Clinical UM Guideline


Subject:   Acute Inpatient Rehabilitation
Guideline #:   CG-REHAB-09Current Effective Date:   10/08/2013
Status:   ReviewedLast Review Date:   08/08/2013

Description

Inpatient rehabilitation hospitals/units are licensed and certified facilities, which primarily promote special rehabilitative health care services rather than general medical and surgical services.  Rehabilitation is defined as restoration of a disabled person to self-sufficiency or maximal possible functional independence.  An inpatient rehabilitation program utilizes an inter-disciplinary coordinated team approach that involves a minimum of three (3) hours rehabilitation services daily.  These services may include physical therapy, occupational therapy, speech therapy, cognitive therapy, respiratory therapy, psychology services, prosthetic/orthotic services, or a combination thereof. 

Inpatient rehabilitation may be provided in a hospital, a free-standing facility or skilled nursing facility. The setting for inpatient rehabilitation is principally determined by the individual's medical and functional status and the ability of the rehabilitation facility to provide the necessary level of care. Acute inpatient rehabilitation is required when an individual's medical status is such that the intensity of services required could not reasonably be provided in an alternative setting (subacute facility or outpatient rehabilitation department). Examples of conditions requiring acute inpatient rehabilitation include, but are not limited to, individuals with significant functional disabilities associated with stroke, spinal cord injuries, acquired brain injuries, major trauma and burns.

This document addresses rehabilitation services provided in the inpatient hospital setting and includes the following acute inpatient rehabilitation tools:

Appendix 1 Inpatient Rehabilitation For Central Nervous System Insult

Appendix 2 Inpatient Rehabilitation for Neurological Disorders

Appendix 3 Inpatient Rehabilitation for Musculoskeletal/Orthopedic Disorders

Appendix 4 Additional Clinical Considerations for Review

Frequently Used Assessment Tools

Please see the following documents for additional information regarding non-skilled and skilled services in other settings:

Clinical Indications

Admission Criteria 

Medically Necessary:

Acute inpatient rehabilitation services are medically necessary when all of the following are present: 

  1. Individual has a new (acute) medical condition or an acute exacerbation of a chronic condition that has resulted in a significant decrease in functional ability such that they cannot adequately recover in a less intensive setting; AND
  2. Individual's overall medical condition and medical needs either identify a risk for medical instability or a requirement for physician and other personnel involvement generally not available outside the hospital inpatient setting; AND
  3. Individual requires an intensive inter-disciplinary, coordinated rehabilitation program (as defined in the description of service) with a minimum of three (3) hours active participation daily; AND
  4. Individual is medically stable enough to no longer require the services of a medical/surgical inpatient setting; AND
  5. The individual is capable of actively participating in a rehabilitation program, as evidenced by a mental status demonstrating responsiveness to verbal, visual, and/or tactile stimuli and ability to follow simple commands.  For additional information regarding cognitive status, please refer to the Rancho Los Amigos Cognitive Scale (Appendix B); AND
  6. Individual's mental and physical condition prior to the illness or injury indicates there is significant potential for improvement; (See Note below) AND
  7. Individual is expected to show measurable functional improvement within a maximum of seven (7) to fourteen (14) days (depending on the underlying diagnosis/medical condition) of admission to the inpatient rehabilitation program; AND
  8. The necessary rehabilitation services will be prescribed by a physician, and require close medical supervision and skilled nursing care with the 24-hour availability of a nurse and physician who are skilled in the area of rehabilitation medicine; AND
  9. Therapy includes discharge plan.

Note:  It is not necessary that there is an expectation of complete independence in the activities of daily living; but there should be a reasonable expectation of improvement that is of practical value to the individual, measured against his condition at the start of the rehabilitation program. Additionally, the individual must have no lasting or major treatment impediment that prevents progress. (For example severe dementia).

Not Medically Necessary:
Acute inpatient rehabilitation services are considered not medically necessary for individuals who do not meet the medical necessity criteria set forth above and the following:

  1. Coma stimulation;
  2. Educational training related to specific employment requirements;
  3. Care is custodial.

Regarding major joint replacements:
If a single joint is replaced, typically postoperative acute inpatient rehabilitation is considered not medically necessary unless the individual has significant comorbidity (ies) resulting in functional deficits which would necessitate an acute inpatient level of rehabilitation in order to achieve a satisfactory outcome within a reasonable time period.  Of note, postoperative acute inpatient rehabilitation may be medically necessary for individuals undergoing more than one major joint replacement during a single hospitalization.

Regarding back surgery and compression fractures:
Acute inpatient rehabilitation is considered not medically necessary for the following:

Continuation of Services Criteria

Acute inpatient rehabilitation requires evidence of an inter-disciplinary, coordinated rehabilitation team review at least once weekly, which should document ALL of the following:

In general the documentation should provide evidence that the individual is benefiting from the program, that there is progress towards reasonable goals, and that acute inpatient rehabilitation continues to be the most appropriate level of care.

