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Inpatient Rehabilitation Facility Prospective Payment System Spotlight

Guidance for technical updates to the Inpatient Rehabilitation Facility Prospective Payment System

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: April 22, 2020

  • The IRF-PAI Data Specifications Version 3.00.1 (FINAL) – in effect on October 1, 2018 is available for download from the Software webpage.
  • IRF Classification Criteria.  A technical update was made to the Specifications for Determining IRF “60% Rule” Compliance file and is available from the IRF Classification Criteria webpage.
  • Impairment Group Codes That Meet Presumptive Compliance Criteria-3 (ICD-10-CM).  A technical revision was made to the list of impairment group codes that are used for determining presumptive compliance with the IRF 60 percent rule file (page 1) and is available from the available on the Data Files webpage.
  • IRF Rate Setting, Provider Specific Impact Analysis, and the Case-Mix Groups, Relative Weights, and Average Length of Stay files are available on the Data Files webpage
  • CMG Version 3.10 is available for download from the Software webpage.
  • CMS-1688-F:  Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2019 is on public display at the Office of Federal Register and will be published on August 6, 2018.  The wage index file is available on the Data Files webpage. The IRF Patient Assessment Instrument (PAI), effective October 1, 2019, is available on the IRF Patient Assessment Instrument web page. 
  • The IRF Technical Report “Analyses to Inform the Potential Use of Standardized Patient Assessment Data Elements in the Inpatient Rehabilitation Facility Prospective Payment System” is available on the IRF Research web page.
  • IRF Rate Setting, Case-Mix Groups, Relative Weights, and Average Length of Stay associated with the FY 2019 IRF PPS proposed rule (CMS-1688-P) are available on the Data Files webpage.
  • CMS-1688-P: Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2019 is on public display at the Office of Federal Register and will be published on May 8, 2018. The wage index file is available on the Data Files web page.
    • The IRF Technical Report “Analyses to Inform the Potential Use of Standardized Patient Assessment Data Elements in the Inpatient Rehabilitation Facility Prospective Payment System” is available on the IRF Research web page.
    • Proposed IRF-PAI (version 3.0) – Effective October 1, 2019 (FY 2020), as proposed in the FY 2019 IRF PPS proposed rule, and a table listing changes from the previous version are available on the IRF-PAI webpage.
  • IRF-PAI Errata Version 3.00.1 for Data Specifications Version 3.00.0 (DRAFT) – in effect for October 1, 2018 is available on the Software webpage.
  • FY 2016 SSI Ratios for IRFs is available from the SSI Data webpage
  • IRF-PAI Data Specifications Version 3.00.0 (DRAFT) – in effect on October 1, 2018 is available from the Software web page.  This DRAFT version supports Version 2.0 of the IRF-PAI.  Please note the revisions to allowed item values for Section GG items, the removal of two Section GG items and ten Section M items, and the new Section N.  
  • Complete List of IRF Clarifications for the Coverage Requirements (PDF) - the attached document combines all of the clarifications for the IRF coverage requirements into one cohesive document.
  • IRF Classification Criteria.  Updates were made to the Determining IRF Compliance and Presumptive Methodology files and are available from the IRF Classification Criteria webpage.
  • jIRVEN v1.4.0 is now available for download from the Software webpage.
  • IRF-PAI Data Specifications Version 2.01.1 (Final) – in effect on October 1, 2017 is available from the Software web page.  This version supports Version 1.5 of the IRF-PAI.  There have been no additional changes since the DRAFT version 2.01.0 posted below.
  • CMG Version 3.00 is available for download from the Software webpage.
  • IRF-PAI (versions 1.5 and 2.0), Updated Section 2 (Item by Item IRF PAI Coding Instructions) of IRF-PAI Training Manual, and Change Tables are available on the IRF-PAI webpage
  • FY 2018 IRF PPS Final Rule (82 FR 36238) published on August 3, 2017.  The associated data files are available on the Data Files web page.
  • CMS-1671-F: Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2018 is on public display at the Federal Register.  The associated wage index and presumptive methodology data files are available on the Data Files web page.
  • The FY 2015 SSI Data/Ratios for IRFs is available for download from the SSI Data webpage.
  • In response to our recently released FY 2018 IRF PPS proposed rule, we have received inquiries from stakeholders regarding a couple of technical omissions contained within the FY 2018 proposed presumptive compliance files posted on our website.  In responding to these inquires we have updated this file to address the following omissions: 

    *  Add G72.89 to the IGC etiologic diagnosis exclusion codes under IGC 3.8 , and  
    *  Add the appropriate 7th character extension codes to the major multiple trauma code lists.

    The revised FY 2018 proposed presumptive compliance files can be found on our IRF PPS Data Files webpage at FY 2018 Data Files Proposed (ZIP).
     
