Drill Down – IRF Coverage Criteria Are You
Covered?
RAC region A contractor Performant posted a Complex audit review issue based on
Inpatient Rehabilitation Facility (IRF) Admission for the states of: CT, DC, DE, MA, ME, NH, NJ,
NY, PA, RI and VT.
The issue is that IRF benefits are designed to provide
intensive rehabilitation therapy in a facility for patients who, due to the
complexity of their nursing, medical management, and rehabilitation needs,
require and can reasonably be expected to benefit from an inpatient stay and an
interdisciplinary team approach. Performant’s complex review will determine if
the patient met the coverage criteria for the admission to the IRF.
The complete list of coverage criteria can be found in 42
CFR 412.604. Some examples for conditions for payment under prospective payment
system for inpatient rehabilitation facilities are:
·
The patient actively participates in an ongoing
therapeutic intervention of multiple therapies (physical, occupational,
speech-language, or prosthetics/orthotics).
·
The patient can actively participate in 3 hours
of therapy per day 5 days a week or 15 hours of intensive therapy 7 days a
week.
·
Requires physician face to face visits with the
patient who is a rehabilitation physician.
·
Requires a comprehensive preadmission screening
by a licensed clinician designated by the rehabilitation physician preceding 48 hours of admit.
·
Interdisciplinary team approach to care, with
documented meetings and plan of care.
The OIG office has cited criteria for those patients that do
not need IRF care as outlined in the Centers for Medicare & Medicaid
Services (CMS) Publication Medicare Benefit Policy Manual 100-02 Chapter 1,
Section 110 as:
·
Uncomplicated hip or knee surgery or other
single joint replacement that requires only pain medication and simple therapy.
·
Simple orthopedic injuries and medical
neurological conditions that require only general muscle strengthening and
reconditioning.
In the above cases, pre-admission screening procedures did
not identify consistently those patients who could be treated in a less
intensive facility or those who were not capable of significant improvement as
a result of therapy or unable to participate fully in an IRF.
RAC issues for the
week of July 15th – July 19th, 2013:
RAC Region A
Performant
Inpatient Rehabilitation Facility
Claim Types
§ Inpatient
Rehabilitation Facility (IRF) Admission - The
IRF benefit is designed to provide intensive rehabilitation therapy in a
facility for patients who, due to the complexity of their nursing, medical
management, and rehabilitation needs, require and can reasonably be expected to
benefit from an inpatient stay and an interdisciplinary team approach. The
review will determine if the patient met the coverage criteria for the admission
to the IRF.
No comments:
Post a Comment