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IRF is not an alternative to acute inpatient care CMS does not believe that patients should be
transferred to IRF’s before their medical conditions are sufficiently stable to enable them to participate in the intensive rehabilitation program provided by the IRF. (CFR42 part 112 pg. 39793)
This was ALWAYS intended but not specifically spelled out.
Dispelled Coverage Criteria vs. Classification Criteria
Regulations updated IRF coverage criteria, NOT IRF CLASSIFICATION criteria. (CFR42 part 112 pg.39789)
No intention for coverage criteria to have bearing on facility exclusion from IPPS, the requirements for the classification of facilities as IRFs, or the 60 percent rule.
Individual elements of the preadmission screening may be evaluated by any clinician or group of cliniciansdesignated by a rehabilitation physician, as long as the clinicians are licensed(to the extent possible under State licensure laws and
requirements), and qualified to perform the evaluation within their scopes of practice and training. (CFR42 part 112 pg.39790 &39791
The preadmission screening documentation must indicate: (Chapter 1 110.1 Required Documentation)
Prior level of function. Expected level of improvement. Expected length of time to achieve Expected Improvement. Evaluation of patient risk for clinical complications. Conditions that caused need for rehabilitation. Combinations of treatments needed (therapies) Expected frequency Duration for IRF treatment. Anticipated D/C destination Post-D/C treatment and other information relevant
In addition, the rehabilitation physician must document that he or she has reviewed and concurs with the findings and results of the preadmission screening.(Chapter 1 110.1 Required Documentation)
Post-Admission physician evaluations go beyond an H&P. Thus we believe post-admission physician
evaluations requires the unique training & experience of the rehabilitation physician as they perform a hands on evaluation.
We believe it is necessary for a patient to be seen by a rehabilitation physician within 24 hours. (CFR42 part 112 pg. 39792)
It is important for a rehabilitation physician to note the discrepancy and to document any deviations from the preadmission screening as a result. Retained in the medical record at the IRF.
MediLinks unique design ‘pulls forward’ pre-admission documentation to assist the physician in creating the integrated POC.
Must include: An estimated length of stay. Detailed medical prognosis Anticipated interventions / RISKS Expected functional outcomes Expected discharge destination from the IRF stay.
The documented overall plan of care (including an estimated length of stay, intensity, frequency, duration) must be completed within the first 4 days of the IRF admission; it must support the determination that the IRF admission is reasonable and necessary and it must be retained in the medical record of the IRF. (Chapter 1 – 110.1.3)
Good practice to conduct the first interdisciplinary conference within the first 4 days of admission.
Any IRF admission for the sole purpose of determining whether the patient can benefit significantly from treatment in the IRF or other settings is not considered reasonable and necessary. (CFR42 part 112 pg.39790 & 39791 & Chapter 1 – 110.1.1)
10 day ‘trial’ admit goes away. Determination is made by preadmission screening/concurrence by physician and SEALED through the 24 hour post admission physician evaluation which must again substantiate clinically relevant criteria that MATCH an expected medically necessary admission.
In rare cases when pre/post review reveals marked improvement in functional ability or an inability to meet the demands of the IRF rehabilitation program, the IRF must immediately begin the process of discharging the patient to another setting of care. (Chapter 1 – 110.1.2)
IRF Services provided after the 3rd day of admission will not be considered reasonable and necessary.
Medicare has authorized contractors to down-code IRF claims to the appropriate CMG for IRF patient stays of 3 days or less. (CFR42 part 112 pg. 39791 & Chapter 1 – 110.1.2)
Consideration or reassessment of the patient’s functional goals at least 3 times per week by the rehabilitation physician and his/her documentation of these visits in the medical record is the minimum standard that should be applied in an IRF.
In order for IRF care to be considered reasonable and necessary, the documentation in the patient’s medical record (which must include the preadmission screening described in section 110.1.1, the post-admission physician evaluation described in section 110.1.2, and the overall plan of care described in section 110.1.3 and admission orders 110.1.4) must demonstrate a reasonable expectation that the following were met AT THE TIME of ADMISSION to the IRF; (Chapter 1 -110.2)
3.) Reasonably expected to actively participate and benefit significantly from the intensive rehab. Reasonably expected to make MEASURABLE IMPROVEMENT OF PRACTICAL VALUE to IMPROVE FUNCTIONAL STATUS. Within a prescribed period of time.
4.) Face to face visits; 3x/ week to assess medical & functional status.
