(Medicare Benefit Policy Manual)

3. The patient must reasonably be expected  to actively participate in, and benefit significantly from, the intensive rehabilitation therapy program that is defined in section 110.2.2 at the time of admission to the IRF.  The patient can only be expected to benefit significantly from the intensive rehabilitation therapy program if the patients condition and functional status are such that the patient can reasonably be expected to make measurable improvement (that will be of practical value to improve the patients functional capacity or adaptation to impairments) as a result of the rehabilitation treatment, as defined in section 110.3, and if such improvement can be expected to be made within a prescribed period of time.  The patient need not be expected to achieve complete independence in the domain of self-care nor be expected to return to his or her prior level of functioning in order to meet this standard.   4. The patient must require physician supervision by a rehabilitation physician, defined as a licensed physician who is determined by the IRF to have specialized training and experience in inpatient  rehabilitation .  The requirement for medical supervision means that the rehabilitation physician must conduct face- to-face visits with the patient at least 3 days per week throughout the patients stay in the IRF to assess the patient both medically and functionally, as well as to modify the course of treatment as needed to maximize the patients capacity to benefit from the rehabilitation process.  Beginning with the second week of admission to the IRF, a non-physician practitioner who is determined by the IRF to have specialized training and experience in inpatient rehabilitation may conduct 1of the 3 required face- to-face visits with the patient per week, provided that such duties are within the non-physician practitioners scope of practice under applicable state law.  In the first week of the patients IRF stay, the rehabilitation physician is required to visit the patients a minimum of three times to ensure that the patients plan of care is fully established and optimized to the patients care needs in the IRF.  For the second, third, fourth weeks of the stay, and beyond, CMS will continue to require Medicare fee-for- services beneficiaries in the IRFs to receive a minimum of three rehabilitation physician visits per week, but will allow non-physician practitioners to independently conduct one of these three minimum require visits per week.   5. The patient must require an intensive and coordinated interdisciplinary approach to providing rehabilitation, as defined in section 110.2.5.  110.2.1 - Multiple Therapy Disciplines  (Rev. 112, Issued: 10-23-09, Effective: 01-01-10, Implementation: 01-04-10)  A primary distinction between the IRF environment and other rehabilitation settings is the interdisciplinary approach to providing rehabilitation therapy services in an IRF.  Patients requiring only one discipline of therapy would not need this interdisciplinary approach to care.  For this reason, the information in the patients IRF medical record (especially the required documentation described in section 110.1) must document a reasonable expectation that, at the time of admission to the IRF, the patient required the active and ongoing therapeutic intervention of multiple therapy disciplines (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics), one of which must be physical or occupational therapy.  110.2.2 - Intensive Level of Rehabilitation Services  (Rev. 10892; Issued: 08-06- 21; Effective: 11 -08-21; Implementation: 11-08-21)   A primary distinction between the IRF environment and other  rehabilitation settings is the intensity of rehabilitation therapy services provided in an IRF. For this reason, the information in the patients IRF medical record (especially the required documentation described in section 110.1) must document a reasona ble expectation that at the time of admission to the IRF the patient generally required the intensive rehabilitation therapy services that are uniquely provided in IRFs. Although the intensity of rehabilitation services can be reflected in various ways, th e generally -accepted standard by which the intensity of these services is typically demonstrated in IRFs is by the provision of intensive therapies at least 3 hours per day at least 5 days per week. However, this is not the only way that such intensity of services can be demonstrated (that is, CMS does not intend for this measure to be used as a rule of thumb for determining whether a particular IRF claim is reasonable and necessary).   The intensity of therapy services provided in IRFs could also be demonstrated by the provision of 15 hours of therapy per week (that is, in a 7- consecutive  calendar day period starting from the date of admission). For example, if a hypothetical IRF patient was admitted to an IRF for a hip fracture, but was also undergoing chemotherapy for an unrelated issue, the patient might not be able to tolerate therapy on a predictable basis due to the chemotherapy.  Thus, this hypothetical patient might be more effectively served by the provision of 4 hours of therapy 3 days per week and 1  hours of therapy on 2 (or more) other days per week in order to accommodate his or her chemotherapy schedule.  Thus, IRFs may also demonstrate a patients need for intensive rehabilitation therapy services by showing that the patient required and could reasonably be expected to benefit from at least 15 hours of therapy per week (defined as a 7- consecutve calendar day period starting from the date of admission), as long as the reasons for the patients need for this program of intensive rehabilitation are well -documented in the patients IRF medical record and the overall amount of therapy can reasonably be expected to benefit the patient.  Many IRF patients will medically benefit from more than 3 hours of therapy per day or more than 15 hours of therap y per week, when all types of therapy are considered.  However, the intensity of therapy provided must be reasonable and necessary under section 1862(a)(1)(A) of the Act and must never exceed the patients level of need or tolerance, or compromise the pati ents safety.  See below for a brief exceptions policy for temporary and unexpected events.  In accordance with 42 CFR  412.622(a)(3)(ii), t he required therapy treatments must begin within 36 hours from midnight of the day of admission to the IRF.  Therap y evaluations are generally considered to constitute the beginning of the required therapy services. As such, they should generally be  included in the total daily/weekly provision of therapies used to demonstrate the intensity of therapy services provided in an IRF.   The standard of care for IRF patients is individualized (i.e., one -on-one) therapy.  Group therapies serve as an adjunct to individual therapies. In those instances in which group therapy better meets the patients needs on a limited basis, th e situation/rationale that justifies group therapy should be specified in the patients medical record at the IRF.   