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Mystery Solved: Which Patients Are Good Candidates For Acute Inpatient Rehabilitation?

Occupational Therapy Environment, Saint Luke's Hospital, WA

For most physicians who practice inpatient medicine, acute inpatient rehabilitation facilities are mysterious places with inscrutable admissions criteria. This is partly because physical medicine and rehabilitation (PM&R) has done the poorest job of public relations of any single medical specialty (Does anyone know what we do?), and also because rehab units have been in the cross hairs of federal funding cuts for decades. The restrictive CMS criteria for inpatient rehabilitation have resulted in contortionist attempts to practice our craft in an environment where clinical judgment has been sidelined by meticulous ICD-9 coding.

But I will not bore you with the reasons behind our seemingly capricious admissions criteria. Instead I will simply tell you what they are in the simplest way possible. After much consideration, I thought it would be easiest to start with the contraindications to acute rehab – I call these “red lights.” If your patients have any of these, then they will not qualify for transfer to the acute inpatient rehab unit. I followed the absolute contraindications with relative contraindications (you guessed it, “yellow lights”) – these patients require some clinical and administrative judgment. And finally, I’ve listed the official green lights – the diagnosis codes and medical necessity rules for the ideal inpatient rehab candidate.

I hope that these rules demystify the process – and can help discharge planners, rehab admissions coordinators, and acute care attending physicians alike help to get the right patients to acute inpatient rehab.

RED LIGHT (Patient does not meet criteria, admission is not currently indicated):

  1. Inability to Participate: Patient cannot tolerate 3 hours of therapy per day.
  2. Unwillingness to participate: The patient does not wish to participate in PT/OT/speech therapies and/or shows no evidence of motivation in previous attempts to perform therapy
  3. Poor rehabilitation potential: The patient’s functional status is currently no different than their usual baseline. (Confirmed by previous history, medical records, or reliable source.)
  4. Dementia: The patient has a chronic brain deficiency that is not expected to improve and makes carryover of training unlikely or impossible.
  5. Doesn’t need help from at least 2 different rehab disciplines: The patient must demonstrate likely benefit from working with at least 2 of these: PT, OT, Speech.
  6. Acute illness or condition: The patient has an acute illness/condition requiring medical intervention prior to transfer to an acute rehab facility – these include:
    • septicemia (infection with fever and elevated white count)
    • delirium (medication effect, dehydration, infectious, toxic-metabolic)
    • unstable vital signs (severe hyper or hypotension, severe tachy or brady arrhythmia, hypoxia despite oxygen supplementation)
    • acute psychotic episode (including active hallucinations or delusions)
    • uncontrolled pain (the patient’s pain is not sufficiently controlled to allow participation in therapy)
    • severe anemia
    • extreme fatigue or lethargy due to medical condition
  7. Procedure or workup pending: The patient is in the middle of a work up for DVT, cardiac disorder, stroke, infection, anemia, chest pain, bleeding, etc. or is about to undergo a procedure (surgery, imaging study, interventional or lab test) that could alter the immediate course of his/her medical/surgical management.

YELLOW LIGHT (The patient may not be a good rehab candidate, clinical/administrative judgment required regarding admission):

  1. Possible poor rehabilitation potential: The patient’s prior level of function (PLOF) is likely low or similar to current level, however there is no clear documentation of the patient’s PLOF. It is unclear if aggressive rehabilitation will substantially improve the patient’s functional independence.
  2. Unclear benefit of ARU versus SNF: The patient is unlikely to avoid future placement at a skilled nursing facility. Would it be in the patient’s best interest to transfer there directly?
  3. Mild dementia or chronic cognitive impairment: The patient has carryover challenges but is able to participate and follow directions. There may be family members who could benefit from PT/OT/Speech training so they can take the patient home and be his/her caregiver(s).
  4. Unclear safe discharge plan:  The patient lives alone or has no family support or has no financial means to improve their living conditions or their home is unfit for living/safe discharge or patient refusing SNF but qualifies otherwise.
  5. Insurance denial: The patient’s insurer declines their inpatient rehab stay. Physiatrist may attempt to overturn decision or facility may wish to take patient on a pro bono status.  Uninsured patients may be candidates for emergency Medicaid. Facility must decide if they will lobby for it.
  6. Severe behavioral disorders (unrelated to acute TBI): Verbally abusive, violent, inappropriate or disruptive to other patients.
  7. The patient meets medical necessity criteria for acute inpatient rehab but their impairment is not represented by one of the 13 impairment categories approved by CMS. (E.g. medical debility, cardiac impairment, pulmonary disease, cancers, or orthopedic injury without required comorbidities). Admission may depend upon individual facility’s case mix and its current annual compliance rate with 60% rule.

GREEN LIGHT (The patient is a good candidate for acute inpatient rehab if they have no red or yellow lights, meet criteria for medical necessity AND meet the impairment categories listed below):

MEDICAL NECESSITY DEFINITION:

Acute inpatient rehabilitation services are medically necessary when all of the following are present:

  • Individual has a new (acute) medical condition or an acute exacerbation of a chronic condition that has resulted in a significant decrease in functional ability such that they cannot adequately recover in a less intensive setting; AND
  • Individual’s overall medical condition and medical needs either identify a risk for medical instability or a requirement for physician and other personnel involvement generally not available outside the hospital inpatient setting; AND
  • Individual requires an intensive inter-disciplinary, coordinated rehabilitation program (as defined in the description of service) with a minimum of three (3) hours active participation daily; AND
  • Individual is medically stable enough to no longer require the services of a medical/surgical inpatient setting; AND
  • The individual is capable of actively participating in a rehabilitation program, as evidenced by a mental status demonstrating responsiveness to verbal, visual, and/or tactile stimuli and ability to follow simple commands.  For additional information regarding cognitive status, please refer to the Rancho Los Amigos Cognitive Scale (Appendix B); AND
  • Individual’s mental and physical condition prior to the illness or injury indicates there is significant potential for improvement; (See Note below) AND
  • Individual is expected to show measurable functional improvement within a maximum of seven (7) to fourteen (14) days (depending on the underlying diagnosis/medical condition) of admission to the inpatient rehabilitation program; AND
  • The necessary rehabilitation services will be prescribed by a physician, and require close medical supervision and skilled nursing care with the 24-hour availability of a nurse and physician who are skilled in the area of rehabilitation medicine; AND
  • Therapy includes discharge plan.

