Inpatient Rehabilitation Facilities (IRF)

Published 02/27/2023

This electronic Comparative Billing Report (eCBR) focuses on providers that submit claims for patients receiving care within an Inpatient Rehabilitation Facilities (IRF).

For your personalized Inpatient Rehabilitation Facilities (IRF) results log on to eServices.

eCBR information is one of the many tools used by Palmetto GBA to assist individual providers in identifying variation and improving performance. Becoming proactive in addressing potential billing issues and performing internal audits will help ensure you are following Medicare guidelines.

Overview of IRF

After an illness, injury, or surgery, some patients need intensive inpatient rehabilitation services, such as physical, occupational, or speech therapy. Such services are frequently provided in skilled nursing facilities (SNFs) but are sometimes provided in inpatient rehabilitation facilities (IRFs). IRFs may be freestanding facilities or specialized units within acute care hospitals. To qualify as an IRF, a facility must meet Medicare’s conditions of participation for acute care hospitals. In addition, the facility must be primarily focused on treating one of 13 conditions that typically require intensive rehabilitation therapy, and must meet other requirements, such as having a medical director of rehabilitation who provides services in the facility.

Medicare patients are assigned to CMGs based on the primary reason for intensive rehabilitation care (for example, a stroke or hip fracture), age, and level of motor and cognitive function.

Under the IRF PPS, each Medicare patient is assigned to a rehabilitation impairment category (RIC) based on the principal diagnosis or impairment and further classified within a RIC to a CMG based on the level of motor and cognitive function and, for some CMGs, the patient’s age. Within each CMG, patients are further classified into one of four tiers based on the presence of certain comorbidities that have been found to increase the cost of care. Each CMG tier has a specific weight that is used to adjust the base payment rate up or down, to reflect the costliness of patients in that CMG tier relative to the costliness of the average Medicare IRF patient. Patients with a length of stay less than 4 days are assigned to a single CMG regardless of diagnosis, age, level of function, or presence of comorbidities. The IRF PPS also has outlier payments for patients who are extraordinarily costly.

In 2020, Medicare spent $8.0 billion on IRF care provided to fee-for-service (FFS) beneficiaries in about 1,160 IRFs nationwide. About 335,000 beneficiaries had 379,000 IRF stays. On average, the FFS Medicare program accounted for about 54 percent of IRF discharges.

Methods

The metrics reviewed in this CBR are the proportion of billing for CMG code usage in the grouping with comparisons to peers within the state and jurisdiction. This report is an analysis of Medicare Part A claims extracted from the Palmetto GBA data warehouse. The analysis shows the portions of your billing for each grouping compared to your peers in Jurisdictions J/M.

Example of eCBR

Inpatient Rehabilitation Facilities (IRF) eCBR example

Please be aware that the information contained within this CBR is not intended to be punitive or an indication of fraud. Rather, it is intended to be proactive communication that will assist you in identifying potential billing issues and help you with performing a self-audit of your conformity with Medicare guidelines.