Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, has conducted post-payment review of claims for Medicare Part A Inpatient Rehabilitation Facility (IRF) billed for dates of service from January 1, 2018 through December 31, 2018. Below are the review results:

Background

Inpatient rehabilitation hospitals and rehabilitation units of acute-care hospitals are collectively known as IRFs. IRFs provide intensive rehabilitation therapy in a resource-intensive inpatient hospital environment for patients who, because of the complexity of their nursing, medical management, and rehabilitation needs, require and can reasonably be expected to benefit from an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation care (the Medicare Benefit Policy Manual, Publication 100-02, Chapter 1, §110).

In a recent 2018 Office of Inspector General (OIG) report, titled “Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements” (A-01-15-00500), the OIG found that for many IRF’s, medical record documentation did not support that IRF care was reasonable and necessary in accordance with Medicare’s requirements.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical review activities on claims to determine if IRF stays were reasonable and necessary. Noridian completed medical record review on claims in accordance with applicable statutory, regulatory and sub-regulatory guidance.

Common Reasons for Denial

• Documentation does not support Reasonable and Necessary
  • Medicare Benefit Policy Manual Chapter 1, Section 110.2.2 requires Intense Level of Rehabilitation Services
• No Response to the Documentation Request
  • CMS Internet-Only Manuals, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 B/C requires providers/suppliers to respond to requests for documentation within 45 calendar days of the additional documentation request. The documentation was not submitted or not submitted timely.
• Documentation does not support close Physician Supervision and Medical Management
  • Medicare Benefit Policy Manual Chapter 1, Section 110.2 contains Inpatient Rehabilitation Facility Medical Necessity Criteria
• Documentation does not support the Preadmission Screening was included
  • 42 CFR 412.622(a)(4)(i) requires the Preadmission Screening to be submitted with the documentation and meet the requirements

References/Resources

• Social Security Act (SSA), Title XVIII, §1833(e). Payment of Benefits
• SSA, Title XVIII, §1861(s)(2)(K). Miscellaneous Provisions (Definitions of Services, Institutions, Etc.)
• SSA, Title XVIII, §1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer
• SSA, Title XVIII, §1869(f)(1)(B). Determinations; Appeals
• SSA, Title XVIII, §1879(a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
• SSA, Title XVIII, §1893(f)(7)(A)(B)(i-iv). Medicare Integrity Program
• 42 C.F.R., 412.604. Conditions for payment under the prospective payment system for inpatient rehabilitation facilities
• 42 C.F.R. 412.606. Patient Assessment
• 42 C.F.R. 412.610. Assessment schedule
• 42 C.F.R. 412.612. Coordination of the collection of patient assessment data
• 42 C.F.R. 412.618. Assessment process for interrupted stays
• 42 C.F.R. 412.622(a)(3), (4), and (5). Basis of payment
• 42 C.F.R. 424.5(a)(6). Basic Conditions
• CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110. Inpatient Rehabilitation Facility (IRF) Services
• CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.3. Documentation requirements for Therapy Services
• CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 20. Services Not Reasonable and Necessary
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 40.3.6 and 40.3.6.4. Routine Notice Prohibition & ABN Prohibition Exceptions
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 50.3. Financial Liability Protections
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8. No Response or Insufficient Response to Additional Documentation Requests
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.1. Documents on which to Base a Determination
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4. Signature Requirements
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2. Reasonable and Necessary Criteria
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5. Denial Types
• Local Coverage Article (LCA) A52757. Rehabilitation Delivery Methods. Effective 10/01/2015-09/14/2018
• LCA A52775. Medical Necessity of Therapy Services. Effective 10/01/2015-present
• LCA A53304. Medical Necessity of Therapy Services. Effective 10/01/2015-present

Last Updated Oct 11, 2021