DAR File No. 40180
This rule was published in the February 15, 2016, issue (Vol. 2016, No. 4) of the Utah State Bulletin.
Health, Health Care Financing, Coverage and Reimbursement Policy
Rule R414-2B
Inpatient Hospital Intensive Physical Rehabilitation Services
Notice of Proposed Rule
(Amendment)
DAR File No.: 40180
Filed: 02/01/2016 09:48:15 AM
RULE ANALYSIS
Purpose of the rule or reason for the change:
The purpose of this change is to consolidate the scope of inpatient intensive physical rehabilitation services to the Medicaid provider manual.
Summary of the rule or change:
This amendment removes all provisions in the rule text and defers to the scope of services found in the "Hospital Services Utah Medicaid Provider Manual".
State statutory or constitutional authorization for this rule:
- Section 26-18-3
- Section 26-1-5
Anticipated cost or savings to:
the state budget:
There is no impact to the state budget because services provided to Medicaid recipients remain unaffected by this change.
local governments:
There is no impact to local governments because services provided to Medicaid recipients remain unaffected by this change.
small businesses:
There is no impact to small businesses because services provided to Medicaid recipients remain unaffected by this change.
persons other than small businesses, businesses, or local governmental entities:
There is no impact to Medicaid providers and to Medicaid recipients because services provided to Medicaid recipients remain unaffected by this change.
Compliance costs for affected persons:
There are no compliance costs to a single Medicaid provider or to a Medicaid recipient because services provided remain unaffected by this change.
Comments by the department head on the fiscal impact the rule may have on businesses:
There is no fiscal impact to business because the amendment does not affect any services provided to Medicaid recipients.
Joseph K. Miner, MD, Executive Director
The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:
HealthHealth Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231
Direct questions regarding this rule to:
- Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov
Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:
03/16/2016
This rule may become effective on:
04/01/2016
Authorized by:
Joseph Miner, Executive Director
RULE TEXT
R414. Health, Health Care Financing, Coverage and Reimbursement Policy.
R414-2B. Inpatient [
Hospital
]Intensive Physical Rehabilitation Services.
R414-2B-1. Introduction.
Inpatient intensive physical rehabilitation services are provided for Medicaid recipients in accordance with the Hospital Services Utah Medicaid Provider Manual and Attachment 4.19-A of the Medicaid State Plan, as incorporated into Section R414-1-5.
[R414-2B-100. Authority and Purpose.
(1) This rule defines the scope of inpatient hospital
intensive physical rehabilitation services available to Medicaid
clients who meet the level of care criteria for admission to a
distinct part rehabilitation unit in an acute-care general
hospital.
(2) Inpatient hospital services are required under
Section 1901 et seq. and Section 1905(a)(1) of the Social
Security Act, and by 42 CFR 440.10 (October 1, 1991, edition).
The requirement that inpatient hospital physical rehabilitation
services covered by Utah Medicaid be provided in a distinct part
rehabilitation unit of an acute-care general hospital brings
rehabilitation service under this authority.
(3) This rule is authorized by Sections 26-1-5, 26-1-15,
and 26-18-6, and by Subsections 26-18-3(2) and 26-18-5(3) and
(4).
R414-2B-200. Definitions.
(1) Terms used in this rule are defined in R414-1-1 and
R414-2A-200.
(2) In addition:
(a) "individualized treatment plan" means a
coordinated, multidisciplinary plan of care developed:
(i) by a rehabilitation treatment team consistent with 42
CFR 412.29(d) and 42 CFR 456.80 (October 1, 1991, edition), which
are incorporated by reference; and
(ii) in consultation with the patient, spouse, parents,
legal guardian, or others into whose care the patient may be
released;
(b) "inpatient hospital intensive physical
rehabilitation" means an intense program of physical
rehabilitation provided:
(i) in a distinct part rehabilitation unit of an
acute-care general hospital;
(ii) by a multidisciplinary, coordinated team;
and
(iii) for the purpose of upgrading a patient's
ability to function;
(c) "multidisciplinary treatment team" means a
group of professionals responsible for and involved in a
patient's care, consisting of:
(i) a physician, a rehabilitation nurse, and a therapist;
and optionally
(ii) one or more additional physicians, physiatrists,
rehabilitation nurses, social workers, psychologists, or
therapists;
(d) "program manager" means an individual
assigned to:
(i) assume responsibility for implementation of a
patient's individualized treatment plan;
(ii) ensure that the patient is adequately oriented to
the rehabilitation program;
(iii) ensure that the patient's treatment proceeds in
an orderly, purposeful, and goal-directed manner;
(iv) ensure program response to the needs and preferences
of the patient;
(v) promote participation of the patient on an ongoing
basis in discussion of plans, goals, status, etc.;
(vi) consistently participate in multidisciplinary team
conferences concerning the patient; and
(vii) ensure that the discharge plan and arrangements for
appropriate follow-up and supportive services are properly
made.
