Criteria for Medical Necessity in Inpatient Rehab Facility

The objective of this Position Statement, which covers Rehabilitation Nursing Criteria for Determination and Documentation of Medical Necessity in an Inpatient Rehabilitation Facility, is to establish and present a set of appropriate guidelines that define the criteria of 24 hour availability of rehabilitation nursing with specialized training or experience in rehabilitation for determination of medical necessity in an inpatient rehabilitation facility (IRF).

Introduction

In order for a freestanding rehabilitation hospital or a rehabilitation unit of an acute care hospital to be classified as inpatient rehabilitation facility (IRF), they must meet the requirements specified in Title 42 Code of Federal Regulations (CFR) 412.23(b)(2), as well as other regulatory requirements and are paid under the IRF prospective payment system (PPS). Numerous fiscal intermediaries (FIs) monitor and determine if an IRF met the requirements specified in 412.23(b)(2). IRF care is only considered by Medicare to be reasonable and necessary under 1862(a)(1)(A) of the Social Security Act if the patient meets all of the requirements outlined in 42 CFR §§412.622(a)(3), (4), and (5).

The Medicare Benefits Policy Manual was revised, effective January 2010 with an update effective January 2014, to include documentation - in the medical record that demonstrates determination that an IRF admission is reasonable and necessary, with a focus on the preadmission screening, the post-admission physician evaluation, the overall plan of care and admission orders.

Decisions to admit a patient to an IRF are complex and based on multiple factors, including policy, regulatory standards, and assessment of each beneficiary's individual care needs. In 1982, the Health Care Financing Administration (HCFA), now the Centers for Medicare and Medicaid Services (CMS), identified Conditions of Participations (CoP) that had to be met in order to be classified as an IRF.

The inpatient rehabilitation facility (IRF) benefit is designed to provide intensive rehabilitation therapy in a resource intensive inpatient hospital environment for patients who, due to the complexity of their nursing needs, medical management, and rehabilitation needs, require and can reasonably be expected to benefit from an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation care.

In addition, in order for IRF patients to be considered reasonable and necessary, there must be a reasonable expectation that these criteria are met at the time of admission:

1. The patient requires the active and ongoing therapeutic intervention of multiple therapy disciplines (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics), one of which must be physical or occupational therapy.
2. The patient requires an intensive therapy program; under industry standard, this is usually three hours of therapy per day, at least five days per week; however, in certain, well-documented cases, this therapy might consist of at least fifteen hours of therapy within a seven consecutive day period, beginning with the day of admission to the IRF.
3. The patient requires physician supervision by a rehabilitation physician, defined as a licensed physician with specialized training and experience in inpatient rehabilitation. (The requirement for medical supervision means that the rehabilitation physician must conduct face-to-face visits with the patient at least 3 days per week throughout the patient’s stay in the IRF to assess the patient both medically and functionally, as well as to modify the course of treatment as needed to maximize the patient’s capacity to benefit from the rehabilitation process).
4. The patient can reasonably be expected to actively participate in, and benefit significantly from, the intensive rehabilitation therapy program.

Interdisciplinary services are those provided by a treatment team in which all of its members participate in a coordinated effort to benefit the patient and the patient’s significant others and caregivers. Interdisciplinary services, by definition, cannot be provided by only one discipline. Though individual members of the interdisciplinary team work within their own scopes of practice, each professional is also expected to coordinate his or her efforts with team members of other specialties, as well as with the patient and the patient’s significant others and caregivers. The purpose of the interdisciplinary team is to foster frequent, structured, and documented communication among disciplines to establish, prioritize, and achieve treatment goals.

At a minimum, the interdisciplinary team must document participation by professionals from each of the following disciplines (each of whom must have current knowledge of the patient as documented in the medical record at the IRF):

• A rehabilitation physician with specialized training and experience in rehabilitation services;

• A registered nurse with specialized training or experience in rehabilitation;

• A social worker or a case manager (or both); and

• A licensed or certified therapist from each therapy discipline involved in treating the patient.

The criteria for IRF are subject to Local Coverage Determination (LCD) policies meant to help FIs define medical necessity for beneficiaries within a specific geographic area. The LCDs and IRF medical necessity criteria vary by agent and have become a major tool for allocating health care resources.

