Medical Policy Bulletin

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Title:

Day Rehabilitation

Policy #:

10.00.02

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The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service. This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.

Intent

The intent of this policy is to communicate the medical necessity criteria for day rehabilitation.

For information on policies related to this topic, refer to the Cross References section in this policy.

Description

Day rehabilitation programs are intensive, interdisciplinary, and comprehensive. They typically consist of four to seven hours of daily rehabilitative therapies (ie, physical therapy, occupational therapy, speech therapy) and other medical services (eg, psychological therapy, nursing, case management) five days per week and include a combination of one-to-one and group therapy. Day rehabilitation programs are offered in an outpatient setting, and the individual returns home each evening and for the entire weekend. Day rehabilitation programs can be provided in lieu of acute inpatient rehabilitation, as a substitute for acute inpatient rehabilitation in the continuum of care for those who no longer require continuous medical and nursing care and supervision, or as a progression in the continuum of care to traditional outpatient therapy services.

Policy

Day rehabilitation is considered medically necessary and, therefore, covered when all of the following criteria are met:

• The day rehabilitation program is being prescribed for one of the following circumstances:
  • In lieu of acute inpatient rehabilitation for individuals who are medically stable enough to live at home, but still require several skilled rehabilitation therapies.
  • As a substitute for acute inpatient rehabilitation in the continuum of care for individuals who no longer require continuous medical and nursing supervision but still require acute rehabilitation level therapy that includes coordinated care and multiple intensive therapies to address their extensive rehabilitation needs.
  • As a progression to traditional outpatient therapy services (eg, one hour per therapy discipline, three days a week).
    • Note: When therapy services can be provided in the traditional outpatient setting and the intensity and frequency of day rehabilitation services is not indicated for the individual’s condition, day rehabilitation is not an appropriate service in lieu of traditional outpatient therapy.
• The individual has a rehabilitation diagnosis. These conditions include but are not limited to:
  • Traumatic brain injury
  • Cerebrovascular accident
  • Spinal cord injury
  • Other neurological conditions (eg, multiple sclerosis)
  • Limb amputation
• The individual is medically stable
• The individual has an adult primary caregiver at home that is able to provide assistance in integrating the rehabilitation program into the home
• The individual must require at least 4 to 7 hours of rehabilitative therapies and other medical services per day
  • The individual must require at least two of the following rehabilitative therapy services:
    • Physical therapy
    • Occupational therapy
    • Speech therapy
  • The individual may require other medical services. These include but are not limited to:
    • Nursing care
    • Psychological therapy
    • Case Management
• The individual is expected to functionally improve and has appropriate rehabilitation goals that warrant a day rehabilitation program
• The individual has the ability to communicate (verbally or non-verbally) basic needs*
• The individual is able to consistently follow directions and manage his/her behavior with minimal to moderate intervention by professional staff*
• The individual is willing to participate in a day rehabilitation program*

*This criteria should be evaluated by giving deference to the individual's current medical condition (eg, age, developmental status, injury and/or impairment) and the requirements and goals of the day rehabilitation program (eg, a day rehabilitation program structured for a pediatric patient with a traumatic brain injury).

If the above criteria are not met, day rehabilitation is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the diagnosis or treatment of illness or injury.

For most of the Company's products, day rehabilitation has visit limitations. Individual member benefits must be verified.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

Acute inpatient therapy services are intensive (at least 3 hours a day, 5 to 7 days per week), consisting of at least two rehabilitative therapies, other associated medical services (eg, case management), with 24 hours of medical and nursing supervision. Services are generally performed in a rehabilitation unit within a hospital or in a free-standing rehabilitation hospital.

Traditional outpatient therapy services are moderately intensive multi-disciplinary services performed in an outpatient facility. The individual may receive all three rehabilitative therapy disciplines, but will typically receive 1 hour of each rehabilitative therapy 3 days per week.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, day rehabilitation is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

MEDICARE

There is no Medicare coverage determination addressing this service; therefore, the Company policy is applicable.

References

Braddom R. Physical medicine and rehabilitation. 2nd edition. Philadelphia, PA. Saunders; 2000. Centers for Medicare and Medicaid Services. Medicare Benefit Hospital Manual.Chapter 1 - Inpatient Hospital Services Covered Under Part A. [CMS Web site]. 02/10/06. Available at: http://www.cms.hhs.gov/manuals/downloads/bp102c01.pdf. Accessed November 16, 2009. Company benefit contracts. Crotty M, Giles LC, Halbert J, et al. Home versus day rehabilitation: a randomized controlled trial. Age Aging. 2008;37(6):628-633. Frontera WR, Silver JK, et al. Essentials of physical medicine and rehabilitation. 2nd edition. New York, NY. Saunders; 2008. Hashimoto K, Takatsugu O, et al. Effectiveness of a comprehensive day treatment program for rehabilitation of patients with acquired brain injury in Japan. J Rehabil Med.2006;38(1):20-25. Olsson BG, Sunnerhagen KS. Effects of day hospital rehabilitation after stroke. J Stroke Cerebrovasc Dis. 2006;15(3):106-113. Olsson BG, Sunnerhagen KS. Functional and cognitive capacity and health-related quality of life 2 years after day hospital rehabilitation for stroke: a prospective study. J Stroke Cerebrovasc Dis.2007;16(5):208-215. Specialty-matched consultant review.

Coding Table

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply. The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates. In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

Code System	Code Number(s) and Narrative(s)
CPT	N/A
ICD Procedure	N/A
ICD Diagnosis	N/A
HCPCS Level II	N/A
Revenue Codes	USE THE FOLLOWING CODES TO REPORT DAY REHABILITATION: 0931: Medical rehabilitation day program half day 0932: Medical rehabilitation day program full day

Cross References

Version Effective Date: 02/23/2010