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3 Hour Rule – Defining an IRF/U level of Intense Therapy Services

Written by: Darlene D'Altorio-Jones (1959-2015) on Tuesday, June 17, 2014 Posted in: Inpatient Rehab

3 Hour Rule – A Few Facts and Figures

Given the number of rules that are monitored for adherence to an IRF level of care defined for Medicare part A recipients, the 3 Hour Rule comes as no stranger. If you are an IRF, no doubt you think about this factor each and every day at your facility. How often is it monitored by our peers? Who monitors the 3 Hour Rule and what are the risks of accurately providing the required amount of therapy service? Let’s take a peek at what others say when it comes to 3 Hour Rule and the intensity of therapy standard to justify at a  minimum an IRF/U level of therapy services.

How does your facility track 3 Hour Rule Compliance? Electronic? Manual? Therapist Monitor?


How often is 3 Hour Rule compliance monitored? Clearly once per day is the preferred frequency.


Who is responsible for tracking adherence to the 3 Hour Rule? Therapist, Manager, Director, Scheduler, other is responsible.



What is your perceived risk of managing the 3 Hour Rule accurately? Greater than two-thirds of the responses feel it is very likely or somewhat likely a perceived risk of being audited for the 3 Hour Rule therapy mandate.


Although there are many legitimate reasons a patient may not receive the full intensive scheduled therapy, CMS requires that the reason is specifically attributable to a patient purpose or cause and not a facility driven issue. Making sure documentation is within the medical record for less intense therapy is important. If the intended plan is being changed, rather than just a situational occurrance, that plan must be approved and concurred for by the rehabilitation physician and also noted within the documentation. Intensity within the first week may be the most important as a ‘trial’ or build up to the endurance required for active participation in the IRF/U setting and it must be demonsrated as feasible when admitting the patient. Further, if the patient cannot tolerate 3 hour intensity within the first week you risk being paid a ‘short stay’ payment rather than the fully reimburseable CMG stated for the HIPPS code that is recorded on the billing document and defined by the IRF PAI level of care.

We learned in the necently released IRF proposed rule, by next year 2016 therapy tracking will also include one-on-one co-treatment and group services as an average per week, 1, 2 and all subsequent weeks a patient is in an IRF. If tracking presently has become time cosuming, tracking it in further detail will add to those time requirements.

Read more about the IRF clarifications for intensity expectations and brush up on other blogs we have posted on this subject. With more than two-thirds of respondents feeling this is an auditable risk, it’s never too late to improve the documentation, tracking and workflow required to ensure intensity is met by your patients.

Most importantly, if you utilize MediLinks® documentation, be certain you utilize automated 3 Hour Rule reporting features. Observations and content can be easily adapted for rule reporting if your facility has not taken advantage of these features in the past.

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