Inpatient Rehabilitation Facility PPS
Spotlight
- The FY 2022 SSI Ratios for IRF is available for download.
- CMS-1804-CN-Medicare Program: Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2025 and Updates to the Inpatient Rehabilitation Facility Quality Reporting Program is on public display at the Office of Federal Register and will publish on March 29, 2024 The rule and associated files can be downloaded from theIRF Rules and Related Fileswebpage.
- FY 2021-FY 2024 Wage Index files(Revised): In FY 2021Monmouth County, NJ moved from CBSA 35614 toCBSA 35154. The current wage index files have a duplicate listing for this county in both CBSAs in our FY 2021 through FY 2024 wage index files. The revision to those files has removed Monmouth County from CBSA 35614.
- 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.
- CMG Version 5.30 (ZIP) is now available for download from the IRF Software webpage.
- Presumptive Compliance-3 (ICD-10-CM) and Presumptive Compliance Changes- 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. Also, on Line 126 of the Excel document code S06.4XXA has been updated to S06.4XAA. See the revised Presumptive Compliance-3 and the Presumptive Compliance Changes lists at https://www.cms.gov/medicaremedicare-fee-service-paymentinpatientrehabfacppsirf-rules-and-related-files/cms-1767-f
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.
Hospital Center
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.
IRF Classification Criteria (PDF)
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.
FAQs
A medical rehabilitation hospital, also known as an inpatient rehabilitation facility (IRF), is a type of specialty hospital that focuses on treating people recovering from debilitating injuries, illnesses, surgeries, and chronic medical conditions.
What is the meaning of PPS in IRF? ›
On March 27, 2024, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to update Medicare payment policies and rates under the Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) and the IRF Quality Reporting Program (QRP) for fiscal year (FY) 2025.
What is the 60% rule a criteria for defining a hospital as an inpatient rehabilitation facility? ›
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).
What is the 60% rule for IRF? ›
The 60% Rule is a Medicare facility criterion that requires each IRF to discharge at least 60 percent of its patients with one of 13 qualifying conditions.
What is one example of an inpatient facility? ›
Types of inpatient facilities include acute-care hospitals, rehabilitation centers, psychiatric hospitals, addiction treatment centers and nursing homes.
What is the difference between skilled nursing and inpatient rehab? ›
Patient's in inpatient rehabilitation receive daily rehab therapies, for at least three hours a day for up to five days a week. Skilled nursing facilities offer subacute rehabilitation, which is similar but less intensive as rehab you will find in an inpatient rehab hospital.
Where does PPS stand for? ›
written abbreviation for post postscript: used in front of a short message added after a first postscript at the end of a letter or email: PS Could you bring your notes to the meeting? PPS and don't forget to let Richard know the time's been changed.
What does PPS mean in nursing? ›
The Palliative Performance Scale (PPS)1 can inform decisions about a patient's hospice eligibility by helping clinicians recognize a patient's functional decline.
Is PPS the same as DRG? ›
Medicare's Prospective Payment System
The PPS is the DRG. The DRG is based on the patient diagnosis. The DRG payment is per stay. The amount of reimbursem*nt is based on the relative weight of the DRG.
What are the top 13 diagnoses for inpatient rehab? ›
Sixty percent of patients admitted to the unit must have 1 of 13 conditions: stroke, spinal cord injury, congenital deformity, amputation, major multiple trauma, fracture of the hip, brain injury, burns, active polyarthritis, systemic vasculitis with joint involvement, specified neurologic conditions, severe or ...
Generally, the therapy intensity requirement is met with 3 hours per day 5 days per week or 15 hours per week. The patient must receive a minimum of 15 hours per week of therapy services, unless documentation supports medical issues justifying a brief exception not to exceed three consecutive days.
What types of diagnoses are treated typically in inpatient rehabilitation settings? ›
Examples of common conditions that may qualify you for care in a rehabilitation hospital include stroke, spinal cord injury, and brain injury. You may not qualify for care if, as an example, you are recovering from hip or knee replacement and have no other complicating condition.
What is the final rule of the IRF PPS? ›
The Centers for Medicare & Medicaid Services today released its fiscal year 2024 Inpatient Rehabilitation Facility Prospective Payment System final rule. The rule increases payments by an estimated 4%, or $355 million, in FY 2024 relative to 2023.
What is the inpatient prospective payment system 72 hour rule? ›
This rule, officially called the three-day payment window and sometimes referred to as the 72-hour rule, applies to diagnostic tests and other related services provided by the admitting hospital on the three calendar days prior to the patient's admission.
What is the purpose of the CMS 60% rule? ›
The 60% Rule
The current “60% rule” stipulates that in order for an IRF to be considered for Medicare reimbursem*nt purposes, 60% of the IRF's patients must have a qualifying condition. There are currently 13 such conditions, including, stroke, spinal cord or brain injury and hip fracture, among others.
What is the meaning of rehabilitation facility? ›
Rehabilitation facility means a facility that is operated for the primary purpose of assisting in the rehabilitation of disabled individuals by providing comprehensive medical evaluations and services, psychological and social services, or vocational evaluation and training or any combination of these services and in ...
What is the difference between inpatient and acute care? ›
Acute rehab steps in immediately following severe health events such as stroke, significant injury, or surgery. Inpatient rehabilitation aims to deliver comprehensive, high-intensity, inpatient therapy, helping patients regain their basic functionality and independence of daily life. (Heart.org, 2021).
Why might a patient be required to go to a rehabilitation center after a hospital stay? ›
A rehab facility can provide care for someone following a stroke, surgery, illness, or infection. These conditions may require IV therapies, antibiotic administration, wound care, or other forms of medical care.
What is the meaning of IRF? ›
Inpatient Rehabilitation Facility
Patients who stay in an IRF can rebuild their strength and mobility and recover from various illnesses or injuries, including joint replacements, brain injuries, strokes, cardiac events, and neurological disorders.
