Inpatient Rehab Coding Challenges: IRF-PAI vs. UB-04 Coding

by Nirmala Sivakumar, CCS, CDIP

While freestanding rehabilitation hospitals have a dedicated rehabilitation coder, the coding for rehab units within an acute hospital is done by coders that may not be familiar with IRF-PPS coding guidelines. Many HIM professionals that code for the rehab units are not familiar with how IRFs are reimbursed and may assume that payment is based on the Diagnosis Related Group (DRG) generated by the principal diagnosis on the UB-04.

It is essential that HIM Managers and Coders understand IRF-PPS guidelines and the differences in the coding of the two documents, the IRF-PAI and the UB-04. The codes reported on these two documents might differ in some scenarios. However, they must tell the same story on the patient’s reason for admission to inpatient rehab.

Choosing the principal diagnosis on the bill must be accurate and based on physician documentation for the reason for admission and in accordance with coding guidelines. Though the ICD-10 codes reported on the UB-04 do not affect Medicare reimbursement, they still need to be coded accurately.

There is a need for IRF-specific training resources to support both coders and those who depend on their coding:

• Different coders may interpret guidelines differently, which leads to inconsistencies in coding.
• Though Prospective Payment System (PPS) coordinators are responsible for the completion of the IRF-PAI, they are not generally proficient in ICD-10 coding. PPS coordinators rely on the coding team to provide accurate ICD-10 codes for the IRF-PAI.

All of these factors combined could lead to inaccurate coding and potentially have an impact on an IRF’s 60% presumptive compliance and reimbursement. Inconsistencies and questionable coding choice can also trigger potential audits.

Inpatient Rehabilitation Facility: IRF-PAI and UB-04 Coding
Inpatient rehab coding presents a challenge for HIM coders, even those with many years of coding experience. While both the IRF-PAI and UB-04 forms are used by Inpatient Rehabilitation Facilities to report ICD-10-CM codes, there are several key differences. This webinar will help the IRF coder gain a clear understanding of IRF PPS guidelines and how ICD-10-CM coding conventions apply to the IRF setting. Learn more here.

Nirmala Sivakumar, CCS, CDIP
Nirmala Sivakumar, is an IRF Coding Educator based in PA. She has created and presented many webinars and workshops on IRF coding and improving clinical documentation. She has trained and mentored many rehab coders. She also has experience in conducting coding audits. She enjoys sharing her expertise and knowledge and has a desire to help coders and PPS Coordinators overcome the challenges of IRF PPS coding.

She has held previous positions as Health Information Management Supervisor for one of HealthSouth’s (Encompass) acute inpatient rehab hospital and as a HIM Coding Consultant at Uniform Data Systems for Medical Rehabilitation. She can be reached at [email protected] or visit www.irfcodingexplained.com.