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Appropriate Patient Placement

Differences between inpatient rehabilitation & skilled nursing care

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Page 1: Differences between inpatient rehabilitation & skilled nursing care

Appropriate Patient Placement

Page 2: Differences between inpatient rehabilitation & skilled nursing care

Definitions of Skilled and IRF Care Definition of

Rehabilitation CareThe Inpatient Rehabilitation Facility (IRF) provides services to an inpatient who needs a relatively intense rehabilitation program that requires a multidisciplinary coordinated team approach to upgrade his functional ability.

Definition of the Skilled Nursing Care:

The SNF provides intermittent and/or daily skilled care services. These services are provided by professional nurses and/ or rehabilitation professionals.

Page 3: Differences between inpatient rehabilitation & skilled nursing care

Definitions Continued

IRF Requires a Relatively Intensive Rehabilitation Approach The general threshold for

supporting IRF care is that the patient must require and receive at least 3 hours a day of PT, OT or ST.

Daily is defined as 5 days per week.

Page 4: Differences between inpatient rehabilitation & skilled nursing care

Definitions Continued

Skilled Care requires that patients be in an appropriate RUGs payment group to be considered a “skilled” patient.

Page 5: Differences between inpatient rehabilitation & skilled nursing care

Both Programs Require: Additional Requirements:

These services must be reasonable and necessary for the treatment of the patient’s condition; and,

It must be reasonable to furnish the care in an inpatient hospital setting, rather than in a less intensive setting such as SNF, an SNF level of care in a swing bed, or on an outpatient basis.

Page 6: Differences between inpatient rehabilitation & skilled nursing care

Overview of these Medicare Programs Historical Perspective:

Medicare/Medicaid legislation passed in 1965Amended in 1982 by TEFRA act, which limited

payment to IRFs, while SNF remained cost-based.

Both programs excluded from hospital DRG payment system.

In 1997 the HCFA/CMS published criteria for Prospective Payment Systems (PPS) for IRFs & SNFs.

In 1998 the Final Rule for SNF PPS was published

In 2001 the Final Rule for IRFs was published.

Page 7: Differences between inpatient rehabilitation & skilled nursing care

Same Program Philosophies

Both Use a Philosophy of Rehabilitation Focus on

rehabilitative and recuperative care

Monitor health statusFacilitate self-careMaximize functioning

and independence

Page 8: Differences between inpatient rehabilitation & skilled nursing care

IRF Patient Characteristics IRF Patient

Characteristics – 13 DiagnosisDiagnosis of patients

in the IRF○ Stroke○ Spinal cord injury○ Congenital deformity○ Amputation○ Major multiple trauma○ Burns

○ Fracture○ Brain injury○ Polyarthritis,

including rheumatoid arthritis

○ Neurological disorders, including MS, motor neuron disease, polyneuropathy

Page 9: Differences between inpatient rehabilitation & skilled nursing care

SNF Patient Characteristics Patients are admitted that fall into these

specific RUGs groupings:Rehabilitation – PT,OT, ST & Restorative

NursingExtensive Services – Nursing ServicesSpecial Care – Nursing ServicesClinically Complex – Nursing Services

Page 10: Differences between inpatient rehabilitation & skilled nursing care

RUGs III Prospective Payment System (PPS) In 1998, Medicare introduced Resource

Utilization Groups (RUGs) and the RUGS III Perspective Payment System (PPS) that defined specific patient categories and services that are considered “skilled”. Therefore, patients falling into one of these “skilled” groups met the requirements for Medicare payment of skilled care.

Page 11: Differences between inpatient rehabilitation & skilled nursing care

Services IRFs Must Provide Types of services that must be

provided:Rehabilitation Nursing: B/B Training, etc.Rehabilitative Services: Physical therapy,

occupational therapy, speech therapyAudiologyProstheticsOrthoticsSocial and/or psychological services

Page 12: Differences between inpatient rehabilitation & skilled nursing care

Services SNFs Must Provide

Nursing Restorative Services: ROM, B/B Training, etc.

Rehabilitative Services: Physical therapy, occupational therapy, speech therapy

AudiologyProstheticsOrthoticsEmergency Dental Social and/or psychological services

Page 13: Differences between inpatient rehabilitation & skilled nursing care

Regulatory Components

Regulatory Components for Both Programs Administration Physical environment Patient rights Rehabilitative nursing

services Multidisciplinary

approach to care

Page 14: Differences between inpatient rehabilitation & skilled nursing care

Overview of the IRF, cont. Regulatory Components

Pharmaceutical servicesDietary servicesPhysician servicesSocial services, discharge planningRehabilitation Therapy Quality Assessment/Performance Improvement

Page 15: Differences between inpatient rehabilitation & skilled nursing care

The Medicare Program Medicare:

Federal health insurance program available for people over 65 years of age, and certain individuals under age 65

Part A – hospital services, including IRF, skilled, hospice○ Included as part of social security benefits, subject to

deductibles

Part B – outpt/physician services, equip○ Monthly fee; annual deductible

Page 16: Differences between inpatient rehabilitation & skilled nursing care

The Medicare Program IRF - 90 Days per spell of illness SNF – 100 Days per spell of illness Hospital deductible due for each spell of

illness IRF - first 60 days fully covered if meets

acute care criteria; co-pay for 61st-90th day; no pre-qualifying hospital stay required

SNF – first 20 days fully covered if meets RUGs criteria; co-pay for the 21-100th day; 3-day pre-qualifying hospital stay required.

