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OhioBWC - Basics: (Policy library) - File

Policy Name:

Brain Injury Residential Rehabilitation Services

Policy #:

MP-02-01

Code/Rule Reference:

R.C. 4123.05; O.A.C. 4123-6-02.2

Effective Date:

06/01/17

Approved:

Freddie Johnson, Chief of Medical Services (signature on file)

Origin:

Medical Policy

Supersedes:

All medical policies, procedures, directives and memos regarding brain injury claims that predate the effective date of this policy.

History:

New

Review date:

07/01/20

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure that the Bureau of Workers’ Compensation (BWC) provides direction for the identification and provision of appropriate brain injury residential rehabilitation services based on the injured worker’s (IW) level of cognitive and physical function when he or she has experienced a work-related brain injury.

 

II. APPLICABILITY

 

This policy applies to MCO staff, BWC’s catastrophic nurse advocates (CNA) and BWC’s medical administrative staff.

 

III. DEFINITIONS

 

Acquired Brain Injury: An injury to the brain, occurring after birth, which is not hereditary, congenital, degenerative or caused by birth trauma. 

 

Lifelong Living Brain Injury Facility: A facility that provides post-acute residential living services for the duration of the IW’s life, if needed.

 

Neurobehavioral Brain Injury Rehabilitation: A program that provides intensive physical and cognitive services for the individual with a brain injury who is exhibiting maladaptive behavior.

 

Post-Acute Brain Injury Facility: A facility that provides non-hospital based post-acute care for an individual who no longer requires a comprehensive inpatient rehabilitation program but  demonstrates the need for continued rehabilitation and specialized services.

 

Transitional Living Placement Facility: A facility that provides short-term reintegration services for an individual to transition into the community or a more appropriate setting.

 

Traumatic Brain Injury (TBI): An injury to the head arising from an external force (i.e., blunt or penetrating trauma or acceleration or deceleration forces).

1.    Mild TBI (MTBI): Manifested by at least one of the following:

a.    Any period of loss of consciousness (LOC) up to 30 minutes;

b.    Any dysfunction of memory for events immediately before the trauma or post-traumatic amnesia (PTA), which occurs up to 24 hours after the trauma;

c.    Any alteration in mental state at the time of the accident (e.g., transient confusion, disorientation, impaired consciousness); and/or

d.    Focal neurological deficit(s) that may be transient and show no evidence of traumatically induced intracranial lesion on neuroimaging studies.

2.    Moderate/Severe TBI: Manifested by at least one of the following:

a.    LOC greater than 30 minutes;

b.    PTA greater than 24 hours; and/or

c.    Evidence of traumatically induced intracranial lesion on neuroimaging studies.

 

IV. Policy

It is the policy of BWC:

A.    To authorize brain injury residential rehabilitation services when the request:

1.    Meets the Miller criteria (refer to the Miller policy); and

2.    Is made after:

a.                                        The stabilization of life threatening conditions; and

b.    The IW is physically, emotionally, cognitively and psychologically able to participate at least three hours per day in active therapy.

B.    To require that Brain Injury Residential Rehabilitation facilities are accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) for brain injury services and are BWC-certified as a type 82 provider:

1. Treatment at a facility that is enrolled, but not certified, as a type 82 provider may be approved if no BWC-certified facilities are available within a 45-mile radius of the IW’s home.

2. A facility may also be approved, if after the MCO staffs with BWC catastrophic nurse, BWC approves the placement.

 

C.   That claims for an IW receiving brain injury residential rehabilitation services, other than lifelong living services, are designated as catastrophic claims in the claims management system.

D.   That the IW remains in case management with a nurse case manager while participating in any brain injury residential rehabilitation program, other than lifelong living services.

E.    That the MCO shall process a request for brain injury residential rehabilitation services provided through a facility in accordance with the Physician’s Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9) in the MCO Policy Reference Guide (MPRG).

