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Inpatient rehabilitation facility (IRF) coverage, documentation requirements and common errors

Our collaboration with CMS continues to focus on reducing the Comprehensive Error Rate Testing (CERT) claims paid error rate. IRF coverage requirements continue to represent a top ranked error area due to improper payments resulting from medical record documentation that does not support that IRF care was reasonable and necessary in accordance with Medicare requirements.

IRF coverage requirements

An IRF is a hospital, or part of a hospital, which provides an intensive rehabilitation program to inpatients and provides skilled nursing care to inpatients on a 24-hour basis, under the supervision of a doctor and a registered professional nurse.

A primary distinction between an IRF and other rehabilitation settings is the intensity of rehabilitation therapy services provided in an IRF. For this reason, the patient’s medical record must document a reasonable expectation that at the time of admission, the patient required the intensive services uniquely provided in IRFs.

An IRF provides intensive rehabilitation services using an interdisciplinary team approach in a hospital environment. 

It is a reasonable expectation that the patient will benefit from intensive rehabilitation in an inpatient hospital environment and an interdisciplinary team approach to the delivery of rehabilitation care. 

Admission to an IRF is appropriate for patients with complex nursing, medical management, and rehabilitative needs.

Medicare coverage criteria for IRF services

For IRF care to be considered reasonable and necessary, the documentation in the patient’s medical record must demonstrate a reasonable expectation that the following criteria are met:

  • Requires active and ongoing intervention or multiple therapy disciplines: Physical therapy (PT), occupational therapy (OT), speech language pathology (SLP), or prosthetics/orthotics, with at least one being PT or OT.
  • Requires an intensive rehabilitation therapy program. The generally accepted standard of care is one-on-one therapy, generally consisting of three hours per day, five days per week. In certain well-documented cases, this intensive rehabilitation might consist of at least 15 hours of therapy within a seven consecutive day period, beginning with the date of admission to the IRF.
  • Beginning October 1, 2026, all required therapy treatments and/or therapy evaluations ordered at admission must begin no later than 36 hours from midnight on the day of admission to the IRF. Initiation of only one ordered therapy discipline does not satisfy this requirement. Group therapy is acceptable but may not constitute the majority of the therapy. Justification for the use of group therapies must be documented in the medical record. 
  • Reasonably be expected to actively participate in and benefit significantly from the intensive therapy program. The patient's condition and functional status are such that the patient can reasonably be expected to make measurable improvement, expected to be made within a prescribed period of time, and as a result of the intensive rehabilitation therapy program, which will be of practical value to improve the patient's functional capacity or adaptation to impairments.
  • Requires physician supervision by a rehabilitation physician or other licensed treating physician with specialized training and experience in rehabilitation. There must be face-to-face visits at least three days per week, beginning with the first week throughout the patient's IRF stay. Note: Beginning the second week of admission to the IRF, a non-physician practitioner may conduct one of the three required face-to-face visits per week. 
  • Requires intensive and coordinated interdisciplinary team approach to foster frequent, structured, and documented communication among disciplines to establish, prioritize, and achieve treatment goals.

IRF documentation requirements

Determination of whether an IRF admission is reasonable and necessary must be based on an assessment of each individual's care needs documented in the medical records. 

The documentation in the patient’s medical record must justify the IRF stay. It must demonstrate that the patient is making functional improvements that are ongoing, sustainable, and of practical value, as measured against the patient’s condition at the start of treatment. 

The patient’s medical record must contain the following documentation:

Admission orders

  • Must be generated by a licensed rehabilitation physician at the time of admission.
  • Admission orders should generally be retained in the patient’s medical record at the IRF.

Preadmission screening (PAS)

  • It must be completed within 48 hours prior to admission. 
  • The PAS documentation must justify that the patient requires, will benefit from, and is able to actively participate in intensive rehabilitation therapy.
  • The PAS can be conducted by a licensed or certified clinician, but the rehabilitation physician must sign and date the screening before the patient is admitted.
  • Required elements include:
    • 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
    • Expected length of time necessary to achieve that level of improvement (i.e., estimated length of stay)
    • Evaluation of the patient’s risk for clinical complications
    • Conditions/comorbidities that caused the need for rehabilitation
    • Treatments needed (i.e., physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics), and
    • Anticipated discharge destination
  • The rehabilitation physician must also review and document concurrence with the preadmission screening before the patient is admitted to the IRF.

Individualized overall plan of care (IPOC)

  • Must be completed within four days of the IRF admission. 
  • The IPOC should generally detail the patient’s medical prognosis and the anticipated interventions, functional outcomes, and discharge destination from the IRF stay.
  • The rehabilitation physician is responsible for developing the overall plan of care with input from the interdisciplinary team. 
  • IPOC documents the following:
    • Expected intensity (meaning number of hours per day)
    • Frequency (meaning number of days per week)
    • Duration (meaning the 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

