This bulletin is to be shared with all managerial staff and health practitioners who are responsible for coding, billing, and submitting medical records.  Additional copies may be downloaded from our web site at: www.highmarkmedicareservices.com.

This bulletin has been updated. Please refer to Hospital Notice 07-007.

Purpose

The purpose of this notice is to inform the provider community of the results surrounding a service-specific probe review of Inpatient Rehabilitation Facility (IRF) admissions,  conducted by Highmark Medicare Services (Highmark Medicare Services).  The information in this notice is also intended to reduce provider denials and to decrease the claims-error rate.

Regulations

Medicare coverage regulations stipulate that to be paid by Medicare, health care services must be considered "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member." The Social Security Act 1862(a)(1)(A) prohibits payment for services that are not medically reasonable and necessary. The Social Security Act 1833(e) prohibits payment if sufficient supporting documentation is not provided to Medicare. Section1886 (j) defines IRF payment.

Additionally, Medicare Benefit Policy Manual, Publication 100-2, Chapter 1, Section 110 defines inpatient hospital stays for rehabilitation care.

Highmark Medicare Services (Highmark Medicare Services) routinely performs data analysis as required by CMS. Based on this analysis, a decision is made to review a sample number of medical records to assess that guidelines / regulations are being met for the services billed. On October 29, 2004, all Highmark Medicare Services IRF service providers were notified that a limited sample of claims would be requested for review.

IRF Service-Specific Probe Review Summary 

The sample of medical records reviewed by Highmark Medicare Services clinicians in October 2004, again revealed that the major deficiencies noted during this service-specific probe review were:

• Lack of medical necessity, and
• Lack of documentation to support the claim

In comparison to a previous probe that was completed in January 2004, there was a significant increase in compliance with receiving the needed documentation to properly review the medical record for medical necessity. Still some providers continued to not meet this requirement set forth by the Social Security Act 1833(e). The providers did not supply the needed therapy evaluations, the therapy times or units to support “hours” of therapy, the IRF PAI or FIM scores to support the HIPPS code and / or H&P’s, pre-assessments or progress notes.

The IRF probe findings revealed the major reason for denial was due to lack of medical necessity/ reasonableness per the Social Security Act 1862 (a)(1)(A).

The medical review process found that a majority of the IRF admissions were for unilateral humeral, knee or hip fractures status post surgeries of the affected limb. Also, de-conditioning / debility were among the reasons for the IRF admissions. The documentation in the medical records did not support the need for intensive multi-disciplinary rehabilitation care for these conditions.

Medical Necessity

According to the Medicare Benefit Policy Manual, Publication 100-2, Chapter 1, Section 110.1, IRF services must be reasonable and necessary (in terms of efficacy, duration, frequency and amount) for treatment of the patient’s condition, and the services must be relatively intense requiring a multidisciplinary coordinated team approach. It also must be reasonable and necessary to furnish the care on an inpatient hospital basis, rather than in a less intensive facility such as a SNF, or on an outpatient basis.

When Highmark Medicare Services clinicians analyzed the medical record, consideration was given to the patient’s medical, surgical, rehabilitation needs and functional impairments. A determination was made whether an IRF stay was reasonable and necessary at that point in time for that unique patient.

Some of the criteria used to determine medical necessity include:

• The patient requires twenty-four hour availability of a physician with special training in the field of rehabilitation, and the medical record shows assessment and intervention of the physician at least every two to three days.
• The patient requires twenty-four hour availability of a registered nurse with training or experience in rehabilitation.
• The patient’s condition requires skilled intervention for at least 3 hours per day, or if less, the medical record shows that an intense inpatient rehabilitation need exists, however significant complications permit only a lower level of rehabilitation to occur. If rehabilitation must be discontinued due to new acute medical complications or destabilization of a previously stable condition, a transfer to an acute care setting should be considered.
• The skilled services required are diverse and complex, requiring a coordinated multidisciplinary approach. Skilled services are defined as those that require attendance of professional clinical staff. Skilled services are of a complexity that cannot be easily taught to a patient or family member for independent performance. The multi-disciplinary case conferencing must be well documented in the patient’s medical record. Communication between disciplines is essential for solving complex physiological problems and functional challenges.
• A good probability exists for measurable functional improvement, within a reasonable period of time. Anticipated results are documented in the medical record using measurable goals and established time frames for meeting these goals. Medicare does not cover vocational goals, or job retraining.
• Achievable self-care goals are appropriate in order to enable the patient to perform independently or with limited assistance from significant others, thus eliminating the need for expensive, long-term inpatient care.
• Documentation Requirements

  When a provider receives an Additional Development Request (ADR), they should submit all of the documentation requested on the ADR:

  • Physician's orders and progress notes for dates of service
  • Nurse's notes
  • Medication and treatment records
  • Completed admission / discharge IRF Patient Assessment Instrument (PAI) assessment and Assessment Reference Date (ARD) date
  • Clinical documentation to support PAI assessment (i.e., clinical records from preceding acute care stay, transfer sheets, discharge summary, social service, history and physical)
  • Records for Physical Therapy, Occupational Therapy, Speech Therapy and Wound Care (decubitus) records (if applicable) for service
    • Initial evaluation and all progress notes
    • Treatment records verifying treatment plan, goals, and minutes
  • Documentation to support the Health Insurance Prospective Payment System (rate code) (HIPPS)
  • PAI consent
  • Functional Independence Measure (FIM) records
  • Itemized bill

  As stated in the Medicare Benefit Policy Manual, Publication 100-2, Section 110.5, “coverage stops when further progress toward the established rehabilitation goal is unlikely or when further progress can be achieved in a less intensive setting.” Coverage ends when it is reasonable for the physician, in consultation with the rehabilitation team, to conclude that further significant improvement will not occur, and the discharge plan which has been previously established, should take place.

  References:

  Social Security Act § 1886 (j) defines the current IRF-PPS.

  Social Security Act § 1862 (a)(1)(A) prohibits payment for services that are not medically reasonable and necessary.

  Social Security Act § 1833 (e) prohibits payment if sufficient supporting documentation is not provided to Medicare.

  Medicare Benefit Policy Manual, Publication 100-2, Chapter 1, Section 110 defines utilization guidelines for Inpatient Rehabilitation stays.
  http://www.cms.hhs.gov/manuals/downloads/bp102c01.pdf

  Provider Notice 04 – 034, Medical Necessity for Inpatient Rehabilitation Facility Services (IRF)

  Provider Notice 04 – 037, Documentation Requirements for Inpatient Rehabilitation