Virginia Administrative Code, Chapter 60, Section 12VAC30-60-120 - Quality management: Intensive physical rehabilitative services and comprehensive outpatient rehabilitation facility services | Virginia Administrative Code

A. Within 24 hours of an individual's admission for either intensive inpatient rehabilitation or comprehensive outpatient rehabilitation facility (CORF) services, a physician shall be required to complete and sign and date the admission certification statement, as defined in 12VAC30-50-225 and 42 CFR 456.60, of the need for intensive rehabilitation or CORF services and the initial plan of care or orders.

1. Excluding CORF services, all other plans of care for inpatient rehabilitation services, including 60-day recertifications and the 60-day plan of care renewal orders shall be ordered by either a physician or a licensed practitioner of the healing arts, including nurse practitioners or physician assistants, within the scope of their licenses under state law.

2. If therapy services are recertified by a practitioner of the healing arts other than a physician, supervision shall be performed by a physician as required by §§ 54.1-2952 and 54.1-2957.01 of the Code of Virginia and 42 CFR 456.60.

3. For CORF providers, federal requirements do not permit nurse practitioners or physician assistants to order CORF intensive rehabilitation services. A physician shall be responsible for all documentation requirements, including admission certifications, recertifications, plans of care, progress notes, discharge orders, and any other required documentation (42 CFR 485.58(a)(i)).

4. Admission certification requirements shall apply to all individuals who are currently Medicaid eligible and to those individuals for whom a retroactive Medicaid eligibility determination is anticipated for coverage of an inpatient rehabilitative stay or for CORF services.

B. Within 72 hours of an individual's admission to an intensive rehabilitation or CORF program or upon notification to the provider of the individual's Medicaid eligibility or that the individual's Medicare benefits are exhausted, the provider shall notify DMAS or its contractor in writing, or as required, of the individual's admission and the medical need for service authorization.

1. This notification shall include a description of the admitting diagnosis, plan of care, and expected progress and a physician's written admission certification statement that the individual meets the rehabilitation admission criteria. DMAS or its contractor shall review such requests for service authorization and make a determination based on medical necessity criteria (see 12VAC30-50-225) as designated by DMAS and notify the provider of its decision. If services are approved, DMAS or its contractor shall establish and notify the provider of an approved length of stay. Additional lengths of stay shall be requested by the provider prior to the end date of the initial service authorization and must be approved by DMAS or its contractor for reimbursement. Admissions or lengths of stay not authorized by DMAS or its contractor shall not be approved for reimbursement.

2. For continued intensive rehabilitation or CORF services, the individual must demonstrate an ability to actively participate in goal-related therapeutic interventions developed by the interdisciplinary team.

C. Documentation of rehabilitation services required by DMAS for reimbursement for all disciplines of intensive rehabilitation or CORF services shall include all of the following:

1. A written physician admission certification statement.

2. A 60-day written recertification statement if a continued stay is determined to be medically necessary by the physician or other licensed practitioner of the healing arts within the scope of the practitioner's license. Admission certification or recertification statements for CORF services shall be signed and dated only by licensed physicians.

3. A physician's written initial plan of care shall include orders for medications, the frequency and duration of services, required rehabilitation therapies, diet, medically necessary treatments, and other required services such as psychology, social work, and therapeutic recreation services.

a. Except for CORF services, the plan of care may be written by either a physician or by a licensed practitioner of the healing arts within the scope of the physician or licensed practitioner's license.

b. For CORF services, the plan of care shall be written, signed, and dated only by a licensed physician.

4. An initial evaluation that describes the individual's clinical signs and symptoms necessitating admission to the rehabilitation program.

5. A description of any prior treatment and attempts to rehabilitate the individual.

6. An accurate and complete chronological description of the individual's clinical course and progress in treatment.

7. Documentation by each participating therapy discipline of a comprehensive plan of care developed by the licensed therapist.

8. Documentation that an interdisciplinary coordinated team plan of care specifically designed for the individual has been developed within seven days of admission.

9. Detailed documentation of all treatment rendered to the individual in accordance with each discipline's plan of care with specific attention to frequency, duration, modality, the individual's response to treatment, and the identification of the licensed therapist or therapy assistant and dated signature of who provided such treatment.

10. Documentation of all changes in the individual's condition or conditions.

11. Documentation describing a discharge plan that includes the anticipated improvements in functional levels, the timeframes necessary to meet the individual's goals, and the individual's discharge destination.

