Medical Review

Inpatient Rehabilitation Facility (IRF) - Service Specific Post-Payment Final Findings

CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Noridian’s priority is to minimize potential future losses to the Medicare Trust Fund by preventing inappropriate Medicare payments. This is accomplished through provider education, training, and the medical review of claims. A post-payment review has been initiated based on data analysis.

This is to update providers of the claim review findings and closure of the file of Inpatient Rehabilitation Facility (IRF) claims for JE.

Summary of Findings

Since the initiation of the review, 396 claims were reviewed from October 12, 2020 through November 1, 2021 with an overall claim error rate of 35.6% and payment error rate of 29.8%. The breakdown of those findings are as follows:

  • 255 claims were accepted.
  • 22 claims received correction for the following reasons:
    • Documentation did not support discharge status code as billed on the claim.
    • Documentation did not support HIPPS code as billed on the claim.
  • 119 claims were denied in full for the following reasons:
    • Documentation did not support all required attendees were present at interdisciplinary team conference (ITC).
    • Documentation did not support medical necessity of interdisciplinary team approach to care.
    • Documentation did not support pre-admission screening (PAS) was signed and dated with rehabilitation physician concurrence.
    • Documentation did not support post-admission physician evaluation (PAPE) was completed timely.
    • Documentation did not support interdisciplinary plan of care (POC) was completed timely.

If you are a provider that had claims involved in the review sample and disagree with a claim determination, the normal appeal process may be followed as directed on the Noridian website under Appeals or as directed in your claim remittance advice.

Education

Paragraph Name Paragraph Details
Individualized Overall Plan of Care Per Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 1, Section 110.1.3, in order for the Inpatient Rehabilitation Facility (IRF) stay to be considered reasonable and necessary, the plan of care (POC) must be completed within the first 4 days of the IRF admission. It must be individualized to the unique care needs of the patient.

Documentation must demonstrate timely physician involvement with synthesis of the POC. Whereas the individual assessments of appropriate clinical staff will contribute to the information contained in the overall POC, it is the sole responsibility of the rehabilitation physician to integrate the information that is required into the overall POC and to document it in the patient's IRF medical record.

The overall POC must include the patient’s medical prognosis, anticipated interventions by physical, occupational, speech and/or prosthetic/orthotic therapies with number of hours per day, number of days per week, and total number of days during the IRF stay. These expectations for the patient’s course of treatment must be based on consideration of the patient’s impairments, functional status, complicating conditions, and any other contributing factors. The POC must also include anticipated functional outcomes, estimated length of stay and discharge destination.
Interdisciplinary Team Conference

Per Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 1, Section 110.2.5, at a minimum, the interdisciplinary team must document participation by professionals from each of the following disciplines (each of whom must have current knowledge of the patient as documented in the medical record at the IRF):

  • A rehabilitation physician with specialized training and experience in rehabilitation services;
  • A registered nurse with specialized training or experience in rehabilitation;
  • A social worker or a case manager (or both); and
  • A licensed or certified therapist from each therapy discipline involved in treating the patient.

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.

The conferences must be held at a minimum of once per week. All patients that are in the IRF at the time of the weekly interdisciplinary team meeting must be discussed at that meeting.

Documentation of each team conference must include the names and professional designations of the participants in the team conference. It is expected that all treating professionals from the required disciplines will be at every team conference.
Medical Necessity Criteria

Per Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 1, Section 110.2-110.2.5, in order for the Inpatient Rehabilitation Facility (IRF) care to be considered reasonable and necessary, the documentation in the patient’s IRF medical record must demonstrate a reasonable expectation that the following criteria were met at the time of admission to the IRF:

  • Patient required close medical management by a licensed physician with specialized training and experience in inpatient rehabilitation with face to face visits at least three days per week throughout the IRF stay
  • Patient required an intensive and coordinated interdisciplinary team approach, including complex nursing services
  • Patient required active and ongoing therapeutic interventions with multiple therapy disciplines, one of which must be physical or occupational therapy
  • Patient must be expected to actively participate with an intensive rehabilitation therapy program, generally demonstrated by therapy at least 3 hours per day at least five days per week

