(Medicare Claims Processing Manual)

4. The A/B MAC (A) will use the list of hospital patient numbers to determine the IRFs total inpatient population during the IRFs compliance review period. The A/B MAC (A) will then determine whether the compliance percentage threshold differs or is the same throughout the IRFs compliance review  period.If the compliance percentage threshold differs during the compliance review period (i.e., if it is 50 percent for one portion of the period and 60 percent for the other portion), then the A/B MAC (A) must determine that at least 50 percent of the IR Fs total inpatient population consisted of Medicare Part A fee-for-service patients for both time periods. For example, the A/B MAC (A) will consider the portion of the period in which the compliance percentage threshold is 50 percent and the portion of the period in which the compliance percentage threshold is 60 percent independently and determine if the IRFs total inpatient population consists of at least 50 percent Medicare Part A fee- for-service patients in each of the two time periods.  If, however, the compliance percentage threshold is the same throughout the IRFs compliance review period (i.e., 60 percent throughout the period), then the A/B MAC  (A) must determine that at least 50 percent of the IRFs total inpatient population consisted of Medicare Part A fee -for-service or Medicare Part C (Medicare Advantage) patients (beginning on or after October 1, 2009) for the entire 12-month period. In addition to the above processes, the A/B MAC (A) has the discretion to sample and compare other parameters (that is, diagnoses, procedures, length-of-stay, or any other relevant parameter) to determine that the Medicare Part A fee- for-service and Medicare Part C (Medicare Advantage) population (beginning on or after October 1, 2009) is representative of the IRFs total inpatient population.  A determination by the A/B MAC (A), in accordance with the preceding methodologies, that the IRFs inpatient population for the compliance review period consisted of at least 50 percent Medicare Part A fee- for-service and Medicare Part C (Medicare Advantage) patients (beginning on or after October 1, 2009) means that the A/B MAC (A) can use the procedure stipulated below in subsection C to presumptively de termine if the IRF met the compliance threshold as specified above in  140.1.1B- D.  5. The A/B MAC (A) will inform the RO if an IRF fails to send the list showing the hospital patient number associated with each inpatient IRF admission during the most recent, consecutive, and appropriate 12-month period, as defined by CMS.  Further, the A/B MAC (A) will inform the RO if the list of hospital patient numbers does not show the payer or payers or the admission and discharge dates for each hospital patient number on the list. The RO will notify the IRF that failure to send the A/B MAC (A) the list within an additional 10 calendar days will result in a determination by the RO that the IRF has not met the requirements specified above in 140.1.1B-D and the facility will no longer be eligible for payment under the IRF PPS.   C. - Verification of the Medical Condition Criteria Using the Inpatient Rehabilitation Facility -Patient Assessment Instrument (IRF -PAI) Data  Records (The Presumptive  Methodology)   1. To determine if a facility has presumptively complied with the criteria specified above in 140.1.1B- D, the CMS will enable the A/B MAC (A) to access the CMS' IRF-PAI data records. Specifically, each A/B MAC (A) will be allowed to access only the IRF-PAI information submitted by IRFs that submit claims to that A/B MAC  (A). In order to ensure that the software that matches each IRF to a particular A/B MAC (A) is constantly updated, the A/B MAC (A) must electronically send the RO a table that has at least the following title and column headings:  A/B MAC (A) List Of  IRF Provider Numbers (Specify The A/B MAC (A)s Name)    The Name of Each IRF That Submits Claims To This A/B MAC (A)   IRF Provider Number  IRF Cost Reporting Period    After checking the A/B MAC (A)s list of IRFs for completeness and, as necessary, communicating with the A/B MAC (A) to ensure the accuracy of the information, the RO will forward the A/B MAC (A)s list of IRFs to the CMS designated mailbox IRFACTIVEPROVIDER@cms.hhs.gov.  The CMS contractor that maintains the IRF-PAI database will then, if necessary, update the IRF -PAI database software used to presumptively verify compliance with the requirements specified in 140.1.1B-D. The A/B MAC (A) must coordinate with their CMS R O to obtain access to the software system.   The A/B MAC (A) will provide the RO with user information from all A/B MAC (A) staff that are required to access the IRF -PAI data records.   2. When the A/B MAC (A) accesses the IRF -PAI data records, the A/B MAC (A) will be able to generate an IRF compliance review report using the IRF -PAI information from the IRFs on the A/B MAC (A)s list. The CASPER software used to generate the IRF compliance review report will automatically use the specific diagnosis codes from the appropriate files listed in Presumptive Methodology Files  Implementation of Changes that is attached to the IRF Compliance Rule Specification Files, which are available for do wnload from the IRF PPS website at http://www.cms.gov/Medicare/Medicare- Fee-for-Service- Payment/InpatientRehabFacPPS/Criteria.html , to determine if a particular IRF is presumptively in compliance with the requirements specified in 140.1.1B-D. Prior to generating the IRF compliance review report, the A/B MAC (A) must allow the IRF to decide whether the IRF compliance review report will be generated using the IRF-PAI data records of patients who were admitted during the IRFs compliance review period (even if they were discharged outside of the compliance review period), or the IRF-PAI data records of patients who were discharged during the IRFs compliance review period (even if they were admitted outside of the compliance review period).  