Widespread Probe Review Results – FI – Review of CMGs A0803 or A0804, TOB 11X

Alabama Medical Review Part A has recently completed the prepay probe review of CMGs A0803 or A0804. TOB 11X.  The claims were randomly selected across the provider community billing this service that met the parameters of the edit. The review results are as follows:

The medical review decisions were based on the LCD for Inpatient Rehabilitation (L15198).

This determination (LCD) addresses Medicare coverage for inpatient rehabilitation services provided in freestanding and “excluded” [as defined in 42 CFR, Section 412.25] rehabilitation units (IRF). For the purposes of this LCD, a distinction exists between the ‘percent’ rule and medical necessity. The ‘percent’ rule is an accounting standard by which IRFs are classified whereas the medical necessity is a standard which applies to all IRF admissions. The medical necessity for the provision of rehabilitative services in an inpatient setting is the primary focus. We note a distinction between medical necessity for individual therapy services, which may be reasonable and necessary in a particular case, and the medical necessity of providing those services in an inpatient rehabilitation setting (medical reasonableness or appropriateness). This LCD describes the relevant factors that differentiate Medicare coverage for rehabilitation in an IRF from coverage for rehabilitation in other settings, such as acute care hospitals, skilled nursing facilities (SNFs), home health care, and outpatient settings.

Notations in italics are quotations taken from the Medicare Benefit Policy Manual (PUB 100-2), Chapter 1 Section 110, formerly the Hospital Manual, Section 211. Numerical notations in parenthesis are the specific citings from Chapter 1. This LCD is not intended to replace or re-quote the entire language in the Medicare Benefit Policy Manual (PUB 100-2), Chapter 1 Section 110, but to highlight portions of this Section that warrant further interpretation, guidance, and education for coverage. The fact that all language from this Section is not included does not diminish its composite authority.

Indications

Physicians generally agree on the circumstances that justify a medical or surgical patient's hospitalization. In addition, in some cases an admission to a rehabilitation hospital or to the rehabilitation service of a short-term hospital can be justified on essentially the same medical or surgical grounds. In other cases, however, a patient's medical or surgical needs alone may not warrant inpatient hospital care, but hospitalization may nevertheless be necessary because of the patient's need for rehabilitative services.

Patients needing rehabilitative services require a hospital level of care, if they need a relatively intense rehabilitation program that requires a multidisciplinary coordinated team approach to upgrade their ability to function. There are two basic requirements that must be met for inpatient hospital stays for rehabilitation care to be covered:

• The services must be reasonable and necessary (in terms of efficacy, duration, frequency, and amount) for the treatment of the patient's condition; and
• It must be reasonable and 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 order to meet the above requirements the following basic components must be met:

Close medical supervision by a Physician with specialized Training or Experience in Rehabilitation (110.4.1)
A patient's condition must require the 24-hour availability of a physician with special training or experience in the field of rehabilitation. This need should be verifiable by entries in the patient's medical record that reflect frequent and direct, and medically necessary physician involvement in the patient's care; i.e., at least every two to three days during the patient's stay. This degree of physician involvement which is greater than is normally rendered to a patient in a SNF is an indicator of a patient's need for services generally available only in a hospital.

Twenty-four hour Rehabilitation Nursing (110.4.2)
The patient requires the 24-hour availability of a registered nurse with specialized training or experience in rehabilitation.

Intense Level of Services (110.4.3)
The general threshold for establishing the need for inpatient hospital rehabilitation services is that the patient must require and receive at least three hours a day of physical and/or occupational therapy. (The furnishing of services no less than five days a week satisfies the requirement for "daily" services.) While most patients requiring an inpatient stay for rehabilitation need and receive at least three hours a day of physical and/or occupational therapy, there can be exceptions because individual patient's needs vary. In some instances, patients who require inpatient hospital rehabilitation services may need, on a priority basis, other skilled rehabilitative modalities such as speech-language pathology services, or prosthetic-orthotic services and their stage of recovery makes the concurrent receipt of intensive physical therapy or occupational therapy services inappropriate. In such cases, the 3-hour a day requirement can be met by a combination of these other therapeutic services instead of or in addition to physical therapy and/or occupational therapy.

Multi-disciplinary Team Approach (110.4.4)
A multidisciplinary team usually includes a physician, rehabilitation nurse, social worker and/or psychologist, and those therapists involved in the patient's care. At a minimum, a team must include a physician, rehabilitation nurse, and one therapist.

