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, Section 1815(a)- Payment to Providers of Services
2. 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
3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e)- Payment of Benefits
4. Social Security Act (SSA), Title XVII- Health Insurance for the Aged and Disabled, §1834(m)(4)(F)- Telehealth Service
5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1886(j)- Prospective Payment for Inpatient Rehabilitation Services
6. 42 CFR §400.200- Subchapter A, General Provisions, Definitions for Public Health Emergency
7. 42 CFR §405.929- Post-Payment Review
8. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
9. 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
10. 42 CFR 405.986- Good Cause for Reopening
11. 42 CFR §411.15(k)(1)- Any Services that are not Reasonable and Necessary
12. 42 CFR 412.29- Classification criteria for payment under the inpatient rehabilitation facility prospective payment system
13. 42 CFR 412.604(c)- Completion of patient assessment instrument
14. 42 CFR 412.606(b)- Comprehensive Assessments
15. 42 CFR 412.612(a) - Responsibilities of the clinician
16. 42 CFR §412.620- Patient classification system
17. 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
18. 42 CFR 414.65- Payment for Telehealth Services
19. 42 CFR §424.32- Basic requirements for all claims
20. 45 CFR §162.1002(c)- Medical data code sets, for the period on or after October 1, 2015
21. Medicare Benefit Policy Manual, Chapter 1- Inpatient Hospital Services Covered Under Part A, §110 – Inpatient Rehabilitation Facility (IRF) Services
22. Medicare Claims Processing Manual, Ch. 1- General Billing Requirements, §80.3.2.2- Consistency Edits for Institutional Claims
23. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §140.3- Billing Requirements Under IRF PPS
24. Medicare Program Integrity Manual MPIM, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6