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CRITERIA MANUAL CHAPTER 5.5

ACUTE INPATIENT INTENSIVE REHABILITATION

I. Inpatient intensive rehabilitation hospital services are covered for eligible Medi-Cal patients by the Medi-Cal Program in accordance with Section 14064 of the Welfare and Institutions (W&I) Code. The Department and the rehabilitation community understand and use the term “acute inpatient intensive rehabilitation” to mean the same as the term “inpatient intensive rehabilitation hospital services” as used in the statute. The term “acute inpatient intensive rehabilitation” also includes those rehabilitation services described in W&I Code, Section 14132.8.

Acute inpatient intensive rehabilitation is a program of rehabilitation, as defined in Section II.E, provided to a patient admitted to an acute care bed (certified pursuant to 42 CFR Part 482) in a rehabilitation center, licensed in accordance with Title 22, CCR, Sections 70595 – 70603. The acute intensive rehabilitation shall be provided under the general or direct supervision of a physician, as specified in Section 14064 of the W&I Code. Acute inpatient intensive rehabilitation is intended to help the physically or cognitively impaired patient to achieve or regain his/her maximum potential for mobility, self-care, and independent living by restoring maximum independent function, resulting in a sustained higher level of self care and discharge to home or other community setting, or to a lower level of care, in the shortest possible time.

Acute inpatient intensive rehabilitation services are covered services only when provided to a patient admitted to an acute care bed (certified

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pursuant to 42 CFR Part 482) in a rehabilitation center, licensed in accordance with Title 22, CCR, Sections 70595-70603.

II. For the purposes of adjudicating TARs for acute inpatient intensive rehabilitation, the following definitions shall apply:

A. “Activities of daily living” means those activities performed by an individual for essential living purposes. These activities shall include grooming, oral hygiene, bathing, toileting, eating, meal preparation, dressing, sleeping, communication, and mobility necessary to perform the above listed activities, to navigate environmental obstacles such as stairs, ramps, and curbs, and to access transportation for the purposes of activities common to everyday living.

B. “Acute inpatient intensive rehabilitation treatment plan” or “rehabilitation treatment plan” means a written plan for treatment of the patient’s medical condition, which shall include all of the following:
1. A statement(s) of the patient’s medical problem(s).
2. A description(s) of the intervention(s) determined by the multidisciplinary team to be appropriate for the patient’s problem(s).
3. The goal(s) of treatment.
4. The expected outcome(s) of treatment, with specific time frames for the patient to attain the stated goal(s), as determined by the multidisciplinary team.

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C. “Multidisciplinary team” means the group of medical care providers, including those as specified in Title 22, CCR, Section 70599, that are responsible for implementing the rehabilitation treatment plan. Such a team shall be comprised of physicians, nurses, and therapists.

D. “Physician” , for the purpose of this chapter, means either the patient’s physician or the physician’s designee, or a physician employed by, or serving as a consultant to, the rehabilitation hospital.

E. “Rehabilitation” means those services specified in Section 14064 of the W&I Code.

III. Referral shall be made to the California Children’s Services (CCS) program for authorization of services and case management, as required by Title 22, CCR, Section 51013, when a person under 21 years of age has a CCS-eligible medical condition as defined in Title 22, CCR, Sections 41800-41876.

IV. Acute inpatient intensive rehabilitation requires authorization by a Medi- Cal Consultant. Authorization shall be based upon medical necessity substantiated by documentation submitted with the Treatment Authorization Request (TAR). Authorization shall be granted in increments of up to 30 days.

V. Authorization of acute inpatient intensive rehabilitation shall not be granted when the primary reason for the acute inpatient intensive rehabilitation is any of the following:

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A. Education or vocational training.

B. Treatment for cardiac or respiratory improvement, in the absence of two or more functional deficits, as specified in Section VI.B.

C. Treatment for any medical condition, in the absence of two or more functional deficits, as specified in Section VI.B.

D. Treatment for drug or alcohol addiction.

E. Behavioral modification therapy, except as a treatment modality for the requirements specified in Section VI.B. of this chapter.

