(Medicare Benefit Policy Manual)

The IRF benefit is not to be used as an alternative to completion of the full course of treatment in the referring hospital.  A patient who has not yet completed the full course of treatment in the referring hospital is expected to remain in the referring hospital, with appropriate rehabilitative treatment provided, until such time as the patient has completed the full course of treatment.  Though medical management can be performed in an IRF, patients must be  able to actively participate in and benefit from the intensive rehabilitation therapy program provided in IRFs in order  for an IRF claim to be considered reasonable and necessary, in accordance with 42 CFR   412.622(a)(3)(ii).  Therefore, patients who are not able to actively participate in and benefit from the intensive rehabilitation therapy services because they are still completing their course of treatment in the referring hospital should remain in the referring hospital until they are able to do so.   Conversely, the IRF benefit is not appropriate for patients who have completed their full course of treatment in the referring hospital, but do not require intensive rehabilitation. Medicare benefits are available for such patients in a less -intensive s etting.   IRF care is only considered by Medicare to be reasonable and necessary under 1862(a)(1)(A) of the Social Security Act if the patient meets all of the requirements outlined in 42 CFR  412.622(a)(3), (4), and (5).  This is true regardless of whether the patient is treated in the IRF for 1 or more of the 13 medical conditions listed in 42 CFR  412.29(b)(2) or not. Medicare requires determinations of whether IRF stays are reasonable and necessary to be based on an assessment of each beneficiary's in dividual care needs.   For detailed guidance on the required qualifications of a therapist, required skills of a therapist, and medically necessary and appropriately documented therapy services, see Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, sections 220 and 230.  The policies in those sections describe a standard of care that should be consistent throughout the therapy disciplines, regardless of the setting of care.   110.1 - Documentation Requirements  (Rev. 10892; Issued: 08-06- 21; Effective:  11-08-21; Implementation: 11-08-21)   Part A/B  Medicare Administrative Contractors ( MACs ) (A) must consider  completion of the requirements at 42 CFR  412.622(a)(3), (4), and (5)  in a patients IRF medical record when determining whether an IRF admission w as reasonable and necessary.   110.1.1 - Required Preadmission Screening  (Rev. 10892; Issued: 08-06- 21; Effective: 11 -08-21; Implementation: 11-08-21)   In accordance with 42 CFR  412.622(a)(4)(i) a preadmission screening is an evaluation of the patients c ondition and need for rehabilitation therapy and medical treatment that must be conducted by licensed or certified clinician(s) within the 48 hours immediately preceding the IRF admission.  A preadmission screening that includes all of the required element s, but that is conducted more than 48 hours immediately preceding the IRF admission, will be accepted as long as an update is conducted in person or by telephone to document the patients medical and functional status within the 48 hours immediately preced ing the IRF admission in the patients medical record at the IRF.  The preadmission screening in the patients IRF medical record serves as the primary documentation by the IRF clinical staff of the patients status prior to admission and of the specific r easons that led the IRF clinical staff to conclude that the IRF admission would be reasonable and necessary.  As such, IRFs must make this documentation detailed and comprehensive .  In accordance with 42 CFR  412.622(a)(4)(i)(B) t he preadmission screening documentation must indicate the patients prior level of function (prior to the event or condition that led to the patients need for intensive rehabilitation therapy), expected level of improvement, and the expected length of tim e necessary to achieve that level of improvement. It must also include an evaluation of the patients risk for clinical complications, the conditions that caused the need for rehabilitation, the treatments needed (i.e., physical therapy, occupational thera py, speech -language pathology, or prosthetics/orthotics), and anticipated discharge destination.   If the patient is being transferred from a referring hospital, the preadmission screening  could either be done in person or through a review of the patients medical records from the referring hospital (either paper or electronic format), as long as those medical records contain the necessary assessments to make a reasonable determination. However, a preadmission screening conducted entirely by telephone should generally include transmission of the patients medical records from the referring hospital to the IRF and a review of those records by licensed or certified clinical staff  member in the IRF  to ensure it includes a detailed and comprehensive review of the  patients condition and medical history in accordance with 42 CFR  412.622(a)(4)(i)(B).   The IRF should develop a thorough preadmission screening process for patients admitted to the IRF from the home or community -based environment, which should ensure t hat patient preadmission screenings  include all of the required elements described in 42 CFR  412.622(a)(3), (4), and (5).  However, such admissions may not necessarily involve the use of medical records from a prior hospital stay in another inpatient hos pital setting unless such records are pertinent to the individual patients situation.   Individual elements of the preadmission screening may be evaluated by any clinician or group of clinicians designated by a rehabilitation physician, as long as the cli nicians are licensed or certified to perform the evaluation.  Although clinical personnel are required to evaluate the preadmission screening information in accordance with 42 CFR  412.622(a)(4)(i ), each IRF may determine its own processes for collecting and compiling the preadmission screening information.  The focus of the review of the preadmission screening information will be on its completeness, accuracy, and the extent to which it supports the appropriateness of the IRF admission decision, not on how the process is organized.  