evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
(i) the IRFs Medicare population (including Medicare Part A fee -for-service and Medicare Part C (Medicare Advantage) patients, effective October 1, 2009) is not at least 50 percent of its total inpatient population; or  (ii) the A/B MAC (A) is unable to generate a valid IRF compliance review report using the IRF-PAI database methodology specified previously; or (iii) the A/B MAC (A) generates an IRF compliance review report, based on the use of the presumptive methodology, which demonstrates that the IRF has not met the requirements specified above in 140.1.1B- D.  If the IRFs Medicare Part A fee -for-service and Medicare Part C (Medicare Advantage) populations (combined, effective October 1, 2009) comprise less than 50 percent of the IRFs total inpatient population, or the A/B MAC (A) otherwise determines that the Medicare Part A fee- for-service and Medicare Part C (Medicare Advantage) populations (combined, effective October 1, 2009) are not representative of the overall IRF inpatient population, or the A/B MAC (A) is unable to generate a valid report using the pre sumptive methodology, the presumptive determination is that the IRF did not meet the requirements specified above in 140.1.1B -D.  2. As previously stated above, the A/B MAC (A) will instruct the IRF to send the A/B MAC (A) a list showing the hospital patient number of each inpatient that the IRF admitted during the most recent, consecutive, and appropriate 12- month period, as defined by CMS.  The list of hospital patient numbers must include the payer(s) and admission and discharge dates that correspond with the inpatients whose hospital patient numbers are shown on the list. The A/B MAC (A) will then use generally accepted statistical s ampling techniques to obtain a random sample of inpatients  from the list. The random sample of inpatients drawn from the list must be sufficiently large to ensure that the A/B MAC (A) can determine, with at least 95 percent confidence, whether the IRFs compliance percentage is below the required compliance threshold (i.e., not in compliance) or at or above the required compliance threshold (i.e., in compliance).
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For example, suppose that the required compliance threshold for an IRF to be in compliance with the requirements specified above in 140.1.1B -D is 60 percent. The A/B MAC (A) reviews a random sample of claims from IRF A and estimates that IRF As complianc e percentage is 58 percent.  Suppose that the standard deviation that the  A/B MAC (A) calculates for IRF As random sample of IRF claims is plus or minus 4 percentage points, so that the 95 percent confidence interval in this particular example is between 54 percent and 62 percent (with 58 percent as the midpoint). In this case, the IRF is considered to be in compliance with the 60 percent rule, since 60 percent is within the 95 percent confidence interval. To verify whether the IRF is in fact in compliance  with the requirements specified above in 140.1.1B -D, the A/B MAC (A) may need to draw a larger random sample of the IRFs inpatients. For example, a larger random sample of IRF As inpatients might have reduced the standard deviation to plus or minus 1 percentage point, which would have led the 95 percent confidence interval to be between 57 percent and 59 percent. This would have demonstrated with 95 percent confidence that the IRF was not in compliance with the requirements specified above in 140.1.1B -D (because the entire 95 percent confidence interval was below the required compliance threshold of 60 percent).   If the compliance percentage threshold differs within the compliance review period (i.e., is 50 percent for a portion of the compliance review period and 60 percent for the other portion of the period), then a random sample of inpatients will be drawn from  each of the two time periods separately.  The use of generally recognized statistical sampling principles may result in a determination that it would be inappropriate to use a sample to determine the facilitys compliance percentage. If a random sample is not appropriate in a particular case, then the A/B MAC (A) will use the IRFs entire inpatient population to determine the  IRFs compliance percentage. In addition, if the IRF had 100 or fewer inpatients during the compliance review period, then the A/B MAC (A) must use the IRFs total inpatient population (consisting of both Medicare and non - Medicare inpatients)
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if the IRF had 100 or fewer inpatients during the compliance review period, then the A/B MAC (A) must use the IRFs total inpatient population (consisting of both Medicare and non - Medicare inpatients) to determin e the IRFs compliance percentage.  Prior to selecting the random sample of inpatients, the A/B MAC (A) must allow the IRF to decide if the IRF wants the sample to contain either the patients who were admitted during the IRFs compliance review period (even if some of those patients were dis charged outside of the compliance review period) or the patients discharged during the IRFs compliance review period (even if some of those patients were admitted outside of the compliance review period).  If the A/B MAC (A) uses a random sample of the IRFs inpatient population (rather than the IRFs total inpatient population) to determine the IRFs compliance percentage, then the A/B MAC (A) must ensure that an adequate sample size is used to determine (w ith at least a 95 percent statistical level of confidence) whether or not the IRF has met the requirements in 140.1.1B -D. In some cases, this will require the A/B MAC (A) to expand the size of the random sample of inpatients selected from a particular IRF . The A/B MAC (A) will instruct the IRF to send it copies of specific sections of the medical records for all of the inpatients to be used in the compliance review. The A/B MAC (A) has the discretion to decide which specific sections of the medical recordsto  obtain, provided that the requested medical record sections contain enough information to allow the A/B MAC (A)s reviewers to determine the medical condition(s) for which each inpatient received treatment in the IRF. In addition to submitting the request ed sections of the medical records, the IRF has the discretion to send the A/B MAC (A) other clinical information regarding these same inpatients.
