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Eli's Rehab Report

Inpatient Insights:

4 Red Flags That Spell Payer Scrutiny at Your IRF

Published on Mon Mar 16, 2009

Plus, things you may not know you can do with physician orders.

You know how easy it is to get denials in your inpatient rehab facility -- but paring them down can be just as easy. Check to see if your IRF is showing patterns of these four items, and nip them in the bud. Better reimbursement is likely to follow.

1. Weekend and Monday discharges. Your fiscal intermediary or Medicare Administrative Contractor may be suspicious if you've met the three-hour rule requirement for five days right before the weekend begins,but you keep the patient through the weekend and discharge on Sunday or Monday, says Denese Estep, OTR, senior consultant for DE Consulting LLC in Sherwood, Ark.

And this can look especially suspicious if you don't offer therapy on the weekends. "The rules state that you have to justify admission during the entire stay," Estep continues. "So what exactly did you treat functionally or medically over the weekend that required the patient to be there? Why could you not have discharged on Friday?" If there's a good reason, your answers should be spelled out clearly in your documentation.

Real-life solution: Recalling tricky Monday discharges, "since we don't offer any therapy on Sundays, we'd have to do three hours of therapy for those patients on Saturday, and the patients would go two days without therapy. Once we figured this out, we got our MDs to agree to not have any discharges on Mondays," says Jennifer Weiss, PT, inpatient rehab coordinator for Ingalls Health System in Harvey, Ill.

Heads up: Some FIs and MACs will even question Tuesday discharges, but not as often as weekend and Monday discharges, Estep says.

2. No hold or resume orders on file. If you're on a roll with a patient and have been providing three hours of therapy for nearly each day of her stay, and suddenly the patient gets sick or must stop therapy for some other legitimate reason, that's OK -- but you must have the proper documentation on file.

"Providers often misunderstand that if you have to hold therapy for any reason, they need a physician order to do that," Estep says. Remember that by the rules, inpatient rehab services are to be directed by a physician, so if therapy services they ordered suddenly stop, then the physician has to say that's OK.

Important: It's also helpful to document what the patient is doing otherwise if he has stopped therapy. For example, if the patient gets ill and needs to be examined, there should be activity on record on the nursing or physician side of things showing medication, tests, exams, etc., Estep says. And don't forget -- if and when the patient is ready for therapy again, you need a physicianorder to resume therapy.

3. Too many orders for graduated therapy. You've seen it happen more and more with the heightened scrutiny of medical necessity: patients get admitted into rehab who are too sick to withstand three hours per day. In these cases, you do have the option of getting physician orders for graduated therapy without being penalized, Estep says. But the catch is that the patient must be able to work up to three hours "within a reasonable time" and the physician order needs to spell out the progression of graduation.

Danger zone: "I knew of a hospital that had graduated orders for therapy for all their patients, all the time," Estep recalls. "No one was meeting the three-hour rule, and that is not appropriate."

4. Unnecessary use of speech. The three-hour requirement is supposed to focus primarily on PT and OT,with speech "as needed," according to the rules. So be careful of ordering speech left and right without really examining whether the patient really needs it. "If your program is short on PT and OT and can't meet the threehour rule, then it's OK to substitute speech sometimes, but only if the patient needs it," Estep says.

Careful: Some FIs/MACs make it hard to count any speech toward the three-hour rule, Estep recalls. "I was the consultant for programs in Mississippi, Louisiana, New Jersey, and Arizona that all had difficulty with this issue."

However, if you're in an appeal situation, you might be able to fight for it if you can demonstrate a need, she says. "I appealed the question in Mississippi and Louisiana and won."

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