CMS Pub. 100-02, ch. 1, § 110.2.2

A primary distinction between the IRF environment and other rehabilitation settings is

the intensity of rehabilitation therapy services provided in an IRF. For this reason, the

information in the patient’s IRF medical record (especially the required documentation

described in section 110.1) must document a reasonable expectation that at the time of

admission to the IRF the patient generally required the intensive rehabilitation therapy

services that are uniquely provided in IRFs. Although the intensity of rehabilitation

services can be reflected in various ways, the generally-accepted standard by which the

intensity of these services is typically demonstrated in IRFs is by the provision of

intensive therapies at least 3 hours per day at least 5 days per week. However, this is not

the only way that such intensity of services can be demonstrated (that is, CMS does not

intend for this measure to be used as a “rule of thumb” for determining whether a

particular IRF claim is reasonable and necessary).

The intensity of therapy services provided in IRFs could also be demonstrated by the

provision of 15 hours of therapy per week (that is, in a 7-consecutive calendar day period

starting from the date of admission). For example, if a hypothetical IRF patient was

admitted to an IRF for a hip fracture, but was also undergoing chemotherapy for an

unrelated issue, the patient might not be able to tolerate therapy on a predictable basis due

to the chemotherapy. Thus, this hypothetical patient might be more effectively served by

the provision of 4 hours of therapy 3 days per week and 1 ½ hours of therapy on 2 (or

more) other days per week in order to accommodate his or her chemotherapy schedule.

Thus, IRFs may also demonstrate a patient’s need for intensive rehabilitation therapy

services by showing that the patient required and could reasonably be expected to benefit

from at least 15 hours of therapy per week (defined as a 7-consecutve calendar day

period starting from the date of admission), as long as the reasons for the patient’s need

for this program of intensive rehabilitation are well-documented in the patient’s IRF

medical record and the overall amount of therapy can reasonably be expected to benefit

the patient. Many IRF patients will medically benefit from more than 3 hours of therapy

per day or more than 15 hours of therapy per week, when all types of therapy are

considered. However, the intensity of therapy provided must be reasonable and

necessary under section 1862(a)(1)(A) of the Act and must never exceed the patient’s

level of need or tolerance, or compromise the patient’s safety. See below for a brief

exceptions policy for temporary and unexpected events.

In accordance with 42 CFR § 412.622(a)(3)(ii), the required therapy treatments must

begin within 36 hours from midnight of the day of admission to the IRF. Therapy

evaluations are generally considered to constitute the beginning of the required therapy

services. As such, they should generally be included in the total daily/weekly provision

of therapies used to demonstrate the intensity of therapy services provided in an IRF.

The standard of care for IRF patients is individualized (i.e., one-on-one) therapy. Group

therapies serve as an adjunct to individual therapies. In those instances in which group

therapy better meets the patient’s needs on a limited basis, the situation/rationale that

justifies group therapy should be specified in the patient’s medical record at the IRF.

Brief Exceptions Policy - While patients requiring an IRF stay are expected to need and

receive an intensive rehabilitation therapy program, as described above, this may not be

true for a limited number of days during a patient’s IRF stay because patients’ needs vary

over time. For example, if an unexpected clinical event occurs during the course of a

patient’s IRF stay that limits the patient’s ability to participate in the intensive therapy

program for a brief period not to exceed 3 consecutive days (e.g., extensive diagnostic

tests off premises, prolonged intravenous infusion of chemotherapy or blood products,

bed rest due to signs of deep vein thrombosis, exhaustion due to recent ambulance

transportation, surgical procedure, etc.), the specific reasons for the break in the provision

of therapy services should generally be documented in the patient’s IRF medical record.

If these reasons are appropriately documented in the patient’s IRF medical record, such a

break in service (of limited duration) should generally not affect the determination of the

medical necessity of the IRF admission. Thus, A/B MACs (A) may consider approving

brief exceptions to the intensity of therapy requirement in these particular cases if they

determine that the initial expectation of the patient’s active participation in intensive

therapy during the IRF stay was based on a diligent preadmission screening, post-admission physician evaluation, and overall plan of care that were based on reasonable

conclusions.