(Medicare Claims Processing Manual)
3. The A/B MAC (A) will examine the medical record sections and any other information submitted by the IRF to determine if the IRF meets the requirements specified above in 140.1.1B -D.  To determine if a specific inpatient matches one of the medical conditions specified in 140.1.1C, the A/B MAC (A) may use the diagnosis and impairment group codes specified 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 , for general guidance.  The A/B MAC (A) is not permitted to use these codes to make a final determination as to whether or not the specific inpatient required intensive rehabilitation services for treatment of one or more of the medical conditions specified in 140.1.1C. The determination of whether a specific inpatient required intensive rehabilitation services for treatment of a condition can only be determined through careful review of that inpatients unique clinical characteristics and circumstances, as reflected in the inpatients medical record.   4. In general, when the A/B MAC (A) is using a sample of medical records to determine compliance with the requirements in 140.1.1B- D, the A/B MAC (A) always has the discretion to determine if a patient meets or does not meet any of the medical conditions listed  in 140.1.1C based upon a review of the clinical record, regardless of the results of the presumptive methodology described previously. In other words, the compliance percentage that is determined using the medical review methodology described in this section will supersede the compliance percentage that was determined for the same compliance review period using the presumptive methodology. To ensure that the compliance review process is similar for all IRFs, the A/B MAC (A) must have written policies that describe the reasons for using a random sample of medical records to determine an IRFs compliance percentage when the presumptive methodology has shown that the IRF met the compliance  threshold.
(Medicare Claims Processing Manual)
5. The A/B MAC (A) will inform the RO if an IRF fails to provide information in accordance with the requirements specified above in subsection D2. The RO will notify the IRF that failure to provide the A/B MAC (A) with the information in accordance with the r equirements specified above in subsection D2 will result in a determination by the RO that the IRF has not met the requirements specified  above in 140.1.1B- D.  F. - By the 15th day of each month, the A/B MAC (A) responsible for determining the compliance percentage for each IRF using either of the methods specified above in 140.1.3C or 140.1.3D will submit a report to CMS via e-mail.  Instructions regarding the format of the report, how to complete the report, and where to send it are specified on the IRF PPS website at: http://www.cms.gov/Medicare/Medicare-  Fee-for-Service-  Payment/InpatientRehabFacPPS/Criteria.html .  G. - The A/B MAC (A) must verify that the requirements specified above in 140.1.1B-E and 140.1.2 G- K were  met.  H. - The State Agency will determine whether the criteria specified above in  140.1.1F-K and 140.1.2 Q were met.  140.1.4 - New IRFs (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)
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140.1.4 - New IRFs (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)  An IRF hospital or IRF unit is considered new if it has not been paid under the IRF PPS for at least 5 calendar years.  A new IRF will be considered new from the point that it first participates in Medicare as an IRF until the end of its first full 12 -month cost reporting period.  A new IRF must provide written certification that the inpatient population it intends to serve will meet the requirements in 140.1.1B- D above. The written certification is effective for the first full 12 -month cost reporting period that occurs after the IRF begins being paid under the IRF PPS, and for any cost reporting period of not less than 1 month and not more than 11 months occurring between the date the IRF begins being paid under the IRF PPS and the start of the IRFs first full 12 -month cost reporting period.   As described in section 140.1.9 below, retroactive adjustments may be made for any period during which the hospital has self- attested to meeting the requirements specified in 140.1.1B-D, but is shown not to have actually met these requirements during that period.  140.1.5 - Changes in the Status of an IRF Unit  (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)
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For purposes of payment under the IRF PPS, the status of an IRF unit may be changed from not excluded from the IPPS to excluded from the IPPS only at the start of a cost reporting period. If an IRF unit is added to a hospital after the start of a cost reporting period, it cannot be excluded from the IPPS before the start of the hospital's next cost reporting period.  The status of an IRF unit may be changed from excluded from the IPPS to not excluded from the IPPS at any time during a cost reporting period, but only if the hospital notifies the A/B MAC (A) and the RO in writing of the change at least 30 days before the date of the change.  In addition, the hospital must maintain the information needed to accurately determine which costs are and are not attributable to the IRF unit. A change in the status of a unit from excluded to not excluded that is made during a cost reporting period must remain in effect for the remainder of that cost reporting period.   140.1.6 - New IRF Beds  (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)  Any IRF beds that are added to an existing IRF must meet all applicable State Certificate of Need and State licensure laws.  