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Inpatient Rehabilitation Facility (IRF) Billing Services Billing & RCM Services
Qualigenix bills IRF stays so the case-mix group on the claim matches the IRF-PAI, the medical record supports the admission, and the facility's 60% compliance threshold holds. Medicare pays an IRF one amount per discharge, set by the case-mix group (CMG) the IRF-PAI produces. CMS's 2025 improper payment data put IRF errors at 21.5% of payments, and the top root cause was documentation that didn't support medical necessity. Our CPC- and CCS-certified coders work from the IRF-PAI, the therapy record and the physician notes together.
What IRF Billing Requires
IRF billing under Medicare runs on the IRF prospective payment system: the IRF-PAI assessment produces a CMG, the CMG is reported as a HIPPS code on revenue code 0024 of a TOB 11X inpatient claim, and Medicare pays one rate per discharge. The record also has to show that the patient needed, and could take part in, intensive therapy from more than one discipline, under a rehabilitation physician and a weekly interdisciplinary team conference. Qualigenix handles the coding, the claim build and the denial work, with a 98.6% compliance and audit pass rate. Call 786-259-0231 to review your IRF's claims.
01
CMG & HIPPS Accuracy
The CMG is reported as a 5-character HIPPS code that starts with A, B, C or D. When the HIPPS on the claim doesn't match the IRF-PAI on file, Medicare's claims system can reprice the stay to the assessment's HIPPS code.
02
Admission Authorizations
Medicare Advantage and commercial plans that require authorization for IRF admission tie the approval to the admit date and the expected length of stay. An extension that isn't requested in time leaves the remaining days unpaid.
03
IRF-PAI Timing
The IRF-PAI has to be completed in its assessment window, transmitted, and matched to the claim. A late or missing assessment changes the payment Medicare calculates for the stay.
04
Interrupted-Stay Rules
When a patient leaves and returns within 3 days, Medicare treats it as one stay and the claim carries occurrence span code 74. A longer interruption is billed as a discharge and a new admission.
05
Benefit-Period Tracking
IRF days draw on the patient's Part A inpatient hospital days. A patient with a recent acute or psychiatric stay may arrive with fewer covered days than the IRF expects.
06
Medical Necessity Records
Medicare's 2025 improper payment data lists unsupported medical necessity as the most frequent IRF root cause, followed by missing interdisciplinary team meeting notes and missing preadmission screenings. Medicare contractors also flag insufficient therapy minutes, missing plans of care and missing supervision by a rehabilitation physician.
06
IRF Denial Drivers
IRF denials come from medical necessity findings, CMG and HIPPS mismatches, authorization gaps, benefit-day errors, and documentation missing from the preadmission screening, post-admission evaluation or plan of care.
07
60% Rule Compliance
To keep its IRF status, a facility must show that at least 60% of its patients have one or more of the qualifying conditions listed in 42 CFR 412.29. Diagnosis and comorbidity coding on each stay feeds that calculation.
PRECISION: WHAT QUALIGENIX DOES
How Qualigenix Closes IRF Revenue Gaps
Qualigenix codes each IRF stay from the IRF-PAI and the medical record together, and checks the claim against both before it's filed.
CMG Validation
We compare the HIPPS code on each claim with the IRF-PAI and the record that supports it, and resolve differences before submission.
Admission Auth Management
We obtain authorizations for IRF admissions, track approved days against the length of stay, and request extensions before the approved window closes.
IRF-PAI Reconciliation
We match each claim to its transmitted IRF-PAI by dates and HIPPS code, and flag assessments that are late or missing.
Interrupted-Stay Billing
We bill short interruptions with occurrence span code 74 on one claim and treat longer interruptions as a discharge and readmission.
Benefit-Day Verification
At admission we check the patient's remaining Part A days, lifetime reserve days and any Medicare Advantage limits.
Documentation Review
Before billing, we check the record for the preadmission screening, post-admission physician evaluation, plan of care, therapy minutes and weekly team conference notes.
Denials, ADRs & Appeals
We answer additional documentation requests and appeal IRF denials with the full record organized to Medicare's coverage criteria. Qualigenix overturns 79% of the denials it works, across 50,000 denials worked each month.
60% Rule Monitoring
We report the facility's compliance percentage from coded diagnoses so leadership can see the trend before the review period closes.
CASE STUDY 01
How a 3-provider podiatry group cleared $214K in aged A/R
THE SITUATION
A 3-provider podiatry group with roughly 60% Medicare payer mix carried $412,000 in A/R, 38% of it past 120 days. Routine foot care claims (11720, 11721, 11055–11057) had stalled on inconsistent Q7/Q8/Q9 modifiers and class-finding documentation, so payers held or partially paid and nobody worked the remainder. Medicare crossover to secondaries was not being posted, and small patient balances were written off.
