August/September 2005

Trends and Issues

By Cherilyn G. Murer, JD, CRA

The Medical Day Hospital

This CORF has few regulatory restrictions

New treatment options and changes in the health care system reimbursement structure have also brought about drastic changes in the venues where cancer is treated. The shift of cancer treatment from inpatient to outpatient settings is now almost totally complete. According to the National Cancer Institute, nearly 90% of all cancer treatment is delivered in an outpatient setting. Rehabilitation service providers have available to them an ideal venue in which to offer comprehensive outpatient treatment services: the medical day hospital.

The medical day hospital is a comprehensive outpatient rehabilitation facility (CORF) that provides a very high level of structured and specialized comprehensive restorative care to individuals with acute and chronic disorders, including postsurgical, respiratory, neurological, pain, and oncological conditions. Services provided include assessment, diagnostic evaluation, treatment, management, and monitoring of patients. These multidisciplinary services combine to form a structured ambulatory program that provides the ideal alternative to inpatient settings, as demanded by today's health care environment.

TREATMENT REQUIREMENTS
Because medical day hospitals are CORFs, they face few regulatory restrictions in offering comprehensive treatment to cancer patients. CORF services are covered if the patient has rehabilitation potential and the patient is certified by a physician as requiring skilled therapy services. In other words, the patient must have the potential to have function restored, and the services of a skilled therapist must be necessary to achieving that potential. Both of these factors will often be present in cancer patients.

For patients that meet the rehabilitation potential requirement, the facility must offer at least:

• Physician services;
• Physical therapy; and
• Social or psychological services.

In addition to the three required offerings, CMS will also reimburse in the medical day hospital a number of other services that will benefit many cancer patients, including:

• Occupational therapy;
• Speech-language therapy or pathology;
• Respiratory therapy;
• Prosthetic and orthotic devices—which includes testing, fitting, or training in the use of such devices;
• Nursing;
• Drugs and biologicals—which are not usually self-administered by the patient, ie, chemotherapy;
• Supplies, appliances, and equipment, including the purchase or rental of durable medical equipment (DME) from the CORF; and
• A single home visit—includes evaluating the potential impact of the home environment on rehabilitation goals.

All services must be furnished under a written plan of treatment. The treatment plan must be signed by a physician who CMS expects will establish the plan with the clinical staff providing the actual therapy. The physician signing the plan of treatment may be either the facility's own physician (ie, the medical director) or a referring physician, provided the plan contains the diagnosis; the type, amount, frequency, and duration of skilled rehabilitation services to be performed; and the anticipated skilled rehabilitation goals.

Note that the physician services that are reimbursable by Medicare to the medical day hospital are not ordinary patient office visits. Rather the reimbursable services are administrative services, consultation with and medical supervision of nonphysician staff, team conferences, and case reviews. Examinations for the purpose of establishing and reviewing the plan of care will be reimbursed to the CORF, provided that they do not result in a billable service for which the physician would bill the patient individually.

Nevertheless, the physician may provide customary examinations and consultations in the medical day hospital setting. However, the physician bills Medicare under Part B for these services, just as he or she would if the patient were seen in an inpatient hospital.

CHEMOTHERAPY
As noted above, the CORF is distinguished from other outpatient rehabilitation venues by its ability to receive reimbursement for a variety of services, including the provision of drugs and biologicals that are not usually self-administered by the patient and nursing services. Thus, outside of the hospital environment, the medical day hospital represents a unique outpatient facility in which the cancer patient can have chemotherapy administered by a team of qualified professionals, and the facility can receive appropriate reimbursement for providing that service.

THE HOME EVALUATION VISIT
As a CORF, the medical day hospital is eligible to receive Medicare reimbursement for a single home evaluation visit. The visit is covered if is part of the plan of treatment, signed by the referring physician, and performed in conjunction with a "core" CORF service, such as occupational or speech therapy. The home visit facilitates incorporating the challenges of the patient's home environment into the individual patient's rehabilitation plan. The home visit is not intended to be a treatment session. Medicare generally pays for the home visit where it is clearly established, either through the process of establishing the plan of treatment, or through the patient's progress—or lack thereof—as the plan is carried out, that the patient's home environment may be impeding recovery.

For cancer patients, the home visit can be a key component of the plan of care. Both the National Cancer Institute and the American Cancer Society have stressed that the shift to outpatient venues has made family caregivers vital to the patient's recovery, but without proper evaluation and guidance, this key element in the patient's course of treatment is almost assuredly doomed to failure. When woven into the plan of care, the home evaluation visit allows for a professionally tailored, effective strategy for producing a positive outcome.

PSYCHOLOGICAL SERVICES
Psychological services are covered by Medicare in the medical day hospital setting whenever the service is reasonably necessary as part of the patient's rehabilitation plan. Whenever excessive fear or anxiety presents a barrier to recovery, psychological therapy is considered a necessary part of the treatment plan, which will be reimbursed by CMS. Obviously, fear and anxiety is often a major consideration in the treatment of cancer patients, and the availability of reimbursement for this service is a major advantage for the medical day hospital venue.

Furthermore, the availability of reimbursement for psychological services means that family counseling, a key modality for cancer patients, will be available in the medical day hospital. As long as family counseling is a reasonable and necessary service for the treatment of the patient, it will be covered by Medicare in a medical day hospital setting. It should be noted that coverage is available only if the counseling is primarily to aid the recovery of the cancer patient, and not for the primary purpose of aiding a family member in coping with the patient's condition. However, as noted above, education of the family has been identified as a key component in successful outpatient treatment of cancer patients. Without an involved and committed family support system, the patient has little hope of experiencing a successful course of treatment. Therefore, for virtually all cancer patients, family counseling will be a vital part of the treatment program, and the medical day hospital is uniquely positioned to provide—and be reimbursed for—that service.

The shift of cancer care from the inpatient arena to outpatient venues has challenged the health care industry to provide appropriate forums for addressing all aspects of the cancer patient's course of treatment, including the administration of chemotherapy, psychological services for dealing with the serious psychological ramifications of the disease, home visits, and family counseling for assuring that the home environment supports and contributes to the patient's recovery. In the medical day hospital, rehabilitation service providers have available a venue that not only is uniquely positioned to provide these services in a comprehensive multidisciplinary manner, but also has the capability of receiving appropriate reimbursement for the delivery of those services.

Cherilyn G. Murer, JD, CRA, is CEO and founder of the Murer Group, a legal-based health care management consulting firm in Joliet, Ill, specializing in strategic analysis and business development. She may be reached at (815) 727-3355 or via her Website at www.murer.com.

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