HI 00610.375 Comprehensive Outpatient Rehabilitation Facility (CORF) Services
P.L. 96-499 (the Omnibus Reconciliation Act of 1980) added to the scope of benefits available to beneficiaries under Part B, certain services furnished by comprehensive outpatient rehabilitation facilities (CORFs). A CORF is recognized as a provider of services, reimbursable on the basis of its reasonable costs. The CORF must provide at least the following three services: physicians' services, physical therapy, and social or psychological services. In addition to this basic package of services, the CORF may furnish and receive reimbursement for as many of the other covered CORF items and services as it wishes.
The facility must have adequate space and equipment necessary to provide any of the services it elects to provide. Additionally, in order to accept a patient, the CORF must be able to provide all of the services required by the patient, as established in the plan of treatment. If the CORF does not have personnel to provide the service, it must arrange for the services to be provided at the CORF, as needed, by outside practitioners. Reimbursement is made by assigned Part A intermediaries acting in the role of Part B carriers.
CORF services are subject to the Medicare Part B deductible and coinsurance provisions; i.e., the CORF may bill the beneficiary only the unmet portion of the deductible and 20 percent of its customary charges for covered services.
A. Covered CORF services
The following are covered CORF services:
Physicians' services related to administrative functions
Physical therapy, occupational therapy, speech pathology services, and respiratory therapy
Social and psychological services
Nursing care provided by or under the supervision of a registered professional nurse
Prosthetic and orthotic devices, including testing, fitting, or training in the use of such devices
Drugs and biologicals which cannot be self-administered
Supplies, appliances, and equipment, including the purchase or rental of durable medical equipment (DME) from the CORF
A single home visit to evaluate the potential impact of the home environment on the rehabilitation goals
B. Noncovered services
The statute specifies that no service may be covered as a CORF service if it would not be covered as an inpatient hospital service if provided to a hospital patient. This does not mean that the beneficiary must require a hospital level of care or meet other requirements unique to hospital care. This provision means that the service, if otherwise covered, would be covered if provided in a hospital. Accordingly, coverage determinations for CORF services are based on established coverage guidelines.
CORF services are not covered if not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the function of a malformed body member. There must be potential for restoration or improvement of lost or impaired functions. For example, repetitive services that do not require the skilled services of nurses or therapists, such as maintenance programs or general conditioning or ambulation, are not covered. These services could be performed in the patient's residence by nonmedical personnel, such as family members. It is not reasonable and necessary for such services to be performed in an ambulatory care setting by CORF personnel.
C. Provision of services
1. Place of treatment
Except for a home evaluation, all CORF services must be furnished on the premises of the CORF, and program reimbursement is made only to the CORF.
2. Personnel qualification requirements
Services must be furnished or supervised by personnel determined to be qualified in accordance with 42 CFR 488.70.
3. Services furnished under arrangements
CORF services provided under arrangements are subject to the provisions of HI 00401.210.
4. Referral for treatment
To become a patient of a CORF, the beneficiary must be under the care of a physician who certifies that the beneficiary needs skilled rehabilitation services. The referring physician must advise the CORF of the beneficiary's medical history, current diagnosis and medical findings, desired rehabilitation goals, and any contraindications to specific activity or intensity of rehabilitation services.
5. Plan of treatment
CORF services must be furnished under a written plan of treatment established by a physician. The physician may be either a physician associated with the CORF or the referring physician if he or she provides a detailed plan of treatment that meets the following requirements:
It must contain the diagnosis, the type, amount, frequency and duration of services to be performed, and the anticipated rehabilitation goals.
It should be sufficiently detailed to permit an independent evaluation of the patient's specific need for the indicated services and of the likelihood that he or she will derive meaningful benefit from them.
It must be reviewed by the CORF physician at least once every 60 days.
Following the review, the physician should certify that the plan of treatment is being followed and that the patient is making progress in attaining the established rehabilitation goals.
When the patient has reached a point where no further progress is being made toward one or more of the goals, Medicare coverage ends with respect to that aspect of the plan of treatment.
D. Specific CORF services
1. Physicians' services
Certain administrative services provided by the physician associated with the CORF are considered CORF services and are reimbursable to the CORF. These services include: examinations for the purpose of establishing and reviewing the plan of treatment, consultation with and medical supervision of non-physician staff, and other medical and facility administration activities.
Physicians' diagnostic and therapeutic services furnished to an individual patient are not CORF physicians' services. If covered, payment for these services is made by the carrier on a reasonable charge basis subject to the same limitations applicable to physicians' services furnished in outpatient hospital settings.
2. Physical therapy services
The coverage guidelines in HI 00601.050A apply to physical therapy services provided by CORFs. Note that under those guidelines, maintenance physical therapy, i.e., repetitive services required to maintain a level of functioning, would not be covered. However, the establishment of a maintenance program for a patient whose restoration potential has been reached would be a covered service. This could include examinations, evaluations of the patient's condition, preparation of the maintenance program, and the training of nonskilled persons to carry out the program.
3. Occupational therapy services
The coverage guidelines in HI 00601.050C also apply to occupational therapy services furnished by a CORF. Note that services involving vocational or prevocational assessment are not covered when they relate solely to vocational rehabilitation; that is, to prepare the patient to qualify for specific employment opportunities, achieve certain work skills, or accommodate a certain work setting. Such services are not considered reasonable and necessary for the diagnosis or treatment of illness or injury.
