Providers welcome new admission guidelines

AAPM&R forms task force on medical necessity

After months of gloom and doom surrounding the 75% rule and the draft Local Medicare Review Policies (LMRPs) on inpatient rehabilitation admission, rehab advocates say they finally see a glimmer of hope. Not a big bucket of sunshine — the 75% rule and the draft LMRPs still are on the table — but a welcome ray of hope, nonetheless.

The American Medical Rehabilitation Providers Association in Washington, DC, sees a positive alternative in a new local coverage determination document released by AdminaStar Federal, says Carolyn Zollar, JD, AMRPA’s vice president for government relations. AdminaStar is the Medicare fiscal intermediary for Indiana, Illinois, Kentucky, and Ohio.

When three other fiscal intermediaries — Riverbend Government Benefits Administrator (Tennessee and New Jersey), Blue Cross and Blue Shield of Georgia, and Veritus Medicare Services (Pennsylvania) — released their draft LMRPs in the fall, rehab providers worried the policies would be a disaster for inpatient rehab. Providers said the proposed narrow criteria for admitting patients to inpatient rehab would shut many patients out of services they need and even force some rehab hospitals to close.

While the previously released LMRPs were virtually identical, the AdminaStar document takes its own tack on the issue of what types of patients should be admitted for inpatient rehabilitation.

According to Bruce Gans, MD, chief medical officer at the Kessler Institute for Rehabilitation in West Orange, NJ, that’s a good thing. "The AdminaStar document has absolutely no relation to the other documents, and it was clearly not just a minor variation or derivative of one commonly produced document. It’s a totally different approach," says Gans, who is also the president-elect of the Chicago-based American Academy of Physical Medicine and Rehabilitation (AAPM&R).

Fiscal intermediaries began producing local coverage policies for inpatient rehab after a 2002 program memorandum from the Centers for Medicare & Medicaid Services gave them the responsibility for auditing inpatient rehab claims.

With all the differing opinions coming from the payer side, the AAPM&R has decided to officially weigh in on inpatient rehab admission. The organization has formed a task force of eight physicians and four consultants to establish its own professional recommendations of what are the appropriate criteria for determining medical necessity for admission into an inpatient rehab facility, Gans says. Over the next six months, the task force will review the existing documents and what little literature exists on the topic and try to articulate the standards and criteria to which rehab hospitals should be held.

He maintains that fiscal intermediaries really don’t need a local coverage document, but if they must have one, the AdminaStar version is the best. "The Medicare 110 benefit policy regulations are quite clear and quite readily usable to assess a patient’s appropriateness for admission by anybody who knows and understands rehab," he says.

Gans, who says he found the Riverbend LMRP to be a "disturbing document" that couldn’t possibly have been written by physicians with rehab experience, says the AdminaStar document does appear to have been written by people with knowledge of medical rehab. "It approaches the whole concept of how to identify what patient is appropriately cared for in inpatient rehabilitation settings from the perspective of rehab. It recognizes the purposes of admission are for function and that need for admission doesn’t always correlate well with diagnosis," he adds. "That is one of the problems that has been identified with the other approach and how attendant it is on the notion of diagnosis. What the field has said all along is that it’s not medical diagnosis that determines appropriateness but rather functional need and potential benefit from the kind of resources that are available at a rehab hospital."

The AdminaStar document (go to: www.amrpa.org/PDF_Files/Inpatient_Rehabilitation_IAC_Jan_Mar.pdf) does not include a listing of diagnoses appropriate for inpatient rehabilitation but instead asserts, "The need for inpatient rehabilitation is more dependent on the effects of a patient’s injury or illness [impairments, functional deficits, achievable goals] than on the precipitating cause [diagnosis]."

The document summary states that inpatient rehabilitation will be considered medically reasonable and necessary as long as:

  • There is a reasonable expectation of measurable improvement that will be of practical value to the patient within a predictable and reasonable period of time.
  • The patient requires the active and ongoing therapeutic intervention of at least two disciplines, one of which must be a therapy, acting in a coordinated fashion.
  • The patient requires and can tolerate at least three hours per day of skilled therapy at least five times per week.
  • The therapy cannot be provided in a less intensive setting.

The AdminaStar document probably would not force hospitals to change the way they admit patients. "But it would relieve a lot of the anxiety that we feel when we admit somebody who we know needs our care and services but we know puts us in jeopardy of having a denial," Gans says. "That’s the good news. Each case needs to be judged on its own merits. You can’t develop a blanket guideline that automatically could be applied to people."

But overall, both the 75% rule and the LMRPs should be stopped, he says. Gans sees two different questions to be answered:

1. How do you define a rehab hospital in contrast to an acute care hospital? "That actually has very little to do with the attributes of the individual patient and mostly to do with what the facility does, what the services are, what the resources are like," he says.

2. How do you determine which individual patient belongs in that setting? "That’s a job for the local coverage determination. There are specific attributes that should be defined. The AdminaStar document shows it’s not impossible. Now somebody has published a model that is really close to being right. It should be quite a usable tool for the fiscal intermediaries but also for the field," Gan adds.

Need more information?

  • Bruce Gans, MD, Chief Medical Officer, Kessler Institute for Rehabilitation, 1199 Pleasant Valley Way, West Orange, NJ 07052. Phone: (973) 243-8535.
  • Carolyn Zollar, Vice President for Government Relations, American Medical Rehabilitation Providers Association, 1710 17th St. N.W., Washington, DC 20036. Phone: (888) 346-4624.