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LCD
ID Number
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L22951
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LCD
Title
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Inpatient
Rehabilitation
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Contractor's
Determination Number
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L22951
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AMA
CPT / ADA
CDT Copyright Statement
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CPT codes,
descriptions and other data only are copyright 2007 American Medical
Association (or such other date of publication of CPT). All Rights
Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology,
(CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. © 2002,
2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
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CMS
National Coverage Policy
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IOM 100-02 Chpt. 1 Section 110
110 - Inpatient Hospital Stays for Rehabilitation Care
110.1 - General
Physicians generally agree on the circumstances that justify a medical or
surgical patient's hospitalization. In addition, in some cases an admission
to a rehabilitation hospital or to the rehabilitation service of a
short-term hospital can be justified on essentially the same medical or
surgical grounds. In other cases, however, a patient's medical or surgical
needs alone may not warrant inpatient hospital care, but hospitalization
may nevertheless be necessary because of the patient's need for
rehabilitative services.
Patients needing rehabilitative services require a hospital level of
care, if they need a relatively intense rehabilitation program that
requires a multidisciplinary coordinated team approach to upgrade their
ability to function. [1] There are two basic requirements that must be met
for inpatient hospital stays for rehabilitation care to be covered:
The services must be reasonable and necessary (in terms of efficacy,
duration, frequency, and amount) for the treatment of the patient's
condition; [2] and
It must be reasonable and necessary to furnish the care on an inpatient
hospital basis, rather than in a less intensive facility such as a SNF, or
on an outpatient basis. [3]
Medicare recognizes that determinations of whether hospital stays for
rehabilitation services are reasonable and necessary must be based upon an
assessment of each beneficiary's individual care needs. [4] Therefore,
denials of services based on numerical utilization screens, diagnostic
screens, diagnosis or specific treatment norms, "the three hour
rule," or any other "rules of thumb," are not appropriate.
110.2 - Preadmission Screening
Before a patient is admitted to a rehabilitation hospital for treatment, a
preadmission screening is normally done. This screening is a preliminary
review of the patient's condition and previous medical record to determine
if the patient is likely to benefit significantly from an intensive
hospital program or extensive inpatient assessment.
While preadmission screening is a standard practice in most rehabilitation
hospitals and may provide useful information for claims review purposes, the
absence of preadmission screening in a particular case is not adequate
reason for denying a claim. However, in a case where an inpatient
assessment showed that a patient clearly was not a good candidate for an
inpatient hospital program, then the presence or absence of preadmission
screening information is important in determining whether the inpatient
assessment itself was reasonable and necessary. If preadmission screening
information indicated that the patient had the potential for benefiting
from an inpatient hospital program, a period of inpatient assessment could
be covered, up to the point where it was determined that inpatient hospital
rehabilitation was not appropriate, since preadmission screening cannot be
expected to eliminate all unsuitable candidates. [5]
110.2.1 - Admission Orders
42 CFR 412.606
At the time that each Medicare Part A fee-for-service patient is admitted,
the inpatient rehabilitation facility must have physician orders for the
patient's care during the time the patient is hospitalized.
110.3 - Inpatient Assessment of Individual's Status and Potential for
Rehabilitation
CFR 412.606
Medicare Part A fee-for service beneficiaries in IRFs
are assessed by a clinician using the CMS’ patient assessment instrument
upon admission and at discharge. The CMS’ patient assessment instrument
consists of nine sections, each to collect different categories of patient
information. These categories include identification and demographic
information about the patient, medical information, and information related
to quality of care and basic patient safety. IRFs
must computerize and electronically report the patient assessment data.
In general, the admission assessment must have an assessment reference date
of day three of the IRF stay, be based upon observations done in the first
three days of the IRF stay and be completed by day 4 of the IRF stay.
The discharge assessment must have an assessment reference date that is the
actual day that one of two events occurs first: (1) the day on which the
patient is discharged from the IRF; or (2) the day on which the patient
dies. The discharge assessment is based upon observations done in the three
calendar days prior to and including the assessment reference date on the
discharge assessment. The discharge assessment must be completed by the 5th
calendar day that follows the discharge assessment reference date with the
discharge assessment reference date itself being counted as the first day
of the five calendar day time period.
In certain cases, a beneficiary may have an interrupted stay that may
affect the assessment reference dates, completion dates, and encoding date.
An interrupted stay is defined as one in which an IRF patient is discharged
from the IRF and returns to the same IRF within three consecutive calendar
days that begins with the day of discharge and ends on midnight of the
third day.
When a beneficiary has an interrupted stay, the interrupted stay must be
documented on the assessment instrument. If the interruption is less than
three calendar days, the IRF does not need to complete a new admission
assessment. However, in those cases where the patient is discharged and
returns after three consecutive calendar days, the IRF is required to
complete a new admission assessment.
110.3.1 - General
Coverage is available for inpatient assessment of a patient's potential
to benefit from an intensive coordinated rehabilitation program only if it
was reasonable and necessary to perform the assessment in the hospital.[6]
This determination is made on the basis of information available in the
patient's medical record. It is important to note that the assessment
process is not merely a paperwork review, but rather an onsite professional
review of the patient's condition by the necessary disciplines. Inpatient
assessments conducted by a rehabilitation team through examination of the
patient usually require between 3 to 10 calendar days, but on occasion may
require more. This 3 to 10 day period is often one where the patient is
receiving therapies rather than simple screening assessments. Where more
than 10 days are required, the case is carefully reviewed to ensure that
such additional time was necessary. An inpatient assessment may be covered
even if the assessment subsequently indicates that a patient is not
suitable for an intensive inpatient hospital rehabilitation program, if the
patient's condition on admission was such that an extensive inpatient
assessment was considered reasonable and necessary for a final decision to
be made on a patient's actual rehabilitation potential. Where the initial
assessment has resulted in a conclusion that the individual is a poor
candidate for rehabilitation care, coverage for further inpatient hospital
care is limited to a reasonable number of days needed to permit appropriate
placement of the patient.
