MEDICAL POLICY

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Criteria for Acute Inpatient Rehabilitation Care

Number 11.01.501*

Effective Date August 16, 2013

Revision Date(s) 08/12/13; 10/09/12

Replaces N/A

*Medicare has a policy

Policy

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Acute inpatient physical rehabilitation (IPR) care may be considered medically necessary when a patient may be expected to achieve significant practical improvement, in a reasonable amount of time, measured against his/her condition at the start of the rehabilitation program.

An acute IPR program may be considered medically necessary when ALL of the following criteria are met:

  • The facility is a Medicare certified inpatient rehabilitation facility (IRF) or has a Medicare certified program;
  • The patient no longer has acute medical needs that require acute inpatient hospital care;
  • The complexity of the patient’s nursing, medical management and rehabilitation needs require an integrated multidisciplinary approach that includes ALL of the following:
  • The intensity, frequency and duration of therapeutic activities make it impractical to obtain the services in a less intensive setting and
  • Frequent assessment and evaluation by the multifunctional rehab team, including the physiatrist or rehabilitation trained physician specialist, are required because of complex needs and potential changes in medical or physical status and
  • Access to rehabilitation nursing care (RN) is needed 24 hours a day, 7 days a week
  • The patient must be willing and able to take an active part in and benefit from intensive rehabilitation therapy for at least three hours per day, on at least five days of the week;
  • At least two or more therapies are necessary to treat identified functional and/or cognitive issues from physical therapy, occupational therapy, and/or speech-language therapy;
  • The licensed treating physician a physiatrist or rehabilitation trained physician specialist, conducts a face-to- face evaluation of the patient at least 3 days per week to analyze and modify the treatment plan and goals;
  • The rehabilitation evaluation starts on the day of the admission to the IRF;
  • Rehabilitation therapy begins within 36 hours of admission to the IRF;
  • The rehabilitation plan includes realistic individual goals that are clearly identified and are likely to be met within a predictable timeframe;
  • In most circumstances, there is an expectation that the patient will transfer to the home setting.

Related Policies

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10.01.500

Skilled Nursing Care in the Home

Policy Guidelines

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Acute inpatient rehabilitation (IPR) care is provided by an identifiable team as part of an intensive integrated program at an inpatient rehabilitation facility (IRF) or a specialized unit within a hospital. The program is directed by a physiatrist or rehabilitation physician specialist. Patients admitted to the facility or hospital rehabilitation unit usually spend 3 to 6 hours a day in a structured rehabilitation program, or at least 15 hours over 5 days.

The patient’s clinical information for admission will be reviewed using the following source:

  • The criteria listed in this policy (see Policy section and Administrative Guidelines below)

The patient’s clinical information for ongoing care will be reviewed using the following source:

  • Milliman Care Guidelines®

Administrative Guidelines

Ongoing acute IPR care may be covered after the initial assessment only when the rehabilitation team concludes that the patient is expected to achieve a significant practical improvement, in a reasonable amount of time. Complete independence in activities of daily living (ADLs) may not be reasonable, but functional improvement is documented, using a nationally recognized functional assessment tool (e.g., the Functional Independence Measure (FIM®) instrument, or others).

Ongoing coverage of inpatient rehabilitation care stops when:

  • Further progress toward the established rehabilitation goals is unlikely OR
  • Further progress can be achieved in a less intensive environment, such as an outpatient setting OR
  • The patient is unwilling or unable to actively participate in the intensive inpatient rehabilitation program.

NOTE: The MCG™ manuals are proprietary and cannot be published and/or distributed. However, on an individual member basis, the Company can share a copy of the specific criteria document used to make a utilization management decision. If you would like a copy of these criteria, you may request a copy by calling the Customer Service number on the member’s health plan card.

The Company reserves the right to review and modify the MCG™ (formerly Milliman Care Guidelines) criteria or Customized Guidelines at any time.

