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A Technical Denial Based on Time is Most Unfortunate

Written by: Darlene D'Altorio-Jones (1959-2015) on Monday, July 20, 2015 Posted in: Inpatient Rehab

Denials based on technical aspects of review are clearer cut when a chart being audited meets or does not meet the projected expectation. This is particularly true if the technical aspect is a time expectation.

Given 24 hours or 48 hours to complete an expected task is no exception and in many ways is one of the easiest ways for Medicare Auditors to pull back thousands of dollars.

Even though time technicalities, when the inpatient rehabilitation hospital regulations were first published were not meant to purposefully deny an entire record; the reality is that time often is the deciding factor for hit or miss and missing comes with a huge price tag.   The entire stay can be denied and there is no rebuttal against meeting or missing time.

Has your facility looked at the requirements specifically and technically and determined whether your staff are meeting the expectations when monitors include time and its definition for success as discussed in the clarification documents published by CMS for inpatient rehabilitation hospitals/units?

The clarifications are specific to the Code of Federal Regulations  Title 42, Chapter IV, Subchapter P;    Section 412.622 ‘Basis of Payment’ which reiterates each of the clarification items and specifically emphasizes the 48 hours ‘immediately preceding’ the admission and the Post Admission Evaluation to be completed within 24 hours of the patients admission.   These IRH/U clarifications guide the specific time expectations when it comes to admission.  These are payment criteria rather than ‘certification criteria’ validating the necessity of the admission.

It’s hard to be successful in the care and rehabilitation of a patient that meets their goals and expends your resources only to leave that money on the table in the end because an additional development request indicated a time marker was not met.

Be sure you have self-audited your workflow and processes and take the equation of time out of the decision to withhold money for your care.

Often clerks enter the admission time into the hospital system and generally those individuals are not familiar with the importance of time when it comes to an inpatient rehabilitation facility. The time entered can be off by hours or when they had the time to enter or begin the admission information.  This time stamp is most critical and should not be taken lightly in the IRH/U.

Last year CMS published a document that specifically spells out the admission time expectations for the medical record.   In that document they address the inpatient rehabilitation hospital/unit and refer to the payment criteria definitions specific to the IRH/U.   It’s imperative that once a physician determines to admit a patient to the inpatient rehabilitation unit specifically in the same facility, that the admission time is picked up as the time the physician wrote the order and that the patient is transferred as close to that time as possible to the receiving unit. This would be the ‘formal admission to the hospital’ mentioned on page 6, # 4.  The ‘formal admission’ is specifically the time that the patient arrived or was admitted to the IRH/U.

Given this advice is followed, the expectations for time generated off of the ADT system when a chart is audited will specifically enable the expectations for completion of work and workflows.

CMS expects that the moment a patient arrives in your unit that you are responsible for the care and management of that patient. The arrival time in the chart is very transparent to auditors. Often each page of the chart is stamped with the patient name, date of admission and time of admission. Given this information, expectations within 48 hours of admission, 24 hours after admission can be easily understood and followed for documentation purposes.

If you have a lax admission processing time and your time stamp is not reflective of the admission to your IRH/U then it’s time to place a process improvement project in place. Your patient received your care and you expect to be reimbursed for that care but if you’re not meeting the coverage criteria for IRH/U and the expected published timeframes to complete documentation then your care could be paid through your reserves. Not fair, so get it right!


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