Inpatient Rehabilitation Facility (IRF) Services. Part A Provider Outreach and Education September 2015

Transcription

1 Inpatient Rehabilitation Facility (IRF) Services Part A Provider Outreach and Education September 2015

2 DISCLAIMER This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and CMS. The most current edition of the information contained in this release can be found on the Noridian website at and the CMS website at The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2015 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. September

3 Agenda Inpatient Rehabilitation Facility (IRF) Services Documentation Requirements Inpatient Rehabilitation Facility Medical Necessity Criteria Targeted and Probe Audits CERT Facts and Reminders September

4 Helpful Acronyms CERT IOM IRF ITC PAI PAPE PAS OIG RA Comprehensive Error Rate Testing Internet Only Manual Inpatient Rehabilitation Facility Interdisciplinary Team Conference Patient Assessment Instrument Post-Admission Physician Evaluation Preadmission Screening Office of Inspector General Recovery Auditor September

5 IRF Coverage Requirements This section covers IRF benefit policy and documentation guidelines

6 IRF PPS Services Patients expected to benefit from an interdisciplinary team approach to the delivery of rehabilitation care Intensive level of care in the hospital Documentation requirements outlined in the Medicare Benefit Policy Manual (MBPM) Chapter 1, Section Guidance/Guidance/Manuals/downloads/bp1 02c01.pdf September

7 IRF PPS Services Policy Full course of treatment in the referring hospital must be complete before patient can be transferred to the IRF Patient must be able to fully participate and benefit from IRF program Patient must require intensive rehabilitation September

8 IRF PPS Documentation Medical records for admission to be considered reasonable and necessary: Preadmission Screening (PAS) Post-Admission Physician Evaluation (PAPE) Individualized overall plan of care (POC) Physician Admission Orders IRF-Patient Assessment Instrument (PAI) September

9 Preadmission Screening (PAS) IOM Chapter 1, Section

10 Preadmission Screening Evaluation of the patient s condition and need for rehabilitation therapy and medical treatment is a key factor Qualified licensed or certified clinician must complete screening within 48 hours preceding the IRF admission September

11 Preadmission Screening 2 A comprehensive screening containing all the required elements conducted 48 hours prior to admission is acceptable Update must occur within 48 hour Supports admission decision Initial determination whether patient meets requirements for reasonable and necessary Physician review and concurrence Retained in the patient s medical record September

12 Preadmission Screening 3 Must indicate: Patient s prior level of function Expected level of improvement Expected length of time needed to achieve that level of improvement Evaluation of the patient s risk for clinical complications Conditions that caused the need to rehabilitation September

13 Preadmission Screening 4 Must include: Combinations of treatments needed Physical Therapy (PT) Occupational Therapy (OT) Speech-Language Pathology (SLP) Prosthetics/orthotics September

14 Preadmission Screening 5 Also must include: Expected frequency and duration of treatment Anticipated discharge destination Anticipated post-discharge treatments Any additional information relevant to the patient s care needs September

15 Preadmission Screening 6 Rehabilitation physician documents concurrence with finding and results After the preadmission screening is completed and prior to the IRF admission Must either sign and date the original document or Sign and date a copy and fax it to the IRF September

16 Post-Admission Physician Evaluation (PAPE) IOM Chapter 1, Section

17 PAPE Document the patient s status after admission to IRF Compare to what is noted in the preadmission screening documentation Note any discrepancy or deviation from PAS Begin development of the patient s expected course of treatment September

18 PAPE 2 Evaluation must be performed by rehabilitation physician Completed within the first 24 hours after admission Must support the admission is reasonable and necessary Must be retained in the patient s medical record at the IRF September

19 Individualized Overall Plan of Care (POC) IOM Chapter 1, Section

20 Individualized Overall Plan of Care (POC) Individualized to patient s unique care needs Based on information: In the preadmission screening In the post-admission physician evaluation Amassed from therapy assessments Integrated by a rehabilitation physician Must be completed within 4 days of admission Must be signed by rehabilitation physician September