The fact that an individual received therapy prior to admission to a
hospital for a rehabilitation program does not necessarily mean that the
initial assessment period was not reasonable and necessary. However, if
during a previous hospital stay an individual completed such a program for
essentially the same condition for which inpatient hospital care is now
being provided, the assessment period could be covered only if:
Some intervening circumstance rendered such an assessment reasonable and
necessary; or
The subsequent admission is to an institution utilizing techniques or
technology not previously available or not available in the first
institution.
110.3.2 - Specific Examples
After an inpatient hospital stay for rehabilitation care which resulted in
little improvement in the patient's condition, an individual who undergoes
surgery for severe contractures as a result of arthritis may require a
reassessment of rehabilitation potential in light of the surgery.
The fact that an individual has some degree of mental impairment is not,
per se, a basis for concluding that a multi-disciplinary team evaluation is
not warranted. Many individuals who have had CVAs
suffer both mental and physical impairments. The mental impairment often
results in a limited attention span and reduced comprehension with a
resultant problem in communication. With an intensive rehabilitation
program, it is sometimes possible to correct or significantly alleviate
both the mental and physical problems.
Absent other complicating medical problems, the type of rehabilitation
program normally required by a patient with a fractured hip during or after
the non-weight-bearing period or a patient with a healed ankle fracture
does not require an inpatient hospital stay for rehabilitation care.
Accordingly, an inpatient assessment is not warranted in such cases.[8] On the other hand, an individual who has had a
CVA that left them significantly dependent in the activities of daily
living (even after physical therapy in a different setting) might be a good
candidate for a more extensive inpatient assessment if the patient has
potential for rehabilitation and their needs are not primarily of a
custodial nature.
110.4 - Rehabilitation Hospital Screening Criteria
Rehabilitative care in a hospital, rather than in a SNF or on an
outpatient basis, is reasonable and necessary for a patient who requires a
more coordinated, intensive program of multiple services than is generally
found out of a hospital. A patient probably requires a hospital level of
care if they have either one or more conditions requiring intensive and
multi-disciplinary rehabilitation care, [9] or a medical complication in
addition to their primary condition, so that the continuing availability of
a physician is required to ensure safe and effective treatment. [10]
The QIOs will review rehabilitation services if
they are rendered at the inpatient facility as part of that particular
admission.
The CMS has developed a set of screening criteria to assist the QIOs in applying this level-of-care requirement. The
criteria (which are listed below) are designed to enable the QIOs to identify those cases that clearly involve a
hospital level of rehabilitative care. The QIOs
are expected to use these criteria in performing their screens of
rehabilitative hospital claims. Thus, if a case satisfies each of the
criteria, the QIO may approve the claim at the initial screening level.
However, the fact that a case fails to satisfy the criteria does not
mean that the QIO denies the claim. Rather, it only means that the QIO
refers the case to a physician reviewer for a determination as to the
medical necessity of the patient's hospitalization. [11]
These criteria set forth below are intended to be applied only at the
initial screening level (which is typically conducted by the QIO's nurse reviewer). The criteria do not apply to
cases referred to a QIO's physician reviewer. For
determinations about reasonableness, medical necessity, and appropriateness
of setting, the QIO's physician reviewer is expected
to make a determination on the basis of their knowledge, expertise and
experience, and upon an assessment of each beneficiary's individual care
needs rather than on fixed criteria.
At the initial screening, a QIO determines that the patient requires a
rehabilitative hospital level of care if all of the following screening
criteria are met. [12]
110.4.1 - Close Medical Supervision by a Physician With Specialized
Training or Experience in Rehabilitation
A patient's condition must require the 24-hour availability of a
physician with special training or experience in the field of
rehabilitation. This need should be verifiable by entries in the patient's
medical record that reflect frequent and direct, and medically necessary
physician involvement in the patient's care; i.e., at least every two to
three days during the patient's stay. This degree of physician involvement
which is greater than is normally rendered to a patient in a SNF is an
indicator of a patient's need for services generally available only in a
hospital setting.[13]
110.4.2 - Twenty-Four Hour Rehabilitation Nursing
The patient requires the 24-hour availability of a registered nurse with
specialized training or experience in rehabilitation.[13]
110.4.3 - Relatively Intense Level of Rehabilitation Services
The general threshold for establishing the need for inpatient hospital
rehabilitation services is that the patient must require and receive at
least three hours a day of physical and/or occupational therapy. (The
furnishing of services no less than five days a week satisfies the
requirement for "daily" services.) [14]While most patients
requiring an inpatient stay for rehabilitation need and receive at least
three hours a day of physical and/or occupational therapy, there can be
exceptions because individual patient's needs vary. In some instances,
patients who require inpatient hospital rehabilitation services may need,
on a priority basis, other skilled rehabilitative modalities such as
speech-language pathology services, or prosthetic-orthotic
services and their stage of recovery makes the concurrent receipt of
intensive physical therapy or occupational therapy services inappropriate.
In such cases, the 3-hour a day requirement can be met by a combination of
these other therapeutic services instead of or in addition to physical
therapy and/or occupational therapy.
An inpatient stay for rehabilitation care can also be covered even
though the patient has a secondary diagnosis or medical complication that
prevents participation in a program consisting of three hours of therapy a
day. Inpatient hospital care in these cases may be the only reasonable
means by which even a low intensity rehabilitation program may be carried
out. [15]The intermediary secures documentation of the existence and
extent of complicating conditions affecting the carrying out of a
rehabilitation program to ensure that inpatient hospital care for less than
intensive rehabilitation care is actually needed.
