Re: CMS-1474-P – Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for FY 2004 (68 Federal Register 26786).

Liberty Place, Suite 700
325 Seventh Street, NW
Washington, DC 20004-2802
(202) 638-1100 Phone

Friday, June 13th 2003

Thomas A. Scully, Administrator
Centers for Medicare & Medicaid Services
Attention: CMS – 1474 – P
Post Office Box 8010
Baltimore, MD 21244-8010

Dear Mr. Scully:

On behalf of our nearly 5,000 member hospitals, health care systems, networks and other providers of care, the American Hospital Association (AHA) appreciates the opportunity to comment on the Centers for Medicare & Medicaid Services’ (CMS) proposed rule concerning the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS).

The proposed rule would update fiscal year 2004 payments to IRFs by 3.3%, the current estimate of inflation or, market basket rate; revise the methodology for determining payment for extraordinarily high-cost cases (outliers); and begin enforcement of the inpatient rehabilitation program’s 75% Rule.

Our letter will focus on CMS’ misguided proposal to reinstate the 75% Rule in its current form.


To qualify as an IRF, a freestanding rehabilitation hospital or rehabilitation unit of a hospital must satisfy a test known as “the 75 Percent Rule,” among other criteria.  This rule requires the facility to show that at least 75 percent of its inpatient population received intensive rehabilitative services for the treatment of a selected set of conditions during the most recent 12-month cost reporting period.  

The 75% Rule was one of several criteria originally intended to distinguish between facilities that should be reimbursed under the acute care hospital prospective payment system (PPS), and those that should be reimbursed on a cost basis because the PPS diagnosis-related groups did not accurately account for the long lengths of stay and the additional cost of treating patients in inpatient rehabilitation facilities.

The list of 10 conditions in the 75% Rule – often called the “HCFA 10” – has not been updated since it was implemented in 1983, and therefore fails to take into account medical advances of the past two decades.  

Over the past 20 years, interpretation and enforcement of the 75% Rule has varied among CMS’s fiscal intermediaries (FIs).   FIs and providers established parameters for which treatments are allowable under the 75% Rule and, over time, influenced the admissions practices of IRFs.  The weight given by CMS to the 75% Rule assessment methodology used by a single FI, Riverbend, is inappropriate.  Prior to the recent phase of aggressive assessments, the other FIs were sending a different message to providers about which treatments would be allowable under the 75% Rule.  CMS’ acknowledgement of this inconsistency led to the current moratorium on enforcement of the rule.  

In the proposed rule, CMS presented a broad assessment of compliance with the 75% Rule in calendar year 2002 based on analysis by RAND.  Based on this assessment, CMS has wrongly implied that a majority of the field intentionally disregarded the 75% Rule.  In fact, CMS and the FIs are key contributors to the current state of confusion and concern in the field related to the 75% Rule.  For providers, the proposed rule’s excessively narrow interpretation of the 75% Rule is a major change, since for many the interpretation is a significant departure from that previously communicated by FIs (other than Riverbend, as of 2001).  

The AHA shares the view of the medical director of CMS’ fiscal intermediary Riverbend, who acknowledged in correspondence to a New Jersey hospital that “… the 75% Rule is antiquated and generally irrelevant, and should either be rescinded or significantly changed.”   The AHA supports modifying the 75% Rule by expanding the “HCFA 10” to include 20 of the 21 rehabilitation impairment categories (RICs), with the exception of RIC 20, the miscellaneous category.  

The Current 75% Rule is Outdated and Obsolete

The “HCFA 10” represent the inpatient rehabilitation procedures most prevalent 20 years ago and have not been updated since their implementation in 1983.   The demand for inpatient rehabilitation treatments approved for payment under the PPS, but not included in the “HCFA 10,” has grown substantially over the past 20 years for a number of reasons.  First, technological advances have created new surgeries and treatments resulting in survival rates not imaginable 20 years ago. This has increased the demand for post-acute inpatient rehabilitation care.  Second, many highly effective rehabilitation therapies that were not medically viable in 1983 improve the lives of Medicare beneficiaries today.  Finally, the aging of the population is increasing the prevalence of other health conditions and associated comorbidities that call for post-surgical inpatient rehabilitation.  These include conditions that are not in the “HCFA 10,” such as heart disease, lung disease, and cancer.  

