The Anatomy of a Rehab Patient
The Case Manager’s Dilemma:
Who Should You Refer?
Medicare vs Commercial
• Medicare:
– Must be “reasonable and necessary”
– Does not say that “if the patient can be treated in SNF,
they cannot be seen in an IRF”
• Commercial:
– Totally up to the payer
• The only MC rule that applies to the commercial patient is that we
must count them in our CMS-13 calculations
– So, if functional loss and belief that IRF is the best
discharge disposition, refer and we will attempt to get
prior authorization
• Worker’s Comp will often approve rehab in spite of patient’s
inability to participate at the high level of therapy intensity that
Medicare requires
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Medicare: Reasonable and Necessary
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Significant functional loss
– Needs assist in several one or areas of function
• Gait, transfers, bowel and bladder, dressing, eating
– Potential for gain (as assessed by the IRF and IRF physician)
Need for intensive therapy
– 2 therapies
– 3 hrs. per day, 5 days per week or 15 hours per week
• Includes activities of daily living (feeding, grooming, bathing, dressing)
• Not all about time in the gym
• let the IRU decide if patient can tolerate
Rehab Nursing 24/7
– To reinforce skills from therapy and to teach and coach
– To address medical issues and treatment as well as functional issues
Interdisciplinary Care
– Rehab nursing to reinforce skills from therapy and to teach and coach
– Social work/Case Management to address discharge planning and resource needs
– Therapy services
– Rehab physician
Rehab physician supervision
– To coordinate the entire team
– To work with consulting medical staff
– To lead the team in addressing function in spite of or along with medical management
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Commercial Insurance Issues
• Not governed by Medicare requirements except that the CMS-13
diagnostic compliance is calculated on the entire population
• Each payer may have their own pre-cert requirements
– Admissions Coordinator will facilitate this step
• Significant push to send patients to SNF
– Less expensive on the surface; not necessarily so
– May need to have physician advocate for patient with insurer’s Medical
Director; but…..
• Commercial Payers can and do approve cases that would not meet MC
payment requirements; and
– It is appropriate for us to take those patients
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Commercial Patients
• Does the patient have an IRF benefit?
• Does the patient have functional loss?
• Do you believe the patient would benefit from an
interdisciplinary treatment plan to help them achieve
higher levels of independence?
• If yes, refer to IRF. Let our clinical assessment staff
review the case and make a recommendation.
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Reasonable Criteria for
Admission
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The CMS-13 Diagnostic Categories (to some extent)
Prior Level of Community Activity
Significant Functional Loss
Potential for Significant Practical Improvement
Intensive Therapy Services
Rehab Nursing Requirements
Requirement for Medical Supervision
– Comorbid Conditions
– Face-to-face physician visit 3 x per week
• Requirement for Coordination of Care
• Approved funding (yes, this is legal)
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Who should be referred to IRF?
GENERAL GUIDELINES
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What’s in a Diagnosis?
• Medicare requires that the IRF accept 60% of it’s
patients from certain diagnostic categories.
– This is a certification requirement, not a coverage
requirement
– Patients outside these diagnoses are often good
candidates for IRF
• Don’t deny a patient access just because of a diagnosis;
but…
• If they have one of these diagnoses and they have functional
loss, it’s likely they will qualify
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CMS DIAGNOSTIC
CATEGORIES
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Stroke
Fracture Femur
Spinal cord injury
Brain injury
Burns
Congenital Deformity
Amputation
Major Multiple Trauma
• Neurological disorders
• Polyarthritis
– Active polyarticular RA
– Systemic vasculidities with
joint inflammation
– Severe or advanced osteo – 2
or more Joints
– Total Joint Replacement if
one or more:
• Bilateral
• Obesity (BMI > 50)
• Patient age 85 or over
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And, just to prove that diagnosis alone
doesn’t drive rehab,
The Most Common Diagnoses - 2010
Diagnosis
%
Stroke
20.5
Hip Fracture
14.4
Major Joint Replacement
11.2
Debility
9.9
Neurological
9.7
Brain Injury
7.3
Other Ortho
6.5
Cardiac
5.0
Spinal Cord Injury
4.3
Other
11.3
Much overlap with SNFs, but
hospital-based units have easy
access to patients and physiatrist
Medical Directors on hospital
staff who can complete preadmission consultations in the
hospital. Freestanding IRFs have
sophisticated and aggressive
referral development programs.
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Elements of “Reasonableness”
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Rehabilitation Needs
Close Medical Supervision
24 Hour Rehabilitation Nursing
Relatively Intense Level of Rehab Services
Multidisciplinary Team Approach
Coordinated Program of Care
Significant Practical Improvement
Reasonable Goals
Appropriate Length of Stay
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Rehabilitation Needs
• Does the patient have functional losses that are new
or that are exacerbated by this new event?
– What was the patient’s prior level of function?
– Active in the community (or in the case of a nursing home
resident, within the nursing home community)?
– How do the new functional losses impact the patient’s
ability to return to home/community?
