Clinical UM Guideline



Subject: Inpatient Subacute Care
Guideline #:  CG-MED-29 Current Effective Date:    06/28/2017
Status: Reviewed Last Review Date:    05/04/2017

Description

This document addresses services provided in the subacute care setting.

The American Health Care Association (AHCA), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the Association of Hospital-Based Skilled Nursing Facilities have defined subacute care as:

Comprehensive inpatient care designed for someone who has an acute illness, injury, or exacerbation of a disease process.  It is goal-oriented treatment rendered immediately after, or instead of, acute hospitalization to treat one or more specific active complex medical conditions or to administer one or more technically complex treatments, in the context of a person's underlying long-term conditions and overall situation (American Health Care Association, 1996).

Subacute care is a distinct form of health care service that focuses on providing the skilled medical care needed to transition individuals from the acute care setting (UB Foundation Activities, Inc., 2001-2004).  Subacute care may be rendered in a freestanding facility or in a designated unit of a general or rehabilitation hospital.  Subacute care requires a treatment plan with specific goals attained through the provision of skilled nursing, rehabilitative and medical services by licensed professionals.  Specifically, subacute care should not be confused with custodial care which is designed to assist medically stable individuals with their activities of daily living, (ambulating, exercising, bathing and dressing).  Custodial care does not require the skills of a trained professional or supervision of a physician.  For additional information regarding custodial care, please refer to CG-MED-19 Custodial Care.

Inpatient subacute level of care may be used specifically for rehabilitation purposes for any number of conditions.  In general, the rehabilitation needs of these individuals require less than three modalities, most often physical therapy.  The overall functional deficit for these individuals is such that complex adaptive equipment and modifications are not needed. 

Please see the following documents for additional information regarding skilled and non-skilled services in other settings:

Clinical Indications

Medically Necessary:

Inpatient subacute care is considered medically necessary for individuals who meet the following criteria (A and B):  Individuals requiring inpatient rehabilitative services should meet the following criteria in A, B and C below:

  1. Individuals must meet ALL of the following (1-4):
    1. Do not require acute inpatient hospital or acute rehabilitative care but still require highly skilled nursing and access to technologically advanced therapies; and
    2. Have medical needs greater than that which could be met in a home setting; and
    3. Though stable, require diagnostics or invasive procedures or rehabilitation, but not intensive procedures requiring an acute level of care; and
    4. Have a determined course of treatment.
  2. Individuals must meet ALL of the following (1-4):
    The severity of the individual's condition requires:
    1. Active physician direction with frequent on-site visits; and
    2. Professional nursing care; and
    3. Significant ancillary and rehabilitation services; and
    4. An outcomes-focused interdisciplinary approach utilizing a professional team.
  3. Individuals requiring rehabilitative services in the subacute setting should meet the criteria above (A-B) in addition to the following (1-6):
    1. Individual requires one or two rehabilitative services daily; and
    2. Individual's mental and physical condition prior to the illness or injury indicates there is significant potential for improvement (See Note below); and
    3. Individual should be medically stable enough to no longer require the services of a medical/surgical inpatient setting and to actively participate in an moderately intensive rehabilitation program; and
    4. Individual is capable of actively participating in a rehabilitation program, as evidenced by a mental status demonstrating responsiveness to verbal or visual stimuli and ability to follow simple commands.  For additional information regarding cognitive status, please refer to the Rancho Los Amigos Scale of Cognitive Functioning (Appendix B); and
    5. Individual is expected to show measurable functional improvement within a maximum of seven (7) to fourteen (14) days (depending on underlying diagnosis/medical condition) of admission to the inpatient rehabilitation program; and
    6. Therapy includes a discharge plan.
      Note: It is not necessary that there is an expectation of complete independence in the activities of daily living; there should be a reasonable expectation of improvement that is of practical value to the individual, measured against his/her condition at the start of the rehabilitation program. Additionally, the individual must have no lasting or major treatment impediment, such as severe dementia, that prevents progress.