F.    That an IW receiving services from a brain injury residential rehabilitation facility requires comprehensive rehabilitative services that may include, but are not limited to, the following services:

1.    Physical therapy (PT);

2.    Occupational therapy (OT);

3.    Speech therapy;

4.    Recreational therapy; and/or

5.    Neuropsychological treatments.

G.   The following are requirements the MCO must follow to authorize the following services:

1.    Post-acute and/or neurobehavioral brain injury rehabilitation services shall be authorized for no more than 18 months, unless medically necessary.

a.    If it is medically necessary to extend post-acute or neurobehavioral brain injury rehabilitation services beyond 18 months, the claim shall be reviewed with a BWC CNA prior to authorizing an extension.

b.    Post-acute brain injury rehabilitation and/or neurobehavioral rehabilitation services shall be authorized for no more than 90 days at a time, with a review of placement occurring every 90 days to ensure continued appropriateness of placement. 

2.    Transitional residential services may be authorized for no more than 90 days, with a review of placement occurring every 90 days to ensure continued appropriateness of placement.

3.    Lifelong living TBI services provided at a residential TBI facility shall be authorized for no more than one year at a time, with a review of placement occurring every year to ensure continued appropriateness of placement.

 

V.  Billing and Reimbursement

It is the policy of BWC that:

A.    Reimbursement shall be made in accordance with the level of service(s) provided and shall be reevaluated when service(s) are reauthorized.

 

B.    Facilities shall use the correct billing code for all TBI and residential rehabilitation services.

 

C.     Brain injury residential rehabilitation services are billed as an all-inclusive code that shall include the following:

1.   Psychotherapy;

2.      Group therapy;

3.      Recreational therapy (including group outings);

4.      Behavioral counseling;

5.      Vocational counseling;

6.      Team conferences;

7.      Report preparation;

8.      Room and board;

9.      Medical management;

10.  Pharmacology management;

11.  Nutritional and dietary monitoring;

12.  Nursing and case management services;

13.  Structured schedule for activities of daily living (ADLs);

14.  Restorative services such as PT, OT, and speech therapy; and

15.  Family involvement, which may include home visits and phone contacts.

D.   The daily per diem rate for residential post-acute TBI rehabilitation services shall not cover:

1.    Physician fees;

2.    Prescription medications;

3.    Durable medical equipment (DME); and

4.    Medical services such as labs or radiology, or driver’s evaluations.

E.    Payment for request(s) that were preauthorized and meet the Miller criteria may be reimbursed (e.g., One-on-one sitter services).

F.    Lifelong living long-term TBI residential programs are billed as an all-inclusive code that shall include:

1.    Group therapy;

2.    Room and board;

3.    Assistance with ADLs;

4.    Nursing and staff oversight;

5.    Pharmacology management;

6.    Nutritional and dietary monitoring;

7.    Recreational activities, including group activities;

8.    Case management, team conferences and report preparation; and

9.    Family involvement, which may include home visits and phone contracts.

G.   The daily per diem rate for lifelong living long-term residential programs shall not cover:

1.    Physician fees;

2.    Prescription medications;

3.    Durable medical equipment (DME);

4.    Speech therapy and behavioral therapy;

5.    Medical services such as labs or radiology; and

6.    Physical and occupational therapy not provided in a group setting.

 

H.   Lifelong living residential services, other than services performed by TBI facilities, shall be billed using the appropriate residential fee code. This includes residential care, assisted living and skilled nursing facilities.

 

I.      All requests for reimbursement that are above the BWC fee schedule shall be negotiated by the MCO and approved by BWC as outlined in the Pricing Override Process policy and procedure.

Staff may refer to the corresponding procedure for this policy entitled “Brain Injury Residential Rehabilitation Services” for further guidance.

