Widespread Part A Targeted Review Results –Inpatient Rehabilitation Facilities CMG
A2001-A2004, CMG A0801-A0803-TOB 11X
Medical Review Part A has recently completed the 1st quarter of 2014 widespread prepay
targeted review of bill type 11X:
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CMG A0801-A0806, Replacement of Lower Extremity Joint
CMG A2001 – A2004, Debility
Claims which met the edit parameters were randomly selected across the provider community.
The edit numbers for A0801-A0806 are 5176K for Alabama, 5014R for Georgia, and 5009N for
Tennessee. The edit numbers for A2001-A2004 are 5177K for Alabama, 5015R for Georgia, and
5010N for Tennessee. Based on the outcome of this review, Cahaba will continue the
prepayment targeted review.
State
Alabama
Georgia
Tennessee
State
Alabama
Georgia
Tennessee
Inpatient Rehabilitation Facilities
CMG A2001-A2004
Number of Providers
36
9
16
CMG A0801-A0803
Number of Providers
33
4
8
Error Rate
96%
94%
100%
Error Rate
100%
100%
100%
Review of the claims submitted indicated that the documentation submitted did not meet
technical requirements and admission did not appear reasonable and necessary. Please refer to
examples below:
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Preadmission screen was not completed within the 48 hour time frame of admission to
give accurate, recent findings of the patient’s condition.
Physician signature was dated, but is not timed to validate physician review and
concurrence of preadmission screen prior to IRF admission.
Preadmission screen was not always submitted as required by Medicare prior to IRF
admission.
Post admission M.D. evaluation was not always submitted as required by Medicare.
Overall plan of care was not individualized as defined by CMS. 3 hours/day 5 days/wk or
15 hours over 7 days or 90 min of PT and 90 min of OT does not meet CMS intent for
individualized plan of care.
Physician signature on overall plan of care or on progress notes was not always timed
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Signature on the preadmission screen and post-admission physician evaluation did not
meet time requirements. Example would be from a patient admitted on April 24, 2010
and the preadmission screen is not signed by the rehab physician until April 27, 2010.
The post admission history and physical was not was not completed until April 26, 2010.
Potential risk for clinical complications as documented on preadmission screen (fall,
DVT, infection, unsteady gait, decreased balance, need for post-op wound/incision care,
or continued antibiotic meds, etc) does not raise the patient's needs to the level which
would require inpatient care.
No detailed justification for IRF admission on the preadmission screen or on the postadmission physician evaluation. The documentation will state that the patient requires
intense services of inpatient rehabilitation and direction by rehabilitation physician and
24 hour rehabilitation nursing care however no details are documented to support this
statement.
Functional status as documented on preadmission screen would not support the need for
an intense therapy program or for multiple therapy disciplines.
The documentation in the record indicated discrepancy between the post admission
physician evaluation which would state no change from preadmission screen and the
therapy evaluation would indicate a change from the preadmission screen with no
explanation of discrepancy.
Repetitious therapy services to address strength & endurance would not require the
intensity of an inpatient rehabilitation program.
In addition denials were also due to documentation not being submitted within the required time.
According to The Medicare Program Integrity Manual, PUB 100-8, Chapter 3, § 3.4.1.2, if a
coverage or coding determination cannot be made based upon the information on the claim, the
Medicare Administrative Contractor (MAC) may solicit additional documentation from the
provider by issuing an Additional Documentation Request (ADR) and must notify the provider
of the 30 day time-period to respond. If the ADR-requested information is not is received within
45 days after the date of the request, then the claim must be denied.
To eliminate 56900 denials, please review the following elements to ensure appropriate and
timely record processing:
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Print screen the ADR letter and attach the copy to the front of the requested medical
documentation
Send requested information by your preferred method: mail, fax, CD, esMD, etc…
Include ALL requested documentation outlined in the ADR
Submit the above information in a timeframe to ensure the MAC receives the
information by the 45th day after the date of the request.
Reasonable and Necessary:
Per 42 CFR 412.622(a)(3)(4) and (5), “In order for an IRF claim to be considered reasonable and
necessary under section 1862(a)(1) of the Social Security Act, there must be a reasonable
expectation that the patient meets all of the following requirements at the time of the patient’s
admission to the IRF—
1. Requires the active and ongoing therapeutic intervention of multiple therapy disciplines
(physical therapy, occupational therapy, speech-language pathology, or
prosthetics/orthotics therapy), one of which must be physical or occupational therapy.
