UTILIZATION MANAGEMENT GUIDELINE

COVERAGE GUIDELINE
CODING
RELATED POLICIES
SCOPE
ADDITIONAL INFORMATION
HISTORY

Inpatient Rehabilitation (IPR) Care: Guideline for Admission and Transition of Care

Number 11.01.501*

Effective Date January 1, 2015

Revision Date(s) 12/22/14; 08/11/14; 08/12/13; 10/09/12

Replaces N/A

*Medicare has a policy.

Coverage Guideline

Clinical Indications for Admission

An acute Inpatient Rehabilitation (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
  • 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
  • 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
  • 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.

Acute IPR may be considered not medically necessary when:

  • The patient does not meet the criteria for an acute IPR program (see the indications above)
  • Rehabilitation services are for improving athletic performance, job function, recreation or school performance
  • Rehabilitation therapies do not require a multidisciplinary team approach
  • Rehabilitation therapies could be provided in a less intensive setting such as a skilled nursing facility, home or other outpatient setting
  • The patient is unable or unwilling to actively participate in the multi-disciplinary rehabilitation program or make progress toward the goals in the treatment plan
  • Treatment is for maintaining physical condition or slow deterioration in function rather than to restore function that was lost due to illness injury or trauma

Common conditions/services that may be considered not medically necessary for IPR level of care include, but are not limited to:

  • Single joint replacement without one or more comorbidity which significantly limits functional capacities
  • Uncomplicated lumbar or cervical compression fractures without neurological involvement
  • Uncomplicated laminectomy or spinal fusion without other significant comorbidities
  • Brain injury with Rancho level 4 or below
  • Ventilator dependence
  • Progressive neurologic disorder such as Multiple Sclerosis or Parkinson Disease without a preceding acute care incidence
  • Custodial level of care

Clinical Indications for Transition of Care

Transition from an inpatient rehabilitation facility (IPR) to an alternate level of care may be considered medically necessary when ONE of the following criteria are met:

  • All functional rehabilitation goals have been achieved in all therapeutic disciplines
  • Two or more therapy services are no longer required to meet rehabilitation goals
  • Further progress toward rehabilitation goals is not expected or can be achieved at a lower level of care
  • The patient in unwilling or unable to continue participating in the rehabilitation program for 3 hours/day at least 5 days/week
  • The patient has become medically unstable and requires transfer to an acute care hospital

In addition, the following discharge criteria should be met for a safe transition to a lower level of care:

  • The patient is medically stable and any needed skilled services at a lower level of care have been arranged
  • Patient and care giver education is completed for a safe transition to a lower level of care

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

Coding

N/A

Related Guidelines / Policies

10.01.500

Skilled Home Health Care Services

Scope

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. This medical policy does not apply to Medicare Advantage.

Additional Information

This guideline incorporates clinical, facility, and care based indicators to determine the appropriateness of admission to inpatient rehabilitation (IPR) level of care. In addition, transition of care guidelines are given as indicators to determine if the patient may be appropriate for safe transfer from the inpatient rehabilitation facility to home or an alternate setting.

Patients may require acute IPR after amputation, stroke, cardiac events, or other exacerbations of conditions that result in significant functional deficits. 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.

Acute IPR care is provided by a multidisciplinary 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. 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, and rehabilitation nursing. 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.

Definition of Terms

  • 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).
  • Physical Functional Impairment: physical functional impairment means a limitation from normal (or baseline level) of physical functioning that may include, but is not limited to, problems with ambulation, mobilization, communication, respiration, eating, swallowing, vision, facial expression, skin integrity, distortion of nearby body parts or obstruction of an orifice. The physical functional impairment can be due to structure, congenital deformity, pain, or other causes. Physical functional impairment excludes social, emotional and psychological impairments or potential impairments.

References

  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://www.archives-pmr.org/article/S0003-9993(05)01273-6/abstract. Last accessed November 12, 2014.
  2. Center for Medicare and Medicaid Services. Medicare benefits policy manual. Chapter 1-Inpatient hospital services covered under part A [Internet] Section 110, IRF. Available online at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads//bp102c01.pdf. Last accessed November 12, 2014.
  3. Center for Medicare and Medicaid Services. The inpatient rehabilitation facility: patient assessment instrument (IRF_PAI) [Internet] 2012. Available online at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Downloads/IRFPAI-manual-2012.pdf. Last accessed November 21, 2014.
  4. Finch, M., Sandel, M.E., et al. (1997). Admission examination factors predicting cognitive improvement during acute brain injury rehabilitation. Brain Injury 11(10):713-721.
  5. Kane RL. Finding the right level of post hospital care. Journal of the American Medical Association 2011;305(3):284-93.
  6. Lees L. Exploring the principles of best practice discharge to ensure patient involvement. Nursing Times 2010;106(25):10-14.
  7. Prvu Bettger JA, Stineman MG. Effectiveness of multidisciplinary rehabilitation services in post-acute care: state-of-the-science. A review. Archives of Physical Medicine and Rehabilitation 2007; 88(11):1526-34.
  8. Reimer, M., LeNavenec, C. Rehabilitation outcome evaluation after very severe brain injury. Neuropsychology Rehabilitation 2005;15(3-4):473-479.
  9. Roos, M. Effectiveness and practice variation of rehabilitation after joint replacement. Current Opinion in Rheumatology, 2003;15(2):160-162.

History

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.

05/16/14

Update Related Policies; change title of policy 10.01.500.

08/11/14

Annual Review. Added not medically necessary criteria to the policy section. Policy revised based on a literature search through July 2014. Reference to using MCG as a tool to guide determinations is removed. Reference 3 added; others renumbered/removed. Policy statements changed as noted. Codes removed; revenue and diagnosis codes are not reviewed with relationship to this policy.

12/22/14

Policy converted to Utilization Management Guideline addressing transition of care for inpatient rehabilitation. No change in coverage intent; considered medically necessary when criteria in this guideline are met. Updates are effective January 1, 2015.


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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