The inconsistency between the PPS and the 75% Rule sends a mixed message to the field.   On one hand, CMS validated the conditions included in the rehabilitation PPS as appropriate treatments for IRFs to provide to Medicare beneficiaries.  On the other hand, the 75% Rule is a test that encompasses only a subset of the RICs included in the PPS. CMS will reimburse an IRF for conditions such as cardiac, pulmonary, and cancer treatments, but does not include these conditions in the assessment of compliance with the 75% Rule.  The IRF PPS implemented by CMS in January 2002 defines the conditions suitable for inpatient rehabilitation and is consistent with current inpatient rehabilitation medical practice.  As such, the field supports the new PPS.  The PPS parameters related to IRF treatments, in combination with the other existing conditions of participation, ensure that Medicare patients receive intensive, medically appropriate rehabilitation care in IRFs.  

Existing Regulatory Standards for IRFs

Many regulatory standards distinguish IRFs from other providers.   When implemented in 1983, the purpose of the 75% Rule was to ensure that IRFs primarily provide intensive rehabilitation services.  However, other policy safeguards also accomplish this goal.  Still, CMS has demonstrated unreasonable determination to retain the rule in its current form, despite other regulations that effectively determine appropriate IRFs.  The AHA agrees that appropriate criteria are needed to ensure that IRFs deliver intensive rehabilitation in accordance with accepted medical practice.  The AHA views the existing conditions of participation set forth in the CMS Program Manual as more than adequate for preventing lower-intensity inpatient rehabilitation providers from qualifying as an IRF.   Such criteria explicitly distinguish IRFs from other health settings.  They reflect the role met exclusively by IRFs within the continuum of care and include the criteria outlined below.  Non-IRF health providers do not provide these high standards of medical staffing and care delivery needed to effectively integrate acute care with intensive daily therapy.

  • IRF patients must receive close medical supervision from physicians who are available on a 24-hour per day basis and who have special training or experience in the field of rehabilitation.  This supervision is far greater than would be rendered to a patient in a SNF, and physicians serving SNF patients do not, as a matter of course, have this specialized training or experience.
  • For each IRF patient, a physician establishes, reviews and revises the plan of care in consultation with other professional personnel.  The plan of care must include a reasonable expectation of improvement in a patient’s level of function.
  • Each IRF has a director of rehabilitation who is a full-time physician who, following medical school, has completed four years of training in the medical management of patients requiring rehabilitation services, including neurological, musculo-skeletal, respiratory, and cardiac care.  No requirement for a full-time physician’s involvement exists for SNFs.
  • In IRFs, 24-hour per day rehabilitation nursing is required to be provided by registered nurses with specialized training or experience in rehabilitation.  This level of service is not generally readily available in SNFs, home care or other settings.
  • Each IRF patient must require and receive at least three hours per day of physical and/or occupational therapy at least five days per week.  Again, no other provider group is held to this standard and most SNFs and other post-acute settings are not equipped to provide this intense level of rehabilitation services.
  • A multi-disciplinary team, including, at a minimum, a physician, rehabilitation nurse and one therapist, must provide a coordinated program of care that is documented in the patient’s chart.  The team must hold conferences at least every two weeks.  In SNFs, physicians rarely, if ever, participate in-person in team conferences; even therapists’ participation is inconsistent, and rehabilitation nurses are not generally on staff.

IRFs provide a multidisciplinary team approach to rehabilitation.   Physicians, most commonly physiatrists, lead the distinct teams of professionals caring for patients in IRFs.  The presence of full-time physiatrists who oversee and coordinate care on a daily basis is integral to each patient’s rehabilitation process.  The multidisciplinary team is specially trained to integrate the treatment and management of complex medical conditions with intensive rehabilitation techniques and activities.   This approach is essential to achieving optimal outcomes for this very ill patient population.  At a minimum, the team includes the patient and their support system, rehabilitation nurses, physical, occupational, recreational, and speech therapists, social workers, and psychologists.  IRFs incorporate additional clinicians as the patient’s needs dictate.  A majority of daily therapy is executed under the care of certified therapists, as opposed to therapy aides.

Given the advanced health needs of IRF patients, the value of round-the-clock monitoring by rehabilitation nurses cannot be overstated.  Rehabilitation nurses have received additional training and education emphasizing a holistic approach to care.  Typically registered nurses, they provide a hands-on approach to care delivery and promote a “well role” for patients versus a “sick role,” encouraging self-care and independence.  Rehabilitation nurses focus their care on teaching patients and families appropriate rehabilitation methods and techniques.  These techniques provide patients and their families the strategies to sustain a patient’s optimal health and independent function at home.