21 Individualized Overall POC 2 Estimated length of stay Medical prognosis Anticipated interventions, functional outcomes and discharge destination Expected Therapy: Intensity (# of hours per day) Frequency (# of days per week) Duration (total # of days during the IRF stay) September

22 Physician Admission Orders IOM Chapter 1, Section

23 Admission Orders At the time of admission into the IRF Physician must generate orders to admit Orders must be retained the patient s medical record at the IRF Signature requirements CMS IOM, Medicare Program Integrity Manual (MPIM) Publication Chapter 3, Section Section D Signature Guidelines Section E Electronic Signatures September

24 Signature Log Used to establish signature legibility throughout medical record documentation Typed listing of provider names followed by handwritten signature Must also include professional credentials/titles September

25 For an attestation statement to be valid, it must be signed by the performing provider Location of Attestation Form JF - documents/10529/ /cert+p oint+of+contact+provider+form/6d c53-437d-b8d1- b7a5a77083aa JE documents/10525/78978/signature+ Attestation+Statement/ September

26 Signature Requirements Met 1 Legible full signature 2 Legible first initial and last name 3 Illegible signature over a typed or printed name Example : John Whigg, MD 4 5 Illegible signature where letterhead, addressograph or other information on page indicates identity of signator. Example: An illegible signature appears on a prescription. Letterhead of prescription lists 3 physicians' names. One of the names is circled. Illegible signature NOT over a typed/printed name and NOT on letterhead, but submitted documentation accompanied by signature log or attestation statement 6 Initials over a typed or printed name 7 Initials NOT over typed/printed name but accompanied by signature log or attestation statement 8 Unsigned handwritten note where other entries on same page in same handwriting are signed September

27 When Attestation Statement or Signature Log is Needed 1 Illegible Signature NOT over a typed/printed name, NOT on letterhead and documentation is unaccompanied by signature log or attestation statement Example: 2 3 Initials NOT over a typed/printed name unaccompanied by signature log or attestation statement Unsigned typed note with provider's typed name Example: John Whigg, MD 4 Unsigned typed note without providers typed/printed name 5 Unsigned handwritten note the only entry on page 6 "signature on file" September

28 Electronic Signatures Providers using electronic systems need to recognize there is potential for misuse or abuse with alternate signature methods Systems and software products must include protections against modification and should apply administrative safeguards that correspond to standards and laws; September

29 Electronic Signature Guidelines The individual whose name is on alternate signature method and provider bears responsibility for authenticity of information being attested to; Physicians are encouraged to check with their attorneys and malpractice insurers in regard to use of alternative signature methods; September

30 Patient Assessment Instrument (IRF-PAI) IOM Chapter 1, Section

31 Patient Assessment Instrument (PAI) IRF-PAI must be included in the patient s medical record either in electronic or paper format PAI must include the HIPPS code received from the CMS repository Data collected on the IRF-PAI corresponds with patient s medical records at the IRF September

32 Validation Process for PPS Patient Assessments IRF PAI information Provider-submitted HIPPS code Patient s HICN, (IRF-PAI item 2) Date of Birth (IRF-PAI item 6) Provider CCN/PTAN (IRF-PAI item 1B) Statement from and through dates (IRF- PAI item 40) Admission date (IRF-PAI item 12) September

33 Validation Process for PPS Patient Assessments 2 Before billing IRF claims to Medicare verify IRF-PAI validation report Claim will RTP with Reason Code when incorrectly billed Avoid RTP by ensuring that the IRF-PAI finalizes; it is error free Use occurrence code 50 to indicate the assessment date September

34 IRF-PAI on CMS Website Contains useful tools Updated IRF-PAI Training Manual Final IRF-PAI effective for October 1, 2015 System Maintenance and data transmission information Fee-for-Service- Payment/InpatientRehabFacPPS/IRFPAI.h tml September