2. Generally requires and can reasonably be expected to actively participate in, and benefit
significantly from, an intensive rehabilitation therapy program.
a. Under current industry standards, this intensive rehabilitation therapy program
generally consists of at least 3 hours of therapy (physical therapy, occupational
therapy, speech-language pathology, or prosthetics/orthotics therapy) per day at
least 5 days per week.
b. In certain well-documented cases, this intensive rehabilitation therapy program
might instead consist of at least 15 hours of intensive rehabilitation therapy within
a 7 consecutive day period, beginning with the date of admission to the IRF.
c. Benefit from this intensive rehabilitation therapy program is demonstrated by
measurable improvement that will be of practical value to the patient in improving
the patient’s functional capacity or adaptation to impairments.
d. The required therapy treatments must begin within 36 hours from midnight of the
day of admission to the IRF.
3. Is sufficiently stable at the time of admission to the IRF to be able to actively participate
in the intensive rehabilitation therapy program.
4. Requires physician supervision by a rehabilitation physician, defined as a licensed
physician with specialized training and experience in inpatient rehabilitation.
a. The requirement for medical supervision means that the rehabilitation physician
must conduct face-to- face visits with the patient at least 3 days per week
throughout the patient’s stay in the IRF to assess the patient both medically and
functionally, as well as to modify the course of treatment as needed to maximize
the patient’s capacity to benefit from the rehabilitation process.”
5. Patient must require an intensive and coordinated interdisciplinary approach to providing
rehabilitation.
Documentation Requirements:
The patient’s medical record at the IRF must contain the following documentation:
1. A comprehensive preadmission screening that meets all of the following requirements
a. It is conducted by a licensed or certified clinician(s) designated by a rehabilitation
physician within the 48 hours immediately preceding the IRF admission.
b. A preadmission screening that includes all of the required elements, 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 update the
patient’s medical and functional status within the 48 hours immediately preceding
the IRF admission and is documented in the patient’s medical record.
i. It includes a detailed and comprehensive review of each patient’s
condition and medical history.
ii. It serves as the basis for the initial determination of whether or not the
patient meets the requirements for an IRF admission to be considered
reasonable and necessary in paragraph (a)(3) of this section.
iii. It is used to inform a rehabilitation physician who reviews and documents
his or her concurrence with the findings and results of the preadmission
screening.
iv. It is retained in the patient’s medical record at the IRF.
2. A post-admission physician evaluation that meets all of the following requirements
a. It is completed by a rehabilitation physician within 24 hours of the patient’s
admission to the IRF.
b. It documents the patient’s status on admission to the IRF, includes a comparison
with the information noted in the preadmission screening documentation, and
serves as the basis for the development of the overall individualized plan of care.
c. It is retained in the patient’s medical record at the IRF.
3. An individualized overall plan of care for the patient that meets all of the following
requirements
a. It is developed by a rehabilitation physician with input from the interdisciplinary
team within 4 days of the patient’s admission to the IRF.
b. It is retained in the patient’s medical record at the IRF.
4. Interdisciplinary team approach to care. In order for an IRF claim to be considered
reasonable and necessary under section 1862(a)(1) of the Act, the patient must require an
interdisciplinary team approach to care, as evidenced by documentation in the patient’s
medical record of weekly interdisciplinary team meetings that meet all of the following
requirements
a. The team meetings are led by a rehabilitation physician and further consist of a
registered nurse with specialized training or experience in rehabilitation; a social
worker or case manager (or both); and a licensed or certified therapist from each
therapy discipline involved in treating the patient. All team members must have
current knowledge of the patient’s medical and functional status.
b. The team meetings occur at least once per week throughout the duration of the
patient’s stay to implement appropriate treatment services; review the patient’s
progress toward stated rehabilitation goals; identify any problems that could
impede progress towards those goals; and, where necessary, reassess previously
established goals in light of impediments, revise the treatment plan in light of
new goals, and monitor continued progress toward those goals.
c. The results and findings of the team meetings, and the concurrence by the
rehabilitation physician with those results and findings, are retained in the
patient’s medical record.”
Medical review decisions were based on:
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Title XVIII of the Social Security Act:
o Section 1862 (a)(1)(A)
o Section 1833(e)
42 Code of Federal Regulations, Section 412.622(a)(3)(4) and (5)
Medicare Benefit Policy Manual, Publication 100-02, Chapter 1, Section 110
Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Sections 220 and 230