F. Treatment for mental illness.

VI. Initial authorization of acute inpatient intensive rehabilitation shall be granted only when, at a minimum, all of the following conditions are met:

A. The patient has been evaluated by a physician who has:
1. Determined and documented that the patient requires all of the following:
a) 24-hours per day oversight by a physician, with a minimum of two visits per week by the physician and written progress notes at each visit.
b) A minimum of 18 hours per week of a combination of two or more of the following therapy disciplines:

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(1) Physical therapy, pursuant to the standards of practice specified in Business and Professions Code Section 2600 et seq., which shall include orthotic or prosthetic training, as specified on the patient’s rehabilitation treatment plan, provided by the physical therapist.

(2) Occupational therapy, pursuant to the standards of practice specified in Business and Professions Code Section 2570 et seq., which shall include orthotic or prosthetic training, as specified on the patient’s rehabilitation treatment plan, provided by the occupational therapist.

(3) Speech therapy, pursuant to the standards of practice specified in Business and Professions Code Section 2530 et seq., which shall include intensive or advanced assistive technology training, such as the use of an augmentative and alternative communication (AAC) device, as specified on the patient’s rehabilitation treatment plan, provided by the speech therapist.

(4) Services provided by a prosthetist or orthotist, such as measuring and fitting of prosthetic or orthotic appliances.

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(5) Psychological and social work services not to exceed 4 hours of the required 18 therapy hours in any given week.

2. Participated in the development of, or concurred with, the rehabilitation treatment plan developed by the multidisciplinary team, as specified in Section II.B. of this chapter. Such participation or concurrence shall be documented in the patient‘s medical record.

B. The patient has a severe functional deficit in two or more of the following areas: , documented by the physician. At least one of the documented functional deficits shall be in the area of activities of daily living skills, mobility skills, safety, or communication.

1. Activities of daily living skills, which shall include those activities specified in Section II.A.
2. Mobility skills, which shall include ambulation or transfer deficits or wheelchair dependency.
3. Bladder or bowel control and need for development of a bladder or bowel management program.
4. Severe pain that markedly limits function, but which will not preclude the patient’s participation in the acute inpatient intensive rehabilitation program.
5. Safety and judgment deficits, which if left untreated would result in injury to the patient or the development of medical complications such as falls, contractures, decubiti, or urinary tract infections.

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6. Cognition deficits requiring cognitive evaluation and retraining.

7. Communication deficits, including severe speech or language impairment or need for training in the use of assistive technology, such as an AAC device in the acute inpatient intensive rehabilitation setting.

C. The following are documented by the physician:
1. One of the following:
a) For the patient without cognitive deficit(s), the patient has been medically and psychologically stable for at least 24 hours and can physically and psychologically tolerate and participate in the proposed acute inpatient intensive rehabilitation program.
b) For the patient with cognitive deficit(s), the patient has been medically stable for at least 24 hours and can physically tolerate and participate in the proposed acute inpatient intensive rehabilitation program. The patient’s psychological status, as evaluated in light of the cognitive impairment, is considered stable and does not in itself present an obstacle to the accomplishment of the specified goals.

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2. One of the following:

a) For the patient without cognitive deficit(s), the patient demonstrates understanding of his or her medical condition and the motivation to cooperate with and participate in the proposed acute inpatient intensive rehabilitation program.

b) For the patient with cognitive deficit(s), any lack of understanding the patient may have of his or her medical condition will not interfere with his or her ability to participate in the acute inpatient intensive rehabilitation program. The patient demonstrates the ability to follow directions or otherwise cooperate with and participate in the proposed acute inpatient intensive rehabilitation program.

3. There is the expectation by the physician that the patient will be able to improve his/her functional abilities in order to either:
a) Regain or attain the ability to provide self-care in activities of daily living, or
b) Transition or return to a community setting with or without the assistance of a caregiver, or to a lower level of care.

4. Any concurrent medical or psychological condition(s) that requires monitoring or treatment does not significantly preclude the patient’s participation in the acute inpatient

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intensive rehabilitation program. If the acute inpatient intensive rehabilitation program is interrupted for treatment of a documented medical or psychological condition for more than three consecutive days, re-institution of acute inpatient intensive rehabilitation shall require the submission of a new TAR. Authorization of acute inpatient intensive rehabilitation in this case shall be granted only when the requirements specified in Section VI. are met.

