Currentpriority healthPolicy N/A

Inpatient Hospital Services Covered Under Part A

Defines Medicare Part A coverage rules for inpatient hospital and CAH services including definition of inpatient services, excluded services, covered components (bed/board, nursing, drugs, supplies, etc.), rules for private/ward accommodations, and requirements for inpatient admission orders and physician certification for payment.

Policy Summary

Payerpriority health

PolicyInpatient Hospital Services Covered Under Part A

Policy CodePolicy N/A

Change TypeRevised (Transmittal Rev. 234) and clarifications for RNHCI/IRF payment

Effective DateJan 1, 2016

Next Review Date

Key ActionObtain and document signed physician certification for cases >=20 inpatient days, outlier cases, and CAH cases per regulatory timing and ensure inpatient admission orders are documented and authenticated prior to discharge.

SourceLink

POLICY UPDATE CHANGES

Chapter 1 Rev. 234 issued 03-10-17 Effective 01-01-16 (sections on Covered Inpatient Hospital Services and Admission/Certification updated).

Medicare home benefit extended to include RNHCI items and services provided in the beneficiary's home following MMA 2003.

Payment methodology for RNHCI nursing visits defined as 80% of HHA LUPA rate adjusted by MSA wage index, using labor/non-labor fixed allowances.

>=20 daysLong-stay certification threshold

96CAH certification expectation (hours)

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Coverage Summary

This policy chapter defines Medicare Part A coverage for inpatient hospital and critical access hospital (CAH) services, specifying what constitutes inpatient hospital services (e.g., bed and board, nursing and related services, use of facilities, drugs/biologics, supplies and certain diagnostic/therapeutic services, select intern/resident services, and transportation) and the conditions under which Medicare will pay for those services. Effective date for the revisions cited in this chapter is 2016-01-01, and the chapter status is CURRENT.

The chapter incorporates statutory and regulatory definitions and conditions for Part A coverage, references applicable physician certification and admission order requirements (including CMS transmittal revisions clarifying admission order and medical review requirements), and directs providers on documentation and administrative requirements that determine inpatient status and payment under Medicare Part A.

Key thresholds and high-level bullets

Long-stay certification threshold>= 20 inpatient days

CAH certification expectationPatient may reasonably be expected to be discharged or transferred within 96 hours

Two-midnight benchmarkExpectation: stay will span at least two midnights (benchmark only)

IRF preadmission screening timingWithin 48 hours immediately preceding IRF admission (or update within 48 hours)

Intensive therapy requirements>= 3 hours/day x >=5 days/week OR >= 15 hours within 7 consecutive days

Physician visit frequency>= 3 face-to-face visits per week by rehabilitation physician (one may be NPP beginning week 2)

RNHCI DME countDefined list of nonmedical DME (e.g., canes, walkers, commodes, K0001, E0250 series — 26 HCPCS codes listed)

RNHCI nursing visit payment percentage80% of the HHA home health aide LUPA base rate (adjusted by MSA wage index)

Medical-Necessity Criteria and Coverage Conditions

Bed and Board / Accommodations - Private Room Rules

Medicare payment and conditions related to private rooms, isolation, deluxe rooms, and all-private facilities:

General payment and differential: Program pays same amount for routine accommodations whether private (medically necessary or not), semiprivate, or ward (if ward consistent with program purposes). Provider may charge a private room differential only if the private room is not medically necessary and the patient requested it after being informed of the charge; differential may not exceed difference between customary private charge and most prevalent semiprivate rate. If billed as covered on CMS-1450, A/B MAC will deem private room medically necessary; if shown as noncovered differential, A/B MAC assumes not medically necessary.

When private room is medically necessary

Isolation need: Need for isolation to avoid jeopardizing patient's or others' health or recovery (examples: communicable disease, MI, CVA, psychotic episode).

