Inpatient Rehabilitation Facility Review Demonstration Required Documentation for a Pre-Claim Review Submission

An Inpatient Rehabilitation Facility (IRF) is designed to provide intensive rehabilitation therapy within a resource-intensive hospital environment for patients who, due to the complexity of their medical, nursing and rehabilitation needs, require (and can reasonably be expected to benefit from) an inpatient stay and an interdisciplinary approach to the delivery of rehabilitation care.

Specific medical record documentation at the time of an IRF admission must support a reasonable expectation that the patient needs multiple intensive therapies (one of which must be physical or occupational therapy); the patient must be able to actively participate and demonstrate measurable improvement; and the patient requires supervision by a rehabilitation physician to assess and modify the course of treatment as needed to maximize the benefit from the rehabilitation process.

For a pre-claim review (PCR) review submission, each patient’s medical record should contain, but is not limited to, the following documentation: 

• Pre-Admission Screening (PAS)
  • The PAS is an evaluation of the patient’s condition and need for rehabilitation therapy and medical treatment that must be conducted or updated by licensed or certified clinician(s) within the 48 hours immediately preceding the IRF admission
  • Serves as the primary documentation of the patient’s status prior to admission and documents the specific reasons that led the IRF clinical staff to conclude that the IRF admission was reasonable and necessary
  • Must include:
    • Prior level of function
    • Expected level of improvement
    • Expected length of time to achieve that level of improvement
    • An evaluation for the risk for clinical complications 
    • Conditions that caused the need for rehabilitation 
    • The treatments needed (i.e., physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics) 
    • Anticipated discharge destination
  • All findings of the preadmission screening should be conveyed to a rehabilitation physician who must document that he or she has reviewed and concurs with the findings and results of the preadmission screening prior to the IRF admission
     
• Therapy Evaluation/Note(s)
  • Documentation should support the patient’s need for 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
  • Documentation should demonstrate the required therapy services began within 36 hours from midnight of the day of admission to the IRF
     
• Rehabilitation Physician Supervision Note(s)
  • The patient must require supervision by a rehabilitation physician who is a licensed physician who is determined by the IRF to have specialized training in inpatient rehabilitation
  • The requirement for medical supervision means that the rehabilitation physician must conduct face-to-face visits with the patient at least three days per week throughout the patient's stay in the IRF 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
    • Beginning with the second week of admission to the IRF, a nonphysician practitioner who is determined by the IRF to have specialized training and experience in inpatient rehabilitation may conduct one of the three required face-to-face visits with the patient per week, provided that such duties are within the nonphysician practitioner’s scope of practice under applicable state law
  • Documentation submitted for PCR should demonstrate the supervision visit(s) have been initiated
     
• Additional Reasonable and Necessary Documentation Requirements
  • Documentation should also demonstrate the patient:
    • Generally, requires and can reasonably expected to actively participate in, and benefit from, an intensive rehabilitation therapy program
    • Is sufficiently stable at the time of admission to the IRF to be able to actively participate in the intensive rehabilitation therapy program
       
• Resubmissions Will Require Additional Documentation (when available)
  • If the provider receives a non-affirmed decision, the submitter should review the decision letter that was provided, make whatever modifications are needed to the PCR package, and resubmit the request. This includes indicating the request is a resubmission of a non-affirmed decision and providing the non-affirmed UTN on the request form.

Note: The response will be sent to the submitters using the same method as the request was sent, if available, and a notification of the decision via telephone within two (2) business days. However, if the submission is via fax, a response is only sent via fax if a return fax number is included in the request. Otherwise, the response will be sent via greenmail.

Resources

• Code of Federal Regulations: 42 CFR 412.622 — Basis of payment
• CMS Internet-Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110 (PDF)
• Inpatient Rehabilitation Facilities (IRF) Reason Codes and Statements (PDF)
• Review Choice Demonstration for Inpatient Rehabilitation Facility Services 
• IRF RCD Operational Guide (PDF)
• IRF RCD Flowchart (PDF)