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Written by: Darlene D'Altorio-Jones (1959-2015) on Tuesday, November 15, 2011 Posted in: Inpatient Rehab

In a day where electronic documentation and gathering of information from various areas to place within a document seems to be a “secretarial” type duty, that statement cannot be farther from the truth when it comes to committing data to the IRF Patient Assessment Instrument (PAI). Although portions of the PAI are demographically related to the patient, by and large the rest of the document takes knowledge and expertise of a clinical mind set to understand; validate per PAI Manual instructions and discern appropriateness in completing and committing to the answers before uploading as a completed document.

Although clinicians scoring the PAI should have thorough knowledge of the rules within the manual,  I will often review data and quickly identify the areas persons are unfamiliar with; such as when it’s permissible to score a zero at admission and discharge. What’s the difference between not observing an area (deserving no assessment), versus committing to the answer “does not occur,” which is a Medicare definition that has specific meaning when applied.

Another example is the use of coding professionals to assist with coding the PAI. The PAI manual encourages collaboration and validation with a coding expert. However, it’s necessary for that coding expert to apply the PAI manual criteria when completing the PAI and then standard coding practices when completing the Universal Bill.  It is allowable for a certain level of disconnect between these two documents – but often, those are not exercised because there is not a strong clinician validating and assimilating the information placed on the PAI.

The PAI is the historical validation of the types of patients we treat in an IRF. This information is aggregated to direct present burden of care cost allocation and further practice guidelines, rules and regulations. It’s very important!  The baseline of the document guides the direction of care provided to each patient as a plan of care and what areas need tackling so an individual has the ability to relearn function sufficiently to match caregiver abilities with the hopes of returning to the community.

If it was you, or a family member, you would want an accurate record of change. The information provided in the PAI is as critical as the care provided;  it is part of the medical record and should accurately describe the baseline and improvements made.

Therefore, in regards to who must have responsibility for the IRF PPS, generally, the person called the IRF – PAI Coordinator must meet these requirements.

This answer is found in the electronic Code of Federal Register under the section that is specific to conditions of participation for IRFs.

CFR; Title 42, Chapter IV., Subpart P 412.612

“412.612 Coordination of the collection of patient assessment data.

(a) Responsibilities of the clinician. A clinician of an inpatient
rehabilitation facility who has participated in performing the patient
assessment must have responsibility for –

(1) The accuracy and thoroughness of the specific data recorded by that
clinician on the patient’s assessment instrument; and

(2) The accuracy of the assessment reference date inserted on the patient
assessment instrument completed under 412.610(c).

(b) Penalty for falsification. (1) Under Medicare, an individual who
knowingly and willfully  –

(i) Completes a material and false statement in a patient assessment is
subject to a civil money penalty of not more than $1,000 for each
assessment; or

(ii) Causes another individual to complete a material and false statement in
a patient assessment is subject to a civil money penalty of not more than
$5,000 for each assessment.

(2) Clinical disagreement does not constitute a material and false

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