In the post-acute care venue, there is much debate on exactly what is the correct level of care required to get the patient back to their home setting. “Medical necessity is a United States legal doctrine, related to activities which may be justified as reasonable, necessary, and/or appropriate, based on evidenced-based clinical standards of care,” per Wikipedia definition. Medicare’s definition is the same; when major regulatory changes in IRF were published in 2010, Medicare redefined medical necessity as reasonable and necessary, so I know this to be true.
I also know that prior to those changes, there were many educational offerings to expose and redefine exactly how one should prove appropriateness for the rehabilitation admission. It was defined that if due-diligence in the pre-admission screen, detailing each of the required criteria were met and the physician concurred with the admission and saw the same needs within 24 hours after admission through the post admission evaluation, that THEN medical necessity is met and that a retrospective decision stating that they COULD have been treated at a SNF level of care would not be argued.
The defense provided in the pre-admission screen is clearly the largest evidence. It must define the exact purposes for treatment at an IRF/IRU level of care, even if that treatment mitigates potential risks that require greater surveillance than what is commonly available at a lesser level of care.
The discussion and audio transcript of that November 12th, 2009 call is at the CMS website. Below, are very important paragraphs pulled from the discussions that took place that day.
1.)
2.) 
As Medical Necessity has been re-introduced into the RAC discussion for review, with at least two districts already reviewing REASONABLE and NECESSARY as the criteria for the admission decision, the items discussed above may HUGELY lead toward debate. Did you spend the time to justify the criteria required for admission? Does that documentation warrant a level of care that expects greater vigilance in medical and nursing management to maintain a safe effective intensive level of rehabilitation? Was the process a truly descriptive one and not just a page or two of check boxes, which CMS has stated will NOT meet the expectations for the pre-admission screen.
The first clarification document published by CMS states:
“Clarification regarding “check boxes” on the pre-admission screening form.
On the November 12 provider training conference call, CMS indicated that the pre-admission screening documentation must not be presented entirely in the form of “check boxes,” but instead must contain some narrative information. Thus, for example, the documentation cannot merely contain “yes/no” check boxes for whether the patient has a risk for clinical complications. It must describe in detail what conditions/comorbidities the patient has and why these indicate a specific risk for clinical complications that require physician monitoring in order for the patient to actively participate in an intensive rehabilitation therapy program. This detailed description, by the very nature of it, would need to be in narrative form. However, the rehabilitation physician is not required to write this narrative if the narrative is written by the licensed or certified clinician/clinicians conducting the preadmission screening.”
It takes time to complete a thorough pre-admission assessment, but an hour or two that can fully uphold reasonable and necessary loopholes gives some assurance that after you have expended your resources in full, that specific reimbursement will not be retracted.