110.4.4 - Multi-Disciplinary Team Approach to Delivery of Program
A multidisciplinary team usually includes a physician, rehabilitation
nurse, social worker and/or psychologist, and those therapists involved in
the patient's care. At a minimum, a team must include a physician,
rehabilitation nurse, and one therapist.[16]
110.4.5 - Coordinated Program of Care
The patient's records must reflect evidence of a coordinated program,
i.e., documentation that periodic team conferences were held with a
regularity of at least every two weeks [17]to:
Assess the individual's progress or the problems impeding progress;
Consider possible resolutions to such problems; and
Reassess the validity of the rehabilitation goals initially established.
A team conference may be formal or informal; however, a review by the
various team members of each other's notes does not constitute a team
conference. The decisions made during such conferences, such as those
concerning discharge planning and the need for any adjustment in goals or
in the prescribed treatment program, must be recorded in the clinical
record.
110.4.6 - Significant Practical Improvement
Hospitalization after the pre-admission screening is covered only in those
cases where the pre-admission screening results in a conclusion by the
rehabilitation team that a significant practical improvement can be
expected in a reasonable period of time. [18]It is not necessary that
there be an expectation of complete independence in the activities of daily
living, but there must be a reasonable expectation of improvement that is
of practical value to the patient, measured against the patient's condition
at the start of the rehabilitation program. For example, a multiple
sclerosis patient's condition may have deteriorated as a result of a
secondary illness. To be restored to a level of function before the
secondary illness, the patient may require an intensive inpatient hospital
rehabilitation program. While such a program does not restore the level of
function before multiple sclerosis developed, a return to pre-secondary
illness level is considered to be a "significant practical
improvement" in the condition. In addition, a beneficiary must
classify into one of the CMG’s payable by Medicare under the IRF PPS.[19]
110.4.7 - Realistic Goals
While there may be instances where an intense rehabilitation program may
enable a Medicare patient to return to the labor market, vocational
rehabilitation is generally not considered a realistic goal for most aged
or severely disabled individuals. The most realistic rehabilitation goal
for most Medicare beneficiaries is self-care or independence in the
activities of daily living; i.e., self-sufficiency in bathing, ambulation,
eating, dressing, homemaking, etc., or sufficient improvement to allow a
patient to live at home with family assistance rather than in an
institution. [20]Thus, the aim of the treatment is achieving the
maximum level of function possible.
110.5 - Length of Rehabilitation Program
Coverage stops when further progress toward the established
rehabilitation goal is unlikely or when further progress can be achieved in
a less intensive setting. [21]In deciding whether further care can be
carried out in a less intensive setting, both the degree of improvement
that has occurred and the type of program required to achieve further
improvement must be considered. In some cases, an individual may be
expected to continue to improve under an outpatient program. There are
other situations where further improvement in the individual's ability to
function relatively independently in the activities of daily living can be
expected only if a multidisciplinary team effort is continued.
While occasional home visits and other trips into the community are factors
in determining whether continued stay in the hospital is necessary, such
excursions alone are not a basis for concluding that further hospital care
is not required. Planned home visits and trips to the community are
frequently used to test the individual's ability to function outside the
institutional setting and assist in discharge planning for the individual.
It is also important to consider how close the patient may be to the
planned end of the rehabilitation hospital stay when further progress
becomes unlikely. If a patient is within a few days of discharge, transfer
to a less intensive setting in another facility would be inappropriate even
though further progress in the hospital setting is unlikely. However, it
could be appropriate to utilize a "swing bed" arrangement, if it
exists in the same facility, for rendering necessary services to the patient
pending discharge.
When discharge or transfer to another facility is appropriate, the
cut-off point for coverage should not be the last day on which improvement
actually occurred. Rather, coverage should continue through the time it
would have been reasonable for the physician, in consultation with the
rehabilitation team, to have concluded that further improvement would not
occur and to initiate the patient's discharge.
Since discharge planning is an integral part of any rehabilitation program
and should begin upon the patient's admittance to the facility, an extended
period of time for discharge action would not be reasonable after
established goals have been reached, or a determination made that further
progress is unlikely, or that care in a less intensive setting would be
appropriate.[22]
IOM 100-04 Chpt. 3 Section 140 - Inpatient
Rehabilitation Facility Prospective Payment System (IRF PPS)
The statutory authority for the MR program includes the following sections
of the Social Security Act (the Act):
Section 1833(e) which states, in part "...no payment shall be made
to any provider... unless there has been furnished such information as may
be necessary in order to determine the amounts due such provider ...;"
Section 1842(a)(2)(B) which requires contractors to "assist in the
application of safeguards against unnecessary utilization of services
furnished by providers ...; "
Section 1862(a)(1) which states no Medicare payment shall be made for
expenses incurred for items or services that "are not reasonable and
necessary for the diagnosis or treatment of illness or injury or to improve
the functioning of a malformed body member;"
The remainder of Section 1862(a) which describes all statutory exclusions
from coverage;
Sections 1812, 1861, and 1832 which describe the Medicare benefit
categories; and
Sections 1874, 1816, 1842 which provide further authority.
42 CFR 421.100 The regulatory authority for the MR program
IOM 100-08 Chpt. 1 Section 1.1.2 - Authority
for the FI to review IRF claims
Social Security Act, Title XVIII, section 1888 [42 U.S.C. §1395ww(j)]
defines the current IRF-PPS.
Social Security Act, Title XVIII, section 1154 (a)(2)(B) defines the
utilization review requirement to review services that could be effectively
provided more economically on an outpatient basis or in an inpatient health
care facility of a different type.
Social Security Act, Title XVIII, section 1833(a)(8)(B)(i) allows payment for ancillary services and therapies
when Part A coverage is not made.
Social Security Act, Title XVIII, sections 1861(v)(1)(G)(i) and (ii) allow payment at an average SNF rate when
inpatient hospital care is not medically necessary but no post-hospital
care beds are available.
