Inpatient Rehabilitation Facility RCD Top 3 Non-Affirmation and Claim Denial Reasons

Published 01/29/2025

We encourage all providers to review this information to ensure timely processing of claims and pre-claim review (PCR) requests. The following chart shows the cumulative non-affirmation and claim denial reasons for Alabama Inpatient Rehabilitation Facility (IRF) Review Choice Demonstration (RCD) providers.

Table 1: Cycle 1 Top 3 Non-Affirmations

Rank	Code	Category	Description
1	IRF5A	Medical Necessity	The documentation does not support the beneficiary required supervision by a rehabilitation physician. Refer to: eCFR :: 42 CFR 412.622(a)(3)(iv) — Basis of payment Medicare Benefit Policy Manual Chapter 1, Section 110- Inpatient Rehabilitation Facility (IRF) Services (PDF)
2	IRF5D	Medical Necessity	The documentation does not support the patient is sufficiently stable at the time of admission to the IRF to be able to actively participate in and benefit significantly from the intensive rehabilitation therapy program. Refer to: eCFR :: 42 CFR 412.622(a)(3)(ii) — Basis of payment Medicare Benefit Policy Manual Chapter 1, Section 110.2. — Inpatient Rehabilitation Facility Medical Necessity Criteria (PDF)
3	IRF8G	Medical Necessity — Therapy Services	Documentation does not support that therapy services began within thirty-six hours from midnight of the day of admission to the IRF. Refer to: eCFR :: 42 CFR 412.622(a)(3)(ii) — Basis of payment Medicare Benefit Policy Manual Chapter 1, Section 110.2.2 — Intensive Level of Rehabilitation Services

Rank

Code

Category

Description

IRF5A

Medical Necessity

The documentation does not support the beneficiary required supervision by a

rehabilitation physician. Refer to:

IRF5D

Medical Necessity

The documentation does not support the patient is sufficiently stable at the time of admission to the IRF to be able to actively participate in and benefit significantly from the intensive rehabilitation therapy program. Refer to:

IRF8G

Medical Necessity — Therapy Services

Documentation does not support that therapy services began within thirty-six hours from midnight of the day of admission to the IRF. Refer to:

Table 2: Cycle 2 Top 3 Non-Affirmations

Rank	Code	Category	Description
1	IRF5A	Medical Necessity	The documentation does not support the beneficiary required supervision by a rehabilitation physician. Refer to: eCFR :: 42 CFR 412.622(a)(3)(iv) — Basis of payment Medicare Benefit Policy Manual Chapter 1, Section 110: Inpatient Rehabilitation Facility (IRF) Services (PDF)
2	IRF5D	Medical Necessity	The documentation does not support the patient is sufficiently stable at the time of admission to the IRF to be able to actively participate in and benefit significantly from the intensive rehabilitation therapy program. Refer to: eCFR :: 42 CFR 412.622(a)(3)(ii) — Basis of payment Medicare Benefit Policy Manual Chapter 1, Section 110.2: Inpatient Rehabilitation Facility Medical Necessity Criteria (PDF)
3	IRF5B	Medical Necessity	Documentation does not support that upon admission to the IRF the patient generally required the intensive rehabilitation therapy services that are uniquely provided in IRFs. Refer to: eCFR :: 42 CFR 412.622(a)(3)(i) — Basis of Payment Medicare Benefit Policy Manual Chapter 1, Section 110.2: Inpatient Rehabilitation Facility Medical Necessity Criteria (PDF)

Table 1: Cycle 1 Top 3 Non-Affirmations

Table 2: Cycle 2 Top 3 Non-Affirmations

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Inpatient Rehabilitation Facility RCD Top 3 Non-Affirmation and Claim Denial Reasons

Table 1: Cycle 1 Top 3 Non-Affirmations

Table 2: Cycle 2 Top 3 Non-Affirmations

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