Understanding Medicare Coverage in Rehabilitation.

January 14, 2013

Many people have difficulty in understanding the requirements for a patient to be admitted to a rehabilitation facility. A potential patient must first meet the requirements set forth by Medicare. To help in understanding the criteria for admission to a specialized hospital for rehabilitation, we will try to expand on the government (Medicare) guidelines, with the hope that this will help to clarify the admission process.

Basis for Coverage for Inpatient Rehabilitation in a Hospital Setting
• Patients needing rehab services require a hospital level of care and a multidisciplinary team approach to upgrade their ability to function. There are two requirements that must be covered.
1.The services must be reasonable and necessary.
2. It must be necessary to furnish care in a hospital rather than a less intensive setting, such as a Skilled Nursing facility or on an outpatient basis.

Services are deemed medically necessary when the patient:
• Requires close medical monitoring and physician oversight
• Requires rehab nursing on a 24 hour basis.
• Requires a relatively intense level of therapy
• Requires a coordinated multidisciplinary team approach to care
• Demonstrates the potential for significant improvement
• Has realistic goals requiring inpatient rehab

Medical Monitoring and Physician Oversight
• A patient’s condition must require the 24 hour availability of a physician. This need should be verifiable by entries in the patient’s medical record that reflect frequent, direct and medically necessary physician involvement in the patient’s care, at least every two to three days.

24 Hour Availability of a Registered Nurse
Examples of nursing documentation reflecting such care may include:
• Progress in bowel and bladder continence.
• Skin Integrity issues, including positioning techniques
• Ongoing assessment of nutritional or hydration status in patients
• Ongoing assessment of safety concerns, including physical and cognitive/perceptual concerns
• Educational interventions with patient and/or family including:
o Tracheostomy care
o Tube feedings
o Catheterization
o Medication and potential side effects
o Bowel bladder programs
o Discharge planning

Relatively Intense Level of Therapy
• The general threshold is that the patient must require at least 3 hours of therapy per day of physical therapy and occupational therapy, 5 days per week.
• The 3 hour rule is a “rule of thumb.” If a medical condition limits participation, an equivalent amount of combined therapy, medical and nursing care may substitute.

Coordinated, Multidisciplinary Team Approach
• Documentation should reflect not only multidisciplinary but also inter-disciplinary nature of treatment

Starting on October 1, 2012 CMS (Medicare) required that inpatient rehabilitation facilities submit data on two quality measures:
• Catheter associated urinary tract Infections
• New or worsened pressure ulcers.

Failure to submit the required quality data results in a 2% financial penalty to the hospital.

At Helen Hayes Hospital, our staff consistently monitors these requirements not only for the welfare of the patients, but also the financial well-being of the hospital. Potential patients and their family members and caregivers are always welcome to contact our Admission Referral Center with any questions or concerns they may have. The phone number is: 845-786-4535.

-Bruce Marshall, DDS
Director, Medical and Professional Services