Page 17: Differences between inpatient rehabilitation & skilled nursing care

The Medicare Program

Spell of Illness:The period which begins when a patient is

furnished inpatient hospital care. The spell of illness ends when the patient has neither been an inpatient of the hospital or skilled nursing bed for 60 consecutive days.

The benefits (days) are renewable with each new spell of illness.

Page 18: Differences between inpatient rehabilitation & skilled nursing care

SNF Prequalifying Stay

3 day qualifying stay in the rehabilitation unit would qualify a patient for skilled care.

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Medicare Criteria

Page 20: Differences between inpatient rehabilitation & skilled nursing care

Criteria for IRF Care

Technical requirements

Rehabilitation Diagnosis

Coverage of services

Page 21: Differences between inpatient rehabilitation & skilled nursing care

Criteria for IRF Care Technical Requirements

The patient must○ Require the therapeutic services of physical therapy,

occupational therapy or speech therapy for three hours a day, five days a week;

○ Have potential for improvement;○ Be somewhat medically stable;○ Be motivated.○ Rehabilitation services must be reasonable and

necessary for their condition.○ As a practical matter, services must be provided on an

inpatient basis.

Page 22: Differences between inpatient rehabilitation & skilled nursing care

Criteria for IRF Care Rehabilitation Diagnostic Groups – 13

diagnosis specified Must require intensive rehabilitative

services for the treatment of one or more of the following conditions:StrokeSpinal cord injuryCongenital deformityAmputationMajor multiple traumaFracture

Page 23: Differences between inpatient rehabilitation & skilled nursing care

Criteria for IRF Care Polyarthritis, including

rheumatoid arthritis Neurological disorders,

including multiple sclerosis, motor neuron diseases, polyneuropathy, muscular dystrophy and Parkinson’s disease

Burns

Page 24: Differences between inpatient rehabilitation & skilled nursing care

Criteria for IRF Care-Rehab Diagnosis

95 Case Mix Groups (CMGs) Pain syndromes: back, soft tissues, etcCardiac disorders: CHF, MI within 8 weeks,

CIHDPulmonary disorders: bronchitis, COPD,

asthma, pulmonary insufficiencyDevelopment disability: mental retardationDebility: muscular wasting, CFSMedically complex conditions: infections,

neoplasms, nutrition, circulatory DO, resp. DO, terminal care, skin disorders, renal failure

Page 25: Differences between inpatient rehabilitation & skilled nursing care

Criteria for IRF Care-75% Rule

Phase In to Compliance – now at 60 or 65%

75% rule: Seventy-five (75%) of

patients admitted into the IRF must fall into one of the 13 specified diagnosis.

Twenty-five (25%) of patients admitted can fall into the other categories defined in the CMG impairment groups.

Page 26: Differences between inpatient rehabilitation & skilled nursing care

Criteria for IRF Care Coverage of Rehabilitation Services:

Services must be provided with the expectation that the condition will improve in a reasonable and generally predictable period of time.

Inpatient rehabilitation services are a more coordinated, intensive program of multiple services than is typically available outside of the hospital.

Page 27: Differences between inpatient rehabilitation & skilled nursing care

Criteria for IRF Care Coverage of Rehabilitation Services:

A patient who has one or more conditions requiring intensive and multidisciplinary rehab care, or who has a medical complication in addition to his primary condition, so that the continuing availability of a MD is required to ensure safe and effective treatment, probably requires a hospital level of rehabilitation care.

Page 28: Differences between inpatient rehabilitation & skilled nursing care

Criteria for IRF Care Coverage of Rehabilitation Services:

Coverage is available for an inpatient stay for a patient to assess the potential for benefiting from an intensive coordinated rehabilitation program. Generally, for a 3-10 day period. However, it must have been reasonable and necessary to perform this 3-10 day inpatient rehabilitation assessment as supported from clinical data in the acute care chart.

Page 29: Differences between inpatient rehabilitation & skilled nursing care

Criteria for IRF Care Coverage of Rehabilitation Services:

If the rehabilitation assessment stay results in the conclusion that the individual is a poor candidate for rehab, coverage for further inpatient hospital care is limited to a reasonable number of days needed to find placement elsewhere for the patient.

Page 30: Differences between inpatient rehabilitation & skilled nursing care

Criteria for SNF Care Technical Requirements

The patient must require skilled care - provided by professional nurses and/or professional therapists.

