evekhm/cms_iom_500 huggingface dataset:
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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.
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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.
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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
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(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)  In addition to the requirements specified above in 140.1.1, an inpatient rehabilitation unit must meet the additional criteria in paragraphs A through M below in order to be excluded from the IPPS and be paid instead under the IRF PPS.   A. - The inpatient rehabilitation unit must be a part of an institution that has in effect an agreement to participate as a hospital that is not excluded in its entirety from the IPPS.   B. - The inpatient rehabilitation unit must have written admission criteria that are applied uniformly to both Medicare and non- Medicare patients.
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B. - The inpatient rehabilitation unit must have written admission criteria that are applied uniformly to both Medicare and non- Medicare patients.   C. - The inpatient rehabilitation unit must have admission and discharge records that are separately identified from those of the hospital in which it is located and are readily retrievable. The record must indicate the dates of the admission and discharge f or patients of the unit. The IRF must also have a process in place to ensure that each patients medical record at the IRF meets the hospital conditions of participation in 42 CFR Part 482 and  all of the documentation requirements specified in 42 CFR 412.622 (a)(3), (4), and (5).  Further guidance on the IRF documentation requirements is available in chapter 1, section 110 of the Medicare Benefit Policy Manual (Pub. 100 -02).  The inpatient rehabilitation unit's policies must provide that necessary clini cal information is transferred to the unit when a patient of the hospital is admitted to the inpatient rehabilitation unit, as described further in chapter 1, section 110.1.1 of the Medicare Benefit Policy Manual (Pub. 100- 02).   D. - If state law provides special licensing requirements for rehabilitation units, the inpatient rehabilitation unit must be licensed in accordance with the applicable requirements.   E. - The hospital's utilization review plan must include separate standards for the type of care offered by the inpatient rehabilitation unit.   F. - The beds assigned to the inpatient rehabilitation unit must be physically separate from (i.e., not co- mingled with) beds not included in the unit.  This means that patients from other parts of the hospital may not be treated in the beds assigned to the inpatient rehabilitation unit.   G. - The hospital must have enough beds not excluded from the IPPS to permit the provision of adequate cost information. The A/B MAC (A)  has discretion as to how to apply generally accepted accounting principles when making this analysis.   H. - The inpatient rehabilitation unit and the hospital in which it is located must be serviced by the same A/B MAC (A) .  I. - The inpatient rehabilitation unit must be treated as a separate cost center for cost finding and apportionment purposes.
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I. - The inpatient rehabilitation unit must be treated as a separate cost center for cost finding and apportionment purposes.   J. - The accounting system of the hospital in which the inpatient rehabilitation unit is located must provide for the proper allocation of costs and maintain statistical data that are adequate to support the basis of allocation.   Compliance with the criteria in items H, I, and J above may be determined based on the hospital's most recently filed cost report or, if necessary, by the hospital's presentation of evidence that shows, to the satisfaction of the A/B MAC (A) , that the hospital has the accounting capability to meet these criteria for the cost reporting period for which the exclusion from the IPPS, if approved, applies.   K. - The cost report for the hospital must include the costs of the inpatient rehabilitation unit, covering the same fiscal period as the hospital, and use the same method of cost apportionment as the hospital.   L. - As of the first day of the first cost reporting period for which all other exclusion requirements are met, the inpatient rehabilitation unit must be fully equipped, staffed, and must be capable of providing hospital inpatient rehabilitation care regardl ess of whether there are any inpatients in the unit on that date.   M. - Each hospital may have only one unit of each type (psychiatric and rehabilitation) excluded from the IPPS.   The criteria specified in paragraphs A through M above are used to determine whether a part of a hospital qualifies for exclusion from the IPPS. An excluded unit must be established as a separate cost entity for cost reporting purposes.
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The criteria specified in paragraphs A through M above are used to determine whether a part of a hospital qualifies for exclusion from the IPPS. An excluded unit must be established as a separate cost entity for cost reporting purposes.   If a hospital wishes to have a unit excluded from the IPPS for a cost reporting period, it must notify its A/B MAC (A) , no later than 5 months prior to the start of that cost reporting period, of the following:  (1) the particular areas that it has designated as the unit, and (2) the square footage and number of beds in the unit.  The A/B MAC (A)  or RO will inform the IRF of the proper procedures. The hospitals notification of its intent to have a unit excluded from the IPPS must be sent to the A/B MAC (A)  at the same time that it is sent to the RO, and it must identify the designated space for the excluded unit through the use of room numbers and/or bed numbers.  The RO will then determine, based on information obtained from the State Survey Agency and the  hospitals A/B MAC (A) , whether the unit qualifies for exclusion from the IPPS. If the RO rejects the hospitals request to have the unit excluded from the IPPS, it will notify the A/B MAC (A) , CMS, and the hospital prior to the start of the hospitals ne xt cost reporting period. If the RO approves the hospitals request to have the unit excluded from the IPPS, it will notify the hospital prior to the start of the hospitals next cost reporting period, and will also notify the A/B MAC (A)   of the units exclusion from the IPPS and of the units new provider identification number.   The hospital must self -attest that it meets all of the applicable criteria for having a unit that is excluded from the IPPS.  This self -attestation is subject to verification by the RO, the State Agency, and the A/B MAC (A).
