(Medicare Claims Processing Manual)

(B) The A/B MAC (A) computes one weighted average compliance percentage for the entire 12 -month compliance review period. The resulting weighted average compliance percentage will be used to determine if the facility met the compliance threshold requirements i n 140.1.1B -D. The following is an example of how this second method would be applied: The compliance review period for an IRF that has a cost reporting period from  August 1, 2005 to July 31, 2006 is April 1, 2005 to March 31, 2006. However, the compliance review period is divided into two portions: April 1, 2005 to July 31, 2005 and August 1, 2005 to March 31, 2006.  In the following hypothetical example, 45 percent of the cases met at least one of the medical conditions listed above in 140.1.1C from April 1, 2005 to July 31, 2005, and 80 percent of the cases met at least one of the medical conditions listed in 140.1.1C from August 1, 2005 to March 31, 2006. The weighted average compliance percentage from the two portions of time must be calculated as follows for compliance review periods beginning on or after January 1, 2013.  4/12 = 0.333 which is rounded to 0.33 8/12 = 0.666 which is rounded to 0.67 0.33 X 45% = 0.1485  0.67 X 80% = 0.5360   0.1485 + 0.5360 = 0.6845 which is rounded to 68%  Based on this result of 68 percent from the weighted average calculation, it will be determined that the IRF met the compliance percentage threshold for the compliance review period starting on April 1, 2005.  3. Guidelines for Determining an IRFs Compliance Percentage When the Required Compliance Percentage Threshold Is the Same for the Entire Compliance Review Period  To minimize the level of effort required by Medicare contractors and IRFs, contractors must review one continuous 12- month period if the compliance percentage threshold is the same throughout the entire compliance review period for all compliance review periods beginning on or after January 1, 2013.   4. Guidelines for Determining the Compliance Review Period of a Facility Classified as a New IRF. According to the regulations in 412.25(c), a new IRF can only begin being paid under the IRF PPS at the start of a cost reporting period. If the IRF begins trea ting patients prior to the start of a cost reporting period, it may receive payment under the IPPS until the start of the next cost reporting period, at which point it can begin receiving payment under the IRF PPS if it meets all of the applicable requirem ents in 412.25 and 412.29. A new IRF will have a compliance review period that starts immediately when its cost reporting period starts, and ends four months before the start of its next cost reporting period. For example, if a facility has a cost report ing period that starts on July 1, 2012 and is a new IRF, its compliance review period would start on July 1, 2012 and end on February 28, 2013. Thus, a facility classified as a new IRF will have an initial compliance review period that is 8 months in length, in order to allow the RO and A/B MAC (A) a 4 -month time period to make and administer a compliance determination.   5. Guidelines for Determining an IRFs Compliance When the IRF Expands its Bed Capacity. Effective October 1, 2011, as long as an IRF meets all of the applicable requirements in 412.25(b) and 412.29(c)(2), it may add new beds one time, at any time, during a cost reporting period. The IRF must provide written certification that the inpatient population it intends to serve (including the patients served in the new beds) meets the requirements in 412.29(b).  In addition, the new IRF beds will be included in the  compliance review calculations  under412.29(b) from the time that they are added to the IRF.   6. Guidelines for Determining the Compliance Review Period of a Facility That Changes Its Cost Reporting Period. A facility that changes its cost reporting period will have a new compliance review period that is based on its new cost reporting period. For exa mple, if an IRF changes the start of its cost reporting period from July 1, 2011 to October 1, 2011, then the start date of its compliance review  period  will also change from March 1, 2011 to June 1, 2011. Excessive changes to cost reporting periods are not permitted. The table below entitled Examples of Compliance Review Periods provides examples of compliance review periods associated with various cost reporting periods. Examples of Compliance Review Periods. For a facility that has been classified as an IRF, but is not a new IRF as defined below in 140.1.4, the following table provides examples of the compliance review periods associated with different cost reporting periods.  