(Medicare Benefit Policy Manual)

In addition, as noted at 85 FR 27573 contractors shall not include freestanding IRF patient medical records that have DS at the end of their unique hospital patient identifier numbers when reviewing whether the IRF meets the following coverage requirements:     Has in effect a preadmission screening procedure,    Has in effect a procedure for ensuring that patients receive close medical supervision by a physician,    Has a plan of treatment for each patient, or    Uses an interdisciplinary approach to care.   Contractors shall allow freestanding IRFs to be paid at the usual IRF prospective payment amounts for these patients.  110.3 - Definition of Measurable Improvement  (Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)  A patient can only be expected to benefit significantly from an intensive rehabilitation therapy program provided in an IRF, as required in section 110.2.3, if the patients IRF medical record indic ates a reasonable expectation that a measurable, practical improvement in the patients functional condition can be accomplished within a predetermined and reasonable period of time.  In general, the goal of IRF treatment is to enable the patients safe return to the home or community-based environment upon discharge from the IRF.  The patients IRF medical record is expected to indicate both the nature and degree of expected improvement and the expected length of time to achieve the improvement.  Since dis charge planning is an integral part of any rehabilitation program and must begin upon the patients admission to the IRF, an extended period of time for discharge from the IRF would not be reasonable and necessary after established goals have been reached or the determination has been made that further progress is unlikely.  For an IRF stay to be considered reasonable and necessary, the patient does not have to be expected to achieve complete independence in the domain of self -care or return to his or her p rior level of functioning.  However, to justify the need for a continued IRF stay, the documentation in the IRF medical record must demonstrate the patients ongoing requirement for an intensive level of rehabilitation services (as defined in section 110.2.1) and an inter-disciplinary team approach to care (as defined in section 110.2.2).  Further, the IRF medical record must also demonstrate that the patient is making functional improvements that are ongoing and sustainable, as well as of practical value, measured against his/her condition at the start of treatment.  Since in most instances the goal of an IRF stay is to enable a patients safe return to the home or community-based environment upon discharge, the patients treatment goals and achievements during an IRF admission are expected to reflect significant and timely progress toward this end result.  During most IRF stays, therefore, the emphasis of therapies would generally shift from traditional, patient- centered therapeutic services to patient/care giver education, durable medical equipment training, and other similar therapies that prepare the patient for a safe discharge to the home or community-based environment.  CMS notes that as evidenced by the criteria established above, an IRF claim could ne ver be denied for the following reasons: (1) because a patient could not be expected to achieve complete independence in the domain of self-care or (2) because a patient could not be expected to return to his or her prior level of functioning.  120 - Servi ces Related to and Required as a Result of Services Which Are Not Covered Under Medicare  (Rev. 189, Issued: 06-27-14, Effective: 05-30-14, Implementation: 06-29-14)  Medical and hospital services are sometimes required to treat a condition that arises as a result of services that are not covered because they are determined to be not reasonable and necessary or because they are excluded from coverage for other reasons.  Services "related to" non- covered services (e.g., cosmetic surgery, non -covered organ transplants, non-covered artificial organ implants, etc.), including services related to follow- up care and complications of non- covered services which require treatment during a hospital stay in which the non- covered service was performed, are not covered services under Medicare.  Services "not related to" non -covered services are covered under Medicare.   Following are examples of services "related to" and "not related to" non- covered services while the beneficiary is an inpatient:   A beneficiary was hospital ized for a non- covered service and broke a leg while in the hospital.  Services related to care of the broken leg during this stay is a clear example of "not related to" services and are covered under Medicare.    A beneficiary was admitted to the hospital for covered services, but during the course of hospitalization became a candidate for a non-covered transplant or implant and actually received the transplant or implant during that hospital stay.  When the original admission was entirely unrelated to the diagnosis that led to a recommendation for a non-covered transplant or implant, the services related to the admitting condition would be covered.   A beneficiary was admitted to the hospital for covered services related to a condition which ultimately led to identification of a need for transplant and receipt of a transplant during the same hospital stay.  If, on the basis of the nature of the services and a comparison of the date they are received with the date on which the beneficiary is identified as a transplant candidate, the services could reasonably be attributed to preparation for the non-covered transplant, the services would be "related to" non-covered services and would also be non- covered.   Following is a n example of services received subsequent to a non- covered inpatient stay:   After a beneficiary has been discharged from the hospital stay in which the beneficiary received non -covered services, medical and hospital services required to treat a condition or complication that arises as a result of the prior non -covered services may be covered when they are reasonable and necessary in all other respects.  Thus, coverage could be provided for subsequent inpatient stays or outpatient treatment ordinarily covere d by Medicare, even if the need for treatment arose because of a previous non -covered procedure.  Some examples of services that may be found to be covered under this policy are the reversal of intestinal bypass surgery for obesity, complications from cosm etic surgery, removal of a non-covered bladder stimulator, or treatment of any infection at the surgical site of a non-covered transplant that occurred following discharge from the hospital.  However, any subsequent services that could be expected to have been incorporated into a global fee are not covered.  Thus, where a patient undergoes cosmetic surgery and the treatment regimen calls for a series of postoperative visits to the surgeon for evaluating the patient's progress, these visits are not covered.  