Virginia Law

A. Definitions. The following words and terms when used in this section shall have the following meanings unless the context clearly indicates otherwise:

"Actively participate" means the individual regularly, as may be ordered by the physician, attends planned therapeutic activities and demonstrates progress towards goals established in the plan of care.

"Admission certification statement" means that the physician signs and dates an initial written statement in the individual's medical record of the need for intensive rehabilitation services. This statement shall be documented at the time of the rehabilitation admission.

"Comprehensive outpatient rehabilitation facility" or "CORF" means a facility that offers a coordinated intensive rehabilitation day program that uses an interdisciplinary team approach and includes, at a minimum, physicians' services and rehabilitation nursing in addition to at least two of the following four therapy services: (i) physical therapy, (ii) occupational therapy, (iii) cognitive rehabilitation therapy, or (iv) speech-language pathology.

"Licensed practitioner of the healing arts" means either a nurse practitioner, a physician assistant, or other practitioner as licensed by the Commonwealth to render covered services.

"Physical rehabilitation services" means medically prescribed treatments for improving or restoring functions that have been impaired by illness or injury, or where function has been permanently lost or reduced by illness or injury, for improving the individual's ability to perform those tasks required for independent functioning.

"Plan of care" means a written order signed and dated by a physician or other licensed practitioner that is specific to the individual that includes orders for rehabilitation therapies, including the frequency and duration of services; required medications; treatments; diet; and other services as needed, for example, psychological services, social work services, or therapeutic recreation services.

"Recertification" means that the physician or other licensed practitioner shall sign and date at least every 60 days a written statement in the individual's medical record of the continuing need for intensive rehabilitation services.

"Therapist plan of care" means a written treatment plan, developed by each licensed therapist involved with the individual's care, to include measurable long-term and short-term goals, interventions or modalities, frequency and duration, and a discharge disposition. These therapist plans of care shall be written, signed, and dated by either a licensed physical or occupational therapist, speech-language pathologist, cognitive rehabilitative therapist, psychologist, social worker, or certified therapeutic recreational specialist.

B. Medicaid covers intensive inpatient physical rehabilitation services in facilities certified as physical rehabilitation hospitals or physical rehabilitation units in acute care hospitals.

C. Medicaid covers intensive outpatient physical rehabilitation services in facilities that are certified as comprehensive outpatient rehabilitation facilities (CORFs). With the exception of the physician admission certification statement, all of the service criteria for intensive rehabilitation services also apply to CORFs.

D. The application of a national standardized set of medical necessity criteria in use in the industry, such as McKesson InterQual^® Criteria or an equivalent standard authorized in advance by DMAS, shall be required for this service. In addition, an individual qualifies for intensive inpatient rehabilitation or comprehensive outpatient physical rehabilitation as provided in a CORF if all of the following criteria are met:

1. Adequate treatment of the individual's medical condition requires an intensive physical rehabilitation program consisting of an interdisciplinary coordinated team approach to improve his ability to function as independently as possible.

2. It has been established that the rehabilitation program cannot be safely and adequately carried out in a less intensive setting.

3. In addition to the medical condition requirement, individuals shall meet the following criteria in order to be eligible for intensive inpatient rehabilitation or comprehensive outpatient physical rehabilitation provided in a CORF:

a. The individual shall require at least two of these four therapies in addition to requiring rehabilitative skilled nursing:

(1) Occupational therapy;

(2) Physical therapy;

(3) Cognitive rehabilitation therapy; or

(4) Speech-language pathology services.

b. The individual's medical condition shall be stable and compatible with an active rehabilitation program.

4. The individual shall (i) have a rehabilitation potential such that the individual's condition can be expected, based on the physician's assessment, to improve significantly in a reasonable and generally predictable period of time or (ii) require rehabilitation services as necessary toward the establishment of a safe and effective home maintenance therapy program required in connection with a specific diagnosis.

E. Within 24 hours of an individual's admission to intensive physical rehabilitation services, all of the physician requirements of 12VAC30-60-120 A shall be met.

F. An intensive physical rehabilitation program provides medically necessary intensive skilled rehabilitation nursing, physical therapy, occupational therapy, and, if needed, speech-language pathology, cognitive rehabilitation, prosthetic-orthotic services, psychology, social work, and therapeutic recreation services. With the exception of CORF services, the physician or other licensed practitioner shall be responsible for admission and discharge orders. If verbal orders are given, written plans of care shall be signed and dated within 72 hours of the verbal order. The nursing staff shall support the other disciplines in carrying out the individual's interdisciplinary plan of care treatment activities on the medical nursing unit and furnishing other needed nursing services. The individual interdisciplinary plan of care must be carried out under the continuing direct supervision of a physician or other licensed practitioner with special training or experience in the field of physical medicine and rehabilitation. For CORF services, only physicians shall be permitted to initiate plans of care or orders.

1. For an individual with a potential for physical rehabilitation for which an outpatient assessment cannot be adequately performed, an admission to intensive inpatient rehabilitation for an evaluation of no more than seven calendar days in duration shall be allowed. During this admission, a comprehensive rehabilitation evaluation shall be made of (i) the individual's medical condition, functional limitations, prognosis, possible need for corrective surgery, and ability to participate in rehabilitation and (ii) the existence of any social problems affecting rehabilitation. After these evaluations have been made, the physician, in consultation with the interdisciplinary rehabilitation team, shall determine and justify the level of care required to achieve the stated goals.

2. If during a previous hospital admission the individual completed a rehabilitation program for essentially the same condition for which inpatient hospital rehabilitation care is now being considered, reimbursement for the evaluation shall not be covered unless there is a documented intervening circumstance, such as an injury or serious illness, that necessitates a reevaluation.

3. Admissions for evaluation or training, or both, for solely vocational or educational purposes or for developmental or behavioral assessments shall not be covered services under the authority of this section.

G. All providers of rehabilitation services shall be enrolled as a Medicaid provider. Inpatient rehabilitation providers and CORFS shall enroll via the Rehabilitation Hospital Participation Agreement, and Comprehensive Outpatient Rehab Facility Participation Agreement, respectively.

H. To receive continued intensive rehabilitation services, the individual must demonstrate an ability to actively participate in goal-related therapeutic interventions developed by the interdisciplinary team. This shall be evidenced by regular attendance in planned therapy activities and demonstrated progress toward the established goals.

I. Intensive rehabilitation services shall be considered for termination regardless of the service authorized length of stay when one or more of the following conditions are met:

1. No further potential for improvement is demonstrated and the individual has reached his maximum progress;

2. Lack of participation on the part of the individual is evident;

3. An unstable condition affects the individual's ability to actively participate, as defined in subsection A of this section, in a rehabilitative plan of care;

4. Progress toward an established goal or goals cannot be achieved within a reasonable period of time as determined by the licensed therapist;

5. The established goal serves no purpose to increase meaningful functional or cognitive capabilities;

6. The service no longer requires the skills of a qualified therapist; or

7. A home maintenance program has been established to maintain the individual's function to the level to which it has been restored.