The Association of Rehabilitation Nurses (ARN) is pleased to provide this position statement to CMS regarding the criteria of 24 hour availability of rehabilitation nursing with specialized training or experience in rehabilitation for determination of medical necessity in an IRF and recognizes that CMS has a central role to play in improving rehabilitation care of individuals with chronic illness and physical disabilities. ARN is a professional nursing specialty association of more than 5,000 professional nurses, which is responsible for establishing the scope of rehabilitation nursing practice and for setting standards for professional rehabilitation nursing practice. ARN's mission is to promote and advance professional rehabilitation nursing practice through education, advocacy, collaboration, and research to enhance the quality of life for those affected by disability and chronic illness.

Set out below is ARN’s position statement, a summary of our major recommendations, followed by a rationale for the recommendations.

Position Statement

The Association of Rehabilitation Nurses (ARN) believes that the recovery from an acute episode of illness or injury depends on adequate medical treatment and early identification of needs for rehabilitation care. ARN believes that IRFs are a part of the quality care continuum and that individuals can benefit from rehabilitation nursing at any stage of the life span. It is ARN’s belief that the determination of need for intensive rehabilitation should be more dependent on the effects of a patient’s injury or illness (impairments, functional deficits, achievable goals) and not on the diagnosis.

Rehabilitation nurses, through specialty knowledge and expertise, promote and maintain the patient’s level of functioning. Although the proportions of skill mix of licensed and unlicensed staff must be appropriate and determined by the number of patients; levels of intensity of the patients for whom care is being provided; contextual issues including architecture and geography of the environment and available technology; level of preparation and experience of those providing care and accreditation standards, ARN believes a facility must employ registered nurses certified in rehabilitation nursing (CRRN) to improve a patient’s progress, thereby decreasing length of stay and resulting in a cost reduction. Certification in rehabilitation nursing is professional recognition of knowledge and skills in this specialty practice. It is ARN’s belief that IRFs must utilize the expertise of a CRRN for the supervision, orientation process, competency evaluation, and education of staff.  ARN believes that the expertise of a certified rehabilitation registered nurse must be available in the assessment, implementation, and evaluation of a rehabilitation program to meet the needs of the rehabilitation population being served. Ultimately, ARN believes that accountability and coordination of cost-effective quality rehabilitation care is best accomplished by registered nurses who have been educated and certified in the rehabilitation specialty.

The rehabilitation nurse, easily accessible to individuals, families, team members and other concerned parties, and by virtue of specialized education, expertise, and interest in caring for individuals with chronic illness and disabilities, is a key partner in a successful rehabilitation program. ARN believes the outcomes of rehabilitation are maximized when the rehabilitation nurse takes a leadership role and collaborates with rehabilitation team members.

ARN believes that the 2014 Standards and Scopes of Rehabilitation Nursing Practice should be implemented and evaluated to improve the quality of care for rehabilitation patients. ARN supports the development and implementation of a standard patient assessment screening tool across the post acute care continuum based on patient needs that will measure the effectiveness of post acute care and provide outcome data to determine the appropriate post acute care setting at the appropriate time thus improving both quality of care and continuity of care in a cost effective manner. Lastly, ARN believes the documentation of the rehabilitation professional registered nurse should reflect the need for specialized rehabilitation nursing and should include the identification of relevant International Classification of Functioning, Disability and Heath (ICF) components and domains that will provide a standard language and framework for measuring health and disability.

Recommendations

ARN recommends CMS:

1. Include and define the criteria of availability of rehabilitation nursing with specialized training or experience in rehabilitation for determination of medical necessity in an inpatient rehabilitation facility (IRF),
   • Incorporate the definition of Generalist Rehabilitation Nurse with Specialized Knowledge and Certified Rehabilitation Registered Nurse to define rehabilitation nursing with specialized training or experience in rehabilitation,
   • Incorporate that rehabilitation nurses acquire and maintain current knowledge and competency in nursing practice through self-study, educational programs, certification and by adhering to the rehabilitation nursing scope and standards of practice,
   • Incorporate that orientation, education and competency evaluation of the specialized rehabilitation professional registered nurse must be provided by a certified rehabilitation registered nurse (CRRN) to ensure quality care and to meet the needs of the rehabilitation population being served,
   • Incorporate that a CRRN is available in an IRF for the assessment, implementation, and evaluation of a rehabilitation program to improve patient’s progress,
   • Incorporate that the documentation must support the need, availability and provision for rehabilitation nursing care over a 24 hour period, 7 days a week.

