IRF Classification Criteria
An inpatient rehabilitation hospital or an inpatient rehabilitation unit of a hospital (otherwise referred to as an IRF) is excluded from the IPPS and is eligible for payment under the IRF PPS if it meets all of the criteria specified in 42 Code of Federal Regulations (CFR) 412.25 (for units) and 412.29. Specifically, to be classified for payment under Medicare’s IRF prospective payment system, at least 60 percent of a facility’s total inpatient population must require IRF treatment for one or more of 13 conditions listed in 42 CFR 412.29(b)(2).
Determining IRF "60 Percent Rule" Compliance
The Medicare Administrative Contractors (MACs) are responsible for determining whether facilities meet the 60 percent rule requirements for payment under Medicare’s 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. Application of this rule involves a number of steps that are detailed in a document that has been prepared to assist software developers and others who wish to replicate CMS's procedures. Five appendices to the document contain tables that may be useful to programmers. (October 1, 2015 version and October 1, 2017 version).
- Determining IRF compliance 2015-10-01.pdf.
- Determining IRF compliance 2017-10-01.pdf
- Presumptive Methodology Files—Implementation of Changes - 2015-10-01.pdf.
- Presumptive Methodology Files—Implementation of Changes – 2017-10-01.pdf.
- Presumptive Compliance-1.xlsx - in Excel format.
- Presumptive Compliance-2.xlsx - in Excel format.
- Presumptive Compliance-3.xlsx - in Excel format.
- Impairment Group Codes That Meet Presumptive Compliance Criteria-1.xlsx - in Excel format.
- Impairment Group Codes That Meet Presumptive Compliance Criteria-2.xlsx - in Excel format.
- Impairment Group Codes That Meet Presumptive Compliance Criteria-3.xlsx - in Excel format.