Form CMS-10765 Review Choice Demonstration for Inpatient Rehabilitation

OMB Control Number: 0938-1420

Expiration Date: XX/XX/202X

Review Choice Demonstration for Inpatient Rehabilitation Facility Services

Inpatient Rehabilitation Facilities (IRFs) will initially choose between two options:

• Pre-claim review for all IRF claims or

• Postpayment review of all IRF claims

An IRF that chooses the pre-claim review option must submit a pre-claim review request prior to the submission of the final claim for payment. IRFs have an unlimited number of resubmissions of the pre-claim review request prior to the final claim being submitted for payment.

Submitters should include, at a minimum, the following data elements in an IRF pre-claim review request:

Beneficiary Information

• Beneficiary’s Name;

• Beneficiary’s Medicare Number (also known as HICN or MBI); and

• Beneficiary’s Date of Birth.

Physician/Practitioner Information

• Physician/Practitioner’s Name;

• Physician/Practitioner’s National Provider Identifier (NPI);

• Physician/Practitioner PTAN (optional); and

• Physician/Practitioner’s Address.

Inpatient Rehabilitation Facility Information

• IRF Name;

• CMS Certification Number;

• PTAN (optional); and

• IRF Address.

Submitter Information

• Contact Name; and

• Telephone Number.

Other Information

• Submission Date;

• Indicate if the request is an initial or resubmission review

• If resubmission, the UTN must be included.

Additional Required Documentation

Each beneficiary’s medical record at the IRF must contain the following documentation:

• Pre-admission screening

• A comprehensive evaluation:

  • Serves as the primary documentation of the patient’s status prior to admission and documents the specific reasons that led the IRF clinical staff to conclude that the IRF admission was reasonable and necessary.

• Must include:

  • Prior level of function

  • Expected level of improvement

  • Expected length of time to achieve that level of improvement

  • Risk for clinical complications (detailed description)

  • Conditions/comorbidities that caused the need for rehabilitation and why these require physician monitoring (detailed description)

  • Combinations of treatments needed

  • Anticipated discharge destination

• Licensed or certified clinicians conducting the preadmission screening must write out the detailed reasoning/justification for the IRF admission.

• Individualized overall plan of care

  • The purpose of the overall plan of care is for the rehabilitation physician to gather pertinent information that has been collected regarding the patient’s medical and functional treatment needs and goals since the beginning of admission and to synthesize this information into an overall plan of care that will guide the patient’s treatment during the IRF stay.

  • A non-physician practitioner can fulfill the IRF services and documentation requirements currently required to be performed by the rehabilitation physician in 42 CFR § 412.622(a)(3), (4), and (5).Beginning with the second week of admission to the IRF, a non-physician practitioner who is determined by the IRF to have specialized training and experience in inpatient rehabilitation may conduct 1 of the 3 required face-to-face visits with the patient per week, provided that such duties are within the non-physician practitioner's scope of practice under applicable state law.

• Interdisciplinary Team Approach

  • The team meetings are led by a rehabilitation physician and occur at least once per week throughout the duration of the patient's stay to implement appropriate treatment services; review the patient's progress toward stated rehabilitation goals; identify any problems that could impede progress towards those goals; and, where necessary, reassess previously established goals in light of impediments, revise the treatment plan in light of new goals, and monitor continued progress toward those goals.

• Medical Necessity

  • Documentation support that the patient required the active and ongoing therapeutic intervention of multiple therapy disciplines (one of which must be physical or occupational therapy). In addition, the patient requires an intensive rehabilitation therapy program, and that the patient can actively participate and benefit significantly from the intensive rehabilitation. Furthermore, documentation reflects the requirement for medical supervision.

• Resubmissions will require additional documentation, when available

IRFs with claims undergoing prepayment or postpayment review should follow the normal claim review processes.

PRA Disclosure:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1420. This information collection is used to determine proper payment or if there is a suspicion of fraud. The information requested includes all documents and information that show the number and level of services requested are reasonable and necessary for the beneficiary. The time required to complete this information collection is estimated to average less than 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is required, to obtain or retain a benefit. Section 402(a)(1)(J) of the Social Security Amendments of 1967, as amended [42 U.S.C. 1395b-1(a)(1)(J)] authorizes the Secretary to “develop or demonstrate improved methods for the investigation and prosecution of fraud in the provision of care or services under the health programs established by the Social Security Act [the Act].” Pursuant to this authority, CMS is implementing a Medicare demonstration project, which CMS believes will help assist in developing improved procedures for the identification, investigation, and prosecution of Medicare fraud occurring among IRFs providing services to Medicare beneficiaries. The nature and extent of confidentiality to be provided, is considered private/confidential to the extent permitted by law. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard or MCE@cms.hhs.gov, Attn: Information Clearance Officer.