12. Discharge summary shall be completed by each licensed discipline offering services to include goal outcomes. The provider may complete the discharge summary before the individual's discharge or up to 30 days after the date of the individual's discharge.

D. Services not specifically documented in the individual's medical record as having been rendered will be deemed not to have been rendered and no reimbursement will be provided.

E. Intentional altering of medical record documentation shall be prohibited. If corrections in medical records are required, the agency's provider-specific rehabilitation guidance documents provide information on the procedures to be used.

F. The interdisciplinary rehabilitative team shall meet and prepare written documentation of the interdisciplinary team plan of care within seven days of admission. Interdisciplinary rehabilitative team conferences shall be held as needed but at least every two weeks to assess and document the individual's progress or problems impeding progress. The interdisciplinary rehabilitative team shall assess the validity of the rehabilitation goals established at the time of the initial evaluation, determine if rehabilitation criteria continue to be met, and revise the individual's goals as needed. A simple reading review by the various interdisciplinary rehabilitative team members of each other's notes shall not constitute an interdisciplinary rehabilitative team conference. Where practical, the individual or family or both shall participate in the interdisciplinary rehabilitative team conferences. A dated summary of the conferences documenting the names and professional titles of the interdisciplinary rehabilitative team members present shall be recorded in the clinical record and shall reflect the reassessments of the various interdisciplinary rehabilitative team members.

G. DMAS or its contractor shall perform quality management reviews to determine if services were appropriately provided as verified in the medical record documentation and to ensure that the services provided to Medicaid individuals were medically necessary and appropriate and that the individual continued to meet intensive rehabilitation criteria throughout the entire admission in the rehabilitation program.

H. When a provider has been determined during a quality management review as not complying with DMAS regulations, DMAS or its contractor may request corrective action plans from the provider. The corrective action plan shall address how the provider will become compliant with DMAS regulations and requirements in the areas for which the provider has been cited for noncompliance.

I. Properly documented medical reasons for furlough visits away from the inpatient rehabilitation provider may be included as part of an overall rehabilitation program. Unoccupied beds or days resulting from an overnight therapeutic furlough shall not be reimbursed by DMAS.

J. Discharge planning shall be an integral part of the overall plan of care that is developed at the time of admission to the program. The plan shall identify the anticipated improvements in functional abilities and the probable discharge destination. The individual, unless unable to do so, or the responsible party shall participate in the discharge planning. Notations concerning changes in the discharge plan shall be entered into the record at least every two weeks as a part of the required interdisciplinary team conference.

K. Each of the following intensive rehabilitation professionals have specific licensure and documentation requirements based on their disciplines that shall be adhered to. This subsection outlines these requirements for physician, nursing, physical therapy, occupational therapy, speech-language pathology, cognitive rehabilitation therapy, psychology, social work, therapeutic recreation, and prosthetic and orthotic services as follows:

1. Physician services are those services furnished to an individual that meet all of the following conditions:

a. The individual shall be under the care of a physician who is legally authorized to practice and is acting within the scope of the physician's license or a licensed practitioner of the healing arts as defined in 12VAC30-50-225. The physician shall be licensed by the Virginia Board of Medicine and have specialized training or experience in the field of physical medicine and rehabilitation;

b. Within 24 hours of an individual's admission, the physician shall provide a written initial admission certification consistent with 42 CFR 456.60. The physician shall provide a 60-day written recertification statement of the continued need for intensive physical rehabilitation services. DMAS shall not provide reimbursement for services that are not supported by physician written admission certifications and 60-day recertifications;

c. The physician plan of care shall be written to include orders for medications, rehabilitation therapies, treatments, diet, and other required services pursuant to 42 CFR 456.80. Failure to obtain the physician written renewal of the plan of care every 60 days shall result in nonpayment for services rendered; and

d. The service shall be specific and provide effective treatment for the individual's condition in accordance with accepted standards of medical practice.