Social Security Act, Title XVIII, section 1862(a)(1)(A)
prohibits payments for services which are not medically reasonable and
necessary.
Social Security Act, Title XVIII, section 1833 (e) prohibits payment if
supporting documentation is not provided to Medicare.
42 Code of Federal Regulations (42 CFR): Sections 412.600, 412.23, 412.29,
412.25
Federal Register; Department of Health and Human Services; Centers for
Medicare and Medicaid Services; Final Rules; Dates August 7, 2001; August
1, 2003; and May 7, 2004.
Program Manual A-01-110 contains instructions for the implementation of
IRF-PPS.
Balanced Budget Act of 1997 (PL105-33, August 5, 1997), Subchapter B,
Section 4421 establishes the PPS for IRF.
Omnibus Budget Reconciliation Act of 1987, (Pub 100-203) Section 4094.
Medicare Benefit Policy Manual (Pub 100-2), Chapter 1, Section 110.
Medicare Claims Processing Manual (Pub 100-4), Chapter 3, Section 140.
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Primary Geographic
Jurisdiction
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New
Jersey
Tennessee
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Secondary Geographic
Jurisdiction
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Mississippi
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Oversight
Region
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Region IV
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Original
Determination Effective Date
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For services performed
on or after 08/01/2007
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Original
Determination Ending Date
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Revision
Effective Date
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Revision
Ending Date
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Indications
and Limitations of Coverage and/or Medical Necessity
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This policy defines
the limitations of Medicare coverage for Inpatient Rehabilitation services
provided in free-standing and “excluded” rehabilitation units [SSA §1886 (d)(1)(b)]. The medical necessity for the provision of
those services in an inpatient rehabilitation facility (IRF) is discussed.
A distinction exists between medical necessity for individual therapy
services, which may be reasonable and necessary in a particular case, and
the medical necessity of providing those services in an inpatient
rehabilitation environment (“medical appropriateness”). The Inpatient
Rehabilitation policy addresses only the medical appropriateness of
inpatient care following an admission (or transfer) to an IRF. It does not
address inpatient rehabilitation provided as part of a medical-surgical
stay in an acute care setting, nor does it address the medical necessity of
specific therapeutic services when they are considered individually.
The coverage elements of the policy are organized into three sections:
- The Policy in Briefsection provides an
executive summary of the indications and limitations.
- The General Indicationssection presents criteria
for assessing the medical necessity of an inpatient rehabilitation
stay as it applies to the individual patient. It also cross-references
external regulatory requirements.
- The Level of Evidence section
applies the general criteria to specific clinical situations, focusing
on the level of evidence required to support medical necessity and
medical appropriateness in those situations./li>
The Utilization Guidelines section of the LCD discusses clinical categories
with examples of the types of conditions and level of impairment that are
envisioned as consistent with the category. In most cases the resultant
disability is not discussed; the disability or collection of disabilities
that necessitates inpatient rehabilitation is best considered at the level
of the individual patient. The utilization guidelines are neither
comprehensive nor absolute but are expected to serve as benchmarks. Most
significantly, though, the Utilization Guidelines are expected to serve as
benchmarks of the level of evidence that is expected to support the
decision to admit. In no way should a patient be considered as ineligible
for inpatient rehabilitation solely because of the diagnosis or degree of
impairment. However, a patient with a medical diagnosis that is typically
associated either with spontaneous improvement or a focal impairment (or,
conversely, a lack of rehab potential) requires a very high level of
evidence (documentation) in the medical record to conclusively demonstrate
that an inpatient level of care is required and a less intensive SNF or
outpatient setting would not adequately meet the rehabilitation needs.
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The Policy in Brief
This policy defines the limitations of Medicare coverage for Inpatient
Rehabilitation services provided in free-standing and “excluded” rehabilitation
units. The policy addresses only the medical appropriateness of inpatient
care following an admission (or transfer) to an IRF. It does not address
the medical necessity of specific therapeutic services when they are
considered individually.
Due to the unique considerations of each individual inpatient admission,
Riverbend does not consider the automated review of cases to be
reasonable. Medical necessity guidelines delineated in this policy must
therefore always be applied to a specific case based on the documented
unique circumstances of that case. However, in the absence of markedly
extenuating circumstances, it can be expected that these medical
necessity guidelines are applicable. This policy uses the concept of
“Level of Evidence” to distinguish those types of cases that would
typically be expected to be considered appropriate based on routine
documentation from those cases in which the documentation would be
expected to specifically demonstrate unusual circumstances or
atypical conditions.
Inpatient Rehabilitation will be considered to be both medically
necessary and medically appropriate if a patient meets BOTH of the
following preconditions:
- Precondition A: The patient MUST have a
reasonable expectation of improvement. AND
- Precondition B: The patient MUST have
realistic goals for the inpatient stay.
AND the patient meets at least ONE of the following four conditions:
- Condition 1: Medical Supervision. The
therapy cannot be provided in a less intensive setting due to a need
for frequent physician assessment or intervention in response to a
significant risk of rapid change in physical or medical status OR
- Condition 2: Rehabilitation Nursing.
The therapy cannot be provided in a less intensive setting due to a
need for 24-hour a day access to a registered nurse (RN) OR
- Condition 3: Intense Rehabilitation
Services. The patient requires either three hours per day of skilled
therapy on a daily basis or, in the instance of a medical condition
that limits participation, an equivalent amount of combined therapy
and other nursing or orthotic
interventions related to their need for rehabilitation, or requires
specialized equipment that is not available on an outpatient basis
OR
- Condition 4: Multidisciplinary Team
Approach. The patient requires the active and ongoing therapeutic
intervention of at least two disciplines (physical therapy, nursing,
occupational therapy, speech therapy, psychology/social work, and
prosthetics/orthotics), one of which must
be a therapy, and the disciplines must have a need for frequent
interactions (tight coordination) in order to provide appropriate
medical (rehabilitative) care.
