Medicare Compliance & Reimbursement

Proposed refining of covered IRF diagnoses 'disappoints' some. 

The long-awaited report from the Government Accountability Office on the 75-percent rule (which determines whether a facility qualifies as in IRF) came out in late April, and providers are reeling from what it says - and what it doesn't say.

"I was very disappointed by the GAO report," laments Karen Eyberger, rehab development manager for Genesis HealthCare System in Zanesville, OH.
 
Qualifying For IRF Services May Get Tougher

In a move that left many providers shaking their heads, the GAO recommended that the Centers for Medicare and Medicaid Services further refine the rule to "describe more thoroughly the subgroups of patients within a condition that require IRF services."

The GAO called on the Institute of Medicine to convene an expert panel to discuss the 75-percent rule, including a discussion about whether CMS should add more diagnoses to the list of qualifying conditions.

The verdict: "The experts IOM convened questioned the strength of the evidence for adding conditions to the list, finding the evidence for certain orthopedic conditions particularly weak, and they called for further research to identify the types of patients that need inpatient rehabilitation and to understand the effectiveness of IRFs," the report says.

Panelists did agree that condition alone doesn't provide sufficient information about a patient, and that functional status also should figure into whether the patient qualifies, the report says.

Translation: The chances that CMS will broaden the list of 13 qualifying conditions is slim - in fact, it is more likely to place additional restrictions on those diagnoses that currently count toward the percentage threshold.

"The GAO's recommendation to further define the admitting diagnoses into 'subgroups' was chilling," says Eyberger. "If some of the diagnoses under the rule get more specific, no patient will be able to meet them."

Another blow: The GAO notes that CMS has not routinely reviewed inpatient rehab facilities' admission decisions and urges the agency to change that.