35 Reasonable and Necessary Criteria IOM Chapter 1, Section 110.2

36 Reasonable and Necessary Criteria Physician supervision Demonstrated by face-to-face visits by a rehabilitation physician at least 3 days per week throughout the IRF stay Licensed physician with specialized training and experience in inpatient rehabilitation Other physician specialties may treat and visit, as needed Do not count toward this requirement September

37 Reasonable and Necessary Criteria 2 Multiple therapy disciplines (PT, OT, SLP, Prosthetics/Orthotics) Ongoing therapeutic intervention; one of which must be physical or occupational therapy Minimum intensity threshold for therapy services is 15 hours/week September

38 Intensive Therapy Services Therapy treatment schedule can vary based on the patient s medical needs: Generally, 3 hours of therapy per day at least 5 days per week; or At least 15 hours of intensive rehabilitation therapy within a 7-consecutive day period, beginning with the date of admission Reasons must be documented in the medical record September

39 Intensive Therapy Services 2 Therapy treatment schedule can vary based on the patient s medical needs: The minimum 15 hours/week intensity is not met due to non-medical reasons Therapy minutes must be made up during the same 7 consecutive day period starting with the day of admission September

40 Intensive Therapy Services 3 Examples of medical reasons for exception of therapy minutes A brief exception, not to exceed 3 consecutive days, may be allowed for a reduction in the minimum therapy minutes/week These excepted minutes would not have to be made up Documentation must clearly identify specific medical rationale to justify need for exception September

41 Intensive Therapy Services 4 Intensity of therapy must never exceed the patient s level of need or tolerance Ability to participate in ITP Reasonable measurable improvement expected September

42 Intensive Therapy Services 5 Required therapy treatments must begin within 36 hours from midnight of the day of admission to the IRF Therapy evaluations may constitute the initiation of therapy services Therapy evaluations count for the purposes of demonstrating the intensity of therapy requirement September

43 Rehabilitation Therapy Tips Group and/or concurrent therapy may not constitute the majority of therapy Therapy minutes cannot be rounded for the purposes of documenting the required intensity Time spent in family conferences does not count toward intensity of therapy requirements September

44 Reasonable and Necessary Criteria Documentation shows reasonable expectation that at the time of admission the patient s condition requires an interdisciplinary team approach including: Complex nursing and close physician medical management Rehabilitation care Multiple therapy disciplines September

45 Reasonable and Necessary Criteria 2 Interdisciplinary Team Approach to Care Held at a minimum of once per week (7 calendar days beginning with the day of admission) Team purpose Frequent, structured and documented communication to establish, prioritize and achieve treatment goals Each member works within their scope of practice September

46 Required Team Participants Rehabilitation physician with specialized training and experience in rehabilitation services Registered nurse with specialized training or experience in rehabilitation Social worker or case manager (or both) Qualified licensed or certified therapist from each therapy discipline involved in treating the patient September

47 Weekly Team Meetings Focus on: Assessing the individual s progress towards the rehabilitation goals 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 September

48 Discharge Planning and Dates Discharge planning is an integral part of any rehabilitation program and must begin upon the patient s admission to the IRF, an extended period for discharge would not be reasonable and necessary Rare cases use ABN for delayed extended period and occurrence code 76 IRF-PAI discharge dates and IRF claim dates should match September

49 Medical Review and CERT Facts and Reminders

50 Probe and Targeted Review Pre-payment probe reviews ensure claims process correctly the first time Decreases later recovery of payment Targeted reviews are based on error findings Provider education provided to prevent future inappropriate billing Providers are notified of selection by ADR September

51 Probe and Targeted Review 2 IOM, MPIM, Publication Chapter 3, Section CERT, RA, OIG and GAO may initiate reviews Data demonstrate vulnerability and improper payment September

