Skip to Main Content

Print | Bookmark | Font Size: + | –

November 21, 2025

Reason Code 37096: No IRF Assessment

The Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) is a clinical assessment tool used to collect data for quality measure calculation and payment determination. IRF provider staff are required to complete the IRF-PAI for all patients.

For Medicare payment determinations:

  • IRF provider staff enter the assessment into their software.
  • The assessment data runs through grouping software.
  • The grouping software generates a case-mix group (CMG).
  • IRF provider staff report the CMG (HIPPS code) on their Medicare claim.
  • The claims processing system uses the HIPPS code to calculate Medicare’s payment.

CMS provides free grouping software, but many providers create their own to integrate data entry and grouping functions with their administrative systems. As a result, the HIPPS code reported on a claim may differ from the HIPPS code the assessment system calculated. 

To prevent inaccurate payments, the Fiscal Intermediary Standard System (FISS) validates information reported on the claim against the assessment record stored in the CMS National Assessment Collection Database:

  • IRF claims (except Medicare Advantage) suspend to SMFRX0 (reason code 37069).
  • During the nightly cycle, FISS attempts to locate a matching assessment record.
  • FISS may repeat this process for up to 4 nightly cycles (SMFRX0 – SMFRX4).
  • If a match is found, CGS validates the IRF-PAI submission date:
    • If the submission and occurrence code 50 dates match, CGS releases the claim.
    • If the submission date is later than the occurrence code 50 date, more than 27 days from the discharge date, and condition code D2 isn’t present, CGS releases the claim and applies the late submission penalty.
  • If no match is found after the 4th nightly cycle (SMFRX4):
    • The claim returns to provider (RTPs) with reason code 37096.

How to resolve reason code 37096:

  • Make sure the IRF-PAI finalized in the CMS National Assessment Collection Database before you submitted a claim.
    • If not, F9 or submit a new claim.
  • Review the data elements below. Verify that the information reported on the claim is an exact match to the information stored on the IRF-PAI.
    • If you identify an error, correct it, and F9 or submit a new claim.
    • If you don’t identify any errors, F9 or submit a new claim.
IRF Claim IRF-PAI
Medicare Beneficiary Identifier (MBI) Item 2
Beneficiary’s date of birth Item 6
PTAN (6-digit provider number) Item 1B
Through date of service Item 40
Admission date Item 12
HIPPS code System-generated
Occurrence code 50 date Submission date
Patient status other than 30 Items 44C & 44D

References:

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved