Eli's Rehab Report

Published on Fri Jan 16, 2009 PDF

Know this list, and you're on the road to solid reimbursement.

In the previous article, you read about preadmission screening for inpatient rehab facilities -- but that's just the tip of the documentation iceberg. Get familiar with this larger list of must-haves the Centers for Medicare & Medicaid Services (CMS) spells out in Transmittal 112:

1) A qualified clinician must complete a preadmission screening no more than 48 hours before IRF admission;

2) The physician must generate admission orders for the patient's care at the time of admission;

3) A rehab physician must perform a postadmission evaluation no later than 24 hours after the IRF admission;

4) The physician must complete an overall plan of care with an estimated length of stay within the first four days of IRF admission;

5) You must include the IRF patient assessment instrument (IRF-PAI) form in the patient's medical record;

6) CMS requires documented visits from the rehab physician at least three times a week; and

7) Documentation must include notes from once-aweek interdisciplinary team conferences including the physician's concurrence with all decisions made in the meeting.

Bottom line: The physician must be heavily involved in all facets of documentation. "The biggest challenge will be implementing the key physician tasks with documentation at the appropriate time and in the right sequence," says Angie Phillips, PT, executive VP and COO of GlobalRehab Hospitals in Dallas.

Fran Fowler, FAAHC, managing director of Health Dimensions Group in Atlanta, agrees that the time crunch will be a challenge. "The preadmission screening and the 24-hour physician documentation after admission are two areas I think will be heavily probed over the next six months to a year," she says.

For more details on required steps past the preadmission screening, stay tuned to future issues of Physical Medicine & Rehab Coding Alert.