52 CERT Errors for IRF Services Documentation does not support medical necessity Missing required documentation Preadmission Screening (PAS), post-admission physician evaluation (PAPE), Interdisciplinary Team Approach meeting notes, Plan of Care developed by the Rehabilitation Physician Missing, incomplete, or illegible signature Admission order to the IRF September

53 CERT Errors and Resolution CERT ERROR Lacked professional credentials and consistent e-signature documentation How to Prevent Rehabilitation physician must sign and date the preadmission screening before the patient is admitted September

54 CERT Errors and Resolution 2 CERT ERROR Timeliness requirement for preadmission screening not met, unqualified staff conducted the screening How to Prevent Conducted by a qualified licensed clinician, within 48 hours before the admission and the rehabilitation physician concurs prior to admission September

55 CERT Errors and Resolution 3 CERT ERROR Timeliness requirement for postadmission physician evaluation not completed timely How to Prevent Conducted by the rehabilitation physician, within 24 hours after the admission and support admission is reasonable and necessary September

56 Insufficient Documentation Reviewer received from a provider the following medical records for 8-day IRF stay IRF-PAI, physician admission order to the IRF, lab results, medication administration records, physician preadmission screening, MD progress notes, plan of care, discharge summary, nursing and therapy notes September

57 Claim Review Decision Missing medical records from previous claim example Interdisciplinary team meeting notes Post-admission evaluation/assessment The purpose of the post-admission physician evaluation; note patient status after admit, develop expected treatment course with input from team members September

58 Medical Necessity Not Supported Reviewer received the following records for a 3-week IRF stay PAS, PAPE, nursing progress notes, NP s discharge summary, interdisciplinary team meeting notes, plan of care; PT, OT and SLP notes, physician orders from hospital, consults and progress notes; September

59 Medical Necessity Not Supported 2 Diagnostic lab test and radiology reports. IRF-PAI, signature log and electronic signature protocol Inpatient hospital admission record showed patient IRF stay was interrupted one day September

60 Claim Review Decision Missing medical records from the previous claim example Physician IRF admission order Legible physician orders must be retained the patient s medical record at the IRF Signature log or attestation for illegible signature Electronic signature protocol for e-signature September

61 Medical Necessity Not Supported Reviewer received the following medical records for a 14-day IRF stay PAS, PAPE, IRF orders, PT/OT/SLP evaluations and plans, daily therapy/care notes, physician progress notes, discharge planning, team meeting notes, IRF-PAI September

62 Claim Review Decision Missing medical records from the previous example Plan of care integrated by the rehabilitation physician An individual plan of care is required to combine information in the preadmission screening, post-admission assessment, therapy evaluations and notes to show the overall plan of care for the patient September

63 Decision Letter for CERT Error Noridian will send an Insufficient, No Document, No Response Error letter Encourages corrective action Corrective action list 15 day last attempt to obtain medical records Appeal sending missing documentation within 120 days of the decision Educational materials and a plan of action request September

64 RESOURCES

65 CMS Resources CMS IRF Coverage Requirements Fee-for-Service- Payment/InpatientRehabFacPPS/Coverage. html Change Request (CR) 7760 IRF PAI Validation Process Guidance/Guidance/Transmittals/Downloads/ R2495CP.pdf September

66 CMS Resources Medicare Learning Network IRF Fact Sheet Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/Inpatient_Reh ab_fact_sheet_icn pdf CMS IRF PPS web page Fee-for-Service- Payment/InpatientRehabFacPPS/index.html September

67 JEA Noridian Resources CERT & Reviews rt-reviews ADR Submission rt-reviews/mr/adr-submissions Documentation of Medical Necessity rt-reviews/mr/documentation September

68 JFA Noridian Resources CERT & Reviews t-reviews ADR Submission t-reviews/mr/adr-submissions Documentation of Medical Necessity t-reviews/mr/documentation September

69 Thank You