Discharge Criteria
Discharge from acute inpatient rehabilitation is appropriate if one or more of the following is present:

  1. Treatment goals necessitating the inpatient setting were achieved; OR
  2. Absence of participation in an interdisciplinary rehabilitation program; OR
  3. The individual has limited potential for recovery (e.g. The individual's functional status has remained unchanged or additional functional improvement appears unlikely within a reasonable time frame ([7 to 14 days)]); OR
  4. Individual is unable to actively participate in at least 3 hours of intensive therapies per day, at least 5 days per week; OR
  5. The level of rehabilitative/restorative care required could be safely and effectively rendered in an alternate, less intensive setting, e.g., outpatient, SNF, or home health, (still may require 24 hour supervision).
  6. The overall medical status is such that no further progress is anticipated or only minimal gains that could be expected to be attained with either less intensive therapy program or regular daily activities. 

Additional Clinical Review
Additional clinical consideration to determine if the individual is a suitable candidate for acute inpatient rehabilitation services may be necessary when any of the following occur:

Notes:

Place of Service/Goal Length of Stay
Place of Service:Inpatient
Goal Length of Stay:

Varies depending on the cause and severity of the original injury.  Please refer to the following Appendices for additional information:

  • Appendix 1 – Inpatient Rehabilitation for Central Nervous System Insult
  • Appendix 2 – Inpatient Rehabilitation for Neurological Disorders
  • Appendix 3 – Inpatient Rehabilitation for Musculoskeletal/Orthopedic Disorders
Case Management

Individuals with more complex cases may require specific case management. A discharge plan of care should be developed with input from the individual, caregiver, physician, therapists and other involved providers. Discharge planning should be an integral part of all rehabilitation stays and should be an ongoing activity throughout the entirety of the confinement.

It is recognized that, in some circumstances lay family members and friends can be trained to safely and effectively provide chronic services that are typically considered skilled, e.g., pharyngeal suctioning, or gastrostomy feedings.

Discharge Plan

Usual:   Home Health Care (HHC), or outpatient therapy setting
Alternate:  Skilled nursing facility (SNF), subacute

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Revenue Code 
0118Room and board, private; rehabilitation
0128Room and board, semi-private; rehabilitation
0138Room and board, semi-private; rehabilitation
0148Room and board, private, deluxe; rehabilitation
0158Room and board, ward, rehabilitation
  
ICD-9 Diagnosis 
 All diagnoses:
  
ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014:
 All diagnoses
  
Discussion/General Information

Acute Inpatient Rehabilitation refers to a rehabilitation program provided in an acute care institution (or a distinct part of an institution) which provides an intensive multidisciplinary, coordinated team approach to rehabilitation services for the injured or disabled to restore lost function following an acute illness or accidental injury. The aim of the treatment is achieving the maximum level of function possible.

Comprehensive acute inpatient rehabilitation programs offer a wide range of therapeutic services provided by registered, certified, licensed, or degreed professionals utilizing a multidisciplinary, goal oriented, team approach with treatment plans designed specifically for the individual's needs. Acute inpatient rehabilitation programs must follow a multidisciplinary, coordinated team approach by providing services not available in the outpatient setting or skilled nursing facilities.

Examples of Inpatient Rehabilitation Disciplines/Services Provided as Part of an Interdisciplinary Team Program:

  1. Skilled Rehabilitation Nursing: 
    1. Bowel/bladder management;
    2. Skin & wound assessment/care/treatment;
    3. Medication management;
    4. Individual/family/caregiver training;
    5. 24-hour reinforcement of therapy goals/objectives;
    6. Ongoing assessment of individual's status.
  2. Physical Therapy
    1. Treatment of limited mobility; e.g., inability to transfer, impaired coordination/truncal balance, functional ambulation less than 100 feet, passive and active range of motion of lower extremities;
    2. Instruction in use of durable medical equipment (DME);
    3. Fitting of prosthetic or orthotic device(s);
    4. Individual/family/caregiver training.
  3. Occupational Therapy
    1. ADL training; e.g., toileting, grooming, dressing, feeding;
    2. Perceptual motor training (spatial orientation, depth or distance perception) directly impacting ability to initiate or maintain freedom of movement in a safe environment;
    3. Individual/family/caregiver training;
    4. Safety skills or problem-solving techniques; e.g., emergency procedures and injury prevention;
    5. Splinting of upper body extremities.
  4. Speech Therapy
    1. Treatment of communication disorders (expressive or receptive dysphasia or aphasia) resulting in less than basic communication levels;
    2. Treatment of swallowing dysfunction (dysphagia);
    3. Teaching simple, problem-solving techniques or safety skills;
    4. Individual/family/caregiver training.
  5. Social Services Medical Social Worker (MSW)
    1. Integrates the individual's and the family's social needs into the plan of care;
    2. Coordinates discharge planning activities;
    3. Makes community referrals and consults with other agency personnel.
  6. Neuropsychological Services
    1. PhD., SCi.D prepared disciplines
    2. Cognitive screening and neuropsychological testing.
  7. Physical Medicine and Rehabilitation Services Specialist (Physiatrist)
    1. Daily medical supervision of the individual's rehabilitation treatment plan.

