[Blog Series] IRF Regulations Part 3: The Impact of COVID-19 on Documentation Requirements

by Kay Hashagen, Senior Consultant on September 30, 2020

In this third and final part of the Blog Series for Inpatient Rehabilitation Facilities (IRFs), we will discuss important considerations related to documentation to support medical necessity and correct coding and billing under COVID-19 regulations.

More information on the Medicare changes can be read in the “COVID-19: An Advocates Guide to Beneficiary-Related Medicare Changes.” If you have not reviewed the first two blogs, read, “[Blog Series] IRF Regulations Part 1: 1135 Waiver Highlights” and “[Blog Series] IRF Regulations Part 2: Coverage Requirements for the Fiscal Year 2021.”




For admissions to IRF services that are not related to the pandemic, best practice would be for the IRF to continue to meet all relevant requirements outlined by the Centers for Medicare & Medicaid Services (CMS) before the pandemic; however, the waiver allows increased flexibility. The requirement for the 60% Rule is waived during the public health emergency (PHE). Also, IRF coverage and classification requirements are waived under the following circumstances:

  • If the patient is admitted to a freestanding IRF to alleviate acute care hospital bed capacity issues.
  • If the IRF is located in an area that is in Phase 1 or has not yet entered Phase 2.

To further support the documentation requirements, CMS has provided codes that should be used on the claim form when IRFs utilize the COVID-19 flexibilities. The following letters should be applied to the end of the unique hospital identification number (or medical record number in the IRF) to identify the eligible patients.

  • D–60% Rule
  • DS–Coverage and classification requirements
  • DDS–Both 60% rule and coverage and classification requirements

Here are additional focused recommendations for COVID specific instances related to documentation are posed:

Housing Billing Updates

  • Suppose an IRF unit is housing patients that would usually be seen in the acute care hospital because of COVID-19. In that case, the Inpatient Prospective Payment System (IPPS) hospital should bill for the care and annotate the patient’s medical record to indicate the patient is an acute care inpatient being housed in the excluded unit because of capacity issues related to the disaster or emergency.

Billing for IRF PPS Updates

  • Freestanding IRFs can admit acute care patients and bill under the IRF PPS without meeting the IRF coverage or classification requirements for surge patients. Only freestanding IRFs in areas under a surge status can bill for IRF PPS and only for patients admitted assisting with capacity at acute care hospitals. The DS or DDS modifiers would be required.

Therapy Documentation Updates

  • CMS has waived 42 CFR § 412.622(a)(3)(ii), which requires that IRF patients be expected to participate in and benefit from 3-hours of therapy per day or 15-hours per week. Patients may meet all other criteria but may not be able to participate in the intensity of therapy. The documentation should support the reason why the therapy is not being provided. The DS modifier should be applied to the end of the IRF’s unique patient identifier number to highlight patients who are being treated in a freestanding IRF hospital solely to alleviate acute-care inpatient bed capacity.
  • The requirement for the three weekly rehabilitation physician visits still stands, although some variations are allowed. CMS is allowing the visits to be conducted via telehealth during this public health emergency. Documentation should support the criteria for the visit whether it is in person or via telehealth. Per the Final Rule, non-physician practitioners (NPPs) will be allowed to perform specific duties that are currently required to be performed by a rehabilitation physician. NPPs are physician assistants, clinical nurse specialists, and nurse practitioners, who have specialized training and experience in inpatient rehabilitation as determined by the IRF, if state and local laws permit it. In the final rule, the NPPs may perform one of the three required face-to-face visits instead of the rehabilitation physician beginning in the second and later weeks of a patient's IRF stay. The documentation should denote who completed the visit through credentials. The IRF may need to demonstrate the knowledge and training of the NPP with regards to the IRF.

Documentation Updates

  • Patients can be excluded from the 60 percent rule calculation if admitted “solely to respond to the emergency.” The documentation in the medical record should clearly explain the situation. The invoice should include the modifier DDS to exclude the patient from the 60 percent rule calculation and the coverage and classification requirements.
  • CMS no longer requires the post-admission physician evaluation (PAPE) for all patients. However, there is no change in the pre-admission screen (PAS) or the development of the individualized overall plan of care (IPOC), except for those who are being transferred from an acute care hospital due to a COVID-19 surge. The information gathered during the PAPE is essential to the development of the IPOC. The documentation must support the timely development of the IPOC. IRFs may want to continue with the PAPE or the evaluation process, but the 24-hour requirement is no longer in effect.
  • Team conferences are still required weekly. CMS has stated that it is appropriate for IRFs to conduct team meetings remotely during the PHE. CMS did not provide any specific instructions for documentation. The documentation should identify the conference date, all persons who were in attendance with their credentials, and all the usual information that is required at the team conference. The documentation should identify if any participants were in person and those who were participating via remote connections.

Stay tuned as COVID-19 updates and requirements are still changing. Best practice is to make sure your IRF documentation tells the story of the admission and supports the coding. LW Consulting, Inc. is prepared to provide additional direction or review your coding and documentation.


For more information, contact Jim Wright, Director by calling 717-213-3128 or email JWright@lw-consult.com.

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Topics: Compliance