Inpatient Rehabilitation Facility (IRF)

Wisconsin Physicians Service (WPS) Medical Review (MR) is providing this article to update providers on the status of service specific prepay edits. MR service specific complex review edits are commonly known as prepay edits. These prepay edits suspend claims from multiple providers when a claim is submitted for payment which includes specific coding criteria for that service.

This article details the initiation of a service specific edit. WPS MR prepay edits are continually reviewed based on reviewed claim data. Edits are modified or terminated as data analysis supports decreased vulnerability to the Medicare Trust Fund and/or workload analysis.

The following MR service specific prepay edit in the WPS legacy region is active.

Reason Code: 50IRF
Date Initiated: February 8, 2011
This prepay edit is the result of: Probe review results.

Probe reviews were conducted on admissions to Inpatient Rehabilitation Facilities (IRFs) billing specific Health Insurance Prospective Payment System (HIPPS) codes. Probe results showed the greatest errors to be for admissions with shorter stays and single joint procedures. A prepay edit has been initiated for all providers billing the criteria identified having a high potential for error based on our probe data analysis.

A complex medical review will be performed on each claim to determine if medical necessity and proper coding requirements have been met. A common reason for denial is as follows:

An IRF admission is designed to provide intensive rehabilitation therapy, due to the complexity of nursing, medical management, and rehabilitation needs. These patients must require and reasonably be expected to benefit from the IRF stay, and must be able to participate in the intensive rehabilitation program.

"The IRF benefit is not to be used as an alternative to completion of the full course of treatment in the referring hospital. A patient who has not yet completed the full course of treatment in the referring hospital is expected to remain in the referring hospital, with appropriate rehabilitative treatment provided, until such time as the patient has completed the full course of treatment. Though medical management can be performed in an IRF, patients must be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in IRFs in order to be transferred to an IRF.

  • IRF admissions for patients who are still completing their course of treatment in the referring hospital and who therefore are not able to participate in and benefit from the intensive rehabilitation therapy services provided in IRFs will not be considered reasonable and necessary. Conversely, the IRF benefit is not appropriate for patients who have completed their full course of treatment in the referring hospital, but do not require intensive rehabilitation. Medicare benefits are available for such patients in a less-intensive setting." (CMS IOM Publication 100-02, Chapter 1).Adobe Portable Document Format
  • There are comprehensive regulations in the CMS IOM Publication 100-02, Chapter 1, Section 110.Adobe Portable Document Format Providers are encouraged to reference these regulations to ensure compliance.

Page Last Updated: Thursday, 15-Dec-2011 14:00:32 CST