Examples of Services that Typically Do Not Require Admission to an Inpatient Rehabilitation Program 

The following services are examples of services that do not require the skills of a licensed nurse or rehabilitation personnel and are therefore considered not medically necessary in the acute inpatient rehabilitation or skilled nursing facility settings unless there is documentation of comorbidities and complications that require individual consideration.

  1. Routine services directed toward the prevention of injury or illness;
  2. Routine or maintenance medication administration. Admissions solely for the administration of routine or maintenance medications, including daily IV, IM and SQ medications are not considered skilled. Parenteral medication administration in medically stable individuals is most often managed in the home setting by a home health or home infusion therapy provider;
  3. Care solely for the administration of oxygen, and nebulizer treatments;
  4. Routine enteral feedings;
  5. Routine colostomy care;
  6. Ongoing intermittent straight catheterization for chronic conditions;
  7. Custodial care;
  8. Emotional support or counseling;
  9. Suctioning of the nasopharynx or nasotrachea. Suctioning daily or PRN less frequently than every four hours PRN is not considered skilled;
  10. Administration of suppositories or enema;
  11. Routine foot and nail care;
  12. Individuals on established levels of ventilatory support (excludes teaching of care to caregivers);
  13. Urinary catheters. The presence of a stable indwelling or suprapubic catheter, the need for routine intermittent straight catheterization, catheter replacement or routine catheter irrigation does not qualify a individual for acute inpatient rehabilitation or SNF placement unless other skilled needs exist;
  14. Heat treatment – wet or dry:
    1. Whirlpool baths, paraffin baths or heat lamp treatments do not qualify an individual for care in an acute inpatient rehabilitation or SNF;
    2. There may be a rare instance when a severely compromised individual with desensitizing neuropathies or severe burns requires skilled observation during the above treatments. These cases are to be reviewed on an individual consideration basis. Documentation must support the medical necessity for such observation.
References

Peer Reviewed Publications:

