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IRF

Review inpatient rehabilitation indicators

Use the prompts and examples to think through the current clinical picture. Select Yes or No for every item without entering patient-specific information.

1
Medically stable for rehabilitationIs the patient stable enough to leave the acute-care hospital while still needing ongoing medical management during rehabilitation?
Examples—not all-inclusive
  • Vital signs and active medical conditions are reasonably controlled
  • No emergency procedure or acute diagnostic workup is pending
  • Medical needs can be managed while the patient participates in therapy
  • Therapy is not expected to be repeatedly stopped by an unstable condition

Ask yourself: Which acute issue could interrupt rehabilitation, and is it controlled well enough for consistent participation?

2
Two or more therapy disciplines neededDoes the patient need active treatment from at least two therapy disciplines for separate, meaningful functional deficits? At least one should be PT or OT.
Examples—not all-inclusive
  • PT for gait or transfers plus OT for dressing, bathing, or other daily activities
  • PT for mobility plus speech therapy for swallowing, communication, or cognition
  • OT for self-care plus speech therapy for cognitive, language, or swallowing deficits

Ask yourself: What distinct problem would each discipline treat, and why would one discipline alone be insufficient?

3
Physical or occupational therapy requiredIs PT or OT medically necessary to address a significant functional limitation that requires skilled progression and hands-on treatment?
Examples—not all-inclusive
  • Walking, wheelchair mobility, transfers, stairs, balance, or fall risk
  • Dressing, bathing, toileting, grooming, feeding, or upper-extremity function
  • Equipment selection, compensatory techniques, or caregiver training
  • A need that goes beyond general strengthening, supervision, or maintenance

Ask yourself: Which daily task can the patient not perform safely now, and what skilled PT or OT intervention is needed to improve it?

4
Able to tolerate intensive therapyIs there a reasonable expectation that the patient can actively participate in an intensive rehabilitation program, with appropriate scheduling and rest breaks?
Examples—not all-inclusive
  • About 3 hours of therapy a day for 5 days a week
  • Approximately 15 hours of therapy over 7 consecutive days when clinically appropriate
  • The attention, endurance, behavior, pain control, and medical stability needed to participate
  • A schedule that can be modified while remaining intensive and goal-directed

Ask yourself: What shows that the patient can participate consistently, and what barriers would need to be managed during the therapy day?

5
Measurable functional improvement expectedIs meaningful, measurable functional improvement expected within a reasonable inpatient rehabilitation stay?
Examples—not all-inclusive
  • Safer walking, wheelchair mobility, transfers, or stair use
  • Greater independence with dressing, bathing, toileting, or eating
  • Improved swallowing, communication, memory, attention, or problem-solving
  • Reduced caregiver burden or a safer discharge to home or another community setting

Ask yourself: What can the patient do now, what realistic level could be reached during the stay, and how would that change the discharge plan?

6
Rehabilitation physician oversight neededDoes the patient need close medical and functional management by a rehabilitation physician during the stay?
Examples—not all-inclusive
  • Neurological changes after stroke, brain injury, spinal cord injury, or another disorder
  • Pain, spasticity, bowel, bladder, skin, or swallowing management
  • Cardiopulmonary or other comorbidities that affect therapy tolerance
  • Medication adjustments, complication prevention, or coordination of rehabilitation goals with medical care

Ask yourself: Which medical issue could change the rehabilitation plan, and why would less frequent physician oversight be insufficient?

7
Coordinated interdisciplinary care neededDo the medical and functional needs require several disciplines to work from one coordinated plan with shared goals?
Examples—not all-inclusive
  • Rehabilitation physician and rehabilitation nursing coordinating with PT, OT, and speech therapy as needed
  • Medical, mobility, self-care, cognition, communication, swallowing, and discharge needs affecting one another
  • Regular team review to measure progress and adjust the treatment plan
  • Case management, caregiver education, equipment, and home-environment planning

Ask yourself: Which shared goals require the team to coordinate, and what decisions would need to be adjusted together as the patient progresses?

8
CMS-13 condition categoryDoes the patient have one of the condition categories CMS uses for the IRF 60% classification rule? Review the category details carefully.
CMS-13 categories
  • Stroke
  • Spinal cord injury
  • Congenital deformity
  • Amputation
  • Major multiple trauma
  • Fracture of the femur (hip fracture)
  • Brain injury
  • Neurological disorders, including multiple sclerosis, motor neuron diseases, polyneuropathy, muscular dystrophy, and Parkinson’s disease
  • Burns
  • Active polyarticular rheumatoid arthritis, psoriatic arthritis, or seronegative arthropathy with the functional impairment and prior-treatment criteria specified by CMS
  • Systemic vasculitis with joint inflammation meeting CMS functional impairment and prior-treatment criteria
  • Severe or advanced osteoarthritis involving two or more major weight-bearing joints and meeting CMS functional impairment, joint, and prior-treatment criteria
  • Knee or hip replacement during the immediately preceding acute hospitalization when it was bilateral, the patient’s BMI is at least 50, or the patient is age 85 or older

Ask yourself: Which category applies—and, separately, what evidence supports the need for intensive interdisciplinary rehabilitation, physician oversight, and expected functional improvement?

Important: A CMS-13 condition may support IRF screening and the facility’s 60% rule calculation, but it does not automatically establish individual medical necessity or admission eligibility. View 42 CFR § 412.29

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