Health Information Management

Ensure strong appeals for IRF denials by documenting eight coverage criteria

JustCoding News: Inpatient, March 3, 2010

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A major focus area for the Recovery Audit Contractor (RAC) demonstration program was inpatient rehab facility (IRF) admissions. Many providers were stunned by the large dollar amounts recouped when RACs deemed that admissions did not meet medical necessity criteria.

Marion Watson, PT, MBA, director of rehabilitation services at Glendale Adventist Medical Center in Glendale, CA, experienced this first-hand when her facility received 440 requests for records during the demonstration project, only eight of which the RAC deemed appropriate for an inpatient rehab stay. Watson shared her perspective during an HCPro, Inc., audio conference, "RACs and Inpatient Rehab: Understand the Top Demo Targets to Survive Audits," on November 18, 2009.

Most of her facility’s denials were upheld in the first and second level of appeals. However at the third level of appeals, an administrative law judge (ALJ) overturned a high percent of cases in favor of the provider.

Make sure RACs apply appropriate LCDs

If you receive RAC denials, make sure your RAC applies the relevant regulatory data. “One of the experiences we had in California was that some denials were based on criteria that wasn’t applicable for the dates of service they were denying,” said Tanja Twist, MBA/HCM, director of patient financial services at Methodist Hospital in Arcadia, CA, who also spoke during the audio conference. “So really scrutinize those denial letters, and make sure they’re using relevant data and criteria.”

“The appeals process is critical. Be proactive and plan a preemptive strike on this,” said Nancy Beckley, MS, MBA, CHC, co-founder and president of Bloomingdale Consulting Group, Inc., in Brandon, FL, who also spoke during the audio conference. Providers whose local coverage determinations (LCD) have changed since 2007 should gather legacy copies of all their LCDs so that they have this critical information on hand when they’re preparing an appeal or in the event that they receive a demand letter that may reference the wrong LCD, Beckley advises.

“It’s really important to gear up even at appeal level one as if you’re heading toward that ALJ level,” Twist said. “You may not be able to submit any new data after appeal level two, so it’s good to get into the practice to preparing for the ALJ right off the bat.”

Audit records and establish an appeals team

A vital part of preparing for potential audits is to conduct ongoing concurrent audits of medical records.

Watson pointed out that physician documentation was her facility’s weakest area. “We had to be on top of our physicians to make sure they were clearly documenting the medical necessity reasons for that patient requiring an inpatient rehab stay.”

To prepare for ALJ hearings, it’s critical to identify the members of your appeals team because they will have a consistent presence throughout the duration of the hearing, Watson said.

“Our rehab physician was our lead speaker,” she said. “We found that he lent a lot of credibility in the eyes of the ALJ.”

Also consider having legal representation with you during hearings.

“While the rehab professionals can clearly speak to the clinical aspects of your case, there are many legal and technical issues that arise at the ALJ level,” Watson said. “So we found legal representation to be quite helpful for us.”

Others you might want to have on your appeals team include a registered nurse or therapy representative.

As part of the team preparation, the organization of the testimony is critical. Ensure that your physician knows the medical record inside and out. Also highlight important documentation in the medical record, and tab the medical record so that you can present your case in a clear concise manner to the ALJ and reference examples by citing specific page numbers in the medical record.

Address eight coverage criteria

Regarding ALJ hearings, Watson said her organization felt that if they could show that the documentation in the medical record met the eight coverage criteria, this would support that it was a clean chart.

So during their appeals at the ALJ level her organization spoke specifically to eight Medicare coverage criteria, the first being the most important.

1. Close medical supervision by a physician with specialized training in rehab. It’s important to do the following:

  • Reference the pre-admission screening form
  • Cite the primary diagnosis, comorbidities, lab results, diagnostic testing, medications and frequency of use, and consultations
  • Reference dates and page numbers in the medical record
  • Explain the results and possible consequences of abnormal test results
  • State reasons that the patient required a rehab admission and could not be safely treated at a lower level of care

Consider presenting worst-case scenarios. “For example, if the patient had untreated urinary retention, what is the worst case that could happen if this went untreated, pointing out to the ALJ that undetected and/or untreated urinary retention can lead to a urinary tract infection, kidney infection, or sepsis,” Watson said.

2. 24-hour rehab nursing. The important aspects related to rehab nursing mirror the elements requiring physician supervision. “But we went on to explain that it really is that nurse’s eye watching that patient 24/7 that prevents complications and manages any comorbidities or minor things that come up during a rehab stay,” Watson said. Explain the critical role nurses play involving the following:

  • Injections and medication administration
  • Carry over of rehab principles and techniques, especially at night when patients are fatigued and possibly disoriented
  • Wound care, bowel, or bladder retraining and/or management
  • Pain management
  • Assisting patients with swallowing

“We also made it a point to note that because of the 24-hour nursing, many of our patients did not develop further complications,” Watson added.

