Comprehensive Outpatient Rehabilitation Facility Services

Affected Providers

Physicians and non-physician practitioners who bill for comprehensive outpatient rehabilitation facility (CORF) services.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for CORF services is 45.4%, with a projected improper payment amount of $10.8 million.

Denial Reasons

Insufficient documentation accounted for 84.3% of improper payments for CORF services during the 2024 reporting period, while incorrect coding (1.2%) and other errors (14.5%) also caused improper payments. “Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials

Combine documentation on each patient into 1 clinical record that has:

• The first assessment and subsequent reassessments of the patient’s needs
• The current plan of treatment
• Identification data and consent or authorization forms
• Pertinent medical history, past and present
• A report of pertinent physical exams, if any
• Progress notes or other documentation that shows the patient’s reaction to treatment, tests, or injury or shows the need to change the established treatment plan
• Upon discharge, a discharge summary, including patient's functional status with documentation of progress towards goal achievement, prognosis, and future treatment considerations

Specific Requirements for Payment

Referral & Medical History

According to 42 CFR 410.105(a)(1–4), you can provide services only to a patient who’s referred by a physician who certifies that the patient needs skilled rehabilitation services. Before or at the start of treatment, the referring physician must make this information available to the CORF:

• The patient’s significant medical history
• Current medical findings
• Diagnosis and contraindications to any treatment modality
• Rehabilitation goals, if determined

When & Where Services Are Provided

Provide services on the premises of the CORF while the patient is under a physician’s care.

We allow limited services away from the CORF premises:

• You can provide physical therapy, occupational therapy, and speech-language pathology services away from the premises of the CORF, including at the patient’s home, when payment isn’t made under Title XVIII of the Social Security Act
• We also cover the single home environment evaluation visit specified in 42 CFR 410.100(l)

Treatment Plan

According to 42 CFR 410.105(c), for each patient, you must establish, sign, and date a treatment plan before starting treatment. The treatment plan must:

• Prescribe the type, amount, frequency, and duration of the services to be provided and show the diagnosis and expected rehabilitation goals
• Be reviewed by a facility physician or the referring physician who, when appropriate, consults with the professional personnel providing the services. This review takes place at least every:
  • 60 days for respiratory therapy services
  • 90 days for physical therapy, occupational therapy, and speech-language pathology services
• Show the reviewing physician certifies or recertifies that they are following the plan, the patient is making progress in meeting the rehabilitation goals, and treatment is having no harmful effects on the patient.

Claims

Complying with Outpatient Rehabilitation Therapy Documentation Requirements has more information on billing claims for physical therapy assistants or outpatient therapy assistants in a CORF.

Documentation Requirements

Example of Improper Payments Due to Insufficient Documentation for CORF Services

A CORF provider submits the following treatment plan documentation per the review contractor’s request:

• Diagnoses
• Long-term treatment goals
• Rehabilitation therapy service types
  • Description of specific treatments or intervention type
  • Therapy amount
  • Therapy frequency
  • Therapy duration
• The treating physician’s dated signature and credentials

What Documentation Was Missing?

The doctor didn’t include the establishment date in the plan of care.

What Happens Next?

The review contractor completes the claim as an insufficient documentation error, and the Medicare Administrative Contractor recoups payment.

Recommendation

To prevent claim denials and improper payments, the certifying physician must collect and submit proper documentation when billing CORF services.

For treatment plan and certification documentation requirements, see 42 CFR 410.105(c).