Religious Nonmedical Health Care Institution (RNHCI) — Election, Home Benefit, DME, and Nursing Visits

Excepted vs Nonexcepted Medical Treatment; Revocation of RNHCI Election

Definitions and examples to determine whether care revokes RNHCI election and revocation mechanics:

Excepted vs nonexcepted definitions: Excepted medical care: care that does not revoke RNHCI election (e.g., required vaccinations; emergency care at scene or during transport; unconscious beneficiaries receiving emergency care). Nonexcepted medical care: medical care other than excepted care; receiving nonexcepted care for which Medicare payment is sought revokes the RNHCI election.

Examples of nonexcepted care: Examples include medical diagnosis/treatment for persistent headaches/chest pains; transfer to community hospital for radiological studies and fracture reduction; intractable back pain receiving medical/surgical/chiropractic services; requesting physician to prescribe wheelchair or other DME.

Revocation mechanics: Revocation can be achieved by submitting a written statement to the intermediary indicating desire to cancel election or automatically by seeking nonexcepted medical care for which Medicare payment is sought.

Regulatory and Billing Codes

Covered CPT Codes - Termination of Pregnancy (require G7 modifier)CPTCovered

59840	Induced termination of pregnancy; curettage and evacuation
59841	Induced termination of pregnancy, completed surgically; dilation and evacuation
59850	Termination of pregnancy, by hysterotomy
59852	Termination of pregnancy, by hysterectomy
59855	Termination of pregnancy, by amniocentesis

Covered HCPCS Codes - RNHCI home benefit nonmedical DMEHCPCSCovered

E0100	Crutches, underarm, wood, pair
E0110	Crutch substitutes, lower-leg platform, each
E0165	Walker, folding, adjustable
E0260	Hospital bed, semi-electric
E0300	Commodes, adjustable or fixed, any type
K0001	Standard wheelchair, basic
K0003	Lightweight wheelchair

Provider Actions and Billing Rules

Documentation-focused Callouts

Billing / Denial / Prior-Auth Callouts

Background and Definitions

This chapter is part of the CMS Medicare Benefit Policy Manual (Chapter 1) and provides background and context for manual instructions on inpatient hospital services, including the statutory and regulatory purpose: to define inpatient hospital services under Title XVIII and related CFR provisions and to identify conditions under which Medicare Part A will cover and pay for inpatient care.

It establishes administrative requirements tied to payment, including the central role of the inpatient admission order (the ordering practitioner’s formal instruction to admit an individual for inpatient services) and the physician certification requirements that apply for certain cases (for example, long-stay cases of >=20 inpatient days, outlier cases, and CAH cases). These administrative elements are prerequisites to Part A billing and are used by Medicare contractors to determine coverage and payment.

Term	Definition
Inpatient hospital services
Services furnished to an inpatient of a participating hospital or CAH including bed and board, nursing, use of facilities, drugs, supplies, diagnostic/therapeutic services, certain intern/resident services, and transportation.
Private room differential
The charge a provider may impose when a private room is not medically necessary and requested by the beneficiary; limited to the difference between the customary private charge and the most prevalent semiprivate rate.
Ordering practitioner
A physician or other practitioner licensed by the state to admit inpatients, granted hospital privileges to admit inpatients, and knowledgeable about the patient's hospital course and condition; responsible for the inpatient admission order.
Rehabilitation physician
A licensed physician determined by the IRF to have specialized training and experience in inpatient rehabilitation responsible for developing the overall plan of care and conducting face-to-face visits.
Private-duty nurse/attendant
Registered, licensed practical nurses, or other trained attendants whose services are rendered to and restricted to a particular patient by arrangement between patient and attendant; services are not covered under Part A.
Intensive rehabilitation therapy program
Generally at least 3 hours per day at least 5 days per week, or alternatively at least 15 hours within a 7-consecutive calendar day period starting at admission.
DS patient identifier
Suffix 'DS' appended to freestanding IRF patient identifiers to indicate patients admitted solely to alleviate acute care hospital bed capacity during a PHE surge and exempt from certain IRF requirement reviews.
Excepted medical treatment (RNHCI)
Medical care received involuntarily or required by law or emergency care where beneficiary cannot consent; does not revoke RNHCI election.
Nonexcepted medical treatment
Medical care other than excepted care; receipt of nonexcepted care for which Medicare payment is sought revokes RNHCI election.
Visit (RNHCI nurse)
An episode in which an RNHCI nurse renders physical care to an RNHCI beneficiary in the home setting; a single billable unit.

