CMS Clarifies IRF Medical Reviews

February 23, 2018
Rick Gawenda

The Centers for Medicare and Medicaid Services (CMS) has issued clarifying instructions for conducting medical review of Inpatient Rehabilitation Facility (IRF) claims when reviewing the requirements for the intensive level of rehabilitation therapy services. The instructions state the Medicare Administrative Contractors, Supplemental Medical Review Contractor, Recovery Audit Contractors and the Comprehensive Error Rate Testing contractor shall not make absolute claim denials based solely on a threshold of therapy time not being met. When the current industry standard of generally 3 hours of therapy (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics) per day at least 5 days per week or at least 15 hours of intensive rehabilitation therapy within a 7 consecutive day period is not met, the claim shall undergo further review.

To read the clarifying instructions, click HERE.

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