Inpatient rehabilitation facility (IRF) services are intended for patients requiring a resource-rich environment due to their complex nursing, medical and rehabilitation management needs.

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).