This notice is a reissue of the Provider Notice 04-034.

Background:

Medicare coverage regulations stipulate that to be paid by Medicare, health care services must be considered “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”  The Social Security Act 1862 (a)(1)(a) prohibits payment for services that are not medically reasonable and necessary.  The Social Security Act 1833 (e) prohibits payment if sufficient supporting documentation is not provided to Medicare.  Section 1886 (j) defines IRF payment.  The Pub 100-2, Section 110 defines inpatient hospital stays for rehabilitation.  The purpose of this article is to discuss and further clarify these guidelines.

Preadmission Screening:

Preadmission screening is usually completed before a patient is admitted to the IRF.  Information is gathered to determine if the patient will benefit significantly from an intensive, multidisciplinary, inpatient hospital stay.  If, after admission to the IRF, the admission assessment reveals that the patient is not a good candidate for an inpatient hospital program, then the preadmission screening may be reviewed to determine if it supports the initial assessment period as reasonable and necessary.

Medical Necessity:

According to the Pub 100-2, 110.1, Inpatient Rehabilitation Facility services “must be reasonable and necessary (in terms of efficacy, duration, frequency, and amount) for treatment of the patient’s condition; 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.”   When Fiscal Intermediary (FI) clinicians analyze a medical record, consideration is given to the patient’s medical, surgical, rehabilitation needs, and functional impairments.  A determination will be made whether this Inpatient Rehabilitation Facility (IRF) stay is reasonable and necessary at this point in time for this unique patient. 

The medical record must document that the planned treatment in the IRF will reasonably be expected to result in measurable function improvement.

Some of the criteria used to measure medial necessity include:

• The patient requires twenty-four hour availability of a physician with special training in the field of rehabilitation.  The medical record shows assessment and intervention of the physician at least every two to three days
• The patient requires twenty-four hour availability of a Registered Nurse with training or experience in rehabilitation
• The patient’s condition requires skilled intervention for at least 3 hours per day, or if less, the medical record shows that an intense inpatient rehabilitation need exists, however, significant complications permit only a lower level of rehabilitation to occur.  If rehabilitation must be discontinued due to new acute medical complications or destabilization of a previously stabile condition, a transfer to an acute care setting should be considered.
• The skilled services required are diverse and complex, requiring a coordinated multidisciplinary approach.  Skilled services are defined as those that require attendance of professional clinical staff.  Skilled services are of a complexity that cannot be easily taught to a patient or family member for independent performance.  The multidisciplinary case conferencing must be well documented in the patient’s medical record.  Communication between disciplines is essential for solving complex physiological problems and functional challenges
• A good probability exists for measurable functional improvement, within a reasonable period of time.  Anticipated results are documented in the medical record using measurable goals and established time frames for meeting these goals.  Medicare does not cover vocational goals, or job retraining.  Achievable self-care goals are appropriate in order to enable the patient to perform independently or with limited assistance from significant others, thus eliminating the need for expensive, long term inpatient care

Case Examples:

(Note:  These are simplified, short examples, which include some pertinent observations for discussion.  Complex medical review requires submission of the requested documentation from an actual medical record after services are performed for a unique patient.)

Case One

Mrs. B. is an obese 78-year-old female who had a total right knee arthroplasty two days ago.  She has a history of osteoarthritis, insulin dependent diabetes mellitus onset in 2001, and GI bleeding associated with NSAID use.  She exhibits weakness and debilitation, has moderate pain control issues, and requires assistance with wound care due to poor eyesight and numbness in her fingers.  Because she has lacked motivation for self-care in the past, and her daughter works full time, her physician orders physical therapy daily for the first week, and an occupational therapy evaluation.  Are Inpatient Rehabilitation Facility Services reasonable and medically necessary for Mrs. B.?

Answer:

The average length of stay in the acute care facility is 3-4 days for a single knee arthroplasty; patients usually going directly home after this time.  Occasionally, patients may require home health follow up or a short SNF admission.  Mrs. B’s clinical team determines that in this case, the patient will benefit from skilled assessment of her surgical wound, assistance with medication and pain management, as well as the services of a physical therapist for gait training and strengthening.  An evaluation by an occupational therapist is also indicated for the assessment of her home environment, device needs, and ability to perform activities of daily living (ADLs). She will also need some assistance with bathing and meal preparation.