Interdisciplinary team (IDT) meeting requirements

  • The first interdisciplinary team meeting must occur on or before the fourth day from the date the patient is admitted to the IRF (42 CFR § 412.622(a)(5)).
    • Day one is the day of admission.
    • The initial IDT meeting should support coordinated care early in the patient’s stay.
    • The initial IDT meeting and individualized overall plan of care are separate requirements that both support coordinated care and must be completed by day four.
      • The initial IDT meeting documentation should be separate from the plan of care documentation in the medical record.
    • If day four falls on a weekend or holiday, IRFs should plan workflows so the initial IDT meeting still occurs by day four.
    • The initial IDT meeting documentation should show that the meeting discussed: 
      • Implementation of appropriate therapy services identified in the PAS and ordered at admission. 
      • Establishment or review of the patient’s stated rehabilitation goals.
      • Any problems that could impede those goals.
  • After the initial IDT meeting, the date of that meeting determines the timing for the patient’s remaining IDT meetings.
    • The rehabilitation physician’s concurrence must be documented and retained in the medical record with the IDT meeting findings.
    • Remaining IDT meetings must occur at least once per week after the date of the prior team meeting (42 CFR § 412.622(a)(5)(iii)).
    • For purposes of 42 CFR § 412.622, a “week” means a period of seven consecutive calendar days. 
  • Must include the rehabilitation physician, a registered nurse with specialized training in rehabilitation, a social worker or case manager (or both), and a licensed or certified therapist from each discipline involved in treating the patient. 
  • Must be led by a rehabilitation physician either in person or remotely who documents concurrence with all decisions made at each meeting.
    • Other required team members must attend in person.
    • The current requirement does not allow Physician Assistants to lead IDT meetings.
  • IDT meeting to focus on:
    • Assessing the individual's progress towards the rehabilitation goal
    • 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

Medical necessity documentation requirements

  • Therapy evaluation/skilled notes.
  • Documentation may include history and physical, individualized plan of care, skilled notes, interdisciplinary team notes, admission orders, etc.
  • Documentation should support the patient required active and ongoing therapeutic intervention of multiple therapy disciplines (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics therapy), one of which must be physical or occupational therapy.
  • Documentation to support the patient requires an intensive therapy program (per industry standards, generally at least three hours of therapy per day at least five days per week).
  • Documentation must demonstrate all required therapy treatments and/or therapy evaluations ordered at admission must begin no later than 36 hours from midnight on the day of admission to the IRF (42 CFR § 412.622(a)(3)(ii)). 
    • Starting only one therapy does not meet the requirement. 
    • Therapy evaluations are generally considered to constitute the beginning of required therapy services and may count toward meeting the 36-hour requirement. 
    • Compliance is determined through review of the IRF medical record documentation.
    • The 36-hour requirement applies only to therapy treatments and/or therapy evaluations ordered at admission, which may occur by a rehabilitation physician concurring with the PAS or ordering additional therapies at admission. 
    • Therapies ordered after the rehabilitation physician’s initial concurrence with the PAS and admission orders are not subject to the 36-hour requirement. Therapies/evaluations ordered after the initial admission orders should still begin as soon as possible to support high-quality care.
    • The medical record should clearly show:
      • The patient’s admission date and time.
      • Which therapy treatments and/or evaluations were ordered at admission.
      • The date and time each required therapy treatment and/or evaluation began.
  • Documentation should demonstrate that the patient can reasonably be expected to actively participate in, and benefit significantly from, an intensive rehabilitation therapy program.
  • Documentation to support the requirement for medical supervision meaning the rehabilitation physician has conducted the initial face-to-face visit(s) that are required to be conducted at least three days per week throughout the patient’s stay in the IRF. (Beginning with the second week, a non-physician practitioner who is determined by the IRF to have specialized training may conduct one of the three required face-to-face visits).

Inpatient rehabilitation facility patient assessment instrument (IRF-PAI) 

  • Must correspond with all information in the patient’s medical record.
  • As per the requirements, the IRF patient assessment instrument (IRF-PAI) forms should generally be included in the patient’s medical record at the IRF (either in electronic or paper format).
  • An updated form and instructions can be found on the IRF-PAI page of the CMS website. 

Note: The post admission physician evaluation (PAPE) documentation requirement previously required was removed in the FY 2021 IRF PPS Final Rule (85 FR 48424). However, the history and physical is still required under the Conditions of Participation.

Common IRF errors

The following are common IRF errors that have been identified:

  • Medical necessity errors:
    • Beneficiary did not have a need for multiple therapy disciplines.
    • Medical records did not support the fact that the beneficiary had intensive rehabilitative therapy needs following discharge from the hospital.
    • On admission the beneficiary was minimum assist in most areas.
    • Beneficiary should not have been expected to appropriately participate due to cognitive deficits.
    • Preadmission screening (PAS) that supports beneficiary functional status on admit was minimal assist and moderate assist functional status.
    • Beneficiary was too sick to participate fully in an intense rehabilitation program (pneumonia and recurrent arrhythmia).
  • Insufficient documentation errors:
    • Missing individualized plan of care (POC) and interdisciplinary team meeting notes/records.
    • PAS was inadequate due to illegible physician signature and signature log for the physician to identify illegible signature on the PAS was illegible.
    • Missing physical therapy and occupational therapy treatment notes with timed minutes and interdisciplinary meeting notes/records.
    • Interdisciplinary team meeting notes inadequate:
      • Missing acknowledgement of participants in attendance.
  • Missing physician signature of concurrence with team conference meeting notes.
  • Missing case management or social worker notes for IRF admission.

 

References