SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Date of Adoption: August 18, 1999.
Purpose: The department originally intended to amend WAC 388-86-112 and 388-550-2300, but decided instead to put all WAC sections related to physical medicine and rehabilitation (PM&R) into WAC 388-550, Hospital services under a subheading "Acute Physical Medicine and Rehabilitation (Acute PM&R)." Combining these sections into one new subheading will make it easier for staff and other users to find the information they need. At the same time, the department is updating policy and payment methodology to reflect current practice. WAC 388-86-112 and 388-550-2300 are being repealed to eliminate duplication.
Citation of Existing Rules Affected by this Order: Repealing WAC 388-86-112 and 388-550-2300.
Statutory Authority for Adoption: RCW 74.08.090, 74.09.520.
Adopted under notice filed as WSR 99-14-038 on June 30, 1999.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 9, Amended 0, Repealed 2.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 9, Amended 0, Repealed 2.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 9, Amended 0, Repealed 2. Effective Date of Rule: Thirty-one days after filing.
August 18, 1999
Marie Myerchin-Redifer, Manager
Rules and Policies Assistance Unit2519.7ACUTE PHYSICAL MEDICINE AND REHABILITATION (ACUTE PM&R)
Acute physical medicine and rehabilitation (acute PM&R) is a twenty-four-hour inpatient comprehensive program of integrated medical and rehabilitative services during the acute phase of rehabilitation. It requires prior authorization by medical assistance administration (MAA).
(1) A multidisciplinary team coordinates individualized client acute PM&R services at an MAA-approved rehabilitation facility to achieve the following for the client:
(a) Improved health and welfare; and
(b) Maximum physical, social, psychological and vocational potential.
(2) MAA determines the length of stay based on individual cases and community standards of care for acute PM&R services.
(3) When MAA’s authorized acute period of rehabilitation ends, the provider transfers the client to a more appropriate level of care. Therapies may continue to help the client achieve maximum potential through other covered programs such as:
(a) Home health services (see subchapter II of WAC 388-551);
(b) Nursing facilities (see WAC 388-97); or
(c) Outpatient hospital services (see WAC 388-550).
The following definitions and abbreviations and those found in WAC 388-500-0005 and 388-550-1050 apply to this subchapter. Defined words and phrases are bolded in the text. In case of any conflicts, this section prevails for this subchapter.
"Accredit” (or "Accreditation”) is a term used by nationally recognized health organizations, such as CARF, to state a facility meets community standards of medical care.
"Acute” means an intense medical episode, not longer than two months.
"Acute physical medicine and rehabilitation (acute PM&R)” means a comprehensive inpatient rehabilitative program coordinated by a multidisciplinary team at an MAA-approved rehabilitation facility. The program provides twenty-four-hour specialized nursing services and an intense level of therapy for a diagnostic category for which the client shows significant potential functional improvement.
"CARF.” The official name for 'The Rehabilitation Accreditation Commission' of Tucson, Arizona. CARF is a national private agency that develops and maintains current, "field-driven” (community) standards through surveys and accreditations of rehabilitation facilities.
"Level A services” mean hospital-based acute rehabilitation services for medically stable clients with conditions that require complex nursing, medical and therapy needs as listed in WAC 388-550-2551(2). Such conditions include, but are not limited to, traumatic brain injuries, spinal cord injuries, and complicated bilateral amputations.
"Level B services” mean hospital- or nursing facility-based acute rehabilitation services for medically stable clients with new or exacerbated multiple sclerosis, mild head injuries, spinal cord injuries following the removal of the thoracic lumbar sacral orthosis (TLSO), and other medical conditions that require less complex nursing, medical and therapy needs as listed in WAC 388-550-2551(3).
(1) Clients in any of the following medical programs are eligible to receive acute PM&R Level A and Level B services:
(a) Children's health (V);
(b) Categorically needy program (CNP);
(c) Categorically needy program - qualified Medicare beneficiary (CNP-QMB);
(d) General assistance - determination pending for disability (GAX);
(e) Limited casualty program - medically needy program (LCP-MNP); and
(f) Medically needy program - qualified Medicare beneficiary (MNP-QMB).
(2) Clients in any of the following programs may receive only Level A hospital-based services:
(a) Medically indigent program (MIP) - emergency hospital-based and emergency transportation services. These clients may only receive services when:
(i) They are transferred directly from an acute hospital stay; and
(ii) The client's acute PM&R needs are directly related to the emergency medical need for the hospital stay;
(b) General assistance unemployable (GAU - No out-of-state care);
(c) CNP - emergency medical only;
(d) LCP-MNP - emergency medical only; and
(e) Alcoholism and drug addiction treatment and support act (ADATSA) (GAW).
(3) Clients in programs not listed in this section are not covered for acute PM&R services. See WAC 388-529-0100 and 388-529-0200 for scope of medical coverage.
(4) If a client is enrolled in an MAA Healthy Options managed care plan at the time of acute care admission, that plan pays for and coordinates acute PM&R services as appropriate.
(1) To provide acute PM&R services to medical assistance clients, a provider obtains MAA approval for the faculty. To obtain MAA approval for the facility, the provider must:
(a) Submit a letter of request;
(b) Include evidence that confirms the requirements listed in subsection (2) and (3) of this section are met; and
(c) Send the letter and documentation to:
Acute PM&R Program Manager
Division of Health Services Quality Support
Medical Assistance Administration
PO Box 45506
Olympia WA 98504-5506
(2) In order to be approved by MAA as a Level A provider, a hospital must be:
(a) Medicare certified;
(b) Accredited by the joint commission on accreditation of hospital organizations (JCAHO);
(c) Licensed by department of health (DOH) as an acute care hospital (as defined by DOH in WAC 246-310-010, Definitions);
(d) CARF accredited for comprehensive integrated inpatient rehabilitation programs; and
(e) Operating per the standards set by DOH, excluding the certified rehabilitation registered nurse (CRRN) requirement, in either:
(i) WAC 246-976-830, Level I trauma rehabilitation designation; or
(ii) WAC 246-976-840, Level II trauma rehabilitation designation.