The above indications for Inpatient Rehabilitation define medical
necessity in all specific instances, but there are combinations of
clinical situations (impairment, disability, disease and environment)
that define cases that typically require an inpatient venue, that typically
do not require an inpatient venue, and that typically MAY require
an inpatient venue when certain conditions exist. The significance of the
grouping is as follows:
1. Any case MAY be appropriate for inpatient rehabilitation.
2. A case of a type that is typically appropriate for inpatient should be
presumed to require inpatient rehabilitation, assuming that other
conditions such as capability of improvement are met, unless the medical
record clearly and unambiguously shows that services can be provided on a
less intensive basis.
3. A case of a type that can be typically performed in a less intensive
setting should not be presumed to be appropriate for inpatient
rehabilitation; rather, the medical record should clearly demonstrate
that the less intensive setting of a SNF or the non-residential
outpatient setting would not meet the clinical needs of this particular
patient and would be less beneficial.
4. A case of the type that may have highly variable rehabilitation needs
should not be presumed to require inpatient rehabilitation but should not
require an unusual level of evidence to support a determination that a
less intensive setting is inappropriate. However the documentation should
still make a compelling case for the inpatient venue as opposed to a less
intensive setting or a continuation of an acute inpatient stay.
The following categories of patients are presumptively considered
appropriate for inpatient rehabilitation. Medical necessity should be
apparent from the simple descriptive narrative in the medical record.
· Major Stroke
· Major Trauma
· Brain Injury
· Significant Spinal Cord Injury
· Major Burn
Many categories of patients are highly variable in their need for an
inpatient venue. The documentation must make a reasonable case for the
inpatient venue as opposed to a less intensive setting or a continuation
of an acute inpatient stay. This is considered to be a moderate level of
evidence. These cases include:
· Major Focal Trauma
· Peripheral Nerve Pathology
· Bilateral Knee Replacement
· Hip Fracture
· Amputation
· Auto-immune Disease with Focal Pathology
· All Others: Any category of patient not elsewhere described
Patients in the following categories may still require inpatient
rehabilitation but this would be much less common. If inpatient
rehabilitation is required, it is expected that the medical records of
these patients must clearly, explicitly and unambiguously make a
compelling case for the necessity of inpatient rehabilitation. This is a
high level of evidence and indicates the situations in which additional
effort and documentation may be required. These cases include:
· Auto-immune Disease with Diffuse Pathology
· Minor Trauma, including Compression Fractures
· TIA and Possible Neurologic Events
· Single Joint Replacement
· Post-operative and General Debility
· Coma Stimulation, Cognitive Rehabilitation
· Cardiac, Pulmonary and Pain Rehab
All patients are potential candidates for inpatient rehabilitation. It is
the unique combination of impairments, disability, pathology and
environment that establishes the medical necessity for an inpatient
venue.
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General Indications for Inpatient Rehabilitation
Regulatory Basis for Inpatient Rehabilitation
There is a regulatory limitation on coverage for inpatient rehabilitation
that is based on the Social Security Act and published Medicare
regulations. These regulations are not part of a Local Coverage Decision
(LCD). Rather, they set limits on coverage that Local Coverage Decisions
cannot exceed. These regulations are referenced in the CMS National
Coverage Policy section (above) and discussed in the companion article (Related
Documents section, below.)
Due to the unique considerations of each individual inpatient admission,
Riverbend does not consider the automated review of cases to be reasonable.
Medical necessity guidelines delineated in this policy must therefore always
be applied to a specific case based on the documented unique circumstances
of that case. However, in the absence of markedly extenuating
circumstances, it can be expected that these medical necessity guidelines
are applicable. This policy uses the concept of “Level of Evidence” to
distinguish those types of cases that would typically be expected to be
considered appropriate based on routine documentation from those cases in
which the documentation would be expected to specifically
demonstrate unusual circumstances or atypical conditions.
Medicare screening criteria do not create an absolute threshold between
inpatient rehabilitation and a less intensive venue except in so far as a
patient that simultaneously meets all criteria should be deemed appropriate
for inpatient rehabilitation. Nonetheless those criteria individually
create an established benchmark that has been in common usage for many
years. Those criteria are:
1. Medical Supervision.
2. Rehabilitation Nursing.
3. Intense Rehabilitation Services.
4. Multidisciplinary Team Approach.
5. Probability of Practical Improvement.
Medical Necessity
Whereas screening criteria describe appropriateness based on meeting
all five criteria combined with the establishment of reasonable goals,
Medicare regulations do not prohibit coverage in other broader
circumstances. Riverbend therefore defines the definitive medical
necessity criteria for coverage of inpatient care as a medical
rehabilitation requirement for any one of the key areas of intensive
service:
Inpatient Rehabilitation will be considered to be both medically
necessary and medically appropriate if a patient meets BOTH of the
following preconditions:
- Precondition A: The patient MUST have a
reasonable expectation of improvement. AND
- Precondition B: The patient MUST have
realistic goals for the inpatient stay.
AND the patient meets at least ONE of the following four conditions:
- Condition 1: Medical Supervision. The
therapy cannot be provided in a less intensive setting due to a need
for frequent physician assessment or intervention in response to a
significant risk of rapid change in physical or medical status OR
- Condition 2: Rehabilitation Nursing.
