CMS Clarifies Medical Review Policy for Intensive Rehabilitation Therapy

The Centers for Medicare & Medicaid Services has clarified its inpatient rehabilitation facility medical review guidelines to confirm that auditors should not deny claims solely because a therapy time threshold, commonly referred to as the “3-hour rule,” was not met. Effective March 23, when this standard is not met the auditor “shall use clinical review judgment to determine medical necessity…based on the individual facts and circumstances of the case, and not on the basis of any threshold of therapy time,” the guidance states. Contractors also should not deny claims “solely because the situation/rationale that justifies group therapy is not specified in the patient’s medical records at the IRF,” the guidance states.