R414-2B-300. Program Access Requirements.
(1) Hospital admission requirements for inpatient
intensive physical rehabilitation services are specified in
R414-2A-300. In addition, patient hospital intensive physical
rehabilitation is a covered Medicaid service only when:
(a) the admission is the initial admission for
rehabilitation service, or the admission results from a
deterioration as a result of a secondary illness and an inpatient
intensive physical rehabilitation program is needed to restore
the level of function as closely as possible to the pre-secondary
illness level;
(b) the patient requires close medical supervision by a
physician with specialized training or experience in
rehabilitation;
(c) the patient requires 24-hour-a-day nursing care or
supervision by a registered nurse with specialized training or
experience in rehabilitation;
(d) the severity of the patient's illness and the
intensity of service required are such that these services cannot
be provided in an alternative setting;
(e) the patient meets the admission criteria accepted by
division staff and physician consultants for one of the
categories of trauma or disease specified in
R414-2B-300(2).
(f) a multidisciplinary team approach is required for
delivery of an intensive physical rehabilitation
program;
(g) the patient's cognitive and sensory capacity will
allow active participation by the patient in an intensive
physical rehabilitation program; and
(h) a program manager is assigned, an estimated length of
stay is documented in the medical record within 5 days of the
client's admission to the hospital, and appropriate discharge
planning, including home care assessment, is initiated.
(2) Inpatient hospital intensive physical rehabilitation
services may be provided to Medicaid clients only when one or
more of the following diagnoses is present:
(a) Stroke: neurological deficit secondary to recent
cerebrovascular disease (i. e., thrombosis, aneurysm, hemorrhagic
or embolic) resulting in disability requiring initial intensive
treatment. Rehabilitation therapy must begin within 60 days from
the onset of the stroke.
(b) Spinal cord injury: trauma resulting in quadriplegia
or paraplegia requiring initial intensive inpatient physical
rehabilitation therapy.
(c) Head injury or brain injury, or both: head trauma
with documented neurological deficits requiring initial intensive
inpatient physical rehabilitation therapy.
(d) Brain or spine surgery requiring post-surgery
intensive inpatient physical rehabilitation therapy.
(e) One of the following diseases of the central nervous
system manifested by debilitation of the neurological system or
neuromuscular system, or both, requiring intensive inpatient
physical rehabilitation therapy:
(i) Parkinson's disease;
(ii) multiple sclerosis;
(iii) post meningoencephalitis;
(iv) amyotrophic lateral sclerosis;
(v) myelopathy (i. e., transverse myelitis,
infarction).
(f) One of the following neuromuscular diseases:
(i) myopathy;
(ii) myositis.
(g) One of the following diseases of the peripheral
nervous system:
(i) Guillain-Barre syndrome;
(ii) subacute peripheral neuropathy;
(iii) chronic peripheral neuropathy.
(h) Amputation with complicating medical condition: loss
of one or more extremities resulting in disability requiring an
initial intensive physical rehabilitation program. Amputation
alone does not qualify the patient for intensive physical
rehabilitation. The complicating medical condition must be a
separate disease process that requires the close attention and
medical supervision of a physician.
(i) Fracture of the femur with a complicating medical
condition. The fracture must be complex or unusual requiring
initial intensive physical rehabilitation. The fracture alone
does not qualify the patient for intensive physical
rehabilitation. The complicating medical condition must be a
separate disease process that requires the close attention and
medical supervision of a physician.
(j) Arthritis and rheumatic diseases: muscular deficit or
skeletal deficit, or both, secondary to rheumatic disease, e.g.,
rheumatoid arthritis, polymyositis, systemic lupus, or other
connective tissue disease resulting in disability requiring an
intensive physical rehabilitation program.
