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 _____________."
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
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.
110.4.4 – Multi-Disciplinary Team Approach to Delivery of Program
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