The common diagnoses of IRF patients – from stroke and brain injury to burns, joint replacement and heart disease, in combination with comorbidities and other health problems – result in a loss of function that disrupts the lives of Medicare beneficiaries.  IRFs treat a very sick population.  These patients need access to acute care that is integrated with restorative care.  Medicare beneficiaries want to regain the functional status needed to return home as quickly as possible.  IRFs facilitate this recovery through a combination of specialty caregivers, intense focus on restorative therapies, the physician-led integrated approach, and the daily application of at least three hours of therapy, five days per week.  In comparison, Medicare requires SNFs to provide at least 30 minutes of care per day, five days per week.

Using the RICs as New Criteria for the 75% Rule

CMS validated the conditions within the 21 RICs as appropriate for treatment by IRFs through research conducted to develop the IRF-PPS implemented January 2002.  The new PPS is based on extensive and thorough analysis by RAND with input from the inpatient rehabilitation field.  As noted, providers strongly support the IRF-PPS since it is consistent with the current practice of inpatient rehabilitation medicine.  Its exclusion from the current 75% Rule of inpatient rehabilitation conditions that CMS has deemed appropriate for payment is irrational.  CMS should not favor certain RICs, – the “HCFA 10” – over other non-“HCFA 10” RICs.  This irresponsibly penalizes Medicare beneficiaries seeking treatment for other conditions by placing an arbitrary 25% limit on these treatments.  For these reasons, AHA seeks from CMS the expansion of the “HCFA 10” to 20 of the 21 RICs.

Additionally, we would propose that the RICs, especially RIC 20, the miscellaneous category, be reevaluated and updated on a periodic basis to allow for innovation and change in the practice of rehabilitative medicine.   We have completed a detailed analysis (see Attachment A) of the RICs and describe the appropriateness for including each RIC in the criteria used in the 75% Rule.

Implications of Enforcing the Current 75 Percent Rule

CMS’ proposed rule includes a perplexing assessment by CMS of the field’s level of compliance with the 75% Rule.  We find it very unusual that CMS has chosen an excessively narrow definition of compliance that rules out 87 percent of all rehabilitation hospitals and units.  The results of this analysis clearly illustrate the inadequacy of the current 75% Rule.  The entire rehabilitation field is tremendously concerned with CMS’ actions.

The methodology used by RAND to develop its assessment of compliance for calendar year 2002 incorporates erroneous exclusions.  First, the omission of all joint replacements is inconsistent with parameters communicated by many FIs to providers in their regions.  Second, joint replacement associated with polyarthritis or other conditions included in the “HCFA 10” should appropriately be counted in any valid assessment of compliance.  Further, many ICD-9 codes are absent that are commonly and appropriately used to code treatments that are allowable under the “HCFA 10.”  The evidence is clear:  If only 13 percent of rehabilitation hospitals and units are meeting the 75% Rule, then the 75% Rule is broken and must not be enforced in its current form.

All Medicare beneficiaries need equitable access to inpatient rehabilitation care and the impact of again enforcing the current 75% Rule would significantly limit some patients’ ability to receive appropriate care in rehabilitation hospitals and units.   Today, some facilities limit non-“HCFA 10” treatments despite the growing demand for other rehabilitation services.  If an IRF determines it is in jeopardy of exceeding the 75% Rule, it must reduce services for non-“HCFA 10” treatments to maintain compliance with the 75% Rule.  This harms Medicare patients who, as a result, do not benefit from the specialized treatment provided in an IRF.  This creates an inequity between those patients receiving specialized rehabilitation care and those being denied the benefit of IRF care due to the restrictiveness of the 75% Rule.  In effect, there are two standards in existence today for inpatient rehabilitation treatments – a standard of access for beneficiaries with conditions included in the “HCFA 10,” and a lower standard of access for beneficiaries with conditions outside the “HCFA 10” – even when these conditions require a similar intensity of rehabilitative care.  It is impossible for caregivers involved in inpatient rehabilitation to explain this inequity to Medicare beneficiaries.  The result: a system that provides incentives to practice a 1983 standard of rehabilitative medicine in 2003.