  1. Altmaier EM, Lehmann TR, Russell DW, et al.  Year Book:  The effectiveness of psychological interventions for the rehabilitation of low back pain:  A randomized controlled trial evaluation.  1994 Year Book of Chiropractic; article 1-52. 
  2. Andrews K. Recovery of patients after four months or more in the persistent vegetative state.  BMJ. 1993; 306(6892):1597-1600.
  3. Botte MJ, Ezzet KA, Pacelli LL, et al.  What's new in orthopaedic rehabilitation.  J Bone Joint Surg Am. 2002; 84-A(12):2312-2320.
  4. Bottemiller KL, Bieber PL, Basford JR, Harris M. FIM score, FIM efficiency, and discharge disposition following inpatient stroke rehabilitation. Rehabil Nurs. 2006; 31(1):22-25.
  5. Brandstater ME, Brown SE. Physical medicine and rehabilitation.  JAMA. 1996; 275(23):1843-1844.
  6.   Brandstater ME.  Physical medicine and rehabilitation.  JAMA 1995; 273(21):1710-1712.
  7. Cameron ID, Handoll HH, Finnegan TP, et al.  Co-ordinated multidisciplinary approaches for inpatient rehabilitation of older patients with proximal femoral fractures. Cochrane Database Syst Rev. 2001;(3):CD000106.
  8. Cromes GF, Helm PA.  The status of burn rehabilitation services in the United States:  results of a national survey.  J Burn Care Rehabil. 1992; 13(6):656-662.
  9. Evans RL, Connis RT, Hendricks RD, Haselkorn JK.  Multidisciplinary rehabilitation versus medical care: a meta-analysis.  Soc Sci Med. 1995; 40(12):1699-1706.
  10. Evans RL, Haselkorn JK, Bishop DS, Hendricks RD.  Characteristics of hospital patients receiving medical rehabilitation: an exploratory outcome comparison.  Arch Phys Med Rehabil.1991; 72(9):685-689.
  11. Evans RL, Haselkorn JK, Bishop DS, Hendricks RD.  Factors influencing the decision to rehabilitate: an initial comparison of rehabilitation candidates.  Soc Sci Med. 1991; 33(7):801-806.
  12. Evans, RL, Connis RT, Haselkorn JK. Hospital-based rehabilitative care versus outpatient services: effect on functioning and health status. Disabil Rehabil. 1998; 20(8):298-307. 
  13. Falconer JA, Naughton BJ, et al.  Year Book: Stroke inpatient rehabilitation:  A comparison across age groups.  1995 Year Book of Neurology and Neurosurgery; 122(95):15-22.
  14. Fischer DA, Tewes DP, Boyd JL, et al.  Home based rehabilitation for anterior cruciate ligament reconstruction. Clin Orthop Relat Res. 1998; 347:194-199.
  15. Gladman JR, Lincoln NB.  Follow-up of a controlled trial of domiciliary stroke rehabilitation (DOMINO Study).  Age Ageing. 1994; 23(1):9-13.
  16. Greenwood RJ, McMillan TM, Brooks DN, et al.  Effects of case management after severe head injury.  BMJ. 1994; 308(6938):1199-1205.
  17. Hamilton BB, Granger CV.  Disability outcomes following inpatient rehabilitation for stroke.  Phys Ther. 1994; 74(5):494-503.
  18. Horn SD, DeJong G, Smout RJ, et al. Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better? Arch Phys Med Rehabil. 2005; 86(12 Suppl 2):S101-S114.
  19. Johnston MV, Granger CV.  Outcomes research in medical rehabilitation: A primer and introduction to a series.  Am J Phys Ther Rehabil 1994; 73(4):296-303.
  20. Johnston MV, Wood K, Stason WB, Beatty P.  Rehabilitative placement of poststroke patients: reliability of the Clinical Practice Guideline of the Agency for Health Care Policy and Research.  Arch Phys Med & Rehabil. 2000; 81(5):539-548.
  21. Jones, GR, Miller TA, Petrella RJ. Evaluation of rehabilitation outcomes in older patients with hip fractures. Am J Phys Med Rehabil. 2002; 8(7)1:489-497.
  22. Kulp CS, O'Leary AA, Wegener ST, et al.  Inpatient arthritis rehabilitation programs in the US:  results from a national survey.  Arch Phys Med Rehabil. 1988; 69(10):873-876.
  23. Levy M, Berson A, Cook T, et al. Treatment of agitation following traumatic brain injury: a review of the literature. NeuroRehabilitation. 2005; 20(4):279-306.
  24. Lindeboom R, Vermeulen M, Holman R, De Haan RJ.  Activities of daily living instruments: optimizing scales for neurologic assessments.  Neurology. 2003; 60(5):738-742.
  25. Macario, A, Schilling P, Rubio R, Goodman S. Economics of one-stage versus two-stage bilateral total knee arthroplasties. Clin Orthop. 2003; 414:149-156.
  26. Mahomed NN, Koo Seen Lin MJ, Levesque J, et al. Determinants and outcomes of inpatient versus home based rehabilitation following elective hip and knee replacement.  J Rheumatol. 2000; 27(7):1753-1758.
  27. Maulden SA, Gassaway J, Horn SD, et al. Timing of initiation of rehabilitation after stroke. Arch Phys Med Rehabil. 2005; 86(12 Suppl 2):S34-S40.
  28. Mukand JA.  Human immunodeficiency virus infection and diffuse polyneuropathy:  Implications for rehabilitation medicine.  West J Med 1991; 154(5):549-553.
  29.  O'Dell MW. Rehabilitation medicine consultation in persons hospitalized with AIDS:  An analysis of thirty cases.  Am J Phys Med Rehabil. 1993; 72(2):90-96.
  30. O'Toole DM, Golden AM.  Evaluating cancer patients for rehabilitation potential.  West J Med 1991; 155(4):384-387.
  31. Oldmeadow LB, McBurneyH, Robertson VJ. Predicting risk of extended inpatient rehabilitation after hip or knee arthroplasty. J Arthroplasty. 2003; 18(6) 775-779.
  32. Osberg JS, DiScala C, Gans BM.  Utilization of inpatient rehabilitation services among traumatically injured children discharged from pediatric trauma centers.  Am J Phys Med Rehabil. 1990; 69(2):67-72.
  33. Reimer M, LeNavenec CL. Rehabilitation outcome evaluation after very severe brain injury. Neuropsychol Rehabil. 2005; 15(3-4):473-479.
  34. Roos, M. Effectiveness and practice variation of rehabilitation after joint replacement. Curr Opin Rheumatol. 2003; 15(2):160-162.
  35. Siegel JH, Gens DR, Mamantov T, et al.  Effect of associated injuries and blood volume replacement on death, rehabilitation needs, and disability in blunt traumatic brain injury.  Crit Care Med. 1991; 19(10):1252-1265.
  36. Slade A, Tennant A, Chamberlain MA.  A randomised controlled trial to determine the effect of intensity of therapy upon length of stay in a neurological rehabilitation setting.  J Rehabil Med. 2002; 34(6):260-266.
  37. Stineman MG, Williams SV.  Predicting inpatient rehabilitation length of stay.  Arch Phys Med Rehabil 1990; 71(11):881-887.
  38. Walsh DC, Hingson RW, Merrigan SJ, et al.  A randomized trial of treatment options for alcohol-abusing workers.  N Engl J Med. 1991; 325(11):775-782.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Physical Medicine and Rehabilitation. Standards for Assessing Medical Appropriateness Criteria for Admitting Patients to Rehabilitation Hospitals or Units. Updated September 2011.  Available at: http://www.aapmr.org/advocacy/health-policy/medical-necessity/Documents/MIRC0211.pdf.  Accessed on June 30, 2013.
  2. Centers for Medicare & Medicaid Services (CMS). Hospital Manual – Chapter II. 211 Inpatient hospital stays for rehabilitation care. Modified: September 2004. For additional information visit the CMS website: http://www.cms.hhs.gov/ Accessed on June 30, 2013. Centers for Medicare & Medicaid Services (CMS). 3. Medicare Medical Policy Bulletin V-2.
  3. Sources of Information and Basis for Decision.  Hospital Manual, Chapter II, section 211, 2003. . For additional information visit the CMS website: http://www.cms.hhs.gov/. Accessed on June 30, 2013.
  4. Chestnut, R, Carney, N, Maynard, H, et al. Rehabilitation for traumatic brain injury: Evidence report/Technology assessment. Evid Rep Technol Assess (Summ). 1998; (2):1-6.
  5. National Guideline Clearinghouse. Rehabilitation of persons with traumatic brain injury.  NIH Consensus Statement 1998; 26-28; 16(1)1-41 & JAMA. 1999; 282(10):974-983.
  6. No authors listed. Post Stroke Rehabilitation; Assessment, Referral and Patient Management. Am Fam Physician. 1995; 52(2):461-470.
  7. VA/DoD. Clinical Practice Guideline for the Management of Stroke Rehabilitation. Working Group. 2003; Version 1.1.
Web Sites for Additional Information
  1. National Institute of Neurological Disorders and Stroke 2001 Jul.  Post-Stroke Rehabilitation Fact Sheet. Updated June 18, 2013. Available at: http://www.ninds.nih.gov/disorders/stroke/poststrokerehab.htm. Accessed on June 30, 2013.
  2. National Institute of Neurological Disorders and Stroke 2002 February. Traumatic Brain Injury: Hope Through Research. Updated February 11, 2013. Available at: http://www.ninds.nih.gov/disorders/tbi/detail_tbi.htm#42783218.  Accessed on June 30, 2013.
History

