Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Medicare Part A billed on dates of service from January 1, 2023, through December 31, 2023. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

Inpatient rehabilitation hospitals and rehabilitation units of acute-care hospitals, collectively known as Inpatient Rehabilitation Facilities (IRFs), provide intensive rehabilitation therapy in a resource-intensive, inpatient hospital environment. These are for patients who, because of the complexity of their nursing, medical management, and rehabilitation needs, require and can be expected to benefit from an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation care.

Over the years, the IRF benefit has been reviewed by the Office of the Inspector General (OIG). It continues to be a part of the work done by the OIG. In a 2018 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 IRFs, medical record documentation did not support that IRF care was reasonable and necessary in accordance with Medicare’s requirements.

Comprehensive Error Rate Testing (CERT) data from 2023 reflects a projected improper payment amount for IRF services of $1.9 billion, resulting in an improper payment rate of 27.3 percent. The Supplemental Medical Review Contractor (SMRC) completed prior IRF medical review projects between 2015 and 2022. Findings supported additional review and education on the IRF benefit was indicated.

Reason for Review

The SMRC is tasked to perform data analysis and conduct medical record reviews on claims billed with Type of Bill (TOB) 11X, with Revenue (REV) Code 0024 billed with date of service January 1, 2023, through December 31, 2023.

The SMRC will conduct medical record reviews in accordance with statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

Access related project details below.

• Documentation Requirements
• References

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review.

Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.

1. History and Physical Reports (include medical history and current list of medications).
2. Initial and updated versions of the preadmission screening/notes.
3. Post admission assessment/post admission physician evaluation, if counted as a face-to-face visit or is part of the history and physical.
4. Documentation of the required minimum of three face-to-face encounters per week during the Inpatient Rehabilitation Facility (IRF) stay.
5. Signed and dated overall plan of care/amendment including, short and long-term goals with any updates to the plan of care.
6. Plan of Care/Updates and Interdisciplinary Team/Group (IDG/IDT) notes with full list of participants and clear distinction of professional disciplines to cover all days in this billing period, which may include the latest update prior to this billing period.
7. Physical Therapy (PT)/Occupational Therapy (OT)/Speech Language Pathology (SLP) – Initial evaluation/re-evaluation, plans of care, progress reports, treatment encounter notes, therapy minute logs, and discharge summary.
8. Documentation in the medical record to support rehabilitation therapy that was waived.
9. Review of beneficiary’s prior and current medical and functional conditions and comorbidities.
10. IRF PAI (Patient Assessment Instrument).
11. Documentation to support the code(s) and modifier(s) billed.
12. Beneficiary’s medical records (which include practitioner medical records including consultations, hospital records, nursing home records, home care nursing notes, physical/occupational therapy notes) that support the item(s) provided is/are reasonable and necessary.
13. Notes/documentation related to and explaining an interruption in treatment.
14. Admit to discharge including Discharge Summary from hospital or other facility.
15. Addendum to record.
16. List of all non-standard abbreviations or acronyms used, including definitions.
17. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services).
18. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC).
19. Any other supporting documentation including clinical and/or nursing notes/documentation.
20. If medical record documentation is submitted via esMD; Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation.
21. Please Note: It is the responsibility of the provider to obtain all documentation from the ordering/referring provider to ensure medical necessity criteria have been met.

References

Social Security Act (SSA), Title XI

• §1135 Authority to Waive Requirements During National Emergencies

Social Security Act (SSA), Title XVIII

• §1814(a)(2)(B) Conditions of and Limitations on Payment for Services
• §1815(a) Payment to Providers of Services
• §1833(e) Payment of Benefits
• §1834(m)(4) (F) Special Payment Rules for Particular Items and Services
• §1862(a)(1)(A) Exclusion from Coverage and Medicare as a Secondary Payer
• §1879(a)(1) Limitation on Liability of Beneficiary where Medicare Claims are Disallowed.
• §1886(j) Prospective Payment for Inpatient Rehabilitation Services

42 Code of Federal Regulations (CFR)

• §400.200 General Definitions
• §411.15(k)(1) Particular Services Excluded from Coverage
• §412.29 Classification Criteria for Payment Under the Inpatient Rehabilitation Facility Prospective Payment System
• §412 Subpart A Prospective Payment Systems for Inpatient Hospital Services. General Provisions
• §412 Subpart P Prospective Payment for Inpatient Rehabilitation Hospitals and Rehabilitation Units
• §424.5(a)(6) Basic Conditions

Public Law

• Robert T. Stafford Disaster Relief and Emergency Assistance Act, Pub. L. No. 100-707, 102 Stat. 4689 (1988), Codified as Amended 42. U.S.C. § 5121. Disaster Relief and Emergency Assistance Amendments. May 2021. Retrieved from Stafford Act, as Amended – FEMA P-592 vol. 1 May 2021

Federal Register

• Final Rule Volume 87, No. 146. Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2022. August 1, 2022. Retrieved from https://www.govinfo.gov/content/pkg/FR-2022-08-01/pdf/2022-16225.pdf

Internet-Only Manual (IOM), Medicare Benefit Policy Manual (MBPM), Publication (Pub.) 100-02

• Chapter (Ch) 1, §110 Inpatient Rehabilitation Facility (IRF) Services

IOM, Medicare Claims Processing Manual (MCPM), Pub. 100-04

• Ch. 3, §140.3 Billing Requirements Under IRF PPS

IOM, Medicare Program Integrity Manual (MPIM), Pub. 100-08

• Ch. 3, §3.2.3.8 No Response or Insufficient Response to Additional Documentation Requests
• Ch. 3, §3.3.2.1 Documents on which to Base a Determination
• Ch. 3, §3.3.2.4 Signature Requirements
• Ch. 3, §3.6.2.2 Reasonable and Necessary Criteria

Other

• Comprehensive Error Rate Testing (CERT). 2023 Medicare Fee-for Service Supplemental Improper Payment Data. December 7, 2023. Retrieved from 2023 Medicare Fee-for-Service Supplemental Improper Payment Data | CMS
• Office of Inspector General (OIG), Report A-01-15-00500. Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements. September 2018

Last Updated Jan 24, 2025