June 16, 2004

Medical Director,
Associated Hospital Service
2 Gannett Drive
South Portland, ME 04106

SUBJ: Draft LCD for Inpatient Rehabilitation (DL16555)

On behalf of the members of the American Therapeutic Recreation Association and recreational therapists working in inpatient rehabilitation settings, we are pleased to provide our comments regarding the “ Draft Local Coverage Determination for Inpatient Rehabilitation”. Our members in Massachusetts and Maine have actively reviewed this LCD and provided us with their comments. On behalf of all our members, we provide this unified response.

The American Therapeutic Recreation Association (ATRA) supports all efforts in inpatient rehabilitation settings to increase efficiencies, effectiveness and improve patient outcomes. We are most pleased with the clarifications provided in the LCD that will increase agency interpretation, implementation and evaluation of the Medicare policies. The language in the LCD is important in that it provides important emphasis on the care and treatment of various inpatient rehabilitation groups and emphasizes that care is provided in a multidisciplinary team approach. The LCD’s recognition that “…the need for inpatient rehabilitation is more dependent on the effects of a patient’s injury or illness (impairments, functional deficits, achievable goals) than on the precipitating cause (diagnosis)…” is laudable. This ruling is consistent with the provision of care that is most reasonable and necessary on a case-by-case basis unlike rulings drafted by other intermediaries.

We are however, specifically concerned with the exclusion of recreational therapy from the list of skilled rehabilitative modalities that may satisfy screening criteria for active and ongoing therapeutic intervention as well as intensity of service screening criteria. Recreational Therapy is recognized as a skilled rehabilitative therapy by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), CARF . . . The Rehabilitation Commission; and within the Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facilities Minimum Data Set Draft 3.0. Recreational therapy, when medically necessary and reasonable plays a critical role in the comprehensive rehabilitation of the inpatient rehabilitation client. Recreational therapy in health care is a skilled rehabilitation therapy modality and as such, should be included in the identified therapies.

We are concerned that this prohibitive language will deny Medicare beneficiaries access to the most appropriate mix of rehabilitative services. The omission of recreational therapy may not have been intentional, however historically, providers will only adhere to services identified in written regulations or guidelines. ATRA’s position that recreational therapy is a skilled rehabilitative modality should be recognized in the LCD descriptions of other skilled rehabilitative modalities.

Communications between ATRA and CMS over the years both confirm the coverage of recreational therapy and clarify that the regulatory language at question is not intended to preclude the utilization of recreational therapy in satisfying the three-hour a day requirement of intense rehabilitative services. ATRA has archived documents relevant to this issue and for your reference, all of ATRA’s correspondence with CMS as well as relevant rulings regarding this matter are located on ATRA’s website. To visit the link, please go to http://atra-tr.org/3hourrule/ with username of atra and password of rehabadmin.

Recreational Therapy in the inpatient rehabilitation facility (as well as other settings) is delivered under the supervision of a physician with a reasonable expectation to improve patient functioning and achieve functional goals in line with those of the rehabilitation team. When indicated, recreational therapy services are prescribed and carried out as active treatment in order to compliment or supplement other rehabilitative modalities utilized in the inpatient rehabilitation facility. Qualified recreational therapists (nationally certified) are skilled in assessing individual progress and problems impeding progress, proficient in determining possible resolutions to such problems, and accustomed to reassessing those measures taken in determining the validity of the goals initially established; each of which are emphasized in the proposed section regarding the coordinated, multi-disciplinary team approach to rehabilitation.

The exclusionary language of the proposed LCD concerns our members particularly because recreational therapy has had, and can continue to have, a significant impact on the lives of Medicare beneficiaries in the inpatient rehabilitation setting. In addition, utilization of recreational therapy is a cost efficient option in providing rehabilitative services.

We specifically recommend the identification of recreational therapy as bolded below:

On page six, 2 b. The patient requires the active and ongoing therapeutic intervention of at least two disciplines (physical therapy, rehabilitation nursing, occupational therapy, recreational therapy, speech therapy, psychology, social work, prosthetics/orthotics)…”

On page 12, “…In some instances, patients who require inpatient hospital rehabilitation services may need, on a priority basis, other skilled rehabilitative modalities such as recreational therapy services, speech-language pathology services, or prosthetic-orthotic services and their stage of recovery makes the concurrent receipt of intensive physical therapy or occupational therapy services inappropriate.”

Without language that specifically recognizes recreational therapy as a skilled rehabilitative modality, Medicare recipients will not have access to the most appropriate mix of rehabilitative therapies.

I would be pleased to answer further questions or provide clarification of recreational therapy services as a skilled rehabilitative modality. Please do not hesitate to contact me at (703) 683-9420 or by email national@atra-tr.org.

Thank you in advance for your assistance in resolving this issue.

Sincerely,

Ann D. Huston, MPA, CTRS
Executive Director

cc: Peter Thomas, ATRA Legislative Counsel
ATRA Board of Directors