IRF stays were reasonable and necessary. Noridian will complete medical record review on claims in accordance with applicable statutory, regulatory and sub-regulatory guidance.

Claim Sample Detail

TOB
11X: Inpatient Rehabilitation Facility (IRF)

Access related project details below.

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR letter, to obtain the necessary documentation to perform the medical record review. Documentation requested has been made specific to assist the supplier in collecting and submitting pertinent information thereby reducing provider burden.

  1. Admission orders
  2. Applicable history and physical
  3. Pre-admission screen
  4. Post-admission physician evaluation
  5. Documentation of required physician face-to-face visits
  6. All supporting clinical and/or nursing notes/documentation
  7. Individualized overall plan of care
  8. Record of interdisciplinary team conferences with attendance records
  9. Therapy logs – all therapy disciplines
  10. Completed Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI)
  11. Notes/documentation related to an interruption in treatment
  12. Any and all other documentation supporting reasonable and necessary Inpatient Rehabilitation care, including but not limited to:
    • The nature and degree of the beneficiary’s expected improvement;
    • The expected length of time to achieve the improvement;
    • The need for a continued stay;
    • Demonstration that the beneficiary made functional improvements that were ongoing and sustainable measured against his/her condition at the start of treatment; and
    • An integrated medical and functional course of care for the patient
  13. Valid electronic or handwritten signatures, when applicable
  14. Copies of any patient notices given (e.g., Advance Beneficiary Notice of Noncoverage), if applicable

References/Resources

  • Social Security Act (SSA), Title XVIII, §1833(e). Payment of Benefits
  • SSA, Title XVIII, §1861(s)(2)(K). Miscellaneous Provisions (Definitions of Services, Institutions, Etc.)
  • SSA, Title XVIII, §1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer
  • SSA, Title XVIII, §1869(f)(1)(B). Determinations; Appeals
  • SSA, Title XVIII, §1879(a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
  • SSA, Title XVIII, §1893(f)(7)(A)(B)(i-iv). Medicare Integrity Program
  • 42 Code of Federal Regulations (C.F.R.) 411.404. Criteria for determining that a beneficiary knew that services were excluded from coverage as custodial care or as not reasonable and necessary
  • 42 C.F.R., 412.604. Conditions for payment under the prospective payment system for inpatient rehabilitation facilities
  • 42 C.F.R. 412.606. Patient Assessment
  • 42 C.F.R. 412.610. Assessment schedule
  • 42 C.F.R. 412.612. Coordination of the collection of patient assessment data
  • 42 C.F.R. 412.618. Assessment process for interrupted stays
  • 42 C.F.R. 412.622(a)(3), (4), and (5). Basis of payment
  • 42 C.F.R. 424.5(a)(6). Basic Conditions
  • CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110. Inpatient Rehabilitation Facility (IRF) Services
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.3. Documentation requirements for Therapy Services
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 20. Services Not Reasonable and Necessary
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 40.3.6 and 40.3.6.4. Routine Notice Prohibition & ABN Prohibition Exceptions
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 50.3. Financial Liability Protections
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8. No Response or Insufficient Response to Additional Documentation Requests
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.1. Documents on which to Base a Determination
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4. Signature Requirements
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2. Reasonable and Necessary Criteria
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5. Denial Types
  • Local Coverage Article A52757. Rehabilitation Delivery Methods. Effective 10/01/2015-09/14/2018
  • Local Coverage Article A52775. Medical Necessity of Therapy Services. Effective 10/01/2015-present
  • Local Coverage Article A53304. Medical Necessity of Therapy Services. Effective 10/01/2015-present

Last Updated Nov 4, 2019