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January 9, 2017

Comprehensive Error Rate Testing (CERT) and Inpatient Rehabilitation Facility (IRF) Errors and Common Denial Reasons

A part of all Medicare Administrative Contractors' tasks is working with providers to lower the CERT error rate. Through analysis of feedback reports, CGS has found that IRF errors are rising. A listing of the most common denial reasons by CERT are:

  1. Patient not able to participate in the regimen
  2. Documentation shows patient did not participate in the regimen
  3. Documentation shows the patient did not receive the required amount of therapy minutes
  4. The preponderance of therapy minutes were not individual but were group therapy
  5. The rehabilitation physician did not see the patient on a regular basis

Through this article, we will touch on each denial reason and discuss the requirements of each, as well as addressing reference materials for the particular denial.

The patient/beneficiary is not able to participate in the regimen

Denials are issued when the patient/beneficiary is unable to participate in the regimen prescribed for them during the IRF stay. It is expected that patients/beneficiaries admitted to an IRF be able to fully participate in their prescribed plan of care. Refer to the CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 1, section 110 for the following: "IRF admissions for patients who are still completing their course of treatment in the referring hospital and who therefore are not able to participate in and benefit from the intensive rehabilitation therapy services provided in IRFs will not be considered reasonable and necessary".

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Documentation shows patient did not participate in the regimen

Denials are issued when no documentation is provided that demonstrates the patient/beneficiary has participated in the prescribed regimen. Refer to the CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 1, section 110.2 for the following: "The patient must reasonably be expected to actively participate in, and benefit significantly from, the intensive rehabilitation therapy program that is defined in section 110.2.2 at the time of admission to the IRF."

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Documentation shows the patient did not receive the required amount of therapy minutes

Denials are issued when documentation shows that patients/beneficiaries did not receive the required amount of therapy minutes. Therapy minute documentation must be submitted to show that therapy is being conducted along the parameters developed in the plan of care. This also demonstrates participation. This information is found in the CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 1, section 110.2.2. In this section it states: "Although the intensity of rehabilitation services can be reflected in various ways, the generally-accepted standard by which the intensity of these services is typically demonstrated in IRF's is by the provision of intensive therapies at least 3 hours per day at least 5 days per week. However, this is not the only way that such intensity of services can be demonstrated (that is, CMS does not intend for this measure to be used as a rule of thumb for determining whether a particular IRF claim is reasonable and necessary). The intensity of therapy services provided in IRFs could also be demonstrated by the provision of 15 hours of therapy per week (that is, in a 7-consecutive day period starting from the date of admission).

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The preponderance of therapy minutes were not individual but were group therapy

The denial is issued as the majority of therapy minutes submitted is group therapy minutes. There are times where group therapy is appropriate for patients. The CMS Medicare Benefits Policy Manual (Pub. 100-02), chapter 1, section 110.2.2 covers group therapy. It states: "The standard of care for IRF patients is individualized (i.e. one-on-one) therapy. Group therapies serve as an adjunct to individual therapies. In those instances in which group therapy better meets the patient's needs on a limited basis, the situation/rationale that justifies group therapy should be specified in the patient's medical record at the IRF."

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The rehabilitation physician did not see the patient on a regular basis

These denials result when there is no documentation submitted that a physician saw the patients as required. CMS Medicare Benefits Policy Manual (Pub. 100-02), chapter 1, section 110.2.2 states: "The requirement for medical supervision means that the rehabilitation physician must conduct face-to-face visits with the patient at least 3 days per week throughout the patient's stay in the IRF to assess the patient both medically and functionally, as well as to modify the course of treatment as needed to maximize the patient's capacity to benefit from the rehabilitation process."

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To further our education efforts for IRF providers, we will be releasing several articles covering the requirements associated with the Plan of Care, Preadmission Screening, and the Post-admission Physician Evaluation. In these coming articles, we will review the requirements of each of these admission components and provide reference points for our providers. Additionally, we will be working with CGS Provider Outreach and Education (POE) to meet our providers' needs in this area.

Reference: CMS Medicare Benefit Policy Manual, (Pub. 100-02), chapter 1External PDF


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