Therapy Requirements for Inpatient Rehabilitation Facilities
The Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 1 is the primary source for inpatient hospital services covered under Part A.
Individualized Therapy Treatment:
CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110.2.2 states:
“The standard of care for IRF patients is individualized (i.e., one-on-one) therapy. Group therapies serve as an adjunct to individual therapies. In those instances in which group therapy better meets the patient’s needs on a limited basis, the situation/rationale that justifies group therapy should be specified in the patient’s medical record at the IRF.”
Therapy documentation should provide specific justification for the need for group or concurrent therapy in each session it is provided during the IRF stay. During a review, the MACs will determine the medical necessity of the group or concurrent therapy, as this is not the standard of care for the IRF setting.
Brief Exceptions Policy:
“While patients requiring an IRF stay are expected to need and receive an intensive rehabilitation therapy program, as described above, this may not be true for a limited number of days during a patient’s IRF stay because patients’ needs vary over time.”
The brief exceptions policy should be at most three consecutive days and should generally be documented in the medical record.
Example: A beneficiary requires a blood transfusion and needs to miss one-two days of therapy until laboratory levels are adequate, and vitals are stabilized. The provider should document the reason for missed therapy day(s) in the medical record to help the MAC determine if the intensity level of the IRF is required.
Active Participation in Intensive Rehabilitation:
“A primary distinction between the IRF environment and other rehabilitation settings is the intensity of rehabilitation therapy services provided in an IRF. For this reason, the information in the patient’s IRF medical record (especially the required documentation described in section 110.1) must document a reasonable expectation that at the time of admission to the IRF, the patient generally required the intensive rehabilitation therapy services that are uniquely provided in IRFs.”
The MAC will review the IRF medical records provided, including the therapy and physician documentation, to assess the overall need for the intensity level of the IRF setting. Denials for the intensity of IRF services can commonly occur when:
- Therapy minutes are not met, and documentation does not support the brief exceptions policy.
- Therapy is more group/concurrent and not individualized.
- Therapy documentation does not support the need for skilled services: therapy has become repetitive, therapy notes are continually copied and pasted, no progression of services from evaluation to discharge.
- Medical status prevents the beneficiary from participating, making progress, and/or tolerating the services' intensity.
- Medical and functional status are "high level" and does not require medical monitoring or the intensity of therapy at three hours a day.
- Medical monitoring was not needed at the intensity of the IRF; co-morbidities are stable and could be monitored at home.
IRF Therapy Requirements also include:
- Therapy treatment must begin within 36 hours from midnight on the day of admission.
- Therapy evaluations are generally considered to constitute the beginning of therapy.
- Therapy evaluations should generally be included in the daily/weekly provision of therapy services.
- Provision of 15 hours of therapy per week. The generally accepted standard is three hours of therapy daily, five days per week.
- CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 1
- Inpatient Rehabilitation Facility: Benefit, Coverage and Documentation
- CMS.gov Inpatient Rehabilitation Facilities
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