01-046 IRF Longer LOS 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 Medicare IRF’s billed on dates of service from January 1, 2019 through December 31, 2019. 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

The Office of Inspector General (OIG), under Report A-01-15-00500 dated September 2018, titled “Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements”, estimated that, in 2013, Medicare paid $5.7 billion for inpatient rehabilitation facility (IRF) stays, nationwide, that were not reasonable and necessary. Of the 220 randomly selected IRF claims, 175 stays did not meet Medicare coverage and documentation requirements therefore were not deemed to be reasonable and necessary.

In addition, the Comprehensive Error Rate Testing (CERT) program found that the error rate for IRF stays increased over 50% from 2012 to 2016. Historically, IRF medical review projects were completed by the previous Supplemental Medical Review Contractor (SMRC) in 2015 and 2016. Furthermore, Noridian Healthcare Solutions (Noridian), as the current Supplemental Medical Review Contractor (SMRC) performed initial data analysis in 2019 that supported additional medical review of IRF claims, conducted under project 01-025.

Noridian, the current SMRC, was issued a Project Authorization Form (PAF) for Task Order 1 and Task Order 6 on March 16, 2021, to conduct data analysis and related medical record review activities of IRF claims for claims with a Length of Stay (LOS) of greater than 8 days.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical review on inpatient rehabilitation facility (IRF) claims. Noridian will complete medical review on a sample of claims related to inpatient rehabilitation facility (IRF) services. The SMRC will conduct reviews in accordance with applicable statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

TOB Details
11X: Inpatient Rehabilitation Facility (IRF) Part A claims with greater than eight day lengths of stay

Access related project details below.

Documentation Requirements

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

  1. Physician/Non-Physician (NPP) order or evidence of intent to order
  2. History and Physical reports (include medical history and current list of medications)
  3. Initial and updated Preadmission screening/notes
  4. Post admission assessment/post admission physician evaluation completed within the first 24 hours of admission and supporting medical necessity of admission
  5. Documentation of Face-to-Face Encounter and/or Signed Attestation
  6. Signed and dated overall plan of care including, short- and long-term goals with any updates to the plan of care
  7. PT/OT/SLP – Initial evaluation, multi-disciplinary plan of care, progress reports, treatment encounter notes, therapy minute logs, and discharge summary
  8. IRF PAI (Patient Assessment Instrument) with documentation supporting information entered
  9. Record of interdisciplinary team conferences with attendance records and signatures
  10. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  11. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
  12. List of all non-standard abbreviations or acronyms used, including definitions
  13. If an electronic health record is utilized, include your facility’s process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician
  14. All supporting clinical and/or nursing notes/documentation
  15. Any other supporting documentation

References/Resources

  • Social Security Act (SSA) Title XVIII, Sections 1814(2)(B), (6). Conditions of and Limitations on Payment for Services
  • Social Security Act (SSA) Title XVIII, Section 1815(a). Payment to Providers of Services
  • Social Security Act (SSA) Title XVIII, Section 1833(e). Payment of Benefits
  • Social Security Act (SSA) Title XVIII, Section 1861(s)(2)(K). Miscellaneous Provisions (Definitions of Services, Institutions, Etc.)
  • Social Security Act (SSA) Title XVIII, Section 1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer
  • Social Security Act (SSA) Title XVIII, Section 1869(f)(1)(B). Determinations; Appeals
  • Social Security Act (SSA) Title XVIII, Section 1879(a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
  • Social Security Act (SSA) Title XVIII, Section 1886(j). Prospective Payment for Inpatient Rehabilitation Services
  • Social Security Act (SSA) Title XVIII, Section 1893(f)(7)(A)(B)(i-iv). Medicare Integrity Program
  • Code of Federal Regulations Title 42, Section Prospective Payment Systems for Inpatient Hospital Services. Subpart A. General Provisions.
  • Code of Federal Regulations Title 42, Section 412, Subpart P. Prospective Payment for Inpatient Rehabilitation Hospitals and Rehabilitation Units
  • Code of Federal Regulations Title 42, Section 424.5(a)(6). Basic Conditions
  • Code of Federal Regulations Title 42, Section 424.535. Revocation of Enrollment in the Medicare Program
  • Code of Federal Regulations Title 42, Section 482.24(c)(1). Condition of Participation: Medical Record Services
  • Medicare Benefit Policy Manual, Publication 100-02, Chapter 1, Section 110. Inpatient Rehabilitation Facility (IRF) Services
  • Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Section 220.3. Documentation Requirements for Therapy Services
  • Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Section 230. Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology
  • Medicare Benefit Policy Manual, Publication 100-02, Chapter 16, Section 20. Services Not Reasonable and Necessary
  • Medicare Claims Processing Manual, Publication 100-04, Chapter 3, Section 140.Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS)
  • Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.2.3.2. No Response or Insufficient Response to Additional Documentation Requests
  • Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.2.3.8. No Response or Insufficient Response to Additional Documentation Requests
  • Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.3.2.1. Documents on which to Base a Determination
  • Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.3.2.4. Signature Requirements
  • Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.6.2.2. Reasonable and Necessary Criteria
  • Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.6.2.5. Denial Types
  • 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 May 7, 2021