Inpatient Rehabilitation Facility (IRF)
An IRF is a hospital, or part of a hospital, that provides an intensive rehabilitation program to inpatients. Patients who are admitted must be able to tolerate an intensive level of rehabilitation services and benefit from a team approach. The IRF benefit is not to be used as a substitute to complete the full course of treatment in the referring hospital. A patient who has not yet completed the full course of treatment in the referring hospital is expected to remain there, with appropriate rehabilitative treatment provided, until the full course of treatment has been completed. The medical records must support that the documentation and criteria requirements are both met for the IRF stay to be considered medically reasonable and necessary.
The documentation requirements are outlined in the Internet Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110
- Preadmission Screening, Post-Admission Physician Evaluation, Individualized overall plan of care (POC), Physician Orders and IRF-Patient Assessment Instrument (PAI)
A comprehensive preadmission screening process is the key factor in initially identifying appropriate candidates for IRF care. It must be conducted by qualified licensed or certified clinician(s) within the 48 hours immediately preceding the IRF admission.
The preadmission screening documentation must indicate the patient's prior level of function (meaning prior to the event or condition that led to the patient's need for intensive rehabilitation therapy), expected level of improvement, evaluation of the patient's risk for clinical complications and the expected length of time necessary to achieve that level of improvement.
Post-Admission Physician Evaluation
The purpose of the post-admission physician evaluation is to document the patient's status AFTER admission to the IRF, NOTE ANY DISCREPANCIES WHEN comparing to the patient's status documented in the preadmission screening documentation, and then begin developing the patient's expected course of treatment that will be completed with input from all of the interdisciplinary team members into the overall plan of care.
Individualized Overall POC
The individualized overall plan of care must be "individualized" to the unique care needs of the patient based on information found in the preadmission screening, the post-admission physician evaluation and what is collected in therapy assessments. THE INFORMATION MUST BE integrated by a rehabilitation physician to support a documented overall plan of care that is completed and signed within four (4) days of admission.
The physician must generate orders to admit the patient into the IRF. The orders must be retained the patient's medical record at the IRF and meet the signature requirements in the Internet Only Manual (IOM) Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 126.96.36.199
The CMS IRF Patient Assessment Instrument webpage contains:
- Updated IRF-PAI Training Manual
- Copy of the Final IRF-PAI for October 1, 2016
- System Maintenance and data transmission information
The IRF-PAI must be included in the patient's medical record either in electronic or paper format. The data collected on the IRF-PAI should correspond with the information in the patient's medical records at the IRF.
The medical records must demonstrate a reasonable expectation of the following reasonable and necessary criteria in the Internet Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110.2 .
The patient's medical condition and functional status must require the level of care available at the IRF including close medical management and physician supervision, complexity of nursing services and intense interdisciplinary therapy services. IRF medical record documentation must support that each of these items listed were met throughout the patient's course of treatment.
- Multiple Therapy Disciplines - Multiple therapy disciplines i.e., physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics must be actively involved in treating the patient.
- Intensive Level of Rehabilitation Services - Minimum therapy intensity can be demonstrated by at least three (3) hours per day at least five (5) days a week. Intensity may also be demonstrated by the provision of 15 hours in a seven (7) -consecutive day period starting from the date of admission, in certain well-documented cases. Documentation must clearly indicate the clinicians name, professional credentials and the amount (in minutes) of each therapy service provided for each date.
- Intensive Therapy Program - The patient's condition and functional status must be such that they can reasonably be expected to make measurable improvement participating in the intensive therapy program available at the IRF. The standard of care for IRF patients is individualized therapy (not group therapy).
- Physician Supervision - The patient's condition and/or status must require the level of physician supervision available in the IRF. The rehabilitation physician must conduct face-to-face visits with the patient at least three (3) days per week throughout the patient's stay to assess the patient both medically and functionally, as well as to modify the course of treatment as needed to maximize the patient's capacity to benefit from the rehabilitation process.
- Interdisciplinary Team Approach - The purpose of the interdisciplinary team is to foster frequent, structured, and documented communication among disciplines to establish, prioritize, and achieve treatment goals. Each individual member of the team must work within their scope of practice and is expected to coordinate efforts to benefit the patient's progress and individual needs. Periodic team conferences must be held at least once a week and the decisions made during these meetings such as discharge planning, adjustments in goals or treatment program must be recorded in the patient's medical record. Documentation must also support that all required qualified team members are present at each interdisciplinary conference.
- CMS Internet Only Manual (IOM), Medicare Benefit Policy Manual, Publication 100-02 Chapter 1, Section 110 - Explanation of IRF benefit and criteria to be met for medical necessity
- CMS IOM Publication 100-04 Medicare Claims Processing Manual, Chapter 3 – Inpatient Hospital Billing, Sections 140, 150 – Explains billing requirements for all types of inpatient services
- IRF Prospective Payment System
- IRF Quality Reporting & Program Details
Last Updated Jan 20, 2017