Continuing Education

**Comorbidity Tier Clarifications**: CMS provided additional guidance on actively treated comorbidities, emphasizing that documentation must show evidence of treatment during the IRF stay, not just mention in the H&P.

**High-Impact Comorbidity Updates**: Septicemia coding now requires specific documentation of ongoing IV antibiotics or infectious disease management during the IRF stay.

**FIM Scoring Revisions**: Updated guidance on scoring cognitive FIM items for patients with traumatic brain injury, requiring more detailed assessment documentation.

**60% Rule Compliance**: Reminder that the 13 qualifying conditions must be the primary reason for IRF admission and rehabilitation services.

**Submission Timeline**: Reinforced requirement for timely IRF-PAI submission within required timeframes to avoid compliance issues.

**Top Audit Trigger #1: Inconsistent FIM Scores** - 42% of audited cases showed FIM scores that didn't align with therapy notes or discharge summaries. MACs are using automated algorithms to flag cases with unusual FIM patterns.

**Top Audit Trigger #2: Missing Comorbidity Evidence** - 38% of tier downgrades resulted from lack of documented treatment evidence for coded comorbidities. Simply listing diagnoses in H&P is insufficient.

**Top Audit Trigger #3: 60% Rule Non-Compliance** - Facilities with compliance rates between 58-62% are receiving increased scrutiny. MACs are conducting desk audits to verify qualifying condition documentation.

**Emerging Trend: Late Submissions** - IRF-PAIs submitted after the required timeframe are triggering automatic review flags, even if otherwise accurate.

**Payment Recoupment Data**: Average recoupment per audited case is $3,200, with tier downgrades accounting for 65% of payment adjustments.

**Patient Profile**: 68-year-old female admitted to IRF following left MCA stroke with right hemiparesis. PMH: Type 2 diabetes, CKD Stage 3, CHF, hypertension, and septicemia diagnosed 2 days before IRF transfer.

**Comorbidity Analysis**:

• Diabetes Type 2 - Actively treated with insulin sliding scale QID, blood glucose monitoring TID, endocrinology consult

• CKD Stage 3 - Monitored with BMP every 3 days, nephrology following, fluid restriction orders

• CHF - Daily weights, I&O monitoring, furosemide 40mg PO daily, cardiology consult

• Hypertension - Lisinopril 10mg daily, BP monitoring TID

• Septicemia - IV ceftriaxone 2g daily x 14 days, infectious disease following, daily WBC monitoring

**Tier Assignment Decision**: Septicemia is a high-impact comorbidity. Patient has 4 additional actively treated comorbidities (diabetes, CKD, CHF, hypertension). High-impact + 3 or more = Tier 3.

**Documentation Requirements**: All comorbidities must have evidence of active treatment during IRF stay. Physician orders, medication administration records, lab results, and consultant notes all support active treatment.

**FIM Scores**: Admission FIM: 52 (Motor: 38, Cognitive: 14). Discharge FIM: 78 (Motor: 58, Cognitive: 20). Gain of 26 points demonstrates appropriate IRF-level improvement.

**Outcome**: IRF-PAI submitted accurately with Tier 3 assignment, all documentation supported coding, no audit issues.

**Preadmission Screening Mandate**: All IRF admissions must have documented preadmission screening within 48 hours before admission, conducted by a qualified clinician (RN, PT, OT, or physician).

**Required Elements**: Screening must document: (1) Medical stability for intensive rehab, (2) Rehabilitation potential with specific functional goals, (3) Ability to participate in 3 hours therapy/day, (4) Need for interdisciplinary approach.

**Physician Certification**: Rehabilitation physician must certify within 24 hours of admission that patient requires and can benefit from intensive rehabilitation.

**Common Deficiencies**: MACs are citing facilities for vague statements like 'patient appropriate for rehab' without specific functional goals or therapy tolerance assessment.

**Best Practice**: Use structured preadmission screening form with objective criteria and measurable rehabilitation goals.

**Query Triggers**: Query when documentation is unclear, incomplete, conflicting, or when clinical indicators suggest undocumented condition.

**Compliant Query Format**: Must be open-ended, present clinical findings objectively, avoid leading language, and allow physician to use clinical judgment.

**Non-Compliant Queries**: Do not suggest specific diagnoses, reference payment impact, or imply required response.

**Documentation**: All queries must be part of permanent medical record with physician response and signature.

**Timing**: Queries should be initiated during IRF stay when possible, not retrospectively after discharge.

**Example Compliant Query**: 'The patient's BMP shows creatinine 2.8 mg/dL (baseline 1.0), BUN 45, and GFR 28. Nephrology was consulted and recommended fluid restriction. Could you please clarify the current renal status and any related diagnoses?'

**Example Non-Compliant Query**: 'Can you add CKD Stage 3 to the diagnosis list? This would support Tier 2 coding.'

**Patient Profile**: 72-year-old male admitted to IRF following bilateral hip fracture repair (ORIF). Developed post-operative complications including acute blood loss anemia requiring transfusion and hospital-acquired pneumonia.

**Primary Diagnosis**: Bilateral hip fracture (qualifies for 60% Rule)

**Comorbidity Analysis**:

• Acute blood loss anemia - 2 units PRBC transfused, Hgb monitored daily, iron supplementation

• Hospital-acquired pneumonia - IV antibiotics x 10 days, chest PT, incentive spirometry, oxygen 2L NC

• Type 2 diabetes - Insulin management, blood glucose monitoring QID

• Hypertension - Antihypertensive medications, BP monitoring

• COPD - Bronchodilators, respiratory therapy

• Chronic pain - Pain management protocol, opioid monitoring

**Tier Assignment**: 6 actively treated comorbidities = Tier 2 (3-6 comorbidities)

**FIM Scores**: Admission FIM: 48 (Motor: 32, Cognitive: 16). Discharge FIM: 89 (Motor: 68, Cognitive: 21). Gain of 41 points.

**Documentation Key**: Post-surgical complications (anemia, pneumonia) are separately codable comorbidities when actively treated. Do not confuse with surgical aftercare.

**Outcome**: Appropriate Tier 2 assignment, strong documentation, successful IRF stay with excellent functional gains.

**Presumptive Compliance Overview**: Facilities meeting certain criteria may qualify for presumptive compliance, reducing audit frequency.

**Criteria for Presumptive Compliance**:

• Submission accuracy rate >95% over 12-month period

• No significant audit findings in past 2 years

• Timely submission of all IRF-PAIs

• Active internal quality assurance program

**Desk Audit Process**: MAC requests medical records for 5-10 randomly selected patients. Facility has 30 days to submit complete documentation.

**Common Desk Audit Findings**:

• Missing physician face-to-face documentation within 24 hours

• Incomplete IPOC by Day 4

• FIM scores not supported by therapy notes

• Comorbidity coding without treatment evidence

• Preadmission screening not documented

**Preparation Strategy**: Maintain audit-ready documentation for all patients. Conduct monthly internal audits using same criteria as MAC.