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Will your IRFs Documentation Pass an Audit?

Written by: Virginia Littlepage on Tuesday, June 6, 2017 Posted in:

physical therapy workflow software

The dreaded request for documentation for determining whether it contains sufficient information to support the IRF claim! If you are already under review, then you know what I am talking about. However, if you aren’t then it is time to reassess and learn from what is happening out there.

Recently, I heard from a hospital based IRF regarding the results of their review last month and subsequent denials for payment. The common language in the rationale for denying the claim was that the review documentation did not support a valid individualized overall plan of care. This was followed by various reasons, depending on the claim being reviewed. So, I thought it might be good to take another look at the requirements of this document as defined in the Medicare Benefit Policy Manual – Chapter 1.

Individualized Overall Plan of Care Must Contain

  • Estimated Length of Stay
  • Medical Prognosis & Anticipated Interventions
  • Expected Intensity (hours per day)
  • Frequency (number of days per week)
  • Duration (total number of days in IRF) for….
  • Physical Therapy
  • Occupational Therapy
  • Speech-Language Pathology
  • Prosthetic/Orthotic Therapies
  • Functional Outcomes
  • Discharge Destination

Other factors to remember regarding this document include:

  • Information from the preadmission screening, post-admission physician evaluation, together with information from the assessments of all disciplines involved in the patient’s treatment/care will be synthesized by a rehabilitation physician to support the overall plan of care.
  • Discrepancies between PT, OT, SLP, and prosthetic/orthotic therapies documented expected intensity, frequency, and duration and the expectation documented in the overall plan of care must be documented in detail in the medical record.
  • Must be completed within the first 4 days of the IRF admission, including signature of the rehabilitation physician.
  • Must support the determination that the IRF admission is reasonable and necessary.

The review also covered other areas of documentation, with the rationale, again, depending on the claim, including:

  • Lack of physician signature on the admission orders.
  • Start of therapy not beginning within 36 hours from midnight on date of admission (this was specific to admissions over holidays).
  • Team conference did not include all of the required participants (rehabilitation physician, registered nurse, social worker/case manager, licensed therapist from each discipline involved in treating the patient).

The takeaway here is that it is critical that all IRFs regularly review the IRF requirements and complete internal audits to assure that all requirements are met. Chapter 1 in the Medicare Benefits Manual defines what is needed in each step of the IRF process. Below are a few things you can do immediately to assist in decreasing the likelihood of denials:

  1. If you haven’t read Chapter 1 lately, take the time to sit down and read the section specific for IRFs.
  2. Review your internal audit documents, assure that all aspects of Chapter 1 specific to IRFs are covered.
  3. Review your internal audit policy. Do you need to audit more frequently? Should you complete a 100% chart review for a period of time? Does the person completing the audit understand how to determine if chart supports medical necessity?
  4. Share the results of audit with staff (including physicians) and provide training with concrete examples of how to document for medical necessity.
  5. Wait for that review notice with a smile! Knowing that your IRF has is covered!

Mediware offers a free, in-depth, confidential review of your facility that focuses on 9 key areas of compliance and their impact on revenue.


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