AMRPA Conference Coverage

Don’t assume the 75% rule will be modified

Know the conditions of participation rules

In the era of continual regulatory changes for rehab providers, it’s very important to stay focused on following the conditions of participation (COPs) rules since these provide the best guide for compliance, an expert advises. "We’ve been having our clients focus on making sure they’re in compliance with the conditions of participation, relative to maintaining their rehabilitation certification," says Michael Soisson, MS, MHA, a senior consultant with Gill/Balsano Consulting in Norcross, GA.

Many in the rehab industry continue to hope for the permanent elimination or major modifications to the 75% rule, which requires that at least 75% of a rehab facility’s diagnoses fall into 13 diagnoses that were determined years ago for rehab providers. However, it does not appear as though Congress will make any changes to the 75% rule before the end of 2004, he says.

Effective July 1, 2004, the moratorium on the 75% rule was lifted with a four-year phase-in strategy that will require facilities to meet 50% through June 30, 2005; 60% from July 2005 to June 2006; 65% from July 2006 to June 2007; and 75% thereafter, Soisson explains. "We always felt that it doesn’t necessarily make sense that the diagnosis of patients coming into your facility are driving your certification as a facility," he says. "It seems like a patient’s medical condition and functional status is what should determine whether they go into rehab or not."

However, the reality is that the 75% rule has continued to exist, and rehab providers may have to learn to live with it, Soisson adds. Two years ago, a study showed that only 13% of rehab providers were in compliance with the 75% rule, so this could be a major problem for the industry, he notes.

The software rehab providers use to track their compliance with the 75% rule also could pose problems, Soisson says. The software isn’t as sophisticated as needed to capture all of the patients who should fall within the 75% rule diagnoses, so he advises rehab providers to conduct their own medical record reviews, looking specifically at the primary reason for admission. "The second issue is you need to be able to document and prove it," Soisson says. "Just because your coder or admissions person says the patient is admitted for that condition doesn’t make it accurate."

The doctor’s physical, the medical records, and the patient’s history all need to document and back up the claim that the patient is admitted for a particular condition related to rehab, he says. For example, patients who have polyarthritis in multiple joints qualify for the 75% rule, but if physicians do not document that patients had arthritis in other weight-bearing joints, they don’t qualify for the 75% rule, Soisson says.

He offers these additional tips for improving compliance with the conditions of participation:

Provide close medical supervision.

Each patient should receive close medical supervision, as well as rehabilitation nursing care, therapy, and psychosocial services as needed, Soisson says. Physicians should document that the rehab services are needed and document the medical supervision, he advises. "Sometimes, we see that a physician who is supposed to be closely monitoring the patient comes in every day or every other day," Soisson says. "When you look at the documentation, it says, The patient is doing fine; continue treatment," and that’s it."

But if there are four or five days in a row of that type of documentation, then it would be questionable whether the patient is receiving close medical supervision, he explains. "What should happen is that the physician documents that he talked with the therapist and nurses and met with the patient and saw the patient in the therapy gym and documents how the patient progresses," Soisson says. "Then every two weeks, there’s a team conference that pulls together that information."

Document the plan of treatment.

Likewise, there should be a documented plan of treatment, he says. "Each patient has a plan of treatment that is reviewed and revised by the physician and rehab team," Soisson notes. "Some patients will stay a week, and some will stay three weeks; so the plan is reviewed as appropriate, and it at least has to have the doctor’s name on it."

Coordinate the multidisciplinary team approach.

"There has to be evidence that there’s a multidisciplinary approach to care with therapy, nursing, doctors, and other consults as needed," he says. "And at least every two weeks, there’s a team conference where the patient’s goals and treatment plans and discharge plans are being discussed."

Use preadmission screening.

Rehab facilities can run into problems if there is no formal screening process to make certain patients are candidates for rehab, accompanied by documentation that shows why, Soisson says. "The preadmission screening process is a problem area," he notes. "Rehab staff think a patient is a good candidate for rehab, but no one has signed off and said, Yes, the patient is a good candidate for rehab, and here’s why.’"

The solution is to document a review of the medical record while the patient is in acute care, perhaps by having the physician conduct a consultation on a patient in acute care and applying the rehab criteria to the case before saying that the patient would benefit from rehab services, Soisson says.

Encourage nurses to be certified.

Another troublesome area involves adequate nurse staffing because of the nursing shortage, he points out. If an organization doesn’t have some of its nursing staff certified in rehab nursing, then there’s the question of whether the facility truly is providing rehab nursing, Soisson says. "So we’re encouraging clients to get as many nurses certified as possible, but if that’s not practical in the short run, then do continuing education with specific rehab nursing issues," he says.

Make certain patient meets requirement for medical necessity.

"The expectation is that the patient meets the criteria for medical necessity," Soisson says. "The problem is that Medicare looks at this in a retrospective review," he says. So if a rehab facility has admitted a patient who doesn’t meet medical necessity criteria, the facility would not know that this is Medicare’s decision until after the patient has been treated for a couple of weeks and the claim was submitted, Soisson says.

"Then you lose all you’ve provided and don’t get paid for that," he says. "And you run the risk, if you have enough cases of those, to have the fiscal intermediary say that you don’t look like a rehab provider because you’re providing a level of care that’s not rehabilitation."

This past year, there has been a trend of fiscal intermediaries publishing their own review policies, and these seem to present a consistent view of what constitutes medical necessity, Soisson notes. "As the Centers for Medicare & Medicaid Services (CMS) forces fiscal intermediaries to be more diligent organizations, then rehab providers will have to make sure patients are meeting those criteria," he adds.

Audit medical records admission.

"We feel strongly that some medical record audits for preadmission and admission acceptance and continued stay need to be done on a regular basis," Soisson says. "At least on a yearly basis, a rehab facility ought to get some outside help with auditing because you can get too close to it yourself, and you are not always as objective as you need to be," he says. "So the real issue is having someone take a really good look at medical records to see if you are, in fact, proving that these patients belong in rehab and are staying as long as they should have stayed," Soisson explains.

For instance, if a patient could have gone to a skilled nursing facility, then the patient should not have been admitted to rehab, he says. "They need to have that inpatient rehab level of care, and that’s an intensity of service condition," Soisson says. Patients admitted to inpatient rehab must require 24-hour nursing care, regular physician interaction and monitoring, three hours of therapy a day, five days a week, and documentation for all of these services, he adds.

Rehab providers will need to continue to monitor compliance with the COPs, including medical necessity, because CMS has vowed to hold facilities accountable for the COPs, Soisson says.