Inpatient Rehabilitation Facility (IRF) Compliance Review - ' 60 Percent Rule'

Published 01/10/2019

The Medicare Administrative Contractors (MACs) are responsible for determining whether facilities meet the 60 percent rule requirements for payment under Medicare’s Inpatient Rehabilitation Facility (IRF) prospective payment system. This determination is made on an annual basis at the beginning of each facility's cost reporting period and remains in effect for the duration of that cost reporting period.

The verification process used to determine if the IRF met the classification criteria is found in the CMS IOM 100-4, Chapter 3 (PDF, 2.22 MB), Section 140.1.3.  

A. Determination of the Compliance Review Time Period
General Guideline to Determine the Compliance Review Period:
Palmetto GBA will use data from the most recent, consecutive, and appropriate 12-month compliance review period ending four months prior to the beginning of current cost reporting period to determine if a facility is in compliance with all of the criteria used to classify a facility as an IRF. The facility will be notified by initial request letter two weeks prior to the end of the compliance review period being used.

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 example, if an IRF changes the start of its cost reporting period from July 1, 2017, to October 1, 2017, then the start date of its compliance review period will also change from March 1, 2017, to June 1, 2017.

B. Types of Data Used to Determine Compliance with the Classification Criteria
The verification procedure using the IRF-PAI data will only be used if the A/B MAC (A) has verified that the IRF’s Medicare Part A fee-for-service inpatient population and Medicare Part C (Medicare Advantage) inpatient population combined is at least 50 percent of the IRF’s total inpatient population.

In order to verify that an IRF’s Medicare Part A fee-for-service and Medicare Part C (Medicare Advantage) inpatient populations (combined) reflect the IRF’s total inpatient population, written notification will instruct the IRF to send to Palmetto GBA, by a specific date, a list showing the hospital patient number of each inpatient IRF admission during the IRF’s 12-month compliance review period.

Note that the term "hospital patient number" used throughout this section refers to a unique patient identifier used internally within the hospital for patient identification and record-keeping purposes. For each inpatient on the list, the IRF must include the payer the IRF can bill, or has billed, for treatment and services furnished to the inpatient. If an inpatient on the list has multiple payers that the IRF can bill, or has billed, the IRF must include and specify each type of payer. In addition, for each inpatient on the list, the IRF must include the IRF admission and discharge dates.

Palmetto GBA will use the list of hospital patient numbers to determine that at least 50 percent of the IRF’s total inpatient population consisted of Medicare Part A fee-for-service or Medicare Part C (Medicare Advantage) patients for the entire 12-month period. Meeting or exceeding the 50 percent requirement means that Palmetto GBA will perform the presumptive test noted below.

Please note that Palmetto GBA has the discretion to sample and compare other parameters (diagnoses, procedures, length-of-stay, or any other relevant parameter) to determine that the Medicare Part A fee-for-service and Medicare Part C (Medicare Advantage) population is representative of the IRF’s total inpatient population.

Palmetto GBA will inform the CMS Regional Office (RO) if an IRF fails to send the list that includes all required documentation. The RO will notify the IRF that failure to send Palmetto GBA the list within an additional ten 10 calendar days will result in a determination by the RO that the IRF has not met the requirements and the facility will no longer be eligible for payment under the IRF PPS.

C. Verification of the Medical Condition Criteria Using the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) Data Records (The Presumptive Methodology)
To determine if a facility has presumptively complied with the criteria specified in §140.1.1B-D, Palmetto GBA will access the CMS' IRF-PAI data records.

The IRF must decide whether the IRF compliance review report will be generated using the IRF-PAI data records of patients who were admitted during the IRF’s compliance review period (even if they were discharged outside of the compliance review period), or the IRF-PAI data records of patients who were discharged during the IRF’s compliance review period (even if they were admitted outside of the compliance review period).

If an IRF’s inpatient Medicare Part A fee-for-service and Medicare Part C (Medicare Advantage) populations (combined) are at least 50 percent of its total inpatient population and the IRF-PAI data records support that at least 60 percent of the submitted assessments met the eligibility requirements (presumptive methodology), then the IRF is presumed to have met the requirements to continue to be paid as an IRF.

However, even when an IRF is presumed to have met the requirements, the RO and Palmetto GBA have the discretion to instruct the IRF to send to the RO or Palmetto GBA specific sections of the medical records of a random sample of inpatients, or specific sections of the medical records of inpatients identified by other means by the CMS or Palmetto GBA.

D. Additional Verification of Arthritis Condition Criteria
If Palmetto GBA has determined, using the process outlined above, that the IRF does not presumptively meet the requirements specified §140.1.1B-D, then Palmetto GBA must access an IRF-PAI data report called the IRF Arthritis Verification Report through the CASPER system.

Palmetto GBA will determine whether or not adding all of the cases listed on the IRF Arthritis Verification Report for that IRF would be enough to increase the IRF’s compliance percentage to equal or exceed 60 percent.

