Discharge Planning: What Do I Wish I Knew As A Clinician?

I officially became a licensed Physical Therapist on September 11, 2006. The acute care setting was where I spent the majority of my 1st 7 years as a clinician. I have learned from multiple intelligent co-workers since I started my career, but there are some lessons that I didn't learn until I started my nonclinical career. In acute care, therapists are often asked what discharge recommendations they have for a patient. Personally, I think this is an area not discussed much in school. Much that is learned often comes from the advice of senior clinicians followed by clinical experience. With my job as a Pre-Service Coordinator, I find that knowing who is versus who isn't appropriate for Acute Inpatient Rehabilitation (AIR) at an Inpatient Rehab Facility (IRF) seems to be a common issue. I want to share what I wish I knew as a clinician when it comes to recommending if someone goes to an IRF.


1) Medicare (CMS) has strict guidelines for inpatient rehab

Prior to taking my job as a Pre-Service Coordinator, I had 14+ years of experience as a PT and achieved Board Certification in Geriatrics. I would like to say I was very knowledgeable regarding CMS guidelines. If you were to have asked me, "What makes someone appropriate for inpatient rehab?" I would have said, "They can handle 3 hours of therapy 5 days a week." Based on all the charts I review, I think that is what most therapists think too. Yes, it is true that a patient needs to tolerate 3 hours of therapy a day (or 15 hours per week), but that is only 1 of the criteria.

Inpatient rehab guidelines are in Chapter 1 of The Medicare Benefit Policy Manual. Section 110.2 (page 35) provides 5 "MUSTS."

  1. Needs multiple therapy disciplines (PT, OT, SLP, Prosthetics/Orthotics). 1 needs to be PT or OT.

  2. Requires intensive therapy (i.e. 3 hours a day/5 days a week).

  3. Patient will participate and significantly benefit from the intensive therapy through measurable improvement within an prescribed amount of time.

  4. Physician oversight through face-to-face visits 3 days a week.

  5. Requires intensive and coordinated interdisciplinary approach.

The thing that gets most therapists, and is honestly outside our control the majority of the time, involves the 4th one. Does the patient need a physician to oversee care 3 days a week? The problem is that the answer is often "no." Despite meeting all the other criteria, missing 1 of the 5 will lead to a denied authorization.


2) Your documentation may make a good candidate get denied

Therapists want to show progress, but many times trying to show progress within a short period of time may minimize the need for intensive inpatient rehab. I see this frequently with reviewing charts and it makes me cringe because I know the thought process of the clinician. Common issues I see include:

  • Walking the patient hundreds of feet when their biggest problem is balance.

  • Performing functional mobility at an easier, modified position only (e.g. bed mobility with head of bed elevated or edge of bed transfers).

  • Focusing on the ADLs that the patient does well only instead of the ADLs that require more assistance.

Unfortunately, I have made similar errors as a clinician. If I could go back in time, I would have focused my treatments and documentation on the major deficits to show greater need for therapy services. I highly encourage other therapists recommending IRF consider doing the same because I wish I was told this when I was a clinician.


3) Medicare has an appeals process

My job as Pre-Service Coordinator involves telling people the bad news that rehab authorization has been denied. Along with the denial notification, I always inform them of the option to appeal the decision. I don't know statistically how many choose to appeal and how many of those appeals are overturned. I do believe there are many that would likely have a successful appeal but forfeit their rights because of the inconvenience. I understand it is an annoyance because the process takes time, but not appealing only reinforces the belief that it lacks medical necessity.

Medicare has a very good booklet called Medicare Appeals going over the process if you want to learn more about appeals. There is way too much information to discuss it in this blog.

No matter what, I believe therapists should advocate for their patient. It is very difficult navigating the medical system when you have medical knowledge. I cannot imagine what it would be like having no medical background. Patients depend on your expertise and if you feel very strongly about a discharge recommendation, please advocate for your patients!


Are you a clinician who wants to join the nonclinical world? The most important thing you need to start is to have a good nonclinical resume! You can download my free e-book Nonclinical Resumes That Get Interviews!

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Phillip Magee in scrubs

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