The noose has tightened’
The rehab community by and large considers the Centers for Medicare & Medicaid Services’ (CMS) proposal to change the 75% rule a big disappointment. But providers and advocates are even more worried about the draft Local Medicare Review Policy (LMRP) for inpatient rehabilitation admission that three fiscal intermediaries recently proposed.
"We’re very concerned with the LMRP. That would be a disaster for inpatient rehab as we know it," says Bill Munley, MHSA, CRA, administrator of the rehab/neuro/ortho service line at St. Francis Hospital in Greenville, SC.
The document was drafted by fiscal intermediaries Riverbend Government Benefits Administrator (Tennessee and New Jersey), Blue Cross and Blue Shield of Georgia and Veritus Medicare Services (Pennsylvania). It defines the medical necessity for the provision of therapy services in an inpatient rehabilitation environment.
The summary of the LMRP (go to: www.riverbendgba.com/vlmrp/d103-03a.html) says inpatient rehab is covered for patients who have a reasonable expectation of practical improvement and are receiving medically necessary rehabilitative services that include all the following:
- require around-the-clock availability of an RN and/or frequent (every two to three days) assessment and intervention by a physician;
- require coordinated multidisciplinary care;
- require intensive (typically three hours per day) skilled intervention;
- cannot be provided in a less intensive setting.
Inpatient rehabilitation typically is covered for:
- Pathology that results in significant loss of function to two or more extremities.
- CNS (central nervous system) pathology that results in significant loss of function of a single extremity along with the loss of higher functions such as speech/language, balance, and coordination.
- Single extremity loss of function combined with medical complications that necessitate continuous RN or physician supervision and which is not part of the normal acute inpatient recovery process.
Inpatient rehabilitation typically is not covered for:
- single extremity deficits (except amputations);
- simple fractures;
- joint replacement;
- compression fractures and laminectomies/ fusions;
- diffuse weakness or general debility;
- post-op recovery;
- niche rehabilitation (coma, cognitive, cardiac, pulmonary, pain, etc.).
Different from 75% rule
Dan Duvall, MD, medical director for the Chattanooga, TN-based Riverbend, says the fiscal intermediaries felt the need to clearly delineate the criteria for medical necessity after a 2002 program memorandum from CMS gave them the responsibility for auditing inpatient rehab claims. For 10 years prior, it had been unclear who had that responsibility, which meant there wasn’t a lot of review activity going on, Duvall says.
"We have had the authority to make these decisions for the last year but we thought it would be better to try to get a good working document put together first so that it would be as clear as possible how we are interpreting these regulations that we’re now responsible for," he explains.
Duvall says the LMRP has nothing to do with the 75% rule. The LMRP deals with individual cases and whether they meet CMS requirements. "There is a reasonable correlation in that a lot of patients who fall in the 25% of the 75% rule also are patients who have diagnoses and treatment plans that are borderline under Medicare requirements for inpatient coverage," he adds. "There’s a rough correlation but not an absolute correlation by any means. The other thing is that the 75% rule was actually written in such a way that if a hospital is truly pursuing its rehab status in the way CMS originally envisioned it, then the hospital should have no problems meeting the 75% rule."
Theresa Edelstein, vice president of continuing care services for the New Jersey Hospital Association in Princeton, might agree with Duvall that the two issues are unrelated, but for a different reason. "The LMRP renders the 75% rule almost moot," she says. "The draft LMRP together with the 75% rule proposal has the makings of disastrous results for some rehab providers. The fiscal intermediaries are saying that orthopedic patients rarely if ever need inpatient rehab. Some will face significant downsizing or closure depending on their orthopedic referrals. Nurses will probably be absorbed in other parts of the health care system, but therapists, custodians, dietary workers, housekeeping staff will be out of work."
Edelstein says that if the LMRPs are approved as written, the face of rehab will change. "The noose has tightened with this draft," she says.
Duvall, however, says there are no absolutes in the document. "The policy says that everything should be evaluated on a case-by-case basis. It does say that, in general, uncomplicated joint replacements typically don’t require the level of intensity that would require inpatient care. That’s a long way from saying no inpatient joints can be in the hospital." For example, a single knee replacement probably would not require inpatient care. But a patient who had multiple joints replaced at the same time or who had a single joint replacement along with significant upper extremity impairment likely would qualify, Duvall says.
"The decision criteria would say that the care for certain patients in an inpatient environment is not medically necessary because those same services can be delivered as efficiently in a skilled nursing facility or on an outpatient basis," Duvall says. "It shouldn’t be throwing out patients who need the care, but rather it’s saying that if you have a patient who only needs physical therapy, then they could just as well get the therapy in a skilled nursing facility [SNF] environment."
Bruce Gans, MD, chief medical officer at the Kessler Institute for Rehabilitation in West Orange, NJ, says that as a physiatrist, he finds the LMRP to be a disturbing document. "As I see it, it shows a great deal of medical naiveté being expressed with regards to understanding the rehabilitation purposes and processes," he says. "The documents talk almost exclusively about impairment level issues, counting the number of limbs that are involved. It’s almost completely devoid of recognition that somebody gets admitted to a rehab program not just because they have an impairment but because there is a major functional limitation, a disabling condition."
Gans says he rejects "the entire premise of the LMRP." He says it’s hard to believe that any rehab physicians were involved in writing the document.
Duvall points out that a number of physicians, including rehab specialists, were consulted throughout the one-year draft process.
Gans agrees that not every joint replacement patient needs to be in the hospital. Some can be served on an outpatient basis, while those who need nursing care but not three hours a day of therapy can be served in a SNF. But there’s a third category of patients who have a lot of active medical problems along with the joint replacement and who need inpatient rehab. "They need much more intensive therapy because of the combination of the effect of the arthritis and the joint replacement on their ability to dress, feed themselves, transfer, and manage wound care. It’s a combination of factors that collectively say this patient really needs to be in the hospital.
On a positive note, Gans says these policies could force rehab doctors to get involved upstream by working to get patients so capable before elective surgery that they will do better after. "We don’t do a good enough job of pre-surgically rehabilitating people and getting them prepped to the ideal position to recover quickly," he says. "Unfortunately, the rehab doctors are usually not involved in the care until after the surgery."
Carolyn Zollar, JD, vice president for government relations at American Medical Rehabilitation Providers Association in Washington, DC, also is puzzled at the origin of the LMRP. "The fiscal intermediaries are issuing medical review policies saying who can and cannot be admitted to rehab. This issue is larger and more critical than the 75% rule. They’re very tight — tighter than the 75% rule — and we don’t know where they came from," she says. "They have to be fought tooth and nail in every state, and we’re working on that as well. If they go into effect, you won’t be able to admit patients to even come in the door."
Duvall says the LMRP is not likely to have the major impact the rehab providers fear. "It is my expectation that we’re talking about a relatively small number of patients at each hospital but that it’s fairly uniform across hospitals. The majority of cases at rehab hospitals still clearly require inpatient care, and it’s the minority that fall in the borderline category.
"The hospitals should have been reasonably consistent all along. Clearly, it’s going to make some difference because if it wouldn’t, there would be no reason for having the policy in the first place. Over the 10 years without any significant review, facilities tend to have had a fairly diverse interpretation of the regulations," he adds.
The rehab community by and large considers the Centers for Medicare & Medicaid Services proposal to change the 75% rule a big disappointment. But providers and advocates are even more worried about the draft Local Medicare Review Policy for inpatient rehabilitation admission that three fiscal intermediaries recently proposed.
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