Inpatient Rehabilitation Facility (IRF) 60% - JF Part A
Inpatient Rehabilitation Facility (IRF) 60%
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 prior to the beginning of each facility's cost reporting period and remains in effect for the duration of that cost reporting period.
There are two methods used to determine if the facility has met the 60 percent rule requirements, the presumptive methodology and the medical review methodology.
Presumptive Methodology
The presumptive methodology requires that the provider has at least 50% of their listing population as Medicare Part A fee-for-service and Medicare Part C (Medicare Advantage) patients. To verify this, Noridian will instruct the provider to send a list showing the hospital patient number of each inpatient that the IRF admitted during the most recent, consecutive, and appropriate 12-month-period, as defined by CMS. This list of patient numbers must include the payer(s) and admission and discharge dates that correspond with the inpatients whose hospital patient numbers are shown on the list. To determine if a facility has presumptively complied with the criteria specified in CMS Internet Only Manual (IOM) 100-04, Medicare Claims Processing Manual, Chapter 3, Section 140.1.1B-D, CMS has enabled the MAC to access only the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) information submitted by IRFs that submit claims to that MAC. When Noridian accesses the IRF-PAI data records, we will be able to generate an IRF compliance review report using the IRF-PAI information from that IRF. The Internet Quality Improvement and Evaluation System (iQIES) system software used to generate those IRF compliance review reports will automatically use the specific diagnosis codes from the appropriate files listed in "Presumptive Compliance" relative to the appropriate fiscal year regulation to determine if a particular IRF is in compliance. Prior to generating the IRF compliance review report, Noridian must allow the IRF to decide whether the report will be generated using the data records of patients who were admitted or discharged during the IRF's compliance review period. If choosing data records of admission, this will include those discharged outside of the compliance review period, and if choosing data records of discharge, it will include those admitted outside of the compliance review period.
If the presumptive methodology shows that the IRF met or exceeded the requirements outlined in CMS IOM 100-04, Medicare Claims Processing Manual, Chapter 3, Section 140.1.1B-D and that the IRFs inpatient Medicare Part A fee-for-service and Medicare Part C (Medicare Advantage) populations combined are at least 50 percent of its total inpatient population, and the presumptive compliance percentage as determined in the IRF compliance report is 60% or greater, then the IRF is presumed to have met the criteria requirements. However, even when an IRF is presumed to have met the requirements, Noridian still has discretion to instruct the IRF to send to either CMS Office of Program Operations & Local Engagement (OPOLE) or Noridian, specific sections of the medical records of a random sample of inpatients, or specific sections of the medical records of inpatients identified by other means by CMS or the MAC.
Medical Review Methodology
If the IRF's Medicare population is not at least 50 percent of its total inpatient population, or the Noridian is unable to generate a valid IRF compliance review report using the IRF-PAI database, or the IRF compliance review report based on the use of the presumptive methodology demonstrates that the IRF has not met the requirements specified in CMS IOM 100-04, Medicare Claims Processing Manual, Chapter 3, Section 140.1.1B-D, Noridian will instruct the provider to send a list showing the hospital patient number of each inpatient that the IRF admitted during the most recent, consecutive, and appropriate 12-month-period, as defined by CMS. This list of patient numbers must include the payer(s) and admission and discharge dates that correspond with the inpatients whose hospital patient numbers are shown on the list. Using the listing of patients submitted by the provider, Noridian will use the generally accepted statistical sampling to obtain a random sample of inpatients from the list. Noridian must then determine, with at least 95 percent confidence, whether the IRF's compliance percentage is below the required compliance threshold or at or above the required compliance threshold. Like with the presumptive methodology, prior to the selection of the random sample of inpatients, Noridian must allow the IRF to decide whether the report will be generated using the data records of patients who were admitted or discharged during the IRF's compliance review period. If choosing data records of admission, this will include those discharged outside of the compliance review period, and if choosing data records of discharge, it will include those admitted outside of the compliance review period.
The requested support will include, but is not limited to, the face sheet, history and physical (H&P), and discharge summary. The MAC has the discretion to decide which specific sections of the medical records to obtain, and the IRF has the discretion to send the MAC other clinical information regarding these same inpatients.
If requested documentation is not received, Noridian will inform OPOLE that the IRF failed to provide information in accordance with the requirements and OPOLE will notify the IRF that failure to provide the MAC with the information will result in a determination by OPOLE that the IRF has not met the requirements in CMS IOM 100-04, Medicare Claims Processing Manual, Chapter 3, Section 140.1.1B-D.
Patient Listings
The patient listing and attestation statement will be requested via an emailed request each year and will outline the request and review period. Patient listings should be submitted to IRF-60-Percent-Review@noridian.com in an excel format. If the patient listing is not submitted in excel format, the listing will be returned to the provider to be reformatted and resubmitted. For your convenience, we have a Sample Patient Listing [Excel] as a reference.
New IRFs
An IRF hospital or IRF unit is considered new if it has not been paid under the IRF PPS for at least 5 calendar years. A new IRF will be considered new from the point that it first participates in Medicare as an IRF until the end of its first full 12-month cost reporting period.
A new IRF must provide written certification that the inpatient population it intends to serve will meet the requirement of IRF 60% compliance. The written certification is effective for the first full 12-month cost reporting period that occurs after the IRF begins being paid under the IRF PPS, and for any cost reporting period of not less than 1 month and not more than 11 months occurring between the date the IRF begins being paid under the IRF PPS and the start of the IRFs first full 12-month cost reporting period.
Retroactive adjustments may be made for any period during which the hospital has self-attested to meeting the requirements specified in CMS IOM 100-04, Medicare Claims Processing Manual, Chapter 3, Section 140.1.1B-D, but is shown not to have met these requirements during that period. Self-attestations should be submitted via email to IRF-60-Percent-Review@noridian.com. You can complete the IRF Self-Attestation form we have created for your convenience on our Audit and Reimbursement Forms page.
If you have questions related to IRF 60%, or to notify of an opening or closing of an IRF related to IRF 60% compliance, please email them to IRF-60-Percent-Review@noridian.com. All IRF questions unrelated to 60% review should be directed to the Provider Contact Center.