WHAT QUALIGENIX DID
We ran a full A/R aging segmentation, worked claims by payer and denial reason rather than by date, rebilled the stalled routine-care claims with corrected modifiers, and reactivated secondary and crossover billing.
Key Outcomes & Turnaround
38% to 14%A/R past 120 days
$214,000recovered from aged A/R
90 daysto turn it around
~60%Medicare payer mix
Audited Practice Results
How a solo podiatrist lifted first-pass acceptance to 96%
THE SITUATION
A solo podiatrist coding 320 encounters a month was stuck at 82% first-pass acceptance. Routine foot care went out without the systemic-condition diagnosis pairing and class findings Medicare requires, so it read as non-covered. Wound debridement was coded to the wrong depth (11042 for skin and subcutaneous where the note supported 11043 for muscle and fascia). Same-day E/M with a procedure went out without modifier 25 and got bundled.
WHAT QUALIGENIX DID
We rebuilt the coding workflow: diagnosis-to-CPT pairing rules for at-risk foot care, correct Q-modifier logic, depth-based debridement coding tied to the operative note, and disciplined use of modifiers 25 and 59/XS.
Key Outcomes & Turnaround
82% to 96%first-pass acceptance
+11%per-encounter reimbursement
60 daysto turn it around
320/moencounters coded
Audited Practice Results
How a 2-location podiatry practice cut its denial rate by two-thirds
THE SITUATION
A 2-location podiatry practice sat at a 19% denial rate, mostly Medicare routine-foot-care and nail-debridement rejections. The denials clustered in three buckets: medical-necessity rejections on routine foot care (missing qualifying diagnosis and class findings), frequency-edit denials on nail debridement billed inside the 60-day window, and missing Q modifiers that flagged services as non-covered.
WHAT QUALIGENIX DID
We built a front-end denial-prevention layer, checking eligibility and coverage against payer LCDs before claims went out, plus a structured appeal workflow with documentation templates mapped to each denial reason.
Key Outcomes & Turnaround
19% to 6%denial rate
$68,000recovered on appealed claims
4 monthsto turn it around
2 locationspractice size
Audited Practice Results
IRF Claim Coding Built Around Your Stays
Qualigenix builds each IRF claim from the parts Medicare prices: the HIPPS code, the bill type, the diagnosis coding and the occurrence codes.
Rev Code 0024 & HIPPS
Revenue code 0024 marks a claim for payment under the IRF PPS. It appears once per claim and must carry a valid HIPPS code for the CMG.
COMPLIANCE
How We Keep IRF Billing Compliant
Qualigenix keeps IRF billing compliant by billing each stay only as the IRF-PAI and the medical record support it, and by applying Medicare's IRF coverage criteria as written. That means intensive therapy from more than one discipline, supervision by a rehabilitation physician, a weekly interdisciplinary team conference, and a facility mix that meets the 60% threshold. We review each claim for overcoding and undercoding: a missed comorbidity leaves payment unclaimed, and an unsupported CMG invites recoupment. Our coding holds a 98.6% compliance and audit pass rate, with an over- and undercoding rate under 2%. All patient data is handled in HIPAA-compliant workflows under strict security controls.
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Audit Pass Rate
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Variance Threshold
Why IRFs Choose Qualigenix
Our IRF coders read the IRF-PAI, the therapy minutes and the physician notes as one record, because Medicare's reviewers do. CMS's latest error data shows IRFs among the four largest drivers of Medicare fee-for-service improper payments.
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IMPROPER PAYMENT RATE
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QUESTIONS BUYERS ASK
Frequently Asked Questions
Qualigenix charges a percentage of collections, so the fee tracks what your facility is paid. The rate depends on discharge volume, payer mix and scope. Call 786-259-0231 to discuss your facility.
Yes. We request IRF admission authorizations from Medicare Advantage and commercial plans, track approved days, and request extensions before they run out.
Yes. We report your compliance percentage from coded diagnoses against the qualifying conditions in 42 CFR 412.29, so you can act before the review period ends.
Medicare pays IRFs one amount per discharge under the IRF prospective payment system. The IRF-PAI assessment sets the case-mix group, which is reported as a HIPPS code on revenue code 0024 and adjusted for facility factors.
We compare the HIPPS code on each claim with the transmitted IRF-PAI and the record behind it, including the impairment group and coded comorbidities, before the claim is filed.
Yes. We take over aged IRF claims and work them by payer, denial reason and ADR status. Our A/R follow-up has reduced days in A/R from 54 to 36.