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Medical Billing for Inpatient Rehabilitation Facilities & Programs

Rehabilitative Medicine Billing That Pays What You Earn

Inpatient rehabilitation facility billing operates under a prospective payment system using Case Mix Groups (CMGs) based on the IRF-PAI assessment. The 60% rule, therapy intensity requirements, and physician oversight documentation are central to IRF compliance and reimbursement. Outpatient rehabilitation billing adds occupational therapy, speech therapy, and the Medicare therapy threshold management layer. 360Solutions provides rehabilitative medicine billing specialists who manage IRF-PAI coding, CMG optimization, therapy cap tracking, and functional outcomes documentation.

24%
avg IRF revenue lost from CMG miscoding and IRF-PAI errors
$3,200
avg additional revenue per admission with correct CMG assignment
95%
IRF-PAI submission accuracy rate with specialist coding
Rehabilitative Medicine Billing Challenges
Where practices lose the most revenue:
✓
IRF-PAI & CMG Assignment
✓
60% Rule Compliance
✓
Therapy Intensity Documentation
✓
Physician Oversight Requirements
Rehabilitative Medicine Billing Challenges

Where Rehabilitative Medicine Practices Lose Revenue

These are the coding and billing pitfalls that cost rehabilitative medicine practices the most — and where our specialised billers add the most value.

IRF-PAI & CMG Assignment

The IRF-PAI assessment drives CMG assignment, which determines the entire facility's payment for the admission. Incorrect FIM scores, wrong impairment group coding, or missed comorbidities in the CMG calculation result in systematic underpayment across every IRF admission.

60% Rule Compliance

Medicare requires that at least 60% of an IRF's Medicare patients have one of the 13 qualifying diagnoses. Incorrect admission diagnosis coding that misrepresents the qualifying condition creates compliance risk and potential recoupment. Documentation must support the qualifying diagnosis at admission.

Therapy Intensity Documentation

IRF patients must receive at least 3 hours of PT and/or OT therapy per day for 5 of 7 consecutive days (or 15 hours in 7 days). Therapy time must be documented in individual daily treatment notes — failure to meet or document the threshold triggers IRF admission recoupment.

Physician Oversight Requirements

IRF regulations require the rehabilitation physician to conduct face-to-face visits at least 3 times per week. Each visit must be documented with a physician note. Missing visits or absent documentation causes IRF status denial and conversion to inpatient acute care payment.

Coding Intelligence

High-Risk CPT Groups

Code ranges payers audit most aggressively in Rehabilitative Medicine.

97001 / 97003
PT evaluation / OT evaluation — used for IRF-based outpatient services
97110 / 97530
Therapeutic exercise / therapeutic activities — timed per 15 min
99221–99223
Initial hospital visit — IRF physician admission evaluation
99231–99233
Subsequent hospital visits — IRF physician 3x/week oversight visits
G0179 / G0180
Physician re-certification of care plan — rehab physician
Denial Intelligence

Common Denial Patterns

Knowing these before submission is the difference between a 60% and a 96% first-pass rate.

CMG miscoded due to incorrect FIM motor or cognitive scores in IRF-PAI

Qualifying IRF diagnosis not documented at admission in physician order

Therapy intensity threshold not met or not documented in daily therapy notes

Physician oversight visit notes absent for required 3x per week IRF visits

60% rule qualifying diagnosis not present in patient's primary impairment group

Free Denial Audit

Send us your last 90 days of remittance data — we'll identify your top 3 fixable denial sources at no cost.

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Our Process

How 360Solutions Works for Rehabilitative Medicine Practices

01

Free 2-Week Billing Audit

We review your last 90 days: denial breakdown by category, AR aging by payer, charge lag, collection rate, and any recurring coding issues specific to your specialty. No commitment required.

02

Specialty Coder Assignment

You are paired with a coder trained specifically in rehabilitative medicine coding. They learn your providers, your documentation patterns, and your payer mix before touching a claim.

03

Parallel Billing Transition

We run alongside your current billing for 10–14 days with zero cash flow disruption. Claims keep moving during the transition. Your account manager provides daily status updates.

04

Live KPI Dashboard

Real-time visibility into billed, paid, denied, AR aging, and collection rate — segmented by provider and payer. No black box, no month-end surprises.

05

Weekly Account Manager Call

Every week your dedicated account manager walks through last week's KPIs, denial trends, and any action items. Critical issues are escalated the same day — not at the next scheduled call.

Rehabilitative Medicine Billing FAQ

Questions From Rehabilitative Medicine Practices

We review the IRF-PAI at admission and at discharge, verify FIM scores against nursing and therapy documentation, confirm the correct impairment group code, and check that comorbidities that qualify as CMG tier adjustments are captured. Any discrepancy is resolved before the PAI is submitted.
Yes. We manage IRF facility billing (UB-04 claims) and the rehabilitation physician's professional billing (CMS-1500 claims) simultaneously. We ensure that the physician's visit documentation supports the facility's billing requirements for CMS compliance.
Transfer mid-stay affects IRF payment — CMS uses a per-diem rate for short stays below the average length of stay for that CMG. We calculate the applicable per-diem rate, submit the transfer claim with the correct discharge code, and coordinate billing with the receiving acute care hospital.
Yes. Post-IRF outpatient therapy continues under standard PT/OT/SLP billing rules with Medicare therapy threshold management. We track each patient's annual therapy spend from their IRF stay through outpatient continuation and apply KX modifiers at the correct threshold.
Ready to Fix Your Rehabilitative Medicine Billing?

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No-Obligation Audit

Two weeks, no contract. A certified rehabilitative medicine billing specialist reviews your claims, denial patterns, and AR — and shows you exactly what is recoverable.

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