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Written by: Darlene D'Altorio-Jones (1959-2015) on Monday, May 23, 2011 Posted in: Inpatient Rehab

The following quote comes directly from the National Provider Conference Call Transcript, available on the Inpatient Rehab Facility Web page on; educating new coverage requirements, CMS would no longer talk aboutwhether the patient could have been treated in a skilled nursing facility or another setting of care.

In reference to Medical Necessity Audits, CMS stated they would no longer validatewhether the patient could have been treated in a skilled nursing facility or another setting of care.” The defense for medical necessity lies specifically in the arguments presented in the physician’s attestation for appropriate admission, based on the pre-admission screen. Verbatim from the November 12, 2010 call:

“As you all have just heard, previously the regulations for coverage and non-coverage of IRF admissions depended on a retrospective look back to see if the services could have been provided at a lower level of service. Questions that were frequently asked included among others — did the patient need a doctor to frequently assess or intervene in a patient’s care? And did the patient need a nurse with specialized rehabilitation training or experience? The current regulations do not allow for this. Instead, assuming all documentation requirements are met at the time of admission to an IRF, the patient’s need – must need- as you have just heard – multiple therapies, one of which must be PT or OT; an interdisciplinary approach; medical supervision as was just defined for you; and the patient’s potential must be such that they can participate in and benefit from intensive therapy, and specifically that they are medically appropriate to do so.” This strengthens thorough pre-admission assessment practices.

I know we’ve felt burned by past experiences when Fiscal Intermediaries, now MACs, aggressively denied joint replacement patients on the probability that skilled was a more appropriate placement. Most of the previous denials were made based on the presumption that SNF care was more appropriate.

Factually, there was no credit or defense that these patients did not experience adverse events because they were well-managed with expedient discharges from having received the appropriate level of interdisciplinary care with excellent outcomes. That is what IRFs are paid to do, and in hindsight, are now gun-shy because denied patients met the then 85-2 ruling of medical necessity. How do you argue, other than with a crystal ball, that skilled may have yielded similar results? CMS is trying to mend this broad brush misconception.

The 85-2 ruling is gone. Joint replacement patients, even electives, will sometimes have predisposing clinical histories that will be well served at an intensity level for physician, nursing and therapy management defined by inpatient rehab; while some will not. Screening appropriately defines which patients are candidates for IRF. The pendulum has swung too far in the opposite direction and it is our due diligence that can bring it back in the right direction. This is an appeal to all to do what is best for the patient.

There will be appropriate patients outside the 60% rule RICs that will still need our care. This is not only true with joint replacement, but also with mild to moderate strokes and other services that require higher levels of clinical hands-on time not available in the staffing models of skilled units. Given brief intense inpatient rehabilitation, discharge to community is even more probable. Let’s use all available CMGs when the patient is appropriate for a rehab level of care.

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