130  Religious Nonmedical Health Care Institution (RNHCI) Services  (Rev. 45, Issued:  02-10-06; Effective:  05-11-06;Implementation:  05-11-06)  Section 1821 of the Social Security Act provides for coverage of services furnished in a Medicare qualified religious nonmedical health care institution (RNHCI), when the beneficiary meets specific coverage conditions.  The beneficiary must have a valid election for RNHCI services and would otherwise qualify for care in a conventional hospital or post hospital e xtended care facility that was not a religious nonmedical health care institution.   The RNHCI benefit provides only for Part A inpatient services.  The Medicare program will only pay for nonmedical health care services furnished in RNHCIs, as defined in Section 1861(ss)(1) of the Act and 42 CFR 403 Subpart G.  The program does not pay for supporting religious services or payment for the religious practitioner. The cost of religious items/services and the cost of using a religious practitioner is a personal financial responsibility and not covered by Medicare.  130.1  Beneficiary Eligibility for RNHCI Services  (Rev. 45, Issued:  02-10-06; Effective:  05-11-06;Implementation:  05-11-06)  A beneficiary may elect to receive care in an RNHCI based on his or her own religious convictions or to revoke that election at any time if for any reason he or she decides to pursue medical care. Section 1821(a) of the Act requires that as a condition for Part A Medicare coverage, the beneficiary must have a condition that wo uld qualify under Medicare Part A for inpatient hospital services or extended care services furnished in a hospital or skilled nursing facility that is not an RNHCI if it were not for their religious convictions.  When a beneficiary has an effective electi on on file with CMS but does not have a condition that would qualify for Medicare Part A inpatient hospital or posthospital extended care services if the beneficiary were an inpatient of a hospital or a resident of a SNF that is not an RNHCI, then services furnished in an RNHCI are not covered by Medicare.  A Medicare claim for services that were furnished to that beneficiary would be treated as a claim for noncovered services.  If the beneficiary only needs assistance with activities of daily living, then the beneficiary's condition could not be considered as meeting the Medicare Part A requirements.  Prior to submitting a claim to Medicare it is the responsibility of the RNHCIs utilization review committee to determine that the beneficiary meets the Medicare Part A requirements.   If no valid election is filed or the election has been revoked and no new election is in effect, the beneficiary does not have Medicare coverage for services furnished in an RNHCI. Consequently, a Medicare claim for services furnished to such a beneficiary would also be treated as a claim for noncovered services.   In those cases where a beneficiary is admitted to an RNHCI with a valid election, the submission of prior claim for medical services to the Common Working File will revoke the election during the course of the RNHCI stay.  If this is the first revocation, the beneficiary may make a new election without any disruption to the benefit.  If this, however, is the second or subsequent revocation, the applicable waiting period applies and the remainder of the stay is not covered by Medicare (see 130.2.2).  130.2  Election of RNHCI Benefits  (Rev. 45, Issued:  02-10-06; Effective:  05-11-06;Implementation:  05-11-06)  For an RNHCI to receive payment under the Medicare program,  the beneficiary must make a written election to receive benefits under 1821 of the Act.  To elect religious nonmedical health care services, the beneficiary or the beneficiarys  legal representative must attest that the individual is conscientiously opposed to acceptance of nonexcepted medical treatment, and the individuals acceptance of such treatment would be inconsistent with the individuals sincere religious beliefs.   Relig ious non- medical care or religious method of healing means health care furnished under established religious tenets that prohibit conventional or unconventional medical care for the treatment of a beneficiary, and the sole reliance on these religious tenet s to fulfill a beneficiary's total health care needs.   Medical care or treatment means health care furnished by or under the direction of a licensed physician that can involve diagnosing, treating, or preventing disease and other damage to the mind and bod y. It may involve the use of pharmaceuticals, diet, exercise, surgical intervention, and technical procedures.   The signed and notarized election must include a statement that the receipt of nonexcepted medical services would constitute a revocation of the  election and may limit further receipt of payment of religious nonmedical health care services.  The election is effective on the date it is signed, and it remains in effect until revoked in writing or by the receipt and filing of a claim for nonexcepted medical treatment.   The completed election form must be filed with the specialty contractor, a copy retained by the RNHCI provider and a copy provided to the beneficiary.  See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 3, Section 170 for instr uctions on submission of elections to the specialty contractor.  Section 1821 defines excepted medical treatment as medical care or treatment that is received involuntarily or is required under Federal, State or local law.  The term is intended to identi fy the kinds of medical services that can be provided to a beneficiary with an election for RNHCI services without revoking the election.   Examples of excepted medical care include, but are not limited to the following:    A beneficiary that receives vaccinations required by a State or local jurisdiction.  This is compliant behavior to meet government requirements and not considered as voluntarily seeking medical care or services; or    A beneficiary who is involved in an accident and receives medical attention  at the accident scene, or in transport to the hospital, or at the hospital before being able to make their beliefs and wishes known; or    A beneficiary who is unconscious and receives emergency care and is hospitalized before regaining consciousness or bei ng able to locate his or her legal representative.   Nonexcepted medical treatment is defined as medical care or treatment other than excepted medical treatment. The term is intended to define the kinds of medical services that, if received by a beneficiary who has previously elected RNHCI services, would revoke the individual's election of services.  Examples of nonexcepted medical care could include but are not limited to the following:   A beneficiary receiving medical diagnosis and/or treatment for persistent headaches and/or chest pains.   A beneficiary in an RNHCI who is transferring to a community hospital to have radiological studies and the reduction of a fracture.   A beneficiary with intractable back pain receiving medical, surgical, or chiropractic services.    A beneficiary who has requested a physician to prescribe a wheelchair or other durable medical equipment item.