1. Appropriate Patient Placement

2. Definitions of Skilled and IRF Care
 Definition of  Definition of the Skilled
Rehabilitation Care Nursing Care:
The Inpatient Rehabilitation
Facility (IRF) provides
 The SNF provides
services to an inpatient intermittent and/or daily
who needs a relatively skilled care services.
intense rehabilitation These services are
program that requires a
multidisciplinary
provided by professional
coordinated team approach nurses and/ or
to upgrade his functional rehabilitation
ability. professionals.

3. 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.

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

5. 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.

6. Overview of these Medicare
Programs
 Historical Perspective:
Medicare/Medicaid legislation passed in 1965
Amended 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.

7. Same Program Philosophies
 Both Use a
Philosophy of
Rehabilitation
Focus on
rehabilitative and
recuperative care
Monitor health status
Facilitate self-care
Maximize functioning
and independence

8. IRF Patient Characteristics
 IRF Patient
Characteristics –
13 Diagnosis
 Diagnosis of patients ○ Fracture
in the IRF ○ Brain injury
○ Stroke ○ Polyarthritis,
○ Spinal cord injury including rheumatoid
arthritis
○ Congenital deformity
○ Neurological
○ Amputation disorders, including
○ Major multiple trauma MS, motor neuron
○ Burns disease,
polyneuropathy

9. SNF Patient Characteristics
 Patients are admitted that fall into these
specific RUGs groupings:
Rehabilitation – PT,OT, ST & Restorative
Nursing
Extensive Services – Nursing Services
Special Care – Nursing Services
Clinically Complex – Nursing Services

10. 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.

11. Services IRFs Must Provide
 Types of services that must be
provided:
Rehabilitation Nursing: B/B Training, etc.
Rehabilitative Services: Physical therapy,
occupational therapy, speech therapy
Audiology
Prosthetics
Orthotics
Social and/or psychological services

12. Services SNFs Must Provide
Nursing Restorative Services: ROM, B/B
Training, etc.
Rehabilitative Services: Physical therapy,
occupational therapy, speech therapy
Audiology
Prosthetics
Orthotics
Emergency Dental
Social and/or psychological services

13. Regulatory Components
 Regulatory
Components for Both
Programs
 Administration
 Physical environment
 Patient rights
 Rehabilitative nursing
services
 Multidisciplinary
approach to care

14. Overview of the IRF, cont.
 Regulatory Components
Pharmaceutical services
Dietary services
Physician services
Social services, discharge planning
Rehabilitation Therapy
Quality Assessment/Performance Improvement

15. 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

16. 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.

17. 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.

18. SNF Prequalifying Stay
 3 day qualifying
stay in the
rehabilitation unit
would qualify a
patient for skilled
care.

19. Medicare Criteria

20. Criteria for IRF Care
 Technical
requirements
 Rehabilitation
Diagnosis
 Coverage of
services

21. 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.

22. 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:
Stroke
Spinal cord injury
Congenital deformity
Amputation
Major multiple trauma
Fracture

23. Criteria for IRF Care
 Polyarthritis, including
rheumatoid arthritis
 Neurological disorders,
including multiple
sclerosis, motor neuron
diseases,
polyneuropathy, muscular
dystrophy and
Parkinson’s disease
 Burns

24. Criteria for IRF Care-Rehab
Diagnosis
 95 Case Mix Groups (CMGs)
Pain syndromes: back, soft tissues, etc
Cardiac disorders: CHF, MI within 8 weeks,
CIHD
Pulmonary disorders: bronchitis, COPD,
asthma, pulmonary insufficiency
Development disability: mental retardation
Debility: muscular wasting, CFS
Medically complex conditions: infections,
neoplasms, nutrition, circulatory DO, resp. DO,
terminal care, skin disorders, renal failure

25. 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.

26. 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.

27. 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.

28. 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.

29. 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.

30. 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.

31. 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.

32. 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.

33. 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

34. 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

35. 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

36. 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

37. RUGs Groups
 Special Care Group
 Any one of the following:
Multiple Sclerosis with ADL sum >= 10
Quadriplegic with ADL sum >= 10
Cerebral Palsy with ADL sum >= 10
Respiratory Therapy = 7
Ulcers (2+ sites over all stages ), with
treatment
Any stage 3 or 4 pressure ulcer with
treatment

38. RUGs Groups
 Special Care Group
 Any one of the following:
Surgical wounds or Open Lesions with treatment
Radiation therapy
Tube Fed+ and Aphasia
Fever with one or more of the following:
○ Dehydration
○ Pneumonia
○ Vomiting
○ Weight Loss
○ Tube Feeding+

39. 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

40. 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

41. RUGs Groups
As of 1-1-2006 Medicare introduced a new
RUGs Group:
Rehabilitation, Plus Extensive Services
Highest Paid RUGs Group
Patient’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.

42. IRF PPS
 CMG’s being refined
 Case-Level Adjustments:
Transfer Adjustment
Short Stay Payment
Expired
Interrupted Stay
 Co-morbidity Adjustment – continues to
change/adjust payment for patient co-
morbidities

43. 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

44. 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