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September 2, 2015

Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF – PAI) Submission Errors Can Result in a Twenty-Five Percent Payment Reduction

CGS continues to receive a number of calls from IRFs related to reason code 37096 and the application of the twenty-five percent penalty to some claims. This article has been revised to provide additional clarification on how to avoid these errors.

The IRF-PAI is used to gather data to determine the payment for each Medicare Part A fee-for-service and Medicare Part C (Medicare Advantage) patient admitted to an inpatient rehabilitation unit or hospital.

jIRVEN (Inpatient Rehabilitation Validation and Entry system) is a free java-based application that allows IRFs to collect and subsequently submit the IRF PAI data to the CMS National Assessment Collection Database. The software runs the data from the PAI through grouping software that generates a case-mix group based on clinical characteristics and expected resource needs to be used on the IRF claim via a Health Insurance Prospective Payment System (HIPPS) code. Separate payments are calculated for each group, including the application of case and facility level adjustments.

To prevent inaccurate payments, the Fiscal Intermediary Shared System (FISS) suspends claims with HIPPS codes and creates a finder file of claim information on the mainframe at each MAC's Enterprise Date Center (EDC). A file exchange mechanism  transmits these files to the data center where the assessments are housed. There, the corresponding assessment information will be found in the Quality Improvement and Evaluation System (QIES) and an updated file returned to the EDC for further FISS processing.

Submission Date and Claims Processing: Scenarios

IRF claims submitted to FISS will suspend to status/location SMFRX0 with reason code 37069. FISS then communicates with the CMS National Assessment Collection Database to request a match of the claim with the assessment. Each nightly cycle, the status/location changes the last digit until four nightly cycles are completed (SMFRX0 – SMFRX4).

If no return file is received after the fourth nightly cycle or there is not an exact match, the claim will Return to Provider (RTP) with reason code 37096. If your claim RTPs:

  • Ensure the IRF-PAI finalized at the CMS National Assessment Collection Database prior to submitting your claim. This can be verified by checking your IRF-PAI validation report. If the IRF-PAI was not finalized prior to submitting the claim, F9 or submit a new claim.
  • Verify that the patient information on both the IRF-PAI and the claim match the Common Working File (CWF) and that the following items on the claim match the information on the IRF- PAI:
    • Beneficiary's HIC number (IRF-PAI item 2);
    • Beneficiary's date of birth (IRF-PAI item 6);
    • Provider Transaction Access Number (PTAN) (IRF-PAI item 1B);
    • Claim statement covers through dates (IRF-PAI item 40);
    • Claim admission date (IRF-PAI item 12);
    • HIPPS Code (UB-04 Form Locator code (FL) 44);
    • Occurrence code 50 date (UB-04 FL 31-36); and
    • Patient status other than 30 (UB-04 FL 17)

If an error is found, correct it and F9 or submit a new claim. If no errors are found, F9 or submit a new claim.

If a return file is received by CGS and a match is found, the following scenarios are possible:

  • Claim is released for processing - If the submission date in the assessment response matches the occurrence code 50 date on the IRF claim, CGS will release the claim for processing.
  • Twenty-five percent penalty is assessed:
    • If the PAI is transmitted more than 27 calendar days from (and including) the date the beneficiary is discharged, the IRF's payment rate for the applicable case-mix group will be reduced by 25 percent.
    • If the submission date in the response information is later than the occurrence code 50 date, no condition code D2 is present, and the submission date is more than 27 days from the discharge date, CGS will release the IRF claim for processing but apply the late submission penalty.

Avoid the Penalty!

  • Review the information on the claim with the information on the IRF-PAI to ensure all items are correct and the fields match. Make corrections if the fields don't match.
  • Remember: Even if the QIES assessment shows "Accepted" on the report, it does not signify that all of the required data is present and matches.


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