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:
| Legible handwritten physician and/or clinician signatures |
| Valid electronic physician and/or clinician signatures |
|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 |
|IRF Patient Assessment Instrument (PAI)|
|Documentation to support information entered on IRF PAI|
| Interdisciplinary communication, meetings, or team conferences documentation |
| Physical Therapy (PT), Occupational Therapy (OT), Speech Language Pathology (SLP) |
|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 |
|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|
- IRF Plan of Care Documentation Requirements
- IRF Services and Pre/Post-Admission Documentation
- CMS Inpatient Rehabilitation Therapy Services: Complying with Documentation Requirements - Fact Sheet
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.
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.
- Noridian Medical Review: Additional Documentation Request (ADR)
- Comprehensive Error Rate Testing (CERT): CID Request
- Level One Appeal: Redetermination Request
View the Inpatient Rehabilitation Facility (IRF) webpage for additional information and resources.
Last Updated Feb 28, 2020
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.