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Written by: Darlene D'Altorio-Jones (1959-2015) on Thursday, November 17, 2011 Posted in: Inpatient Rehab

Inpatient Rehabilitation Facilities (IRFs) and Inpatient Rehabilitation Units (IRUs) Regulations

As discussed in a previous blog, the Code of Federal Regulations, or CFR, holds key legal guidance for conditions of participation for healthcare facilities. Inpatient Rehabilitation facilities/units (IRFs/IRUs) are no exception. Actually, they are an “exception” if you refer to the legal terminology used to describe the services and level of care for IRFs/IRUs.  Inpatient Rehabilitation was carved out in the early 1980’s, along with other types of specialty care such as Children’s Hospitals and Psychiatric care, when acute care facilities started getting paid by diagnostic related group (DRG).  Therefore, in reality, Excluded Hospitals/Units are truly exceptions.

For this reason, being an exception to standard inpatient prospective payment system (IPPS) rules, there is a special section in the law written specifically for Excluded Services.

Title 42, Volume 2, Subpart 412 of the CFR is dedicated to Excluded PPS Systems and Conditions of Participation. Therefore, rehabilitation hospitals/units paid as IRFs are guided by this section. IRFs/IRUs are a level of care also paid/covered under Hospital Benefits – Medicare Part A; services under this section have additional excluded conditions of participation, or variations from the standard Medicare IPPS conditions because they have unique requirements all to themselves. There are real reasons why specific IPPS conditions are not applicable to these levels of care and this section helps carve out those reasons.

Because IRFs/IRUs are covered under the hospital section of Medicare guidance, it’s the largest reason for confusion when deeming status organizations survey these units as they attempt to apply IPPS standards, like CORE measure review, while exempted units were still waiting for guidance in these areas. In some states, the Departments of Health and Human Services have a state law to gather and review measures at least annually. Still, those measures are specific to IPPS, leaving IRFs/IRUs further frustrated and confused.

Excluded IRF/IRU must follow Section 482 conditions of participation, except for the areas where more detailed instructions supersede the standard hospital areas, or are not applicable to an IRF level of care.  Regulations in 482 alone do not govern IRF hospitals/units. You must consider the subpart specialty section of the law to be in full compliance.

Sections 412 of Title 42 cover the laws dealing specifically with excluded hospitals/units are found in Subparts A – P.   

Subpart N covers Psychiatric Hospitals/Services, Subpart O is Long Term Care Hospitals/Units and Subpart P is specific to inpatient rehabilitation hospitals and units; not to be confused with rehabilitation services also found in 482.56, which is therapy provided for hospital patients that are not in excluded specialty IRF PPS care.

Once laws are final in the CFR, CMS provides Transmittals and Change Requests to update  information in their Internet Online Manuals (IOM), these transmittals provide guidance documentation for providers, fiscal intermediaries, Medicare Administrative Contractors (MAC) and all other enforcement bodies. Becoming familiar with where to find information needed in day-to-day monitoring of expected performance is key and is often located within the many manuals provided at the CMS website.

Subpart P for rehab is translated through different manuals, such as the Medicare Benefit Policy Manual  Chapter 1, Section 110 and the Medicare Claims Processing Manual Chapter 3, Section 140. These manuals contain the laws for IRFs on oversight, admission, payment, medical necessity, quality and standards of practice, just to name a few.

Medicare payment is conditional on following published updates to code and guidance regulations. Not following published guidelines can lead to loss of approved IRF status, and or prosecution by the various fraud and abuse contractors, depending on areas of issue.

In the last week of July, 2011, the Department of Health and Human Services released the IRF PPS 2012 Final Rule through the Code of Federal Regulations. Most areas of the rule will go into effect on October 1, 2011 for the 2012 fiscal year. I recommend you create “favorite” links to these areas of the internet as many items often debated have clear definitions among these referenced areas.

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