If adding all of the cases listed on the IRF Arthritis Verification Report for that IRF would be enough to increase the IRF’s compliance percentage to equal or exceed 60 percent, then Palmetto GBA must use generally accepted statistical sampling techniques to obtain a statistically valid random sample of those patients listed on the Arthritis Verification Report.

Note that if adding all the cases listed in the IRF Arthritis Verification Report for that IRF would not be enough to increase the IRF’s compliance percentage to equal or exceed 60 percent, then Palmetto GBA will not proceed further with the IRF arthritis verification process and will use the presumptive compliance percentage generated earlier in the review process.

Palmetto GBA will obtain and examine the medical record sections and any other pertinent information submitted by the IRF to determine if the random sample of patients from the Arthritis Verification Report meet all of the severity and prior treatment requirements specified in §140.1.1B-D.

The percentage of patients from the list that Palmetto GBA determines to have met the severity and prior treatment requirements specified in §140.1.1B-D will be extrapolated to the complete list of patients for the IRF on the IRF Arthritis Verification Report.

Palmetto GBA shall then add the appropriate number of cases from the IRF Arthritis Verification Report to the cases that meet the presumptive compliance criteria, and re-calculate the IRF’s presumptive compliance percentage. For example:

  • IRF A submitted 545 IRF-PAIs in the compliance review period
  • IRF A’s presumptive compliance percentage (determined by Palmetto GBA using the steps outlined in subsection C) was less than 60 percent
  • In this case, Palmetto GBA must access the IRF Arthritis Verification Report
  • The IRF Arthritis Verification Report shows 100 patients listed for IRF A
  • Palmetto GBA determines that inclusion of all 100 patients listed for IRF A would increase IRF A’s presumptive compliance percentage enough to meet or exceed the 60 percent threshold
  • Palmetto GBA uses generally accepted statistical sampling techniques to randomly select 10 patients from that list for medical review, and based on the medical record review determines that seven of the 10 patients meet all of the requirements specified in §140.1.1B-D
  • Palmetto GBA will then extrapolate this percentage (7/10 = 70 percent) to the full list of patients shown on the IRF Eligibility Arthritis Verification Report for IRF A. Thus, Palmetto GBA will add 70 patients (70 percent of 100) listed for IRF A on the IRF Arthritis Verification Report to the total number of IRF A’s patients that meet the presumptive compliance criteria.
  • Palmetto GBA will then recalculate IRF A’s presumptive compliance percentage with the addition of the 70 cases
  • Palmetto GBA will base the determination of the IRF’s presumptive compliance with the requirements specified in §140.1.1B-D on the updated calculation of the IRF’s presumptive compliance percentage
  • The A/B MAC (A) will report this updated presumptive compliance percentage, instead of the presumptive compliance percentage from subsection C, on the quarterly report that Palmetto GBA sends to the appropriate CMS RO (with a copy to the CMS Central Office)

Note: Even when an IRF is presumed to have met the requirements specified in §140.1.1B-D using the updated presumptive methodology calculation, the RO and A/B MAC (A) have the discretion to use the medical review methodology described in subsection E below to verify the IRF’s compliance with the requirements in §140.1.1B-D.

E. Verification of the Medical Condition Criteria Using the Inpatient Rehabilitation Facility’s Total Inpatient Population (Medical Record Review Methodology)
If the IRF’s 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 IRF’s total inpatient population, or Palmetto GBA otherwise determines that the Medicare Part A fee-for-service and Medicare Part C (Medicare Advantage) populations are not representative of the overall IRF inpatient population, or Palmetto GBA is unable to generate a valid report using the presumptive methodology, the presumptive determination is that the IRF did not meet the requirements specified in §140.1.1B-D.

As previously stated, Palmetto GBA will instruct the IRF to send Palmetto GBA 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. Palmetto GBA will then use generally accepted statistical sampling techniques to obtain a random sample of inpatients from the list.

Palmetto GBA 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. Palmetto GBA will examine the medical record sections and any other information submitted by the IRF to determine if the IRF meets the requirements specified in §140.1.1B-D through a careful review of that inpatient’s unique clinical characteristics and circumstances, as reflected in the inpatient’s medical record.

Palmetto GBA will inform the RO if an IRF fails to provide information and the RO will notify the IRF that failure to provide Palmetto GBA with the information will result in a determination by the RO that the IRF has not met the requirements specified in §140.1.1B-D.

F. By the 15th day of each month, Palmetto GBA will determine the compliance percentage for each IRF using either of the methods specified in §§140.1.3C or 140.1.3D and submit a report to CMS via e-mail. Instructions regarding the format, completion and where to send the report are specified on the CMS IRF Classification Criteria webpage.

G. Palmetto GBA verifies that the requirements specified in §140.1.1B-E and §140.1.2 G-K were met.

H. The state agency determines whether the criteria specified in §140.1.1F-K and §140.1.2 Q were met.