New IRF beds may be added one time at any time during a cost reporting period and will be considered new for the rest of that cost reporting period.  A full 12- month cost reporting period must elapse between the delicensing or decertification of IRF beds in an IRF hospital or IRF unit and the addition of new IRF beds to that IRF hospital or IRF unit.  Before an IRF can add new beds, i t must receive written approval from the appropriate CMS RO, so that the CMS RO can verify that a full 12-month cost reporting period has elapsed since the IRF has had beds delicensed or decertified.   New IRF beds are included in the compliance review calculations for determining compliance with 140.1.1B -D above from the time that they are added to the IRF.    140.1.7 - Change of Ownership or Leasing  (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)
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140.1.7 - Change of Ownership or Leasing  (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)  If an IRF hospital (or a hospital that has an IRF unit) undergoes a change of ownership or leasing, as defined in 42 CFR 489.18, the IRF hospital (or IRF unit of a hospital) retains its excluded status and will continue to be paid under the IRF PPS before and after the change of ownership or leasing if the new owner(s) of the IRF hospital (or the hospital with an IRF unit) accept assignment of the previous owners Medicare provider agreement and the IRF continues to meet all of the requirements for payment under the IRF PPS.  Note that an IRFs payment status under the IRF PPS is a Medicare classification s tatus, which cannot be separated from its host hospital and therefore cannot be purchased outside of the purchase of its host hospital.   If the new owner(s) do not accept assignment of the previous owners Medicare provider agreement, the IRF is considered to be voluntarily terminated and the new owner(s) may re-apply to the Medicare program to operate a new IRF, under the requirements for new IRFs in 140.1.4 above.   If, after the change of ownership or leasing, the IRF does not continue to meet all of the requirements for payment under the IRF PPS, then the IRF loses its excluded status and will be paid instead under the IPPS.  140.1.8 - Mergers  (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)
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If an IRF hospital (or a hospital with an IRF unit) merges with another hospital and the owner(s) of the merged hospital accept assignment of the IRF hospitals provider agreement (or the provider agreement of the hospital with the IRF unit), then the IRF hospital or IRF unit retains its excluded status and will continue to be paid under the IRF PPS before and after the merger, as long as the IRF hospital or IRF unit continues to meet all of the requirements for payment under the IRF PPS. Note that an IRFs  payment status under the IRF PPS is a Medicare classification status, which cannot be separated from its host hospital and therefore cannot be merged with another entity outside of the merger with its host hospital.   If the owner(s) of the merged hospital do not accept assignment of the IRF hospitals provider agreement (or the provider agreement of the hospital with the IRF unit), then the IRF hospital or IRF unit is considered voluntarily terminated and the owner(s) of the merged hospital may re -apply to the Medicare program to operate a new IRF under the requirements for new IRFs in 140.1.4 above.   140.1.9 - Retroactive Adjustments for Provisionally Excluded IRFs or IRF Beds  (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)  For cost reporting periods beginning on or after October 1, 1991, if a new IRF (or new beds that are added to an existing IRF) are paid under the IRF PPS for an initial cost reporting period during which the hospital has self -attested to meeting the requir ements specified above in 140.1.1B -D, but the inpatient population actually treated in the new unit or the beds added to the existing unit during that cost reporting period do not meet the requirements specified above in 140.1.1B -D, CMS adjusts payments to the hospital retroactively in accordance with the procedure specified below.
(Medicare Claims Processing Manual)
A. - If an IRF hospital, IRF unit, or group of new IRF beds is paid under the IRF PPS for a cost reporting period based on a written certification that it will meet the requirements specified above in 140.1.1B -D, but does not actually meet the requirement f or that cost reporting period, CMS adjusts Medicare payments to the hospital retroactively in accordance with paragraph C below.  B. - In the case of a unit to which new beds have been added, the requirement in 140.1.1B -D above is applied to the entire unit, including both new and existing beds. If the entire unit is able to meet the requirement, the previously existing unit and the a dded beds are presumed to meet the requirement separately and no payment adjustment as specified below in paragraph C is made. If the unit as a whole does not meet the requirement specified above in 140.1.1B -D, the hospital must furnish the A/B MAC (A) or the State Agency, as specified by the RO, the information needed to determine whether the requirement specified in 140.1.1B -D above was met by the established portion of the unit (that is, the previously existing unit) and by the newly added beds, cons idered separately. If the hospital is not able to demonstrate that the established portion of the unit met the requirement, then that portion of the facility will not be classified as an IRF for the following cost reporting period.  Retroactive adjustments  may apply.