2. Rehabilitative nursing requires education, training, and experience that provides special knowledge and clinical skills to diagnose nursing needs and treat individuals who have health problems characterized by alteration in either cognitive or functional ability, or both. Rehabilitative nursing services are those services furnished to an individual that meet all of the following conditions:

a. The services shall be directly and specifically related to a written plan of care developed by a registered nurse licensed by the Virginia Board of Nursing who is experienced in physical rehabilitation;

b. The services shall be of a level of complexity and sophistication or the individual's condition shall be of a nature that the services can only be performed by a registered nurse or licensed professional nurse, nursing assistant, or rehabilitation technician under the direct supervision of a registered nurse who is experienced in physical rehabilitation;

c. The services shall be provided with the expectation, based on the physician's assessment of the individual's rehabilitation potential, that the individual's condition will improve significantly, as determined by the physician and the interdisciplinary rehabilitative team, in a reasonable and generally predictable period of time as determined by the nurse or therapist, or these services shall be necessary to the establishment of a safe and effective maintenance therapy program required in connection with a specific diagnosis; and

d. The service shall be specific and provide effective treatment for the individual's condition. The amount, frequency, and duration of the service shall comport with accepted standards of medical practice.

3. Physical therapy services are those services furnished to an individual that meet all of the following conditions:

a. The services shall be directly and specifically related to a written plan of care developed by a physical therapist licensed by the Virginia Board of Physical Therapy;

b. The services shall be of a level of complexity and sophistication or the individual's condition shall be of a nature that the services can only be performed by a physical therapist licensed by the Virginia Board of Physical Therapy or a physical therapy assistant who is licensed by the Virginia Board of Physical Therapy and under the direct supervision of a qualified licensed physical therapist;

c. The services shall be provided with the expectation, based on the physician's assessment of the individual's rehabilitation potential, that the individual's condition will improve significantly, as determined by the physician and the interdisciplinary rehabilitative team, in a reasonable and generally predictable period of time, or these services shall be necessary to the establishment of a safe and effective maintenance therapy program required in connection with a specific diagnosis; and

d. The services shall be specific and provide effective treatment for the individual's condition. The amount, frequency, and duration of the services shall comport with accepted standards of medical practice.

4. Occupational therapy services are those services furnished to an individual that meet all of the following conditions:

a. The services shall be directly and specifically related to a written plan of care developed by an occupational therapist certified by the National Board for Certification in Occupational Therapy and licensed by the Virginia Board of Medicine;

b. The services shall be of a level of complexity and sophistication or the individual's condition shall be of a nature that the services can only be performed by an occupational therapist registered and certified by the National Board for Certification in Occupational Therapy or an occupational therapy assistant certified by the National Board for Certification in Occupational Therapy and licensed by the Virginia Board of Medicine under the direct supervision of a qualified occupational therapist as defined in subdivision 4 a of this subsection;

c. The services shall be provided with the expectation, based on the physician's assessment of the individual's rehabilitation potential, that the individual's condition will improve significantly, as determined by the physician and the interdisciplinary rehabilitative team, in a reasonable and generally predictable period of time, or these services shall be necessary to the establishment of a safe and effective maintenance therapy program required in connection with a specific diagnosis; and

d. The services shall be specific and provide effective treatment for the individual's condition. The amount, frequency, and duration of the services shall comport with accepted standards of medical practice.

5. Speech-language pathology therapy services are those services furnished to an individual that meet all of the following conditions:

a. The services shall be directly and specifically related to a written plan of care developed by a speech-language pathologist licensed by the Virginia Board of Audiology and Speech-Language Pathology or, if exempted from licensure by statute, meeting the requirements in 42 CFR 440.110(c);

b. The services shall be of a level of complexity and sophistication or the individual's condition shall be of a nature that the services can only be performed by either a speech-language pathologist licensed by the Virginia Board of Audiology and Speech-Language Pathology or by a speech-language assistant who has been certified by the board and who is under the direct supervision of the speech-language pathologist;

c. The services shall be provided with the expectation, based on the physician's assessment of the individual's rehabilitation potential, that the individual's condition will improve significantly, as determined by the physician and the interdisciplinary rehabilitative team, in a reasonable and generally predictable period of time, or these services shall be necessary to the establishment of a safe and effective maintenance therapy program required in connection with a specific diagnosis; and

d. The services shall be specific and provide effective treatment for the individual's condition. The amount, frequency, and duration of the services shall comport with accepted standards of medical practice.