Mrs. B. is appropriately treated in a less intensive setting.  She meets the homebound criteria for home health services (unable to drive, mobility is difficult, she will leave her home infrequently, and only for short periods due to the considerable and taxing effort required).  The required nursing care is estimated at 1 ½ hr/day 3 times per week for dressing changes, wound assessment, medication management, and lab draws.  Physical Therapy is tolerated for 1 hr/day for the first week and then frequency will be reassessed.  Occupational Therapy is ordered 1 hr/day, 2 times/week.  Unskilled care for a daily bath is arranged by the HHA, and a consult for meals on wheels is initiated.  If the home setting is unsuitable or unsafe for home care, a short SNF admission may be considered.

Case Two

Mr. W. is a 74-year-old Medicare beneficiary who was involved in a motor vehicle accident.  He sustained head trauma, a fractured mandible and bilateral lower extremity fractures.  His health history includes CAD, and angina controlled with medication.  Prior to the accident he was stable and lived independently.  His physician is concerned about cognitive changes, depression, and significant weight loss after his 15-day stay in the acute care facility, in addition to his change in mobility.  Are Inpatient Rehabilitation Facility services reasonable and medically necessary for Mr. W.?

Answer:

Mr. W.’s rehabilitation needs remain acute and complex after his lengthy inpatient acute stay.  His needs are intense, multidisciplinary and his potential for significant improvement remains high.  He should be considered for transfer to the IRF.  His physician has ordered Physical Therapy 5 days/week for range of motion, strengthening and gait training with a walker.  He works with the speech therapist 3 days/week due to chewing and swallowing problems, has an order for OT evaluation as his mobility improves, and his physician anticipates transitioning him from TPN to supplemental tube feedings within the next week.  His skilled care needs exceed three hours/day, at least five days per week.  He requires close monitoring of his neurological status and his physician continues to closely assess bone healing, peripheral neuron-muscular status and the healing process post skin graft.

Case Three

Mr. S. is a 68-year-old male.  He sustained a right hip fracture 2 weeks ago, which was surgically reduced with internal fixation after medical clearance for the surgery was obtained.  He is chronically malnourished, and progress with healing is expected to be slow.  He has a history of iron and folic acid deficiency resulting in anemia.  He is receiving group therapy services, physical therapy, nutritional counseling.  He is unable to prepare meals, he is not yet independent with toileting or personal care, and has no social support.  He lives alone in a secondary story apartment with no elevator.  His physician is evaluating him for discharge.  Are Inpatient Rehabilitation Facility services reasonable and medically necessary for Mr. S.?

Answer:

Mr. S. is a prototypical candidate for SNF services.  Although he continues to need skilled care and therapy 2-3 hours/day, the services are primarily supportive.  He does not have adequate support to allow him to return home.  He does not require the evaluation and treatment of the physician several times per week as would be provided under Inpatient Rehabilitation.  The skilled nursing facility staff can adequately meet his needs in a more cost effective setting.

Discharge from the IRF:

As stated in the Pub 100-2, Section 110.5, “coverage stops when further progress toward the established rehabilitation goal is unlikely or when further progress can be achieved in a less intensive setting”.  Coverage ends when it is reasonable for the physician, in consultation with the rehabilitation team, to conclude that further significant improvement will not occur, and the discharge plan which has been previously established, should take place.

The examples above are for educational purposes only.  They are not intended to be an all-inclusive list.  There are an infinite number of unique circumstances and each patient’s record will be considered individually.

Highmark Medicare Services does not preauthorize payment for Medicare claims.   The claim must be submitted for consideration after the services are provided, and supporting documentation for additional development of the claim should be submitted upon request.  The request for documentation is made in writing to the provider, and is commonly known as an Additional Development Request (ADR). 

Resources:

Social Security Act 1886 (j) defines the current IRF-PPA

Social Security Act 1862 (a)(1)(a) prohibits payment for services that are not medically reasonable and necessary.

Social Security Act 1833 (e) prohibits payment if sufficient supporting documentation is not provided to Medicare.

Medicare Publication 100-2, Section 110.1 through 120 defines utilization guidelines for Inpatient Rehabilitation stays. 

You can contact Highmark Medicare Services for additional information at the following site:  http://www.highmarkmedicareservices.com/contact/index.html