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Written by: Darlene D'Altorio-Jones (1959-2015) on Friday, March 8, 2013 Posted in: Inpatient Rehab

What is the ethical dilemma of a patient reaching a stated goal in rehabilitation, yet not able to complete the discharge due to other areas of the plan of care not yet fulfilled? There are many reasons for this type of scenario to occur; “whether it be due to a family issue, a medical concern, equipment need, etc. – how can the therapist approach caring for the patient when he or she feels that they’ve met the ‘intense’ goals?” was recently posed to me for a blog discussion.

Typical to nearly any answer provided in a blog, each scenario will hold its own facts and good cause for rationale. When it is specific to recovery of functional mobility to meet the plan of care, I will default to this rationale and then provide the CMS rationale when it may be for other causes outside of your control as a health provider or despite best effort, no further progress is expected.

The IRF accepts patients with specific barriers to a discharge goal. Those barriers to discharge are owned by the entire interdisciplinary team. It’s inevitable that various  items will be  manageable more quickly than others. Until the team meets the discharge plan, no less than two therapies along with 24 hour rehab nursing managed by the rehabilitation physician should continue the remaining plan to successfully achieve the hopeful promised discharge capabilities. Reinforcing all mobility and self-care to highest potentials.

If any therapist put themselves in the patients shoes, they too would hope for that concentrated effort – that the interdisciplinary team will work together to meet the established discharge goal. The team seeks to meet the discharge plan; whereas no one stops at the minimum when not all goals are met. Some areas you will exceed the least level required to discharge … until every area is met. Efficacy is met when everyone on the team collaborates to tackle those very specific areas to be certain carryover and capability exist for the realistic discharge expectation, as long as that expectation is still reasonable.

Only when the original plan is no longer viable, despite everyone’s best effort, should the team discontinue the rehab level of care – always taking into consideration the value cost of the patients benefit being utilized. Recalling CMS ALOS is just that – averages,  and those are made up of real length of stays to enable the desired discharge location and permanency of stability. But let’s say the rationale falls outside of ‘reasonable and necessary’ criteria, established goals have all been met and or it is unlikely that further progress will occur to enable your intended discharge plan as established. CMS provides this clarification on how to handle the rare circumstances when greater than 3 days without intensity of services are needed and the discharge has been delayed for circumstance beyond your control.

Clarification regarding whether the discharge dates on the IRF patient assessment instrument (IRF-PAI) and the discharge dates on the IRF claim must be the same.

As we stated on the May 31, 2012, IRF Coverage Requirements National Provider Call, we believe that the discharge dates on the IRF-PAI should always match the discharge dates on the IRF claims. Thus, we removed language from the IRF-PAI Training Manual (effective Oct. 1, 2012) that may have led providers to believe that they could put different discharge dates on the IRF-PAI than on the claim.

Although previous guidance in the IRF-PAI Training Manual suggested that patients could be downgraded from a Medicare Part A IRF stay by “discharging” the patient on the IRF-PAI when the patient no longer required an IRF level of care, this guidance is no longer consistent with Medicare regulations. As stated in Chapter 1, Section 110.3 of the Medicare Benefit Policy Manual (Pub. 100-02), “Since discharge planning is an integral part of any rehabilitation program and must begin upon the patient’s admission to the IRF, an extended period of time for discharge from the IRF would not be reasonable and necessary after established goals have been reached or the determination has been made that further progress is unlikely.” We believe that it is in the patient’s best interest for the IRF to begin the discharge planning process early and continue it throughout the IRF stay. Thus, although we allow a brief period for the IRF to find alternative placement for a patient who no longer meets the IRF coverage criteria, an extended stay in the IRF for such patients is not warranted.

In the very rare case in which it may become apparent that the patient’s discharge from the IRF is going to be delayed for an extended period of time, the IRF should provide the patient with an Advance Beneficiary Notice (ABN) informing the patient that he or she may be liable for any remaining charges. The IRF should also use occurrence code 76 on the IRF claim for the remaining days to indicate that those days are not Medicare-covered under the IRF prospective payment system. Otherwise, the IRF claim will continue to be considered a Medicare Part A stay and will continue to be subject to review under the IRF coverage requirements.”

Although occurrence span code 76 is used to report a period of non-covered care “for which the patient is responsible” (generally speaking), and you are issuing an ABN, this opens another entirely different discussion. Are covered days and ‘regular days’ appropriately established in the common working file so that only those days reported as Part A covered are included? Since even one covered day permits payment at a CMG level and accepting the IRF PPS payment rate as the full rate does not permit ‘balance billing’, what exactly is the significance of the occurrence code 76 except to defer possible denial of the entire stay based on the days when ‘intensity/ reasonable and necessary’ care are questioned by the rehab provider with inability to discharge? Perhaps you should be discussing this in your next executive session and asking for those answers from your MAC.

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