Below are the sections of the IRF compliance review report with example data: IRF Compliance Review Report   State  Provider Number Provider Name  Cost Report Start Date  Compliance Review Period  Any State  IRF Number Best Rehab  08/01/2008  04/01/2007 To  03/31/2008  Submitted Assessments  Eligible Assessments  Percent  100 60 60%  The submitted assessments section identifies all of the IRF -PAI data records that the IRF submitted to the IRF -PAI database during the compliance review period. The eligible assessments are the assessments submitted during the compliance review period that match one of the codes in the appropriate files listed in Presumptive Methodology Files  Implementation of Changes that is attached to the IRF Compliance Rule Specification Files, which can be downloaded from the IRF PPS website at http://www.cms.gov/Medicare/Medicare- Fee-for-Service -Payment/InpatientRehabFacPPS/Criteria.html . The cost report start date shown is the start of the facilitys next cost reporting period.  3. If an IRFs inpatient Medicare Part A fee- for-service and Medicare Part C (Medicare Advantage) populations (combined) (beginning on or after October 1, 2009) are at least 50 percent of its total inpatient population and the presumptive methodology (described above) indicates that the IRF met or exceeded the requirements specified in  140.1.1B-D, then the IRF is presumed to have met the requirements specified above in 140.1.1B-D. However, even when an IRF is presumed to have met the requirements specified above in 140.1.1B-D, the RO and A/B MAC (A) still have the discretion to instruct the IRF to send to the RO or A/B MAC (A) specific sections of the medical records of a random sample of inpatients, or specific sections of the medical records of inpatients identified by other means by the CMS or the A/B MAC (A).   4. Each A/B MAC (A) must submit a report to the appropriate CMS RO (with a copy to the CMS Central Office) on at least a quarterly basis that shows each IRFs status with respect to compliance with the requirements specified above in  140.1.1B- D.  The files listed in Presumptive Methodology Files  Implementation of Changes that is attached to the IRF Compliance Rule Specification Files, which can be downloaded from the IRF PPS website at http://www.cms.gov/Medicare/Medicare-Fee-for- Service - Payment/InpatientRehabFacPPS/Criteria.html , will be used to determine presumptive compliance with the requirements specified above in 140.1.1B- D.  D.  Additional Verification of Arthritis Condition  Criteria   Compliance with the regulatory requirements for the arthritis conditions specified above in 140.1.1 B- D cannot be determined by the presence of an impairment group code or diagnosis code alone, but can only be verified through review of the IRF medical record. For this reason, we removed arthritis impairment group codes and diagnosis codes from the list of codes used to determine presumptive compliance for compliance review periods beginning on or after October  1, 2015. However,  beginning on or after October 1, 2015, we also provided for an additional item on the IRF -PAI (item #24A) to enable IRFs to indicate whether the patients arthritis condition(s) meets all of the relevant regulatory requirements specified in 140.1.1 B-D. Using the process described below, the A/B MAC (A) must verify through medical review whether the IRF cases that would not otherwise meet the compliance criteria, and that have a 1  Yes marked in item #24A, meet the severity and prior treatment requirements in 140.1.1B -D. If so, then the A/B MAC (A) must add the appropriate number of these cases to the cases that meet the presumptive compliance criteria.  The A/B MAC (A) shall use the following process for compliance review periods beginning on or after October 1, 2015:  1. If the A/B MAC (A) has determined, using the process outlined in subsection C above, that the IRF does not presumptively meet the requirements specified above in 140.1.1B- D, then the A/B MAC (A) must access an IRF -PAI data report called the IRF Arthritis Verification Report through the CASPER system.  Below are the sections of the IRF Arthritis Verification Report with example data:   IRF Arthritis Verification Report  Provider Number  Provider Name  Patient Name  Patient ID  IRF-PAI ID  Admission Date  Discharge Date   Best Rehab  A. Smith  B. Jones  Z. Honey  12345678A  22345678A  32345678A  987654321  987654322 987654323 10/1/15  10/2/15 10/3/15 10/15/15  10/14/15 10/13/15  2. The A/B MAC (A) must determine whether or not  adding all of the cases listed  on the IRF Arthritis Verification Report for that IRF would be enough to increase the IRFs compliance percentage to equal or exceed 60  percent.   3. If adding all of the cases listed on the IRF Arthritis Verification Report for that IRF would be enough to increase the IRFs compliance percentage to equal or exceed 60 percent, then the A/B MAC (A) must use generally accepted statistical sampling  techniques  to obtain a statistically  valid  random  sample  of those  patients listed for the IRF on the IRF Arthritis Verification Report. If the total number of patients listed for the IRF on the IRF Arthritis Verification Report is less than 10, then the A/B MAC ( A) will review all patients listed for the IRF on the IRF Arthritis Verification Report. (Note that if adding all the cases listed in the IRF Arthritis Verification Report for that IRF would not be enough to increase the IRFs compliance percentage to equa l or exceed 60 percent, then the A/B  MAC  (A) will not proceed further with the IRF arthritis verification process and will use the presumptive compliance percentage generated from section C  above.)   4. The A/B MAC (A) will obtain and examine the medical record sections and any other pertinent information submitted by the IRF to determine if the patients  from the random sample obtained in step 2 meet all of the severity and prior treatment requirements specified in  140.1.1B -D.