The rehabilitation physician need not be a salaried employee of the IRF , but must be a licensed physician who is determined by the IRF to have specialized training and experience in inpatient rehabilitation , in accordance wit h 42 CFR  412.622(c) .  For ease of exposition throughout this document, this physician will be referred to as a rehabilitation physician.   All findings of the preadmission screening should  be conveyed to a rehabilitation physician prior to the IRF admis sion.  Additionally, in accordance with 42 CFR  412.622(a)(4)(i) , the rehabilitation physician must document that he or she has reviewed and concurs with the findings and results of the preadmission screening prior to the IRF admission.   All preadmission  screening documentation (including documents transmitted from the referring hospital or other prior inpatient hospital stay, if applicable) must be retained in the patients medical record at the IRF  per the regulation at 42 CFR  412.622(a)(4)(i).   110.1.2 - Required Post -Admission Physician Evaluation  (Rev. 10892; Issued: 08-06- 21; Effective: 11 -08-21; Implementation: 11-08-21)   The post- admission physician evaluation  documentation requirement, previously required pursuant to 42 CFR  412.622(a)(4)(ii), was removed in the FY 2021 IRF PPS Final Rule (85 FR 48424).  However, the history and physical is still required under the Conditions of Participation at 42 CFR  482.24(c)(4)(i)(A).  110.1.3 - Required Individualized Overall Plan of Care  (Rev. 10892; Issued: 08-06- 21; Effective: 11 -08-21; Implementation: 11-08-21)   In accordance with 42 CFR  412.622(a)(4)(ii ), information from the preadmission screening and other information garnered from the assessments of all therapy disciplines involved in t reating the patient and other pertinent clinicians, must  be synthesized by a rehabilitation physician to support a documented overall plan of care.  The overall plan of care should generally detail the patients medical prognosis and the anticipated interv entions, functional outcomes, and discharge destination from the IRF stay, thereby supporting the medical necessity of the admission.  The anticipated interventions detailed in the overall plan of care should generally include the expected intensity (meani ng number of hours per day), frequency (meaning number of days per week), and duration (meaning the total number of days during the IRF stay) of physical, occupational, speech-language pathology, and prosthetic/orthotic therapies required by the patient during the IRF stay.  These expectations for the patients course of treatment should generally be based on consideration of the patients impairments, functional status, complicating conditions, and any other contributing factors.   Whereas the individual a ssessments of appropriate clinical staff will contribute to the information contained in the overall plan of care, the rehabilitation physician is responsible (in accordance with 42 CFR  412.622(a)(4)(ii)) for developing the overall plan of care with input from the interdisciplinary team .  In accordance with 42 CFR  412.622(a)(4)(ii), i n order for the IRF admission to be considered reasonable and necessary, the overall plan of care must be completed within the first 4 days of the IRF admission; it must support the determination that the IRF admission is reasonable and necessary; and it must be retained in the patients medical record at the IRF.   While CMS believes that it may be good practice to conduct the first interdisciplinary team meeting within the first 4 days of admission to develop the overall individualized plan of care, CMS believes that there may be other ways of developing the overall individualized plan of care.  Thus, IRFs may develop this required documentation using whatever internal processes they believe are most appropriate, provided that the documentation fulfills all relevant regulatory requirements.  110.1.4 - Required Admission Orders  (Rev. 10892; Issued: 08-06- 21; Effective: 11 -08-21; Implementation: 11-08-21)   At the time that each  Medicare Part A fee- for-service patient is admitted to an IRF, a physician must generate admission orders for the patient's care as per the requirements at 42 CFR  482.12(c)(2),  482.24(c), and  412.3.  These admission orders should generally be retained in the patients medical record at the IRF.   110.1.5 - Required Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF -PAI)  (Rev. 10892; Issued: 08-06- 21; Effective: 11 -08-21; Implementation: 11-08-21)   As per the requirements at 42 CFR  412.606(b), the IRF patient assessment instrument (IRF -PAI) forms should generally be included in the patients medical record at the IRF (either in electronic or paper format).   110.2 - Inpatient Rehabilitation Facility Medical Necessity Criteria  (Rev. 10892; Issued: 08-06- 21; Effective: 11 -08-21; Implementation: 11-08-21)   In order for IRF care to be considered reasonable and necessary, the documentation in the patients IRF medical record (which must include the preadmission screening described in sect ion 110.1.1, the overall plan of care described in section 110.1.3, and the admission orders described in section 110.1.4) must demonstrate a reasonable expectation that the following criteria were met at the time of admission  to the IRF .  Certain exceptio ns to these requirements may apply due to conditions arising during the Public Health Emergency defined in 42 CFR  400.200.  These exceptions are described further in Section 110.2.6 of this manual. 1. The patient must require the active and ongoing therapeu tic intervention of multiple therapy disciplines (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics), one of which must be physical or occupational therapy.  2. The patient must generally require an intensive rehabilitation therapy program, as defined in section 110.2.2.  Under current industry standards, this intensive rehabilitation therapy program generally consists of at least 3 hours of therapy per day at least 5 days per week.  In certain well -documented cases, th is intensive rehabilitation therapy program might instead consist of at least 15 hours of intensive rehabilitation therapy within a 7 consecutive calendar  day period, beginning with the date of admission to the IRF.