How to Address IRF Coding Challenges

How to Address IRF Coding Challenges

Inpatient rehabilitation facilities (IRFs) have a unique reimbursement system, and Pat Trela, RHIA, has been at the forefront of IRF coding since 1971. During her roundtable presentation “Challenges for HIM at the Inpatient Rehabilitation Facility,” Trela, a hospital and healthcare consultant and contractor, addressed issues such as limited educational opportunities for health information management (HIM) professionals specific to the IRF setting, how official ICD-10-CM coding guidelines do not always fit IRF coding, and the excessive number of requests for audits compared to the size of the IRF unit.

Some educational opportunities can be found at AHIMA and at the American Medical Rehabilitation Providers Association if one’s facility is a member. AHIMA offers webinars for code updates and IRF-PPS updates annually, and a toolkit for IRFs. The American Hospital Association’s Coding Clinic® also has some guidance for IRFs, specifically regarding utilization of the seventh character identifying a diagnosis as initial, subsequent, or sequela. Different facilities seem to interpret the subsequent (D) and sequela (S) definitions differently, especially as they pertain to traumatic brain and spinal cord injuries. “With brain and spinal cord injuries, we (IRF) treat the residual deficits because what’s done is done,” Trela said. “There is no treatment directed at the brain injury or the spinal cord injury; only at the residual deficits resulting from the injury, such as cognitive deficits or paralysis.”

Another challenge for IRFs is communication between the prospective payment system (PPS) coordinator and the coding professional. When assigning ICD-10-CM codes, it is important that codes assigned to the IRF Patient Assessment Instrument (PAI) coincide with the codes placed on the UB-04 claim form. The code assignment must also support information utilized for quality reporting. Trela recommended that coding professionals enter the codes on the IRF PAI to ensure the necessary consistency between these two reporting documents. She also recommended coding the patient chart on admission and concurrently, in addition to conducting discharge coding. This practice provides opportunity for queries to aid in capturing incomplete or missing documentation necessary to validate the impairment group, determine average length of stay, and codes for interim billing.

With multiple requests for records coming into IRFs for audits, as well as all other routine requests for records, the processing of these requests needs to be as efficient as possible. When requests come in for auditors, such as from Recovery Audit Contractors (RAC) and Medicare Audit Contractors (MAC), Trela encouraged HIM professionals to “send what is requested, organize the information, and review the information prior to sending to ascertain that the documentation being sent supports the rehabilitation reasonable necessary criteria.”


  1. Has there been any evaluation done on “risk of investment” associated with concurrent coding? I have been involved in this process in the past and from experience; was a significant drain on the acute care side for resource utilization. It is important to note that additional resources were not obtained in facilitating this process. Any suggestions to streamline this process?

  2. Does the “uncertain diagnosis” coding guideline apply to the IRF in the same way as it does for an acute, short term inpatient hospitalization?

  3. Looking for comprehensive IRF Coder Training

  4. IRF vs SNF coding are different, and yes, some invasive procedures should be captured on the IRF side as long as the patient’s head is back in the bed the same day before midnight. Alot of Rehabs are losing money not capturing these procedures performed.

  5. ICD 10-PCS codes are not coded in IRF as revenue codes partially serve the purpose. However it is subject to hospital’s discretion of procedure data tracking method. It would be good if you could throw some light on PCS coding in IRF

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