4. Speech pathology services
Speech pathology services are subject to the guidelines in HI 00601.050B. Services related to congenital speech difficulties, such as stuttering or lisping, would not be covered unless such services are incident to the treatment of otherwise covered CORF services. Although in other outpatient settings, a speech pathologist is permitted to establish a plan of treatment, this is not the case with CORF services. Under the statute, all CORF services must be provided under a plan established by a physician. However, as with other specialities, it is expected that the physician will rely heavily on advice from the speech pathologist.
5. Respiratory therapy services
Respiratory therapy services furnished by a CORF are covered under the guidelines in HI 00601.050D.
6. Prosthetic and orthotic devices
Prosthetic devices, other than dental devices and renal dialysis machines, are covered CORF services, Prosthetic devices are defined as devices that replace all or part of an internal body organ or external body member (including contiguous tissue) or that replace all or part of the function of a permanently inoperative or malfunctioning internal body organ or external body member.
Coverage of a prosthetic device includes all services necessary for formulating its design, material, and component selection; measurement, fittings, static and dynamic alignments; and instructing the patient in its use. Such coverage is included as an integral part of the fabrication of the device.
Orthotic devices are those orthopedic appliances or apparatus used to support, align, prevent, or correct deformities, or to improve the function of moveable parts of the body. As with prosthetic devices, the coverage of an orthosis includes its design, materials, measurements, fabrications, testing, fitting, or training in the use of the orthosis.
7. Social services
Social Services are covered CORF services if they are included in the plan of treatment and contribute to the improvement of the individual's condition. Such services include:
Assessment of the social and emotional factors related to the patient's illness, need for care, response to treatment, and adjustment to care in the CORF.
Assessment of the relationship of the patient's medical and nursing requirements to his or her home situation, financial resources, and the community resources available upon discharge from the CORF.
Counseling and referral for casework assistance in resolving problems in these areas.
8. Psychological services
Covered services include:
Assessment, diagnosis and treatment of the beneficiary's mental and emotional functioning as it relates to his or her rehabilitation.
Psychological evaluations of the individual's response to and rate of progress under the treatment plan.
Assessment of those aspects of an individual's family and home situation that affect the individual's rehabilitation treatment.
Although everyone who has a serious illness or injury may suffer from some degree of anxiety, the coverage of psychological services should not automatically extend to every CORF patient. For example, diagnostic testing for a mental problem would be covered for a cardiac patient who exhibits excessive anxiety or fear following the acute phase of a cardiac problem. However, the routine testing or treatment of all cardiac rehabilitation patients for mental, psychoneurotic, or personality disorders would not be covered.
Family counseling services would be covered only where the primary purpose of that counseling is the treatment of the patient's condition; that is, when there is a need to observe the patient's interaction with family members or to assess the capability of family members to aid in the rehabilitation of the patient. Family counseling services that are primarily directed toward the treatment of a family member's problem with respect to the patient's condition are not covered.
9. Nursing services
Nursing services provided by or under the supervision of a registered professional nurse are covered CORF services.
10. Drugs and biologicals
Drugs and biologicals would be covered when they cannot be self-administered, are administered by or under the supervision of a physician or registered nurse, and are not otherwise excluded from Medicare coverage, such as most injections for immunization. Determinations on whether a drug or biological is of a type that cannot be self-administered should be based on the usual method of administration of the form of that drug or biological as furnished to the CORF patient.
Thus, when a patient is given tablets or other oral medication, these are excluded from coverage since the form of the drug given to the patient is usually self-administered. Similarly, if a patient is given an injection that is usually self-injected, such as insulin, this drug would be excluded from coverage unless administered in an emergency situation such as a diabetic coma, or where, because of the patient's mental or physical condition, self-administration is impossible or unwarranted. However, if a patient receives an injection of a drug that is not usually self-injected and that is also available in oral form, that drug would not be subject to the self-administerable drug exclusion, since it is not self-administerable in the form in which it was furnished to the patient.
11. Supplies, appliances, and equipment
Covered services include:
Nonreusable supplies, such as oxygen or bandages, used in the various therapeutic modalities.
Medical equipment and appliances for the use of patients at the facility.
Durable medical equipment (DME) for use outside the CORF, whether furnished at the CORF or delivered to the beneficiary's home. The beneficiary may obtain DME from the CORF or other DME supplier. The guidelines in HI 00610.190 apply to DME furnished by the CORF. Thus, exercise appliances and other self-help devices that can be used for general conditioning would not qualify as DME. The equipment may be purchased or rented. Payment is made by the intermediary on a reasonable cost basis.
12. Home environment evaluation
One offsite service is permitted - a single home visit to evaluate the potential impact of the home environment on the rehabilitation goals. The purpose of the evaluation is to permit the plan of treatment to be tailored to take into account the patient's home environment. It is not intended that the Medicare program underwrite physical alterations to the home that would facilitate the patient's rehabilitation.
The home evaluation is not covered as a routine service for all CORF patients. It should be covered only if, in establishing or carrying out the plan of treatment, there is a clear indication that the home environment might adversely affect the patient's rehabilitation. Coverage is limited to the services of one professional who is selected by the CORF.