IRF Medical Record Contents

The Medicare Inpatient Rehabilitation Facility (IRF) benefit provides intensive rehabilitation therapy in a resource intensive inpatient hospital environment, including Inpatient Rehabilitation Hospitals and Inpatient Rehabilitation Units. The IRF benefit is for a beneficiary who, due to the complexity of his/her nursing, medical management, and rehabilitation needs, requires and can reasonably be expected to benefit from an inpatient stay and an interdisciplinary team approach to rehabilitation care.

To meet the minimum required documentation elements for an IRF claim, the information must include:

  • A comprehensive preadmission screening (PAS) that is:
    • Conducted by a licensed or certified clinician(s) designated by a rehabilitation physician
    • Completed within 48 hours immediately preceding IRF admission
    • Provides a detailed and comprehensive review of each patient's condition and medical history
  • An individualized plan of care (POC) that:
    • Is developed by rehabilitation physician with input from interdisciplinary team
    • Is based on findings of post-admission physician evaluation
    • Is completed within first 4 days of IRF admission
    • Supports determination that IRF admission is reasonable and necessary
  • Admission orders
  • Physician must generate orders to admit patient into IRF
  • Documenting patient's need for intensive rehabilitation therapy services, including an accurate record, avoiding vague or subjective descriptions of patient's care needs
  • IRF Patient Assessment Instrument (IRF-PAI)
    • Included in patient's medical record must be dated, timed and authenticated by person responsible for providing or evaluating service provided
    • Either in a cover page or handwritten somewhere on form; from person who completed (or transmitted) IRF-PAI
    • Completed at admission and discharge of each patient; before transmission into IRF-PAI software
    • Free downloads of Inpatient Rehabilitation Validation and Entry (IRVEN) software product, including Grouper software. View CMS IRF PPS Software webpage

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.

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Last Updated Fri, 05 Nov 2021 20:28:29 +0000