In our continuing series on the technical requirements of the Jan. 1, 2010 updates to the regulations for inpatient rehabilitation facilities (IRFs), this article will address the requirements for therapy services.

Because the purpose of inpatient rehabilitation is to restore function, it follows that the provision of therapy services is essential to achieve patient goals. Toward that end, Medicare has been proactive related to the requirements for therapy in IRFs. The requirements include specific criteria related to:

  • Orders
  • Multiple therapies
  • Initiation of services within 36 hours of midnight on the day of admission
  • Intensity of service: The “Three-Hour Rule”
  • The provision of 1-to-1 therapy as the standard of care
  • Attendance at the interdisciplinary team meetings


While therapy evaluations and treatment may begin before the post-admission physician evaluation, therapy may not begin before IRF admission orders are signed.

Multiple Therapies

In order to demonstrate the need for an interdisciplinary approach to providing rehabilitation therapy services, Medicare requires that a patient has active and ongoing therapy interventions involving at least two therapy disciplines, with one of those disciplines either physical therapy or occupational therapy. For the purposes of meeting the multiple therapy requirements, Medicare recognizes only physical therapy, occupational therapy, speech-language pathology, and orthotics and prosthetics services.  

Initiation of Services Within 36 Hours of Midnight on the Day of Admission

All required therapy treatments must begin within 36 hours of midnight on the day of admission. Thus, a patient who is admitted at noon on Friday would be expected to have received therapy evaluation(s) to initiate care no later than midnight on Saturday, 36 hours later.  Medicare has clarified that the evaluation serves as the initiation of treatment, and that initiation of services by any one discipline meets the requirement. In one clarification statement, however, Medicare further indicated that while one therapy discipline practitioner performing an evaluation within 36 hours from midnight on the day of admission meets the requirement, the patient must receive his or her intensive rehabilitation program on that same day.

Intensity of Service – The Three-Hour Rule

The aforementioned “Three-Hour Rule” has long been a standard for IRFs. With the updated technical requirements, Medicare has more clearly defined this mandate. First, there is no longer an opportunity to have patients participate in a graduated therapy program that builds up to three hours per day. Medicare requires that “at the time of admission,” the patient must receive three hours of therapy, at least five days per week. Further clarification defined the “week” as starting on the day of admission and running seven consecutive days. There are two caveats to this requirement: the “Brief Exceptions Policy” and the ability to provide 15 hours of therapy in a week for a limited number of patients.

As it pertains to calculating therapy time, there have been a few additional clarifications:

  • Actual time spent in therapy treatment should be recorded and “rounding” is not accepted;
  • Evaluation and reevaluation time can be counted;
  • Time spent in the interdisciplinary team meeting or family care conferences does not count;
  • Only minutes spent in PT, OT, ST and orthotics/prosthetics count toward the intensity-of-therapy rules;
  • Unsupervised modalities are not counted in the therapy minutes; and
  • Services provided by psychological and neuropsychological services, music therapy, recreational therapy, and respiratory therapy also do not count toward the intensity-of-therapy requirements.

For patients for whom an IRF can document a clear reason to adjust therapy schedules to 15 hours per week, the IRF can provide therapy at this level. Typically this schedule would be appropriate for a patient who has specific medical issues and/or needs that impact the patient’s ability to participate in therapy for three hours, five days per week – including patients who are on hemodialysis or chemotherapy – but other situations also could support this therapy schedule.

The “Brief Exceptions Policy” allows for unexpected clinical events that interrupt or limit therapy interventions, including extensive diagnostic tests, requirements for services rendered off-premises, infusion of blood and blood products, and/or DVT treatment. In these situations, not to exceed three consecutive days, the IRF would not be required to meet the intensity-of-therapy mandates. Our recommendation is that, in these situations, IRFs clearly document the reasons for missed or reduced therapy time and make every effort to provide at least 15 hours of therapy in the seven-day period.

Additionally, Medicare has clarified that occasional missed minutes can be made up on a subsequent day. For example, consider a scenario in which a patient misses the last 15 to 30 minutes of treatment on any given therapy day due to vertigo, nausea, or some other interruption. The patient could perform an additional 15 to 30 minutes of therapy on a subsequent day, provided that it was within the same seven-day period and that there was clear documentation as to the reason for the missed therapy.


The Provision of 1-to-1 Therapy as the “Standard of Care”

A longstanding question for IRFs has centered on the amount of “group” therapy permitted by Medicare. While the amount of group therapy permitted in other post-acute settings has been more clearly defined, Medicare has stated that for the IRF, the “standard of care is individualized (i.e., one-on-one) therapy.” Medicare further has clarified that, when group therapy better meets a patient’s needs, the rationale for group therapy must be clearly documented in the record and the “preponderance” of such therapy must be 1-to-1.

Attendance at the Interdisciplinary Team Meeting

A therapist from each discipline involved in a patient’s rehabilitation care must attend the interdisciplinary team meeting. Because state licensure laws preclude therapist assistants from establishing or modifying a patient’s plan of care, and being as these are essential functions of the team meeting, a therapist assistant cannot represent the patient at such meetings. However, this does not preclude the therapist assistant from attending and participating in the team meeting.

Common Issues

In our experience, we have found some common trends:

  • Patients often have legitimate reasons for missed therapy minutes, but these are not always well-documented in the record;
  • If a patient is appropriate for 15 hours of therapy a week due to medical issues or treatments, this must be indicated in the individualized plan of care and discussed at each interdisciplinary team meeting;
  • If one therapy discipline signs off on a case, there can be insufficient documentation to support increased minutes by the remaining therapy providers.

Tips for Success

As with all of the technical requirements, organizations that have standardized processes that are adhered to closely will have greater compliance. Industry best practices include:

  • Compiling a digital or manual daily tally of therapy minutes;
  • Use of a standard form or template to document decreased levels of therapy intensity, and the reasons for any missed minutes;
  • Flexible staffing to cover late-day slots to make up missed minutes from a day; and
  • Electronic scheduling of therapy minutes to meet the individualized plans of care.

Coming next: Rehab Physician Supervision of the IRF Patient.

About the Author

Angela M. Phillips, PT, is president and chief executive officer of Images & Associates. A graduate of the University of Pennsylvania School of Allied Health Professions, she has more than 35 years of experience as a consultant, healthcare executive, hospital administrator, educator, and clinician. Ms. Phillips is one of the nation’s leading consultants assisting Inpatient Rehabilitation Facilities in operating effectively under the Medicare Prospective Payment System (PPS) and in addressing key issues related to compliance for therapy services across all venues.

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