Nationwide Review of Inpatient Rehabilitation Facility Claims Coded as 'Discharged to Home with Home Health Agency Services,' "

EXECUTIVE SUMMARY:

Our objective was to determine whether inpatient rehabilitation facilities (IRFs) coded claims as “discharged to home with home health agency services” in compliance with Medicare's transfer regulation during fiscal year 2003. IRFs did not always code claims in compliance with Medicare's transfer regulation. Nationwide, we identified 585 IRF claims coded and paid as discharges to home with home health agency services that potentially should have been paid as transfers. We visited or contacted four IRFs to verify the coding of 44 of these claims and found that all 44 claims should have been coded as transfers. We also repriced a sample of 100 of the 585 claims and estimated that overpayments to IRFs totaled $2,331,042 in fiscal year 2003.

We recommended that CMS: (1) instruct the fiscal intermediaries to review the claims in question and to recover, as appropriate, the estimated $2,331,042 in overpayments; (2) instruct the fiscal intermediaries to review claims paid after our audit period for possible coding errors; and (3) implement edits in the Common Working File to identify potentially miscoded claims. CMS concurred with the recommendations.