This bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff. 

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Purpose:

The purpose of this bulletin is to provide education to the provider community regarding Inpatient Rehabilitation Services documentation requirements.     

Background:

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 medical record must contain the documentation to support medical necessity.  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 supporting documentation is not provided to Medicare, and §1886 (d)(1)(b) defines IRF coverage limitations and medical necessity. The Pub. 100-2 Ch 1, sec 110 defines utilization guidelines for Inpatient Rehabilitation services. The purpose of this article is to discuss the specific documentation required to support claim payment, as requested in the IRF Additional Documentation Request (ADR).

Preadmission Screening Documentation:

Before a patient is admitted to the IRF, preadmission screening is usually done.  Information is gathered to determine if the patient will benefit significantly from an intensive, multidisciplinary, inpatient hospital level of care.  If, after admission to the IRF, the three-day assessment reveals that the patient is not a good candidate for an inpatient hospital program, then the screening is examined to determine if it supports the initial assessment period as reasonable and necessary.  Therefore, the screening information should be included in the documentation sent to Highmark Medicare Services.  There is no specific format for this information.  It may be included on the discharge summary from the acute care facility, the IRF admission history and physical, the progress notes, or on a separate and distinct form.  The screening should include the rationale for the transfer of the patient to the IRF setting, as opposed to a less intensive and less costly setting.  After admission to the IRF, a more detailed, multidisciplinary assessment is performed to establish the plan of care.

Inpatient Rehabilitation Facility Documentation:

• Admission history and physical, including pertinent information from the prior acute care stay.  These early documents should clearly communicate the assessment and treatment plan of the admitting physician.  The reviewer must be able to ascertain the reason for admission, prior level of function, the therapy required, the anticipated course of treatment and the expected goals. 

• Hospital discharge summary, as well as discharge summaries from other disciplines.  These documents serve to support or clarify the above documentation.

• Physician orders.  At the time of admission, the IRF must have physician orders for the patient’s care during the time the patient is in the IRF. The orders should specify the types and goals of therapies as well as any restrictions or precautions. 

• Physician progress notes.  Progress notes must demonstrate frequent, direct and medically necessary physician involvement, at least every two to three days during the entire IRF stay.  This documentation should include any revisions to the expectations of the anticipated course and predicted functional gains.

• Initial therapy assessments and reassessments.  The assessments should contain quantifiable information regarding functional progress, including the patient’s functional status prior to the acute care admission. 

• Team evaluation notes.  The team evaluation notes must demonstrate a multidisciplinary team approach to improve the patient’s functional ability.  At a minimum, the team notes should document the involvement of a physician, rehab nurse and at least one therapist.  Documented frequency of team conferences should be at least every two weeks.  This documentation should include assessment of progress, problem resolution, any revisions to the expectations of the anticipated course and predicted functional gains.

• Daily therapy and nurse’s notes.  Handwriting must be legible.  Notes must include dates, times and signatures of the providers, as well as credentials such as RN, MPT, PTA, OT, and COTA.

• Reasonable and reportable goals must be documented in a written plan of care.  Goals should be individualized, measurable and realistic.  Goals should relate to basic self-care or independence in activities of daily living.  Vocational, recreational and sports training goals are commendable, but are not covered by Medicare.  A discharge plan should be established at the time of admission, and be revised as needed.

• IRF-PAI: 
  
  
  
  • This CMS patient assessment consists of nine sections, each to collect different categories of patient information.  IRFs must computerize and submit the patient assessment data.  The admission assessment must be based on the information collected in the first three days of the stay, and be completed by the fourth day.  The documentation in the PAI must conform to Medicare requirements for the IRF-PPS.  Refer to the IRF-PAI Training Manual available at http://www.cms.hhs.gov/InpatientRehabFacPPS/downloads/irfpaimanual040104.pdf.
    
  • The discharge assessment is based on information collected in the three calendar days prior to and including the day the patient is either discharged or dies.  The discharge assessment must be completed by the fifth calendar day following the discharge day or date of death.
    