Reinstating the current 75% Rule harms general acute care hospitals and the entire continuum of care offered to Medicare patients.   Enforcement of the current 75% Rule would have significant consequences for general hospitals that lose clinically appropriate discharge options for patients who need post-acute intensive therapy.  Reduced referral options would unnecessarily increase length of stay, create inefficiencies in hospital discharge planning and operations, and exacerbate any existing shortages of inpatient acute care beds.  The ripple effect of enforcing the 75% Rule will be detrimental to the existing continuum of services and the patients who rely on the right care, at the right time, in the right place.

We urge you to adopt a 75% Rule that utilizes all the newly developed RIC payment categories and that incorporates advances in rehabilitation medicine.  The 75% Rule must be modernized; implementation in its current form is irresponsible public policy.  Our proposal to use 20 of the 21 RICs is consistent with current medical practice and the new payment system, adaptable as medicine continues to change, and a reasonable approach to ensure that facilities provide appropriate services for qualification as a rehabilitation hospital or unit.

Thank you for considering our remarks on the proposed rule.  If you have any questions about our comments, please feel free to contact me or Rochelle Archuleta, senior associate director for policy, at (202) 626-2320.


Rick Pollack
Executive Vice President

Attachment A:
The Role of Inpatient Rehabilitation Facilities,
Including Descriptions of Rehabilitation Impairment Categories

It is important to keep in mind that the degree of each patient’s functional loss and potential for regained functionality, rather than merely a patient’s diagnosis, are the critical factors in determining the appropriate intensity of rehabilitative therapy.  This assessment includes deciding whether daily medical supervision is necessary relative to the management of the patient's disease(s) and associated symptoms, whether the patient is willing and able to undergo daily, intensive therapy, the need for multiple professionals to provide specific therapies, and the determination of potential benefit of various recommended therapies.  

The determination is also significantly affected by the presence of comorbidities that complicate the rehabilitation process.  A referring physician identifies the appropriate medical placement for rehabilitation patients based on his or her clinical judgment following evaluation of a patient’s functional loss and related health characteristics.  For those patients deemed to be in need of intensive therapy, the receiving IRF physician and multidisciplinary rehabilitation team implement an intensive rehabilitative plan of care.  For this group of patients, focused, multidisciplinary care is medically necessary to restore loss of function.  This specialized form of care is uniquely provided by inpatient rehabilitation facilities (IRF).

IRF care is a vital component of the continuum of rehabilitation treatment that includes general acute hospitals and skilled nursing facilities.  Each serves a unique and necessary function for Medicare beneficiaries.  Patients treated in IRFs usually have an illness or disease process that is life altering and permanent.  IRFs approach treatment of the patient from a much more functional perspective with the primary goal of returning a patient to a homelike setting with the ability to be as functionally independent as possible, while also treating and monitoring the medical needs of the patient.  

To clarify the types of patients treated by IRFs and illustrate the advanced medical needs of these patients with regard to restoring functional loss, conditions within each of the RICs are described below.  The descriptions highlight the common characteristics found among the patients treated for conditions and related care in each RIC, and justify their inclusion in an updated 75% Rule.  These descriptions also reinforce the distinct role that IRFs play within the continuum of care.  The range of advanced conditions and associated treatments and therapies is vast and demonstrates that providers of inpatient rehabilitation have invested a tremendous effort into assembling focused care teams with unmatched competencies.  

For those 15 RICs already included in the “HCFA 10” (01, 02, 03, 04, 05, 06, 07, 10, 11, 12, 13, 17, 18, 19, 21), the following descriptions are intended to illustrate the complexity of cases treated by IRFs, the need for daily physician oversight for this group of patients, and the value of the constant rehabilitation nurse presence due to the intensity of patient needs related to functional loss.

For those RICs not presently included in the 75% Rule assessment process (08, 09, 14, 15, 16, 20), the following descriptions also demonstrate that IRF-level intensity of care is required to restore patients’ functional independence due to the complexity of patient health status.  As such, these RICs should be included in the assessment of a facility’s compliance with the 75% Rule to ensure patients’ equal access to care for all conditions approved for IRF care under the IRF PPS.   AHA recommends that RIC 20, the miscellaneous category, be excluded from the 75% Rule assessment due to its diverse nature.  However, a thorough evaluation of RIC 20 is essential to identify conditions that no longer should be included in the miscellaneous category (for example, certain cancer treatments) due to their therapeutic significance and increasing frequency of use.  

