Clinical UM Guideline
|Subject:||Inpatient Subacute Care|
|Guideline #:||CG-MED-29||Current Effective Date:||06/28/2016|
|Status:||Reviewed||Last Review Date:||05/05/2016|
This document addresses services provided in the subacute care setting.
The American Health Care Association (AHCA), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the Association of Hospital-Based Skilled Nursing Facilities have defined subacute care as:
Comprehensive inpatient care designed for someone who has an acute illness, injury, or exacerbation of a disease process. It is goal-oriented treatment rendered immediately after, or instead of, acute hospitalization to treat one or more specific active complex medical conditions or to administer one or more technically complex treatments, in the context of a person's underlying long-term conditions and overall situation (American Health Care Association, 1996).
Subacute care is a distinct form of health care service that focuses on providing the skilled medical care needed to transition individuals from the acute care setting (UB Foundation Activities, Inc., 2001-2004). Subacute care may be rendered in a freestanding facility or in a designated unit of a general or rehabilitation hospital. Subacute care requires a treatment plan with specific goals attained through the provision of skilled nursing, rehabilitative and medical services by licensed professionals. Specifically, subacute care should not be confused with custodial care which is designed to assist medically stable individuals with their activities of daily living, (ambulating, exercising, bathing and dressing). Custodial care does not require the skills of a trained professional or supervision of a physician. For additional information regarding custodial care, please refer to CG-MED-19 Custodial Care.
Inpatient subacute level of care may be used specifically for rehabilitation purposes for any number of conditions. In general, the rehabilitation needs of these individuals require less than three modalities, most often physical therapy. The overall functional deficit for these individuals is such that complex adaptive equipment and modifications are not needed.
Please see the following documents for additional information regarding skilled and non-skilled services in other settings:
Inpatient subacute care is considered medically necessary for individuals who meet the following criteria (A and B): Individuals requiring inpatient rehabilitative services should meet the following criteria in A, B and C below:
Note: It is not necessary that there is an expectation of complete independence in the activities of daily living; there should be a reasonable expectation of improvement that is of practical value to the individual, measured against his/her condition at the start of the rehabilitation program. Additionally, the individual must have no lasting or major treatment impediment, such as severe dementia, that prevents progress.
Conditions that may be appropriate for inpatient subacute care include but are not limited to:
Not Medically Necessary:
The individual's inpatient stay becomes not medically necessary when ANY ONE of the following occurs:
The following codes for treatments and procedures applicable to this document are included below for informational purposes. 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.
|0190||Sub-acute care, general classification|
|0191||Sub-acute care, level I|
|0192||Sub-acute care, level II|
|0193||Sub-acute care, level III|
|0194||Sub-acute care, level IV|
|0199||Other sub-acute care|
|Numerous diagnosis codes may be applicable; see clinical indications|
Subacute care requires the coordinated services of an interdisciplinary team including physicians, nurses, and other relevant professional disciplines sufficiently trained and knowledgeable to assess and manage these specific conditions and perform the necessary procedures. According to AHCA, the JCAHO, and the Association of Hospital-Based Skilled Nursing Facilities:
Subacute care is generally more intensive than traditional nursing facility care and less than acute care. It requires frequent (daily to weekly) recurrent individual assessment and review of the clinical course and treatment plan for a limited (several days to several months) time period, until the condition is stabilized or a predetermined treatment course is completed" (American Health Care Association, 1996).
The goal of inpatient subacute care is to match an individual's needs with the medically appropriate level of health care services.
Government Agency, Medical Society, and Other Authoritative Publications:
|Reviewed||05/05/2016||Medical Policy & Technology Assessment Committee (MPTAC) review. Updated the References section. Removed ICD-9 codes from Coding section.|
|Reviewed||05/07/2015||MPTAC review. Updated the References section.|
|Reviewed||05/15/2014||MPTAC review. Updated the References section.|
|Reviewed||05/09/2013||MPTAC review. Updated the References section.|
|Reviewed||05/10/2012||MPTAC review. Updated review date, References and History sections.|
|Reviewed||05/19/2011||MPTAC review. Updated review date, References and History sections.|
|Reviewed||05/13/2010||MPTAC review. Updated review date, references and history sections.|
|Reviewed||05/21/2009||MPTAC review. Updated review date, references and history sections. Deleted place of service /goal length of stay, case management and discharge plan sections.|
|Reviewed||05/15/2008||MPTAC review. Updated references and review date.|
|Reviewed||05/17/2007||MPTAC review. Updated references and review date.|
|Revised||06/08/2006||MPTAC revision. Corrected language in Clinical Indications section to indicate that "Conditions that may be appropriate for inpatient subacute care include but are not limited to:... pulmonary conditions|
|New||03/23/2006||MPTAC initial guideline development.|
|Pre-Merger Organizations||Last Review Date||Document Number||Title|
|Anthem Connecticut||1st quarter, 2005||None||Subacute Care Benefit Detail CT|
|WellPoint Health Networks, Inc.||None|