 

 

 

Procedure Name:

Procedure for Brain Injury Residential Rehabilitation Services

Procedure #:

MP-02-01.PR1

Policy # Reference:

MP-02-01

Effective Date:

06/01/17

Approved:

Freddie Johnson, Chief of Medical Services (signature on file)

Supersedes:

All medical procedures, directives and memos regarding Brain Injury Residential Rehabilitation Services claims that predate the effective date of this procedure.

History:

New

Review date:

07/01/20

 

 

II.    General Requirements for all Brain Injury Residential Rehabilitation Services

A.    The Managed Care Organization (MCO) shall ensure that facilities are accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) for brain injury services and BWC-certified as a type 82 provider. However, the MCO may approve treatment at a facility that is enrolled, but not certified as a type 82 provider, if it determines no BWC-certified facility is available. 

B.    The MCO shall obtain documentation to justify the IW’s admission and/or transfer to a brain injury residential rehabilitation facility that shall include, but is not limited to, the following:

1.  Complete medical history from the date of injury; 

2.  The appropriate multi-disciplinary evaluations and/or a comprehensive summary that indicates that the IW is physically, emotionally, cognitively and psychologically capable of participation in the recommended rehabilitation program; 

3.  Level of cognitive function determined by an evaluation tool (e.g., Ranchos Los Amigos Scale or equivalent cognitive function rating scale);

4.  Screening evaluation that addresses the IW’s rehabilitation potential and specific treatment goals to help the IW improve function or accommodate for lost function.

C.   The MCO shall ensure that all requests for brain injury residential rehabilitation services meet the Miller criteria (refer to the Miller policy).

 

III.   Post-Acute Brain Injury Residential Rehabilitation Services

A.    The MCO shall ensure that:

1.     The IW’s cognitive and physical condition reflects the need for post-acute brain injury residential rehabilitation services.

2.    The IW does not require a neurobehavioral comprehensive residential rehabilitation program.

3.    The IW is medically stable and physically able to participate in active and/or cognitive therapy for three hours or more per day.

4.    The claim contains medical documentation that justifies the transfer of the IW to a post-acute brain injury residential rehabilitation program. 

5.    An initial assessment is scheduled with the facility chosen to provide services for an IW receiving post-acute rehabilitation services.   

B.    The MCO shall obtain, at a minimum, monthly documentation of care provided for the IW in post-acute brain injury rehabilitation facilities. The documentation shall include, but is not limited to, the following:

1.    Treatment history and expected discharge outcomes, to include projected discharge date and the anticipated discharge placement;

2.    Treatment team members and the number of hours the IW spends with the treatment team members;

3.    Treatment progress summary and comparison of progress from previous reports.

4.    Test results and cognitive function assessment/scale, medical problems and how these relate to treatment;

5.    Status of treatment goals; and

6.    Family involvement and support.

 

C.   The MCO shall ensure that post-acute brain injury residential rehabilitation services are authorized for a maximum of 18 months.

1.    If post-acute residential brain injury services are needed for longer than 18 months, the MCO shall base its decision on the IW’s progress and anticipated additional functional gain. 

2.    If the MCO determines that no additional functional gain is demonstrated or anticipated, then the MCO shall have the IW assessed for a more appropriate setting.

3.    The MCO shall review all authorizations extending beyond 18 months for brain injury rehabilitation with a BWC catastrophic nurse.

 

D.   The MCO shall approve post-acute brain injury services for up to a maximum of 90 days at a time.

1.    The MCO shall review placement every 90 days to ensure continued appropriateness of placement. 

2.    The MCO may authorize additional days of treatment beyond the initial 90 days if it has supporting medical documentation provided by the physician of record (POR), treating physician, and/or the facility providing post-acute brain injury residential rehabilitation services. The documentation shall include, but is not limited to:

a.    Medical summary;

b.    Status of treatment goals;

c.    Treatment summary and progress report;

d.    Family interaction and support in treatment;

e.    Current treatment plan, history and expected discharge outcomes;

f.     Treatment team members and contact hours with the treatment team; and

g.    Justification for continuation of residential brain injury rehabilitation services.

