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Written by: Darlene D'Altorio-Jones (1959-2015) on Thursday, June 7, 2012 Posted in: Inpatient Rehab

More than two years has lapsed since IRFs were provided an extremely prescribed set of conditions as coverage requirements for Medicare paid services to beneficiaries accessing an inpatient rehabilitation level of care. Since that time, there has been national education, clarification discussions and a series of documents posted at the CMS website to assist providers in the details that defined those 2010 regulations included in the Medicare Benefit Policy Manual 100-02 Chapter 1:110.

The question is, have you listened and have you adopted practice that falls specifically in line with the expectations? Do you know where you stand for each criteria? An IRF PPS Coverage Requirements National Provider Call took place on May 31, 2012.  It seemed fairly evident by the greater than 30 questions fielded during the call that there is still a significant amount of confusion on how the 11 areas of Section 110 from 110.1.1 – 110.3 will be applied during a compliance audit at either the FI/MAC or RAC level. It’s even harder to believe that these 11 areas require surveillance to over 45 specific measurable items and those items have created to date five separate clarification documents that further define how the audit contractors are to apply meaning to the standards. From areas covered on the most recent call, it is possible another document will also be prepared and posted.

I don’t have to remind you that these are ‘coverage criteria so if they are not met in preponderance of chart audits, they will result in denial of payment, and if grossly ignored will jeopardize excluded status under IRF PPS payment. There are sanctions that default the payer model back to acute care DRG level and can be held there through an entire cost reporting cycle. Facilities that have a large population of Medicare beneficiaries  in their total census need to take a detailed adherence toward all expected workflows and documentation standards. You must audit internally to the greatest degree possible for each expected criteria so that you can continuously improve your processes to meet the expected target.

If you have clinical staff or physicians that beg to differ with these stringent mandates, they pose significant risks to your bottom line and livelihood. No one wants to experience denial and take back of payments for patients that have successfully been rehabilitated and returned to the community only through resource utilization you expertly provided; not even CMS. But if you ignore the obvious, rules are laws and laws not followed result in less than desirable outcomes. Payment neutral can be achieved in several different ways while protecting the Medicare Trust Funds. Foolhardy does not have to be one of those ways.

In this round of audit on medically necessary admissions, the specific criteria is to meet the conditions of coverage. They appear fairly straight forward and can more or less be defined by yes or no for charted presence and some rely on detail to time standards.   An appropriate admission depends on meeting these criteria. It has been said over and again; it is not necessarily just the diagnosis or where they are admitted from, but the ability to meet the coverage criteria. Do a self check. Demonstrate due diligence so that any chart can be pulled and fiercely upholds the outlined criteria. Medical necessity audits are just starting.  There has been time enough to get it right, so let’s get it right!

Mediware now has a searchable document to help pinpoint clarification statements specific to your needs!

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