(Medicare Claims Processing Manual)

All IRFs must notify their A/B MACs (A)  and ROs in writing before making any changes to their operations (i.e. increasing their bed size or square footage, moving to a new location, changing ownership, merging, or other similar changes to the ownership or operations of the facility).   140.1.1 - Criteria That Must Be Met By  Inpatient Rehabilitation Facilities (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)  An inpatient rehabilitation hospital or an inpatient rehabilitation unit of a hospital (otherwise referred to as an IRF) is excluded from the IPPS and is eligible for payment under the IRF PPS if it meets all of the criteria listed below.  Note that in ord er for an individual IRF claim to receive Medicare payment under the IRF PPS, it must meet all of the IRF coverage requirements in 42 CFR 412.622(a)(3), (4), and (5), as further clarified in Chapter 1, Section 110 of the Medicare Benefit Policy Manual (Pub . 100- 02.  A. - The IRF must have (or be part of a hospital that has) a provider agreement under 42 CFR Part 489 to participate in Medicare as a hospital.   B. - During the most r ecent, consecutiv e, and appropriate 12-month time  period (a s defined by CMS or the A/B MAC (A)) the  IRF must have  treated an inpa tient popul ation that met or exceede d the following percent ages:  1.  For cost reporting periods be ginning on or  after July 1, 2004, a nd before July 1, 2005, the hospit al must h ave served an inpa tient population of  whom a t least 50 percent  required intensive rehabilita tive services for treatm ent of one or more of the m edical conditions speci fied below a t  140.1.1C .  2. For cost reporting periods beginning on or after July 1, 2005, the IRF must have served an inpatient population of whom at least 60 percent required intensive rehabilitative services for treatment of one or more of the medical conditions specified below at  140.1.1C.   C. - List of  Medical C onditions:   1. Stroke.  2. Spinal cord inju ry.  3. Congenital deformity.  4. Amput ation.  5. M ajor multiple  trauma.  6. Fr acture of femur (hip frac ture).  7. Brain inju ry.  8. Neurological diso rders, inc luding multiple  sclerosis, motor  neuron dis eases, polyneuropathy, mus cular dystrophy, and Parkinsons disease.  9. Burns.  10. A ctive, polyarticular rheumatoid ar thritis, psor iatic arthritis, a nd seronegative arthropathies resulting in significant f unctional imp airment of ambul ation a nd othe r activitie s of daily living  that have not imp roved after an appropriate, aggressive, and sustained course (as defined below) of outpatient therapy services or services in othe r less int ensive  rehabilita tion s ettings, but ha ve the potential to imp rove with mo re intensive  rehabilita tion.  11. S ystemic vasculidit es with joint in flamma tion, resulting  in significant f unctional impairment of ambul ation a nd othe r activitie s of daily living  that have not impr oved after an appropriate, aggressive, and sust ained course (as defined below) of outpa tient therapy services or  services in othe r less int ensive  rehabilita tion s ettings, but would ha ve the potential to imp rove with mo re intensive rehabilita tion.  12. S evere or advanced osteoarthritis (osteoarthrosis or  degenerative joint dis ease) involving two or  more major weight be aring joints (e lbow, shoulder s, hips,  or knees, but not c ounting a  joint with a  prosthe sis) with joint d eformity and subst antial loss of  range of motion, a trophy of muscles surroundi ng the joint, si gnificant f unctional imp airment of ambul ation a nd othe r activitie s of daily living tha t have not imp roved after the patient has participated in a n appropriate, aggressive, and sust ained course (as defined below) of outpatient therapy services or services in othe r less int ensive  rehabilita tion s ettings, but would ha ve the potential to imp rove with mo re intensive re habilita tion.  ( A joint replaced by a prosthe sis no longe r is conside red to ha ve ost eoarthritis, or  other arthritis, even thoug h this c ondition w as the reason f or the joint re placem ent.)  13. Kne e or hip joint re placem ent, or  both, dur ing a hospit alization imme diately precedi ng the IRF stay and also m eets one  or more of the following specific criteria:  a. The  patient unde rwent bilateral kne e or bilateral hip joint re placement sur gery during the hospit al admission imme diately preceding the IRF admission.   b. The  patient is e xtremely obese with a  Body Mass Index of at least 50 at the  time  of admission to t he IRF.  c. The patient is a ge 85 or  older at the time  of admis sion to the  IRF.  Definition of an appropriate, aggressive, and sustained course of outpatient therapy services or services in other less intensive rehabilitation settings   For the medical conditions specified above in subsections 10, 11, and 12, an appropriate, aggressive, and sustained course of outpatient therapy services or services in other less intensive rehabilitation settings must consist of a course of rehabilitation therapy of at least 3 weeks minimum duration with at least two individual (non -group) therapy sessions per week targeting all clinically impaired joints supported by documentation in the medical record of all such services with periodic assessments for cl inical functional improvement, within 20 calendar days of an acute hospitalization preceding immediately an IRF stay, or 20 calendar days immediately preceding an IRF admission.  However, there may be cases when, in the A/B MAC (A)s judgment, the precedin g interpretation of what is considered an appropriate, aggressive, and sustained course of outpatient therapy services or services in other less intensive rehabilitation settings should not be used.  