3.    If the assessment indicates that post-acute rehabilitation is not needed, the MCO shall investigate a more appropriate placement for the IW.

 

 

 

IV.  Neurobehavioral Brain Injury Residential Rehabilitation Services

A.    The MCO shall ensure that:

1.    An IW that requires a neurobehavioral program is enrolled in a comprehensive neurobehavioral rehabilitation program that includes intensive cognitive restorative services and a comprehensive rehabilitation plan.

2.    The IW’s cognitive and physical condition reflects the need for neurobehavioral brain injury residential rehabilitation services.

3.    The IW is medically stable and physically able to participate in active and/or cognitive therapy for three hours or more per day.

4.    The claim contains medical documentation that justifies the admission and/or transfer of the IW to a neurobehavioral brain injury rehabilitation program.

5.    An initial assessment is scheduled with the facility chosen to provide neurobehavioral rehabilitation services.   

a.    The assessment shall provide additional justification for the neurobehavioral brain injury program.

b.    If the assessment indicates that neurobehavioral rehabilitation is not needed or if the facility is unable to provide the level of services required for an IW, the MCO shall investigate a more appropriate placement for the IW.

 

B.    The MCO shall obtain, at a minimum, monthly documentation of care provided for the IW in neurobehavioral rehabilitation facilities. The documentation shall include, but is not limited to, the following:

1.    Treatment history and expected discharge outcomes, to include projected discharge date and the anticipated discharge placement;

2.    Treatment team members and  the number of hours the IW spends with the treatment team members;

3.    Status of treatment goals;

4.    Treatment progress summary and comparison of progress from previous reports;

5.    Test results, medical issues, or assessments completed during the month;

6.    Family involvement and support.

 

C.   The MCO shall ensure that neurobehavioral brain injury residential rehabilitation services are authorized for a maximum of 18 months.

1.    If neurobehavioral brain injury services are needed for longer than 18 months, the MCO shall base the decision to continue the services on the documented IW progress and anticipated additional functional gain.

2.    If no additional functional gain is demonstrated or anticipated, the MCO shall asses the IW for a more appropriate setting. 

3.    The MCO shall review all authorizations extending beyond 18 months for neurobehavioral brain injury residential rehabilitation with a BWC catastrophic nurse.

 

D.   The MCO shall approve neurobehavioral brain injury residential rehabilitative services for up to a maximum of 90 days at a time.

1.    The MCO shall review placement every 90 days to ensure continued appropriateness of placement. 

2.    The MCO may authorize additional days of treatment beyond the initial 90 days if it has supporting medical documentation provided by the physician of record (POR), treating physician and/or the facility providing neurobehavioral brain injury rehabilitation services. The documentation shall include, but is not limited to:

a.    Medical summary;

b.    Status of treatment goals;

c.    Treatment summary and progress;

d.    Family interaction and support in treatment;

e.    Current treatment plan, history and expected discharge outcomes;

f.     Treatment team members and contact hours with the treatment team; and

g.    Justification for continuation of neurobehavioral brain injury rehabilitation service.

3.    If the assessment indicates that neurobehavioral rehabilitation is not needed, the MCO shall investigate a more appropriate alternative placement for the IW.

 

V.    Transitional Living Placement

A.    The MCO shall only approve transitional living programs when the goal is to reintegrate the IW back into the community.

B.    The MCO shall ensure that the claim contains medical documentation that justifies the movement of the IW to a transitional living program. The MCO shall ensure the documentation includes, at a minimum, the following elements:

1.    Medical necessity;

2.    Post accident history;

3.    Goals and anticipated length of treatment; and

4.    A statement from the POR, treating physician or residential neurobehavioral or post-acute traumatic brain injury (TBI) rehabilitation facility regarding the IW’s rehabilitation potential.

