Checklist: Inpatient rehabilitation facility (IRF) documentation
In accordance with Code of Federal Regulations 42 CFR §412.622(a)(4), this checklist is intended to provide health care providers with a reference to use when responding to medical documentation requests pertaining to IRF services. It is not intended to replace published guidelines. Health care providers retain responsibility to submit complete and accurate documentation.
| Check | Document description |
|---|---|
| Advanced Beneficiary Notice (ABN), if applicable | |
| Documentation is for the correct beneficiary and correct date(s) of service. | |
| Documentation is complete, legible, signed and dated by the physician or clinician. | |
| Pre-admission screening (PAS) | |
| Signed and dated overall individualized plan of care (IPOC), including short- and long-term goals with updates to the plan of care. | |
| Documentation to support interdisciplinary team (IDT) approach. | |
|
Physician and nonphysician practitioners, nurse and ancillary progress notes to support the medical necessity for the IRF:
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Completed admission / discharge IRF-PAI (Patient Assessment Instrument) and supporting documentation: Clinical records from preceding acute care stay
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Records for physical therapy, occupational therapy and/or speech therapy:
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| Documentation to support Health Insurance Prospective Payment System (HIPPS) code billed based on the IRF-PAI assessment | |
| Itemized bill |
References
- CMS IRF RCD Medical Records Review Checklist
- Documentation requirements to support medical necessity
- Inpatient Rehabilitation Facility (IRF) Review Choice Demonstration (RCD) Review Guidelines
- Code of Federal Regulations 42 CFR §412.622(a)(4)
- Inpatient Rehabilitation Facility (IRF)
Disclaimer
This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the Centers for Medicare & Medicaid Services' documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.