IRF Documentation Requirements - JE Part A
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 | |
| 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
| |
IRF PAI (Patient Assessment Instrument)
| |
Interdisciplinary Team Conference notes
| |
| Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations | |
PT/OT/SLP
| |
| 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
- IRF Plan of Care Documentation Requirements
- 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.
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.
- 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.
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.
