An IRF is a hospital, or part of a hospital, that provides an intensive rehabilitation program to inpatients. Patients who are admitted must be able to tolerate an intensive level of rehabilitation services and benefit from a team approach. The IRF benefit is not to be used as a substitute to complete the full course of treatment in the referring hospital. A patient who has not yet completed the full course of treatment in the referring hospital is expected to remain there, with appropriate rehabilitative treatment provided, until the full course of treatment has been completed. The medical records must sufficiently demonstrate that the admission to an IRF was reasonable and necessary.

On this page, view key documentation components.

• Preadmission Screening
• Post-Admission Physician Evaluation (PAPE)
• Individualized Overall Plan of Care (POC)
• Physician Orders
• IRF-Patient Assessment Instrument (IRF-PAI)
• IRF Group and Concurrent Therapy
• IRF Medical Record Content
• IRF Billing Guide
• Part A to B Rebilling Guidance

Preadmission Screening

A comprehensive preadmission screening process is the key factor in initially identifying appropriate candidates for IRF care. It must be conducted by qualified licensed or certified clinician designated by a rehabilitation physician within the 48 hours immediately preceding the IRF admission. Screening must be conducted in person or through a review of the patient's referring hospital medical records when a hospital stay precedes the IRF admission.

The preadmission screening documentation must indicate the patient's prior level of function (meaning prior to the event or condition that led to the patient's need for intensive rehabilitation therapy), expected level of improvement, evaluation of the patient's risk for clinical complications and the expected length of time necessary to achieve that level of improvement. It serves as a detailed comprehensive review of the patient's condition and medical history. It must be signed, dated and timed by the rehabilitation physician.

Post-Admission Physician Evaluation (PAPE)

The post-admission physician evaluation (PAPE) documentation requirement, previously required pursuant to 42 CFR § 412.622(a)(4)(ii), was removed in the FY 2021 IRF PPS Final Rule (85 FR 48424).

The PAPE is no longer required for discharges on or after October 1, 2020. However, the history and physical is still required under the Conditions of Participation at 42 CFR § 482.24(c)(4)(i)(A).

For the purposes of late-file claims with discharges prior to October 1, 2020, the PAPE would still be considered required documentation.

The purpose of the PAPE is to document the patient's status on admission within 24 hours AFTER the IRF admission (including weekends and holidays). NOTE ANY DISCREPANCIES when comparing to the patient's status documented in the preadmission screening. Document all information supporting the medical necessity of the IRF admission and begin development of the patient's expected course of treatment. The PAPE notes any changes that may have occurred since the preadmission screening or notes that no changes occurred. It includes a history and physical exam, the prior and current functional conditions or comorbidities. It must be signed, dated and timed by the rehabilitation physician (42 Code of Federal Regulations (CFR) 482.24(c)(1)).

Individualized Overall Plan of Care (POC)

The rehabilitation physician develops the patient's expected course of treatment completed with input from all interdisciplinary team members. The individualized overall POC must be "individualized" to the unique care needs of the patient based on information found in the preadmission screening, the PAPE and what is collected in therapy assessments. THE INFORMATION MUST BE garnered and integrated by a rehabilitation physician to support a documented overall POC that is completed and signed within four (4) days of admission. It is acceptable to complete on day 1, 2, 3, or 4 of the patient's IRF admission, with the day of admission counting as "day 1". The documented POC must support the determination that the IRF admission is reasonable and necessary.

Physician Orders

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. The physician must assess the patient both medically and functionally; and modify the course of treatment as needed to maximize the patient's capacity to benefit from the rehabilitation process.

Beginning with FY 2019 (IRF discharges beginning on or after October 1, 2018), the admission order documentation requirement at 42 code of Federal Regulation (CFR) 412.606(a) has been removed.

Admission Orders should continue to be appropriately documented in accordance with 482.12(c) and 482.24(c) of the hospital Conditions of Participation (CoPs), as well as the hospital admission order payment requirements at 412.3

IRFs are responsible for meeting all of the inpatient hospital CoPs and the hospital admission order payment requirements

IRF-Patient Assessment Instrument (IRF-PAI)

The CMS IRF Patient Assessment Instrument webpage contains:

• Updated IRF-PAI Training Manual
• System Maintenance and data transmission information

The IRF-PAI must be completed at the admission and discharge of each patient. The IRF-PAI must be included in the patient's medical record either in electronic or paper format. The data collected on the IRF-PAI should correspond with the information in the patient's medical records at the IRF. It is important to remember that prior to submission of the IRF claim to A/B MAC (A), the IRF-PAI must process completely at the CMS National Assessment Collection Database. The provider can verify this by reviewing their IRF-PAI validation report.

Resources

• CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110 - IRF Services
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 140.1.1 - Criteria That Must Be Met By Inpatient Rehabilitation Facilities
• CMS IRF PPS
• CMS IRF Quality Reporting & Program Details
• CMS Medicare Learning Network (MLN) Matters (MM) 12353