Medicare Determinations and Transmittals

Name	Number	Type	Effective Date
CMS IRF PHE flexibilities (interim final rule) - removed post-admission physician evaluation
CMS-1744-IFC
Interim final rule (IFC)
2020-03-30
CMS IRF PHE flexibilities - waiver of 3-hour rule and related modifications
CMS-5531-IFC
Interim final rule (IFC)
2020-04-30
IRF coverage requirements (regulatory citations)
42 CFR § 412.622(a)(3),(4),(5)
Regulation
2011-11-08

Revision History

2016-01-01revised

Chapter 1 Rev. 234 issued 03-10-17 (effective 01-01-16) — updated sections on Covered Inpatient Hospital Services and Admission/Certification, clarifying that an order to admit as an inpatient is required for Part A coverage and specifying physician certification requirements for long-stay (>=20 days), outlier, and CAH cases.

2005-01-01 to 2006-12-30revised

Medicare RNHCI home benefit coverage period established for specified nonmedical home items and services (coverage for dates of service Jan 1, 2005 through Dec 30, 2006) with a total annual payment cap of $700,000 for each calendar year during this period.

2005-04-04 (implementation of transmittal R25BP)

Policy Summary

Payerpriority health

PolicyInpatient Hospital Services Covered Under Part A

Policy CodePolicy N/A

Change TypeRevised (Transmittal Rev. 234) and clarifications for RNHCI/IRF payment

Effective DateJan 1, 2016

Next Review Date

SourceLink

On This Page

Wards

Rules governing assignment to ward accommodations:

Ward assignment rules: Patients should not be assigned to wards except at patient's request or for a reason consistent with program purposes. Assignment consistent with program purposes includes when all semiprivate accommodations are occupied or facility has no semiprivate accommodations; patient must be moved if semiprivate becomes available. Assignment to ward cannot be based on discriminatory reasons (social/economic status, race, religion, Medicare entitlement) or merely for institutional convenience/financial advantage.

Physician Certification and Inpatient Admission Order Requirements

Requirements for physician certification and inpatient orders as conditions of payment for Part A:

Physician certification requirements: Physician certification is required for long-stay cases (>=20 inpatient days), outlier cases (except inpatient psych facilities), and CAH cases. Certification must include reason for inpatient services (continued hospitalization or special/unusual services for outlier), estimated/actual time beneficiary requires/required in hospital, plans for posthospital care (if appropriate), and for CAH services certification that beneficiary may reasonably be expected to be discharged or transferred within 96 hours. Certification must be completed, signed, and documented within regulatory timing (no later than 1 day before CAH claim submission; for other long-stay cases no later than 20 days into inpatient portion). Certifying physician must be MD/DO, dentist (in specified circumstances), or podiatrist (if authorized by state law); may be signed by physician responsible for case or another physician with knowledge and authority. No specific format required; separate signed statement for each certification/recertification (except delayed certs as allowed).long-stay >=20 days; CAH 96 hours

Inpatient order requirements: Inpatient order must specify admission for inpatient services and be furnished by an ordering practitioner licensed by state to admit inpatients, granted privileges by hospital to admit inpatients, and knowledgeable about patient's hospital course/plan of care/current condition. Ordering practitioner must authenticate (sign) the order; initial or verbal orders must be countersigned by the ordering practitioner (or authenticated) prior to discharge. Residents and authorized non-physician practitioners may enter orders as proxies if allowed by state law and hospital bylaws, but ordering practitioner must authenticate prior to discharge. Verbal orders acceptable if documented at time received and authenticated promptly prior to discharge. Inpatient admission order cannot be a standing order; only ordering practitioner (or authorized proxy) can make and take responsibility for admission decision. Inpatient status begins at time of formal admission pursuant to the order that is authenticated timely; if responsible practitioner does not agree admission appropriate, they should not authenticate and beneficiary is not inpatient (may be billed as outpatient Part B).

