Medical Review Changes for Inpatient Rehabilitation Facilities (IRFs)

Two key areas the federal review contractors will be targeting next.

An MLN Matters article published on Dec. 11 reported on a recent advisement from the Centers for Medicare & Medicaid Services (CMS) to its medical review contractors related to therapy services in Inpatient Rehabilitation Facilities (IRFs). Consistent with what we are seeing in the field, two key areas were addressed in this guidance to contractors:

• Therapy intensity of services

• Individualized one-to-one therapy as the standard of care

Intensity of Service

Medical review contractors were advised that further review of claims should occur when at least three hours of therapy per day, at least five days per week (or, in certain well-documented exceptions, at least 15 hours of intensive rehabilitation therapy within a seven-consecutive day period) is not provided. Therapy hours include physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics. CMS instructed that this further review will require the use of clinical review judgment to determine medical necessity of the intensive rehabilitation therapy program based on the individual facts and circumstances of each case, and it will not be based on any threshold of therapy time. 

The good news is that this guidance suggests that Medicare will not arbitrarily deny a claim for missing therapy minutes if the patient’s overall picture demonstrates that the care is reasonable and necessary to be performed in an IRF. The bad news is that there likely will be more upcoming audits based on the intensity of therapy services. 

Auditing the minutes of therapy, at least during the first two weeks, can be automated based on minutes reported in the IRF-PAI, making the identification of cases that do not meet the threshold more common. This trigger for medical review underlines the importance of documentation by clinical staff, both in daily notes and in the team notes, to demonstrate the reasons a patient has not received the requisite therapy – and to validate what changes are being made in the plan to meet the patients’ needs. There should also be support earned for ongoing IRF services by demonstrating that the patient has the potential to achieve goals.

Individualized One-to-One therapy as the Standard of Care

While CMS has frequently noted that the expectation for the therapy mode of care delivery is predominantly one-to-one services, we have seen an increase in denials when patients receive concurrent and/or group therapy, regardless of whether the preponderance of care is one-to-one. In this guidance, CMS further advised its medical review contractors that the standard of care for IRF patients is individualized (i.e., one-on-one) therapy. CMS further noted that group and concurrent therapy can be used on a limited basis, but it did not clarify the parameters for “limited.” Additionally, CMS advised that in those instances in which group therapy better meets the patient’s needs (on a limited basis), the situation/rationale that justifies group therapy should be specified in the patient’s medical record at the IRF. 

What’s the best course of action for IRFs?

Recent work with our clients demonstrates that therapy intensity and complexity is already being reviewed by medical review auditors. We recommend that IRFs review and improve their processes for:

• Tracking and monitoring the minutes of therapy;

• Clearly documenting missed minutes, reasons for missed therapy, and interventions to assure that the intensity is met;

• Documenting the complexity of the therapy provided by ensuring that specific tests and measures and assessment of quality and safety of patient functional activities are included in the notes, rather than just repetitive language about increasing distance for locomotion, etc.; and

• Assuring that the team documentation addresses participation in therapy as part of the ongoing assessment of IRF needs.

The aforementioned MLN Matters article can be located online at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE17036.pdf