Status

Date

Action

Reviewed08/09/2013Medical Policy & Technology Assessment Committee (MPTAC) review Updated review date, References and History sections.
Reviewed08/09/2012MPTAC review Updated review date, References and History sections.
Reviewed08/18/2011MPTAC review Updated Coding, References and History sections.
Reviewed08/19/2010MPTAC review. Updated Review date, References and History sections.
Reviewed08/27/2009MPTAC review. Updated review date, references and history sections.
Reviewed08/28/2008MPTAC review. Updated references and history sections.
Revised08/23/2007MPTAC review. Added language to indicate inpatient rehabilitation is considered not medically necessary for uncomplicated back surgery and uncomplicated compression fractures without neurological involvement. Under Additional Clinical Review section, removed requirement that cases be sent to physician for review and added note about patients with concomitant cognitive and physical issues. Moved information regarding Motor Functional Impairment Status, Cognitive Status, Multidisciplinary Team Support and Frequently Used Assessment Tools, Discharge Indications from appendices 1 -3 to appendix 4. Inserted additional links in document.  Updated references and history sections.
Reviewed05/17/2007MPTAC review. Updated review date and references.
Revised06/08/2006MPTAC. Review.
Revised03/23/2006MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. 
Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

 

 None
Anthem Connecticut

01/2005

NoneAnthem Utilization Management Guidelines for Acute Rehabilitation
Anthem Midwest

04/08/2005

RA-001Rehabilitation: Acute Inpatient – Introduction and Other Diagnosis
Anthem Midwest

05/27/2005

RA-002

Inpatient Rehabilitation and Alternative Settings: Closed

Head Injury/Traumatic Brain Injury

Anthem Midwest

09/01/2004

RA-004Inpatient Rehabilitation and Alternative Settings: Neuromuscular Degenerative Diseases
Anthem Midwest

05/27/2005

RA-005Inpatient Rehabilitation and Alternative Setting: Musculoskeletal
Anthem Midwest

05/27/2005

RA-006Inpatient Rehabilitation and Alternative Settings:  Cerebral Vascular Accident (CVA)
WellPoint Health Networks, Inc.

04/28/2005

NoneAcute Inpatient Rehabilitation
    
APPENDIX 1

APPENDIX 1 

ACUTE INPATIENT REHABILITATION FOR CENTRAL NERVOUS SYSTEM INSULT

(Cerebrovascular Accident[CVA], Acquired Brain Injury and Spinal Cord Injury)

The information provided in this Appendix does not supersede the criteria set forth in the clinical indications section of this document.  Candidates for acute inpatient rehabilitation must meet the criteria set forth in the clinical indications section of this document. Please refer to the clinical indications section for additional criteria. 

Clinical Considerations
Regarding cerebrovascular accident
Acute inpatient rehabilitation is considered medically necessary for individuals who have suffered a cerebrovascular accident (stroke) that results in a significant impairment (contracture, paralysis, severe ataxia or paresis) in at least two extremities or at least one extremity in addition to higher central nervous system functions, including both mentation and autonomic nervous functions such as speech, swallowing and control of secretions.

Regarding acquired brain injury
Acute inpatient rehabilitation is considered medically necessary for individuals who have suffered an acquired brain injury that results in a significant impairment (contracture, paralysis, severe ataxia or paresis) in at least two extremities or at least one extremity in addition to higher central nervous system functions, including both mentation and autonomic nervous functions such as speech, swallowing and control of secretions. 

Regarding spinal cord injury
Acute inpatient rehabilitation is considered medically necessary if a spinal cord injury leads to a significant impairment (contracture, paralysis or severe paresis) of at least two extremities.

