IRF Billing Guide

Requirement Description
Unique Identifying Provider Number Ranges

3rd - 6th digits:

  • 3025-3099 (Free-standing)
  • IRF units will have 3rd digit "T"
Type Of Bill (TOB)
  • 111 - Admit to discharge
  • 112 - 1st sequential (ancillary)
  • 117 - Adjustment or Interim
  • 118 - Cancel
  • 110 - No payment
  • 11Q - Beyond Timely Filing
Billable Visit

CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110

42 CFR §§412.622(a)(3), (4), and (5)

Documentation Requirements (110.1)

  • Preadmission Screening
  • Individualized Overall Plan of Care
  • Admission Orders
  • Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI)

Medical Necessity Criteria (110.2)

  • Patient requires active/ongoing multiple therapy disciplines (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics), one of which must be physical or occupational therapy
  • Minimum 3 hours daily therapy at least 5 days per week, or minimum 15 hours therapy within 7-consecutive day period, beginning with IRF admission date (110.2.2)
  • Patient reasonably expected to participate in and benefit significantly from the intensive rehabilitation therapy program (110.2.2) at time of IRF admission
  • Patient requires physician (defined below) supervision, including face-to-face visits at least 3 days per week throughout the IRF stay
  • Patient requires an intensive and coordinated interdisciplinary approach to providing rehabilitation (110.2.5)
Physician Rehabilitation physician or other licensed treating physician with specialized training and experience in rehabilitation
Interdisciplinary Team

At a minimum, the team consists of:

  • A rehabilitation physician with specialized training and experience in rehabilitation services;
  • A registered nurse with specialized training or experience in rehabilitation;
  • A social worker or a case manager (or both); and
  • A licensed or certified therapist from each therapy discipline involved in treating the patient.

The interdisciplinary team is led by the rehabilitation physician. Periodic team conferences are held at least once per week
Revenue Codes 0024
Services Multiple therapy disciplines (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics therapy) ongoing, one of which must be physical or occupational therapy
Payment Type Federal Case Mix Group (CMG) classification + facility level adjustments. Finalized on last discharge claim
Frequency of Billing Bill upon discharge or interim billing after 60 days from admission and every 60 days thereafter as adjustment claim. No need to split claims for provider/Medicare FYE or calendar years
Billing Pre-Entitlement Days

IOM 100-4, Chapter 3, Section 40		 Provider may only bill for days after entitlement if the claim exceeds cost outlier if they were not entitled to Medicare upon date of admission
Benefit Period

IOM 100-2, Chapter 3

2021 Part A Deductible - $1,484.00

  • 1-60 - days paid in full
  • 61-90 - coinsurance days $371.00 per day
  • 91-150 - Lifetime Reserve Days (LRDs) $742.00 per day
Benefits Exhaust

IOM 100-4, Chapter 3, Section 40.2

Benefits do not exhaust until all 90 days are used in the benefit period and LRDs is Zero

  • Use A3 occurrence code for last covered day on claim that exhausts benefits
Same Day Transfers

IOM 100-4, Chapter 3, Section 40.1

Discharging hospital bills:

  • Day entered non-covered
  • Charges entered covered, with condition code 40

Receiving hospital bills claim as usual. Shared diagnosis-related group (DRG) applies
Provider Liable Days

IOM 100-4, Chapter 3, Section 40.1(F)

IOM 100-4, Chapter 4, Section 240.1
  • Use occurrence span code 77 if part of the claim is not medically necessary or is custodial care
  • Use occurrence span code M1 if the entire claim is not medically necessary or is custodial care
Services Provided at Other Facilities During Inpatient Stay IRF is responsible for all services provided by other facilities during the inpatient stay
72-hour/24-hour Preadmission Bundling Rule

IOM 100-4, Chapter 3, Section 40.3(B)		 Not subject to 72-hour rule but are subject to the 24-hour bundling rule for preadmission services to be included on the IRF claim for services provided within your campus
Same Day Discharge & Readmission

IOM 100-4 Chapter 3, Section 40.2.5		 Discharge to acute and returns to IRF before midnight would have all charges included on IRF claim with no same-day transfer claim submitted by acute hospital
Interrupted Stays/LOA

IOM 100-4, Chapter 3, Section 150.9.1.2

3-day interrupted stay with day of hospital discharge and returns by midnight on the 3rd consecutive day. If this occurs this is considered 1 admission with 1 payment and reflected with days billed in non-covered

  • Occurrence span code 74
  • Revenue code 180
Inpatient Care No Longer Needed

IOM 100-4, Chapter 3, Section 40.2.2(C)

Date beneficiary notified through Limitation Of Liability, including:

  • Occurrence code 31
  • Occurrence span code 76
  • Value code 31
Cost Outliers

IOM 100-4, Chapter 3, Section 20.1.2, 20.7.4		 Cost outlier payment start day is shown on the claim using occurrence code 47. Provider cannot use LRDs prior to cost outlier day if they run out of full/co-insurance days in that benefit period. If the beneficiary starts the admission with no full or co-insurance days available they can start the day of admission using LRDs without waiting for the cost outlier days. If the beneficiary has some full or coinsurance days but not enough to cover up to the cost outlier day, use occurrence span code 70 to reflect the free/inlier days
Ancillary Part B Claims

12x Type Of Bill

  • Beneficiary doesn't qualify under Part A due to entitlement, benefits exhaust or inpatient stay not medically necessary

 

Last Updated Dec 09 , 2023