Rationale with Recommendations

Demographics

Demographic shifts towards an increase in the population of elderly in the United States indicates a substantial increase in the number of people experiencing physical or mental impairments and the proportion of the population at risk of developing a physical or mental impairment that affects their functional ability. The percentage of the population aged 65 and over will increase from approximately 12 percent in 2005 to almost 20 percent by 2030 (United States Census Bureau, 2013). This shift will affect the way the health care industry does business. Aging consumers with a disability will require services from various health care agencies, resulting in a sharp increase in the need for quality rehabilitation and disability-related services.

Recent military conflicts have added many more individuals to the population who need rehabilitation services affecting both military and civilian rehabilitation service providers. Rehabilitation nurses have specialty knowledge and must stay abreast of the new treatments and advances in rehabilitation health care, polytrauma, and post traumatic stress syndrome.

Setting

Rehabilitation can take place in various settings including at home through the Medicare home health benefit (including hospice), in an out-patient therapy facility, in a skilled nursing facility (SNF), in a comprehensive outpatient rehabilitation facility (CORF), in an inpatient rehabilitation facility (IRF),  in a long-term care hospital (LTCH) or in home health care.

Goal and Role of Rehabilitation Nurse

Rehabilitation nursing is a specialty practice within the profession of nursing and involves the diagnosis and treatment for individuals and groups to actual and potential health problems related to altered functional ability and lifestyle. The goal of rehabilitation nursing is to assist individuals with disability and/or chronic illness in restoring, maintaining, and promoting maximal health. Rehabilitation professional registered nurses possess specialized knowledge and clinical skills necessary to provide care for people with physical disability and chronic illness; manage complex medical issues, provide ongoing patient/caregiver education, perform hands-on nursing care by utilizing the nursing process, collaborate with other members of the interdisciplinary rehabilitation team, document effectively to ensure the fulfillment of legal and reimbursement requirements, act as a resource and a role model for nursing staff and students,  and utilize evidence-based practice findings for clinical practice and participate in nursing research studies. Rehabilitation nursing roles include those of caregiver, patient educator, counselor, care coordinator, case manager, patient advocate, consultant, researcher, administrator or manager, and expert witness.

Scope and Standards of Practice

The standards of rehabilitation nursing practice, consistent with the American Nurses Association (ANA) (2015) definitions, purposes, and framework for standards and guidelines, and built on ANA (2015) Nursing: Scope and Standards of Practice, describes a competent level of professional nursing care and professional practice common to all rehabilitation professional registered nurses engaged in clinical practice. The Standards of Practice describe a competent level of nursing care as demonstrated by the nursing process, and the Standards of Professional Performance describe a competent level of behavior in the professional role that includes activities related to quality of practice, education, professional practice evaluation, collegiality, advocacy, collaboration, ethics, research, resource utilization, and leadership (ANA, 2015). These rehabilitation nurses are expected to adhere to the standards of rehabilitation nursing practice and engage in professional role activities appropriate to their education, position, and practice setting (ARN, Standards and Scope, 2014.

Generalist Rehabilitation Nurse with Specialized Knowledge

The professional nurse who practices rehabilitation nursing as a generalist may function in a variety of institutional and community settings. The role a nurse assumes depends on basic nursing preparation; specialized formal or informal education; and clinical experiences with individuals and the families of those individuals who have disabilities, potential disabilities, or chronic illness. Current rehabilitation technologies and therapies require unique knowledge and skills that may be obtained through self-study and continuing education programs. Quality continuing education programs are available through ARN and many of its local chapters and through many institutions with rehabilitation nurses.

The rehabilitation nurse exemplifies a specialized knowledge and skill set that is comprehensive and broad in scope with roots in both professional nursing and rehabilitation functional care concepts. In addition to administering specialized nursing care, the rehabilitation nurse spends a significant amount of time reinforcing patient learning from other disciplines. It is essential that all professional registered nurses practicing rehabilitation nursing possess the basic knowledge and skills that enable them to collect appropriate assessment data for each rehabilitation patient; identify significant problems; establish appropriate diagnoses; and set short and long term goals and identify outcomes that reflect an understanding of the impact of the disability or chronic illness on the planning, delivery, and evaluation of care within the limits of the available economic resources.