Brief Exceptions Policy  - While patients requiring an IRF stay are expected to need and receive an intensive rehabilitation therapy program,  as described above, this may not be true for a limited number of days during a patients IRF stay because patients needs vary over time.  For example, if an unexpected clinical event occurs during the course of a patients IRF stay that limits the patients ability to participate in the intensive therapy program for a brief period not to exceed 3 consecutive days (e.g., extensive diagnostic tests off premises, prolonged intravenous infusion of chemotherapy or blood products, bed rest due to signs of deep vein thrombosis, exhaustion due to recent ambulance transportation, surgical procedure, etc.), the specific reasons for the break in the provision of therapy services should generally be documented in the patients IRF medical record.  If these reasons are appropriately documented in the patients IRF medical record, such a break in service (of limited duration) should generally not affect the determination of the medical necessity of the IRF admission.  Thus, A/B MACs (A) may consider approving brief excep tions to the intensity of therapy requirement in these particular cases if they determine that the initial expectation of the patients active participation in intensive therapy during the IRF stay was based on a diligent preadmission screening, post-admis sion physician evaluation, and overall plan of care that were based on reasonable conclusions.  110.2.3 - Ability to Actively Participate in Intensive Rehabilitation Therapy Program  (Rev. 112, Issued: 10-23-09, Effective: 01-01-10, Implementation: 01-04-10)  The information in the patients IRF medical record (especially the required documentation described in section 110.1) must document a reasonable expectation that at the time of admission to the IRF the patients condition is such that the patient can reasonably be expected to actively participate in, and significantly benefit from, the intensive rehabilitation therapy program that is defined in section 110.2.2.  110.2.4 - Physician Supervision  (Rev. 10892; Issued: 08-06- 21; Effective: 11 -08-21; Implementation: 11-08-21)   A primary distinction between the IRF environment and other rehabilitation settings is the high level of physician supervision that accompanies the provision of intensive rehabilitation therapy services.  For this reason, the information in the patients I RF medical record (especially the required documentation described in section 110.1) must document a reasonable expectation that at the time of admission to the IRF the patients medical management and rehabilitation needs require an inpatient stay and close physician involvement.  Close physician involvement in the patients care is demonstrated by documented face- to-face visits from a rehabilitation physician at least 3 days per week throughout the patients IRF stay.  Beginning with the second week of admission to the IRF, a non-physician practitioner who is determined by the IRF to have specialized training and experience in inpatient rehabilitation may conduct 1 of the 3 required face- to-face visits with the patient per week, provided that such duties are within the non-physician practitioners scope of practice under applicable state law.  In the first week of the patients IRF stay, the rehabilitation physician is required to visit patients a minimum of three times to ensure that the patients plan of care is fully established and optimized to the patients care needs in the IRF.  In the second, third, fourth weeks of the stay, and beyond, CMS will continue to require Medicare fee-for- service beneficiaries in IRFs to receive a minimum of three rehabilitation physician visits per week, but will allow non-physician practitioners to independently conduct one of these three minimum required visits per week.    The purpose of the face- to-face visits is to assess the patient both medically and functionally (wit h an emphasis on the important interactions between the patients medical and functional goals and progress), as well as to modify the course of treatment as needed to maximize the patients capacity to benefit from the rehabilitation process. Other physician specialties may treat and visit the patient, as needed, more often than 3 days per week.  However, the requirement for IRF physician supervision is intended to ensure that IRF patients receive more comprehensive assessments of their functional goals an d progress, in light of their medical conditions, by a rehabilitation physician who is determined by the IRF to have specialized training and experience in inpatient rehabilitation at least 3 times per week.  The required rehabilitation physician and non-physician practitioner visits should generally  be documented in the patients medical record at the IRF per the requirements at 42 CFR  482.24(4)(c)(vi).  110.2.5 - Interdisciplinary Team Approach to the Delivery of Care  (Rev. 10892; Issued: 08-06- 21; Effe ctive: 11 -08-21; Implementation: 11-08-21)   An IRF stay will only be considered reasonable and necessary if at the time of admission to the IRF the documentation in the patients IRF medical record indicates a reasonable expectation that the complexity of the patients nursing, medical management, and rehabilitation needs requires an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation care.  That is, the complexity of the patients condition must be such that the rehabilitation goals indicated in the preadmission screening, and the overall plan of care can only be achieved through periodic team conferences at least once a week of an interdisciplinary team of medical professionals (as defined below).   Interdisciplinary services are those provided by a treatment team in which all of its members participate in a coordinated effort to benefit the patient and the patients significant others and caregivers. Interdisciplinary services, by definition, cannot be provided by only one discipline.  Though individual members of the interdisciplinary team work within their own scopes of practice, each professional is also expected to coordinate his or her efforts with team members of other specialties, as well as with the patient and the patients significant others and caregivers.  The purpose of the interdisciplinary team is to foster frequent, structured, and documented communication among disciplines to establish, prioritize, and achieve treatment goals.   In accordance with the requirements at 42 CFR 412.622(a)(5), at a minimum, the interdisciplinary team must document participation by professionals from each of the following disciplines (each of whom must have current knowledge of the patient as documented in the medical record at the IRF):    A rehabilitation physician who is determined by the IRF to have specialized training and experience in inpatient  rehabilitation;    A registered nurse with specialized training or experience in rehabilitation;    A social worker or a case manager (or both); and    A licensed or certified therapist from each therapy discipline involved in treating the patient.