Health Information Management

Tips to help providers meet new IRF documentation and coverage requirements

HIM-HIPAA Insider, March 2, 2010

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CMS is taking a closer look at admissions to inpatient rehabilitation facilities (IRF) thanks to new documentation and coverage requirements. The changes are effective for all IRF discharges occurring on or after January 1. Use these tips to ensure documentation compliance:
  • Ensure documentation of the post-admission physician evaluation. The post-admission evaluation should identify any relevant changes that have occurred since the preadmission screening. It should also include a documented history and physical exam and a review of the patient’s prior and current medical and functional conditions and comorbidities.
  • Keep admission orders. At the time of admission, a physician must generate admission orders that stay in the patient’s medical record at the IRF.
  • Retain the IRF patient assessment instrument (PAI). The IRF-PAI must also be included in the patient’s medical record at the IRF. The IRF-PAI must correspond with all of the other information in the patient’s IRF medical record.
Editor’s note: For more tips, view the February 2010 issue of Briefings on Coding Compliance Strategies.



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