(Medicare Claims Processing Manual)
If the added beds are shown to have met the requirement specified above in 140.1.1B -D, then those beds are eligible to be included as part of the units classification as an IRF for the following cost reporting period. If the added beds did not meet the r equirement, the A/B MAC (A) adjusts its payment to the unit retroactively in accordance with paragraph C below and the added beds will not be included as part of the unit classified as an IRF for the following cost reporting period.   If the hospital does not have the records needed to discriminate between the performance of the previously existing unit and that of the added beds, or for other reasons does not furnish the information requested by the A/B MAC (A) or State Agency, neither  the previously existing unit nor the added beds will be classified as an IRF for the following cost reporting period. In that case, the A/B MAC (A) adjusts its payment to the entire unit retroactively in accordance with paragraph C below.   C. - The A/B MAC (A) adjusts payment to the hospital by calculating the difference between the amount actually paid for services to Medicare patients in the IRF hospital, IRF unit, or new IRF beds during the period of provisional exclusion, and the amount that would have been paid if the IRF hospital, IRF unit, or new IRF beds had not been excluded from the IPPS. The A/B MAC (A) then takes action to recover the resulting overpayment, or corrects the underpayment to the hospital.  140.2 - Payment Provisions Under IRF PPS  (Rev.  11504, Issued 08- 05-22; Effective:10 -01-22; Implementation: 10 -03-22)  Section 1886 of the BBA provides the basis for establishing the Federal payment rates applied under PPS to IRFs. The PPS incorporates per discharge federal rates based on average IRF costs in a base year updated for inflation to the first effective period of the system.  IRF PPS providers are not subject to the 3-day payment window for pre -admission services, but are subject to the 1-day payment window for pre -admission services.
(Medicare Claims Processing Manual)
Beneficiary liability will operate the same as under the current Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) payment system. Even if Medicare payments are below cost of care for a patient under prospective payment, the patient cannot be billed for the difference in any case.  Below are the annual rate update Change Requests (CRs) for Fiscal Years 2003-2022:   FY 2022  CR 12364  FY 2021  CR 11858  FY 2020  CR 11345  FY 2019  CR 10826  FY 2018  CR 10125  FY 2017  CR 9669  FY 2016  CR 9236  FY 2015  CR 8788  FY 2014  CR 8326  FY 2013  CR 7901  FY 2012  CR 7510  FY 2011  CR 7076  FY 2010  CR 7029  FY 2010  CR 6607 FY 2009  CR 6166 FY 2008  CR 5694 FY 2007  CR 5273 FY 2006  CR 4037 FY 2005  CR 3378 FY 2004  CR 2894 FY 2003  CR 2250  Change Requests can be accessed through the following CMS Transmittals Website: https://www.cms.gov/Regulations -and-Guidance/Guidance/Transmittals/index.html   Rate and weight information used by the IRF Pricer is updated periodically, usually annually, and is published in the Federal Register. Updates occur each October, to reflect the fact that IRF PPS rates are effective for a Federal fiscal year. Updates may also occur at other points in the year when required by legislation.  Whenever these update items change, Medicare also publishes a Recurring Update Notification to inform providers and A/B MACs (A) about the changes. These Recurring Update Notifications also describe how the changes will be implemented through the IRF Price r.  140.2.1 - Phase -In Implementation  (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)
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140.2.1 - Phase -In Implementation  (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)  Under the BBA, the Federal fiscal year in which a facility's cost reporting period begins determines which transition period percentages apply. The first transition period percentages are applicable for cost reporting periods beginning during Federal fiscal year 2001. The second transition period percentages are applicable to cost reporting periods beginning during Federal fiscal year 2002, that is, periods beginning on or after October 1, 2001, and before October 1, 2002. For cost reporting periods beginning during Federal fiscal year 2003 and after, payment is based on 100 percent of the adjusted Federal prospective payment.    Since CMS is implementing the IRF PPS for discharges that occur during the IRF's cost reporting period that begins on or after January 1, 2002, IRFs are phased directly into the second transition period, where payment will be based on 66 2/3 percent of the PPS payment and 33 1/3 percent of the TEFRA payment. A facility will continue to be paid under the TEFRA (reasonable cost -based) system for its entire cost reporting period beginning prior to January 1, 2002.   In addition, 305 of the BIPA 2000 states facilities may elect to be paid 100 percent PPS payment, rather than payment based on the transition method. If a facility chooses not to be paid under the transition method, they must notify their A/B MAC (A) no later than 30 days prior to its first cost reporting period for which the IRF PPS applies to the facility. The request to make the election must be made in writing to the Medicare A/B MAC (A) for the facility.  The A/B MAC (A) must receive the request on or before the 30th day before the applicable cost reporting period begins, regardless of any postmarks or anticipated delivery dates. Requests received, postmarked, or delivered by other means after the 30th day before the cost reporting period begins will not be approved. If the 30th day before the cost reporting period falls on a day that the postal service or other delivery sources are not open for business, the facility is responsible for allowing sufficient time for delivery of the request before the deadline. If a facility's request is not received or not approved, payment will be based on the transition method.