  • IRF-PAI Data Specifications Version 2.01.0 (DRAFT) – in effect on October 1, 2017 is available from the Software web page.  This version supports Version 1.5 of the IRF-PAI and is a revised draft dated 04/25/2017.

  • CMS-1671-P: Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2018 has published at the  Office of Federal Register. Associated data files including, but not limited to, the IRF rate setting, case-mix groups, relative weights, average length of stay, wage index, the tier comorbidities, and the draft presumptive methodology are available on the Data Files web page.

  • IRF-PAI Data Specifications Version 2.01.0 (DRAFT) – in effect on October 1, 2017 is available from the Software web page.
  • 2017 IRF-PAI information is available on the IRF-PAI web page.
  • CMS-1671-P: Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2018 is on public display at the Office of Federal Register. The wage index file, the tier comorbidities file, and the draft presumptive methodology files are available on the Data Files web page.
  • IRF-PAI Therapy Information Data Collection Call - January 12, 2017 
    Thursday, January 12 from 1:30 to 3 pm ET

    To register or for more information, visit MLN Connects Event Registration.
    In the fiscal year 2015 Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) final rule, CMS finalized a new Therapy Information section on the IRF-Patient Assessment Instrument (PAI).  During this call, CMS will focus on reviewing the types and methods of therapy collected on the IRF-PAI, examples of each type of therapy, and how to accurately code and complete the therapy information section on the IRF-PAI.  Prior to the call, participants are encouraged to review the IRF-PAI Training Manual(ZIP) (ZIP).  Participants can also review materials from our 2015 MLN Connects Call  on how to code and complete the new IRF-PAI item for Therapy Data Collection.  A question and answer session will follow the presentation.
    Target Audience: IRF providers
     
  • jIRVEN v1.3.0 is now available for download from the Software webpage.
  • IRF-PAI Data Specifications Version 2.00.1 (FINAL) – in effect on October 1, 2016 is available for download from the Software webpage.
  • Updated IRF Tier Comorbidities List (reflecting ICD-10-CM codes effective October 1, 2016) is now available for download from the Data Files webpage. 
  • Updated Section 4 (Quality Indicators) of IRF-PAI Training Manual V1.4 and Change Table are available on the IRF-PAI webpage
  • CMG Grouper version 2.90 is now available for download from the Software webpage.
  • FY 2017 IRF PPS Final Rule Data Files (81 FR 52056) are available on the Data Files web page.  
  • CMS-1647-F:  Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2017 is on public display at the Office of Federal Register and publishes on Friday, August 5, 2016.  The associated wage index file is available on the Data Files web page.
  • The FY 2014 SSI Data/Ratios for IRFs is available for download from the SSI Data webpage.
  • Special Open Door Forum – Inpatient Rehabilitation Tier Comorbidity Updates:  A link to the transcript and audio file is now available on the Data Files page.
  • jIRVEN v1.2.2, which includes CMG Grouper version 2.82, is now available for download from the Software webpage.
  • The IRF-PAI Errata Version 2.00.4 for Data Specifications Version 2.00.0 (DRAFT) – in effect for October 1, 2016 is available on the Software webpage.
  • The new CMG Version 2.82 is available on the Software webpage.
  • Special Open Door Forum – Inpatient Rehabilitation Tier Comorbidity Updates:  Soliciting Stakeholder Input.  Thursday, June 16, 2016 (2:00-3:30 pm Eastern Time/Conference Call only).  Presentation Slides are available on the Data Files web page.
  • FY 2017 IRF PPS Proposed Rule Data Files (81 FR 24178) are available on the Data Files web page.
  • CMS-1647-P:  Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2017 was published on April 25, 2016.  The wage index file is available on the Data Files web page.
  • jIRVEN v1.2.1, which includes CMG Grouper version 2.81, is now available for download from the Software webpage.
  • IRF-PAI Errata Version 2.00.3 for Data Specifications Version 2.00.0 (DRAFT) – in effect for October 1, 2016 is available from the  Software webpage.
  • The corrected test data for CMG Version 2.81 has posted to the Software webpage.
  • The CMG Version 2.81 Grouper Package is available for download from the Software webpage.
  • All QIES ASAP systems will be down from Wednesday, March 16 after 8:00 p.m. (EST) through Monday, March 21, 2016 at 11:59 p.m. (EST).  This downtime will affect all QIES connectivity and systems.  This means the national database, CASPER reports, and QW will NOT be available during this time.   During the outage, IRF providers WILL NOT be able to submit IRF-PAIs to the QIES ASAP system. The submission deadline for submitting IRF-PAIs is 27 days following discharge.  Thus, for patient discharges occurring 27 days prior the outage dates, IRF providers should make arrangements to submit IRF-PAIs early to ensure that they are submitted on time.  

