Utah Administrative Code
The Utah Administrative Code is the body of all effective administrative rules as compiled and organized by the Division of Administrative Rules (see Subsection 63G-3-102(5); see also Sections 63G-3-701 and 702).
NOTE: For a list of rules that have been made effective since October 1, 2015, please see the codification segue page.
NOTE TO RULEFILING AGENCIES: Use the RTF version for submitting rule changes.
R414. Health, Health Care Financing, Coverage and Reimbursement Policy.
Rule R414-2B. Inpatient Hospital Intensive Physical Rehabilitation Services.
As in effect on October 1, 2015
Table of Contents
- R414-2B-100. Authority and Purpose.
- R414-2B-200. Definitions.
- R414-2B-300. Program Access Requirements.
- R414-2B-500. Miscellaneous Restrictions.
- R414-2B-600. Prior Authorization.
- Date of Enactment or Last Substantive Amendment
- Notice of Continuation
- Authorizing, Implemented, or Interpreted Law
(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).
(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.
(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:
(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.
(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.
(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.
October 2, 2012
For questions regarding the content or application of rules under Title R414, please contact the promulgating agency (Health, Health Care Financing, Coverage and Reimbursement Policy). A list of agencies with links to their homepages is available at http://www.utah.gov/government/agencylist.html or from http://www.rules.utah.gov/contact/agencycontacts.htm.