The therapy cannot be provided in a less intensive setting due to a
need for 24-hour a day access to a registered nurse (RN) OR
- Condition 3: Intense Rehabilitation
Services. The patient requires either three hours per day of skilled
therapy on a daily basis or, in the instance of a medical condition
that limits participation, an equivalent amount of combined therapy
and other nursing or orthotic interventions
related to their need for rehabilitation, or requires specialized
equipment that is not available on an outpatient basis OR
- Condition 4: Multidisciplinary Team
Approach. The patient requires the active and ongoing therapeutic
intervention of at least two disciplines (physical therapy, nursing,
occupational therapy, speech therapy, psychology/social work, and
prosthetics/orthotics), one of which must
be a therapy, and the disciplines must have a need for frequent
interactions (tight coordination) in order to provide appropriate
medical (rehabilitative) care, OR
Special Assessment Condition: An Inpatient Rehabilitation stay will also be
considered to be both medically necessary and medically appropriate for the
purpose of performing an inpatient assessment if and only if an assessment
in an outpatient, SNF, acute inpatient or other non-IRF environment could
not be reasonably expected to provide sufficient information to make a
determination regarding the patient's potential to benefit from an
intensive coordinated inpatient rehabilitation program.
Specific criteria associated with the above conditions include:
Precondition A: The patient MUST have a reasonable expectation of
improvement. Hospitalization after the initial assessment is covered only
in those cases where a significant practical improvement can be expected in
a reasonable period of time, i.e. a reasonable expectation of improvement
that will be of practical value to the patient, measured against his
condition at the start of the rehabilitation program. Vocational
rehabilitation is generally not considered a realistic goal; the most
realistic rehabilitation goal for most Medicare beneficiaries is self-care
or sufficient improvement to allow a patient to live at home with
assistance rather than in an institution. This practical improvement must
also be expected to occur within a predictable and reasonable period
of time. Both the anticipated extent of improvement and the expected time
requirement should be defined at the time of admission although it is
obvious that these projections may change as the clinical course evolves.
Precondition B: The patient MUST have realistic goals for the
inpatient stay. The goals for the inpatient stay must be matched to the
expectations of Precondition A. The goals must be measurable and must be
tied to functional, physiological or medical outcomes that will be of
practical value to the patient. They must also be realistic, associated
with reasonable timeframes, and appropriate to the inpatient venue. Goals
that significantly exceed typical goals for similar functional impairments
(for example, a goal of ambulating ½ mile) are not
considered realistic in the inpatient venue even though they may be
perfectly appropriate long-term goals.
Condition 1: Medical Supervision.
If medical appropriateness is based on the medical supervision requirement,
the patient must demonstrate a need for frequent physician assessment or
intervention due to a significant risk of rapid change in physical or
medical status. Note, however, that when a patient is transferred from an
acute care facility, all acute medical conditions are covered under a
Diagnostic Related Group reimbursement (DRG) and all care for the
acute medical condition is reimbursed under that DRG. Although there is no
single point at which "acute recovery" stops and
"rehabilitation" begins, medical requirements of the acute
recovery phase of an illness do not justify inpatient rehabilitation.
Rather it is the rehabilitation needs, evaluated in light of the medical
needs of co-morbid or complicating conditions, which constitute medical
necessity for an inpatient rehabilitation stay. In other words, if the
patient must be frequently assessed in order to manage treatment of the
medical condition, this justifies an acute inpatient stay not an IRF stay.
If the patient must be frequently assessed in order to tailor the
rehabilitation protocol in response to rapidly changing medical or
rehabilitation needs, this justifies an IRF stay. Frequent assessment or
supervision is interpreted to mean a direct physician assessment and
possible intervention every two to four days.
Condition 2: Rehabilitation Nursing.
The therapy cannot be provided in a less intensive setting due to a need
for 24-hour a day access to a registered nurse (RN). To meet this
condition, the medical record must demonstrate that:
1. the patient requires the care of an RN for the purpose of furthering the
rehabilitative effort as opposed to meeting the medical needs of any
underlying or comorbid medical conditions AND
2. the patient requires that care throughout the
day and night AND
3. the required nursing services are not available
in a SNF.
A requirement for an RN level of nursing care based on the underlying
medical condition is appropriately an indication for acute hospital
admission, a long term care facility stay, SNF placement or home nursing
care. Patient and family education provided by registered nurses is a real
requirement but does not necessitate 24 hour a day access to the RN.
Condition 3: Intense Rehabilitation Services.
If the medical appropriateness is based on a need for intense
rehabilitative services, the patient must require:
a) three hours per day of skilled therapy on a daily basis OR
b) in the instance of a medical condition that limits participation, an
equivalent amount of combined therapy and other nursing or orthotic interventions related to the need for
rehabilitation, OR
c) a need for specialized equipment at such a frequency and duration as to
make it impractical for the patient to use the equipment at an outpatient
facility.
Treatments, therapies and equipment used to establish medical necessity
under any of the clauses listed above must be consistent with the nature
& severity of the illness or injury, and consistent with accepted
standards of medical practice.
In determining the three hour total, the services must be those that can
typically be provided only by a licensed physical therapist, occupational
therapist, physical or occupational therapy assistant under the direct
supervision of a licensed therapist, or speech-language pathologist. This
LCD is not defining the practitioners; it is only defining the services
that are considered to be significant in defining the intensity of service.
Services that are typically provided by nurses, by respiratory therapists,
by recreational therapists, by massage therapists, by therapy aides or by
non-PMR physicians are examples of services that are not considered to
contribute to the intense rehabilitative care, although they may be both
medically appropriate and provided during the IRF stay. Although it would
typically be much less than this, no more than one hour of modalities per
day, interspersed with the active therapy, will be considered to contribute
to the three hours of intense therapy, and then only if the administration
of the modalities requires the skills of therapist.
It is not enough that intensive (three hours per day) therapy is provided;
that level of intensity must also be required (medically necessary) AND it
must be both reasonable and necessary to provide the care to a resident as
opposed to a day patient. Three hours per day would not typically be
considered to be medically necessary if:
1. Patients with similar impairments can be typically treated with less
than three hours per day, or
2. Patients with similar pathology can be typically treated with less than
three hours per day, or
3. Patients with similar impairments typically do not require therapy five
days per week, or
4. Patients with similar pathology typically do not require therapy five
days per week, and
Residential status would not typically be considered to be medically
necessary if patients with similar disabilities can be typically treated in
an outpatient (ambulatory or “day stay”) environment.
