An inpatient rehabilitation facility (IRF) is designed to provide intensive rehabilitation therapy within a resource-intensive hospital environment for patients who, due to the complexity of their medical, nursing and rehabilitation needs, require (and can reasonably be expected to benefit from) an inpatient stay and an interdisciplinary approach to the delivery of rehabilitation care.
Specific medical record documentation at the time of an IRF admission must support a reasonable expectation that the patient needs multiple intensive therapies (one of which must be physical or occupational therapy); the patient must be able to actively participate and demonstrate measurable improvement; and the patient requires supervision by a rehabilitation physician to assess and modify the course of treatment as needed to maximize the benefit from the rehabilitation process.
For a pre-claim review (PCR) review submission, each patient’s medical record should contain, but is not limited to, the following documentation.
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Documentation description |
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Preadmission screening (PAS)* |
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Was the PAS conducted by a licensed or certified clinician(s) designated by a rehabilitation physician within the 48 hours immediately preceding the IRF Admission? |
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Does the PAS document the patient’s prior level of function, or condition that led to the need for intensive rehabilitation? |
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Is the patient’s level of improvement documented? |
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Does the PAS document the expected/estimated length of stay? |
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Does the PAS contain an evaluation of the patient’s risk for clinical complications? |
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Does the PAS document the treatments needed? |
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Does the PAS include an anticipated discharge destination? |
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Does the PAS support that the rehabilitation physician reviewed and documented concurrence with the preadmission screening before the patient was admitted to the IRF? |
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Individualized plan of care (IPOC) |
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This documentation may not be available for submission of pre-claim reviews. |
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Interdisciplinary team approach: 42 CFR 412.622(a)(5) |
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This documentation may not be available for submission of pre-claim reviews. |
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Medical necessity: 42 CFR 412.622(a)(3) |
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Therapy evaluation/skilled notes (required) |
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May include history and physical, IPOC, skilled notes, interdisciplinary team note(s), admission orders |
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Does documentation support that the patient required the active and ongoing therapeutic intervention of multiple therapy disciplines (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics), one of which must be physical or occupational therapy? |
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Does documentation support the patient require an intensive rehabilitation therapy program (per industry standards, generally at least 3 hours of therapy per day at least 5 days per week). Note- Must begin within 36 hours from midnight of the day of admission; therapy evaluations are generally considered to constitute the beginning of the required therapy services and should generally be included in the total daily/weekly. Reviewers should look to brief exceptions policy if non-compliant. |
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Does documentation support that the patient can actively participate and benefit significantly from the intensive rehabilitation? |
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Does documentation support the requirement for medical supervision meaning the rehabilitation physician must conduct face-to-face visits with the patient at least 3 days per week? Note- Beginning with the second week of admission to the IRF, a non-physician practitioner may conduct 1 of the 3 required face-to-face visit per week |
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