Updated on: November 29, -0001

IRF Narrative Assessments: Establishing the Foundation for Reasonable and Necessary Care

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Original story posted on: February 24, 2016

On a recent Monitor Mondays broadcast, we reported that a common finding in our audits of inpatient rehabilitation facility (IRF) records is a missing or inadequate “narrative assessment” statement in the preadmission assessment screening (PAS). When reviewing the PAS, we are looking for sufficient information to support the IRF’s decision to admit the patient for IRF services.  

The screening should include sufficient documentation and assessment to demonstrate that the patient meets the requirements for IRF admission and should demonstrate that the patient meets the following criteria:

  • Has sufficient functional loss to warrant an interdisciplinary approach;
  • Has the need for at least two therapies;
  • Has the need for intensive therapy services;
  • Requires a team approach; and
  • Requires rehabilitation physician management of the patient’s inpatient stay. 

The narrative statement serves to provide the rationale for the stay and the basis for the patient’s ongoing care and services in the IRF. 

Regulatory Requirements

Chapter 1, Section 110.1.1 of the Medicare Benefit Policy Manual provides the regulatory requirement for the preadmission screening. While the language in the Manual provides significant freedom to each organization as to how the preadmission screen is organized and completed, the requirement for “evaluation” is repeated throughout the document. 

The manual clarifies that the PAS is the primary documentation to support the admission:  

“The preadmission screening in the patient’s IRF medical record serves as the primary documentation by the IRF clinical staff of the patient’s status prior to admission and of the specific reasons that led the IRF clinical staff to conclude that the IRF admission would be reasonable and necessary. As such, IRFs must make this documentation detailed and comprehensive.”

Continuing, the Manual notes that “the preadmission screening documentation must indicate the patient’s prior level of function (prior to the event or condition that led to the patient’s need for intensive rehabilitation therapy), expected level of improvement, and the expected length of time necessary to achieve that level of improvement. It must also include an evaluation of the patient’s risk for clinical complications, the conditions that caused the need for rehabilitation, the treatments needed (i.e., physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics), expected frequency and duration of treatment in the IRF, anticipated discharge destination, any anticipated post-discharge treatments, and other information relevant to the care needs of the patient.”

Where’s the Requirement for a Narrative Statement?

On Nov. 12, 2009, during a provider training call, the Centers for Medicare & Medicaid Services (CMS) indicated that the preadmission screen must include narrative information. Subsequent documentation was posted to the CMS website, and it included questions related to that narrative information. The clarification document can be found online here: https://www.cms.gov/medicare/medicare-fee-for-service-payment/inpatientrehabfacpps/downloads/irf-training-call_version_1.pdf and includes the following information:

“On the Nov. 12 provider training conference call, CMS indicated that the preadmission screening documentation must not be presented entirely in the form of ‘check boxes,’ but instead must contain some narrative information. Thus, for example, the documentation cannot merely contain ‘yes/no’ check boxes for whether the patient has a risk for clinical complications.  It must describe in detail what conditions/comorbidities the patient has and why these indicate a specific risk for clinical complications that require physician monitoring in order for the patient to actively participate in an intensive rehabilitation therapy program. This detailed description, by the very nature of it, would need to be in narrative form. “

Using the Narrative Statement to Support Reasonable and Necessary Care

Our advice to our clients is this: Use the narrative statement to summarize the patient’s IRF needs and your rationale for admission. By doing this, you establish the basis for the admission decision and begin setting the framework for IRF treatment. The narrative assessment clarifies why it is reasonable and necessary for the patient to receive services in an IRF rather than in another treatment setting. 

An effective assessment includes a description of the patient’s prior and current levels of function, the expected functional improvement (along with what therapy interventions will be required to reach those goals), and a description of the patient’s ability to participate and benefit from IRF treatment. It also should address the need for rehabilitation physician supervision of the functional rehabilitation program, along with coordination of medical management of comorbid conditions that impact the patient’s care. Finally, it should address the patient’s needs for a multidisciplinary approach that is consistent with the deficits noted.

The Bottom Line

The PAS should clearly identify the patient’s IRF needs and must include sufficient information to support the decision for admission. A detailed and specific PAS serves as the basis for admission and becomes the primary document for the IRF team to utilize in beginning evaluation and treatment planning. 

About the Author

Angela M. Phillips, PT, is president  and chief executive officer of Images & Associates. A graduate of the University of Pennsylvania’s School of Allied Health Professions, she has almost 40 years of experience as a consultant, healthcare executive, hospital administrator, educator, and clinician. Ms. Phillips is one of the nation’s leading consultants assisting inpatient rehabilitation facilities in operating effectively under the Medicare Prospective Payment System (PPS) and in addressing key issues related to compliance.

Contact the Author

angela.phillips@att.net

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Angela Phillips, PT

Angela M. Phillips, PT, is President and Chief Executive Officer of Images & Associates. A graduate of the University of Pennsylvania’s School of Allied Health Professions, she has more than 40 years of experience as a consultant, healthcare executive, hospital administrator, educator, and clinician. Ms. Phillips is one of the nation’s leading consultants assisting Inpatient Rehabilitation Facilities in operating effectively under the Medicare Prospective Payment System (PPS) and in addressing key issues related to compliance. Ms. Phillips is a member of the RACmonitor editorial board and a popular guest panelist on Monitor Mondays.

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