Inpatient Admission Order and Certification - General

Covered when ALL of the following are met:

Required elements for inpatient admission order: An inpatient admission order is present in the medical record written by an authorized ordering practitioner (admitting physician/attending, physician on call, primary/covering hospitalist, primary care practitioner or on-call, surgeon responsible for major surgery or on-call, emergency/clinic practitioners at point of admission, or other practitioners qualified to admit and actively treating the beneficiary).

Utilization review committee physicians not considered sufficiently knowledgeable to order unless acting in direct patient care role

Order timing: The order must be furnished at or before the time of inpatient admission (can be written in advance but admission commences when inpatient services are provided). Retroactive orders are not permitted; if admitted prior to an order and no documented verbal order, inpatient stay does not commence until order is documented.

Authentication and verbal orders: Verbal orders are acceptable if appropriately documented by the receiver and authenticated (countersigned) promptly by the ordering practitioner prior to discharge. If practitioner responsible for authenticating does not agree admission appropriate, they must not authenticate and beneficiary is not considered inpatient.

Specificity of order language: Admission order must specify intent to admit 'to inpatient', 'as an inpatient', 'for inpatient services', or similar language indicating inpatient care. Ambiguous language (e.g., 'admit to ER', 'to Observation') defines a non-inpatient service and does not meet inpatient admission requirements.

Constructive satisfaction alternative: In extremely rare circumstances a missing or defective admission order may be constructively satisfied by medical record documentation clearly demonstrating intent to admit as inpatient, at contractor discretion; this alternative is narrow and should be extremely rare.

Drugs and Biologicals Furnished to Inpatients

Drugs/biologics furnished by hospital are covered when ALL of the following apply:

Drug cost and compendia/formulary: The drug/biological must represent a cost to the institution in rendering services to the beneficiary and must be included or approved for inclusion in an accepted compendium (USP-NF, USP DI, or ADA Guide) or approved by the hospital pharmacy and drug therapeutics (or equivalent) committee; combination drugs qualify if combination or all therapeutic ingredients included/approved.

Safe, effective, and medically necessary: Use of the drug/biological must be safe and effective and otherwise reasonable and necessary per Medicare Benefit Policy Manual Chapter 15; FDA-approved drugs used within labeling are considered safe/effective; off-label uses considered based on generally accepted medical practice and local medical review policy.

Investigational exclusion and nonapproved drugs: Investigational drugs and drugs without final FDA approval are not covered unless CMS instructs otherwise; investigational/nonapproved drugs are excluded from payment even if administered during otherwise covered stay.

Special orders and discharge-limited supplies: Drugs specially ordered for inpatients (not routinely stocked) may be covered if included/approved in designated compendia or hospital committee. Limited supplies of drugs furnished for use outside the hospital to facilitate discharge are covered if medically necessary until patient can obtain continuing supply; generally drugs for use outside hospital are not covered.

Supplies, Appliances, and Equipment

Covered when ALL of the following are met:

Ordinary inpatient items: Items ordinarily furnished by the hospital for care and treatment of the beneficiary solely during the inpatient stay are covered under Part A.

Items leaving hospital: Items that leave the hospital with the patient may be covered if it is unreasonable or medically impossible to limit use to inpatient period (examples: implanted devices, temporary items necessary to permit release such as tracheotomy tubes).

Admission packs routinely furnished to all inpatients are covered; packs not routinely furnished may be charged to beneficiary only if requested and with knowledge of charge.

Temporary/disposable items medically necessary to permit discharge and required until continuing supply obtained are covered.

