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Issue Number - Name
0073-Inpatient Rehabilitation Facility (IRF) Stays:Meeting Requirements to be considered Reasonable and Necessary
Review Type
Complex
Claim Type
IRF
Region and State
RACS 1-4
All States
Date Approved
09/11/2018

Description

Inpatient hospital services furnished to a patient in a inpatient rehabilitation facility will be reviewed to determine that services were medically reasonable and necessary.

Affected Code(s)

IRF1A, IRF1C, IRF1D, IRF1E, IRF1E2, IRF1F, IRF1F2, IRF1F3, IRF1F4, IRF1F5, IRF1F6, IRF1F7, IRF1F8, IRF1F9, IRF1F10, IRF1F11, IRF1F12, IRF1G, IRF1H, IRF2A, IRF2B, IRF2C, IRF2D, IRF2E, IRF2F, IRF2G, IRF2H, IRF2I, IRF2J, IRF2K, IRF2K2, IRF2L, IRF2M, IRF3A, IRF3B, IRF3C, IRF3E, IRF3F2, IRF3F, IRF3G, IRF3H, IRF3I, IRF4A, IRF4B, IRF4C, IRF4C2, IRF4C3, IRF4C4, IRF4D, IRF5F, IRF4G, IRF5A, IRF5B, IRF5C, IRF5D, IRF5E, IRF5G, IRF7A, IRF7B, IRF7C, IRF7D, IRF8A, IRF8B, IRF8D, IRF8D2, IRF8D3, IRF8D4. IRF8F, IRF8F2, IRF8G, IRFXA, IRFXB, IRFXC, IRFXD, IRFXE, IRFXF, IRFXG, IRFXH, IRFXI, IRFXJ, IRFXK, IRFXL, IRFXM, IRFXN, IRFXO, IRFXP, IRFXQ, IRFXR

Applicable Policy References

Social Security Act, Section 1833(e)
Social Security Act, Section 1862(a)(1)(A)
42 CFR 412.29
42 CFR 412.600-412.622
42 CFR 412.622(a)(3), (4), and (5)
CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110 
CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4