An IRF is designed to provide intensive rehabilitation therapy within a resource-intensive hospital environment for patients who, due to the complexity of their medical, nursing and rehabilitation needs, require (and can reasonably be expected to benefit from) an inpatient stay and an interdisciplinary approach to the delivery of rehabilitation care.
Specific medical record documentation at the time of an IRF admission must support a reasonable expectation that the patient needs multiple intensive therapies (one of which must be physical or occupational therapy); the patient must be able to actively participate and demonstrate measurable improvement; and the patient requires supervision by a rehabilitation physician to assess and modify the course of treatment as needed to maximize the benefit from the rehabilitation process.
First Coast has compiled a list of questions on specific topics that are listed in the CMS IRF RCD Medical Records Review Checklist as well as the Code of Federal Regulations that providers can use as a resource to determine if their documents support the medical necessity for an IRF stay.
| Topic |
Questions |
Resource(s) |
| Preadmission Screening (PAS)* |
- Was the PAS conducted by a licensed or certified clinician(s) designated by a rehabilitation physician within the 48 hours immediately preceding the IRF admission?
- Does the PAS document the patient’s prior level of function and condition(s) that led to the need for intensive rehabilitation?
- Is the patient’s expected level of improvement documented?
- Does the PAS document the expected/estimated length of stay?
- Does the PAS contain an evaluation of the patient’s risk for clinical complications?
- Does the PAS document the treatments needed (i.e. physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics), one of which must be physical or occupational therapy?
- Does the PAS include an anticipated discharge destination?
- Does the PAS support the rehabilitation physician reviewed and documented concurrence with the preadmission screening before the patient was admitted to the IRF?
- Does the PAS include a detailed and comprehensive review of the patient’s condition and medical history?
|
42 CFR §412.622(a)(4)(i) |
| Individualized plan of care (IPOC) |
- Does the IPOC reflect that the rehabilitation physician is responsible for developing the overall plan of care with input from the interdisciplinary team?
- Was the IPOC completed within the first four days of the IRF admission?
- Does the IPOC document the following:
- Expected intensity (number of hours per day)
- Frequency (number of days per week)
- Duration (total number of days during the IRF stay) of physical, occupational, speech-language pathology and prosthetic/orthotic therapies required by the patient during the IRF stay
|
42 CFR § 412.622(a)(4)(ii) |
| Interdisciplinary team (IDT) approach |
- Does the medical record documentation support interdisciplinary team meetings (IDT) were held a minimum of once per week? Do the IDT meetings include the following:
- Rehabilitation physician
- Registered Nurse
- Social worker or a case manager (or both)
- Licensed or certified therapist from each therapy discipline involved in treating the patient
- Was the IDT meeting led by a rehab physician either in person or remotely who documents concurrence with all decisions made at each meeting?
- Does the documentation reflect the IDT meeting focused on the following:
- Assessing the individual’s progress towards the rehabilitation goals
- Considering possible resolutions to any problems that could impede progress towards the goals
- Reassessing the validity of the rehabilitation goals previously established
- Monitoring and revising the treatment plan, as needed
|
42 CFR 412.622(a)(5) |
| Medical Necessity |
- Does the documentation contain therapy evaluation/skilled notes?
- Does the documentation include history and physical, IPOC, skilled notes, interdisciplinary team note(s), admission orders?
- Does the documentation support the patient required the active and ongoing therapeutic intervention of multiple therapy disciplines (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics), one of which must be physical or occupational therapy?
-
Does the documentation support the patient required an intensive rehabilitation therapy program (per industry standards, generally at three hours of therapy per day at least five days per week)?
NOTE: Must begin within 36 hours from midnight of the day of admission; therapy evaluations are generally considered to constitute the beginning of the required therapy services and should generally be included in the total daily/weekly. Reviewers should look to brief exceptions policy if non-compliant.
- Does the documentation support an admission to the IRF, the patient is sufficiently stable to actively participate and benefit significantly from the intensive therapy services? Does the documentation support on admission the patient will have measurable improvement that will be of practical value in a reasonable period of time?
-
Does the documentation support the requirement for medical supervision?
- The rehabilitation physician must conduct face-to-face visits with the patient at least three days per week.
NOTE: Beginning with the second week of the admission to the IRF, a non-physician practitioner may conduct one of the three required face-to-face visits per week
|
42 CFR 412.622(a)(3) |
*Note: If the patient is being transferred from a referring hospital, the preadmission screening could either be done in person or through a review of the patient’s medical records from the referring hospital (either paper or electronic format), as long as those medical records contain the necessary assessments to make a reasonable determination. However, a preadmission screening conducted entirely by telephone should generally include transmission of the patient’s medical records from the referring hospital to the IRF and a review of those records by licensed or certified clinical staff member in the IRF to ensure it includes a detailed and comprehensive review of the patient’s condition and medical history in accordance with 42 CFR § 412.622(a)(4)(i)(B).
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