    
  • If the stay is interrupted (the patient is discharged from the IRF and returns within three calendar days), the interruption is clearly documented and the admission assessment is not repeated.  If the interruption in the IRF stay exceeds three consecutive calendar days, the IRF is required to complete a new admission assessment. The medical record is reviewed in its entirety in order to capture a clear understanding of the patient’s status.  It is important that the medical record accurately supports the PAI.

Short excursions into the community are sometimes used to test for discharge readiness.  These excursions should be clearly documented, with assessment of patient’s response.  Excursions alone are not sufficient basis for denying coverage for further hospital care.  This information is located at http://www.cms.hhs.gov/manuals/Downloads/bp102c01.pdf. 

For additional information please reference The Medicare Claims Processing Manual, Chapter 3, located at http://www.cms.hhs.gov/manuals/downloads/clm104c03.pdf and The Medicare Benefit Policy Manual at http://www.cms.hhs.gov/manuals/Downloads/bp102c01.pdf.

Provider Action:

Documentation must show that the care rendered is patient specific and individualized.  Generic treatment plans, physician’s orders and patient care checklists do not adequately demonstrate the professional judgment used, nor support the medical necessity of the care given to each unique Medicare beneficiary.  Individualized, patient specific medical documentation is required.

The documentation must be legible.  Careful attention should be given to the quality and readability of copies submitted to the fiscal intermediary for additional development of the claim.  All staff involved in patient care should sign their documentation, identify themselves using their credentials, and include dates and times as well as a clear description of all care rendered and the patient’s response to the care .

If numerous acronyms and abbreviations are used in the documentation, it is recommended that a list of definitions be provided to facilitate accurate interpretation. 

When preparing to mail documentation to Highmark Medicare Services, use the ADR letter as a reference to be sure all of the requested documentation to support the services billed on the claim are included in the packet.  Several ADRs may be mailed together in one container, but each must be separately stapled with a copy of the specific ADR letter on the top of each individual packet.  If multiple ADRs are stapled together, only the one on the top will be received and moved to a reviewer.  The remaining claims will deny automatically as if no records were received because mail handlers do not sort through the medical record.

Resources:

• The Medicare Learning Network Inpatient Rehabilitation Facility Prospective Payment System fact sheet located at http://www.cms.hhs.gov/InpatientRehabFacPPS/LSIRF/list.asp#TopOfPage
• IRF Regulations and Notices located at http://www.cms.hhs.gov/InpatientRehabFacPPS/LIRFF/list.asp#TopOfPage
• IRF-PAI Training Manual available at http://www.cms.hhs.gov/InpatientRehabFacPPS/downloads/irfpaimanual040104.pdf
• The Medicare Claims Processing Manual, Chapter 3, inpatient Hospital Billing” located at http://www.cms.hhs.gov/manuals/downloads/clm104c03.pdf
• The Medicare Benefit Policy Manual, Chapter 3, “Duration of Covered Inpatient Services”
• The Medicare Claims Processing Manual, Chapter 1, “General Billing Requirements” http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf
• The Medicare Benefit Policy Manual, Chapter 1, “Inpatient Hospital Services Covered Under Part A” http://www.cms.hhs.gov/manuals/Downloads/bp102c01.pdf
• Social Security Act § 1886 (j) describes prospective payment for Inpatient Rehabilitation Services located at http://www.ssa.gov/OP_Home/ssact/title18/1886.htm#e6
• Social Security Act § 1862 (a)(1)(A) prohibits payment for services that are not medically reasonable and necessary located at http://www.ssa.gov/OP_Home/ssact/title18/1862.htm#a4
• Social Security Act § 1833 (e) requires providers to furnish the necessary documentation to support payment located at http://www.ssa.gov/OP_Home/ssact/title18/1833.htm

Assistance:

If you have any questions regarding this bulletin, please contact the appropriate Customer Contact Center at:

Maryland/DC Providers: 1-866-488-0545

Pennsylvania Providers: 1-800-560-6170