1. Abstract:
This Local Coverage Determination (LCD) addresses Medicare coverage for rehabilitation services provided in an Inpatient Rehabilitation Facility (IRF), whether free-standing or an “excluded” unit [as defined in 42 CFR, Section 412.25]. The medical necessity for provision of the rehabilitative services in an inpatient setting is the primary focus. We note a distinction between medical necessity for individual therapy services, which may be reasonable and necessary in a particular case, and the medical necessity of providing coordinated, comprehensive and interdisciplinary services in an inpatient rehabilitation setting. This LCD describes the relevant factors that differentiate Medicare coverage for rehabilitation in an IRF from coverage for rehabilitation in other settings, such as acute care hospitals, skilled nursing facilities (SNFs), home health care, and outpatient settings.
Much of the language in this LCD is taken directly from the Center for Medicare and Medicaid Services’ (CMS’) online manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110 et seq. which replaces information formerly found in the CMS Hospital Manual, section 211.
Rehabilitation medicine is philosophically grounded in a biopsychosocial understanding of health as a functional concept, as opposed to a disease concept. For instance, when an individual survives an acute event with some sort of residual impairment(s) and/or experiences the bodily deterioration that comes with aging, such conditions often cannot be “cured”, but their negative impact on the individual’s life can be ameliorated through the application of rehabilitation principles. The International Classification of Functioning, Disability and Health (ICF), developed by the World Health Organization (WHO) provides a useful structure for thinking about rehabilitation medicine. The ICF is based on the premise that health outcomes can be measured in several domains – disease (will the treatment cure the pathology?), impairment (will the treatment eliminate or decrease problems in the structure or function of a particular body part or system?), disability (will the treatment increase the person’s ability to perform activities of daily living (ADLs) despite impairments in body structure or function?) and handicap (will the person be able to perform his or her normal role in society despite some degree of disability?). This LCD will focus on those aspects of rehabilitation that are most appropriately rendered in an inpatient setting.
There have been relatively few well-controlled research studies measuring the effectiveness of intensive inpatient rehabilitation in comparison with other methods of delivering rehabilitation services to patients in the United States. 25, 15, 21, 19 A significant problem in conducting such research is that a particular patient’s need for rehabilitative services is multi-factorial and doesn’t correlate well with a simple unitary measurement such as diagnosis. 14, 15, 37 A given diagnosis such as stroke can result in a wide range of impairments which, in turn, cause varying levels of disability and/or handicap depending on their interaction with multiple additional factors such as pre-morbid functional level, medical acuity, mental or psychological status, co-morbid conditions, available social support, and environmental barriers within an individual’s living situation. 11, 31, 37
This complexity has led to the development of multiple instruments designed to predict the relationship between a patient’s functional deficits and optimal resource use but, unfortunately, the various settings (IRF, SNF, home health, etc.) where rehabilitation services are offered use different patient classification tools. When researchers compare these instruments, they find substantial variation in their content and in how items are defined and scored, making comparisons across settings difficult. An effort to devise a common instrument for use in all of the various post-acute settings has so far failed to produce a standardized product. 2, 20, 21
Such problems do not mean, however, that there is no way to determine circumstances in which intensive inpatient rehabilitation is appropriate. For instance, there is literature describing other types of studies, research conducted in other countries (keeping in mind differences in health care system structure) and studies looking at specific factors (e.g. early transfer to rehabilitation), all of which can provide guidance in selecting those elements of intensive inpatient rehabilitation that differentiate it from other rehabilitation settings. 11, 27, 15 There is also a wealth of material in chapter 1, section 110 et seq., of CMS publication 100-02, the Medicare Benefit Policy Manual. This material was developed many years ago with considerable input from rehabilitation professionals and, while some particulars are outdated, it still provides an excellent foundation on which to base this LCD.
