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Written by: Mediware on Sunday, July 15, 2012 Posted in: Inpatient Rehab

If you believed that 14 items published for coverage criteria in the Medicare Benefits Policy Manual, 100-02 Chapter 1:110 – 110.3,  leading to appropriate IRF admissions was going to be easy — think again.

We now have 145 clarification statements in the form of questions and answers on the IRF Coverage Criteria page from CMS that define appropriate interpretation and expectations for IRF PPS paid facilities. These five training documents called,  ”Follow-Up Coverage Requirements” specify exact definitions in meeting the 14 coverage criteria.  Getting it right is crucial because in totality they express reasonable and necessary in the eyes of an auditor monitoring if the coverage criteria are being met in the documentation within your medical records.

When one topic spawns more than 30 distinct elements of interpretation, it’s difficult to pull it all together to be certain you understand the expectations. Mediware is committed to helping you get it right and find the right interpretations more easily.

20101To make it easier to locate all the items around the specific topics, we have loaded them into an online  searchable  file for easy reference by placing all like topics together, displaying the question and answers in one place and providing the link back to the resource document at it’s primary source at You can even search by keyword.

These are the topics and the number of items found in total for those areas within the five published documents through 6/30 /2012.  If an additional clarification document is posted, we’ll update the file and re-link you to those possibilities.  You will want to bookmark the CMS Clarifications on IRF  as a favorite in your browser. It will save you lots of time looking for that exact interpretation and how it is being applied toward compliance.


Utilize the link to discuss interpretation and validation that your facility is following each of the areas appropriately. You may also want to cut and paste information into a rebuttal document specific to a challenged regulation topic. These items are pulled together and list the CMS interpretation resource(s) in one place, should you be asked to defend rationale in meeting coverage criteria.  This tool will help you close the gap on compliance toward IRF 2010 regulations now being audited for medical necessity at the FI/MAC and RAC levels.

Be prepared! Perform self-audits and educate expectations so that after earning reimbursement for your resources and care, you may also keep that hard earned cash.  If in preponderance you’re not following these criteria, it’s more than just cash at stake. IRF PPS Excluded status rests on meeting these criteria. One answer toward not providing therapy on weekends made this clear when stating, “failure to comply with all of the IRF coverage requirements may result in the IRF being out of compliance with governing regulations, which could potentially subject the IRF to declassification.”

Mediware provides the resource IRF clarification tool to help you monitor your success!

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