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May 12, 2020

Prevent Inpatient Rehabilitation Facility (IRF) Denials

In order to prevent claim denials, ensure the medical record is submitted within 45 days of the Additional Documentation Request (ADR) and the documentation includes all required policy components.

We frequently see the following claim documentation missing or the documentation does not support the policy requirements:

Reasonable and Necessary

Interdisciplinary Team Meeting

  • Weekly interdisciplinary team meetings, led by a rehabilitation physician and include a registered nurse, social worker or case manager or (both), and the treating disciplines involved in the patient’s care (physical therapist, occupational therapist, and/or speech-language pathologist) participate in the weekly interdisciplinary team meetings

    Clarifications for the IRF Coverage Requirements Overall Plan of care and Interdisciplinary Team Meeting #13 External PDF

     *The interdisciplinary team must be led by a rehabilitation physician who is responsible for making the final decisions regarding the patient’s treatment in the IRF. This physician must document concurrence with all decisions made by the interdisciplinary team at each meeting.*

Supporting Clinical Documentation

  • Preadmission Screening, Post-Admission Physician Evaluation (PAPE), individualized overall plan of care, admission orders, and the Patient Assessment Instrument (PAI)

    *The Preadmission screening must be completed less than 48 hours prior to admission. If the preadmission screening is updated by the preadmission assessment clinician, it must be approved by the rehabilitation physician after the update.*

    *The Preadmission screening must be signed, dated, and timed by the rehabilitation physician prior to the recorded time of admission.*

    *The PAPE must be completed within 24 hours of admission. This document must be completed, signed, and dated within 24 hours (not within a calendar day).*

  • Physician signed and dated progress notes

    *Documentation should be signed prior to the patient’s discharge from the facility.*

  • Signatures and dates of the individuals completing the documentation should be legible on the documentation submitted. (Please include a signature log if needed)

Face to Face Visits

  • Physician signed and dated Face to Face Visits occur at least three times in a 7 consecutive day period

    * For the first week of admission only, the PAPE may be counted as one of the three Face to Face Visits.*

Check

IRF ADR Checklist – Preferred Order

 

1. ADR letter or FISS Page 7 screenprint

 

2. Beneficiary name and date of service on all documentation

 

3. Itemized list of all charges

 

4. Hospital discharge/transfer summary

 

5. Physician's orders and progress notes for dates of service

 

6. All therapy records including progress notes and treatment records

 

7. Pre-admission screening

 

8. IRF-Patient assessment instrument (IRF-PAI) with supporting clinical documentation

 

9. Post-admission physician evaluation

 

10. Plan of care completed within the first four days of IRF admission

 

11. Interdisciplinary team meeting documentation conducted weekly, includes legible names and professional credentials for each attending participant (rehabilitation physician, registered nurse, social worker/case manager, and the treating licensed/certified therapist from each therapy discipline involved in the patient care

 

12. Documentation to support required three weekly rehabilitation physician face to face visits

 

13. Other relevant documentation to support medical necessity

IRF ADR Checklist

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