Impact of Comorbidities.   IRF patients, in addition to needing treatment for their primary diagnosis, possess one or more comorbidities, which significantly complicate care and influence the patient recovery plan.  An interdisciplinary rehabilitation approach is needed to account for the complexity added by comorbidities such as chronic obstructive pulmonary disease, diabetes mellitus or coronary artery disease.  These comorbidities typically require daily medical supervision to maximize a patient’s ability to respond to treatment for the acute condition and associated rehabilitation.  For example, as this process pertains to diabetes patients recovering from a major illness that requires daily, intensive therapy, the medical management effort must acknowledge the presence of common side effects such as kidney disease, heart disease, vision loss, circulatory problems, and nerve damage.  For diabetic patients and other patients with chronic illnesses, medical management must incorporate intensive therapy to restore functional loss related to the primary diagnosis and also the factors relating to pre-existing chronic conditions.  This complex treatment program requires the efforts of a highly specialized rehabilitation team so that functional independence of the patient is regained.

Polyarthritis.   With regard to polyarthritis patients who undergo a related joint replacement, the field presently lacks definitive guidance on appropriate coding.  The fact that joint replacement with an underlying condition of polyarthritis is not linked to a sole RIC, as well as the inconsistent instruction received by providers from CMS FIs, has created substantial confusion among providers.  The AHA urges clarification of how to code joint replacement related to polyarthritis as the underlying condition and for CMS to include this treatment within the conditions that qualify toward the 75% Rule, in alignment with accepted practice of inpatient rehabilitation medicine.   The current guidance established for polyarthritis-related joint replacements by CMS is wholly inconsistent with the standards of accepted medical practice related to treating this group of patients.  It is inappropriate for CMS to limit care for this group of patients based on a clinical judgment that is not medically consistent with the current treatments provided by inpatient rehabilitation medical practitioners.  The common clinical characteristics of all arthritis patients, including polyarthritis patients, are elaborated upon below.

RIC 01 – Stroke
Stroke is the third leading cause of death and disability in the United States and the leading cause of serious long-term disability.  Stroke can impact every facet of a person's life, including cognition, speech, swallowing, behavior, ability to walk, mobility, daily activities, and bowel and bladder function, in addition to the psychological, fiscal, and family burden.  It is common for these disabilities to occur in varying combinations and with varying severity.  Comorbidities such as high blood pressure, heart disease and diabetes add to the complexity of care required by almost all stroke patients.  Through an individualized program of care, the inpatient rehabilitation team works with the patient and caregivers to achieve optimal function and maximum quality of life following a stroke.  The team approach, combined with early and intensive intervention, produces better outcomes related to recovery of function and also facilitate a coordinated transition to home.

RIC 02 – Traumatic Brain Injury (TBI), and
RIC 03 – Non-Traumatic Brain Injury (NTBI)
Persons with TBI are most often men in their teens, young adults, or over the age of 75 injured by firearms, falls, or motor vehicle collisions.  Brain injury causes varying degrees of impairment in awareness, language, swallowing, memory, and ability to learn; loss of muscle strength; spasticity (painful, uncontrolled muscle spasms), loss of sensation, impairment in bladder, bowel and sexual function; increased risk for pressure sores, deep vein thrombosis (blood clots), and contractures (permanent joint deformities); and threats to personal identity, family role, vocation, and spiritual meaning.  Given the breadth and depth of these impacts, patients with new-onset TBI require comprehensive and specialized TBI rehabilitation services that are only fully available in hospital-level rehabilitation programs.  Skilled nursing facilities (SNFs) generally do not employ rehabilitation staff who possess TBI knowledge and treatment skills.  Nor do most SNFs have daily access to the array of acute medical physicians and services these patients routinely require for safe and effective rehabilitation.

Typical causes of NTBI include infection, insufficient oxygenation, bleeding, and cancer.  The loss of function and impact on life for persons with NTBI is just as severe as for persons with TBI.  Thus the rehabilitation needs and appropriateness for inpatient rehabilitation care are the same for TBI and NTBI.

RIC 04 – Traumatic Spinal Cord Injury (TSCI), and
RIC 05 – Non-Traumatic Spinal Cord Injury (NTSCI)
Persons with TSCI are most often young adult men injured in a motor vehicle collision.  In addition to nervous system injury pain, TSCI patients experience the same range of impairments as TBI and NTBI patients.  Also in common with new-onset brain injuries, new TSCI patients require a broad range of specialized inpatient rehabilitation services provided by a multidisciplinary health team guided by daily physician coordination.  

