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Cahaba GBA’s 2014 Medicare Expo. August 6-7, 2014 – Chattanooga, TN Inpatient Rehabilitation Facility (IRF)-Guidelines and Documentation As directed a copy of the presentation is available for viewing or download on the Cahaba GBA website. Disclaimer.

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Cahaba gba s 2014 medicare expo

Cahaba GBA’s 2014 Medicare Expo

August 6-7, 2014 – Chattanooga, TN

Inpatient Rehabilitation Facility (IRF)-Guidelines and Documentation

As directed a copy of the presentation is available for viewing or download on the Cahaba GBA website


This resource is not a legal document. The presentation was prepared as a tool to assist providers and was current at the time of creation.

Responsibility for correct claims submission lies with the provider of services.

Reproduction of this material for profit is prohibited; providers are encouraged to share this education with staff.

Preventing improper payments
Preventing Improper Payments

The Affordable Care Act of 2010

  • Proposals to protect the Medicare Trust Fund

  • Authority to recover overpayments

    Social Security Act

  • Sections 1833(e), 1842(a)(2)(B), and 1862(a)(1)(A)

    Centers for Medicare and Medicaid Services (CMS)

  • Protect the Medicare Trust Fund

  • Identify inappropriate payments

  • Take corrective actions


Medical review
Medical Review


Reduce payment errors by identifying and addressing billing errors

related to coverage and coding of services

Data Driven

  • Indentify vulnerabilities

  • Identify questionable billing patterns

  • Prevent and/or address provider errors

  • Reduce paid claims error rate

  • Publish Local Coverage Determinations (LCD)

    Medical Review and Education-Overview:

    Program Integrity Manual - Pub. 100-08 - Medical Review Program:

Comprehensive error rate testing cert
Comprehensive Error Rate Testing (CERT)

Review Contractor

Documentation Contractor


Protect, Measure, Assess, Evaluate

Reviews Medical Records

Requests Medical Records

Skilled services
Skilled Services


  • Physical Therapy (PT)

  • Occupational Therapy (OT)

  • Speech Therapy (ST)

  • Prosthetics/Orthotics

Pre admission screening
Pre-admission Screening

Medical Record

  • Pre-Admission Screening

    • Must be completed within 48 hours prior to IRF admission

    • Detailed assessment of the patient’s condition and need for rehab

    • Justifies the patient’s need for rehab

    • Must be completed by a licensed or certified professional

    • Rehab physician must review, sign, and date screening

Pre admission screening1
Pre-admission Screening

Must include:

  • Specific condition

  • Prior level of function

  • Expected level of improvement

  • Expected length of stay

  • Risk for clinical complications

  • Treatment needed

  • Expected frequency and duration of treatment

  • Anticipated discharge destination

  • Anticipated post discharge treatments

  • Information relevant to the care needs of the patient

Medical necessity at admission
Medical Necessity at Admission

Reasonable and Necessary

  • Documentation in medical record should demonstrate:

    • Reasonable expectation that the following was met at the time of admission:

      • Require active and ongoing treatment of multiple therapy disciplines, at least one of which must be PT or OT

      • Require intensive rehabilitation therapy program

      • Reasonably be expected to actively participate in and benefit significantly from intensive therapy

      • Physician Supervision by a rehab physician

      • Intensive and coordinated interdisciplinary team approach

Admission orders
Admission Orders


  • Must be generated by a physician at the time of admission

    • Any licensed physician

    • Includes physician extenders working in collaboration with MD

  • Admission orders must be retained in the patient’s IRF medical record

Post admission screening
Post-admission Screening

  • Post-Admission Screening

    • Documentation of patient’s status post admission to SNF

    • Completed by physician in facility within 24 hours of admission

    • Supports medical necessity of admission

      • If it does not support the medical necessity, then discharge from the facility must begin immediately

