11.1 Overview

To address medical and rehabilitation issues that require 24-hour-a-day nursing services, inpatient comprehensive medical rehabilitation services (ICMRS) are provided as recommended by an interdisciplinary team in a hospital setting. These services are available to people who have a traumatic brain injury (TBI), a traumatic spinal cord injury (TSCI), or both. An interdisciplinary team of professionals closely coordinates services to achieve the team’s treatment goals, thereby minimizing a person's physical or cognitive disabilities and maximizing a person's functional capacity. HHSC negotiates contracts with inpatient and outpatient facilities to provide services based on data from the ratio to cost to charges.

Inpatient comprehensive medical rehabilitation services are delivered through contract with hospitals and are governed by the terms of those contracts. The services are specified in the service array and, unless otherwise specified, should be considered all inclusive. If a participant requires medication, the hospital pharmacy provides the medication. Pharmacy charges appear as a line item on the invoice and are paid per the contracted rate. Goods or services approved by the CRS program that are not part of the contracted rate for inpatient comprehensive medical rehabilitation services are considered ancillary. See Chapter 14, Traumatic Brain Injury and Traumatic Spinal Cord Injury – Ancillary Goods and Services for additional details.

11.2 Required Documentation

The primary medical and rehabilitation (PM&R) physician overseeing the participants care while in ICMRS is a separate service which requires pre-authorization. It is the responsibility of the ICMRS provider to notify CRS staff of the PM&R physician’s identity for CRS to pre-authorize and issue a service authorization.

The provider submits:

  • a list of specialists who provide inpatient comprehensive medical rehabilitation services;
  • an estimate of the number of visits that will be needed during the participant’s hospitalization; and
  • a report detailing the charges and services provided during the participant’s stay in the hospital.

See Chapter 4, General Provider Responsibilities for additional documentation requirements.

11.3 Assessment, Planning and Interdisciplinary Meetings

An assessment (see Chapter 10.1) and Individualized Program Plan (IPP) (see Chapter 10.2) must be completed to address participant’s deficits. The CRS counselor may request additional supporting documentation as needed. All planned and needed services for the participant must be documented. This must be reviewed to preauthorize services.

The IDT must meet every 30 days to review the IPP to determine medical necessity for on-going services.

The IPP and supporting data must include information on:

  • the participant’s condition;
  • medical necessity;
  • the course of treatment;
  • the progress the participant’s is making toward the treatment goals;
  • the physician’s hand-written prescriptions for the rehabilitation service;
  • the physician’s current treatment plan;
  • data supporting the treatment plan;
  • staffing summaries and assessments; and
  • the participant’s current medication regime.

Reauthorization may not be approved, if the CRS program does not receive an updated status every 30 days.

11.4 Billing Guidelines

Inpatient comprehensive medical rehabilitation services are billed at a contracted rate. Ancillary goods and services must be preauthorized by a CRS program staff member and are reimbursed based on the fee for service in accordance with 1 TAC §355.9040.

The provider:

  • submits a prescription or a physician’s order to the CRS program staff member to issue a service authorization;
  • submits the participant’s Individualized Program Plan, which identifies the services needed; and
  • obtains authorization from the CRS program staff member.

The CRS program does not pay for personal items, such as television rental, phone calls, gourmet meals, cots and guest trays. In addition, the CRS program does not pay for a private room unless the physician orders it as medically necessary, or no other room is available. If the provider provides services without a service authorization or outside of the scope of originally proposed or approved dates, payment for those services is not guaranteed. Invoices must be submitted at least monthly, and no later than the fifteenth of each month following the service. See Chapter 6, General Billing Guidelines.

11.5 Exceptions and Limitations

Inpatient comprehensive medical rehabilitation services are approved only when no more than one year has elapsed between the date of injury and the date of initial contact. All services must be preauthorized by the CRS counselor. ICMRS services are approved in 30-day increments and cannot exceed a total of 90 days.