Certified Rehabilitation Registered Nurse (CRRN)

Certification in rehabilitation nursing (Certified Rehabilitation Registered Nurse [CRRN]), which may be obtained through the Rehabilitation Nursing Certification Board (RNCB), validates the acquisition of such knowledge and skills. Nelson and colleagues’ (2007) landmark study found an inverse relationship between the percentage of nurses certified in rehabilitation nursing and length of stay (LOS). Specifically, a 1% increase in CRRNs on the unit was associated with an approximated 6% decrease in LOS. This finding supports the value in recruiting and retaining nurses with specialty certification, as well as supporting existing staff in efforts to obtain certification. Preparation for the certification examination is supported by a wide range of educational products by ARN and other quality preparation classes offered through the ARN chapters, private institutions and rehabilitation healthcare organizations.

Rehabilitation Team

Rehabilitation is contingent on a team approach. The collaborative rehabilitation team model facilitates care in a coordinated and cost-effective manner. The rehabilitation professional registered nurse’s role on the rehabilitation team is vital. Members of the rehabilitation team will vary, depending on the practice setting and the disability, but the patient and family/caregiver are always essential core members of the team.

Documentation

The rehabilitation professional registered nurse documents relevant data in a retrievable format. Documentation must support the need, availability and provision for rehabilitation nursing care. Documentation should serve as evidence for the ongoing provision of rehabilitation nursing care within the context of the rehabilitation team in meeting the patient’s rehabilitative needs. 

Documentation should include the following as appropriate, yet not  limited to:

• Rehabilitation diagnosis, course of treatment, plan of care and expected outcomes
• Disease and comorbidity management
• Primary prevention and promotion of health and wellness
• Prevention of secondary complications
• Bowel and bladder management goals; progress in bowel and bladder continence or regulation following an injury that impacts such functions
• Skin care management including body positioning and pressure redistribution, wound care, and the prevention of skin insults
• Medication and pain management
• Reinforcement of self-care and mobility skills
• Functional aspects of daily living skills
• Cardiovascular, pulmonary and autonomic management
• Nutrition and lifestyle adaptations
• Safety (precaution education and carryover); ongoing assessment of safety, including not only physical limitations, but also such cognitive functions as memory, judgment, and problem-solving abilities
• Swallowing precautions and compensatory techniques
• Energy conservation
• Intimacy and sexuality
• Role changes and psychosocial manifestations and adaptation techniques
• Family involvement
• Aftercare including community resources, equipment, emergency services and external support systems
• Patient goals that are practical, realistic and individualized

Goals and interventions that integrate and demonstrate carryover of techniques from therapy to increase the functional status and lessen the burden of care should also be evident in the medical record.

Consideration should be given as to how the medical and functional components of the rehabilitation patient are inter-related and should be documented from the rehabilitation nursing perspective.  Education of the patient and family/caregiver are inherent within rehabilitation nursing; evidence of ongoing patient and family/caregiver education for the above mentioned topics should be documented by the rehabilitation professional registered nurse in the medical record.

CMS requires that the IRF patient assessment instrument (IRF-PAI) is included in the IRF medical record. Because the information in the IRF-PAI must correspond with information provided in the medical record, nursing documentation is vital to supporting the burden of care for medical and functional complexity of the patient.

Frequent conflicting documentation between disciplines, widely fluctuating patient abilities throughout a 24 hour period based upon changes in medical stability, pain, endurance or cognition, or failure to progress as planned should be explained and a realistic plan to address the problem(s) identified. Documentation of discharge plans should be indicated early in the plan of care.

The International Classification of Functioning, Disability and Heath (ICF) is part of the international classification systems developed by the World Health Organization (WHO). The ICF has a focus on human functioning, providing a unified, standard language and framework that facilitates the description of the components of functioning that are impacted by a health condition. While it is not an assessment tool, it does allow the collection of data as to how people with a health condition function in their daily life rather than focusing on their diagnosis or the presence or absence of disease. The ICF describes the situation of the individual within health and health-related domains and within the context of environmental and personal factors. 

