Each pre-claim review request must include, at minimum, the following documentation:

• Pre-Admission Screening
• Supporting Documentation for Admission to the IRF
• Plan of Care (POC)
• Interdisciplinary Team Conference Notes
• Therapy Evaluations/Skilled Notes

Pre-Admission Screening

Determines whether the patient meets Inpatient Rehabilitation Facility (IRF) admission requirements for medical necessity. The screening must be completed or updated by a licensed or certified clinician designated by a rehabilitation physician within 48 hours prior to admission and include a detailed review of the patient's condition and medical history, covering the required components:

• Condition(s) leading to the need for inpatient rehabilitation
• Prior level of function
• Expected level of improvement and timeframe to achieve it
• Risk for clinical complications
• Anticipated treatments/therapies (e.g., physical, occupational, speech therapy, prosthetics/orthotics)
• Expected discharge destination

The rehabilitation physician must review and document concurrence with the screening findings before admission.

Supporting Documentation for Admission to the IRF

Submitted documentation must demonstrate:

• The beneficiary's need for intensive therapy, expected treatments, and ability to participate (e.g., History and Physical, Plan of Care, Therapy Evaluations, Skilled Notes, Interdisciplinary Team notes).
• At admission, the patient required at least two therapy disciplines, one being physical or occupational therapy, with services initiated within 36 hours of midnight on the admission day.
• The rehabilitation physician conducted the required face-to-face visits at least three times per week during the stay (starting week two, a qualified non-physician practitioner may conduct one of the three visits).
• The rehabilitation physician is licensed and determined by the IRF to have specialized training and experience in inpatient rehabilitation.

Plan of Care (POC)

Must be completed within four days of the beneficiary's IRF admission and developed by the rehabilitation physician with input from the interdisciplinary team.

Interdisciplinary Team Conference Notes

Documentation must confirm that the initial weekly interdisciplinary team meeting was held and meets these requirements:

• Attended by the rehabilitation physician, registered nurse, social worker/case manager (or both), and applicable licensed or certified therapists.
• Led by the rehabilitation physician, who concurred with all decisions made.
• Reviewed the beneficiary's progress, or lack of, towards established goals.
• Conducted weekly.
• If a patient is admitted on the scheduled meeting day, CMS expects all current IRF patients to be discussed. If admitted after that day's meeting, the patient should be discussed at the next scheduled meeting (day 8). It is not acceptable to delay discussion until day 9 or 10.

Therapy Evaluations/Skilled Notes

Required (if applicable):

• Initial Physical Therapy Evaluation
• Initial Occupational Therapy Evaluation
• Initial Speech-Language Pathology Evaluation

Additional documentation (as available):

• Physical Therapy Notes
• Occupational Therapy Notes
• Speech-Language Pathology Notes