IRF vs. SNF Criteria Card
A one-page reference for therapists and case managers on what has to be true for acute inpatient rehab or subacute rehab to be approved, and what the therapy note needs to show to get it there.
- Audience
- Acute care therapists, case managers
- Setting
- Discharge planning, rounds
- Format
- Reference card + EHR template
- Pairs with
- Speak MD, MNCR rounds
The problem
The right recommendation, denied on paperwork
Therapists recommend acute rehab every day for patients who clearly need it. Then the referral stalls: the physician isn't sure the patient qualifies, or the insurer reads the therapy note and finds nothing that proves intensive rehab is necessary.
The rules for each setting are specific, but they're spread across federal regulations, payer policies and case management know-how. Most therapists learn them one denial at a time. This card puts them on one page and builds them into the note itself.
The project · IRF vs. SNF card
The card
Side by side
What has to be true at admission under traditional Medicare.
| IRFAcute inpatient rehab | SNFSubacute rehab | |
|---|---|---|
| Therapy | Ongoing therapy from multiple disciplines (PT, OT, speech or prosthetics/orthotics); one must be PT or OT | Daily skilled care: skilled nursing 7 days a week or therapy 5 days a week |
| Intensity | About 3 hours a day, 5 days a week, or 15 hours over 7 days in well-documented cases | No set daily therapy minimum |
| Expected gains | Able to actively participate and expected to make measurable functional gains in a reasonable time | Improvement isn't required; skilled care to maintain function or slow decline can be covered |
| Physician | Rehab physician face-to-face visits at least 3 days a week | Physician certifies that SNF-level care is needed |
| Hospital stay | No minimum inpatient stay | At least 3 inpatient days, not counting discharge day; observation days don't count. Admit usually within 30 days of discharge |
| Team | Coordinated interdisciplinary care with regular team conferences | Medicare-certified facility |
| Paperwork | Preadmission screening within 48 hours before admission; plan of care within the first 4 days | Physician certification and skilled-need documentation |
Medicare Advantage and commercial plans often waive the 3-day hospital stay for SNF, but usually require prior authorization for both IRF and SNF. That makes the therapy note the deciding document.
Quick decision guide
Four questions before rounds
If the answer to any of these is no, IRF is unlikely to be approved yet. Look at SNF, home health or outpatient, and re-check as the patient progresses.
- Does the patient need two or more disciplines, including PT or OT?No → SNF / HHName each discipline and give a one-line reason.
- Can they tolerate about 3 hours of therapy a day?No → SNFUse what you observed: active minutes, rest breaks, vitals response.
- Are measurable functional gains expected in a reasonable time?No → SNFA high prior level of function and a trend in assist levels make the case.
- Do their medical needs call for close rehab physician oversight?No → SNFThis is often what separates IRF from SNF. Ask the hospitalist if you aren't sure.
- All yes: recommend IRF and document each one.
Documentation that gets approved
What the therapy note has to show
Checklist
- PT and OT needs, plus a third discipline such as speech where it applies
- Tolerance for about 3 hours of therapy a day, with observed activity tolerance and participation
- Measurable progress or clear potential: assist levels, trends and specific functional goals
- High prior level of function and a realistic plan to return home
- Medical needs that require close physician oversight
Weak vs. strong wording
"Patient tolerated treatment well" is one of the most common phrases in therapy notes and one of the most common reasons for denial, because it gives a reviewer nothing to measure.
Built into the EHR
The criteria live in the note, not on a separate card
A "Rehab discharge recommendation" section in the OT/PT note template prompts for each criterion as the therapist writes. In an EHR this can start as a therapist's personal text shortcut and later become a department template built by the hospital's EHR analysts.
The same section produces a 30-second summary for the hospitalist, written in physician language, so no one retypes it for rounds or the referral packet.
- MetPT + OT + SLP needed
- MetTolerating ~3 hrs/day
- MetMeasurable gains expected
- Not yetPhysician oversight need documented
Result
How it would be measured
Measures planned for a pilot with rehab and case management.
- IRF denialsDenials citing documentation, before vs. after the template
- Time to referralHours from therapy recommendation to referral sent
- Complete notesShare of IRF recommendations with every criterion filled
- Retyping removedCase manager time spent rebuilding therapy details for packets
Sources: CMS IRF compliance guidance (cms.gov), 42 CFR 412.622, and the Center for Medicare Advocacy SNF coverage guide. Rules change, so check current CMS guidance and each payer's criteria before using this in practice. The EHR template would be built with the hospital's EHR team, rehab leadership and case management.