(3) In order to be approved by and contracted with MAA as a Level B provider, a facility must be:
(a) Medicare certified;
(b) Licensed by DOH as an acute care hospital (as defined by DOH in WAC 246-310-010, Definitions) or nursing facility;
(c) CARF accredited for comprehensive integrated inpatient rehabilitation programs;
(d) Contracted under MAA's selective contracting program, if in a selective contracting area, unless exempted from the requirement by MAA; and
(e) Operating per the standards set by DOH in WAC 246-976-840, Level II trauma rehabilitation designation, excluding the CRRN requirement.
(4) To obtain conditional contract approval, the applying facility must meet the criteria in subsections (1), (2) and/or (3) of this section, excluding the CARF accreditation requirement listed in section (2)(c) and (3)(c) of this section. The facility must:
(a) Actively operate under CARF standards; and
(b) Have begun the process of obtaining full CARF accreditation.
(5) MAA will revoke a conditional contract approval if the facility does not obtain full CARF accreditation within twelve months of the conditional approval date by MAA.
(1) To ensure quality of care, MAA may conduct an on-site review of any MAA-approved acute PM&R facility. See WAC 388-501-0130, Administrative controls, for additional information on audits conducted by department staff.
(2) In addition, MAA-approved Level B nursing facilities are subject to regular on-site surveys conducted by the department’s aging and adult services administration (AASA).
(1) At the time of authorization, MAA determines the most appropriate client placement on a case-by-case basis:
(a) In the level of care (level A or B);
(b) In the least restrictive environment; and
(c) At the lowest cost to MAA.
(2) Examples of client conditions suitable for Level A placement include:
(a) Cognitive and/or motor deficits;
(b) Brain damage from infectious brain diseases;
(c) Quadriplegia or paraplegia;
(d) Skin flap grafts for decubitus ulcers that need close observation by a surgeon, when the client is ready to mobilize or be upright in a chair;
(e) Extensive burns requiring complex medical care and debridement;
(f) Bilateral limb loss requiring close observation when the client has complex medical needs;
(g) Multiple trauma with complicated orthopedic conditions and neurological deficits; or
(h) Stroke with resulting hemiplegia or severe cognitive deficits, including speech and swallowing deficits requiring close observation with radiological examination.
(3) Examples of client conditions suitable for Level B placement include:
(a) New strokes when medically stable;
(b) Newly diagnosed or recently exacerbated multiple sclerosis with new loss of function;
(c) New mild head injury when medically stable; or
(d) Spinal cord injuries following the removal of a thoracic lumbar sacral orthosis after the client's first phase of acute rehabilitation.
(1) The patient care coordinator or the attending physician must call the MAA clinical consultation team before admitting an MAA client.
(2) The patient care coordinator or attending physician must provide to MAA objective information showing that:
(a) Acute PM&R treatment would effectively enable the client to obtain a greater degree of self-care, independence, or both;
(b) The client's medical condition requires that intensive twenty-four-hour inpatient comprehensive acute PM&R services be provided in an MAA-approved acute PM&R facility; and
(c) The client suffers from severe disabilities including, but not limited to, motor and/or cognitive deficits.
(3) Clients must be medically stable and show evidence that they are physically and cognitively ready to participate in the rehabilitation program. They must be willing and capable to participate at least three hours per day, seven days per week, in acute PM&R activities.
(4) For extension of authorization, the facility's rehabilitation staff must provide adequate medical justification, including significant observable improvement in the client’s condition, to MAA prior to the expiration of the initial approved stay. If MAA denies the extension, the client must be transferred to an appropriate lower level of care as defined in WAC 388-550-2501(3).
(5) MAA may authorize administrative day reimbursement for clients who do not meet requirements described in this section, or who stay in the facility longer than the community standard's length of stay. The administrative day rate is the statewide Medicaid average daily nursing facility rate as determined by the department.
(1) A Level A rehabilitation facility is paid by MAA according to:
(a) The individual hospital's current ratio of costs-to-charges as described in WAC 388-550-4500, Payment method--RCC; and
(b) MAA's fee schedule as described in WAC 388-550-6000, Payment--Outpatient hospital services.
(2) Level A inpatient acute PM&R room and board includes, but is not limited to:
(a) Facility use;
(b) Medical social services;
(c) Bed and standard room furnishings; and
(d) Nursing services.
(1) MAA pays a contracted Level B facility for acute PM&R services at a fixed daily rate established by MAA.
(2) MAA may make cost inflation adjustments to the maximum daily rate by using the same inflation factor and schedule that MAA uses to pay independent hospitals. This diagnosis-related group (DRG) reimbursement method is described in WAC 388-550-3450(5)(a).
(3) MAA pays the rate in effect at the time of a client's admission to a facility.
(4) Equipment and services identified in the Level B contract as excluded from the fixed daily rate are paid to the MAA provider that directly provides the equipment or services.
The following section of the Washington Administrative Code is repealed:
The following section of the Washington Administrative Code is repealed:
|WAC 388-86-112||Physical medicine rehabilitation evaluation and treatment.|