The ICF is WHO's framework for measuring health and disability at both individual and population levels. It has been tested for cross-cultural applicability in over 40 countries. The ICF integrates the social and environmental aspects of disability and health and provides a framework that is equally applicable for mental and physical disorders. Thus, it has great potential as a common global framework for organizing and communicating information on human functioning.

Conclusion

Rehabilitation is a continuous process and patients rehabilitate themselves through the influence of a comprehensive approach to care provided by the rehabilitation professional registered nurse. To achieve optimal effectiveness, today’s rehabilitation professional registered nurses need to be cognizant of patients’ needs and desired outcomes, concerns about cost containment, and the service options available along the continuum of care. Over the next few decades, the number of people with chronic illness and disability are expected to rise. This shift will increase the demand for the knowledge and expertise of rehabilitation professional registered nurses. These rehabilitation professional nurses providing health care need to conform to the highest uniform national standards available, ensuring that the continued health and safety of the public are protected and that the care provided is cost-effective in the most appropriate setting and of the highest quality.

With a core purpose to promote and advance professional rehabilitation nursing practice, ARN developed this position statement to provide CMS and FIs with guidelines that could assist in standardizing the language of the LCDs and assist in further defining the criteria of 24 hour availability of rehabilitation nursing with specialized training or experience in rehabilitation for determination of medical necessity in an IRF. ARN appreciates CMS's continuing efforts to ensure that Medicare beneficiaries have access to high quality care in the most appropriate setting and ARN encourages CMS and other insurers to utilize these guidelines in support of continuing efforts to recognize the value of intensive inpatient rehabilitation professional nursing in ensuring safe, high-quality standards.

References

American Nurses Association. (2014). Nursing: Scope and Standards of Practice (3rd ed.). Silver Spring, MD: Author.

American Nurses Association. (2010). Recognition of a Nursing Specialty, Approval of a Specialty Nursing Scope of Practice Statement, and Acknowledgement of Specialty Nursing Standards of Practice. Silver Spring, MD: Author.

Association of Rehabilitation Nurses. (2014). Standards and Scope of Rehabilitation Nursing Practice (6th ed.). Glenview, IL: Author.

Association of Rehabilitation Nurses. (2015). The Specialty Practice of Rehabilitation Nursing: A Core Curriculum (7th ed.). Glenview, IL: Author.

Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual, Chapter 1-Inpatient Hospital Services Covered under Part A (Rev 179, 01-14-2014), pg. 23-29. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c01.pdf.

Centers for Medicare and Medicaid Services. GPO Access Electronic Code of Federal Regulations. Title 42: CFR Public Health, PART 412—PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES, Subpart B—Hospital Services Subject to and Excluded from the Prospective Payment Systems for Inpatient Operating Costs and Inpatient Capital-Related Costs, § 412.23 Excluded hospitals: Classifications. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Downloads/pp368-486.pdf.

Nelson, A., Powell-Cope, G., Palacios, P., Luther, S. L., Black, T., Hillman, T., et al. (2007). Nurse Staffing and Patient Outcomes in Inpatient Rehabilitation Settings. Rehabilitation Nursing, 32(5), 179–202.

United States Census Bureau. (2013). 2012 National Population Projections. Retrieved from http://www.census.gov/population/projections/data/national/2012.html.

Other Resources

Association of Rehabilitation Nurse. The Rehabilitation Staff Nurse Role Description (Brochure).

Association of Rehabilitation Nurses. Rehabilitation Nurses Make a Difference (Brochure).

Association of Rehabilitation Nurses. Factors to Consider in Decisions about Staffing in Rehabilitation Nursing Settings (Position Statement).

Centers for Medicare and Medicaid Services. (2013). Inpatient Rehabilitation Facility Prospective Payment System. Available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/InpatRehabPaymtfctsht09-508.pdf.

Commission on Accreditation of Rehabilitation Facilities. (2008). Standards Manual and Interpretive Guidelines for Medical Rehabilitation. Tucson: CARF.

Institute of Medicine Report (2003). Enabling America: Assessing the Role of Rehabilitation Science and Engineering. Available at http://books.nap.edu/catalog/5799.html

Approved by the ARN Board of Directors September 2008; revised March 2014; revised March 2017