The content of this blog is primarily for those who are Inpatient Rehabilitation Facilities (IRF) or Inpatient Rehabilitation Units (IRU), however, the overarching theme is a good reminder for all healthcare providers. The takeaway is this:
Whatever the MAC says goes!
Regardless of your interpretation of the Centers for Medicare and Medicaid (CMS) regulations printed in the Medicare Benefit Policy Manual (MBPM), or wording in old transmittals, if the Medicare Administrative Contractor (MAC) has a different definition or requirement, that is what takes precedence.
In June of this year, Novitas Solutions, the MAC for Pennsylvania (PA) rolled out the Review Choice Demonstration (RCD) project. The RCD is designed to improve the error rate for claims for IRF/IRU. The MAC in Alabama, Palmetto GBA, rolled out the RCD in August 2023. It is scheduled to begin in Texas and California as the next “roll out” states, before the entire United States.
I recently listened to the update provided by Novitas on August 6, 2024, to review findings from the start of the RCD Cycle 1 on June 17, 2024. There were 1,500 RCD requests in the Pre-Claim Review (PCR) so far. Of those, 1,361 had been affirmed and only 99 were deemed “non-affirmed”. This is greater than a 90% accuracy rate. This accuracy rate is important because the Cycle 1 affirmation rate is set at 80%. It looks like IRFs in PA who chose the PCR are off to a good start.
The most common reason for non-affirmation however is something to be aware of. If the Pre-Admission Screen (PAS) says that PT/OT/ST are recommended, and the rehab physician signs off, those are the disciplines the MAC expects to start within 36 hours of midnight from the admission. If only PT and OT initiated evaluations, this would be a “non-affirmed” sample.
What could be confusing is the interpretation of the RCD requirements compared to usual and customary practices. A common practice is to have at least PT and OT evaluations completed within 36 hours, but not always the SLP evaluation. On October 23, 2009, the Centers for Medicare and Medicaid Services (CMS) released a transmittal which detailed changes for coverage of inpatient rehabilitation facility (IRF) services. This transmittal stated, “that therapy begin within 36 hours of midnight from the day of admission.” This is a definition of therapy requirements that is no longer acceptable!
The wording in the MBPM is outlined in the MBPM, Chapter 1, Section 110.2.2 – Intensive Level of Rehabilitation Services. It clearly states “In accordance with 42 CFR § 412.622(a)(3)(ii), the required therapy treatments must begin within 36 hours from midnight of the day of admission to the IRF. Therapy evaluations are generally considered to constitute the beginning of the required therapy services. As such, they should generally be included in the total daily/weekly provision of therapies used to demonstrate the intensity of therapy services provided in an IRF.”
Another area of confusion could be the interpretation of the CMS RCD requirements which state: “At time of admission, the patient’s condition must require at least two therapy disciplines (one of which must be physical or occupational therapy) and that those services were initiated within 36 hours from midnight of the day of admit to the IRF.” Because it says two disciplines are required, a provider might think that only two disciplines are required to be submitted within 36 hours. If no other disciplines were ordered, two would suffice. However, if SLP was ordered, it also MUST be initiated within 36 hours.
In summary, all ordered therapy disciplines must be initiated within 36 hours of the admission. When submitting documentation to the MAC for the RCD, make sure that all required (i.e. ordered therapy disciplines) are included in the IRF documentation.
If you have any questions, or desire an external review of your documentation, please contact Kay Hashagen at [email protected] or (410) 777-5999.