Skilled services as a practical/economical matter can only be provided on an inpatient basis.

The patient must receive treatment in the SNF for the same illness/injury for which the patient was treated in the hospital.

Page 31: Differences between inpatient rehabilitation & skilled nursing care

Criteria for SNF Care Technical Requirements

All ordered SNF services must be reasonable/necessary for the condition the pt. was treated for in the hospital, including freq. and duration of such services.

The pt. must be certified and recertified as requiring skilled care by the MD on admission, the 14th day and every 30 days thereafter.

Page 32: Differences between inpatient rehabilitation & skilled nursing care

Criteria for SNF Care Technical Requirements

The patient must be placed in a Medicare-certified bed in the SNF.

Physician orders for specific SNF services must be present in the medical record.

Page 33: Differences between inpatient rehabilitation & skilled nursing care

Criteria for SNF Care

Coverage of Services – i.e. RUGs Groups -

Rehabilitation Group - Includes PT, OT & ST 5 Rehabilitation Groups Ultra High

– In the last 7 days: Received 720 or more minutes of

therapy At least 2 disciplines, 1 for at least 5

days, and the 2nd for at least 3 days

Page 34: Differences between inpatient rehabilitation & skilled nursing care

RUGs Groups Very High

– In the last 7 days: Received 500 or more minutes of therapy At least 1 discipline for at least 5 days

High– In the last 7 days

Received 325 or more minutes At least 1 discipline for at least 5 days

Page 35: Differences between inpatient rehabilitation & skilled nursing care

RUGs Groups Medium

– In the last 7 days: Received 150 or more minutes of therapy At least 5 days of therapies across the 3

disciplines Low

– In the last 7 days: Received 45 or more minutes of therapy At least 3 days of any combination of the 3

disciplines, and Two or more nursing rehabilitation services

received for at least 15 minutes each with each administered for 6 or more days

Page 36: Differences between inpatient rehabilitation & skilled nursing care

RUGs Groups Extensive Services Group

Any one of the following services received within the last 14 days with an ADL sum >=7:

– IV Feeding/parenteral feeding (within last 7 days)

– Suctioning– Tracheostomy Care– Ventilator/Respirator– IV Medication

Page 37: Differences between inpatient rehabilitation & skilled nursing care

RUGs Groups Special Care Group Any one of the following:

Multiple Sclerosis with ADL sum >= 10Quadriplegic with ADL sum >= 10Cerebral Palsy with ADL sum >= 10Respiratory Therapy = 7Ulcers (2+ sites over all stages ), with

treatmentAny stage 3 or 4 pressure ulcer with

treatment

Page 38: Differences between inpatient rehabilitation & skilled nursing care

RUGs Groups Special Care Group Any one of the following:

Surgical wounds or Open Lesions with treatmentRadiation therapyTube Fed+ and AphasiaFever with one or more of the following:

○ Dehydration○ Pneumonia○ Vomiting○ Weight Loss○ Tube Feeding+

Page 39: Differences between inpatient rehabilitation & skilled nursing care

RUGs Groups Clinically Complex Group

Any one of the following:– Burns– Coma and not awake and completely ADL

dependent– Septicemia– Pneumonia– Foot Lesions or Infections w/dressings– Internal Bleeding– Dehydration– Hemiplegia with ADL sum >=10

Page 40: Differences between inpatient rehabilitation & skilled nursing care

RUGs Groups

Clinically Complex Group– Tube Feeding– Oxygen Therapy– Transfusions– Chemotherapy– Dialysis– Number of Days in the last 14 days, that the

MD Visited/made order changes:– Diabetes Mellitus and insulin injection 7 days

and MD order change >=2 days– Or Qualified for Special Care with ADL <=6

Page 41: Differences between inpatient rehabilitation & skilled nursing care

RUGs Groups

As of 1-1-2006 Medicare introduced a new RUGs Group:Rehabilitation, Plus Extensive ServicesHighest Paid RUGs GroupPatient’s who are receiving both therapy

minutes and a nursing service specified in the Extensive Services Group

Refinements still being made to this payment system.

Page 42: Differences between inpatient rehabilitation & skilled nursing care

IRF PPS

CMG’s being refined Case-Level Adjustments:

Transfer AdjustmentShort Stay PaymentExpiredInterrupted Stay

Co-morbidity Adjustment – continues to change/adjust payment for patient co-morbidities

Page 43: Differences between inpatient rehabilitation & skilled nursing care

IRF PPS

Recent FI focus of audits Many FI’s have introduced Local

Coverage Determination (LCD) documents to further redefine appropriate IRF patients.

AHA and CMS discussions

Page 44: Differences between inpatient rehabilitation & skilled nursing care

Conclusion Many similarities between the two

programs Both mainly used by Medicare

beneficiaries Patient placement influenced by the two

PPS. Diagnosis in an IRF is a significant issue Skilled documentation is a must in a

SNF

Page 45: Differences between inpatient rehabilitation & skilled nursing care