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Written by: Bob Habasevich, PT on Wednesday, May 4, 2011 Posted in: Inpatient Rehab

Last week, rehabilitation providers were made aware of the CMS intent to authorize its Recovery Audit Contractors (RACs) to review medical necessity criteria for patients admitted to an inpatient rehabilitation facility.

Inpatient rehabilitation providers know there are so many patients who would benefit from receiving rehabilitation in a setting where a team of highly trained clinicians is intensely focused on overcoming the individual medical and functional problems specifically for that patient. However, providers often confuse benefit, appropriate and necessity when describing the value of inpatient rehabilitation hospitalization. This is where the team’s training may not have been adequate to understand the difference and in this regard, they may operate within the expectation that rehabilitating patients with impairments apply equally to everyone.

For patients whose care is paid with taxpayers’ dollars, the medical record must provide clear and specific evidence that medical necessity criteria has been met. This means the RAC attack is on and the medical record is again the battle ground for defending appropriate rehabilitation inpatient care.

Soon, RACs will start reviewing patient records to determine if the patient care process has been adequately documented and meets the Medicare criteria for medical necessity. For a quick review of the criteria, refer to the CMS Manual Pub 100-02, or reference transmittal 119 located on CMS’ website at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R119BP.pdf . Sources at the American Rehabilitation Providers Association have indicated that HealthDataInsights, the RAC for Region D has been approved to begin reviews. According to their CMS contact, the issue description for inpatient rehabilitation hospitals and units (IRH/Us) is as follows: “Medicare pays for inpatient rehabilitation facility (IRF) services that are reasonable and necessary for the setting billed.  Medical documentation will be reviewed to determine that services were reasonable and necessary.”

The check list to prepare for a review must include:

Documentation Requirements

  • Preadmission Screening
  • Post-Admission Physician Evaluation
  • Individualized Overall Plan of Care
  • Admission Orders
  • Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI)

Medical Necessity Criteria

  • Multiple Therapy Disciplines
  • Intensive Level of Rehabilitation Services
  • Ability to Actively Participate in Intensive Rehabilitation Therapy Program
  • Physician Supervision
  • Interdisciplinary Team Approach to the Delivery of Care
  • Measurable Improvement

As in the past, knowing the rules isn’t enough to successfully defend against an attack.  Interpretation and application must demonstrate to a reviewer that the rules have been executed and taxpayer dollars were spent appropriately. This is where front line clinicians must demonstrate the differences of benefit, appropriate and necessity of inpatient rehabilitation.