IRF Documentation Requirements

It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:

Check Brief Description
  Physician/Non Physician Practitioner (NPP) order
  History and Physical reports (include medical history and current list of medications)
  Discharge Summary from hospital or other facility
  Preadmission screening/notes
  Post admission physician evaluation (PAPE)
  • Not required for discharges on/after 10/01/20
  • Late-file claims with discharges prior to October 1, 2020, would still be governed by the PAPE documentation requirement
  Signed and dated overall plan of care including, short and long term goals with any updates to the plan of care
  Practitioner, nurse, and ancillary progress notes
  • Medical necessity for IRF
  • Support minimum required face to face visits
  • Nutrition notes
  • Treatment records
  • Vital signs and weight
  IRF PAI (Patient Assessment Instrument)
  • Documentation to support information
  Interdisciplinary Team Conference notes
  • Names and professional credentials of participants
  Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations
  PT/OT/SLP
  • Initial evaluation
  • Plan of care
  • Treatment encounter notes
  • Therapy minutes log
  • Discharge summary
  Medication Administration Record (MAR) and/or Infusion Flowsheet documenting the quantity administered include a dose, route, and frequency given
  Vital sign records, weight sheets, and treatment records
  Itemization of services
  Advance Beneficiary Notice
  Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  Facility process of how electronic signature is created if using electronic health record

 

Additional Resources

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A Claim Review for detailed information about each of these contractors.

Documentation Submission

Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.

View the Inpatient Rehabilitation Facility (IRF) webpage for additional information and resources.

 

Last Updated Wed, 26 Oct 2022 15:25:21 +0000

Documentation Requirements Disclaimer

The documentation requirements contents/references provided within this section were prepared as educational tools and are not intended to grant rights or impose obligations. Use of these documents are not intended to take the place of either written law or regulations.

The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered.

Important that physician intent, physician decision and physician recommendation to provide services derived clearly from the medical record and properly authenticated.

The submission of these records shall not guarantee payment as all applicable coverage requirements must be met.