Coverage Requirements

The fiscal year (FY) 2010 Final Rule for the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) (CMS 1538-F) implements new IRF coverage requirements that take effect for all Medicare IRF discharges occurring on or after January 1, 2010. A copy of this rule is available for download from the List of IRF Federal Regulations web page. In addition, Chapter 1, §110 of the Medicare Benefit Policy Manual (MBPM, CMS Pub. 100-02) provides additional guidance on these new regulations.

The new IRF coverage requirements replace coverage criteria that were over 25 years old and did not reflect Medicare's current payment structures or current medical best practices. To update these policies, CMS used an internal workgroup consisting of general physicians, physiatrists, and therapists. The workgroup enlisted the advice of Medical Directors from CMS/the Department of Health and Human Services, several fiscal intermediaries, qualified independent contractors, and the National Institutes of Health. The workgroup also considered comments received from industry groups in response to the FY 2009 IRF PPS proposed rule (73 FR 22674) and in response to industry input solicited by CMS contractors who prepared the IRF Report to Congress mandated by section 115(c)(1) of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA), Public Law 110-173.

IRF PPS Coverage Requirements Webinar (PDF) was held on Wednesday, November 29, 2023.  During this webinar, CMS reviewed IRF PPS coverage requirements from pre-admission to discharge and provided a refresher on payment policy requirements. The information covered during the webinar and on the slides represents CMS’ most current guidance for providers on coverage requirements. If you have questions, please send an email to IRFCoverage@cms.hhs.gov.