Length of Stay - Acute Inpatient Rehabilitation Setting for Individuals with Central Nervous System Insult
This is variable and generally related to the severity of the original injury and the duration of coma or loss of consciousness.  Those with longer periods of coma will generally recover more slowly.  This is also applicable to CNS injury related to non-traumatic intracranial insults (stroke, intracranial hemorrhage, metabolic insult). 

Length of stay for spinal cord injuries is related to the level of the injury.  Injuries occurring higher in the spinal cord result in more profound loss of function and generally require longer periods of rehabilitation for adaptation. 

Routine (typically weekly) reviews are completed to assess how the individual is progressing and to determine the expected length of time inpatient rehabilitation will be required.

Please refer to the appendices for additional information regarding the following:

The criteria set forth in this document are based in part on the recommendations set forth in the Centers for Medicare & Medicaid Services (CMS). LMRP #L13627- Inpatient Rehabilitation 

APPENDIX 2
ACUTE INPATIENT REHABILITATION FOR NEUROLOGICAL DISORDERS

(Peripheral Nerve Injury, Multiple Sclerosis, Nerve Root Injury and Postoperative Deficits)

The information provided in this Appendix does not supersede the criteria set forth in the clinical indications section of this document. Candidates for acute inpatient rehabilitation must meet the criteria set forth in the clinical indications section of this document. Please refer to the clinical indications section for additional criteria.

Clinical Considerations

Regarding peripheral nerve injury
Acute inpatient rehabilitation is considered medically necessary for individuals with focal neurologic disorders which involve the peripheral nerves provided there are multiple injuries that result in a significant impairment (contracture, paralysis, or severe paresis) in at least two extremities.

Acute inpatient rehabilitation is considered medically necessary for individuals with diffuse peripheral nervous system disorders (e.g., Guillain-Barré), which involve at least two extremities and result in significant impairment (contracture, paralysis, or severe paresis) AND the weakness is not limited to a qualitative difference since a prior inpatient admission.

Regarding multiple sclerosis
Acute inpatient rehabilitation is considered medically necessary for individuals with central nervous system disorders (e.g. multiple sclerosis) that result in generalized weakness provided:

Regarding nerve root injury
Acute inpatient rehabilitation is considered medically necessary following nerve root injury when the individual experiences a persistent significant impairment (contracture, paralysis, or severe paresis) in at least two extremities and the deficit is not expected to be self-limited after surgical intervention (e.g. decompression).

Regarding postoperative deficits
Acute inpatient rehabilitation is considered medically necessary for individuals recovering from neurosurgical procedures provided there are neurological deficits as a result of the surgery and there is significant impairment such that it involves at least one extremity in addition to higher central nervous system functions.

Length of Stay - Acute Rehabilitation Setting for Individuals with Neurological Disorders
This is variable and generally related to the severity of the original injury or surgical procedure.  Progress may be slower in members of the geriatric population as well as in individuals with co-morbidities, complications, or decreased cognitive status.

Because the length of stay varies depending on the complexity of the individual's condition, it is not unusual that routine (typically weekly) reviews are completed to assess how the individual is progressing and to determine the expected length of time inpatient rehabilitation will be required.

Please refer to the appendices for additional information regarding the following:

The criteria set forth in this document are based in part on the recommendations set forth in the Centers for Medicare & Medicaid Services (CMS). LMRP #L13627- Inpatient Rehabilitation

APPENDIX 3

ACUTE INPATIENT REHABILITATION FOR MUSCULOSKELETAL/ORTHOPEDIC DISORDERS

(Major Joint Replacement, Amputations, Major/Multiple Trauma, and Other Conditions)

The information provided in this Appendix does not supersede the criteria set forth in the clinical indications section of this document. Candidates for acute inpatient rehabilitation must meet the criteria set forth in the clinical indications section of this document. Please refer to the clinical indications section for additional criteria.

Clinical Considerations

Regarding major joint replacements
If a single joint is replaced, typically postoperative acute inpatient rehabilitation is considered not medically necessary unless the individual has significant comorbidity(ies) resulting in functional deficits which would necessitate an inpatient level of rehabilitation in order to achieve a satisfactory outcome within a reasonable time period. Of note, acute postoperative inpatient rehabilitation may be medically necessary for individuals undergoing more than one major joint replacement during a single hospitalization.

Regarding back surgery and compression fractures
Acute inpatient rehabilitation is considered not medically necessary for the following:

Regarding amputations
Acute inpatient rehabilitation is considered medically necessary for individuals who have experienced the loss of more than one body part (with the exception of digits).

Rehabilitation after a single foot or leg amputation may occur in an acute inpatient or less intensive outpatient setting.  This determination is dependent upon: (1) the individual's ability to actively participate in an intensive rehabilitation program; (2) the functional deficit caused by the amputation itself; and (3) the individual's underlying medical condition.

Acute inpatient rehabilitation is considered not medically necessary for individuals who have suffered the loss of fingers, toes or a single hand because they do not require the intensive level of constant care provided in the inpatient setting.  These individuals typically undergo rehabilitation in a less intensive, outpatient setting.