(k) Major multiple trauma: multi-system injury, from
varying etiology, resulting in limitation or disability requiring
an initial intensive physical rehabilitation program.
(l) Burns: limitation of function in the extremities as a
result of burns involving at least 15% of the body.
(3) Coverage of inpatient hospital intensive physical
rehabilitation service is limited to those cases for which an
individualized treatment plan is developed by the physician and
staff of the rehabilitation unit. The plan of care shall include
all of the following:
(a) problems identified, specific patient care needs, and
treatment or services to be provided;
(b) realistic, measurable, and time-specific long-term
and short-term goals, based on the patient's needs and
preferences;
(c) specific time intervals at which treatment or goals
shall be reviewed;
(d) identification of time frames anticipated for
accomplishment of the patient's specific treatment
goals;
(e) measures to be used to assess the outcome of
treatment or services;
(f) name and title of the treatment team member
identified as the program manager for the individual patient;
and
(g) written identification, including name and title, of
the team members or other individuals responsible for
implementing, documenting, and monitoring progress for each
element of the individualized treatment plan.
(4) Inpatient hospital intensive physical rehabilitation
services for a patient who has suffered a stroke or other
cerebral vascular accident may be provided only for those
patients where admission and therapy is initiated within the
first 60 days after onset of the incident.
(5) Inpatient hospital intensive physical rehabilitation
services shall be supported in the patient's medical record
showing evidence that team conferences are held every two weeks.
The team conferences shall:
(a) address the patient's progress or the problems
impeding progress;
(b) consider possible resolutions to such problems;
and
(c) reassess the validity of the rehabilitation goals
initially established.
(6) Inpatient intensive physical rehabilitation services
shall be limited in amount, duration, and scope to that which is
medically necessary and reasonable to accomplish the purpose and
objectives of rehabilitation.
R414-2B-500. Miscellaneous Restrictions.
(1) An off-unit pass must be:
(a) ordered by the attending physician;
(b) adequately documented and evaluated in the progress
notes of the patient's chart as supporting the patient's
individualized treatment plan; and
(c) for the purpose of testing the patient's
readiness for discharge and ability to function outside the
institutional setting.
(2) A therapeutic leave of absence must be:
(a) ordered by the attending physician;
(b) planned by the physician or interdisciplinary team
pursuant to established goals and objectives working toward
discharge; and
(c) adequately documented and evaluated in the progress
notes of the patient's chart as supporting the patient's
individualized treatment plan.
R414-2B-600. Prior Authorization.
(1) All inpatient hospital intensive physical
rehabilitation services require prior authorization, as
follows:
(a) The provider must make an initial telephone request
for prior authorization of service to the Bureau of Managed
Health Care, Utilization Management Unit, no later than the fifth
working day following admission of the patient into an inpatient
hospital intensive physical rehabilitation program.
(b) The provider must submit written documentation from
the patient's medical record to justify and support initial
information provided at the time of the initial telephone
contact. The provider shall submit written documentation
postmarked no later than the tenth working day following
admission of the patient into an inpatient hospital intensive
physical rehabilitation program. The documentation must indicate
all of the following:
(i) the diagnosis and rehabilitation needs meet the
established admission criteria specified in R414-2A-300 and
R414-2B-300.
(ii) clear and convincing evidence that the patient's
rehabilitation needs cannot be met in a less restrictive
setting;
(iii) a reasonable expectation of improvement in the
patient's ability to perform activities of daily living that
will be of significant practical value when measured against the
documented condition at the time of the initial
evaluation;
(iv) the plan of care is directed toward restoring
function rather than toward maintenance of function; and
(v) the patient requires a coordinated program of care and
will receive physical, occupational, or speech therapy services, or
all three, for at least three hours per day, no fewer than 5.5 days
per week (total of 16.5 hours per week minimum), in addition to any
other rehabilitative modalities determined to be
necessary.]
KEY: [m]Medicaid
Date of Enactment or Last Substantive Amendment: [1992]2016
Notice of Continuation: October 2, 2012
Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3(2)
Additional Information
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For questions regarding the content or application of this rule, please contact Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov. For questions about the rulemaking process, please contact the Division of Administrative Rules.