Two terms often misunderstood in the enforcement of regulatory guidance have been the words classification and coverage. The requirements set forth used to determine whether a facility met the definition of an IRF were generally called “classification items.” Guidelines used in particular to define whether a patient can or should be appropriate for an IRF admission and payments were considered “coverage items.”
If admissions were challenged by a Fiscal Intermediary (FI) or Medicare Administrative Contractor (MAC) for a particular patient or set of patients, hospital leaders would feel threatened. There was some unfounded belief that coverage debates could lead to loss of certification status or state licensure as an IRF.
Despite many CMS calming attempts, specifically when the 85-2 criteria was in place prior to 2010, facilities all over the US feared their doors would be closed when a MAC questioned admission appropriateness.
All too often however, decisions were overturned with rebuttals on a large scale. IRFs defended their level of care decisions and continued to argue IRF appropriateness as a level of care through use of classification criteria and treating a population that predominantly met the 60% rule.
At that time, CMS clearly separated discussions on classification and coverage. As a matter of fact, even today on the cms.gov IRF web page, there are clear distinctions and links that discuss classification and coverage requirements.
Classification clearly is upheld by attesting annually to 60% of one’s admission population to be within the defined scope of those 13 diagnoses that generally are best served by a rehabilitation intensity. To operate new beds or sustain beds in a survey, the survey and certification criteria worksheet would be utilized. But because within the survey and certification documents, the coverage requirements are listed, this again brings question for confusion. Are classification and coverage criteria one and the same?
Coverage requirements sunset the HCFA 85-2 ruling in 2010 and re-established the 2010 guidelines as criteria that must be met to be covered or paid at a rehabilitation level of care. Not meeting these guidelines will certainly create non-payment for a particular patient.
On page 47872 of the final 2012 Rule Vol. 76, the final regulation talks about enhancing consistency in the enforcement of coverage and classification criteria. This being said, there is likely argument that classification and coverage requirements should be similar. Made more clear however is that although one or “several” patients may fall short of having coverage criteria completed (such as pre-admission screening and physician oversight), it will be reviewed as to whether there are processes in place to meet the requirements overall. Stating further, if a large percent of coverage criteria are not adequately followed, presumably the classification as an IRF can be challenged.
Given these discussions and intentions, it is imperative that leadership tightly review and manage the expectations surrounding coverage of an IRF. If physicians are not agreeable to the mandates and timelines so clearly defined for coverage, such that large percentages can be found out of compliance; beware that your certification as an IRF can be challenged and all staff may not be working for an IRF much longer – your viability is at stake.