Inpatient Rehabilitation Facility (IRF) Services Part A Provider Outreach and Education September 2015
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 http://www.noridianmedicare.com and the CMS website at http://www.cms.gov 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 2015 2
Agenda Inpatient Rehabilitation Facility (IRF) Services Documentation Requirements Inpatient Rehabilitation Facility Medical Necessity Criteria Targeted and Probe Audits CERT Facts and Reminders September 2015 3
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 2015 4
IRF Coverage Requirements This section covers IRF benefit policy and documentation guidelines
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) 100-02 Chapter 1, Section 110 https://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/bp1 02c01.pdf September 2015 6
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 2015 7
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 2015 8
Preadmission Screening (PAS) IOM 100-02 Chapter 1, Section 110.1.1
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 2015 10
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 2015 11
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 2015 12
Preadmission Screening 4 Must include: Combinations of treatments needed Physical Therapy (PT) Occupational Therapy (OT) Speech-Language Pathology (SLP) Prosthetics/orthotics September 2015 13
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 2015 14
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 2015 15
Post-Admission Physician Evaluation (PAPE) IOM 100-02 Chapter 1, Section 110.1.2
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 2015 17
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 2015 18
Individualized Overall Plan of Care (POC) IOM 100-02 Chapter 1, Section 110.1.3
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 2015 20
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 2015 21
Physician Admission Orders IOM 100-02 Chapter 1, Section 110.1.4
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) Publication100-08 Chapter 3, Section 3.3.2.4 Section D Signature Guidelines Section E Electronic Signatures September 2015 23
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 2015 24
For an attestation statement to be valid, it must be signed by the performing provider Location of Attestation Form JF - https://med.noridianmedicare.com/ documents/10529/2685648/cert+p oint+of+contact+provider+form/6d9 39001-4c53-437d-b8d1- b7a5a77083aa JE https://med.noridianmedicare.com/ documents/10525/78978/signature+ Attestation+Statement/ September 2015 25
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 2015 26
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 2015 27
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 2015 28
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 2015 29
Patient Assessment Instrument (IRF-PAI) IOM 100-02 Chapter 1, Section 110.1.5
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 2015 31
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 2015 32
Validation Process for PPS Patient Assessments 2 Before billing IRF claims to Medicare verify IRF-PAI validation report Claim will RTP with Reason Code 37096 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 2015 33
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 http://www.cms.gov/medicare/medicare- Fee-for-Service- Payment/InpatientRehabFacPPS/IRFPAI.h tml September 2015 34
Reasonable and Necessary Criteria IOM 100-02 Chapter 1, Section 110.2
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 2015 36
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 2015 37
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 2015 38
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 2015 39
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 2015 40
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 2015 41
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 2015 42
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 2015 43
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 2015 44
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 2015 45
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 2015 46
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 2015 47
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 2015 48
Medical Review and CERT Facts and Reminders
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 2015 50
Probe and Targeted Review 2 IOM, MPIM, Publication 100-08 Chapter 3, Section 3.7.1.1 CERT, RA, OIG and GAO may initiate reviews Data demonstrate vulnerability and improper payment September 2015 51
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 2015 52
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 2015 53
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 2015 54
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 2015 55
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 2015 56
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 2015 57
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 2015 58
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 2015 59
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 2015 60
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 2015 61
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 2015 62
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 2015 63
RESOURCES
CMS Resources CMS IRF Coverage Requirements https://www.cms.gov/medicare/medicare- Fee-for-Service- Payment/InpatientRehabFacPPS/Coverage. html Change Request (CR) 7760 IRF PAI Validation Process https://www.cms.gov/regulations-and- Guidance/Guidance/Transmittals/Downloads/ R2495CP.pdf September 2015 65
CMS Resources Medicare Learning Network IRF Fact Sheet https://www.cms.gov/outreach-and- Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/Inpatient_Reh ab_fact_sheet_icn905643.pdf CMS IRF PPS web page https://www.cms.gov/medicare/medicare- Fee-for-Service- Payment/InpatientRehabFacPPS/index.html September 2015 66
JEA Noridian Resources CERT & Reviews https://med.noridianmedicare.com/web/jea/ce rt-reviews ADR Submission https://med.noridianmedicare.com/web/jea/ce rt-reviews/mr/adr-submissions Documentation of Medical Necessity https://med.noridianmedicare.com/web/jea/ce rt-reviews/mr/documentation September 2015 67
JFA Noridian Resources CERT & Reviews https://med.noridianmedicare.com/web/jfa/cer t-reviews ADR Submission https://med.noridianmedicare.com/web/jfa/cer t-reviews/mr/adr-submissions Documentation of Medical Necessity https://med.noridianmedicare.com/web/jfa/cer t-reviews/mr/documentation September 2015 68
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