Widespread Targeted Review Results of Alabama Inpatient Rehabilitation Facilities (IRFs) and Inpatient Rehabilitation Units (IRUs)

Part A Medical Review has recently completed the 4th Quarter widespread targeted prepay review of claims for inpatient rehabilitative services following lower extremity joint replacement that were processed between October 1, 2007, and December 31, 2007. Educational articles providing the results of previous reviews and guidelines for IRF/IRU services were made available on “What’s New from Cahaba” Web page on May 17, 2006, August 3, 2006, October 26, 2006, February 13, 2007, April 24, 2007, July 27, 2007, and October 22, 2007. These articles may be found on the What’s New from Cahaba Web page. The results of the current review are as follows:

Providers Reviewed:            55
Claims Reviewed:                 198
Claims Approved:                 19
Claims Denied:                     179
Charges Reviewed:              $2,541,916.81
Charges Approved:              $249,146.81
Charges Denied:                  $2,292,770.00

Error Rate: 90%*
* error rate is based on the charges denied divided by the charges reviewed

As with previous reviews, the majority of denials of IRF/IRU claims reviewed (156) resulted from inadequate submission of medical justification for the IRF/IRU services, (denial reason code 54155). The medical review of inpatient rehabilitative treatment of lower extremity joint replacement decisions were based on the local coverage determination (LCD) L15198- Inpatient Rehabilitation, which outlines specific documentation requirements to support the medical necessity for all inpatient rehabilitation admissions. The LCD may be found on the Active LCDs Web page.

Additionally, 23 claims were denied because providers did not submit medical record documentation in response to an Additional Development Request (ADR), resulting in a denial with reason code 56900. According to Medicare Program Integrity Manual, (CMS Pub. 100-08), Ch. 3, §3.4.1.2, if a coverage or coding determination cannot be made based upon the information on the claim, the fiscal intermediary (FI) may solicit additional documentation from the provider by issuing an ADR and must notify the provider of the 30-day time period to respond. If the ADR-requested information is not received within 45 days after the date of the request, the claim must be denied.

To eliminate 56900 denials, please review the following elements to ensure appropriate and timely record processing:

Access the Fiscal Intermediary Standard System (FISS) to identify claims selected for ADR. Claims selected for ADR can be identified by accessing FISS Inquiry Option 12, and will appear in status location S B6001. Pages 07 and 08 of the claim will contain the date your documentation is due, and the elements of documentation requested.
Attach a copy of the ADR to the front of the requested medical documentation
Send requested information to the address on the ADR letter
Do NOT send certified mail or overnight mail
Include ALL requested documentation outlined in the ADR
Submit the above information via regular mail in a timeframe to ensure the FI receives the information by the 45th day after the date of the request

It is important for providers to ensure that there is proper documentation in the medical record to support CMS requirements for IRF services and timely submission of requested claims documentation.

Cahaba’s Part A Medical Review department will continue the widespread targeted prepay review of all IRFs and IRUs (Bill Type 11X) with revenue code 0024 (all inclusive ancillary) billing CMG A0801 (replacement of lower extremity joint with motor score from 58-84 without co-morbid conditions) and CMG A0802 (replacement of lower extremity joint with motor score from 55-57 without co-morbid conditions). This review will be identified by edit reason code 5111K.

In addition to the previously mentioned references, IRFs and IRUs billing for inpatient rehabilitation services should review the following resources to ensure adherence to all coverage criteria.

Additional information regarding Inpatient Rehabilitation services may be found in the Federal Register, Volume 69, Number 89/ Friday, May 7, 2004, pages 25762-25763 and the United States Government Accountability Office (GAO) Report, April 2005.

Page last updated: Feb. 28, 2008