Eli's Rehab Report

What you change now will pay off big-time when RAC audits hit.

Now that you've adjusted to revamped Inpatient Rehab Facility Medicare coverage criteria for the past two years, it's time to step it up even more. Recovery Audit Contractors (RACs) will be hitting IRFs again, and they'll play hardball with your documentation.

Follow these five steps to ensure rock-solid plans of care that contribute to a steady flow of reimbursement.

1. Keep an eye on the time. The plan of care (POC) must be completed no later than the end of the fourth day upon admission to the IRF. "The day of admission is considered day one," says Angie Phillips, PT, president & CEO of Images & Associates, an Irving, Texas-based rehab consulting firm. "We have found a number of organizations who interpreted the rule to mean that they have an additional day," and that is incorrect.

Tip: Although you are not required to have your initial team meeting as early as the fourth day, consider killing two birds with one stone with an early team meeting and knocking out the POC when all disciplines can add their two cents, Phillips suggests.

2. Make specificity your #1 goal. "Generic POCs are not acceptable," Phillips says, noting that too many IRFs write POCs that read something like, "at least three hours of therapy, five days per week." Instead, you must write discipline-specific projected therapy times, including "day-by-day variation" for that unique individual. Also be sure to include functional goals. "While this information is often in other areas of the record, you should incorporate it into the POC," Phillips says.

Key: Be sure to specify the duration of each individual therapy discipline -- and don't confuse this with the length of stay, Phillips points out. CMS has clarified: "while the estimated length of stay for a hypothetical patient could be 21 days, the patient could require speech-language pathology treatments for days 1 through 10, and require orthotics/prosthetics on days 10 through 21 of the stay."

3. Think interdisciplinary. When CMS produced its IRF coverage criteria revisions in 2010, it put a strong emphasis on an integrative POC that speaks to both medical and rehab, says Fran Fowler, FAACH, principal of Fowler Healthcare Affiliates in Marietta, Ga. And that interdisciplinary focus in the documentation is key to reimbursement, she says.

What this means: "All providers should have a POC relative to what they see and have them linked," Fowler says. "For example, therapy is working on balance. How does nursing reinforce this? Rehab communicating their POC to nursing and vice versa is still the greatest dividing point."

Integration goes for physicians, too. If an internist is only following medical and a physiatrist is only following function, "someone has to incorporate both into the 24-hour admission follow-up report and POC," Fowler says. Bottom line, the POC must speak to both the medical and rehab aspects of the patient.

4. Include baby steps. Too many times, patient charts say, "goal not met," Fowler says. In an auditor's eyes, if a goal's not met, the patient doesn't belong there. "When I look at documentation like this, usually if I read the rest of the notes, I see that these people are actually making progress -- but those weren't the goals that were set," Fowler observes. Solution: Include "interim goals" in your POC that you can check off at weekly meetings, she suggests. If you can't think of smaller goals, talk to nursing. Remember, the more integrative your POC is, the better!

5. Be open to revisions. Even the most carefully thought-out POC can flop, but don't let this make your patient ineligible for inpatient rehab. Instead, try changing the goals. CMS states the weekly interdisciplinary team meeting may include "monitor[ing] and revis[ing] the treatment plan, as needed."

"You don't need to redo the original POC; just make an addendum that explains how therapy will adjust this and nursing will reinforce that," Fowler says. Just be sure the physician's notes reflect the same thing and refer to the team meeting note.

Editor's Note: See Section 110.1.3 of the Medicare Benefits Policy Manual for current POC requirements.