As we outlined in our previous article, RAC audits are focusing not only on the clinical issues that support reasonable and necessary care, but on the ability of inpatient rehabilitation facilities (IRFs) to meet the technical requirements of the rules and regulations that were updated effective Jan. 1, 2010. This article will outline the requirements for the preadmission assessment screening (PAS) process and identify potential pitfalls for IRFs in their attempts to meet those requirements.
While Medicare historically has required that IRFs implement a preadmission assessment process, the aforementioned regulatory changes outlined very specific requirements. Failure to meet the specific time and content requirements can result in denial of payment for services provided to Medicare beneficiaries.
Key mandates for the preadmission assessment screening process are outlined in Table 1. While these demands are widely known, several areas still have proven problematic for IRFs. These include:
Timing of the Preadmission Assessment
The PAS must be completed during the 48 hours immediately preceding patient admission to the IRF. If completed earlier than this time frame, the IRF may perform an update to the assessment in order to meet the requirement.
Timing of the Rehabilitation Physician’s Review and Concurrence with the Assessment
The rehab physician must review and concur with the assessment before patient admission to the IRF. In some cases we have seen denials of payment when a physician signed and dated the PAS on the day of admission but omitted the time of the signature. IRFs should implement processes to ensure that the PAS is signed, dated and timed prior to patient transfer to the appropriate unit. It is not sufficient for the rehabilitation physician to document within the history and physical or to use a document created after patient admission, noting that the review occurred prior to admission.
Narrative Statement Summarizing the Assessment Findings
The regulations and clarifications specifically include a requirement for a narrative statement summarizing the assessment findings. Checklists, which often are used to reduce the burden of documentation by the clinician completing the assessment, do not meet this requirement. The clinician should include a narrative assessment statement specifying why the patient is being recommended for IRF admission. In our experience, we often find this statement missing from the PAS.
What can organizations do to improve their compliance in meeting the technical requirements for completion of the PAS? We recommend the following:
- Consider use of Web-based PAS tools available from your software vendor.
The leading vendors of IRF-PAI software include those offering Web-based PAS tools that allow the rehab physician to access the assessment and review – and to concur and sign electronically. Use of this process helps expedite the approval process and provides ease of access to the completed document to key IRF personnel responsible for monitoring the process.
- Establish a safety net.
Consider establishing policies that limit communication of the positive admission decision to the referring hospital or provider until the physician’s concurrence and signature have been validated. As an alternative, require the nurse taking the report prior to patient transfer to verify that the PAS has been signed.
- Complete an internal audit to determine compliance.
Review a sampling of charts to determine whether the time frames, key content and signature requirements have been met.
Ensuring compliance with the requirements for the PAS will provide a good foundation for patient care, as well as protect any organization from technical denials on audit.
Coming next month: The post-admission physician evaluation – what’s really required for compliance?
About the Author
Angela M. Phillips, PT, is President & Chief Executive Officer of Images & Associates. A graduate of the University of Pennsylvania, School of Allied Health Professions, she has over 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 acute rehabilitation units and hospitals in operating effectively under the Medicare Prospective Payment System (PPS) and in address key issues related to compliance.
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