• Does the patient need therapy interventions to
regain that function in a reasonable period of time?
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Rehabilitation Needs
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Prior Level of Function
– Specific detail of functional level
• Physical Function
– Include how much help in detail
– Include devices
Community
Activity must be
well documented.
• Community Activity
– Specific detail
» Driving, shopping, Church, other activities
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Current Functional Loss
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Toileting
Toilet Transfers
Bed to/from Chair Transfers
Lower Extremity Dressing
Ambulation
Stairs
Bathing
If patient has minimal to moderate
assistance requirements in several of these
areas, they should be referred.
 Greatest weighting for payment
 Key areas for development of
protocols
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Close Medical Supervision
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Need for rehab physician visits to manage functional rehab program and
coordinate medical issues
Patient requires and receives management of the rehabilitation program BY THE
REHAB PHYSICIAN no less than three times per week
– Face to Face Visits with the Rehab Physician
– Notes address functional issues as well as medical ones
– Notes address progress to date and continued needs and potential for functional gains
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There are orders from the rehabilitation physician written at the time of admission
– Include rehab nursing, therapy, etc .
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Rehabilitation physician synthesizes the interdisciplinary plan of care and specifies
the reason for rehab
There is evidence in the record that the rehab physician attends and leads the
team conference
The documentation in the record must be legible!
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24 Hour Rehabilitation Nursing
• Must be specific orders for rehabilitation nursing procedures
• Nursing plan and daily notes address the patient’s needs related to
rehabilitation
• Rehab nursing staff addresses educational needs
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Disease information
Medication management
Bowel and Bladder
Self-Care
Carryover of the skills learned in therapy to the tasks completed with nursing
staff
• Education about medication and equipment use
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Relatively Intense Level of Rehabilitation
Services
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Must have multiple therapies
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– One of which is PT or OT
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– If group therapy better meets patient
needs, must clearly document
rationale
Intensive level of therapy services
– At least 3 hrs. of therapy 5 of 7 days
– Or, 15 hours per week
– Once again, not all of the exercise is
“gym” time
– Let the IRF decide
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Brief exceptions policy allows some
leeway
– Not more than 3 days
– Clear documentation of why
requirement not met
– Should see discussion in team notes
– If problematic, consider if patient
appropriate for 15 hours per week
Standard of care is 1:1 therapy
Should be a transition from patientcentered therapy to patient/caregiver
education, DME training and home
needs as patient approaches
discharge.
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Different than the acute hospital
interventions that are focused on moving
the patient to the next level of care
Commercial Payers may have their
own interpretation
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Interdisciplinary / Coordinated Delivery of Care
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Patient Focused, Individualized Plan of Care
Interdisciplinary Approach
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Team goals and objectives
Team communication
Coordination of care
ITM at least every week
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Standing team meeting once per week suffices
May be state specific issues requiring more frequent meetings, different documentation
Documentation includes key elements
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Assessing the individual's progress towards the rehabilitation goals;
Considering possible resolutions to any problems that could impede progress towards the goals;
Reassessing the validity of the rehabilitation goals previously established; and
Monitoring and revising the treatment plan, as needed.
Attended by professionals involved in the rehab plan
•
Must include at least:
– The rehab physician (not an extender)
– RN w/ training and experience in rehab (Not an LVN) and who is familiar with the patient
– Social worker or case manager
– Licensed therapist from each discipline involved in treating the patient (Not an assistant) and who is familiar with the
patient
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Significant Practical
Improvement
• Goal of IRF treatment is to enable the patient’s safe return to the home or
community-based environment
– Generally, goal is community discharge; there are exceptions
• Does the medical record demonstrate measurable deficits that are likely to
improve significantly with an intensive rehabilitation program
– Detailed measurements at least weekly in key areas
– FIM Scores are not enough, need formal measurements of ROM, strength and
detail of progress
• In the absence of potential for independence, does documentation
describe what level of functional improvement can be expected from the
plan of care?
MYTH: Potential SNF Placement does not preclude IRF admission and does not
require immediate discharge!
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Functional Loss & Potential for
Improvement
• What is significant, measurable, reasonable?
MEDICARE‘S RESPONSE:
Clarification of the terms “significant benefit,” “measurable improvement,”
“predetermined and reasonable period of time,” and “nature and degree of expected improvement.”
We believe that rehabilitation physicians are typically able to determine from examining a patient what
represents “significant benefit” for that patient, what represents “measurable improvement” for that
patient, what is a “reasonable period of time” to achieve the expected level of improvement, and what the
“nature and degree” of that expected improvement would be. We also expect that the rehabilitation
physicians will be able to clearly explain their reasoning in the patient’s overall plan of care, which must be
documented in the patient’s medical record at the IRF.
What this means to us:
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Medicare accepts that the rehab physician is the best qualified to make a decision
about whether a patient is appropriate for IRF
If the patient has functional loss that would not be expected to return simply with
increased activity, they could and should be referred to the IRF.
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Should I refer?
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