Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, has conducted post-payment review of claims for Medicare IRF’s billed on dates of service from January 1, 2019 through December 31, 2019. Below are the review results:

Background

The Office of Inspector General (OIG), under Report A-01-15-00500 dated September 2018, titled “Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements”, estimated that, in 2013, Medicare paid $5.7 billion for inpatient rehabilitation facility (IRF) stays, nationwide, that were not reasonable and necessary. Of the 220 randomly selected IRF claims, 175 stays did not meet Medicare coverage and documentation requirements therefore were not deemed to be reasonable and necessary.

In addition, the Comprehensive Error Rate Testing (CERT) program found that the error rate for IRF stays increased over 50% from 2012 to 2016. Historically, IRF medical review projects were completed by the previous Supplemental Medical Review Contractor (SMRC) in 2015 and 2016. Furthermore, Noridian Healthcare Solutions (Noridian), as the current Supplemental Medical Review Contractor (SMRC) performed initial data analysis in 2019 that supported additional medical review of IRF claims, conducted under project 01-025.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical review on inpatient rehabilitation facility (IRF) claims with a Length of Stay (LOS) of greater than 8 days. Noridian completed medical review on a sample of claims related to inpatient rehabilitation facility (IRF) services. The SMRC conducted these reviews in accordance with applicable statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

• No Response to the Documentation Request
  • CMS Internet-Only Manual, 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 did not support requirement for the minimum rehabilitation physician visits
  • The patient must require and receive a minimum of three rehabilitation physician visits each week throughout the stay. The Post-Admission Physician Evaluation (PAPE) counts as one of the rehabilitation physician visits. Refer to 42 CFR 412.622(a)(3)(iv), Medicare Benefit Policy Manual Chapter 1, Section 110.2.The documentation submitted did not include the required elements of the face-to-face visits.
• Documentation did not support the required participants for the ITC
  • All required participants must attend each interdisciplinary team conference (ITC) throughout the IRF stay. Refer to 42 CFR 412.622(a)(5)(A); Medicare Benefit Policy Manual Chapter 1, Section 110.2.5.The documentation submitted did not contain all of the interdisciplinary team members attended the ITC.

References/Resources

• Social Security Act (SSA) Title XVIII, Sections 1814(2)(B), (6). Conditions of and Limitations on Payment for Services
• Social Security Act (SSA) Title XVIII, Section 1815(a). Payment to Providers of Services
• Social Security Act (SSA) Title XVIII, Section 1833(e). Payment of Benefits
• Social Security Act (SSA) Title XVIII, Section 1861(s)(2)(K). Miscellaneous Provisions (Definitions of Services, Institutions, Etc.)
• Social Security Act (SSA) Title XVIII, Section 1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer
• Social Security Act (SSA) Title XVIII, Section 1869(f)(1)(B). Determinations; Appeals
• Social Security Act (SSA) Title XVIII, Section 1879(a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
• Social Security Act (SSA) Title XVIII, Section 1886(j). Prospective Payment for Inpatient Rehabilitation Services
• Social Security Act (SSA) Title XVIII, Section 1893(f)(7)(A)(B)(i-iv). Medicare Integrity Program
• Code of Federal Regulations Title 42, Section Prospective Payment Systems for Inpatient Hospital Services. Subpart A. General Provisions.
• Code of Federal Regulations Title 42, Section 412, Subpart P. Prospective Payment for Inpatient Rehabilitation Hospitals and Rehabilitation Units
• Code of Federal Regulations Title 42, Section 424.5(a)(6). Basic Conditions
• Code of Federal Regulations Title 42, Section 482.24(c)(1). Condition of Participation: Medical Record Services
• Medicare Benefit Policy Manual, Publication 100-02, Chapter 1, Section 110. Inpatient Rehabilitation Facility (IRF) Services
• Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Section 220.3. Documentation Requirements for Therapy Services
• Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Section 230. Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology
• Medicare Benefit Policy Manual, Publication 100-02, Chapter 16, Section 20. Services Not Reasonable and Necessary
• Medicare Claims Processing Manual, Publication 100-04, Chapter 3, Section 140. Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS)
• Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.2.3.2. Time Frames for Submission.
• Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.2.3.8. No Response or Insufficient Response to Additional Documentation Requests
• Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.3.2.1. Documents on which to Base a Determination
• Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.3.2.4. Signature Requirements
• Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.6.2.2. Reasonable and Necessary Criteria
• Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.6.2.5. Denial Types
• Local Coverage Article(LCA) A52775. Medical Necessity of Therapy Services. Effective 10/01/2015-present
• Local Coverage Article(LCA) A53304. Medical Necessity of Therapy Services. Effective 10/01/2015-present
• Local Coverage Article (LCA) A53309. Billing and Coding: Therapy Evaluation, Reevaluation, and formal testing. Effective 10/01/2015-present

Last Updated Apr 4, 2022