Definitions

  • FIM® instrument: the functional independence measure is an assessment tool used to document the measurable functional change in patients as a result of inpatient medical rehabilitation. The instrument developed specifically for the IPR setting, consists of 13 motor items and 5 cognitive items. Using a 7-point scale the FIM® instrument measures the level of a patient’s ability and how much assistance is required to complete activities of daily living.
  • Inpatient Rehabilitation Facility (IRF): A Medicare-certified inpatient rehabilitation facility that is licensed to provide an intensive rehabilitation program through a multidisciplinary coordinated team approach under the direction of a licensed physician, board certified in physical medicine and rehabilitation. Rehabilitation hospitals and units must, under Medicare rules, provide 24-hour, 7-day-a-week availability of physicians and nurses with specialized training or experience in medical rehabilitation.
  • Physiatrist: a rehabilitation physician is a medical doctor who has completed training in the medical specialty of physical medicine and rehabilitation (PM&R).

Description

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An acute IPR program uses a multidisciplinary team of health care professionals with training and experience in rehabilitation. Various therapies are coordinated to treat patients with complex medical and rehabilitation needs to restore or improve functional status. The services may include, but are not limited to combinations of the following: physical therapy, occupational therapy, speech therapy, cognitive therapy, respiratory therapy, psychology services, prosthetic/orthotic services, rehabilitation nursing.

The patient admitted to acute rehabilitation care must be capable of fully participating in the IPR program. The goal of acute rehabilitation care is to help patients who are physically or cognitively impaired to achieve or regain their maximum functional potential for mobility, self-care and independent living. Complete independence may not be an ultimate goal. However, a measureable improvement in functional ability must be achievable.

Examples of conditions requiring acute IPR include, but are not limited to, individuals with significant functional deficits related to stroke, spinal cord injuries, acquired brain injuries, major trauma, amputation and burns.

This policy provides guidelines for clinicians facilitating patient’s transition of care to acute IPR programs, as well as identifies the criteria to use when reviewing medical records for admission and ongoing care of patients who require acute IPR care.

Scope

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Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply.

Benefit Application

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Coverage for acute inpatient rehabilitation (IPR) services is subject to the limits and conditions of the member benefit plan.

Rationale

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N/A

References

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  1. Beninato, M., Gill-Body, K.M.,Salles, S., et al. Determination of the Minimally Clinically Important Difference in the FIM Instrument in Patients With Stroke. Arch Phys Med Rehabil Vol 87, pp. 32-39. January 2006. Available online at: http://download.journals.elsevierhealth.com/pdfs/journals/0003-9993/PIIS0003999305012736.pdf Last accessed September 12, 2012.
  2. Center for Medicare & Medicaid Services. Medicare benefits policy manual. Chapter 1-Inpatient hospital services covered under part A [Internet] Center for Medicare & Medicaid Services: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads//bp102c01.pdf. Last accessed July 26, 2013.
  3. Milliman Care Guidelines: 16th Edition, Inpatient Rehabilitation Facility. Available online at: http://careweb.careguidelines.com/ Last accessed on July 26, 2013.
  4. Prvu Bettger JA, Stineman MG. Effectiveness of multidisciplinary rehabilitation services in postacute care: state-of-the-science. A review. Archives of Physical Medicine and Rehabilitation 2007;88(11):1526-34. DOI: 10.1016/j.apmr.2007.06.768.

Coding

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Codes

Number

Description

Revenue Codes

0118

Room and board, private, rehabilitation

 

0128

Room and board, semi-private, rehabilitation

 

0138

Room and board, semi-private, rehabilitation

 

0148

Room and board, private, deluxe, rehabilitation

 

0158

Room and board, ward, rehabilitation

ICD-9 CM Procedure

93.11 - 93.19

Physical therapy exercises

 

93.21 - 93.29

Other physical therapy musculoskeletal manipulation

 

93.31

Assisted exercise in pool

 

93.32

Whirlpool treatment

 

93.33

Other hydrotherapy

 

93.34

Diathermy

 

93.35

Other heat therapy

 

93.38

Combined physical therapy without mention of the components

 

93.39

Other physical therapy

 

93.72

Dysphasia training

 

93.74

Other speech training and therapy

 

93.81

Recreation therapy (may be non-covered per contracts)

 

93.82

Educational therapy (may be non-covered per contracts)

 

93.83

Occupational therapy

 

93.84

Music therapy (may be non-covered per contracts)

 

93.85

Vocational rehabilitation (may be non-covered per contracts)

