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Written by: Mediware on Friday, August 9, 2013 Posted in: Inpatient Rehab

Over the past weeks, I have heard of more audit activity in relationship to IRF Medical Necessity (reasonable & necessary), than I have since testing the waters in the demonstration states prior to setting up permanent RAC jurisdictions. With very prescriptive 2010 mandates, it was just a matter of time to get pushed into the cycle of when this criteria would be challenged for individual records and preponderance in total to demonstrate worthiness for payment as an excluded acute care provider paid under IRF PPS. MAC and RAC are on full prowl for these records.

Connolly RAC posts this description on their website, and it follows precisely the published standards in 42 CFR, Chapter IV 412.622.


Mediware is your friend when it comes to preparedness for audit. If you subscribe and follow standard content, and have applied appropriate due diligence to the prescribed documentation sets and reports, you will have a much easier time completing the tedious steps required to demonstrate that, in fact your patient met each of the listed conditions. In fact, following the step-by-step audit and rebuttal in-services available on our website will be most helpful.

On the Nov. 12, 2009, National Provider Conference Call that CMS provided IRFs to prepare for the 2010 requirements, CMS stated very specifically that in retrospect the IRF stay could not be denied if in fact the criteria were met. In the posted transcript of that day’s call it stated: “Under the new requirements, a patient meeting all of their required criteria for admission to an IRF would be appropriate for IRF care whether he or she could have been treated in a skilled nursing facility. I will now discuss these requirements in detail on the next slide.” (Leading to discussions on slide 13 of this recorded and dictated conference call  with slides available on the link above.)

That was followed by an additional transcribed discussion: “As you have just heard, previously the regulations for coverage and non-coverage of IRF admissions depended on a retrospective look back to see if the services could have been provided at a lower level of service. Questions that were frequently asked included among others – did the patient need a doctor to frequently assess or intervene in a patient’s care? And did the patient need a nurse with specialized rehabilitation training or experience? The current regulations do not allow for this. Instead, assuming all documentation requirements are met at the time of admission to an IRF, the patient’s need – must need-  as you have just heard – multiple therapies, one of which must be PT or OT, an interdisciplinary approach; medical supervision as was just defined for you: and the patient’s potential must be such that they can participate in and benefit from intensive therapy; and specifically that they are medically appropriate to do so.”

Check out the 50 page PDF file transcript of that call that is listed but now unlinked on the CMS website.

I believe that if you have in due diligence and in preponderance truly fulfilled the mandates provided, you can surely refute a denial for medical necessity in good conscious. In fact, I have met very few facilities that within the screening process even come close to accepting upwards of 50 percent of all referrals to their rehab unit. In the rebuttal, be sure you set the tone, let them know your facility follows these very  specifically defined criteria and start to provide your facts! At the chart level and in comparison to all other like patients, shout your outcomes, your non-return to acute care within 30 days for like patients, the evidenced education and training you have fulfilled with facts leading to discharge of the patient in a reasonable amount of time to reach their intended potential, discharge destination and goal. That is what you have to predictably demonstrate. Did you?

These facts are found in your charts and although this is tedious work, it must be done. If you do not refute those denials to demonstrate your professional expertise in caring for these patients then we all lose in the profession of an IRF level of care.

Each patient must individually meet medical necessity guidelines. Each of those patients has been provided a spectrum of CMGs from least to most resource intensive to be paid according to their overall complexity. As long as there is potential for harm and/or risk that you have avoided aptly in your interdisciplinary services for the rehabilitation condition and all those comorbid conditions that could have led to a less than optimal experience with a lesser level of vigilance and concentrated skilled care efforts –  you can defend rightfully that documentation!  Most SNFs provide less than 2 hppd of RN care to each resident. Some provide far less. Given facts for your specific zip code at the CMS SNF compare website, what might your patient have experienced if a lesser level (less than 6-8 hours) of RN care was available to provide the skilled care and carry over of rehabilitation processes along with medical supervision and interventions? You documented these risks in the screening assessment – discuss them!

The physician reviews and attests to the condition of that patient in the pre-admission assessment and post admission evaluation. It should not automatically be assumed that a SNF level of care was less costly. We have all seen empirical evidence in reports that patients are in fact treated more expeditiously in IRFs; sometimes in a third of the length of stay when SNFs are given daily paid PPS rates rather than one set of all inclusive IRF PPS rates it cannot be a given that the care is in fact less costly. CMS discussed this as a fact in their final SNF rule published Aug. 8, 2011.

To provide demanding levels of service, training, education and discharge planning that is retrospectively denied to $0 payment when in fact you produced exactly what you proposed you would deliver and screened this patient to participate at the appropriate capability of participation cannot be tolerated.

Proactive vs reactive is always the better plan. It’s never too late to improve practiced documentation; continuous quality improvement through chart audits to meet medical necessity and to improve your skills and use of tools. If your documentation hasn’t stood up to expectation, then it’s time to prepare a risk assessment and action plan according to your individual needs. Utilize the 2010 elements checklist and put together your action plan. If you don’t have reports and utilization review processes to assure the elements of documentation are in fact completed you may suffer a loss too big to recover.

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