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Making a decision to admit a patient is based on pre-admission screening, but what are the critical pieces of information to focus your attention upon? The first consideration is always going to be the primary impairment, etiologic diagnosis and comorbid conditions. The 60% Rule will be on your mind as well as the interplay between primary impairment and comorbid conditions. Use your outcomes reports to know your compliance percentage and your compliance review period to know where things stand. This will give you context for your decision making. Medicare Administrative Contractors (MACS) use IRF-PPS impairment group codes, etiologic diagnosis and comorbidity codes (ICD-10CM) in their analysis of Presumptive Compliance in addition to a review of medical records to determine compliance percentage. Knowing the rules, is an essential part of your process. For example, and as a reminder, beginning 1, 2017, MACs began to count certain ICD-10 CM codes for patients with traumatic brain injury and hip fracture conditions and cases that contain two or more ICD-10 CM codes from three major multiple trauma lists in specified combinations.

Narrative notes communicate your thinking with regard to a patient’s candidacy for admission. Begin with physiological and safety needs. Describe how the current disease (or exacerbation), disorder or injury has affected the individual from a medical, nursing and functional perspective. Explain resulting impairments and disabilities and why an inpatient rehabilitation program is required for the patient’s safety. Emphasize the complexity of the patient’s problems and that only clinicians skilled in this intensive level of therapy, specialized nursing and physicians specifically trained in rehabilitation medicine can address the patient’s problems safely. I am quite sure that “justifying” your admission decisions is not your favorite thing to do, but it appears to me that when a reviewer begins to examine records, they are approaching the case as if it could have been treated in a lower (less expensive) setting and we want to disprove that theory of the case. Be confident and unequivocal about your opinion that an intensive level of services provides the reasonable and necessary services required for this patient to achieve and maintain a higher level of functioning and quality of life. Relate your decision back to pre-morbid status. What was the patient’s life like before the current problem? In addition to medical/health status, our standards of care also revolve around daily activities, community participation and environment. Describe how the current problem alters the patient’s ability to navigate these domains.