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Legislative Changes to the 75 Percent Rule for Classifying Inpatient Rehabilitation Facilities (IRFs)

In accordance with Section 115 of the Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP) Extension Act of 2007, Section 2005 of the Deficit Reduction Act of 2005 has been amended to revise the following elements of the 75 percent rule that are used to classify IRFs:

  • The compliance percentage that IRFs must meet to be excluded from the acute care inpatient hospital prospective payment system (PPS) and to be paid under the IRF PPS will be set permanently at 60 percent for cost reporting periods beginning on or after July 1, 2005.
  • This statutory change effectively eliminates the increase to 65 percent that had already taken effect for cost reporting periods beginning on or after July 1, 2007, and also eliminates the increase to 75 percent that was scheduled to take effect for cost reporting periods beginning on or after July 1, 2008. All IRF cost reporting periods (or portions of cost reporting periods) beginning on or after July 1, 2005, will be evaluated using the 60 percent threshold.
  • Patient comorbidities that satisfy the criteria specified in 42 Code of Federal Regulations (CFR) §412.23(b)(2)(i) will be permanently included in the calculations used to determine whether an IRF meets the 60 percent compliance percentage.

To minimize the level of effort required from Medicare contractors and IRFs, contractors may now combine the two portions of cost reporting periods that are both reviewed at the 60 percent level into one continuous 12-month review period.

For example, an IRF's compliance review period for the cost-reporting period beginning May 1, 2008, was divided into two periods: one from January 1, 2007, through April 30, 2007, and a separate review period from May 1, 2007, through December 31, 2007. Since both of these review periods will now be evaluated at the 60 percent compliance threshold, contractors may now instead draw one combined random sample of the IRF's cases from the 12-month period as a whole (from January 1, 2007, through December 31, 2007) to determine the facility's compliance with the 60 percent threshold.

Further guidance on this will follow in an upcoming revision of the Internet-Only Manual (IOM).

Cardiac Rehabilitation Extensions

WPS Contract Medical Directors are no longer reviewing and approving Cardiac Rehabilitation Extensions per CMS Change Request 6850 implemented on October 1, 2010.

For specific Cardiac Rehabilitation and Intensive Cardiac Rehabilitation Program Services and Requirements, see CMS Internet Only Manual (IOM) Publications:

Electrical Stimulation for Dysphagia Treatment

Due to increased inquiries regarding coverage of electrical stimulation for dysphagia treatment, WPS Medicare felt it was important to restate our position regarding the coverage of this service. This information can also be found in our Dysphagia Local Coverage Determination (LCD).

The various forms of electrical stimulation for the treatment of dysphagia (e.g., Vitalstim which is a type of neuromuscular electrical stimulation therapy for the treatment of dysphagia, that uses small electrical currents to stimulate the muscles responsible for swallowing) are not covered.

  1. Surface electrical stimulation
    1. Surface electrical stimulation is applied to the skin, which activates sensory fibers in the skin and only those muscles immediately below the skin surface, if enough intensity is applied. Electrical stimulation over the surface of the skin will provide stimulation of the skin but has not been shown to elicit movement to control laryngeal elevation (Freed et al., 2001).
    2. Based upon review of the scientific and clinical literature, the clinical efficacy and clinical utility of this service remains unproven; in fact, there is concerning evidence that this modality places some individuals at risk of aspiration. However, because the code for dysphagia treatment is a comprehensive code that includes all treatment approaches, payment may be made if other medically necessary dysphagia treatments occur during the same session that electrical stimulation is rendered.
  2. Deep pharyngeal neuromuscular stimulation (DPNS)
    1. Deep pharyngeal neuromuscular stimulation is a systematized therapeutic method for pharyngeal dysphagia which utilizes "direct" neuromuscular stimulation to the pharyngeal musculature to restore muscle strength, endurance, pharyngeal reflex responses and pharyngeal reflex coordination for a restored, coordinated swallow response.
    2. Based upon review of the scientific and clinical literature, the clinical efficacy and clinical utility of this service remains unproven. However, because the code for dysphagia treatment is a comprehensive code that includes all treatment approaches, payment may be made for other medically necessary dysphagia treatments.
  3. Instrinsic stimulation
    1. By placing electrodes intramuscularly, individual muscles can be stimulated to achieve specific movements. Intramuscular stimulation of the mylo- and thyrohyoid muscles at rest can raise the larynx 50% of the distance it elevates during 2-ml water swallows (Burnett et al. 2003). If applied at the appropriate moment during swallowing, neuromuscular stimulation could potentially augment a patient's reflexively produced laryngeal elevation.
    2. Based upon review of the scientific and clinical literature, the clinical efficacy and clinical utility of this service remains unproven. However, because the code for dysphagia treatment is a comprehensive code that includes all treatment approaches, payment may be made for other medically necessary dysphagia treatments.

Page Last Updated: Monday, 31-Oct-2011 08:55:48 CDT