Inpatient Facility Coding & Compliance Alert

Boost your bottom line with these IRF PPS requirements.

If you are part of an Inpatient Rehabilitation Facility (IRF), get ready as the OIG plans to review your compliance with various aspects of the IRF PPS (Prospective Payment System), including the documentation required to support Medicare payments. 

As promised in the previous issue of Inpatient Facility Coding and Compliance Alert, we bring you the IRF coverage criteria that help you to understand and customize your facility processes in accordance with federal laws and regulations.

For the purpose of reimbursement, make sure to take care of the following prerequisites.

Step 1: See the Patient Through IRF Admission

The patient should meet all of the following requirements: 

Need: The patient should require the active and ongoing therapeutic intervention of multiple therapy disciplines (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics therapy), one of which must be physical or occupational therapy. 

Capability: The patient should be capable of active participation in a therapeutic intensive rehabilitation therapy program. This includes at least three hours of therapy (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics therapy) per day at least five days per week. The required therapy treatments must begin within 36 hours from midnight of the day of admission to the IRF. 

Stability: Make sure the patient is medically stable at the time of admission to the IRF. The patient must be under medical supervision of the rehabilitation physician, who must visit the patient at least three days per week to assess the patient both medically and functionally, and steer the course of rehabilitation.

Step 2: Ensure Impeccable Documentation

Your documentation should be able to exhibit all the following components: 

Preadmission screening: This screening should be conducted by a designated rehabilitation physician, preferably within 48 hours of the IRF admission. It should include details of patient’s condition and medical history. This preadmission screening helps to verify the patient’s readiness for an IRF admission. Remember to keep the information in patient’s medical record at the IRF.

Post-admission physician evaluation: A rehabilitation physician completes this evaluation within 24 hours of the patient’s admission, documenting the patient’s status on admission to the IRF and verifying the information presented in the preadmission screening documentation. This serves as the basis for developing the overall individualized plan of care. This, too, is retained in the patient’s medical record at the IRF.

Plan of care: This plan is developed by a rehabilitation physician, with input from the interdisciplinary team within four days of the patient’s admission to the IRF, and also maintained in patient’s medical record at the IRF.

Step 3: Requires an Interdisciplinary Team Approach 

“The record must establish that the patient’s nursing, medical management, and rehabilitation needs requires an interdisciplinary team approach to care, in order to support an IRF claim as reasonable and necessary,” stresses Wayne J. Miller, Esq., founding partner of Compliance Law Group in Los Angeles. 

The team consists of a rehabilitation physician, a rehab nurse, a social worker or case manager, and a certified therapist. All team members must have current knowledge of the patient’s medical and functional status. The team should meet at least once per week to review the patient’s progress, implement appropriate treatment services, identify any problems, and reassess the treatment plan and established goals in light of impediments, if any. The results and findings should be available in the patient’s medical record.

Impact to you: If you work for an IRF, it’s time to go through the above mentioned documentation and coverage requirements, and safeguard your revenue. 

For more details, visit:

http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/pdf/CFR-2011-title42-vol2-sec412-622.pdf