In a follow-up to our series of articles on the technical requirements of the January 2010 updates to the regulations for inpatient rehabilitation facilities (IRFs), in this article we are presenting anecdotal information about RAC denials occurring during the past several months.

In the past, reviewers have denied claims because a required item of documentation was missing or did not have a signature. For example, if the preadmission assessment was missing from the documentation or not signed by the rehabilitation physician, the claim would be denied. In our recent appeals work, however, we are seeing that reviewers are becoming much more detailed in their reviews.

Specifically, we are seeing statements such as this: “The preadmission assessment screen was missing from the record or was missing required elements.” This level of review reinforces the need for IRFs to work with physician and clinical staff to ensure not only that the individual required documents are present, but also that the content of each required element is complete and accurate.

While our own findings are not statistically significant, we believe that they are likely to be typical of what is being seen by many providers. Some typical findings from our own experiences during the final quarter of 2013 are outlined below.

Preadmission Assessment Screening

Typical reasons for denials related to the preadmission screening were:

  • The preadmission assessment screening (PAS) was completed more than 48 hours prior to admission. While it was updated by the preadmission assessment clinician, it was not approved by the rehabilitation physician after the update.
  • The PAS was completed and signed by the preadmission assessment clinician but not signed, dated, and timed by the rehabilitation physician prior to the recorded time of admission. In some cases, the rehabilitation physician documented at the time of the history and physical that he or she had approved the admission earlier; however, the requirement is that written concurrence be completed prior to admission.
  • The PAS did not include all the required elements. Typically the missing elements included risks associated with the rehabilitation admission, or the PAS referenced information in a PMR consult from the acute-care hospital and no copy of the consult was available in the record.

Post-Admission Physician Evaluation

Typical reasons for denials related to the post-admission physician evaluation (PAPE) were:

  • There was no comparison statement clearly comparing the patient’s status at the time of the H&P and PAPE to that on the PAS, or there was a statement indicating that there were no significant differences but the record showed that changes in medical or functional status had occurred. Some of these issues were compounded by the IRFs using the copy-forward function in the EMR.
  • There were no statements to reflect the patient’s pre-morbid functional status at the time of admission to the IRF.
  • The PAPE was not completed within 24 hours of admission. This is one of the documents that must be completed, signed, and dated within 24 hours (not within a calendar day). Even PAPEs completed barely in excess of 24 hours were denied.

Individualized Plan of Care

Typical reasons for denials related to the individualized plan of care (IPOC) were:

  • The IPOC was missing from the record.
  • There was no statement related to medical prognosis.
  • There was a lack of specificity in the minutes of therapy that would be provided.
  • There was a failure to outline functional outcome goals and the discharge destination.

Intensity of Service

Typical reasons for denials related to the intensity of service were:

  • Failure of the patient to receive or participate in the requisite three hours of therapy a minimum of five out of seven days, beginning on the day of admission. In some cases, the patient began therapy on the second day of the stay and there was no adjustment in the therapy schedule to ensure compliance on five of the first seven days of therapy. In other cases, the patient missed therapy without any documentation to support why, and no attempt was made to make up the therapy at a later time.

Interdisciplinary Team Meetings

Typical reasons for denials related to the interdisciplinary team meeting included:

  • Failure of team members to attend the team meeting or failure to record attendance.
  • Failure to document progress toward goals, and changes required in order to achieve those goals.

Supervision of the Rehabilitation Program

Typical reasons for denials related to physician supervision of rehabilitation programs included:

  • Failure of the rehabilitation physician to record face-to-face interactions with the patient on a three-times-per-week basis, exclusive of the PAPE and team meeting.
  • Failure of the documentation to demonstrate the need for a rehabilitation physician to manage and coordinate the care of the patient.

Our Recommendations

In order to help prevent denials of payment for IRF services, we recommend the following:

  1. Each IRF should have an organized process for preparing records for an audit. When an additional documentation request (ADR) is received, the audit team should prepare the records in an organized way, include a table of contents indicating where the key documentation requirements are located, and if documents are missing, attempt to locate them prior to submitting the records. While this seems to be a very basic premise, it is often overlooked.
  2. Each IRF should develop a proactive process for internal auditing that provides for the review the key components of each documentation element. (See prior articles in this series for those components.) Additionally, templates should be developed for dictation, hard-copy documentation, and EMR documentation that cue the writer to complete the key elements.

About the Author

Angela M. Phillips, PT, is president and chief executive officer of Images & Associates. A graduate of the University of Pennsylvania’s School of Allied Health Professions, she has more than 35 years of experience as a consultant, healthcare executive, hospital administrator, educator, and clinician. Ms. Phillips is one of the nation’s leading consultants assisting inpatient rehabilitation facilities in operating effectively under the Medicare Prospective Payment System (PPS) and in addressing key issues related to compliance for therapy services across all venues.

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