As you are probably aware, on May 7, 2004, CMS published a final rule titled “Medicare Program; Changes to the Criteria for Being Classified as an Inpatient Rehabilitation Facility (IRF).” This final rule replaces the previous process for certifying IRF compliance and was commonly referred to as the “75% rule”.

There are two significant changes addressed in the final rule. First, the minimum percentage of an IRF’s total patient population that must match one or more specified medical conditions has been lowered to fifty percent for cost reporting periods beginning on or after July 1, 2004. This minimal acceptable percentage, over a three-year period, increases to seventy-five percent for cost reporting periods beginning on or after July 1, 2007. Second, the number of medical conditions that meet the criteria for IRF compliance has increased from ten to thirteen.

The purpose of this letter is to give you an overview of the process and the type of information that will be required in order for Highmark Medicare Services to perform your facility’s IRF compliance review. This overview is based on the most current information available and, if there are any changes to the process or requirements, they will be conveyed in a second mailing that is scheduled for mid-to-late February.

The period to be reviewed will be from July 1, 2004 through February 28, 2005. The information requested would relate to patients that were admitted on or after July 1, 2004 and discharged by February 28, 2005. The initial information requested would include the following: Patient Number, Admission Date, Discharge Date, and Payer Type. Payer type will be divided among Medicare fee for service (not Medicare HMO), Medicaid, and Private Payer. We will be requesting that this information be submitted to us by March 15, 2005.

The first phase of the process will involve using the requested patient information to determine the Medicare patients’ percentage of the total patient population. If the Medicare percentage is 50 percent or more of the total inpatient population, then a “presumptive” review will be performed. This entails reviewing the on-line IRF-PAI Medicare data that CMS has made available for intermediary use. If 50 percent or more of the Medicare patients required intensive rehabilitative services for the treatment of 1 or more of the 13 allowable conditions, then the facility passes the compliance review.

If the percentage of Medicare patients is not greater than 50 percent of the total inpatient population, then a “non-presumptive” review will be performed. This will entail Highmark Medicare Services requesting medical records for each patient selected from a valid random sampling of the total inpatient population for the specified eight-month time period. This will also be described in more detail if it is determined that your facility will be required to submit such data. This is noted as Phase 2 of the compliance review process.

Highmark Medicare Services, upon completion of a provider’s compliance review, will forward the results to CMS Regional Office. CMS, in turn, will communicate the results of the review to the facility.

For more detail on the IRF compliance review, you can access the links Medlearn Matters MM3334 and MM3503 in the left hand margin.

An (*) denotes a link that will take you away from our website.

Regulations & Publications

•  (*) Federal Register
  
  
  • FR Notice Vol. 71, No. 160 - Friday, August 18, 2006
  • FR Notice Vol. 70, No. 156 - Monday, August 15, 2005
  • FR Notice Vol. 69, No. 89 - Friday, May 7, 2004 

MedLearn Matters References

• MM5303 - Implemented December 22, 2006
• MM5016 - Implemented August 7, 2006
• MM3704 - Implemented March 21, 2005
• MM3503 - Implemented November 29, 2004
• MM3334 - Implemented July 1, 2004

IRF Criteria Reference

• 42 CFR 412.23(b)(2) - Search the Code of Federal Regulations,
• CMS' Website - (*) IRF PPS information

IRF FAQs

• General

IRF Patient Data Excel Worksheet

• Rehab.xls

If you have further questions, please contact: Tina Marshall at 412-544-2453 or tina.marshall@highmark.com.