Persons with NTSCI tend to be older than those with TSCI.  Nontraumatic causes include invasive cancer, narrowing of the spinal canal, and infection.  While the onset of the disease is usually slower in these patients, the loss of function and impact on life is just as severe as persons with TSCI.  Thus the rehabilitation needs and appropriateness for acute (hospital-level) rehabilitation care is the same as for TSCI.

RIC 06 – Neurological Disorders
Patients in this RIC include those suffering from multiple sclerosis, Parkinson’s disease, polyneuropathy (widespread impairment of nerve sensation), cerebral palsy, and neuromuscular disorders.  When patients in this impairment category have special needs, such as insensate skin, immobilization and positioning challenges, depression or pain, rehabilitation becomes a complicated process. Consequently, they require a comprehensive rehabilitation approach that coordinates an interdisciplinary team of therapists, nursing and physiatrists.  Such a team is necessary because treatment plans need to be customized to each individual’s medical conditions and rehabilitation goals.  Many patients suffer from spasticity, which requires treatments from physicians and therapists specially trained in managing this condition.  When spasticity is properly managed, function can be restored to the limbs and daily independence maximized.  Other patients have special cognitive and speech goals, which require the specially trained staff and equipment of an IRF.  Finally, many of these patients require extensive lifecare management and discharge planning to facilitate their transition to home or another setting, where they will live more independently.  Frequently, to facilitate a return to home, the following services are needed – extensive family teaching, home modification, and fitting and purchase of durable medical equipment, such as braces and wheelchairs.

RIC 07 – Hip Fracture, and
RIC 08 – Replacement of Lower Extremity Joint
These two patient groups are treated with procedures to surgically implant artificial joints. As such, the subsequent rehab program is identical for both.  Physicians prescribe the intensity of treatment based on the overall medical condition of the patient relative to functional loss, the patient’s need for medical supervision, and the ability of the patient to sustain daily, intensive therapy.  

These patients typically have extensive multi-system co-morbidities that place them at risk for complications following surgery.  Given the propensity toward and incidence of post-operative complications, the extent of medical oversight available in IRFs is clearly warranted.  Complications after joint replacement that are addressed on a daily basis in an IRF include surgical wound management, surveillance for blood clot formation, management of co-existing medical problems temporarily destabilized by surgery, and pain management.  For optimal recovery after major joint replacement, daily, specialized oversight and treatment are needed to avoid common complications and prevent readmissions to acute care facilities due to inadequate patient management.

The treatment method for hip and knee joint replacement is similar except the focus of range of motion is at the hip or the knee. The restoration of range of motion is even more critical for knee rather than hip replacement due to the greater risk of getting a blood clot which can be life threatening.  The intensity of post-joint replacement therapy and the selection of the appropriate care setting are determined by the functional needs of the patient, combined with the patient’s ability to undergo daily, intensive therapy.

RIC 09 – Other Orthopedic
RIC 09 includes patients who have suffered an orthopedic injury that does not include a joint replacement, lower extremity fracture (hip, pelvis, femur shaft) or major multiple trauma where the patient’s function has been impaired and functional gain is expected through proper treatment.  Common causes of other orthopedic cases include traumatic injury, cancer, and osteoporosis.  The other orthopedic injury can be in the upper or lower extremity, including shoulder, arm, leg (anything but femur shaft), foot or ankle, which may or may not be coupled with one or more comorbidities affecting functional ability.  The patient with another orthopedic diagnosis has been determined to need 24-hour nursing care and be able to tolerate at least three hours of therapy per day with an expectation during this period of regaining function.   This type and severity of injury requires the management of treatment by a physician specializing in physical medicine and rehabilitation, commonly a physiatrist.   

RIC 10 – Lower Extremity Amputation, and
RIC 11 – Other Amputation
The majority of amputation patients have significant and multiple comorbidities, the most serious of which are the complications related to diabetes.  Patients who undergo amputations of the extremities require intensive rehabilitation to compensate for the loss of the amputated limb by using a prosthetic device.  A typical rehabilitation program consists of wound healing, stump shaping, gait training and/or functional upper extremity activities as well as monitoring of cardiovascular status to ensure safe patient participation in typical rehabilitative efforts. A significant component of amputation treatment and therapy is the education of patient and caregivers on the care needed to manage the prosthesis and to prevent a second amputation.

