01-085 IRF Notification of Medical Review
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 Inpatient Rehabilitation Facility (IRF) stays billed on dates of service from March 1, 2020, through December 31, 2020. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers or suppliers may wish to consult when submitting claims.
Over the years, the IRF benefit was reviewed by the Office of the Inspector General (OIG) and 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 IRF’s, medical record documentation did not support that IRF care was reasonable and necessary in accordance with Medicare’s requirements.
CERT data from 2021 reflects improper payment error rates for Inpatient Rehabilitation Facilities and Inpatient Rehabilitation Facilities Units of 18.5% and 16.0% respectively.
In addition, between 2015 and 2019, the SMRC completed prior data analysis and medical review of IRF claims. Findings supported that additional review and education on the IRF benefit was indicated.
Reason for Review
The SMRC is tasked with performing claim review on a sample of IRF claims from March 1, 2020, through December 31, 2020. The SMRC will conduct medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.
Claim Sample Detail
|11X: Inpatient Rehabilitation Facility (IRF)||Part A claims|
Access related project details below.
Below is a list of specific documentation requirements that will be included in each ADR, to obtain the necessary documentation to perform the review. The documentation requested has been made specific, to assist the provider in collecting and submitting pertinent information to decrease provider burden.
Providers or suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.
- History and Physical Reports (include medical history and current list of medications)
- Initial and updated versions of the preadmission screening/notes
- Documentation of the required minimum of three Face-to-Face encounters per week during the Inpatient Rehabilitation Facility (IRF) stay
- Signed and dated overall plan of care, including goals along with any updates to the plan of care
- Record of dated Interdisciplinary Team/Group (ITC/IDG/IDT) conference meeting notes with full list of participants, clear distinction of professional disciplines, along with attendance records and signatures
- PT/OT/SLP– Initial evaluation, plan of care, progress reports, treatment encounter notes, therapy minute logs, and discharge summary
- Documentation in the medical record to support rehabilitation therapy that was waived
- Review of beneficiary’s prior and current medical and functional conditions and comorbidities
- Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI)
- Documentation to support the code(s) and modifier(s) billed
- 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
- Notes/documentation related to and explaining an interruption in treatment
- Any addendum to record
- Documentation to support that Local Coverage requirements have been met
- List of all non-standard abbreviations or acronyms used, including definitions
- Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
- Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
- Any other supporting documentation including clinical and/or nursing notes/documentation
- 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
- 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
Social Security Act (SSA), Title XI
- § 1135 Authority to Waive Requirements During National Emergencies.
Social Security Act (SSA), Title XVIII
- § 1814(2)(B), (6) 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.
- Final Rule Volume 85, No. 154. Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2021. August 10, 2020. Retrieved from 2020-17209.pdf (govinfo.gov) .
- Interim Final Rule with Comment Period. CMS 1744-IFC. Medicare and Medicaid Programs, Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency. March 26, 2020. Retrieved from CMS-1744-IFC .
- Coronavirus Aid, Relief, and Economic Security Act. Title III- Supporting America’s Health Care System in the Fight Against the Coronavirus. Subtitle D-Finance Committee, §§ 3710. Medicare Hospital Inpatient Prospective Payment System add-on Payment for Covid-19 Patients During Emergency Period. § 3711. Increasing Access to Post-Acute Care During Emergency Period. January 3, 2020. Retrieved from BILLS-116hr748enr.pdf (congress.gov) .
- Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (Pub. L. 116-123, March 6, 2020). § 101. Telehealth Services During Certain Emergency Periods Act of 2020. Retrieved from PUBL123.PS (congress.gov) .
- Public Health Service Act, 2021, § 319(e). Telehealth Enhancements for Emergency Response. Enacted June 25, 2022. Retrieved from COMPS-8773.pdf (govinfo.gov) .
- 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 .
Internet-Only Manual (IOM), Medicare Benefit Policy Manual (MBPM), Publication (Pub.) 100-02
- 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, § 188.8.131.52 No Response or Insufficient Response to Additional Documentation Requests.
- Ch. 3, § 184.108.40.206 Documents on which to Base a Determination.
- Ch. 3, §220.127.116.11 Signature Requirements.
- Ch. 3, § 18.104.22.168 Reasonable and Necessary Criteria.
Last Updated Dec 22, 2022