ICD-9-CM Diagnosis

433.01

Basilar artery occlusion and stenosis, with cerebral infarction

 

433.11

Carotid artery occlusion and stenosis, with cerebral infarction

 

433.21

Vertebral artery occlusion and stenosis, with cerebral infarction

 

433.31

Multiple and bilateral occlusion and stenosis of precerebral arteries, with cerebral infarction

 

433.81

Other specified precerebral artery occlusion and stenosis with cerebral infarction

 

433.91

Unspecified precerebral artery occlusion and stenosis, with cerebral infarction

 

434.91

Cerebral artery occlusion, unspecified, with cerebral infarction

 

438.20 - 438.22

Late effects of cerebrovascular diseases, hemiplegia/hemiparesis

 

438.30 - 438.32

Late effects of cerebrovascular disease, monoplegia of upper limb

 

438.40 - 438.41

Late effects of cerebrovascular disease, monoplegia of lower limb

 

438.50 - 438.53

Late effects of cerebrovascular disease, other paralytic syndrome

 

713.0 - 713.8

Arthropathy associated with other disorders classified elsewhere

 

714.0 - 714.9

Rheumatoid arthritis and other inflammatory arthropathies

 

819.0 - 819.1

Multiple fractures involving both upper limbs and upper limb with rib(s) and sternum

 

828.0-828.1

Multiple fractures involving both lower limbs, lower with upper limb, and lower limb(s) with rib(s) and sternum

 

851.11 - 851.99

Cerebral laceration and contusion

 

852.00 - 852.59

Subarachnoid, subdural and extradural hemorrhage following injury

 

853.00 - 853.19

Other and unspecified intracranial hemorrhage following injury

 

854.00 - 854.19

Intracranial injury of other and unspecified nature

 

887.0 - 887.7

Traumatic amputation of arm and hand (complete) (partial)

 

896.0 - 896.3

Traumatic amputation of foot (complete)(partial)

 

897.0 - 897.7

Traumatic amputation of leg(s) (complete) (partial)

 

905.0

Late effect of fracture of skull and face bones

 

906.7

Late effect of burn of other extremities

 

906.8

Late effect of burns of other specified sites

 

906.9

Late effect of burn of unspecified site

 

907.0 - 907.9

Late effect of injuries to the nervous system

 

942.30 - 942.39

Burn of trunk, full-thickness skin loss [third degree NOS]

 

942.40 - 942.49

Burn of trunk, deep necrosis of underlying tissues [deep third degree] without mention of loss of a body part

 

942.50 - 942.59

Burn of trunk, deep necrosis of underlying tissues [deep third degree] with loss of body part

 

943.30 - 943.39

Burn of upper limb, except wrist and hand, full thickness skin loss [third degree NOS]

 

943.40 - 943.49

Burn of upper limb, except wrist and hand, deep necrosis of underlying tissues [deep third degree] without mention of loss of a body part

 

943.50 - 943.59

Burn of upper limb, except wrist and hand, deep necrosis of underlying tissues [deep third degree] with loss of a body part

 

945.30 - 945.39

Burn of lower limb(s), full thickness skin loss [third degree NOS]

 

945.40 - 945.49

Burn of lower limb(s), deep necrosis of underlying tissues [deep third degree] without mention of loss of a body part

 

945.50 - 945.59

Burn of lower limb(s), deep necrosis of underlying tissues [deep third degree] with loss of a body part

 

952.00 - 952.9

Spinal cord injury without evidence of spinal bone injury

 

V57.22

Encounter for vocational training (may be non-covered per contracts)

Appendix

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N/A

History

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Date

Reason

06/01/12

New policy, add to Utilization Management section.

10/09/12

Replace Policy. Rewritten for clarification. Policy title updated with the word “inpatient”. Policy wording revised for clarification of active participation. Related policy added for Skilled Nursing Care in the Home. Policy guideline section revised for clarification of criteria used to review clinical information and when coverage stops. Definitions added for FIM scale and physiatrist, other definitions sorted alphabetically. Reference 1 added, other references renumbered. Policy statement intent unchanged.

08/16/13

Replace policy. Added a note stating MCG’s are proprietary and the process to request a copy.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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