Other Diagnostic or Therapeutic Items or Services

Covered when ordinarily furnished to inpatients by the hospital or others under hospital arrangements and meet qualifications:

Off-premises diagnostic/therapeutic services: Diagnostic/therapeutic services furnished off-premises under arrangements and billed by the hospital are covered if provider meets qualification requirements (example: audiologist licensed and certified/eligible).

Therapeutic items such as surgical dressings, splints, prosthetic devices (non-dental), braces, trusses, and artificial limbs are covered when ordinarily furnished to inpatients.

Independent clinical labs: Diagnostic services by independent clinical laboratories under arrangements are reimbursable provided the lab is CLIA certified and meets state/local licensing where applicable; A/B MAC need not verify approval on individual claims but should refer noncompliant labs to regional office.

Hospital-to-hospital lab arrangements: Diagnostic services furnished under arrangements with another participating hospital laboratory are reimbursable on cost basis for PPS-exempt hospitals; otherwise no separate payment for inpatient lab services.

Nursing and Related Services

Covered under Part A when ordinarily furnished to inpatients:

Included nursing services: Nursing and related services, hospital facilities use, and medical social services ordinarily furnished for inpatient care are included in PPS payment.

Private-duty exclusion: Private-duty nurses or private-duty attendants are not covered even if arranged by hospital; when hospital acts on behalf of patient and engages private-duty personnel, those services are not inpatient hospital services.

Inpatient Rehabilitation Facility (IRF) Services - Coverage Necessity

IRF benefit is reasonable and necessary when ALL regulatory requirements are met:

IRF medical necessity overview: Patient requires intensive rehabilitation therapy in a resource-intensive inpatient environment due to complexity of nursing, medical management, and rehab needs and is reasonably expected to benefit from inpatient stay and interdisciplinary team approach. Patient must meet all requirements in 42 CFR § 412.622(a)(3), (4), and (5) regardless of diagnosis list. IRF not alternative to completing full course of treatment in referring hospital; not appropriate for patients who do not require intensive rehabilitation.

IRF Documentation Requirements

IRF admissions require completion/presence of documentation items:

Preadmission screening timing and content: Preadmission screening by licensed/certified clinician(s) within 48 hours immediately preceding IRF admission documenting prior level of function, expected improvement and time to achieve it, risk for complications, conditions causing need for rehab, treatments required, and anticipated discharge destination. If screening >48 hours prior, update must be conducted in person or by telephone within 48 hours preceding admission and documented. Findings must be conveyed to rehabilitation physician who must document review and concurrence prior to admission. All preadmission screening documentation must be retained in IRF record per 42 CFR § 412.622(a)(4)(i).preadmission screening within 48 hours

Overall plan of care timing: An individualized overall plan of care must be developed by the rehabilitation physician synthesizing preadmission screening and therapy assessments detailing medical prognosis, anticipated interventions, functional outcomes, discharge destination, and expected intensity, frequency, and duration of therapy; must be completed within first 4 days of IRF admission and retained in medical record (IRF-PAI inclusion required).overall plan within first 4 days

Rehab physician must synthesize assessments

Admission orders and IRF-PAI: Admission orders generated by a physician at time of admission (per 42 CFR § 482.12(c)(2), § 482.24(c), and § 412.3) and IRF Patient Assessment Instrument (IRF-PAI) forms should be included in patient's IRF medical record per 42 CFR § 412.606(b).

Required IRF Admission Documentation

Documentation required in the IRF medical record to support reasonable and necessary admission:

Required documentation items: Preadmission screening information; Individualized overall plan of care developed/synthesized by rehabilitation physician with interdisciplinary input and completed within first 4 days detailing anticipated intensity/frequency/duration of therapies; Admission orders generated by a physician at time of admission; IRF-PAI forms included in medical record.overall plan within 4 days

IRF Medical Necessity Criteria (at time of admission)

IRF stay is reasonable and necessary only if documentation demonstrates ALL of the following were met at admission (subject to PHE exceptions):

Multiple therapy disciplines: Active and ongoing therapeutic intervention of multiple therapy disciplines required (PT, OT, SLP, prosthetics/orthotics), and one of these must be physical therapy or occupational therapy.