13 Diagnosis Codes Approved by CMS for Acute Inpatient Rehab

1. Stroke

2. Spinal cord injury

3. Congenital deformity

4. Amputation

5. Major multiple trauma

6. Fracture of femur (hip fracture)

7. Brain injury

8. Neurological disorders, including:

• Multiple sclerosis

• Motor neuron diseases (Guillain Barre, ALS)

• Polyneuropathy

• Muscular dystrophy

• Parkinson’s disease

9. Burns

10. Arthritis: Active polyarticular rheumatoid arthritis, psoriatic arthritis, and seronegative arthropathies

resulting in significant functional impairment of ambulation and other activities of daily living;

11. Vasculitis: Systemic vasculidities with joint inflammation resulting in significant functional impairment of ambulation and other activities of daily living

12. Severe or advanced osteoarthritis (osteoarthrosis or degenerative joint disease) involving two or more weight bearing joints (elbow, shoulders, hips, or knees but not counting a joint with a prosthesis) with joint deformity and substantial loss of range of motion, atrophy of muscles surrounding the joint, and significant functional impairment of ambulation and other activities of daily living

13. Knee or hip joint replacement, or both, during an acute care hospitalization immediately preceding the inpatient rehabilitation stay and also meets one or more of the following specific criteria:

  • The patient underwent bilateral knee or bilateral hip joint replacement surgery during the acute care hospital admission immediately preceding the IRF admission
  • The patient is extremely obese with a Body Mass Index of at least 50 at the time of admission to the IRF or
  • The patient is age 85 or older at the time of admission to the IRF.

References:

http://www.anthem.com/medicalpolicies/guidelines/gl_pw_a051177.htm

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/InpatRehabPaymtfctsht09-508.pdf

http://www.gpo.gov/fdsys/pkg/FR-2013-08-06/pdf/2013-18770.pdf

When Breaking The Rules Is The Right Choice

The call never should have been made.

It broke every proscribed rule.

After all, I was not on call. Thanks to the wonders of computer technology, it was very clear that I was being covered by my colleague. And yet, despite this, it came.

“Dr. Fisher, I’m so sorry for calling you at home, but I received a call from Ms. X, the wife of your patient Mr. Y. who said she really needed to speak to you about her husband… she seemed quite concerned and insisted I call you…. I told her I’d see if I could reach you at home… I’m so sorry, but it sounded urgent… I have her number, could I connect you?” Read more »

*This blog post was originally published at Dr. Wes*

Advancing Medical Progress With Case Studies While Maintaining HIPAA Compliance

It was an interesting tweet that referenced a soon-to-be-published case report from the Annals of Emergency Medicine (via @EmergencyDocs) that piqued my interest:

Thrilling case study: emergency doc cracked chest to save 42 y/o woman in cardiac tamponade after ablation therapy. http://bit.ly/umnydc

Details about the case are quite specific and the case report heralds from a town in Minnesota. It describes, in very specific detail, the management of a patient who presented to the emergency room in shock from cardiac tamponade after a catheter ablation procedure for right ventricular outflow tract tachycardia.

Is this unique case report HIPAA compliant?

I would say, according to our current definition of HIPAA’s “personal health information,” such a case report is Read more »

*This blog post was originally published at Dr. Wes*

Following The Rules: Is The Patient Really Yours?

I had a patient with non-valvular atrial flutter denied dabigatran (Pradaxa®) by their insurer recently. The patient had diabetes, hypertension and has had a heck of a time maintaining therapeutic blood thinning levels (prothrombin times).

But those are the rules, you see. Only patients with non-rheumatic atrial fibrillation can get dabigatran, I was told. Dabigatran was never approved for atrial flutter, only atrial fibrillation. Never mind the stroke risk in non-rheumatic atrial flutter, like atrial fibrillation, has been found to be significant.

For my patient, dabigatran would have been the perfect solution.

But increasingly I’m finding the patient is not mine, they’re Read more »

*This blog post was originally published at Dr. Wes*

What Do Clinical Guidelines And The US Tax Code Have In Common?


The above graph from the Cato Institute demonstrates the growing complexity of the U.S. tax code over the years. After doing my taxes recently and trying to track the ins and outs of the law for my wife’s private practice, I can attest to the graph’s accuracy.

But then I was reading an interesting editorial in Circulation: Arrhythmia and Electrophysiology by N.A. Mark Estes III, MD and Jonathan Weinstock, MD that reviewed an article by Roos, et al in the same journal that found only 27 of 698 guideline recommendations from the European Society of Cardiology (median 1.2% per guideline [IQR 0.95% to 3.7%]) were correctly referenced as Class I or III Level of Evidence A recommendations, calling into question the accuracy of guideline recommendations. In their editorial, Estes and Weinstock defended the guideline process but also mentioned the following shocking statistic: Read more »

*This blog post was originally published at Dr. Wes*

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