RIC 12 – Osteoarthritis
RIC 13 – Rheumatoid and Other Arthritis (including Polyarthritis)
Patients treated for osteoarthritis and other forms of arthritis are commonly in their 70s.  Many patients of this age have additional comorbidities and medical needs, which require daily medical management on a frequent basis, especially in light of the intense physical exercise and conditioning they undergo to rehabilitate the treated joint(s).  The combination of post-acute care, medical management needs concerning the underlying arthritis debility, and related comorbidities are viewed by the field as medically appropriate for inpatient rehabilitation for patients suffering serious functional loss and with the capacity to withstand three hours or more of daily, intensive therapy.  

Arthritis produces months and years of weakness and progressive debilitation caused by arthritic changes in multiple joints, increasing fatigue and immobility due to pain.  The resulting sedentary lifestyle reduces cardiac and respiratory capacity and muscle strength.  Therefore, intensive rehabilitation for arthritis patients recovering from one or more joint replacements consists of a two-pronged approach.  The first approach is the strengthening and restoration of function to the replaced joint.  The second and more intense rehab program is directed at strengthening and reconditioning the total patient after prolonged inactivity.  Those patients with cardiac and respiratory comorbidities must recondition their bodies to regain the stamina and energy needed to increase activity allowed by a new joint, free from arthritis.  For these reasons, an intensive, multidisciplinary approach is vital for this group of patients.

RIC 14 – Cardiac
The following conditions are included within RIC 14:  post myocardial infarction, coronary artery bypass grafting, acute congestive heart failure and heart transplantation.  Medical monitoring of these patients is critical for cardiac changes, fatigue, and internal fluid balances.  Daily physician visits are required in conjunction with cardiac monitoring not only during exercise, but while performing routine activities including activities of daily living, transfer training, and ambulation.  The rehabilitation plan of care and its progress are directed by the patient’s healing, as evidenced by daily monitoring.  Adjustments to the rehab program may be needed on a daily basis based on a patient’s tolerance of these activities.  In addition to the need for ongoing monitoring, an aggressive approach is often needed to limit the adverse physiological and psychological effects of cardiac illness, reduce the risk of death and enhance the patient’s vocational and functional status.

RIC 15 – Pulmonary
In addition to close medical management, as described above, pulmonary patients require psychological intervention, stress control, and exercise reconditioning.  Inpatient pulmonary rehabilitation programs have been shown to increase strength and endurance and lead to greater tolerance of dyspnea (shortness of breath) while allowing some patients to wean from continuous oxygen therapy.  These types of conditions require the intensity in therapeutic approaches of a team oriented rehabilitation program in order to achieve positive outcomes.

RIC 16 – Pain Syndrome
Chronic pain is generally caused by injury or diseases such as cancer, arthritis, sickle cell anemia, low back disorders, headaches, and nerve-related pain caused by disorders such as diabetes and fibromyalgia.  People with chronic pain disorders generally have a relatively constant component of pain that is frequently superimposed by exacerbations, known as breakthrough pain.  The impact of pain cannot be underestimated as it affects every aspect of life and results in significant decreased physical and mental functioning as well as social well-being.  Due to the often unpredictable and variable nature of chronic pain and the need to provide a treatment plan directed at improving an individual’s ability to function that is not compromised by either drug side-effects and/or associated pain-related co-morbidities, a coordinated treatment approach is required by a team of specifically trained providers relative to pain control.  

RIC 17 – Major Multiple Trauma – No Brain or Spinal Cord Injury; and
RIC 18 – Major Multiple Trauma – Brain or Spinal Cord Injury
Major multiple trauma (MMT) patients are people who have experienced serious injuries, which may include major multiple fractures or other major trauma (RIC 17).  Many cases involve traumatic brain and/or spinal cord injury (RIC 18).  In the case of RIC 18, the extensive rehab care described for TBI and SCI is also commonly needed for MMT patients.  

RIC 19 – Guillain-Barre Syndrome
Guillain Barre Syndrome (GBS) is characterized by acute onset of weakness following a viral syndrome.  Weakness and paresthesias (hyper sensations) typically start in the feet and ascend over days to weeks.  Cases may involve complete paralysis, including respiratory muscles, leading to ventilator dependence. Swallowing and facial weakness are also common.  Blood pressure, heart rate and heart rhythm abnormalities are present in most GBS patients.  Often these patients are monitored in an ICU setting until their transfer to an inpatient rehabilitation setting.