2. Indications:
Since the need for inpatient rehabilitation is more dependent on the effects of a patient’s injury or illness (impairments, functional deficits, achievable goals) than on the precipitating cause (diagnosis), we have not included a finite listing of diagnoses appropriate for inpatient rehabilitation in this LCD. This is not meant to imply that all diagnoses are similarly weighted in terms of medical necessity – a relatively uncomplicated condition such as post-operative rehabilitation following a unilateral knee replacement will likely require very careful attention to documentation to support intensive inpatient rehabilitation, whereas a patient admitted for rehabilitation following a new traumatic spinal cord injury with paraplegia (e.g. T10 ASIA A level of injury) will be a more obvious candidate.
Evaluation of appropriateness for IRF admission
Pre-admission screening (before the patient is admitted to the IRF)
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. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110.2
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. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110.4.6 See the “Documentation” section for more information on what is meant by “significant practical improvement”.
Inpatient rehabilitation facilities should have in effect a preadmission screening procedure under which each prospective patient’s condition and medical history are reviewed to determine whether the patient is likely to benefit significantly from an intensive inpatient hospital program or assessment. The screening of the patient’s condition is done to determine the patient’s rehabilitation needs and appropriateness of providing those rehabilitation needs in an IRF setting. It is recommended that pre-admission screening be completed as close to discharge from the site where the screening is performed (typically an acute care hospital) in order to better assess the patient’s condition concerning rehabilitation needs and potential. For example, performing a pre-admission screen of a patient on the first post-surgical day while the patient is still heavily medicated and in significant pain would not capture a true picture of the patient’s rehabilitation needs to determine if the admission to the IRF is medically reasonable and necessary. Many post-surgical patients make significant functional gains in the first several days after the surgery while still in the acute care hospital.
Initial assessment (after the patient is admitted to the IRF)
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. 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. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110.3.1
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. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110.3.1
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. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110.3.1
Therapeutic rehabilitation services in an inpatient hospital setting
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. 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; 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. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110.1
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, 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. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110.4
More specifically, inpatient rehabilitation in a hospital setting will be considered medically reasonable and necessary if (a, b, c, and d are all required):
- There is a reasonable expectation of measurable improvement that will be of practical value to the patient within a predictable and reasonable period of time, AND
- The patient requires and can tolerate at least three hours per day of skilled therapy at least five times per week or, in the instance of a medical condition that limits participation, documentation that justifies the medical necessity and the appropriateness for IRF admission despite the lower level of therapy intensity.
(See Item #3 in the “Documentation” section for additional information), AND
- The patient requires active and ongoing, multidisciplinary intervention acting in a coordinated fashion and based on the patient’s needs. (See #4 in the “Documentation” section for additional information regarding the “minimum” IRF team members)
- Factors that support the appropriateness of providing rehabilitation services in an inpatient setting include:
o a patient requires 24-hour a day access to a registered nurse (RN) with specialized training in rehabilitation AND
o a patient requires the 24 hour availability of a physician with specialized training or experience in rehabilitation and requires medically necessary physician visits at least every two to three days during the patient’s stay due to the presence of a co-morbid medical condition or a risk of change in medical status AND
o a patient’s 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 OR
o a patient’s need for the level of intensive, interdisciplinary, and highly coordinated rehabilitation services not available as an outpatient, through home health, or in a skilled nursing facility.
Treatments, therapies and equipment used to establish medical necessity must be consistent with the nature and severity of the illness or injury, and consistent with accepted standards of medical practice.
Further information on how to demonstrate that the admission meets the criteria for inpatient rehabilitation can be found in the “Documentation” section of this LCD.
Coverage stops when further progress toward the established rehabilitation goal is unlikely or when further progress can be achieved in a less intensive setting. 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. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110.5
A claim that does not fulfill the coverage requirements described above may be given individual consideration based on review of all pertinent medical information. Please see “Documentation Requirements” for some examples of medical information that would be pertinent to such review.