HOWEVER, IF the medical record supports a unique situation that would
demand the higher level of intensity or frequency OR IF evidence-based
medical literature supports better long term outcomes with the higher level
of intensity or higher frequency, THEN intensive (three hour per day)
therapy would be considered medically necessary regardless of prevailing or
alternate practice patterns.
As a practical matter, it is unusual that a single discipline is needed at
the level of three hours a day five days per week. (C.f. multidisciplinary
care, below.) If the entire intensity condition (three hours daily) is met
by a single discipline, it is expected that the medical record would
clearly show that this level of intervention was medically necessary and
inappropriate for a SNF or outpatient venue.
In determining an equivalent intensity in the absence of three hours of
formal therapy, consideration will be given to supportive and restorative
care only when that care is essential to get the patient to the point at
which intensive (three hour daily) is tolerated AND the preparatory care
cannot be provided in a less intensive environment. It is expected that
this requirement will be clearly supported by the medical record.
In determining the need for specialized equipment in the absence of three
hours of formal therapy, it is expected that the patient requires the
equipment in order to progress to the point that intensive (three hour
daily) will be tolerated and that this requirement is clearly supported by
the medical record.
Condition 4: Multidisciplinary Team Approach.
A multidisciplinary team must include, at a minimum, a physician,
rehabilitation nurse and one therapist. The patient's records must reflect
evidence of a coordinated program that includes joint involvement in
evaluation and decision-making and must also show the medical necessity of
that coordination.
1. The patient must require the active and ongoing therapeutic intervention
of at least two disciplines (physical therapy, nursing, occupational
therapy, speech therapy, psychology/social work, and prosthetics/orthotics), one of which must be a therapy, AND
2. the coordination between the disciplines must
be sufficiently tight to require frequent formal (biweekly) meetings and
informal (ongoing or every few days) communications in order to coordinate
therapeutic interventions, AND
3. it must be apparent from the medical record that the tight coordination
was needed to benefit the patient, i.e. to frequently adjust the plan of
care of one discipline in response to the assessment or treatment of the
second discipline, or to create a joint plan that coordinates the
interventions in order to optimize benefit or minimize stress to the
patient.
As a practical matter, it is unusual that tightly coordinated
multidisciplinary care is needed at the level of less than three hours a
day five days per week. (C.f., intensive rehabilitation above.) If the
multidisciplinary condition is met through the provision of less than three
hours daily, it is expected that the medical record would clearly show that
this level of coordination was medically necessary and unattainable or
inappropriate in a SNF or outpatient venue.
In considering the requirement for coordinated multidisciplinary therapy,
two disciplines (such as physical therapy (PT) and occupational therapy
(OT) or PT and nursing) are required only if each discipline brings a
unique skillset to the treatment regimen.
Treatment that, in other circumstances, is typically or frequently provided
by a single discipline is not considered multidisciplinary.
Special Assessment Condition: An Inpatient Rehabilitation stay will
also be considered to be both medically necessary and medically appropriate
for the purpose of performing an inpatient assessment if and only if an
assessment in an outpatient, SNF, acute inpatient or other non-IRF
environment could not be reasonably expected to provide sufficient
information to make a determination regarding the patient's potential to
benefit from an intensive coordinated inpatient rehabilitation program.
1. An assessment to determine a requirement for inpatient level of care
does not require an inpatient setting. These assessments can be conducted
at the sending facility or in an outpatient setting.
2. An assessment to determine the capability of the patient for tolerating
intensive rehabilitation MAY occasionally require an intensive evaluation
during a trial of therapy in an inpatient environment. In this instance the
medical record should clearly document the reason for the inpatient
assessment and support its necessity. A pre-admission assessment is almost
always considered reasonable and necessary unless it repeats a recent
evaluation or a conclusion of inappropriateness should have been apparent
on the basis of referral information. However an inpatient assessment for
possible inpatient rehabilitation will be considered to be not medically
necessary if the condition precipitating the assessment typically does not
require inpatient rehabilitation and the medical record does not clearly
identify a compelling reason to believe otherwise.
Requirement for SNF Level of Care: A determination that the patient
is not yet at a level of self-care to live alone is NOT a factor in the
determination of a need for an IRF level of care. Patients who require an
inpatient rehabilitation stay based on an intensity
or multidisciplinary requirement may need that stay in order to improve
their ability to function independently, but this determines the need for
rehabilitation therapy not the need for the inpatient venue. Conversely, a
determination that a patient is not yet at a level of self-care to live
alone IS a factor in the determination of a need for SNF placement, as long
as there is also a requirement for skilled services on either a medical or
rehabilitative basis. In other words, a patient who needs intensive
inpatient multidisciplinary care is appropriate for an IRF regardless of
whether or not he is functionally capable of going home. A patient who is
not capable of going home but does not require intensive multidisciplinary
care is appropriate for a SNF and can receive skilled services there.
III. Application of General Principles to Specific Diseases: Level of
Evidence.
There is a limited collection of peer-reviewed literature comparing the
relative effectiveness of inpatient rehabilitation with intensive
outpatient rehabilitation or SNF rehabilitation in the high level resource
utilization groups. However it is clearly Congress’ statutory and CMS’
regulatory intent to permit those patients requiring intensive
rehabilitation to receive it in an inpatient venue but to also direct all
patients to the least intensive and most cost effective level that will
meet their medical needs. In those few instances where controlled trials
exist, that level of evidence is considered definitive. In the remainder of
clinical scenarios, Riverbend reiterates that it is the unique combination
of circumstances that determines medical appropriateness in a given
situation; patients should not be included or excluded solely on the basis
of diagnosis, impairment, disability, age, comorbidity,
living environment or any other screening criterion.
