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Specific Admission Criteria
The Centers for Medicare and Medicaid (CMS) has developed general criteria for Medicare coverage within an IRF. Admission criteria do not address specific diagnoses, but rather the patient’s need for rehabilitation and its benefits.
For admission to an IRF, a patient must:
- require daily access to a rehabilitation physician, who will oversee the patient's medical needs and functional plan of care
- require 24-hour rehabilitation nursing
- be able to tolerate a relatively intense therapy program, consisting of at least 3 hours of therapy per day (PT, OT, or ST), 5 days a week, or have the potential to build up to this within 10 days
- need at least two forms of therapy
- have the ability to achieve rehabilitation goals in a reasonable period of time
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IRF Physical Space and Staffing Requirements
CMS also requires:
- a distinct part unit with a separate nursing station;
- a dedicated Medical Director (minimum, 20 hours per week);
- minimum census of 75 percent within 10 rehab diagnoses;*
- minimum of three hours of therapy per day (a patient requirement);
- dining, activity and therapy space;
- exam room, offices and conference rooms;
- 24-hour rehab nursing care and 24-hour physician coverage; and
- compliance with federal and state healthcare standards (ADA, Safety,
HIPPA, AIA, CMS).
Certain states have space requirements that may also need to be met in order to open an IRF.
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Inpatient Rehabilitation Facility Diagnoses
CMS requires that at least 75 percent of patients on the unit be admitted with one of the following diagnoses:
- Amputations
- Orthopedic disabilities – long bone fractures
- Cerebrovascular Accident/Stroke
- Spinal cord injury
- Brain injury
- Major multiple trauma
- Neurological disorders (including Multiple Sclerosis, Parkinson’s disease, polyneuropathy)
- Burns
- Congenital deformity
- Active, polyarthricula rheumatoid arthritis, psoriatic arthritis, and seronegative arthropathies
- Systematic vasculidities with joint inflammation
- Severe or advanced osteoarthritis (or degenerative joint disease)
- Patients undergoing knee and/or hip replacement with at least one of the following criteria:
- Simultaneous bilateral knee or hip replacement
- Exreme obesity (Body Mass Index of 50 or more)
- Frail elderly (85 years old or older).
In 2004, CMS developed and implemented a new, more restrictive set of 75 percent guidelines. The new guidelines are being phased in over the next three years, with most hospitals being required to meet a 60% threshold for the current reporting year, and progress to 75% by July 2008. One major change in the guidelines is that joint replacement patients are no longer included in the list of appropriate conditions, unless they exhibit other physical limitations that require care in a hospital. That means most joint replacement patients no longer can receive their post-surgical therapy in a hospital inpatient facility. Instead, they must seek care at other sites, such as a nursing home (otherwise known as a skilled nursing facility). Less often, these patient swill receive their therapy at home or in an outpatient center.
A major issue associated with this change is that most skilled nursing facilities and no outpatient centers offer the intense level of therapy that patients receive in an IRF.
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Timing the Opening of an IRF
The most advantageous time to open an IRF is in conjunction with the beginning of a hospital’s Medicare cost-report year. This critical date is the only time that a facility has the opportunity to change its licensure status with Medicare and thus receive reimbursement for this new service.
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New IRF Openings — Exempt vs. Non Exempt
Opening a new IRF is a very complex task. Several CMS regulations govern the reimbursement of a new IRF — particularly during the first year of operation.
Exempt — New Units
For a unit to receive full Medicare reimbursement for its first year, it must be designated as a distinct part unit (or “exempt from the DRG reimbursement system). An IRF also can be declared exempt if it:
- resides in a new hospital,
- resides in a hospital that has undergone a change of ownership,
- resides in a hospital that is increasing total bed capacity by greater than 50 percent of the number of its new rehab beds,
- occupies space that was previously licensed beds (the decrease in a hospital s total bed capacity must remain in effect for at least a 12-month cost reporting period), and
- represents a conversion of TCU beds (must pass the test above for a decrease in bed capacity).
Non-exempt — Converted Units
An IRF is considered a converted unit if it does not qualify as a new unit, as defined above. A converted unit must have treated, for the most recent 12-month cost reporting period, an inpatient population of which at least 75 percent required “intensive rehabilitation services for the treatment of one or more of ten conditions to be eligible for exempt status.
A non-exempt unit will not receive reimbursement for patients transferred internally. These patients are eligible for reimbursement only for their medical/surgical DRG. For the first year of operation, Medicare patients brought into a non-exempt unit from other hospitals will be eligible for reimbursement under DRG 462. A non-exempt unit becomes exempt at the beginning of the second year of operation.
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Medicare Prospective Payment System (PPS) Reimbursement
Reimbursement for IRFs is driven by Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) data. The three-page IRF-PAI form must be completed on the fourth day of admission and five days following discharge. The IRF-PAI relies on 155 data elements to determine a clinical management group (CMG) and more than 800 comorbidities affecting CMG. The IRF-PAI also requires the measurement of 18 functional abilities. Completing an IRF-PAI takes approximately 45 minutes per patient.
Timely submission of PPS data is critical to the success of a unit, since late
transmission of data incurs a 25 percent penalty.
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