IRF Plan of Care Documentation Requirements - JE Part A
IRF Plan of Care Documentation Requirements
Documentation requirements for contractor review of IRF services are published by the CMS in the Internet Only Manual (IOM). Specifically, the Medicare Benefit Policy Manual, Chapter 1, Section 110.1.3 states that the medical record must clearly indicate the amount, frequency and duration of therapy services for each IRF patient. The anticipated interventions detailed in the overall plan of care must include the number of hours per day, number of days per week, and number of days during the IRF stay of physical, occupational, speech-language pathology, and prosthetic/orthotic therapies for the IRF stay.
Additionally, CMS has educated that the expected amount of therapy time by discipline required during the IRF stay must be documented on the individualized overall plan of care. It is not acceptable to simply use a generalized phrase such as, "At least 3 hours per day, at least 5 days per week" on the individualized overall plan of care. This is not individualized to the unique care needs of the patient and does not indicate the expected amount of therapy by discipline. To meet the requirements, the overall plan of care must indicate the type and expected amount of physical therapy, occupational therapy, speech-language pathology and orthotics/prosthetics needed by the patient on a daily basis.
