The report is available in English with a French summary - KCE

188 Musculoskeletal & Neurological Rehabilitation KCE reports 57
• expect significant practical improvement for patients;
• have realistic goals for treatment aims; and
• each year, have no fewer than 75 percent of all patients admitted with
1 or more of 13 specified conditions.
The 75 percent rule allows inpatient rehabilitation facilities to admit 25 percent of cases
without the specified diagnoses, so IRFs may treat some cases with diagnoses not
compliant with the rule without financial penalty. The purpose of this 75% rule is to
ensure that IRFs are primarily involved in providing intensive rehabilitation services. ss
The diagnoses included in the 75 percent rule, were also known as the Healthcare
Financing Administration–10 (HCFA–10) These criteria were redefined in 2004 in the
CMS conditions (Stroke, Brain injury, Amputation, Spinal cord, Fracture of the femur,
Neurological disorders, Multiple trauma, Congenital deformity, Burns: The original
HCFA condition “polyarthritis” was redefined as: Osteoarthritis (After less intensive
setting); Rheumatoid arthritis (After less intensive setting) Joint replacement (Bilateral,
Age ≥85, Body mass index ≥50) and a seperate condition Systemic vasculidities (After
less intensive setting).
This change contributed to the reduction in the volume of patients admitted to IRFs.
The most common rehabilitation condition for Medicare beneficiaries in 2004 was joint
replacement, followed by stroke and hip fracture.
8.7.2.3 Indication setting
For IRF one of the Medicare conditions is that a preadmission screening process to
determine that each prospective patient is likely to benefit significantly from an intensive
inpatient rehabilitation program. The purpose of prior authorization is to validate that
the service requested is medically necessary and meets criteria for reimbursement.
Prior Authorization does not automatically guarantee payment for the service; payment
is contingent upon passing all edits contained within the claims payment process; the
recipient’s continued Medicaid eligibility; and the ongoing medical necessity for the
service being provided. Prior Authorization requires a written initial physician
certification upon admission to Intensive Rehabilitation Services.
Medicare-medicaid agencies operate with interqual criteria. tt InterQual Criteria are sets
of clinical indicators, that consider the level of illness of the patient and the services
required The criteria are grouped into 14 body systems, and there are 3 sets of criteria
for each body system: Intensity of Service, Severity of Illness Discharge Screens.
Intensity Severity Discharge (ISD) Level of Care Criteria are used to determine the
appropriateness of admission, continued services, and discharge, across the continuum
of care. ISD uses objective, clinical indicators to determine the proper level of care,
based on the patient's severity of illness and service requirements, and to suggest an
appropriate care setting
8.7.2.4 Financing in rehabilitation
The Balanced Budget Act of 1997 mandated use of a prospective payment system (PPS)
to pay for Medicare patient stays at inpatient rehabilitation facilities (IRFs) and stated
that payment amounts should accurately reflect changes in IRFs’ patient case mix.
The Centers for Medicare and Medicaid Services (CMS) implemented the Inpatient
Rehabilitation Facility (IRF) Prospective Payment System (PPS) beginning on January 1,
2002. Before January 2002, Medicare paid IRFs under the Tax Equity and Fiscal
Responsibility Act of 1982 (TEFRA), on the basis of their average costs per discharge,
ss for details see http://www.cms.hhs.gov/InpatientRehabFacPPS/LIRFF/list.asp#TopOfPage
http://www.cahf.org/public/consumer/medicare.php
tt http://www.interqual.com/IQSite/about/history.aspx