CMS Pub. 100-08, ch. 6, § 6.7.1

Requirements

(Rev. 10184; Issued: 06-19-2020; Effective: 07-21-2020; Implementation: 07-21- 2020)

When reviewing IRF claims, the UPIC, MAC, SMRC, CERT and RAC shall verify that

the IRF documentation requirements are met in accordance with IOM 100-02, Medicare

Benefit Policy Manual, Chapter 1, Section 110.

The UPIC, MAC, SMRC, CERT and RAC shall not make absolute claim denials based

solely on a threshold of therapy time not being met. When the current industry standard

of generally 3 hours of therapy (physical therapy, occupational therapy, speech-language

pathology, or prosthetics/orthotics) per day at least 5 days per week or at least 15 hours of

intensive rehabilitation therapy within a 7 consecutive day period is not met, the claim

shall undergo further review.

The UPIC, MAC, SMRC, CERT and RAC shall use clinical review judgment to

determine medical necessity of the intensive rehabilitation therapy program based on the

individual facts and circumstances of the case, and not on the basis of any threshold of

therapy time. The standard of care for IRF patients is individualized (i.e., one-on-one)

therapy. Group and concurrent therapy can be used on a limited basis within the current

industry standard of generally 3 hours of therapy per day at least 5 days per week or at

least 15 hours of intensive rehabilitation therapy within a 7-consecutive day period. In

those instances in which group therapy better meets the patient’s needs on a limited basis,

the situation/rationale that justifies group therapy should be specified in the patient’s

medical record at the IRF. However, MAC, SMRC, CERT and RAC shall not deny solely

because the situation/rationale that justifies group therapy is not submitted in response to

an ADR.