Rehabilitation Hospital Services

Quick Guide to Inpatient Rehab Hospital Coverage

When should Medicare coverage be available for Inpatient Facility (Hospital) Rehabilitation?

Inpatient Rehabilitation Facility care (IRF, also known as Inpatient Rehabilitation Hospital/IRH, or Unit) can be covered by Medicare if it meets the following criteria:

1. The physician certifies that an Inpatient Rehabilitation Facility/IRF level-of-care is medically necessary and orders the patient’s care;

• The care is provided in a Medicare certified facility that has 24-hour a day availability of a physician;

• The care is provided by a coordinated, multidisciplinary team, made up of rehabilitation nurses, therapists, and other specialists, that is overseen by a physician, and meets at least once per week;

• The patient requires a relatively intense, multidisciplinary rehabilitation program with the on-going medical supervision by a rehabilitation physician;
  • Generally, understood as multidisciplinary therapy 3 hours/5 days per week or 15 hours/within 7 consecutive days;
  • Multidisciplinary rehabilitation includes physical therapy, occupational therapy, speech language pathology services, or prosthetics/orthotics therapy – one of which must be physical or occupational therapy.

• The patient can reasonably be expected to make measurable improvement that will be of practical value to improve the individual’s functional capacity or adaptation to impairments.
  • Patients cannot be expected to achieve complete independence in the domain of self-care or be able to return to their prior level of functioning in order to meet Medicare coverage standards.

Other Important Points:

1. Don’t accept assertions that Medicare coverage is not available if the patient has certain conditions or diagnoses. (For example, that patients with below the knee amputations or upper extremity paralysis “only” cannot qualify for Medicare. Coverage.

• In practice, Administrative Law Judges may grant coverage if it can be shown that the patient needed a multidisciplinary, coordinated rehabilitation program provided by a team of professionals which was not actually available at a lower-level-of-care (skilled nursing facility, at home, or on an outpatient basis.)

• It will be helpful to succeed on appeal if the patient needs close physician/medical supervision since that is not available at a lower level-of-care. (For example, needs 24 hour a day availability of a physician and/or nurse with training or experience in rehabilitation).

• Patients do not have to be expected to return to their prior level of function.  It is sufficient if the goal is to improve their level of function or adaptation to impairments.

• The patient’s attending physician is always the key to obtaining Medicare benefits.  If possible, obtain a statement from the individual’s physician explaining why IRF care is medically necessary and that the needed rehabilitation program is not actually available at a lower level of care (skilled nursing facility, home health, or on an outpatient basis).

Articles and Updates

• CMS Revises Inpatient Rehabilitation Facility “Review Choice Demonstration” – Confirming Individual Assessments Must be Used to Adjudicate Claims July 27, 2023
• CMA Comments on CY 2022 HH Prospective Payment System & More August 5, 2021
• Patients Need Therapy – Medicare Payment Systems Create Barriers December 12, 2019
• New Fact Sheet Available – Medicare Inpatient Rehabilitation Hospital/Facility Coverage In Light of Jimmo v. Sebelius April 11, 2019
• CMS Clarifies 3-Hour “Rule” Should Not Preclude Medicare-Covered Inpatient Rehabilitation Hospital Care March 15, 2018
• Value of Inpatient Rehabilitation Hospital Care Reaffirmed May 18, 2016
• Saga of an Inpatient Hospital Appeal: Notice and Use of Lifetime Reserve Days and Comments on Observation Status May 21, 2015
• No Site Neutral Payments for Inpatient Rehabilitation Facilities and Skilled Nursing Facilities December 11, 2014
• Inpatient Rehabilitation Facilities and Skilled Nursing facilities: Vive La Difference! July 31, 2014

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