Conditions that may be appropriate for inpatient subacute care include but are not limited to:

  1. Cardiac Recovery;
  2. Oncology Recovery – receiving chemotherapy and radiation;
  3. Pulmonary conditions;
  4. Orthopedic Rehabilitation;
  5. Neurological disorders/CVA;
  6. Complex wound management;
  7. Intravenous Therapy (more than two times per day).

Not Medically Necessary:

The individual's inpatient stay becomes not medically necessary when ANY ONE of the following occurs:

  1. The individual's condition has changed such that skilled medical or rehabilitative care is no longer needed; or
  2. The individual has met the goals established at or modified following admission and a medically appropriate alternative discharge setting exists; or
  3. The individual has failed to make progress towards treatment goals during a medically reasonable (typically one [1] week) period; or
  4. There is a lack of a consistent individualized therapy program; or
  5. The individual is unwilling to be actively involved in the care as demonstrated by a refusal to participate in the recommended treatment plan; or
  6. The individual's activities or behavior prevents attainment of a successful outcome; or
  7. The individual's primary need becomes psychiatric in nature in which case care should be transitioned to the appropriate setting; or
  8. The individual has only one (1) skilled need and that need can be met in a less intensive medical care setting; or
  9. When the discharge to a lesser level of care is documented as appropriate and safe, but there were delays in formulating the discharge plan; or
  10. It has been determined that the established goals are not realistic or appropriate; or
  11. Care has become custodial.
Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Revenue Code  
0190 Sub-acute care, general classification
0191 Sub-acute care, level I
0192 Sub-acute care, level II
0193 Sub-acute care, level III
0194 Sub-acute care, level IV
0199 Other sub-acute care
   
ICD-10 Diagnosis  
  Numerous diagnosis codes may be applicable; see clinical indications
   
Discussion/General Information

Subacute care requires the coordinated services of an interdisciplinary team including physicians, nurses, and other relevant professional disciplines sufficiently trained and knowledgeable to assess and manage these specific conditions and perform the necessary procedures.  According to AHCA, the JCAHO, and the Association of Hospital-Based Skilled Nursing Facilities:

Subacute care is generally more intensive than traditional nursing facility care and less than acute care.  It requires frequent (daily to weekly) recurrent individual assessment and review of the clinical course and treatment plan for a limited (several days to several months) time period, until the condition is stabilized or a predetermined treatment course is completed" (American Health Care Association, 1996).  

The goal of inpatient subacute care is to match an individual's needs with the medically appropriate level of health care services.

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Health Care Association. Nursing facility sub-acute care: the quality and cost-effective alternative to hospital care, 1996.
  2. UB Foundation Activities, Inc. The inpatient rehabilitation facility – patient assessment instrument (IRF-PAI) training manual. 2002 - 2016. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/IRFPAI.html . Accessed February 24, 2017.
History

Status

Date

Action

Reviewed 05/04/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Updated formatting in the Clinical Indications section. Updated References section.
Reviewed 05/05/2016 MPTAC review. Updated the References section. Removed ICD-9 codes from Coding section.
Reviewed 05/07/2015 MPTAC review. Updated the References section.
Reviewed 05/15/2014 MPTAC review. Updated the References section.
Reviewed 05/09/2013 MPTAC review. Updated the References section.
Reviewed 05/10/2012 MPTAC review. Updated review date, References and History sections.   
Reviewed 05/19/2011 MPTAC review. Updated review date, References and History sections.   
Reviewed 05/13/2010 MPTAC review. Updated review date, References and History sections. 
Reviewed 05/21/2009 MPTAC review.  Updated review date, References and History sections. Deleted Place of Service/Goal Length of Stay, Case Management and Discharge Plan sections.
Reviewed 05/15/2008 MPTAC review. Updated References and review date.
Reviewed 05/17/2007 MPTAC review. Updated References and review date.
Revised 06/08/2006 MPTAC revision. Corrected language in Clinical Indications section to indicate that "Conditions that may be appropriate for inpatient subacute care include but are not limited to:... pulmonary conditions
New 03/23/2006 MPTAC initial guideline development. 
Pre-Merger Organizations Last Review Date Document Number Title
Anthem, Inc.   None  
Anthem Connecticut 1st quarter, 2005 None Subacute Care Benefit Detail CT
WellPoint Health Networks, Inc.   None