Clinical UM Guideline


Subject:Inpatient Subacute Care
Guideline #:  CG-MED-29Current Effective Date:  07/15/2014
Status:ReviewedLast Review Date:  05/15/2014

Description

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. 

This document addresses services provided in the subacute care setting. 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:

Not Medically Necessary: 

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

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 
0190Sub-acute care, general classification
0191Sub-acute care, level I
0192Sub-acute care, level II
0193Sub-acute care, level III
0194Sub-acute care, level IV
0199Other sub-acute care
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 Numerous diagnosis codes may be applicable; see clinical indications
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 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 - 2014. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/IRFPAI.html. Accessed April 11, 2014.
History

Status

Date

Action

Reviewed05/15/2014Medical Policy & Technology Assessment Committee (MPTAC) review. Updated the References section.
Reviewed05/09/2013MPTAC review. Updated the References section.
Reviewed05/10/2012MPTAC review. Updated review date, References and History sections.   
Reviewed05/19/2011MPTAC review. Updated review date, References and History sections.   
Reviewed05/13/2010MPTAC review. Updated review date, references and history sections. 
Reviewed05/21/2009MPTAC review.  Updated review date, references and history sections. Deleted place of service /goal length of stay, case management and discharge plan sections.
Reviewed05/15/2008MPTAC review. Updated references and review date.
Reviewed05/17/2007MPTAC review.  Updated references and review date.
Revised06/08/2006MPTAC 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
New03/23/2006MPTAC initial guideline development.
Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

 

 

None 
Anthem Connecticut

1st quarter, 2005

NoneSubacute Care Benefit Detail CT
WellPoint Health Networks, Inc.

 

None