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
  Legible handwritten physician and/or clinician signatures

 

  Valid electronic physician and/or clinician signatures

 

  • If an Electronic Health Record (EHR) is used, the Electronic Order Signature Process [PDF] should be submitted to verify provider's Electronic Ordering System is secure
  Physician admission order for date of service, if applicable
  Preadmission Screening (PAS) reviewed by physician
  Post-admission Physician Evaluation (PAPE)
  Physician individualized overall Plan of Care (POC)
  Physician/Non-Physician Practitioner (NPP) visit/progress notes and orders

 

  • Documentation to support minimum required three rehabilitation physician face to face visits
  IRF Patient Assessment Instrument (PAI)
  Documentation to support information entered on IRF PAI
  Interdisciplinary communication, meetings, or team conferences documentation

 

  • Documentation including legible names and professional credentials of each qualified participant attending team conference (rehabilitation physician, registered nurse, social worker/case manager, licensed/certified therapist from each therapy discipline involved in treating the patient)
  Physical Therapy (PT), Occupational Therapy (OT), Speech Language Pathology (SLP)

 

  • Plan(s) of care and progress reports since initial evaluation
  • Initial evaluations/re-evaluations
  • Physician order
  • Treatment encounter notes and therapy minutes
  • Therapy discharge summary (if applicable)
  • Summary report of therapy minutes for each day of IRF stay (if applicable)
  Lab reports/results
  Nutrition notes, vital signs and medication administration records
  Nurses notes and treatment records
  Itemized bill indicating revenue code
  Records of patient's condition before, during and after this billing period to support medical necessity and reason service was provided

 

  • Hospital history and physical
  • Hospital discharge summary and transfer form
  Documentation to support indications and/or criteria as specified in Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs) or coverage article for service(s) billed, if applicable
  Advance Beneficiary Notice of Noncoverage (ABN), if applicable

 

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 Feb 08, 2019

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.