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Written by: Darlene D'Altorio-Jones (1959-2015) on Monday, June 6, 2011 Posted in: Inpatient Rehab

The special niche of rehabilitation is at best a conundrum in the overall scheme of post acute care. Many of the challenges were pointed out in the final report discussing, “Uniform Patient Assessment for Post-Acute-Care, Final Report, January 25th, 2006,” authored by the Division of Healthcare Policy and Research which began the discussions for the CARE tool (available at

Inpatient rehabilitation units and free standing inpatient rehabilitation facilities find even greater challenges for where they “fit in” when reviewing regulatory guidelines and general practices from acute care Medicare manuals. Rehab sits on the fence, and for some reason, the clearest of guidelines are disputable. Some items listed may spark discussion, others just a shaking of the head. IRFs feel like a fabled “step child” when it comes to fitting into acute care regulations; free standing rehabilitation hospitals have even more challenges. These are some examples:

1. Inpatient rehabilitation is a Medicare benefit of a Part A stay; clearly acute, yet these services are lumped into the post acute care continuum even though care must be “intense, coordinated and interdisciplinary.”

2. Quality measurement discussions occurring now pull LTACH, IRFs and hospice together for establishing reportable quality metrics. Is this the best fit?

3. Electronic Health Record incentives and benefits initially exclude IRFs. Although, units within hospitals, by windfall, may reap benefits. It’s clear that stand alone hospitals struggle to direct actions toward meaningful use and are excluded in financial benefits to obtain electronic standards.

4. Free standing facilities must abide by criteria outlined in 42 C.F.R. PART 482—Conditions of Participation for Hospitals, in addition to the specialty criteria for rehab found in section 412. Again, offering clear confusion as to why they were not included in EHR criteria and benefits at the first stage.

5. In a deeming status audit, free standing rehabilitation facilities are more specifically aligned with section 412 criteria, which is the specific rehabilitation criteria. However, state and deeming authority checklists utilize the standard set of hospital 482 participation criteria when clearly some are replaced entirely by section 412, given they are an IRF. Try explaining that one to your deeming status surveyors! I have … it’s a priceless discussion.

6. Nursing practice, in terms of time spent with patients, can be the greatest influence of a rehabilitation model of care. However, the regulations speak very little to the mandates of the integrated plan of care required for rehabilitation nursing. In contrast, Hospital Conditions of Participation nursing practice directs 482.23 (4), “The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient.” When practiced in a free standing hospital, this contradicts the uniqueness of the plan of care needing to be interdisciplinary as the essence of IRF criteria.

7. The billing and coding documents required for the most part follow PART A hospital guidelines although HIPPS code, date of transmission and type of bill denote IRF. There is continued confusion for assigned impairments through PAI manual instructions and coding practices for etiologic diagnoses by coding staff. Further, although the 3 Hour Rule is non-rounded time, CPT and units of service must be reported in total by code for the stay on the billing document to be transmitted to the Medicare Audit Contractor and as detail later required to complete cost reporting data. Dual tracking must occur.

8. Final and most important to All IRFs; the OIG just published J5 Report 20110224.pdf indicating that 24 of 53 claims were found in error resulting in $245,090 of incorrect claims for transfer rule issues. Most likely a direct result of the PAI manual requiring an “05” to be listed as the discharge setting to SNF. This code is in conflict with the UB Medicare Claims Billing Manual that states one should code an “03” for SNFs that accept Medicare payment and an “04” for an intermediate level of care. With the PAI as part of the medical record, seeing the code for discharge can be picked up more readily by coders causing an “Oops … why are those numbers different?”

If you add the fact that the PAI manual has not been republished for clarification and scoring guidance since 2004, even though attachment and criteria guidance have been published annually, these all lead to varied reasonable doubt for where to turn for definitive regulatory answers.

I am certain your facility has struggled with a few of these items. Get it out … what other dichotomies exist, I am sure this isn’t a full list.

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