CMS Pub. 100-04, ch. 3, § 140.1.1

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 order 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 recent, consecutive, and appropriate 12-month time period (as

defined by CMS or the A/B MAC (A)) the IRF must have treated an inpatient population

that met or exceeded the following percentages:

1. For cost reporting periods beginning on or after July 1, 2004, and before July 1, 2005,

the hospital must have served an inpatient population of whom at least 50 percent

required intensive rehabilitative services for treatment of one or more of the medical

conditions specified below at § 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 Conditions:

1. Stroke.

2. Spinal cord injury.

3. Congenital deformity.

4. Amputation.

5. Major multiple trauma.

6. Fracture of femur (hip fracture).

7. Brain injury.

8. Neurological disorders, including multiple sclerosis, motor neuron diseases,

polyneuropathy, muscular dystrophy, and Parkinson’s disease.

9. Burns.

10. Active, polyarticular rheumatoid arthritis, psoriatic arthritis, and seronegative

arthropathies resulting in significant functional impairment of ambulation and other

activities of daily living that have not improved after an appropriate, aggressive, and

sustained course (as defined below) of outpatient therapy services or services in other

less intensive rehabilitation settings, but have the potential to improve with more

intensive rehabilitation.

11. Systemic vasculidites with joint inflammation, resulting in significant functional

impairment of ambulation and other activities of daily living that have not improved

after an appropriate, aggressive, and sustained course (as defined below) of outpatient

therapy services or services in other less intensive rehabilitation settings, but would have

the potential to improve with more intensive rehabilitation.

12. Severe or advanced osteoarthritis (osteoarthrosis or degenerative joint disease)

involving two or more major weight bearing joints (elbow, shoulders, hips, or knees, but

not counting a joint with a prosthesis) with joint deformity and substantial loss of range

of motion, atrophy of muscles surrounding the joint, significant functional impairment

of ambulation and other activities of daily living that have not improved after the patient

has participated in an appropriate, aggressive, and sustained course (as defined below) of

outpatient therapy services or services in other less intensive rehabilitation settings, but

would have the potential to improve with more intensive rehabilitation. (A joint

replaced by a prosthesis no longer is considered to have osteoarthritis, or other arthritis,

even though this condition was the reason for the joint replacement.)

13. Knee or hip joint replacement, or both, during a hospitalization immediately

preceding the IRF stay and also meets one or more of the following specific criteria:

a. The patient underwent bilateral knee or bilateral hip joint replacement surgery

during the hospital admission immediately preceding the IRF admission.

b. The patient is extremely obese with a Body Mass Index of at least 50 at the time

of admission to the IRF.

c. The patient is age 85 or older at the time of admission 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 clinical 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 preceding 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 develop, 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 services 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 discretion to review documentation to assure that the patient has

completed an appropriate, aggressive, and sustained course of therapy or services in less

intensive rehabilitation settings. CMS expects that the IRF will obtain copies of the therapy

notes from the outpatient therapy or from the therapy services provided in another less

intensive setting and include these in the patient’s medical record at the IRF (in a section

for prior records). CMS believes that these prior records will be used by therapists and

others caring for the patient in the IRF, and will also be available to the A/B MAC (A) staff

who review the medical records for compliance with the requirements specified above in

§140.1.1B-D.

D. - Comorbidities.—A comorbidity is a specific patient condition that is secondary to the

patient’s 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 effect a preadmission screening procedure under which each

prospective patient's condition and medical history are reviewed to determine whether the

patient is likely to benefit significantly from an intensive inpatient hospital rehabilitation

program. This procedure must ensure that the preadmission screening is reviewed and

approved by a rehabilitation physician prior to the patient’s 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 patient’s capacity to benefit from the rehabilitation process. Beginning with

the second week of admission to the IRF, a non-physician practitioner who is determined by

the IRF to have specialized training and experience in inpatient rehabilitation may conduct 1

of the 3 required face-to-face visits with the patient per week, provided that such duties are

within the non-physician practitioner’s scope of practice under applicable state law.

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 inpatients 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.