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Medical Coding News Archives

New Coverage Requirements for Inpatient Rehabilitation Services

November 24, 2009:

To incorporate changes in current medical practice, the Centers for Medicare & Medicaid Services (CMS) adopted new inpatient rehabilitation facility (IRF) coverage requirements in the fiscal 2010 final rule.

CMS will issue a notice to rescind prior coverage criteria policies contained in ruling HCFAR 85-2-1 effective January 1, 2010. Effective with IRF discharges on or after January 1, 2010, contractors must use the updated coverage policy in the medical review of IRF claims.

In addition to updating the payment rates for IRFs, the final rule updates the coverage requirements for inpatient rehabilitation services. Revisions were made to IRF medical necessity criteria, admissions and post-admission procedures, documentation requirements, and the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI), along with other manual sections. The revisions emphasize the role of a rehabilitation physician in ordering IRF services and providing ongoing oversight of each patient’s care. Under the new coverage criteria, the decision to admit the patient to the IRF is the key to determining whether the admission is reasonable and necessary.

CMS clarified that the new coverage requirements does not affect the criteria for determining whether a facility meets the “60 percent rule” for purposes of qualifying for payment under the IRF PPS rather than the inpatient prospective payment system (IPPS). That rule requires that at least 60 percent of a facility’s patients in a year must have at least one of 13 specified conditions as the principal admitting diagnosis, or as a secondary diagnosis that requires an IRF level of care. The new coverage requirements will be effective for IRF discharges occurring on or after January 1, 2010.

The provisions of the fiscal 2010 final rule for inpatient rehabilitation facilities PPS (CMS 1538-F) for the new coverage criteria are effective for discharges occurring on or after January 1, 2010. For more information, please see: www.cms.hhs.gov/InpatientRehabFacPPS/.

Sarah A. Serling, CPC, CPC-H, CPC-I, CCS-P, CCS
Clinical/Technical Editor


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