- IRF-PAI Data Specifications Version 5.02.0 (DRAFT) is available for download from the IRF PPS Software webpage
- Please note that CMS has removed the file entitled, “ARCHIVED - IRF Coverage Requirements (ZIP)” from the CMS website. This file no longer accurately reflects our policies. We encourage providers to reference the applicable statues, regulations, and other interpretive materials for complete and current information about CMS’s IRF PPS policies.
- Inpatient Rehabilitation Facility Prospective Payment System: Coverage Requirements Webinar — CMS has posted the slides from the IRF PPS Coverage Requirements Webinar (PDF) held on Wednesday, November 29, 2023 at Inpatient Rehabilitation Facility PPS | CMS. 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.
- CMS-1781-CN - Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2024 and Updates to the Inpatient Rehabilitation Facility Quality Reporting Program; Correction is on public display at the Office of Federal Register and will publish on October 4, 2023. The rule and associated files can be downloaded from the IRF Rules and Related Files webpage.
- IRF-PAI Errata Version 5.01.3 for Data Specifications Version 5.00.1 (FINAL) (PDF) (PDF) - An updated errata (V5.01.3) is now available for the IRF-PAI Data Specifications V5.00.1 (FINAL).
- CMG Version 5.30 (ZIP) is now available for download from the IRF Software webpage.
- IRF-PAI Errata Version 5.01.2 for Data Specifications Version 5.00.1 (FINAL) (PDF) - An updated errata (V5.01.2) is now available for the IRF-PAI Data Specifications V5.00.1 (FINAL).
- The IRF legislative history (PDF) file has been updated.
- CMS-1781-F - Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2024 and Updates to the IRF Quality Reporting Program is on public display at the Office of Federal Register and will publish on August 2, 2023. The rule and associated files can be downloaded from the IRF Rules and Related Files webpage.
- Information related to the upcoming April 11, 2023 IRF-PAI informational call for IRF-PAI and LTCH software vendors and developers can be found on the Technical Information webpage.
- The FY 2021 SSI Data Ratios file is available for download from the SSI Data webpage.
- CMG Version 5.20 Final (ZIP) effective October 1, 2022, is now available for download from the IRF Grouper webpage.
- Presumptive Compliance-3 (ICD-10-CM) - A revised file has been added to the associated files to CMS 1767 F. We have made minor code and code label edits to this list. See the revised Presumptive Compliance-3 list at https://www.cms.gov/medicaremedicare-fee-service-paymentinpatientrehabfacppsirf-rules-and-related-files/cms-1767-f
- Presumptive Compliance Changes - A revised file has been added to the associated files to CMS 1767 F. A minor edit was made to this list. On Line 126 of the Excel document code S06.4XXA has been updated to S06.4XAA. See the revised Presumptive Compliance Changes list at https://www.cms.gov/medicaremedicare-fee-service-paymentinpatientrehabfacppsirf-rules-and-related-files/cms-1767-f
- CMS issued the Fiscal Year 2023 Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) final rule to update Medicare payment policies and rates. See a summary of key provisions effective October 1, 2022:
- The Report to Congress: Unified Payment for Medicare-Covered Post-Acute Care has been released and is available from the Research webpage.
- The IRF Classification Criteria webpage has been archived. Refer to the most recent rule for guidance at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/IRF-Rules-and-Related-Files.
Section 4421 of the Balanced Budget Act of 1997 (Public Law 105-33), as amended by section 125 of the Medicare, Medicaid, and SCHIP (State Children's Health Insurance Program) Balanced Budget Refinement Act of 1999 (Public Law 106-113), and by section 305 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (Public Law 106-554), authorizes the implementation of a per discharge prospective payment system (PPS), through section 1886(j) of the Social Security Act, for inpatient rehabilitation hospitals and rehabilitation units - referred to as inpatient rehabilitation facilities (IRFs). The IRF PPS will utilize information from a patient assessment instrument (IRF PAI) to classify patients into distinct groups based on clinical characteristics and expected resource needs. Separate payments are calculated for each group, including the application of case and facility level adjustments.
For a one-stop resource web page focused on the informational needs and interests of Medicare Fee-for-Service (FFS) hospitals, go to the Hospital Center (see under "Related Links Inside CMS" below).
Section 3004 of the Affordable Care Act
CMS has created a website to support Section 3004 of the Affordable Care Act, Quality Reporting for Long Term Care Hospitals, Inpatient Rehabilitation Hospitals and Hospice Programs. This site has been created so that the public can view information, and communications, related to Section 3004. This site is expected to expand as more information is provided. There is also provided a link for emailing comments, questions or ideas to CMS pertaining to Quality Reporting and Section 3004.
IRF Legislative History
Historically, each rule or update notice issued under the annual Inpatient Rehabilitation Facility (IRF) prospective payment system (PPS) rulemaking cycle included a detailed reiteration of the various legislative provisions that have affected the IRF PPS over the years. This document (PDF) now serves to provide that discussion and will be updated when we find it necessary.
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.