The cardio-respiratory system must be serially monitored for signs of compromise and/or progression in weakness. These patients are also at higher risk for deep vein blood clots, pressure ulcers, and pneumonia due to immobility. Close nursing and physician oversight is important to reduce the risk of these complications.  The rehabilitation for GBS patients includes positioning, range of motion exercises, splinting (both static and dynamic), conditioning, and pulmonary toilet.

RIC 20 – Miscellaneous
As noted, the demand for some of the conditions that fall into RIC 20 have grown due to technological gains and an aging population.  RIC 20 should be carefully analyzed with such conditions removed from the miscellaneous category into other RICs that are included within the parameters of a modernized 75% Rule.  In particular, post-acute cancer and transplant rehabilitation continue to grow in prevalence and are providing effective restoration of function for affected patients.  As such, these two conditions should be included in the needed analysis of RIC 20 that identifies conditions to remove from the miscellaneous category into an existing HCFA 10 RIC or other RIC that is applied to an updated 75% Rule.  

Cancer.   Surgical intervention, chemotherapy treatment, and radiation therapy services for the treatment of cancer have improved dramatically in the last two decades.  As individual life expectancy has improved, the debilitating impact of these treatments on patient stamina and function has increased dramatically.  Patients undergoing cancer treatment often have physical, emotional and social issues that affect their quality of life, regardless of the type of cancer.  Inpatient cancer rehabilitation programs pick up where the clinical oncology team leaves off, focusing on improving physical function, managing pain, improving physical conditioning, endurance and exercise performance, and improving the patient’s overall quality of life.

The medical oversight needs of cancer patients requiring inpatient rehabilitation care are significant.  The attending physiatrist works closely with the oncology team to ensure that medical issues are effectively managed in the inpatient rehabilitation environment.  These patients require daily medical oversight to manage the multiple comorbidities and the many specialized medications they have been prescribed.  Cancer rehabilitation is a complex process requiring an interdisciplinary collaboration among a broad array of providers and specialists.  Regardless of an individual’s life expectancy, specialized cancer rehabilitation plays a vital role in improving the quality of life of individuals with cancer.

Transplants.   Over the past 20 years, there has been a significant increase in the number of patients receiving organ transplants.  The number of kidney, liver, heart and lung transplants has increased dramatically, saving thousands of lives.  Given the shortage of organs in the United States, patients may wait for extended periods of time for a transplant which exacerbates the patients debilitation and weakness.  Following surgical transplantation, many patients are challenged with significant debility requiring the expertise of an interdisciplinary rehabilitation team.

The medical oversight needs of transplant patients requiring inpatient rehabilitation care are significant.  In the rehabilitation environment, medical and nursing staff and the other members of the interdisciplinary team have developed unique competencies related to the management and monitoring of medical status and anti-rejection monitoring and treatment.  Given the medical fragility of these patients, daily oversight by a physician is critical as the patient works with the multi-faceted rehabilitation team to improve stamina and re-learn activities of daily living following the transplant.  In addition to treatment of transplant-related needs, patients need significant assistance to improve physical conditioning, endurance, and exercise performance.  Patients left with permanent impairments are especially dependent on the varied experts contributing to the inpatient rehabilitation team.  

RIC 21 – Burns
For children and adults with extensive burns, particularly those that cross joints, inpatient rehabilitation is an important phase in the healing process.  Therapy must focus on wound healing and preventing complications such as infection and joint contractures. Proper positioning, splinting, and exercise are important in the care of these patients. Careful attention must be paid, however, to balancing the risk of disrupting burn healing due to stretching, and the risk of contracture. Proper pain management is necessary to maximize mobility and performance.  Ambulation early in the rehabilitation course is encouraged to reduce the risks of deep vein thromboses, pressure ulcers, and pneumonia from immobility.  Disfiguring scars must be discouraged with pressure garments. Hand deformities can severely limit the patient’s ability to perform activities of daily living so exercise, splint use, and proper management of exposed tendons are crucial to optimize hand function. Heterotopic ossification (abnormal bone and soft tissue regeneration) can result in progressive loss of motion and nerve damage – the risk of which increases with longer periods of immobility. The value of psychology and vocational counseling cannot be overstated in the rehabilitation of the burn patient.


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