Patient reasonably expected to actively participate in, and benefit from, the intensive rehabilitation therapy program
Patient Assessment Instrument The completed Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) form that was submitted to the repository must be included in the patient's medical record. The information in the IRF-PAI must correspond with all of the information provided in the patient's IRF medical record and must support appropriate claim coding. Refer to Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 1, Section 110.1.5.
Patient Status Codes The patient discharge status code identifies where the patient is at the end of a health care facility encounter or at the end of a billing cycle. Incorrect use of patient status codes may lead to rejected or cancelled claims and inappropriate reimbursement. Prior to billing a claim, ensure the correct patient status code is utilized to allow for proper claims processing. Reference the Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual (MCPM), Chapter 25 for additional information on patient status codes.
Post-Admission Physician Evaluation

Per Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 1, Section 110.1.2, the Post-Admission Physical Evaluation (PAPE) documents the patient’s status on admission to the IRF. Additionally, the patient’s expected course of interdisciplinary treatment and the overall plan of care begins with the PAPE. Requirements are met when the PAPE is completed by the rehabilitation physician within the first 24 hours after admission to the IRF and includes:

  • Medical necessity for the IRF admission;
  • Relevant changes identified since the preadmission screening;
  • History and physical exam; and
  • Review of the patient’s prior and current medical and functional conditions and comorbidities

A resident or a physician extender can complete the history and physical, but a rehabilitation physician must visit the patient and complete the other required components of the PAPE within the 24 hours immediately following the IRF admission.
Preadmission Screening The preadmission screening (PAS), in the patient’s Inpatient Rehabilitation Facility (IRF) medical record, serves as the primary documentation by the IRF clinical staff of the patient’s status prior to admission and of the specific reasons that led the IRF clinical staff to conclude that the IRF admission would be reasonable and necessary.

The PAS must be completed by licensed or certified clinician(s) that are qualified to perform the evaluation within their scopes of practice and training. The act of reviewing and selecting what information to record on the preadmission screening form is clinical in nature: assessing the patient's medical and functional status, assessing the risk for clinical and rehab complications, and assessing other aspects of the patient's condition both medically and functionally.

The PAS must support the patient’s prior level of function, expected level of improvement, expected length of stay, patient’s risk for clinical complications, conditions that necessitated the need for an IRF stay, anticipated treatments including frequency and duration, anticipated discharge destination including post-discharge treatments, and any other relevant care issues.

The PAS must be completed within 48 hours immediately preceding the IRF admission. Rehabilitation physician review and concurrence with the PAS findings must be documented after the screening is completed and before the IRF admission. A PAS that includes all the required elements, but is conducted more than 48 hours preceding the IRF admission, will be accepted as long as an update is conducted in person or by telephone to document the patient’s medical and functional status within the 48 hours immediately preceding the IRF admission. The focus of the review of the preadmission screening information will be on its completeness, accuracy, and the extent to which it supports the appropriateness of the IRF admission decision. For additional information refer to Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 1, Section 110.1.1.
Rehabilitation Physician Visits Documentation must support that the minimum intensity requirement for the mandatory rehabilitation physician visits was met. The requirement is that the patient must require and receive a minimum of three face-to-face rehabilitation physician visits each week throughout the IRF stay to ensure comprehensive assessments of the beneficiary’s functional goals and progress. Also, note that each of these mandatory visits must be completed by a rehabilitation physician, not a physician extender, a medical resident may also attend, but the medical record must clearly identify the tasks and examination findings completed by the attending rehabilitation physician. Refer to Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Medicare Benefit Policy Manual Chapter 1, Section 110.2.4 for additional information.

Per the IRF PPS Final Rule 2019, the post admission physician evaluation can be counted towards the minimum three face to face visits per week.

 

View references used in review. Further educational opportunities may be found under Education and Outreach. If you are in need of an individualized education training event, contact the POE Department at mac@noridian.com. If you need coding assistance, please check your CPT®, HCPCS, ICD-10 books and your specific association.

Provider Action Required

File results and trending errors are being shared with all providers to assess compliance and billing practices if the service is provided within your facility. If your facility had claim documentation requested for this review, please refer to the individual result letter you received. You can also access individual determinations for claims that were requested from your facility by reviewing comments in either DDE or on the Noridian Medicare Portal (NMP).

Further provider action recommended includes:

  • Provide education regarding errors noted to applicable staff members.
  • Verify documentation supports medical necessity of Inpatient Rehabilitation Facility (IRF) claims.

Summary

This service specific post-payment file is now closed for JE and Noridian will no longer request documentation for this review. Noridian will continue to monitor data analysis and perform medical review for medical necessity and appropriate coding practices.

If you have any other questions, contact the JE Provider Contact Center at 1-855-609-9960.

 

Last Updated Tue, 30 Nov 2021 21:51:51 +0000