3. Intense level of rehab services. Include the following information when addressing the intense level of rehab services provided:

  • Functional levels on admission, including transfers, gait, and activities of daily living, as well as specifics of strength, range of motion, and balance.

  • Three-hour guideline: While all providers strive to have each patient receive three hours of therapy per day, five days out of each week, there are times that patients do not meet the three hours due to a variety of reasons. For example, there are days in which a patient’s medical condition prohibits them from participating in three hours of therapy. The physician needs to document these details in the medical record.

“We used an average of hours to prove that we had met the intense level of therapy required,” Watson said. “All of our ALJs accepted that as meeting the criteria.”

4. Multidisciplinary team approach. The guidelines state that a multidisciplinary team usually includes the rehab physician, rehab nurse, social worker and/or psychologist, and the therapists involved in treating the patient. At a minimum, the team must include a physician, rehab nurse, and one therapist. Be sure to cite:

  • Team conference members
  • Specific dates and page number from the medical record detailing when the conferences were held and who was present

5. Coordinated plan of care.

  • Include when the physician met and discussed care daily with nursing and therapy staff members
  • Include whether there was a home check or home visit, and when family and/or care giver training was completed

“We emphasized that our rehab physician was on site daily, meeting with the team, talking to the nurses, talking to the patient and therapists, to family members, identifying and dealing with any complications that arose versus if this patient had been in a skilled nursing facility, where all medical care is covered over the phone and a physician visit is only available every 30 days,” Watson said.

6. Significant practical improvement. It is expected that all patients admitted to an inpatient rehabilitation unit will make significant improvements within a reasonable period of time. Be sure to state:

  • Functional levels at discharge with page number citations in the medical record
  • Discharge destination
  • Follow-up care

7. Realistic goals. The most realistic rehab goal for many patients is to make improvement and/or regain enough functional independence in the activities of daily living to allow the patient to return home with minimal or no assistance. List goals identified at admission and cite page number from the medical record and state whether the goals were met. Include reasons why the patient did not meet the goals when necessary.

8. Length of rehabilitation program. State the length of stay in number of days.

“We always provided a summary statement for our judge that included listing the functional status of our patient upon admission, the complications and comorbidities that occurred during that rehab stay,” Watson said. “We noted that because of all of these reasons, this patient really needed to be in an inpatient rehab facility with the 24-hour rehab nursing, with the availability of that rehab physician, stressing that the patient could not have been safely cared for at a lower level of care.”

Watson emphasized that in her experience, the ALJs were fair and unbiased.

“If you are able to present a strong clinical case showing back to your medical record where you have documented the medical necessity, you have a good reason to believe that the final determination will be in your favor,” she said.

Keep in mind that the eight criteria detailed above for an inpatient rehabilitation stay to be considered medically necessary are applicable to IRF cases discharged before January 1, 2010.

Criteria for 2010

For all discharges on or after January 1, there is a new set of IRF coverage criteria. Under the new coverage criteria, the decision to admit the patient to the IRF is critical to determining whether the admission is reasonable and necessary. Much of the new coverage criteria focus on the rehab physician documentation supporting the need for the IRF admission.

The new documentation requirements include:

  • Preadmission screening. This must be completed 48 hours prior to the admission, and the rehab physician must document that he/she has reviewed and concurs with the findings and results of the screening prior to the IRF admission.
  • Post-admission physician evaluation. The rehab physician must complete this within 24 hours of admission and must support the medical necessity of the admission.
  • Individualized overall plan of care. The rehab physician must complete this within four days of the admission. It is expected that the rehab physician will integrate information from the clinical staff assessments into the overall plan of care.
  • Admission orders. A physician must generate admission orders at the time of admission to the IRF.
  • Inpatient rehabilitation facility patient assessment instrument (IRF-PAI). The IRF-PAI must now be included in the patient’s medical record.

In addition to the requirements outlined above, medical necessity criteria also include:

  • Multiple therapy disciplines
  • Intensive level of rehabilitation services
  • The ability to actively participate in intensive rehabilitation program
  • Physician supervision (i.e., the rehab physician must conduct face-to-face visits with the patient at least three days per week)
  • Interdisciplinary team approach to the delivery of care

Editor’s note: Interested in learning more about RACs and inpatient rehab? During HCPro’s 90-minute audio conference, “RACs and Inpatient Rehab: Understand the Top Demo Targets to Survive Audits,” our speakers described their experiences with RAC reviews and audits, discussed mistakes they made, and shared tips for how you can avoid them. Purchase this audio conference to better understand where to focus your own internal audits, develop processes that reduce risk and what steps to take to correct problem areas, and learn how to strengthen your appeals.

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