See section 110.2.1

Intensity requirement: Patient generally requires an intensive rehabilitation therapy program. Intensity demonstration may be met by either: (a) at least 3 hours of therapy per day at least 5 days per week; OR (b) at least 15 hours of intensive rehabilitation therapy within a 7 consecutive calendar day period beginning with date of admission. Therapy treatments must begin within 36 hours from midnight of the day of admission; therapy evaluations count toward intensity. Group therapy is adjunct; documentation required if group therapy used. Brief exceptions allowed for temporary events limiting participation not to exceed 3 consecutive days if documented.3 hrs/day x 5 days OR 15 hrs/7 days; therapy begin within 36 hours; brief exceptions <=3 days

Intensity demonstration options are 'any' within nested node

Ability to participate and measurable improvement: Patient reasonably expected to actively participate in and benefit significantly from intensive rehabilitation and make measurable improvement of practical value within a prescribed period; patient need not regain complete independence to qualify.

See section 110.3

Physician supervision: Requires physician supervision by a rehabilitation physician: face-to-face visits at least 3 days per week throughout stay; beginning second week, a non-physician practitioner may conduct 1 of the 3 required visits per week if within scope; rehabilitation physician must visit minimum three times in first week; visits documented per 42 CFR § 482.24(4)(c)(vi).>=3 visits/week; one may be NPP starting week 2

Interdisciplinary team must meet at least once per week with documented participation. Minimum documented participation by: rehabilitation physician; registered nurse with rehabilitation experience; social worker or case manager (or both); and licensed/certified therapist from each therapy discipline involved. Rehabilitation physician must lead team (in person or remotely) and document concurrence with decisions at each meeting.weekly team meetings

Exceptions and Flexibilities During the COVID-19 Public Health Emergency (PHE)

Temporary waivers and flexibilities applicable to IRF admissions during the PHE when specific conditions are met:

Post-admission evaluation waiver: Post-admission physician evaluation documentation requirement removed for Medicare Part A FFS beneficiaries during the PHE (per CMS-1744-IFC, 03-30-2020).

Telehealth physician visits: Physician visits required under IRF rules may be conducted via telehealth during the PHE (per section 1834(m)(4)(F)).

3-hour rule waiver: Waiver of the IRF '3-hour rule' (requirement for 15 hours/week) for beneficiaries admitted during the PHE (per CMS-5531-IFC, 04-30-2020); contractors shall not review compliance with 42 CFR § 412.622(a)(3)(ii) for admissions during the PHE.

DS identifier exemptions and additional waiver: Additional waiver when all criteria met at admission: patient admitted to freestanding IRF solely to alleviate acute care hospital bed capacity issues AND IRF located in state/region experiencing a surge during the PHE. For freestanding IRF patients identified by adding 'DS' to patient identifier, contractors shall NOT review records for compliance with requirements at 42 CFR § 412.622(a)(3)(i),(iii),(iv),(4),(5); freestanding IRFs may be paid usual IRF prospective amounts for these 'DS' patients.

Definition of Measurable Improvement and Continued Stay Justification

Criteria to justify initial and continued IRF stay:

Measurable improvement expectation: Medical record must indicate reasonable expectation that measurable, practical improvement in functional condition can be accomplished within a predetermined and reasonable period, generally supporting safe return to home/community.

Continued stay justification: To justify continued IRF stay, documentation must demonstrate ongoing requirement for intensive rehabilitation services and interdisciplinary approach, and that patient is making ongoing, sustainable, and practical improvements measured against start of treatment. An IRF claim cannot be denied solely because patient is not expected to achieve complete independence or return to prior level of functioning.

