IRF-PAI Overview
Understanding the IRF-PAI, MAC audits, and compliance requirements for achieving zero-fault accuracy at Oasis Point Rehabilitation Hospital
The Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) is a standardized assessment tool mandated by the Centers for Medicare & Medicaid Services (CMS) for all Medicare-certified inpatient rehabilitation facilities. It serves as the foundation for determining appropriate payment, measuring quality outcomes, and ensuring patients receive the right level of care.
The IRF-PAI provides Medicare with critical insight into whether facilities are admitting appropriate patients who meet medical necessity criteria and can benefit from intensive rehabilitation services. Each assessment captures comprehensive patient data including diagnosis, functional status, cognitive abilities, and comorbidities.
Key Purpose:
The IRF-PAI determines if Oasis Point is bringing the right patients into our inpatient rehabilitation facility based on medical necessity, functional limitations, and rehabilitation potential.
Assessment Timing
- •Admission Assessment: Completed within 3 days of admission
- •Discharge Assessment: Completed within 24 hours before or after discharge
- •Interrupted Stay: When patient leaves and returns within 3 days
Key Data Elements
- •Impairment Group Code (IGC): Primary diagnosis category
- •Comorbidity Tier: Level 1, 2, or 3 based on active conditions
- •FIM Scores: Functional Independence Measure (18 items)
- •Cognitive Function: Memory, problem-solving, expression
Financial Impact
- Incorrect CMG assignment leads to underpayment or overpayment
- MAC recoupment of overpaid claims with interest
- Potential facility closure for repeated non-compliance
Audit Consequences
- Increased MAC audit frequency and scrutiny
- Loss of Medicare provider certification
- Damage to facility reputation and referral relationships
To maintain Medicare certification, Oasis Point must ensure that at least 60% of all patients admitted to the facility fall into one of the 13 qualifying medical condition categories defined by CMS. This is known as the 60% Rule or Compliance Threshold.
CMS-13 Qualifying Conditions
- 1. Stroke
- 2. Spinal Cord Injury
- 3. Congenital Deformity
- 4. Amputation
- 5. Major Multiple Trauma
- 6. Hip Fracture
- 7. Brain Injury
- 8. Neurological Disorders
- 9. Burns
- 10. Active Polyarticular Arthritis
- 11. Systemic Vasculidities
- 12. Severe Osteoarthritis (bilateral joint replacement)
- 13. Knee/Hip Replacement
Critical Warning:
Falling below 60% compliance triggers immediate MAC scrutiny and can result in loss of Medicare certification. Accurate IRF-PAI coding is essential to track compliance in real-time.
The IRF-PAI Coordinator is the single most important position for ensuring zero-fault accuracy and preventing MAC audits at Oasis Point. This role requires clinical expertise, meticulous attention to detail, and comprehensive knowledge of CMS regulations.
Core Responsibilities
- ✓ Complete all IRF-PAI assessments within required timeframes
- ✓ Ensure 100% accuracy in diagnosis coding and tier assignment
- ✓ Verify all data matches medical record documentation
- ✓ Monitor 60% Rule compliance daily
- ✓ Conduct internal audits and quality checks
- ✓ Train clinical staff on documentation requirements
Required Qualifications
- ✓ Licensed RN or therapist (PT/OT/SLP)
- ✓ Minimum 2 years IRF experience
- ✓ Expert knowledge of ICD-10 coding
- ✓ Understanding of FIM scoring methodology
- ✓ Familiarity with CMS regulations and MAC audit processes
- ✓ Strong analytical and documentation skills
15
Questions
80%
Passing Score
~23
Minutes
Quiz Instructions:
- Answer all 15 questions to complete the quiz
- You must score 80% or higher to pass
- You can navigate between questions before submitting
- Review explanations for all questions after submission
- Retake the quiz as many times as needed to pass