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Written by: Darlene D'Altorio-Jones (1959-2015) on Friday, May 11, 2012 Posted in: Inpatient Rehab

Let’s reminisce on a few facts from the Final Rule  1538F published in 2009 covering 2010 IRF fiscal year guidelines. These bullets will ring a bell, but did you consider the impact of all these statements combined? If not, let’s do so now!  It’s a realization that caught me off guard but certainly brings new light to medical necessity/medically reasonable IRF care in light of MAC/RAC audits now starting.

2010 Final Rule discussion facts as published and excerpted:

– It is no longer appropriate to allow up to 10 days in an IRF merely to assess the patient, at that point, the average IRF patient would already be preparing to be discharged. (Ten day ‘trial’ went away)

– Specifically, we mean that, at the time of admission to the IRF, there must be reasonable expectation that the patient is able to tolerate and benefit from the intensive rehabilitation services as generally prescribed in this rule so that he or she can progressively make the improvements needed to achieve results of practical value toward his or her functional capacity or adaptation to impairment.

– We do not believe that it is appropriate to provide four days (at which point the IRF would GENERALLY receive a full CMG payment for the patient) or an undefined amount of time for the IRF to determine whether the patient meets the IRF medical necessity criteria.  This determination should be made at the time of the admission to the IRF.

– Must consider whether the patient’s condition is sufficiently stable to allow the patient to actively participate in an intensive rehabilitation program

– CMS does not believe that patients should be transferred to IRFs before their medical conditions are sufficiently stable to enable them to participate in the intensive rehabilitation therapy program provided in IRFs.

– Must consider whether the patient requires the intensive services of an inpatient rehabilitation setting, which is typically MEASURED by whether the patient generally requires and can reasonably be expected to ACTIVELY participate in at least three hours of therapy per day at least five days per week.

– If patients do not need the intensity of services uniquely provided in IRFs, or benefit from them, then it is not clear to us why they would be admitted to an IRF.

– However, we note that this does not mean that patients’ medical conditions will be fully resolved when they are admitted to IRFs.  As one of the commenters summarized, we are requiring that a patient’s medical condition be such that it can be successfully managed in the IRF setting at the same time that the patient is participating in the intensive rehabilitation therapy program provided in an IRF.

Although there are MANY other references to intensity and clarification documentation that define the exact meaning of a medically necessary admission to an IRF, let’s start with the impact of these baseline expectations written in the Federal Register with this one very powerful comment made in the last paragraph of page 39791 and how that comment was interpreted in the Medicare Billing Manual 100-04.
          – <<<In addition, we believe that, in today’s clinical environment, licensed physicians with training and experience in rehabilitation are able to assess a patient prior to admission to an IRF and determine whether there is a reasonable expectation that the patient can participate in and benefit from treatment in an IRF. In the unusual instance that the rehabilitation physician’sreasonable expectation prior to admission is not realized once the patient is admitted to the IRF, we are allowing the IRF to begin making arrangements to transfer the patient to another setting of care and to receive the short stay outlier payment for IRF stays of three days or less (instead of having the entire claim denied), as long as the reasons for the change in the patient’s status before and after admission are well-documented in the patient’s medical record.>>>

Medicare Billing Manual description  140.3.0:  (Also answer #48 in the  National Follow Up Call – Series #4 document)

– “For atypical cases effective Jan. 1, 2010, the HCPCS/Rates must contain a five digit HIPPS Rate/CMG Code A5001. An atypical case occurs under the new IRF coverage requirements that became effective Jan. 1, 2010, where an IRF is eligible to receive the IRF short stay payment for three days or less (HIPPS Rate/CMG A5001) if a patient’s thorough preadmission screening shows that the patient is an appropriate candidate for IRF care but then something unexpected happens between the preadmission screening and the IRF admission such that the patient is no longer an appropriate candidate for IRF care on admission and the day count is greater than three. In this scenario only, if the patient is discharged/transferred on or after day four, we are instructing IRFs to bill HIPPS Rate/CMG A5001. Thus, whether or not the IRF is able to discharge the patient to another setting of care within three days, the IRF will only be eligible for and receive the IRF short stay payment for three days or less (HIPPS Rate/CMG A5001).”

Be aware that the grouper software does not do this for you. Diligently, you must review each case to decide if you met the medical necessity criteria. More specifically, are you sure you met the intensity requirements within the first week of the patients stay andhave sufficient documentation within the chart that could be considered appropriately exempted based on the reason the patient did not meet planned intensity?
A clarification comment you need to consider is answer #53  from the National Follow Up Call – Series #4 document.

<<<53.  Clarification regarding CMS’s expectations if patients experience a significant change in condition that prevents them from participating in their intensive rehabilitation therapy program within the first 3 days of admission to the IRF, given that the brief exceptions policy cannot be applied to the first 3 days of the admission.

Answer: If the significant change in the patient’s condition means that the patient is no longer appropriate for IRF care, the IRF must immediately begin the process of discharging the patient to a more appropriate setting of care. However, if the significant change in the patient’s condition is expected to be temporary such that the patient will be able to resume their full course of treatment in the IRF for the seven consecutive day period, then the “missed” therapy time can be made up on a subsequent day and the IRF stay may continue.>>>

I realize this is a long winded post, but the details that unfold in this discussion hold extreme consequences. How often have you reviewed intensity criteria within the first week and determined that the patient indeed met all the criteria above. And even if there was a tenuous start in the initial week of care, that at the very least there was sufficient documentation and the patient was still able to meet 15 hours of therapy intensity specific to the patients consecutive seven day period beginning with the date of admission?

Despite excellent outcome, meaning the patient returned to the community and you did this expeditiously; that specific case could be called into question for payment at the CMG rate for 5001 if intensity was not met in the first week (or any time thereafter the first four days if you want to argue the true meaning of intensity criteria). The corrected notice placed this CMI at 0.1474. The standard payment rate is $14,076 for a 1.0 CMI. The standard payment would become $2,074.80 as the entitled payment. The difference should draw your attention to the fact that right now several areas are undergoing medical necessity audits.

The grouper software does not monitor this, so the final question is – Do YOU?

For persons using Medilinks, I highly encourage use of the “Current Stay 3 Hour Rule” report and significant due diligence to intensity and tracking the 3 Hour Rule. Standard content or the adoption of standard content observations and workflow can mitigate this scenario.


Take the 3 Hour Rule comparison survey now to see how you compare to other IRFs.
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