6. Cognitive rehabilitation therapy services are those services furnished to an individual that meet all of the following conditions:

a. The services shall be directly and specifically related to a written plan of care developed by a clinical psychologist experienced in working with the neurologically impaired and licensed by the Virginia Board of Psychology;

b. The services, based on the findings of the neuropsychological evaluation, shall be of a level of complexity and sophistication or the individual's condition shall be of a nature, that the services can only be rendered after a neuropsychological evaluation administered by a licensed clinical psychologist or licensed physician experienced in the administration of neuropsychological assessments and in accordance with a plan of care;

c. Cognitive rehabilitation therapy services shall be provided by occupational therapists, speech-language pathologists, or psychologists, or all of these, who have experience in working with neurologically impaired individuals when such services have been ordered by a physician or other licensed practitioner;

d. The cognitive rehabilitation services shall be an integrated part of the individual's interdisciplinary plan of care and shall relate to information processing deficits that are a consequence of and related to a neurologic event;

e. The services include therapeutic activities to improve a variety of cognitive functions, for example, orientation, attention and concentration, reasoning, memory, recall, discrimination, and behavior; and

f. The services shall be provided with the expectation, based on the physician's or psychologist's assessment of the individual's rehabilitation potential, that the individual's condition will improve significantly in a reasonable and generally predictable period of time, or these services shall be necessary to the establishment of a safe and effective maintenance therapy program required in connection with a specific diagnosis.

7. Psychological services are those services furnished to an individual that meet all of the following conditions:

a. Services shall be ordered by a physician or other licensed practitioner;

b. The services shall be of a level of complexity and sophistication or the individual's condition shall be of a nature that the services as set out in the written plan of care can only be developed and performed by a qualified, licensed psychologist as required by the Virginia Board of Psychology or a licensed clinical social worker, a licensed professional counselor, or a licensed clinical nurse specialist-psychiatric;

c. The services shall be provided with the expectation, based on the assessment of the individual's rehabilitation potential, that the individual's condition will improve significantly in a reasonable and generally predictable period of time, or these services shall be necessary to the establishment of a safe and effective maintenance therapy program required in connection with a specific diagnosis; and

d. The services shall be specific and provide effective treatment for the individual's condition. The amount, frequency, and duration of the services shall comport with accepted standards of medical practice.

8. Social work services are those services furnished to an individual that meet all of the following conditions:

a. Services shall be ordered by a physician or other licensed practitioner;

b. The services shall be of a level of complexity and sophistication or the individual's condition shall be of a nature that the services as set out in the written plan of care can only be performed by a qualified social worker licensed by the Virginia Board of Social Work;

c. The services shall be provided with the expectation, based on the assessment of the individual's rehabilitation potential, that the condition of the individual will improve significantly in a reasonable and generally predictable period of time, or these services shall be necessary to the establishment of a safe and effective maintenance therapy program required in connection with a specific diagnosis; and

d. The services shall be specific and provide effective treatment for the individual's condition. The amount, frequency, and duration of the services shall comport with accepted standards of practice.

9. Therapeutic recreation services are those services furnished to an individual that meet all of the following conditions:

a. Services shall be ordered by a physician or other licensed practitioner;

b. The services shall be of a level of complexity and sophistication or the individual's condition shall be of a nature that the services as set out in the written plan of care are performed as an integrated part of a comprehensive rehabilitation plan of care by a recreation therapist certified with the National Council for Therapeutic Recreation at the professional level;

c. The services shall be provided with the expectation, based on the assessment of the individual's rehabilitation potential, that the individual's condition will improve significantly in a reasonable and generally predictable period of time, or these services shall be necessary to the establishment of a safe and effective maintenance therapy program required in connection with a specific diagnosis; and

d. The services shall be specific and provide effective treatment for the individual's condition. The amount, frequency, and duration of the services shall comport with accepted standards of practice.

10. Prosthetic and orthotic services.

a. Prosthetic services furnished to a patient include prosthetic devices that replace all or part of an external body member and services necessary to design the device, including measuring, fitting, and instructing the patient in its use.

b. Orthotic device services furnished to a patient include orthotic devices that support or align extremities to prevent or correct deformities, or to improve functioning, and services necessary to design the device, including measuring, fitting, and instructing the patient in its use.

c. Maxillofacial prosthetic and related dental services are those services that are specifically related to the improvement of oral function not to include routine oral and dental care.

d. The services shall be directly and specifically related to a written plan of care approved by a physician after consultation with a prosthetist, orthotist, or a licensed, board-eligible prosthodontist who shall be certified in maxillofacial prosthetics.

e. The services shall be provided with the expectation, based on the physician's or other licensed practitioner's assessment of the individual's rehabilitation potential, that the individual's condition will improve significantly in a reasonable and predictable period of time, or these services shall be necessary to the establishment of a safe and effective maintenance therapy program.

f. The services shall be specific and provide effective treatment for the individual's condition. The amount, frequency, and duration of the services shall comport with accepted standards of medical and dental practice.