In these cases, the A/B MAC (A)  has the discretion to de velop, document, and use another interpretation, which is based upon local practices and more current clinical information, that interprets or defines what the A/B MAC (A) considers is an appropriate, aggressive, and sustained course of outpatient therapy services or services in other less intensive rehabilitation settings. Regardless of which interpretation or definition is used by the A/B MAC (A)  with respect to what is considered an appropriate, aggressive, and sustained course of outpatient therapy serv ices or services in other less intensive rehabilitation settings, the course of therapy itself should have the goal of completing the rehabilitation, not preparing a patient for surgery.  The outpatient therapy services (or services in other less intensive settings) must immediately precede the IRF admission or result from a systemic disease activation immediately before admission.   The A/B MAC (A)  has the dis cretion to re view documentation to assure th at the patient has completed an a ppropriate, agg ressive, and susta ined cour se of th erapy or s ervices in le ss intensive re habilitation se ttings.  CMS  expects th at the IRF will obtain copies of the th erapy notes from the outpa tient therapy or from the th erapy services provided in another le ss intensive se tting and include these in the pa tient s medical record at the IRF (in a s ection for prior records).  CMS  believes that these prior rec ords will be  used by therapists and other s caring for the patient in the IRF, and will also be ava ilable to the A/B MAC (A)  staff who re view the  medi cal records for co mpliance with the re quirements sp ecified above in 140.1.1B-D.  D. - Comorbidities. A comorbidity is a specific patient condition that is secondary to the patients principal diagnosis. A patient with a comorbidity may be counted as part of the inpatient population that counts towards the required applicable percentage specified above in 140.1.1B- D if:  1. The patient is admitted for inpatient rehabilitation for a medical condition that is not one of the conditions specified above in sub-section 140.1.1C.  2. The patient has a comorbidity that falls in one of the medical conditions specified above in sub -section 140.1.1C; and   3. The comorbidity has caused significant decline in functional ability in the individual such that, even in the absence of the admitting condition, the individual would require the intensive rehabilitation treatment that is unique to inpatient rehabilitation facilities paid under the IRF PPS.  E. - For the first cost reporting period during which a facility first begins being paid under the IRF PPS as a new IRF, a facility seeking to be paid under the IRF PPS must provide a written certification to the A/B MAC (A)  that the inpatient population it intends to serve meets the requirements specified above in 140.1.1B -D.  However, if CMS discovers that the facility did not actually meet the requirements specified above in 140.1.1B -D during any cost reporting period for which the facility provided such written certification of its intent to meet the requirements in 140.1.1B -D, then  CMS will adjust the payments associated with that cost reporting period as described below in 140.1.9.   F. - The IRF has in e ffect a  preadmission s creening procedure unde r which each prospective  patient's condition a nd m edical histo ry are reviewed to de termine whether the patient is lik ely to be nefit significantly from a n intensive  inpa tient hospit al rehabilita tion program.  This procedure must ensure that the preadmission screening is reviewed and approved by a rehabilitation physician prior to the patients admission to the IRF.  G. - The IRF has in effect a procedure to ensure that patients receive close medical supervision, as evidenced by at least 3 face -to-face visits per week by a licensed physician with specialized training and experience in inpatient rehabilitation to assess the patient both medically and functionally, as well as to modify the course of treatment as needed to maximize the patients capacity to benefit from the rehabilitation process.   H. - The IRF furnishes, through the use of qualified personnel, rehabilitation nursing, physical therapy, and occupational therapy, plus, as needed, speech -language pathology, social services, psychological services (including neuropsychological services), and orthotic and prosthetic services.   I. - The IRF has one physician who serves as director of rehabilitation and who   (1) Provides services to the IRF hospital or its inpatients on a full -time basis or, in the case of a rehabilitation unit, at least 20 hours per week;   (2) Is a doctor of medicine or osteopathy;   (3) Is licensed under State law to practice medicine or surgery; and   (4) Has had, after completing a one -year hospital internship, at least 2 years of training or experience in the medical management of inpatients requiring rehabilitation services.   If an IRF serves both inpatients and outpatients, the time spent by the director in performing administrative duties for the entire facility counts toward the direction requirement since it is not feasible to prorate this administrative time between inpati ents and outpatients. However, any time spent in furnishing direct patient care can count toward the direction requirement only if the care is furnished to inpatients.   J. - The IRF has a plan of treatment for each inpatient that is established, reviewed, and revised, as needed, by a physician in consultation with other professional personnel who provide services to the patient.   K. - The IRF uses a coordinated interdisciplinary team approach in the rehabilitation of each inpatient, as documented by periodic clinical entries made in the patient's medical record to note the patient's status in relationship to goal attainment and discharge plans.  The IRF must also ensure that team conferences are held at least once per week to determine the appropriateness of treatment.   140.1.2 - Additional Criteria That Must Be Met By Inpatient Rehabilitation Units  (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)