Medicare Benefit Policy Manual Checklist

Section 110, Chapter One
Inpatient Hospital Stays for Rehabilitation Care

110.1 - Basic requirements for services to be covered

The services must be reasonable & necessary (in terms of efficacy, duration, frequency, and amount) for the treatment of the patient’s condition

It must be reasonable & necessary to furnish the care on an inpatient hospital basis, rather than in a less intensive facility such as a SNF, or on an outpatient basis.

In addition, a beneficiary must classify into one of the CMG’s payable by Medicare under the IRF PPS.

110.2 - Pre-Admission Screening

Considered standard practice in rehabilitation hospitals to determine whether patient is likely to benefit from either intensive hospital program or extensive inpatient assessment.

110.2.1 –Admission Orders

110.3 – Inpatient Assessment of Individual’s Status & Potential for Rehabilitation

110.3.1 - Inpatient Assessment

Coverage available for “inpatient assessment” of patient’s potential to benefit from IRF only if it was reasonable and necessary to perform the assessment in the hospital.

  • Usually requires 3 to 10 days
  • May be covered even if patient found not suitable

110.3.2 –Specific Examples

110.4 – Rehabilitation Hospital Screening Criteria

Describes the QIO review process. “Screening criteria” developed to assist in applying Medicare requirements.

  • If all criteria satisfied (110.4.1 –110.4.7), claim maybe approved.
  • If all criteria are not met, the case goes to a Physician reviewer. Physician reviewer uses “knowledge, expertise and experience.”

110.4.1 - Close Medical Supervision by a Physician With Specialized Training or Experience in Rehabilitation

"This patient’s condition requires the 24-hour availability of a physician with special training or experience in rehabilitation because _____________."

See: Documenting Physician Services

110.4.2 -Twenty-Four Hour Rehabilitation Nursing

"This patient requires the 24-hour availability of a registered rehabilitation nurse because _____________."

  • Progress in bowel & bladder functional status & management, or
  • Assessment of skin integrity issues/preventative measures, or
  • Assessment of nutritional & hydration status, or
  • Assessment of functional status & safety concerns, physical & cognitive, or
  • Education of patient & caregivers, or
  • Assessment of pain & co-morbidities affecting rehab, or
  • Assisting with discharge planning

See: Rehabiliatation Nursing

110.4.3 - Relatively Intense Level of Rehabilitation Services

Patient must require and receive at least three hours per day of physical and/or occupational therapy or record should reflect what secondary complication or medical complication prevented participation in three hours of therapy a day.

See: Documenting Skilled Therapy Services

110.4.4 – Multi-Disciplinary Team Approach to Delivery of Program

See: Multidisciplinary Team Documentation

110.4.5 –Coordinated Program of Care

Team Conference documentation required at least every two weeks for:

  • assessment of the individual’s progress or the problems impeding progress
  • assessment of possible resolution to such problems
  • re-assessment of the validity of the rehabilitation goals initially established

NOTE: BCBS of Georgia’s Local Coverage Determination (L18887) suggests weekly conferences are necessary to demonstrate inter-disciplinary intensive rehabilitation is being provided. In team conference documentation, progress should be documented in measurable terms.

  • Too imprecise: "Able to ambulate better with less assistance but continues to need physical therapy”
  • Acceptable: “Patient is able to ambulate 20 feet with use of a quad cane and minimal assistance, an improvement over his ability to ambulate 10 feet with a rolling walker and moderate assistance one week ago. Short-term goal is for patient to ambulate 50 feet with a quad cane and contact guard; long-term goal is for patient to ambulate independently with a straight cane at least 200 feet.”

110.4.6 -Significant Practical Improvement

Must document a reasonable expectation of improvement that is of practical value to the patient, measured against the patient’s condition at start of rehab program.

110.4.7 – Realistic Goals



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