5.) Intensive and coordinated program as defined in 110.2.5
Close physician involvement in the patient’s care is generally demonstrated by face-to-face visits from a rehabilitation physician or other licensed treating physician with specialized training and experience in rehabilitation at least 3 days per week throughout the patient’s IRF stay. The purpose of the face-to-face visits is to assess the
patient both medically and functionally, as well as to modify the course of treatment as needed.
The PIP keeps the physician current on the most recent interdisciplinary documented functional status. (Chapter 1 - 110.2.4)
Considered reasonable and necessary if at the time of admission to the IRF the documentation in the patient’s medical record indicates that the complexity of the patient’s nursing, medical management, and rehabilitation needs requires an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation care. (CFR42 part 112 pg. 39793 & Chapter 1 – 110.2.5)
Care can only be achieved through close physician involvement and periodic team conferences; at least once a week.
The patient’s condition and functional status must be such that the patient can reasonably be expected to make measurable improvement (that will be of practical value to improve the patient’s functional capacity or adaptation to impairments) as a result of the rehabilitation treatment, and that such improvement can be expected to be made within a prescribed period of time.
Burden of Care reports provide adjusted daily CMI based on real time functional assistance needs. Management can track continuous improvement and resource reduction as improvement from clinical care is achieved.
Many IRF patients will medically benefit from more than 3 hours of therapy per day, when all types of therapy are considered. The required therapy treatments must begin within 36
hours from midnight of the day of the patient’s admission to the IRF. Evaluations satisfy this requirement.(CFR42 part 112 pg. 39796)
This means that an IRF patient’s daily therapy requirements must generally be met by one-on-one therapy services, as documented in the patient’s medical record. Group therapies are to be used in IRFs primarily as an adjunct to one-on-one therapy services. (CFR42 part 112 pg. 39797)
Therapy aide services are NOT considered skilled, and would not meet the IRF intensity of therapy criterion used to evaluate the appropriateness of IRF care. (CFR42 part 112 pg. 39802)
At a minimum, the interdisciplinary team must document participation by professionals from the following disciplines (each of whom must have current knowledge of the patient as documented in the medical record):
A rehabilitation physician with specialized training and experience in rehabilitation services; A registered nurse with specialized training or experience in rehabilitation; A social worker or a case manager (or both); and A licensed or certified therapist from each therapy discipline involved in treating the patient.
The interdisciplinary team must be led by a rehabilitation physician who is responsible for making the final decisions regarding the patient’s treatment in the IRF. This physician must document concurrence with team decisions at each meeting. Interdisciplinary status relating to TEAM GOALs are
uploaded into the Patient Evaluation Template for physician editing/signature in MediLinks.
During most IRF stays, therefore, the emphasis of therapies would generally shift from traditional, patient centered therapeutic services to patient/caregiver education, durable medical equipment training, and other similar therapies that prepare the patient for a safe discharge to the home or community-based environment (Chapter 1 – 110.3)
Documentation must concentrate on FUNCTIONAL TEAM GOALS and work to remove those barriers vs. discipline specific chatter.
With continual increase in Medicare Advantage or Part C populations; 50% or greater of a facilities population may not be Medicare part A, making presumptive methodology of the total inpatient population within the 60% rule difficult.
Therefore: IRF’s must encode & transmit IRF-PAI data on all part A and Medicare Advantage part C patients to facilitate better calculations under the 60% rule. 10/1/09 is the effective date adopted. The Medicare identification number must be provided.
10% of the average monthly Medicare claims (max 200) per 45 days per NPI can be Audited.
If a facility has 60% Medicare Claims and discharges 700 patients per year. 700 X .60 = 420 patients are Medicare 420 / 12 = 35 pts/ on avg. per month. Reviews can occur every 45 days. (365 / 45 = 8.1 possible
reviews annually). 10% of 35 = 4 patients per each 45 days or 32 patients per
year. If a CMI of 1.0 is paid @ $13,661 X 32 pts. = $437,152.00 of
defensible risk. If your CMI is higher so is your RISK!
Same as FI and MAC identified overpayments A Remittance Advice notice is issued: Remark Code N432: “Adjustment Based on Recovery Audit” Carrier; FI/MAC recoups by offset unless provider has
submitted a check or a valid appeal within the time lines provided.
MediLinks was designed specifically for the rehabilitation niche to meet the unique criteria for interdisciplinary TEAM oriented care and is designed to seamlessly meet the regulations outlined.
Without electronic documentation; abstracting charts in a way that demonstrates each of these criteria being met for every patient would be extremely time & labor intensive.
With MediLinks – it’s seamless & reportable; our solutions were created with rehabilitation needs in mind.