 

C.   The MCO shall obtain, at a minimum, monthly documentation of the IW’s progress in a transitional living program.

 

D.   The MCO shall approve transitional living programs for up to a maximum of 90 days at a time.

1.    The MCO shall review placement every 90 days, and review placement every 30 days for requests for services that extend beyond the initial 90 days to ensure the request includes:

a.    IW progress in the program;

b.    Goals for additional time in the program; and

c.    Justification of medical necessity. 

2.    The MCO shall determine a more appropriate placement if the request does not justify transitional living services extending beyond 90 days or beyond 30 days after the initial 90 days.

 

VI.  Lifelong Living TBI Services

A.    The MCO shall approve lifelong living services when the IW:

1.    Has reached a plateau in his or her physical, cognitive and behavioral functioning; and

2.    Is not expected to return independently to the community or home.

 

B.    When evaluating residential lifelong services provided by a residential TBI facility, the MCO shall:

1.    Ensure that an authorization of lifelong services provided at a residential TBI facility is not approved for more than one year at a time.

2.    Review placement every year to determine if the placement remains appropriate.

a.    If the placement remains appropriate, the MCO shall authorize no more than one additional year.

b.    If the placement is not appropriate, the MCO shall investigate alternative placement for the IW.

 

VII.  Billing and Reimbursement

A.    The MCO shall ensure that reimbursement(s) are made in accordance with the level of service(s) provided and shall be evaluated when service(s) are reauthorized.

 

B.    The MCO shall ensure that the facility use the correct billing code for all TBI and residential rehabilitation services.

 

C.   The MCO shall ensure that brain injury residential rehabilitations services are billed as all-inclusive codes and  the following services shall not be billed separately:

1.    Psychotherapy;

2.    Group therapy;

3.    Recreational therapy (including group outings);

4.    Behavioral counseling;

5.    Vocational counseling;

6.    Team conferences;

7.    Report preparation;

8.    Room and board;

9.    Medical management;

10.  Pharmacology management;

11.  Nutritional and dietary monitoring;

12.  Nursing and case management services;

13.  Structured schedule for activities of daily living (ADLs);

14.  Restorative services such as PT, OT, and speech therapy; and

15.  Family involvement, which may include home visits and phone contacts.

 

D.   The MCO may authorize, if appropriate, payment for other services not included in the daily per diem rate, such as:

1.    Physician fees;

2.    Prescription medications;

3.    Durable medical equipment (DME);and

4.    Medical services such as labs, radiology, or driver’s evaluations.

E.    The MCO shall authorize payment for requests that meet the Miller criteria and that were pre-authorized (e.g., one-on-one sitter services).

F.    The MCO shall ensure that lifelong living long-term TBI residential programs are billed using an all-inclusive code that includes:

1.    Group therapy;

2.    Room and board;

3.    Assistance with ADLs;

4.    Nursing and staff oversight;

5.    Pharmacology management;

6.    Nutritional and dietary monitoring;

7.    Recreational activities, including group activities;

8.    Case management; team conferences and report preparation; and

9.    Family involvement, which may include home visits and phone contracts.

 

G.   The MCO may authorize, if appropriate, other services not included in the daily per diem rate for lifelong living long-term residential programs, such as:

1.    Physician fees;

2.    Prescription medications;

3.    Durable medical equipment (DME);

4.    Speech therapy and behavioral therapy;

5.    Medical services such as labs or radiology; and

6.    Physical and occupational therapy not provided in a group setting.

 

H.   The MCO shall ensure that lifelong living residential services, other than services performed by TBI facilities, use the appropriate residential fee code. This includes residential care, assisted living and skilled nursing facilities.

I.      The MCO shall negotiate all requests for reimbursement above the fee schedule and seek BWC approval as outlined in the Pricing Override Process policy and procedure.

 

Staff may refer to the corresponding policy for this procedure entitled “Brain Injury Residential Rehabilitation Services” for further guidance.

 

 

 


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