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After the initial classification as an IRF, changes in the amount of space occupied by the unit, or in the number of beds in the unit, are allowed to be made one time during a cost reporting period if the hospital notifies its Medicare contractor and the R O in writing of the planned change at least 30 days before the date of the change.  A change in bed size or a change in square footage may occur at any time during a cost reporting period and must remain in effect for the remainder of that cost reporting period.   140.1.3 - Verification Process Used To Determine If The Inpatient Rehabilitation Facility Met The Classification Criteria  (Rev. 4038, Issued: 04- 27-18, Effective: 04-23-18, Implementation: 04- 23-18)  A. - Determination of the Compliance Review Time Period.   1. General Guideline To Determine The Compliance Review Period. In general, the RO and A/B MAC (A) will use data from the most recent, consecutive, and appropriate 12-month time period (as defined by CMS) that starts on or after July 1, 2004, to determine if a facility is in compliance with all of the criteria used to classify a facility as an IRF. The RO and A/B MAC (A) will notify the facility of the time period that will be used. The RO and A/B MAC (A) will begin reviewing data 4 months prior to the start of the facilitys next cost reporting  period. The compliance review periods are determined based on the following: 1. Guidelines for Determining Compliance Review Periods For IRFs With Cost Reporting Periods That Start Between July 1, 2004 and October 31, 2004. Data prior to July 1, 2004 will not be used to determine an IRFs compliance with the requirements in 140.1.1B-D. Thus, for IRFs with cost reporting periods beginning on or after July 1, 2004 and before November 1, 2004, less than 12 months of data will be used in their first compliance review period after July 1, 2004. Refer to the first 5 rows of the Table of Compliance Review Periods (below) for an illustration of this.  2. Guidelines for Determining an IRFs Compliance Percentage When the Required Compliance Percentage Threshold Differs Across Two Cost Reporting Periods
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2. Guidelines for Determining an IRFs Compliance Percentage When the Required Compliance Percentage Threshold Differs Across Two Cost Reporting Periods  When a cost reporting period starts on or after July 1, 2005, but not later than June 30, 2006, and the compliance review period spans two cost reporting periods, the compliance percentage is calculated using either of the following two methods. The IRF mu st have a patient population in each of the two portions of time in order to use either of the two methods described below. (A) The IRF must meet the applicable compliance percentage threshold in each of the two portions of the compliance review period separately, as illustrated in the example below. The following is an example of how this first method would be applied:  The compliance review period for an IRF that has a cost reporting period from July 1, 2005 through June 30, 2006 is March 1, 2005 to February 28, 2006.  The IRF must meet a compliance threshold of 50 percent for the cost reporting period of July 1, 2004 to June 30, 2005. The IRF must meet a compliance threshold of 60 percent for the cost reporting period of July 1, 2005 to June 30, 2006.  In this example, the first portion of the compliance review period (from March 1, 2005 to June 30, 2005) is part of the IRFs cost reporting period that started on July 1, 2004 and ends on June 30, 2005. The second portion of the compliance review period ( from July 1, 2005 to February 28, 2006) is part of the IRFs cost reporting period that starts on July 1, 2005 and ends on June 30, 2006. Therefore,  For the portion of the compliance review period from March 1, 2005 to June 30, 2005, the compliance percentage threshold that the IRF must meet is 50 percent.  For the portion of the compliance review period from July 1, 2005 to February 28, 2006, the compliance percentage threshold that the IRF must meet is 60 percent.  If the IRF does not meet the compliance percentage threshold of 50 percent for the March 1, 2005 to June 30, 2005 portion of the compliance review time period, or the compliance percentage threshold of 60 percent for the July 1, 2005 to February 28, 2006 portion of the compliance review time period, it will be determined that the IRF failed to meet the compliance percentage threshold for the entire compliance review period consisting of March 1, 2005 to February 28, 2006.
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(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.
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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.
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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