Examples of Compliance Review Periods   Start Date of the Cost Reporting Period for Which a Facility Will (or Will Not) be Classified (or Retain Classification) as an IRF Compliance Review Period: (Admissions or Discharges During)  # of Months in Review Period  Compliance Percentage Threshold  07/01/2005  07/01/2004 - 02/28/2005 8 50% 08/01/2005  07/01/2004 - 03/31/2005 9 50% 09/01/2005  07/01/2004 - 04/30/2005 10 50% 10/01/2005  07/01/2004 - 05/31/2005 11 50% 11/01/2005  07/01/2004 - 06/30/2005 12 50% 07/01/2006  03/01/2005 - 02/28/2006 12 03/01/2005 to 06/30/2005:  50 %  07/01/2005 to 02/28/2006:  60 %  08/01/2006  04/01/2005 - 03/31/2006 12 04/01/2005 to 07/31/2005:  50 %  08/01/2005 to 03/31/2006:  60 %  09/01/2006  05/01/2005 - 04/30/2006 12 05/01/2005 to 08/31/2005:  50 %  09/01/2005 to 04/30/2006:  60 %  10/01/2006  06/01/2005 - 05/31/2006 12 06/01/2005 to 09/30/2005:  50 %  10/01/2005 to 05/31/2006:  60 %  11/01/2006  07/01/2005 - 06/30/2006 12 07/01/2005 to 10/31/2005:  50 %  11/01/2005 to 06/30/2006:  60 %  12/01/2006  08/01/2005 - 07/31/2006 12 08/01/2005 to 11/30/2005: 50%  12/01/2005 to 07/31/2006: 60%  For cost reporting periods beginning on or after July 1, 2005, the compliance threshold that must be met is 60 percent. Thus, for all compliance review periods beginning on or after January 1, 2013 (except in the case of new IRFs, as described in section 140.3.4 above), the compliance review period will be one continuous 12-month time period beginning 4 months before the start of a cost reporting period and ending 4 months before the beginning of the next cost reporting period.  B. - Types of Data Used to Determine Compliance with the Classification  Criteria   1. Starting on July 1, 2004, the A/B MAC (A) will use the verification procedures specified below in subsection C which is entitled Verification of the Medical Condition Criterion Using the Inpatient Rehabilitation Facility -Patient Assessment Instrument (IRF- PAI) Data Records or subsection D which is entitled Verification of the Medical Condition Criterion Using the Inpatient Rehabilitation Facilitys Total Inpatient Population to verify that an IRF has complied with the requirements specified above in  140.1.1B- D.  2. The verification procedure specified below in subsection C (that is, verification using the IRF-PAI data) will only be used if the A/B MAC (A) has verified that the IRFs Medicare Part A fee -for-service inpatient population is at least 50 percent of the IR Fs total inpatient population.  Effective for compliance review periods beginning on or after October 1, 2009, A/B MACs (A) must include the IRFs Medicare Part C (Medicare Advantage) inpatient population, along with the IRFs Medicare Part A  fee- for- service inpatient population, in determining whether at least 50 percent of the IRFs total inpatient population is made up of Medicare patients.   3. General Guideline Regarding Submission of a List of the Inpatients in Each IRF: In order to verify that an IRFs Medicare Part A fee -for-service and Medicare Part C (Medicare Advantage) inpatient populations (combined) reflect the IRFs total inpatient population, the A/B MAC (A) in writing will instruct the IRF to send the  A/B MAC (A), by a specific date, a list showing the hospital patient number of each inpatient IRF admission during the IRFs 12-month compliance review period. Note that the term hospital patient number used throughout this section refers to a unique patient identifier used internally within the hospital for patient identification and record -keeping purposes.  For each inpatient on the list, the IRF must include the payer the IRF can bill, or has billed, for treatment and services furnished to the inpatient. If an inpatient on the list has multiple payers that the IRF can bill, or has billed, the IRF must include and specify each type of payer. In addition, for each inpatient on the list, the IRF must include the IRF admission and discharge dates.   Exception to the General Guideline: The Secretary of Health and Human Services can declare a Public Health Emergency under section 319 of the Public Health Service Act or another appropriate statute, and the President can declare either a National Emergency under the National Emergencies Act or a Major Disaster under the RobertT. Stafford Disaster Relief and Emergency Assistance Act, or other appropriate law. In accordance with such declarations, certain regulations or operational policies may bewaived in s pecific geographic areas for limited and defined periods of time. If applicable, in accordance with the waiver provisions, the IRF may be permitted to admit patients (referred to in this section as national emergency or disaster inpatients) who otherwise w ould be admitted to another inpatient setting. The national emergency or disaster inpatients will not be included as part of the IRFs total inpatient population when the IRFs compliance with the requirements specified in140.1.1B -D is determined by the A /B MAC (A) reading a sample of medical records. Therefore, when the IRF submits the list of hospital patient numbers stipulated above in section 140.1.3B3, the IRF will identify each national emergency or disaster inpatient by placing either the capital le tter E or D after the patients unique internal hospital identification number. The A/B MAC (A) will verify the information and, if appropriate, exclude these patients from the list of inpatients used to select a sample of medical records. The IRF shou ld appropriately document in the medical record sufficient information to identify an inpatient as a national emergency or disaster inpatient.