Location: Indiana, United States

I became a Professor Emeritus after serving 29 years as a recreational therapy faculty member at Indiana University. I'm a long-time Hoosier, having grown up in Hanover, Indiana. My RT practitioner work was in psych/mental health. After completing my Ph.D. at the University of Illinois, my first faculty position was at the University of North Texas. RT has been a wonderful profession for me as I have had the opportunity to serve as an author and national leader.

Monday, May 25, 2009

We Each Need to Write 2 Letters -- See Below

What follows is an ATRA ACTION ALERT regarding Inpatient Medical Rehabilitation. All RTs need to take the time to write two letters to CMS in order to make sure RT is included (an example letter is provided below).

On April 29th, 2009, the Centers for Medicare and Medicaid Services (CMS) issued its 2010 proposed rule for the inpatient rehabilitation facility (IRF) prospective payment system (PPS). CMS has also proposed to revise the Medicare Benefits Policy Manual (MBPM) provisions on coverage of IRF services and has established a separate comment period and process for these changes.

Taken together, the proposals represent one of the most comprehensive set of rules changes governing access to inpatient rehabilitation services in years and will set the stage for IRF care for the foreseeable future.

Proposed CMS Change:

In reference to the “3-hour Rule,” the removal of the phrase “other skilled rehabilitative modalities” and insertion of “… active and ongoing therapeutic intervention of at least two therapy disciplines (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics therapy)…” in both the IRF-PPS final rule for 2010 and the Medicare Benefits Policy Manual.

Proposed ATRA Member Actions:

Given the impact such a change will have for years to come, ATRA needs all RT professionals to:

1) Submit two comment letters to CMS (Note: Because CMS will make changes to two different rules and regulations, comments need to be submitted to two different sources); and

2) Solicit similar comments to CMS from your colleagues in your IRF setting including Physicians, Physical Therapists, Occupational Therapists, Nurses and other providers. You can share the draft letter with them.

Drafting a Comment Letter:

1) Please review the attached draft letter. Add your personal information in the beginning paragraph.

2) Your comments addressing the proposed rule change must be submitted to CMS as soon as possible. While the deadline may be June 29th, we need to demonstrate an influx of responses well before that date so PLEASE DO NOT DELAY in drafting and sending your comment letter. The final deadline is no later than June 29th, 2009 at under file “CMS-1538-P”.

3) Your comments addressing the proposed MBPM changes are due no later than June 30th, 2009 at Please send as soon as possible.

4) If you can fax or email ATRA a copy we would appreciate tracking the responses (email or fax 601-582-3354.
[Please use your personal or agency stationary for your response. Also, please ask your administrators to submit a letter on our behalf using facility letterhead. Delete this instruction in your final letter]

Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1538-P
P.O. Box 8012
Baltimore, MD 21244-8012
Re: Proposed Rule for Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2010 (42 CFR, parts 412, May 6, 2009)

To Whom It May Concern:

I am a recreational therapist practicing in XX city and XX state.

I would like to take this opportunity to respond to the Proposed Rule for the Inpatient Rehabilitation Facility (IRF) Prospective Payment System for Fiscal Year 2010. 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 proven 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 utilized with a variety of other patient populations.

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 Ms. Charlene M. Frizzera, Acting Administrator for CMS dated May 4, 2009.

Thank you for your consideration of my views.


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cc: ATRA National Office


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