Regarding major/multiple trauma
Acute inpatient rehabilitation is considered medically necessary for individuals who have:

Regarding arthritis and lupus erythematosus
Acute inpatient rehabilitation is considered medically necessary for individuals with severe arthritis (e.g., rheumatoid arthritis, osteoarthritis, polyarthritis, and lupus erythematosus) provided joint pathology involvement has progressed to the extent that the individual has experienced a significant functional decline in range of motion in the joint or related contractures in at least two extremities.

Regarding other conditions
Acute inpatient rehabilitation is considered not medically necessary for individuals with the following musculoskeletal/orthopedic disorders because they do not require the intensive level of constant care provided in the inpatient setting.  These individuals typically undergo rehabilitation in a less intensive, outpatient setting.

Length of Stay - Acute Rehabilitation Setting for Individuals with Musculoskeletal/Orthopedic Disorders

This is variable and generally related to the severity of the original injury or surgical procedure.  Progress may be slower in members of the geriatric population as well as in individuals with co-morbidities, complications, or decreased cognitive status.

Because the length of varies depending on the complexity of the individual's condition, it is not unusual that routine (typically weekly) reviews are completed to assess how the individual is progressing and determine the expected length of time inpatient rehabilitation will be required.

Please refer to the appendices for additional information regarding the following:

The criteria set forth in this document are based in part on the recommendations set forth in the Centers for Medicare & Medicaid Services (CMS). LMRP #L13627- Inpatient Rehabilitation.  

APPENDIX 4

ADDITIONAL CLINICAL CONSIDERATIONS FOR REVIEW

The information provided in this Appendix does not supersede the criteria set forth in the clinical indications section of this document.  Candidates for acute inpatient rehabilitation must meet the criteria set forth in the clinical indications section of this document. Please refer to the clinical indications section for additional criteria.

Motor Functional Impairment Status
The motor functional status of individuals in this category is characterized by:

Note: See Appendix D for the Functional Independence Measurement and Appendix E for the Disability Rating Scale.

Cognitive Status Required to Benefit from Inpatient Rehabilitation
The individual must be able to follow simple command (verbal or demonstrated) with reasonable consistency (e.g. 50% of the time). Individuals who have experienced a head injury, multiple traumas, cerebrovascular (CV) or central nervous system (CNS) insult may start at a lesser level but must show some potential for progressive improvement in following commands during the first 2 weeks of the rehabilitation program.

Notes:

Multidisciplinary Team Support
The specific needs of an individual will vary, however, care frequently required for individuals and which cannot be achieved at less acute levels of care such as skilled nursing facility (SNF), subacute, home health care (HHC), or outpatient therapy setting, may include the following. Please refer to the Discussion/General Information section of this document for additional information regarding these services.

Please refer to the appendices for additional information regarding the following:

Note:  Individuals discharged from the inpatient rehabilitation setting are frequently transferred to an environment where a lesser degree of skilled medical care is required such as to a Skilled Nursing Facility, a Custodial Care setting or home.  Please refer to the documents on Custodial Care, Skilled Nursing and Skilled Rehabilitative Services (Outpatient), Skilled Nursing Facility and Home Health for additional information.  

APPENDIX A

DETERMINATION OF LEVELS OF CARE

Rehabilitative care in an acute inpatient setting is appropriate for individuals who require a more coordinated, intensive program of multiple services than is generally found in a SNF or outpatient setting.  Individuals are likely to require an inpatient level of rehabilitation if they have one or more conditions requiring intensive and multidisciplinary rehabilitation care, or a medical complication in addition to their primary condition which requires the continuing availability of a physician to ensure safe and effective treatment.

Whether an individual is admitted to a skilled nursing facility or an inpatient rehabilitation center is principally determined by the individual's degree of disability, his/her ability to actively participate in therapy, and the intensity of the program.  This table is provided as a tool to help the user distinguish acute rehabilitative care from the care provided in a skilled nursing facility. 

Acute Inpatient Rehabilitation

Skilled Nursing Facility

Rehabilitation therapy averages a minimum of 3 hours per day, one or more disciplines (PT, OT, ST), at least 5 days per week.

 

Rehabilitation therapy averages a minimum of 0.5 – 2.0 hours per day, at least 5 days per week.

Physicians are actively coordinating multi-disciplinary care and are typically available 24 hours/day.

 

Physicians are typically available intermittently.

Rehabilitation nurses, as part of the integrated team, provide direct, skilled care, assessments and teaching every shift.  Direct nursing care averages 5 hours/day.

 

Nurses provide direct, skilled care assessments at least once per day. 

Management of complicated surgical wound requires care and assessments several times per day, if applicable.

 

Management of stable wound requires care and assessments at least once per day, if applicable.

Individual may have a medical or surgical condition that is stable enough to allow the individual to fully participate in therapies.

Individual may have a medical or surgical condition that does not require hospitalization but is not be stable enough to allow the individual to fully participate in therapies.

