CMS guidance about medical review changes for inpatient rehabilitation facilities (IRF): Bonus or baggage?

There has been lots of buzz about Medicare’s most recent clarifications to contracted auditors related to auditing therapy minutes for inpatient rehabilitation facilities (IRFs).

The news first surfaced on Dec. 11 in MLN Matters SE17036, which featured advisement from the Centers for Medicare & Medicaid Services (CMS) to its medical review contractors related to therapy services in IRFs. We covered that news here later that month.

As is often the case, it has taken some time for this guidance to be incorporated into the Medicare manuals, but on Feb. 23, 2018, that was done, with an effective date of March 23.

The clarifications feature four key points for contractors, including that they should:

  • Verify that IRF documentation requirements are met;
  • NOT make denials solely on any threshold of therapy time;
  • Use clinical judgement to determine medical necessity of the IRF therapy program, based on the individuals facts of the case; and
  • NOT make denials solely because the situation/rationale that justifies group therapy is not specified in the medical record.

What’s the Bonus?

This clarification is welcome news to an industry that is struggling to appeal claims, for many technical issues. Claim denial due to a patient missing just a few minutes of therapy on a given day has long been a frustration to providers. Providing healthcare services in a patient environment that includes a full team of experts requires more than counting therapy minutes, and the potential for fewer denials in this area is long overdue. The guidance provides a logical approach to determining intensity of therapy services, requiring contractors to use clinical judgement in the form of medical review in cases where the therapy threshold (three hours of therapy on five out of seven days, or in certain well-documented situations, 15 hours of therapy per week) is not met.

Additionally, once again, the update to the manual specified that claims should not automatically be denied if the reasons for group therapy are not included in the record. Medical review would be the determining factor.

And the Baggage?

As we noted back in December, this may be a good news versus bad news provision. IRFs should not interpret this guidance as a waiver or repeal of the three-hour therapy requirement as the general standard of care, but as a logical approach by Medicare to address intensity of therapy and individualized care expectations.

The downside? There are likely to be more audits of therapy documentation for this issue. And increasing scrutiny of therapy documentation highlights the importance of documentation by clinical staff, both in daily notes and in the team notes, to demonstrate the reasons why a patient has not received the requisite therapy and to validate what changes are being made in the plan to meet the patient’s needs – as well as to support ongoing IRF services by demonstrating that each patient has the potential to achieve goals.

What’s the Bottom Line?

IRFs welcome this sensible change to the audit process, but also should remain consistent in providing therapy services that meet the guidelines for reasonable and necessary care.


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