If a therapist attends an interdisciplinary team conference (ITC) at an inpatient rehabilitation facility (IRF) without treating the patient first, Medicare auditors probably will deny the claim for the entire stay. Attendance at the ITC by the therapist, rehabilitation physician and nurse after they’re up close and personal with the patient is one of several Medicare coverage guidelines that IRFs must comply with to avoid flunking an audit—although IRF payment criteria are getting a second look from the HHS Office of Inspector General (OIG) in a national review that’s due out soon.
For now, though, it’s not good enough for the therapist to review a report written by another therapist who has seen the patient. “I asked CMS the question on ITC coverage by another therapist because I see staff shortages and scheduling issues where you have contract or weekend staff covering on weekends who are not available for the team conference on Mondays,” said Jane Snecinski, president of Post-Acute Advisors in Atlanta, Georgia. “The response I received is that prior knowledge of the patient through treatment of the patient is a standard of quality and staff shortages shouldn’t impact quality, so the answer is no.”
The failure to treat the patient before the interdisciplinary team meeting is one of the 10 top reasons for denials of payment for inpatient rehab stays, Snecinski said in an HCCA webinar July 10.
IRFs and inpatient rehab units (IRUs) also face denials if patients are described as “medically stable” when discharged from an acute-care hospital to inpatient rehab. “It may be more accurate for physicians to state the patient is ‘medically stable enough to endure intensive therapy,’” (e.g., the patient won’t have a heart attack doing three hours of physical, occupational and speech therapy five days a week), she said. “It’s the combination of the two (medical and therapy needs) that meets the criteria for inpatient rehabilitation.” Without documentation of both, Medicare auditors deny claims for inpatient rehab because IRFs and IRUs are licensed as acute-care beds and certified for rehab, she explained.
And claim denials are significant from auditors (e.g., Targeted Probe and Educate, supplemental medical review contractor, recovery audit contractors)—except for the CMS Review Choice Demonstration, which has been underway in Alabama for a year and Pennsylvania for a couple of months and is expected to start in Texas early next year, Snecinski said. Although CMS hasn’t released results, “the affirmation rate in Alabama for the first year was sky high,” she said.