APPENDIX B

Rancho Los Amigos Cognitive Scale

The Rancho Los Amigos Cognitive Scale is a widely accepted tool which is used to serve as a guidepost of cognitive levels from admission through discharge. The Rancho Los Amigos Cognitive Scale does not require participation from the individual but is based on the clinician's observation of the individual's response to environmental stimuli.  There are currently two versions of this scale; the original scale includes 8 categories, while the revised scale addresses 10 categories.  Both scales are included below for easy reference.

Los Amigos Cognitive Scale - Revised

Level I - No Response: Total Assistance

Level II - Generalized Response: Total Assistance

Level III - Localized Response: Total Assistance

Level IV - Confused/Agitated: Maximal Assistance

Level V - Confused, Inappropriate Non-Agitated: Maximal Assistance

Level VI - Confused, Appropriate: Moderate Assistance

Level VII - Automatic, Appropriate: Minimal Assistance for Daily Living Skills

Level VIII - Purposeful, Appropriate: Stand-By Assistance

Level IX - Purposeful, Appropriate: Stand-By Assistance on Request

Level X - Purposeful, Appropriate: Modified Independent

Los Amigos Cognitive Scale - Original

Rancho Level

Clinical Correlate

I

No Response

II

Generalized response

III

Localized response

IV

Confused-agitated

V

Confused-inappropriate

VI

Confused-appropriate

VII

Automatic-inappropriate

VIII

Purposeful and appropriate

References
  1. Original Scale co-authored by Chris Hagen, Ph.D., Danese Malkmus, M.A., Patricia Durham, M.A. Communication Disorders Service, Rancho Los Amigos Hospital, 1972. Revised 11/15/74 by Danese Malkmus, M.A., and Kathryn Stenderup, O.T.R. Revised scale 1997 by Chris Hagen.
APPENDIX C

Glasgow Coma Scale (GCS)

Eye Opening Response

Verbal Response

Motor Response

Head Injury Classification:

(Adapted from: Advanced Trauma Life Support: Course for Physicians, American College of Surgeons, 1993).

References
  1. Department of Health and Human Services Centers for Disease Control and Prevention.  Glasgow Coma Scale. Last reviewed: February 1, 2013Available at http://www.bt.cdc.gov/masscasualties/gscale.asp   Accessed on June 30, 2013.
  2. Teasdale G, Jennett B. Assessment and prognosis of coma after head injury. Acta Neurochir 1976; 34:45-55.
  3. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. Lancet 1974; 81-84.
APPENDIX D

Functional Independence Measurement (FIM™) Score

Score
(1-7)

 

Score
(1-7)

 

Self-care

Transfers

 

Eating

 

Bed, Chair, Wheelchair

 

Bathing

 

Toilet

 

Dressing Upper Body

 

Tub, Shower

 

Dressing Lower Body

Communication

 

Toileting

 

Comprehension

 

Bladder Management

 

Expression

 

Bowel Management

 

Social Interaction

Locomotion

 

Problem Solving

 

Walking, Wheelchair

 

Memory

 

Stairs

 

  

 

Scoring Guidelines

 

Complete Dependence 
1Total Assist (Subject = 0% +) 
2Maximal Assist (Subject = 25% +) 
Modified DependenceHELPER
3Moderate Assist (Subject = 50% +) 
4Minimal Assist (Subject = 75% +) 
5Supervision 
6Modified Independence (Device)NO HELPER
7Complete Independence (Timely, Safely) 
 
References
  1. Getting Started with the Uniform Data System for Medical Rehabilitation, Version 5.0. Buffalo, NY 14214: State University of New York at Buffalo; 1996.
  2. Guide for the Uniform Data Set for Medical Rehabilitation (including the FIM™ instrument), Version 5.1. Buffalo, NY 14214: University at Buffalo; 1997.
APPENDIX E

Disability Rating Scale (DRS)

CategoryItemInstructionsScore
Arousability, Awareness and ResponsivityEye Opening0 = spontaneous
1 = to speech
2 = to pain
3 = none
 
Communication Ability0 = oriented
1 = confused
2 = inappropriate
3 = incomprehensible
4 = none
 
Motor Response0 = obeying
1 = localizing
2 = withdrawing
3 = flexing
4 = extending
5 = none
 
Cognitive Ability for Self Care ActivitiesFeeding0 = complete
1 = partial
2 = minimal
3 = none
 
Toileting0 = complete
1 = partial
2 = minimal
3 = none
 
Grooming0 = complete
1 = partial
2 = minimal
3 = none
 
Dependence on OthersLevel of Functioning0 = completely independent
1 = independent in special environment
2 = mildly dependent
3 = moderately dependent
4 = markedly dependent
5 = totally dependent
 
Psychosocial AdaptabilityEmployability0 = not restricted
1 = selected jobs
2 = sheltered workshop (non-competitive)
3 = not employable
 
Total DRS Score 

Disability Categories

Total DR Score

Level of Disability

0

None

1

Mild

2-3

Partial

4-6

Moderate

7-11

Moderately Severe

12-16

Severe

17-21

Extremely Severe

22-24

Vegetative State

25-29

Extreme Vegetative State

References
  1. Rappaport, et al. Disability rating scale for severe head trauma patients: coma to community. Archives of Physical Medicine and Rehabilitation. 1982; 63:118-123.