Catherine Boerner (cboerner@boernerconsultingllc.com) is President of Boerner Consulting, LLC, in New Berlin, WI.
I am sure you never feel like you have a shortage of compliance risk areas to look into. To help you prioritize, I recommend you review the list of “Approved RAC Topics” on the CMS website at https://go.cms.gov/2tKqhe4. You can sort the online table by “Provider Type” to help narrow down what areas are applicable to your organization.
What I like about the listing is that you can find all the applicable regulatory citations to include in the background for your compliance risk assessment. For example, under 0073-Inpatient Rehabilitation Facility (IRF) Stays: Meeting Requirements to be considered Reasonable and Necessary, when you click on the area, you will find this list of “Applicable Policy References” that includes:
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Social Security Act, § 1833(e)[1]
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Social Security Act, § 1862(a)(1)(A)[2]
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42 C.F.R. § 412.29
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42 C.F.R. § 412.600-412.622
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42 C.F.R. § 412.622(a)(3), (4), and (5)
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CMS, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 1 § 110
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CMS, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3 § 3.3.2.4
You can then compare this list against the list of the Supplemental Medical Review Contractor (SMRC), with CMS-directed topic selections and time frames at https://bit.ly/3046Kl9. These sites also include great detail of the regulatory requirements that can assist the organization with checking compliance. For example, for Inpatient Rehabilitation Facility Stays, the SMRC requests the following documentation as listed on the website:
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Admission orders
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Applicable history and physical
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Pre-admission screen
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Post-admission physician evaluation
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Documentation of required physician face-to-face visits
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All supporting clinical and/or nursing notes/documentation
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Individualized overall plan of care
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Record of interdisciplinary team conferences with attendance records
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Therapy logs—all therapy disciplines
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Completed Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI)
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Notes/documentation related to an interruption in treatment
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Any and all other documentation supporting reasonable and necessary Inpatient Rehabilitation care, including but not limited to:
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The nature and degree of the beneficiary’s expected improvement;
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The expected length of time to achieve the improvement;
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The need for a continued stay;
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Demonstration that the beneficiary made functional improvements that were ongoing and sustainable measured against his/her condition at the start of treatment; and
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An integrated medical and functional course of care for the patient
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Valid electronic or handwritten signatures, when applicable
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Copies of any patient notices given (e.g., Advance Beneficiary Notice of Noncoverage), if applicable
These are great resources to become familiar with compliance risk areas and lead the organization to understanding the requirements.