Eli's Rehab Report

Published on Tue Jan 01, 1980 PDF

Tweaking criteria could throw a lifeline to threatened facilities

Good news for rehab providers trying to get their patients admitted to inpatient rehab units.

The House of Representatives on Sept. 8 passed an amendment by voice vote that halts the Centers for Medicare & Medicaid Services' (CMS) implementation of the 75 percent rule published in the May 7 Federal Register. The new measure would ensure that rehabilitative care centers can participate in a study by the Government Accounting Office aimed at rewriting the rule.

The new policy would shut too many patients out in the cold, according to Rep. Frank A. LoBiondo (R-N.J.), who sponsored the bill.

By 2007, 75 percent of a rehab facility's admissions would have to fall within a list of 13 conditions for medical necessity. The proposal included a graduated roll-in to meet the 2007 cut off. The purpose of the 75 percent rule was to differentiate the truly high-acuity patients who needed intensive rehabilitative services provided in a hospital setting from patients who could be cared for in skilled nursing facilities (SNF) - at a much lower cost.

What this means for you: Your documentation and selection of ICD9 Codes would either support a patient's meeting the criteria of the 75 percent rule or not support it.  

Choosing the correct diagnosis code designation has more effect than just reimbursement. Just like disregarding the pressure to designate a certain diagnosis code to ensure reimbursement, coders should not feel pressure to designate a certain diagnosis code to fall within one of the 13 conditions for medical necessity.

Both providers and facilities opposing the applicability and appropriateness of the conditions excluded on the list (such as cancer, transplants, as well as cardiac and pulmonary conditions) have given a tremendous response. LoBiondo also says the policy, which was originally introduced in 1984, is in dire need of updates.

"The American Academy of Physical Medicine and Rehabilitation (AAPM&R) has advocated that the rule and its conditions of medical necessity be studied to determine if they are still valid and appropriate," says Allison Waxler, practice management policy analyst at the AAPM&R in Chicago.

"It is imperative that physicians and medical professionals have input to change these outdated criteria," LoBiondo agrees. "Rehabilitative medicine has changed, and this amendment will make sure that government policy will as well."

Lesson learned: New steps to tweak the rehab admissions criteria could throw a lifeline to facilities threatened by the rule.