      • Services after the third day will not be considered reasonable and necessary

Individualized plan of care
Individualized Plan of Care

Plan of care

  • Individual outline of the care provided to the patient

    • Must be completed within four days of admission

    • Diagnosis

    • Therapy services provided

      • Type

      • Amount

      • Duration

      • Frequency

    • Detailed functional outcome

  • Includes anticipated discharge plan

Intensive therapy
Intensive Therapy

  • Treatment Requirements

    • 3 hours per day for 5 days a week OR

    • 15 hours of intensive therapy within a 7 consecutive day period

      • Begins on day of admission

      • Must be well-documented

Intensive therapy1
Intensive Therapy

Reasonable and Necessary Services

  • Medical Record must have documentation that therapy was initiated within 36 hours from midnight of admission

  • Standard of care is one on one therapy

  • Group therapy is acceptable

    • Must be well documented

    • Cannot constitute the majority of therapy

Interdisciplinary team conference
Interdisciplinary Team Conference

Team Meetings

  • Periodic team meetings are to be held at least once per week

    • Assesses the patient’s progress toward rehabilitation goals

    • Analyzes possible resolutions to problems that could hinder the progress towards goals

    • Reassesses the previous rehabilitation goals established

    • Monitor and evaluate the overall plan of care

  • Documentation of team meetings must include

    • Names and profession of each participating member

    • The occurrence of the team meeting

    • The decisions that were discussed related to overall plan of care

Common case mix group cmg errors
Common Case Mix Group (CMG) Errors

  • CMG A0801-A0806

    • Replacement of Lower Extremity Joint

  • CMG A0701- A0703

    • Fracture of Lower Extremity

  • CMG A2001 – A2004

    • Debility

Common errors
Common Errors

  • Preadmission screen was not completed within the 48 hour time frame of admission to give accurate, recent findings of the patient’s condition. 

  • Physician signature was dated, but is not timed to validate physician review and concurrence of preadmission screen prior to IRF admission.

  • Preadmission screen was not always submitted as required by Medicare prior to IRF admission.

  • Post admission M.D. evaluation was not always submitted as required by Medicare. 

  • Overall plan of care was not individualized as defined by CMS. 3 hours/day 5 days/wk or 15 hours over 7 days or 90 min of PT and 90 min of OT does not meet CMS intent for individualized plan of care.

Common cmg errors cont
Common CMG Errors Cont.

  • Physician signature on overall plan of care or on progress notes was not always timed

  • Potential risk for clinical complications as documented on preadmission screen (fall, DVT, infection, unsteady gait, decreased balance, need for post-op wound/incision care, or continued antibiotic meds, etc) does not raise the patient’s needs to the level which would require inpatient care.

  • No detailed justification for IRF admission on the preadmission screen or on the post-admission physician evaluation. The documentation will state that the patient requires intense services of inpatient rehabilitation and direction by rehabilitation physician and 24 hour rehabilitation nursing care however no details are documented to support this statement.

  • Functional status as documented on preadmission screen would not support the need for an intense therapy program or for multiple therapy disciplines.

Irf patient assessment instrument
IRF-Patient Assessment Instrument

  • Include in the medical record

  • Electronic or paper

  • Correspond with medical record

  • Dated, timed and authenticated

  • CR 7901

Cms pai



  • Begins at the time of admission

  • Established goals have been reached

  • Further progress is unlikely

  • Must report the appropriate discharge code


  • Resources

    • Change Request 8105 ‐ Program Integrity Manual Pub. 100 ‐ 8: Chapter 3, Section Amendments, Corrections and Delayed Entries in Medical Documentation

      • Medicare Benefit Policy Manual Pub 100-02 Chapter 1 Section 110

        (Inpatient Hospital Services)

      • Medicare Program Integrity Manual Pub 100-08 Chapter 6

      • Program Integrity Manual Pub. 100 - 8: Chapter 3, Section



    • MM6698: Signature Guidelines for Medical Review Purposes:

    • MLN Matters: Inpatient Rehabilitation Therapy Services: Complying with Documentation Requirements: Fact Sheet

    • MMSE0801: Clarification of Patient Discharge Status Codes and Hospital Transfer Policies

      • Social Security Act 1862 (a)(1)(A)

    Thank you
    Thank You

    The Part A Provider Outreach and Education staff would like to thank you for participating in today’s event.

    Provider Contact Center: 1-877-567-7271