Health Information Management

Ensure thorough inpatient rehabilitation documentation

HIM-HIPAA Insider, January 18, 2011

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Now that medical record audits are the rule rather than the exception, inpatient rehabilitation facilities (IRF) must ensure that documentation justifies patient severity and services rendered.

During the demonstration project, 6% of overpayments—nearly $60 million—RACs identified were in the IRF setting. Nearly all of these overpayments (94%) were due to services that shouldn’t have been rendered in the IRF setting or that were medically unnecessary.
 
To complicate matters, IRFs have been shifting their attention to stringent documentation requirements outlined in the fiscal year (FY) 2010 IRF final rule. The rule continues to stress the importance of medical management and places primary emphasis on functional improvement, says Fran Fowler, MS, FAAHC, principal of Fowler Healthcare Affiliates, Inc. in Atlanta. This means that although patients must meet inpatient admission criteria, the role of the IRF is primarily to increase function.
 
Note: To read more, visit the HCPro website. Subscribers to Briefings on Coding Compliance Strategies have access to this article in the January issue of their newsletters.



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