Drill Down: IRF Coverage Criteria (Are You Covered?)

By
Original story posted on: July 12, 2013

alert-powered-by-decision-health

The RAC Region A contractor, Performant, recently posted a complex audit review issue regarding inpatient rehabilitation facility (IRF) admission in the states of Connecticut, Delaware, Massachusetts, Maine, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont.

IRF benefits are designed to provide intensive, in-facility rehabilitation therapy for patients who, due to the complexity of their nursing, medical management, and rehabilitation needs, require and can reasonably be expected to benefit from an inpatient stay and an interdisciplinary team approach. Performant’s complex review will determine if patients met the coverage criteria for admission to an IRF.

The complete list of coverage criteria can be found in 42 CFR 412.604. Some examples of scenarios for payment under the prospective payment system for inpatient rehabilitation facilities include:

  • The patient actively participates in an ongoing therapeutic regimen featuring multiple therapies (physical, occupational, speech-language, and/or prosthetics/orthotics).

  • The patient actively participates in three hours of therapy per day, five days a week, or 15 hours of intensive therapy, seven days a week.

  • The patient requires face-to-face visits with a rehabilitation physician.

  • The patient requires comprehensive preadmission screening by a licensed clinician designated by a rehabilitation physician at least within 48 hours of admission.

  • The patient requires an interdisciplinary, team approach to care, with documented meetings and a plan of care.

The U.S. Department of Health and Senior Services (HHS) Office of Inspector General (OIG) has cited criteria for those patients who do not need IRF care, as outlined in the Centers for Medicare & Medicaid Services (CMS) Medicare Benefit Policy Manual, 100-02, Chapter 1, Section 110. These criteria include:

  • Uncomplicated hip or knee surgery or some other form of single joint replacement that requires only pain medication and simple therapy.

  • Simple orthopedic injuries and neurological conditions that require only general muscle strengthening and reconditioning.

In the above cases, preadmission screening procedures do not identify consistently those patients who could be treated in a less intensive facility – or those who were not capable of significant improvement as a result of therapy or were unable to participate fully in IRF care.

RAC issues for the week of July 15–19, 2013:

RAC Region A (Performant)

Inpatient Rehabilitation Facility Claim Types

  • Inpatient Rehabilitation Facility (IRF) Admission - The IRF benefit is designed to provide intensive rehabilitation therapy in a facility for patients who, due to the complexity of their nursing, medical management, and rehabilitation needs, require and can reasonably be expected to benefit from an inpatient stay and an interdisciplinary team approach. The review will determine if the patient met the coverage criteria for the admission to the IRF.

About the Author

Dr. Margaret Klasa is the medical director for Context4 Healthcare. She is responsible for the company's business knowledge discovery unit for medical context as it relates to the daily development of data products and software for medical claims editing and coding, with an emphasis on clinical and regulatory guidelines for Medicare, Medicaid and commercial payors.

Contact the Author

Margaret.Klasa@context4.com

To comment on this article please go to editor@racmonitor.com

Margaret Klasa, DC, APN, Bc

This email address is being protected from spambots. You need JavaScript enabled to view it.