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An interdisciplinary team provides this environment in an inpatient setting – a setting that is inappropriate for patients who have not fully completed their treatment in an acute-care hospital setting. It also is inappropriate for patients who do not require a high-intensity level of rehabilitation or could not tolerate the therapy.


To be compliant with Medicare’s updated guidelines, which took effect January 1, 2010, medical records and corresponding clinical documentation will need to support the level of services provided. Medicare considers care delivered at IRFs to be “reasonable and necessary” when it meets the requirements listed below. Use this outline as a requirement checklist for your clinical documentation practices.


Preadmission Screening

  • Complete an evaluation of the patient’s condition and potential need for rehabilitation therapy and medical treatment. Make it comprehensive and be sure it includes the following:
  • Patient’s level of function prior to admission;
  • Expected level of improvement;
  • Expected length of time necessary to achieve a level of improvement;
  • Evaluation of risk for clinical complication;
  • The condition that caused the need for rehab;
  • Treatment needs;
  • Expected frequency; and
  • Anticipated discharge destination.
  • Be sure that a licensed and/or certified clinician performs the evaluation within the 48 hours immediately preceding an IRF admission. Again, these clinicians must be qualified within their scopes of training to perform evaluations.
  • Before the IRF admission, the rehabilitation physician must document that he or she has reviewed the evaluation and concurs with the findings and results of the preadmission screening.

Post-admission Physician Evaluation

  • Within the first 24 hours of an admission. a physician evaluation with the following elements must be completed to support medical necessity of an IRF admission.
  • History and physical exam;
  • Patient’s prior and current medical and functional conditions;
  • Co-morbidities;
  • Specific notations of any discrepancies or deviations from the preadmission screen, including the reason(s) for the temporary change
  • If the physician finds that the patient is no longer a candidate for IR, the facility must immediately begin the process of discharge to another setting (there is a three-day allowance for transition).
  • A rehabilitation physician is defined as a licensed physician with specialized training and experience in inpatient rehabilitation.

Individualized Overall Plan of Care

Any therapy discipline can be instrumental in developing a care plan, but it is the physician who is responsible for integrating the information and documenting the plan. This must be completed within the first four days of an IRF admission and include the following elements:

  • Estimated length of stay;
  • Medical prognosis;
  • Anticipated interventions, including expected intensity, frequency and duration;
  • Functional outcomes; and
  • Discharge destination.

Admission Orders

The rehabilitation physician must generate an admission order at the time that a Medicare Part A fee-for-service patient is admitted.

Patient Assessment Instrument

The IRF medical record must contain the patient assessment instrument (IRF-PAI).

Medical Necessity Criteria

  • Therapeutic interventions must incorporate multiple therapy disciplines, and one of them must be either physical therapy [PT] or occupational therapy [OT]).
  • An intensive rehab therapy program should consist of at least 15 hours during a consecutive seven-day period, beginning with the date of admission to the IRF. An industry standard is seen as at least three hours of intensive therapy per day, occurring at least five days per week.
  • The documentation must show that the patient is an active participant exhibiting measurable improvement to their functional capacity.
  • The documentation must indicate that there is face-to-face correspondence with the rehabilitation physician at least three days per week.
  • The physician visit notes must assess the patient both medically and functionally. The care plan should be reviewed and modified to maximize the patient’s progress.

Multiple Therapy Disciplines

At the time of admission to the IRF, documentation should reflect that the patient was participating actively in continuing therapeutic intervention involving multiple therapy disciplines (PT, OT, speech-language pathology or prosthetics/ orthotics), one of which was PT or OT.

Intensive Level of Rehabilitation Services

  • Documentation must show that therapy treatment began within 36 hours from midnight on the day of admission to the IRF.
  • Documentation must indicate that therapy treatment was individualized, or one-on-one. Group therapies should serve as an adjunct to individual therapies.
  • If an unexpected clinical event occurred during the course of the IRF treatment and limited the patient’s participation, the medical record documentation must indicate the reasons for the break. The break period should not have exceeded three consecutive days.

Active Participation Required

At the time of admission, the patient’s condition should be documented in the medical record along with expectations of participation in, and benefits from, the IR therapy program.

Interdisciplinary Team Approach

An interdisciplinary team should include the following healthcare professionals: a rehabilitation physician, a registered nurse, a social worker and a licensed and/or certified therapist for each treatment discipline being used. Guidelines define the physician as the team leader, and he or she is responsible for final decisions regarding the treatment plan and any necessary revisions.

The team must conduct a conference at least once per week. The content of the meeting should include the following:

  • Assessment of the patient’s progress toward rehab goals;
  • Consideration of possible resolutions to problems impeding progress;
  • Reassessing previously established goals; and
  • Revising the treatment plan as needed.

Definition of Measurable Improvement

The treatment goal or goals must include the following elements and be documented in the patient’s medical record.

  • The goal must involve functional improvement that has practical value and is continuing and sustainable;
  • The goals must be measurable against the patient’s condition at the start of treatment;
  • The goals ultimately must enable a patient’s safe return to the home or the community-based environment upon discharge.
  • The goal must be capable of being met within a predetermined and reasonable period of time.
  • When further progress is unlikely, the discharge plan must be implemented.

What to Expect

Medicare contractors have been instructed to consider documentation contained in a patient’s IRF medical record when determining whether an admission was reasonable and necessary. Their focus will be on the preadmission screening, the post-admission physician evaluation, the overall care plan and the admission orders.

Will your IRF meet the clinical documentation requirements for services delivered? Perhaps the information provided below also will help.

Medicare Benefit Policy, Chapter 1 – Inpatient Hospital Services Covered Under Part A, Section 110 – Inpatient Rehabilitation Facility (IRF) Services at http://www.cms.hhs.gov/manuals/Downloads/bp102c01.pdf.

About the Author

Barbara Vandergrift, RN, BSN, MA, is a senior healthcare consultant with Medical Learning, Inc. (MedLearn), St. Paul, MN. MedLearn is a nationally recognized expert in healthcare compliance and reimbursement. Founded in 1991, MedLearn delivers actionable answers that will equip healthcare organizations with their coding, chargemaster, reimbursement management and RAC solutions.

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