    ****Please Note: Due to the advanced notification regarding the system outage, CMS will not be granting 25% penalty waivers for IRF-PAIs submitted late during this time.  Providers should properly prepare for the system outage while continuing to meet IRF requirements regarding IRF-PAI submissions.
     
  • Updated IRF-PAI Errata for Data Specifications Version 2.00.0 (DRAFT) – in effect for October 1, 2016 is available from the "Software" web page.
  • Errata for IRF-PAI Training Manual Effective October 1, 2015 - available in the updated IRF-PAI Training Manual October 1, 2015 zip files
  • IRF-PAI Errata for Data Specifications Version 2.00.0 (DRAFT) – in effect for October 1, 2016 is available for download from the Software web page.
  • IRF-PAI Data Specifications Version 2.00.0 (DRAFT) – in effect on October 1, 2016 is available for download from the Software web page.
  • IRF-PAI Training Manual- Updated Sections of the IRF-PAI Training Manual are now available for download.  The updated sections reflect the changes being implemented beginning October 1, 2015.
  • jIRVEN v1.2.0 is available for download from the Software web page.
  • Updated IRF Classification Criteria files for determining IRF "60 Percent Rule" compliance are available for download on the IRF Classification Criteria web page.
  • FY 2016 IRF PPS Final Rule (80 FR 47142) published on August 6, 2015.  The associated data files are available on the Data Files web page.
  • New IRF Patient Assessment Instrument (IRF PAI) for October 1, 2016 is available on the IRF Patient Assessment Instrument web page.  The FY 2016 IRF PPS final rule (80 FR XXXXX) is on public display at the Office of Federal Register.  The associated wage index files (80 FR XXXXX) are available on the Data Files web page.
  • ICD-10-CM Files for the IRF PPS are available for download from the Data Files web page.
  • A Clarification on the use of seventh character extensions in ICD-10-CM under the IRF PPS is available for download from the IRF Patient Assessment Instrument web page.
  • FY 2016 IRF PPS Proposed Rule Data Files (80 FR 23332) are available on the Data Files web page.
  • CMS-1624-P:  Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2016 is on public display at the Office of Federal Register and will be published on April 27, 2015.  The wage index file is available on the Data Files web page.
  • Revised FY 2015 IRF PPS Tier Comorbidities list is available on the "Data Files" web page. This revised version of the list replaces the version posted August 22, 2014.  The list has been revised to make the following corrective edits:
    • Tier Comorbidities — ICD-10-CM (for IRF discharges occurring on or after October 1, 2015 if ICD 1 CM is the required medical data code set for use on Medicare claims and IRF-PAI submissions at that time (revised April 14, 2015))
      • Added code G40.411 (the code title is present; the code was inadvertently left off of the list).
      • Deleted one of code G81.93.  The code was duplicated in the list.
      • Deleted one of code L03.113.  The code was duplicated in the list.
      • Added a letter “B” choice to combination code:
        CodeChoiceCode Title
        K26.1AAcute duodenal ulcer with perforation
        K56.60BUnspecified intestinal obstruction
  • UPDATED!  IRF-PAI Errata for Data Specifications Versions 1.12.0 – in effect on October 1, 2015 (PDF).  This Errata originally included corrections to the XML Tags for 4 items (24A1, O0401AB, O0401AC, and O0401AD) and the deletion of an incorrect version note for Item 8.  The updated errata introduces the new edit -1129, which is applicable to two items (ITM_SET_VRSN_CD and SPEC_VRSN_CD) and replaces edit -1010 for those items.  The errata also adds edit -1006 to item 2.
  • CMS held an MLN Connects National Provider Call on January 15, 2015 to train IRF Industry providers on recent changes to the IRF-PAI Training Manual (regarding the Arthritis Attestation (Item 24A) and Therapy Information Section (Items O0401 and O0402)). The video slideshow of the presentation is now available in the "Related Links" section below. CMS has also made additional changes to the Helpful Resources document and Section 2 of the IRF-PAI Training Manual to provide clarification.
  • IRF-PAI Errata for Data Specifications Versions 1.12.0 – in effect on October 1, 2015 (PDF).   This Errata includes corrections to the XML Tags for 4 items (24A1, O0401AB, O0401AC, and O0401AD) and the deletion of an incorrect version note for Item 8.
  • Per the FY2015 IRF PPS Final Rule, CMS has added information to Section 2 (Item by Item IRF-PAI Coding Instructions) of the IRF-PAI Training Manual regarding the Arthritis Attestation (Item 24A) and Therapy Information Section (Items O0401 and O0402). These new IRF-PAI items will be effective as of October 1, 2015.
  • CMS-1608-CN: Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2015; Correction published on October 1, 2014 and is available for download from the "List of IRF Federal Regulations" web page.

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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.