The need for inpatient rehabilitation should be determined first and
foremost by the impairment and disability, or limitation of activity or
participation. The International Classification of Functioning, Disability
and Health or other comparable taxonomy may be valuable in categorizing or
reporting the target of the therapeutic intervention. However, since all
IRF medical appropriateness determinations will be based on the entire
medical record rather than an encoded abstract, the complete documentation
of the impairment and disability in the assessment is much more important
than the category into which the impairment falls. This is the primary
reason why specific ICF codes are not listed for either approval or
disapproval.
The need for an IRF stay is determined secondly by the probability of
improvement with treatment. This is in turn determined both by the specific
impairment and by the pathology (disease) that underlies it. However,
rehabilitation needs overall must also be considered in light of the
probability of similar recovery with less intensive or self-directed care;
medical necessity only exists when the intensive intervention is clearly or
probably superior to the less intensive option. The probability of recovery
(prognosis) is also driven primarily by the underlying pathology. Once
again, though, since all IRF medical appropriateness determinations will be
based on the entire medical record rather than an encoded abstract, the
complete documentation of the pathology in the assessment is much more
important than the disease category into which the pathology falls. This is
the primary reason why specific ICD9 codes are not listed for either
approval or disapproval.
The General Indications for Inpatient Rehabilitation define medical
necessity in all specific instances, but there are combinations of clinical
situations (impairment, disability, disease and environment) that define
cases that typically require an inpatient venue, that typically
do not require an inpatient venue, and that typically MAY require an
inpatient venue when certain conditions exist. The significance of the
grouping is as follows:
5. Any case MAY be appropriate for inpatient rehabilitation.
6. A case of a type that is typically appropriate for inpatient should be
presumed to require inpatient rehabilitation, assuming that other conditions
such as capability of improvement are met, unless the medical record
clearly and unambiguously shows that services can be provided on a less
intensive basis.
7. A case of a type that can be typically performed in a less intensive
setting should not be presumed to be appropriate for inpatient
rehabilitation; rather, the medical record should clearly demonstrate that
the less intensive setting of a SNF or the non-residential outpatient
setting would not meet the clinical needs of this particular patient and
would be less beneficial.
8. A case of the type that may have highly variable rehabilitation needs
should not be presumed to require inpatient rehabilitation but should not
require an unusual level of evidence to support a determination that a less
intensive setting is inappropriate. However the documentation should still
make a compelling case for the inpatient venue as opposed to a less
intensive setting or a continuation of an acute inpatient stay.
These situations could be grouped either by impairment, by disability, by
pathology or by some other combination of common characteristics. PM&R
physicians are typically fully conversant with IRF standards, though; it is
referring physicians who benefit most from a screening taxonomy that
provides insight into why an IRF might redirect a particular patient to a
less intensive setting. Since non-physiatrists are most conversant with a
classification based on pathology, this grouping is retained. In order to
emphasize that the underlying pathology is useful in establishing general
expectations but cannot be used to allow blanket approvals or denials, the
discussion of the level of evidence expected to support a given category of
patients is considered to be a Utilization Guideline and can be found in
that section. It is emphasized that any patient, regardless of the etiology
of the impairment and disability, may be appropriate for inpatient
rehabilitation if the inpatient conditions are met, the disability is not
expected to resolve with the resolution of the underlying pathology, and
the documentation clearly supports the requirement for the inpatient care.
From a policy standpoint, certain categories of patients are presumptively
considered appropriate for inpatient rehabilitation. Medical necessity
should be apparent from the simple descriptive narrative in the medical
record. A low level of supporting evidence is therefore required to support
medical necessity. These cases include:
· Major Stroke
· Major Trauma
· Brain Injury
· Significant Spinal Cord Injury
· Major Burn
Many categories of patients are highly variable in their need for an
inpatient venue. Medical necessity may not be apparent from the simple
descriptive narrative in the medical record. Admitting physicians should
pay careful attention to cases in these categories and utilization review
committees should consider them to be their bread and butter. Many of these
cases will be appropriate for inpatient rehabilitation but many will also
be appropriate for, at one end, a less intensive setting or, at the other
extreme, a delay in admission until the episode of acute inpatient care has
been completely addressed. The documentation must make a reasonable but
explicit case for the inpatient venue as opposed to a less intensive
setting or a continuation of an acute inpatient stay. This is considered to
be a moderate level of evidence. These cases include:
· Major Focal Trauma
· Peripheral Nerve Pathology
· Bilateral Knee Replacement
· Hip Fracture
· Amputation
· Auto-immune Disease with Focal Pathology
Some categories of patients are typically but not always treated in less
intensive settings. Patients in these categories may still require
inpatient rehabilitation but this would be much less common. If inpatient
rehabilitation is required, it is expected that the medical records of
these patients must clearly, explicitly and unambiguously make a compelling
case for the necessity of inpatient rehabilitation. In other words, both
the physician and the facility are expected to explicitly evaluate the need
for inpatient care since other options are frequently available. If those
other options are considered and rejected as inappropriate, the medical
record must clearly document that they were considered and the rationale
for the rejection. Implicit evidence is acceptable in other categories; in
these groupings an explicit rationale is required and must be supported by
the facts of the case. This is a high level of evidence and indicates the
situations in which additional effort and documentation may be required.
These cases include:
· Auto-immune Disease with Diffuse Pathology
· Minor Trauma, including Compression Fractures
· TIA and Possible Neurologic Events
· Single Joint Replacement
· Post-operative and General Debility
· Coma Stimulation, Cognitive Rehabilitation
· Cardiac, Pulmonary and Pain Rehab
A complete discussion of Levels of Evidence is included in the Utilization
Guidelines section of this policy.
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Coverage
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Hospital Care
(Inpatient)
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