In other words, inpatient rehabilitation will be considered medically reasonable and necessary as long as all of the following are met:

• There is a reasonable expectation of measurable improvement that will be of practical value to the patient within a predictable and reasonable period of time.
• As a general threshold, the patient must require, receive, and tolerate at least three hours a day of physical and/or occupational therapy at least five times per week. In some instances, patients may need on a priority basis other skilled rehabilitative modalities such as speech-language pathology services or prosthetic-orthotic services that may contribute to the “three hour rule”. There may be occasional situations where a patient’s active/acute medical co-morbidities (e.g. COPD exacerbation) may temporarily interrupt/decrease this “three hour” requirement. If such circumstances allow the patient to remain in the IRF setting, the interruption of services should not be prolonged, or documentation should reflect the need for continued inpatient rehabilitation.
• The patient’s plan of care is developed and managed by a coordinated multi-disciplinary team. Although CMS requires the frequency of team conferences to be “at least every two weeks”, more frequent (i.e. weekly) team conferences may be indicated, as in the case of a stay lasting less than two weeks, to effectively demonstrate that the requisite inter-disciplinary intensive rehabilitation is being provided and the patient is making measurable progress.
• The rehab should be provided in an IRF rather than a less intensive setting due to:
• required 24-hour a day access to a registered nurse (RN) with specialized training in rehabilitation; AND
• required frequent rehab physician assessment, or intervention due to potential risk of significant change in physical or medical status, and direction of the rehab team; AND
• required rehabilitation services at such an intensity, frequency and duration as to make it impractical for the patient to receive such rehabilitation services in a less intensive setting.

Medicare recognizes that determinations of whether hospital stays for rehabilitation services are reasonable and necessary must be based upon an assessment of each beneficiary's individual care needs. Therefore, denials of services based on numerical utilization screens, diagnostic screens, diagnosis or specific treatment norms, "the three hour rule," or any other "rules of thumb," are not appropriate.

Limitations

The ‘Limitations’ section is intended to provide guidance and raise awareness where aspects of coverage may be limited or denied. This LCD will not implement automated denials.

• The required services are available in a less intensive setting (Outpatient or SNF) and the patient is medically appropriate for such a setting, such that the admission criteria in the 'Indications' section are not met.
• The physician did not order an intensive level of care as described in this determination.
• Only services performed by occupational therapists, physical therapists, speech language pathologist, prosthetists, and orthotists may contribute to the “three hour rule”.
• Although re-enforcement across disciplines (i.e. PT, OT, rehab nursing) is expected, there should be no duplication of services unless each reflects the uniqueness of their services provided by the respective discipline.
• Coordinated multi-disciplinary care was not provided. (e.g. lack of goals, lack of input across different disciplines)
• The Inpatient Rehabilitation Facility – Patient Assessment Instrument (IRF-PAI) fails to support the Rehabilitation Impairment Category (RIC) or failure of the medical record to substantiate the data reported in the IRF-PAI.
• Although all admissions must meet medical necessity, routine admissions for single joint replacements’ postoperative rehabilitation, debility, cardiac rehabilitation, and pulmonary rehabilitation would not be expected. However when such an admission meets the coverage criteria, careful attention to documentation as to why the patient requires intensive inpatient rehabilitation should be present.

The majority of denials were due to one of the following reasons:

• Lack of timely submission of requested documentation (Denial Reason 56900):  Claims were denied due to a lack of record submission in a timely manner.  According to The Medicare Program Integrity Manual, PUB 100-8, Chapter 3, § 3.4.1.2, if a coverage or coding determination cannot be made based upon the information on the claim, the Fiscal Intermediary (FI) may solicit additional documentation from the provider by issuing an Additional Documentation Request (ADR) and must notify the provider of the 30 day time-period to respond.  If the ADR-requested information is not is received within 45 days after the date of the request, then the claim must be denied.

To eliminate 56900 denials, please review the following elements to ensure appropriate and timely record processing:

• Beginning January 1, 2007, Cahaba no longer sends letters to inform providers of Additional Development Requests (ADRs).  Instead, providers will need to access the Fiscal Intermediary Standard System (FISS) to identify claims selected for ADR.  Claims selected for ADR can be identified by accessing FISS Inquiry Option 12, and will appear in status location S B6001.  Pages 07 and 08 of the claim will contain the date your documentation is due, and the elements of documentation requested.
• Print screen the ADR letter and attach the copy to the front of the requested medical documentation
• Send requested information to the address on the ADR letter
• Do NOT send certified mail or overnight mail
• Include ALL requested documentation outlined in the ADR
• Submit the above information via regular mail in a timeframe to ensure the FI receives the information by the 45th day after the date of the request.

• The documentation submitted did not support medical necessity for inpatient rehabilitation (Denial Reason 54155). The documentation submitted lacked medical justification for inpatient rehabilitation services. 

As a result of this prepay probe review, Alabama Part A Medical Review will continue with a prepay targeted review of CMGs A0803 or A0804, TOB 11X.  Also, providers identified through data analysis as driving this aberrancy may warrant provider-specific medical review. 

Page last updated: May 21, 2008

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