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Terms in this set (16)
Medical necessity, intensive level or rehabilitation service, interdisciplinary team approach, measurable improvement, documentation of IRF services
What are the IRF criteria?
Requirement of active and ongoing intervention of multiple therapy disciplines (at least one of which is PT/OT), require an intensive rehab therapy program (3 hours of therapy ≥5 days a week OR ≥15 hour intensive rehab therapy within a 7-consecutive day period starting with day of admission), reasonably be expected to actively participate in and benefit from the intensive rehab therapy program, require physician supervision by a rehab physician with face-to-face visits ≥3 days/week to assess patient's medical and functional status and to modify course of treatment PRN, and require an intensive and coordinated interdisciplinary team approach to the delivery of rehabilitative care.
Medical necessity is based on an assessment of each patient's individual care needs at time of admission:
The patient generally requires the intensive rehab therapy services that are uniquely provided in IRFs. The patient should be able to tolerate 3 hours of therapy a day for 5 days a week (this is not a rule of thumb; intensity may also be demonstrated with ≥15 hours over 7 consecutive days starting with admission date).
Documentation must show that there is a reasonable expectation that, at the time of admission to the IRF:
one-on-one therapy. Group therapy is acceptable but must be well-documented and may not constitute the majority of therapy provided to the patient.
The standard of care at an IRF is:
periodic conferences of an interdisciplinary team of medical professionals
The complexity of the pt.'s condition must be such that the rehab goals indicated in the preadmission screening, the post-admission physician eval, and the overall POC can only be achieved through
to foster frequent, structured, and documented communication among disciplines to establish, prioritize, and achieve treatment goals
What is the purpose of the interdisciplinary team?
Once a week (7-day consecutive period based on patient's day of admission)
When must team conferences be held?
Rehab MD, RN, social worker and/or case manager, and a therapist from EACH discipline involved in treating the patient
Who must be included in team conferences?
Assessing the pt.'s progress toward rehab goals, considering possible resolutions to any problems that could impede the pt.'s progress toward goals, reassessing the validity of the rehab goals previously established, and monitoring and revising the treatment plan PRN
The periodic interdisciplinary team conference must focus on:
The patient is making functional improvements that are ongoing, sustainable, and of practical value, as measured against the pt.'s condition at start of treatment
Documentation must demonstrate an ongoing requirement for an intensive level of rehab services and an interdisciplinary team approach to care. The IRF medical record must demonstrate:
Physician-related items; required IRF-PAI (Inpatient Rehab Facility Patient Assessment Instrument) for quality indicators
Documentation of IRF services
Recovery Audit Contractors (RACs), Medicare Administrative Contractors (MACs), and others (know this all started because of audits for medical necessity, hospitals appealed denials >>> backlog. People are still appealing and there is still backlog)
Who performs CMS-mandated audits on IRFs?
Level 1: redetermination by a Medicare Administrative Contractor (MAC) through written appeal. Level 2: reconsideration by a Qualified Independence Contractor (QIC) through written appeal. Level 3: decision by Office of Medicare Hearings and Appeals (OMHA) in Administrative Law Judge (ALJ) hearing. Level 4: review by the Medicare Appeals Council through written appeal. Level 5: judicial review in Federal District Court.
What are the five levels in the Medicare appeals process?
All the money for the claim (average $20,000/claim)
How much money do providers lose when claims are denied?
About 3-6 years after providers are asked to return all of the money CSM originally paid them
Because of the backlog, when do ALJ hearings usually take place?
CMS announced a voluntary settlement process. Through this process, CMS will pay 69% of the net claims that are still pending appeal (Methodist will participate in this).
What is CMS doing to alleviate the backlog in the appeal process?
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