5. Improvement of the patient’s functional abilities cannot be achieved at a lower level of care.

VII. Continuing authorization of acute inpatient intensive rehabilitation shall be granted only when all of the following is documented by the physician:
A. The criteria specified in Section VI.A., B., and C. are met.

B. An increased level of functional abilities has been achieved and additional improvement is anticipated.

C. Acute inpatient intensive rehabilitation is medically necessary to improve the newly achieved functional ability or to achieve improvement in another functional deficit area.

D. Improvement of the patient’s functional abilities cannot be achieved at a lower level of care.

E. New therapeutic goals and timelines have been established on the rehabilitation treatment plan, as specified in Section II.B., for at least two of the therapy disciplines specified on the previous rehabilitation treatment plan.

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VIII. Continuing authorization of acute inpatient intensive rehabilitation shall not be authorized when any of the following conditions are present, based upon the documentation submitted with the TAR:

A. All of the established goals have been attained and no further goals are specified on the rehabilitation treatment plan.

B. Improvement of the patient’s functional abilities has plateaued , resulting in one or more of the goals having not been met and further improvement is not anticipated.

C. Improvement of the patient’s functional abilities can be achieved at a lower level of care.

D. The patient has been unable or unwilling to cooperate with the acute inpatient intensive rehabilitation program.

IX. Authorization of a trial period of acute inpatient intensive rehabilitation:

A. When rehabilitation potential is determined by the Medi-Cal consultant to be likely based upon the documentation of criteria specified in Section VI.B., but criteria specified in Sections VI.A. and C. are not fully determined, authorization shall be granted for up to 14 calendar days to determine if improvement in practical function can be accomplished, and to establish medical necessity for continuing acute inpatient intensive rehabilitation.

B. Continued authorization beyond 14 calendar days shall be granted only if the criteria specified in Sections VII.A. through E. are met, as

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determined by the Medi-Cal consultant, based upon the documentation submitted with the TAR.

X. In addition to the documentation requirements specified in Sections VI. and VII., the documentation submitted with the TAR for acute inpatient intensive rehabilitation shall include all of the following:

A. For initial authorization:

1. A written summary of patient evaluation by a physician, which shall include all of the following:
a) Diagnoses, physical findings, and description of functional deficits.
b) Pertinent history of functional deficits.
c) A summary of the patient’s premorbid functional level, which shall include physical, cognitive, psychological, vocational, and family or social functioning.
d) A description and results of all previous rehabilitation services related to the requested admission.
e) A description of the patient’s ability to understand and cooperate with the acute inpatient intensive rehabilitation program as specified in Section VI.C.2. of this chapter.

2. An evaluation of the patient’s functional level by each therapy discipline, as specified in Section VI.A.1.(b)(1)

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through (5), that is specified on the rehabilitation treatment plan.

3. One of the following:

a) A detailed plan for completion of an initial evaluation and rehabilitation treatment plan, as specified in Section IX.A., if the request is for a 14-day trial of acute inpatient intensive rehabilitation.
b) A detailed rehabilitation treatment plan, as specified in Section II.B.

B. For continuing authorization:

1. A written summary by a physician, which shall include all of the following:
a) Current physical assessment.
b) Specific progress for each functional deficit identified in the prior rehabilitation treatment plan.
c) Medical justification of continuing need for acute inpatient intensive rehabilitation, which shall include an explanation of why the patient’s rehabilitation needs cannot be met at a lower level of care.

2. An updated rehabilitation treatment plan that anticipates improvement in performance of activities of daily living within a specified period of time, as determined by the physician

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and multidisciplinary team.

3. Multidisciplinary team conference notes, which shall include documentation of all of the following:

a) Participation of all appropriate staff, as specified in Section II.C.

b) Measured progress, such as level of functional ability for each goal specified on the rehabilitation treatment plan.

c) At least two multidisciplinary team conferences per month.

d) Updated discharge plan.

4. Orders by the physician, written within the previous two weeks, specifying rehabilitation services to be provided.

5. Therapy summary, which shall include the number of hours of therapy per week, for each therapy discipline provided. The therapy summary may be provided using the multidisciplinary conference notes or other documentation that meets this requirement.

6. Rehabilitation nursing summary documenting nursing services provided. The nursing summary may be provided using the multidisciplinary conference notes or other documentation that meets this requirement.

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Manual of Criteria, Acute Inpatient Intensive Rehabilitation