Rehabilitative Auditing Interpretations
By Barbara A. Rubin, MEd, RHIA
Spring has sprung and so have multiple articles addressing different aspects of inpatient rehabilitative services. External auditing services have been spotlighted as many auditing groups are casting a wider net of auditing precautions in documentation demands driven by the Centers for Medicare & Medicaid Services (CMS) and inpatient rehabilitative facility (IRF) regulatory updates.
On October 23, 2009, the CMS issued new regulations, originally written 25 years ago, for inpatient rehabilitative facilities for 2010. These changes affect discharges made on or after January 1, 2010.
To protect your facility from errors that may trigger future governmental and external audits, the following suggestions may prove helpful. These new requirements provide direction to make certain admissions are reasonable and medically necessary since the new policy requires preadmission screening to be performed within 48 hours of admission to an inpatient rehabilitative facility setting. The key factor in the preadmission evaluation is that a certified clinician is responsible for filling it out and a licensed physician is responsible for signing and dating it prior to admission.
The preadmission must summarize the patient’s condition, the reason the admission to an inpatient rehabilitative facility is necessary, the specific care to be rendered, the patient’s functioning level prior to admission, and what the expected outcomes of this level of care will deliver.
Discharge planning begins and is documented at the time of admission. The expectations for patient improvement must be defined in measurable outcomes.
Past practices have been termed trial admissions. Previously, trial admissions were allowed for approximately three to 10 days for determining whether a patient would benefit from inpatient rehabilitative services. This practice no longer meets what the CMS considers reasonable and necessary. Rather than utilize the trial admissions, the CMS now expects the prescreening process to determine whether patients would benefit from inpatient services.
Within 24 hours of admission, the admitting physician must perform a postadmission review to ascertain whether the care plan submitted by the interdisciplinary team is appropriate and the patient’s admission is at the proper level of service. This postadmission review will include the diagnosis and any change to the patient’s condition since the preadmission evaluation and will ensure continuity with the preadmission data previously collected.
The CMS guidelines further specify the need for a required individualized overall plan of care (POC), which must be completed within the first four days following admission. The POC must include the prognosis, any expected interventions, the expected outcomes, and discharge planning. Included in the expected interventions are how often services will be rendered and the duration and intensity of physical, occupational, and speech rehabilitation needed. The responsibility of documentation and the completion of the POC lie with the servicing physician.
Admission orders are required to be documented in the patient’s chart by the physician at the time of admission. The IRF Patient Assessment Instrument forms must be in agreement with the multitask caregiving team’s treatment plan that was created on admission.
Medical necessity documentation must include the following at the time of admission:
If multiple therapies are to be rendered, it must be documented at the time of admission. Documentation for single therapies will not meet medical necessity. Documentation supporting services from the caregiving team must be by the following individuals:
Documentation for intensity level of services for the correct level of care is essential. Documentation must show that therapy began within 36 hours of midnight from the day of admission.
Measurable improvement is another area that may face scrutiny for future audits. Discharge planning must begin and be clearly documented at the time of admission along with defining the discharge expectations for patient improvement in measurable outcomes. Documentation must show the patient is making progressive improvements that are reflective of when treatment began.
Effective with IRF discharges on and after January 1, 2010, external auditors and Medicare administrative contractors must use the updated coverage policy in the medical review of IRF claims. If denials are sufficient in number, it may ultimately create the potential to threaten the IRF’s status as exempt from the inpatient prospective payment system.
With all the revisions and potential for more intense external audits, Congresswoman Lois Capps of California has summarized that the expectations for auditing be mandatory and before a denial to inpatient rehabilitative services is rendered, a physician reviews the determination. The logic of this suggestion is that the Medicare Benefit Manual states a physician’s order is necessary at the time of admission and a physician’s evaluation is mandatory as a post-prescreening process. Because a physician is expected to approve the schedule of therapies prior to admission, the denial should be made by equal credentials and not that of clerical reviewers.
Physician involvement is necessary to analyze service denials by a physician trained in physical medicine and rehabilitation, as is required by the Medicare Benefit Policy Manual (www.cms.hhs.gov/manuals/downloads/bp102c01.pdf). Clinical documentation carries a different meaning to a physician than to a coder, an auditor, or a payer and has continually compounded the frustrations of revenue cycle best practices.
A suggested outline for random audit reviews may include a checklist of the following areas:
— Barbara A. Rubin, MEd, RHIA, is an AHIMA ICD-10-certified Train the Trainer quality compliance manager and an educator for Kforce.