Services Related to and Required as a Result of Noncovered Services

Rules for coverage when services relate to non-covered procedures:

Related vs not-related coverage: Services 'related to' non-covered services performed during the same hospital stay are non-covered (e.g., follow-up care or complications of a non-covered transplant). Services 'not related to' non-covered services are covered (e.g., treatment for a broken leg sustained during a covered hospitalization). After discharge from a stay involving non-covered services, subsequent inpatient or outpatient services required to treat complications arising from prior non-covered services may be covered if reasonable and necessary and not part of an expected global fee. Examples provided (reversal of intestinal bypass, treatment of infection at surgical site) illustrate covered subsequent services; routine postop visits within a global fee are not covered.

Re-election after Prior Revocation

Re-election after prior revocation rules:

Re-election waiting periods: After an initial revocation, the individual may again file a written election which takes effect immediately upon execution. If an individual revokes a second election, the third election cannot become effective until 1 year after the most recent revocation. Subsequent elections (after third) are not effective until 5 years after the most recent revocation. Once an election is revoked, Medicare payment cannot be made to an RNHCI unless a valid election is filed.

RNHCI Home Benefit Eligibility and Coverage

Conditions for RNHCI home services coverage:

Eligibility and confinement: Beneficiary must have a valid RNHCI election and be confined to their home for health reasons (42 CFR 409.42(a)). Care must be intermittent and needs met by intermittent care. Utilization review committee must review and plan initial and continued home care and approve DME and continuation of services. Only nonmedical services in the home are payable; religious items/services provided by the RNHCI are not covered by Medicare. Home benefit excludes services excluded from home health benefit (drugs/biologics, transportation, services not covered inpatient, housekeeping services, ESRD services, prosthetic devices, medical social services to family) as defined at 42 CFR 409.49.

Coverage period limited in source to 2005-2006 in historical context

DME Coverage under RNHCI Home Benefit

RNHCI covers a defined list of nonmedical DME comparable to inpatient RNHCI items; physician order not required:

DME list and plan-of-care support: Covered DME must be included on the defined RNHCI DME list and be supported by the RNHCI patient's home plan of care and nurses' notes. Those RNHCIs offering home services may order these items without a physician order and without compromising the beneficiary election.

Payment routing and supplier arrangements: RNHCI must establish payment arrangement with one or more DME suppliers; RNHCI will submit DME claims to the RNHCI specialty FI (do not submit to DMERC or beneficiary election may be revoked). Payment to RNHCIs for these specified DME items will be made based on the DME fee schedule. Coinsurance applies; deductible does not apply.

RNHCI Home Nursing Visits Coverage and Payment

Conditions and payment methodology for intermittent RNHCI nursing visits:

Visit definition and non-skilled nature: Only intermittent RNHCI nursing visits to the home are covered and billable to Medicare; a visit is a single billable unit regardless of number of caregivers or duration. RNHCI nurses are not credentialed/licensed healthcare professionals; services are non-skilled and comparable to HHA home health aide tasks (ADL assistance, light housekeeping incident to visit, documenting visit).

Payment methodology: Payment is 80% (.80) of the HHA LUPA home health aide base rate adjusted by MSA wage index; labor/non-labor portions use fixed allowances from HHA PPS. RNHCI nursing visits are paid using the LUPA system even when patient would not be classified as low utilization.80% of HHA LUPA adjusted by MSA

Billing implication: RNHCI nursing visits are billed as single visit units; example LUPA calculations described in manual illustrate application.

2021-11-08 (effective)revisedLatest

IRF policy updates (Rev. 10892, effective 11-08-21) codified documentation and medical necessity requirements: reinforced preadmission screening within 48 hours, requirement that a rehabilitation physician review and concur prior to IRF admission, completion of individualized overall plan of care within first 4 days, detailed intensity thresholds (>=3 hrs/day x >=5 days or >=15 hrs/7 days), therapy start within 36 hours from midnight of admission, and physician supervision/visit and interdisciplinary team requirements. (This entry reflects material clarifications to IRF documentation and coverage rules.)