3. Limitations
The following paragraphs describe services that would likely be found not reasonable and necessary and therefore would be denied as inpatient rehabilitation services:
- There is no reasonable expectation of improvement in quality of life or level of functioning. (For discussion of the concept of “health-related quality of life” (HRQOL) see, for example, Measuring Healthy Days: Population Assessment of Health-Related Quality of Life, published by the Centers for Disease Control and Prevention in November, 2000 and available at www.cdc.gov/nccdphp/hrqol/pdfs/mhd.pdf.)
- Failure to meet the coverage requirements for inpatient rehabilitation as stated above – i.e. the services are available in a less intensive setting (Outpatient or SNF) and the patient is medically appropriate for such a setting. Determining whether “the services are available” in a less intensive setting includes assessing whether the patient needs a coordinated and inter-disciplinary program of rehabilitation and, if so, whether such a program is available in the less intensive setting.
- The reason for admission is due to a medical condition that is more appropriately considered part of the acute inpatient stay (premature discharge from the acute care hospital to the rehabilitation facility). Examples include a patient who could have been discharged with home or outpatient therapy had he stayed another few days in the acute care setting to treat co-morbid medical conditions or a person transferred to an IRF with a medical problem that prohibits meaningful participation in a rehabilitation program at the time of transfer (e.g. someone on bed rest). A 2003 report to Congress by the Medicare Payment Advisory Commission (MEDPAC) notes that available evidence strongly suggests that increases in post-acute care services reflect the substitution of post-acute care for some inpatient services.
- The physician did not order an intensive level of care as described in this policy and there was no documentation to support an exception to the intensity requirement.
- The facility did not provide the services ordered, such that an intensive multi-disciplinary level of care was not provided for the bulk of the inpatient stay and there was no documentation to support an exception to the intensity requirement.
- Documentation does not support the intensity of service. Three hours of skilled rehabilitative services per day at least five days per week were not provided and there was no documentation to explain why the patient was nevertheless appropriate for inpatient rehabilitation.
- Some or all of the services that contributed to the 3 hour guideline were not skilled or supported as medically necessary.
- Coordinated multi-disciplinary care was not required or provided.
- Services provided after a given date were not medically necessary in an inpatient environment as the patient no longer required an inpatient level of care. (Documentation does not justify length of stay.)
- The medical record fails to substantiate the data reported in the Inpatient Rehabilitation Facility – Patient Assessment Instrument (IRF-PAI).
- 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. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110.5
- 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. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110.2
4. Other Comments
This Local Coverage Determination consolidates and replaces all previous policies and publications on this subject by the carrier and fiscal intermediary predecessors of National Government Services (AdminaStar Federal, Anthem Health Plans of New Hampshire, Associated Hospital Service, Empire Medicare Services, and United Government Services).
For claims submitted to the fiscal intermediary: This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated National Government Services to process their claims.
Bill type codes only apply to providers who bill these services to the fiscal intermediary. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier.
Limitation of liability and refund requirements apply when denials are based on medical necessity. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be considered medically necessary by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes. In these instances it is recommended, although not required, that the provider notify the beneficiary in writing with a Notice of Exclusion of Medicare Benefits (NEMB).
Notice to beneficiaries related to discharge and coverage notification as described in CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 2, Sections 80-80.2, applies.
Hospitals have been instructed to provide Hospital-Issued Notices of Noncoverage (HINNs) to beneficiaries prior to admission, at admission, or at any point during an inpatient stay if the hospital determines that the care the beneficiary is receiving, or is about to receive, is not covered because it is:
- Not medically necessary;
- Not delivered in the most appropriate setting; or
- Is custodial in nature.
If the facility portion of inpatient rehabilitation services is denied as not medically necessary this does not mean that the physician service is also not medically necessary. The physician service to the patient may be medically necessary even though the level of service rendered in an inpatient rehabilitation facility is not medically necessary.
Physician visits to a patient must involve a face-to-face encounter. Physician visits that only comprise team conferences or discussion with staff can not be billed to the carrier.
Notes Related to Revision Effective Dates:
12/01/2007-Cor#1
Corrected version of policy published 12/01/2007 (during the Notice Period) with no change in the original effective date of 12/01/2007. |