I Sent in My Letters. Have You?

I sent in my letters in response to the public policy alert I posted earlier today. The same letter can be used for both the "Three Hour Rule" and the for Medicare Benefits Policy Manual. You just have to submit the letter to each of the two places indicated in the public policy alert.

Here (below) is the letter I sent:

May 25, 2009

Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1538-P
P.O. Box 8012
Baltimore, MD 21244-8012

To Whom It May Concern:

As a university professor, for 35 years I taught, researched, and wrote my about my profession of recreational therapy. I am now retired but I am taking the time to write to you because I know of the value of recreational therapy and hope that my letter will help you to understand the importance of including recreational therapy services under the Medicare Program.

I am responding specifically to the Proposed Rule for the Inpatient Rehabilitation Facility (IRF) Prospective Payment System for Fiscal Year 2010 (42 CFR, parts 412, May 6, 2009). My principal concern relates to the proposed changes to the so-called “Three Hour Rule” that is used as a guideline for determining a patient’s need for a relatively intense level of therapy services.

Under the current Three Hour Rule, the physician and rehabilitation team are given flexibility to determine, on a priority basis, which skilled modalities are appropriate for each patient in the IRF setting. A number of specific therapies are explicitly identified as “skilled modalities,” including but not limited to physical therapy (PT), occupational therapy (OT), speech language pathology (ST), and orthotics and prosthetics (O&P). Until recently, over half the fiscal intermediaries permitted recreational therapy services to be counted as a skilled modality for purposes of qualifying under the Three Hour Rule.

The proposed changes restrict the current language of the Three Hour Rule by limiting the therapies that may be counted toward the total amount of therapy time to PT, OT, ST and O&P only, leaving no discretion for clinicians to determine the appropriate mix of therapy services for each patient. The modification, as proposed, excludes recreational therapy, despite the fact that recreational therapy provided in an IRF must be medically necessary and ordered by a physician as part of the patient’s treatment plan.

Elimination of recreational therapy as counting toward the Three Hour Rule will have a negative impact on access to this important therapy and is not reflective of current practices in inpatient rehabilitation. Furthermore, such an exclusion is not consistent with CMS policy on medical necessity and deference to the judgment of the treating physician.

Recreational therapy, when provided by a qualified recreational therapy professional (nationally certified and/or state licensed), has been shown to have a statistically positive effect on Functional Independence Measure (FIM) score gains for both stroke and spinal cord injury patients (See Williams, R., et al, 2007 and Hawkins, B., 2009) and is commonly successfully employed with a variety of other patient populations (see Austin, 2009).

I am therefore requesting that CMS explicitly include recreational therapy in the list of therapy services that may be counted under the Three Hour Rule when ordered by a physician as part of a patient’s plan of care and provided by a qualified recreational therapy professional. This should be reflected in both the regulations and the Medicare Benefits Policy Manual.

Furthermore, I would like to offer my support to the position and request made by Congresswoman Tauscher and Congressman Thompson in their letter to Charlene M. Frizzera in which they requested that recreational therapy be included under the Three Hour Rule.

Sincerely yours,



David R. Austin, Ph.D., CTRS
Professor Emeritus
Indiana University
3040 N Ramble Road West
Bloomington, IN 47408