skip to Main Content
Written by: Darlene D'Altorio-Jones (1959-2015) on Friday, October 11, 2013 Posted in: Inpatient Rehab

When the 2014 Rule was debated and then completed, the rationale for squeezing presumptive compliance became paintstakingly clear. If you presume without true due dilligence to the Rehab 13 criteria within your documentation, the benefit of the doubt has been removed and manual medical review will preside not this year but the next IRF fiscal year (discharges after Oct. 1, 2014). Take this as time to educate and prepare what your pre-admission screening must demonstrate to include these conditions in order to meet manual review. Let’s review.

Based on discussions at AMRPA conference in September 2013, I heard estimates that up to 35 percent of the present cases would fail presumptive but perhaps meet conditional and that 15 percent may fail BOTH. So the question stands, ‘how well do you document presumptive compliance?’ Remember missing the mark here declassifies a facility for payment under IRF PPS. If you are not ready to be paid one of two rehab DRG’s for the type of care you provide – take notes.

Going forward, mostly unspecified codes, arthritis codes, congenital anomaly, unilateral upper extremity amputations and codes that certainly could not tolerate a rehab level of care such as ‘brain death’ are OUT of presumptive calculations. For the most part, I think many bank on the arthritis conditions meeting presumption because you know your staff are aware of the conditions and you are certain they document toward those conditions. RIGHT? Oh, maybe not? Regulations are very specific about what must be in the documentation but I’m not certain everyone attempts to demonstrate to the degree required what must absolutely be in the documentation to pass conditional thresholds.

Presume that ALL those codes would undertake further scrutiny of a manual medical review to decide if they were in or out of conditional compliance. (Table 9 of the 2014 rule outline the removed presumptive codes – pdf page 33 of 76.)

If your documentation does not provide all the nuances for the arthritis compliance, it is not too late to be certain that the pre-admission assessment not only shows due-dilligence but references and has copies of the documentation required to show those items had been considered in your overall compliance percentage upon manual review. Remember, presumptive compliance was one of the items held until the next fiscal year to catch up with ICD-10 coding implementation; but again, take a retrospective look back and audit those you called ‘presumptively compliant’ in the arthritis categories to provide a glimpse of the improved documentation you will need to educate and enforce.

CMS makes this statement, “in the May 7, 2004 Final Rule, we limited the conditions to those that met defined severity and prior treatment requirements, and that were sufficiently severe as to require intensive inpatientrehabilitation services. As discussed above, ICD–9–CM diagnosis codes alone do not provide sufficient information to establish whether these pretreatment and severity requirements have been met. More detailed information is necessary to determine if the patient meets the pretreatment and severity requirements. Verification using the medical review compliance method will allow an IRF to have these patients included in their compliance percentage.”

Rehab 13 conditions 11, 12 & 13 make these very specific mandates to include in conditional compliance toward the 60% rule:

  • Active, polyarticular rheumatoid arthritis, psoriatic arthritis and seronegative arthropathies resulting insignificant functional impairment of ambulation and other activities of daily living that have not improvedafter an appropriate, aggressive, and sustained course of outpatient therapy services or services in other less intensive rehabilitation settings immediately preceding the inpatient rehabilitation admission or that result from a systemic disease activation immediately before admission, but have the potential to improve with more intensive rehabilitation.

(The pre-admission assessment must discuss the significant functional impairment of ambulation and ADL’s and include that an outpatient therapy or other LESS intensive rehabilitation was undertaken prior to the acute care admission. It is imperative to add information about how these conditions were met; did this patient have outpatient therapy or even home health or skilled servcies specifically in an attempt to avoid an acute admission if you are going to utlize the arthritis condition as the primary reason for the rehabilitation stay?)

  • Systemic vasculidities with joint inflammation, resulting in significant functional impairment of ambulation and other activities of daily living that have not improved after an appropriate, aggressive and sustained course of outpatient therapy services or services in other less intensive rehabilitation settings immediately preceding the inpatient rehabilitation admission or that result from a systemic disease activation immediately before admission, but have the potential to improve with more intensive rehabilitation.

(Similar discussion from above, except here you may demonstrate an acute flare up documented just prior to the admission with or without the previous setting requirements. Remember, you must still document the significant ADL impairments in relation to the reason for the stay if you can demonstrate potential for imiprovement with more intense services.)

  • Severe or advanced osteoarthritis (osteoarthrosis or degenerative joint disease) involving two or moremajor weight bearing joints (elbow, shoulders, hips or knees, but not counting a joint with a prosthesis) with joint deformity and substantial loss of range of motion, atrophy of muscles surrounding the joint, significant functional impairment of ambulation and other activities of daily living that have not improved after the patient has participated in an appropriate, aggressive, and sustained course of outpatient therapy services or services in other less intensive rehabilitation settings immediately preceding the inpatient rehabilitation admission but have the potential to improve with more intensive rehabilitation. (A joint replaced by a prosthesis is no longer is considered to have osteoarthritis, or other arthritis, even though this condition was the reason for the joint replacement.)

(Be prepared to discuss joint deformity, substantial documented proof of range of motion loss, atrophy of muscles and again significant functional ADL impairments that had not improved with outpatient or less intense services just prior.) Hip or Knee replacements must ALSO demonstrate one of these three characteristics in your preadmission screening documentation for the patient to be included as conditionally compliant, assuming you are also defending that medically necessary IRF care can be tolerated and the patient can significantly benefit from a multidisciplinary level of service requiring management by a rehabilitation physician.

(A) The patient underwent bilateral knee or bilateral hip joint replacement surgery during the acute hospital admission immediately preceding the IRF admission.

(B) The patient is extremely obese with a Body Mass Index of at least 50 at the time of admission to the IRF.

(C) The patient is age 85 or older at the time of admission to the IRF.

Remember, 2015 will replace presumptive with conditional compliance with manual medical review of all areas that were previously considered ‘presumptive’ in the arthritic and joint replacement categories. Check to be sure your presumed cases would actually meet a medical review audit now!