Description
Medicare only pays for services that are reasonable and necessary for the setting billed. The inpatient rehabilitation facility (IRF) benefit is designed to provide intensive rehabilitation therapy in a resource intensive inpatient hospital environment for beneficiaries who, due to the complexity of their nursing, medical management, and rehabilitation needs, require and can reasonably be expected to benefit from an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation care. In order for IRF care to be considered reasonable and necessary, the documentation in the beneficiary’s IRF medical record must demonstrate a reasonable expectation that CMS criteria, as defined in 42 C.F.R. §§412.600-622 and CMS Pub. 100-02, Ch. 1 section 110, was met at the time of admission to the IRF. Claims that do not meet the indications of coverage and/or medical necessity will be denied and result in an overpayment.
Affected Code(s)
Inpatient Rehabilitation Facility, 11X
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. SSA, Title XVIII- Health Insurance for the Aged and Disabled, §1833(e)- Payment of Benefits
3. SSA, Title XVII- Health Insurance for the Aged and Disabled, §1834(m)(4)(F)- Telehealth Service
4. 42 CFR §400.200- Subchapter A, General Provisions, Definitions for Public Health Emergency
5. 42 CFR §405.929- Post-Payment Review
6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
7. 42 CFR 405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
8. 42 CFR 405.986- Good Cause for Reopening
9. 42 CFR 412.29- Classification criteria for payment under the inpatient rehabilitation facility prospective payment system
10. 42 CFR 412.604(c)- Completion of patient assessment instrument
11. 42 CFR 412.606(b)- Comprehensive Assessments
12. 42 CFR 412.622- Basis of Payment, (a)- Method of Payment, (3)- IRF Coverage Criteria, (4)- Documentation, (5)- Interdisciplinary Team Approach to Care, and (c) Definitions- Week
13. 42 CFR 414.65- Payment for Telehealth Services
14. MBPM, Chapter 1- Inpatient Hospital Services Covered Under Part A, §110 – Inpatient Rehabilitation Facility (IRF) Services
15. MCPM, Chapter 3- Inpatient Hospital Billing, §140.3- Billing Requirements Under IRF PPS
16. MPIM, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6