Bulletin Board
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
Cardiac Rehabilitation services provided in connection with a cardiac rehabilitation exercise program may be considered reasonable and necessary for up to 36 sessions, generally two to three sessions a week in a single 12 to 18 week period.
Coverage for continued participation in cardiac exercise programs beyond 12 to 18 weeks or 36 treatment sessions could be allowed, on a case-by-case basis, with exit criteria taken into consideration. A written request for an extension of cardiac rehabilitation must be submitted by the attending physician, along with supporting documentation, to our Medicare Medical Director for a determination of medical necessity. (The contractor has the discretion to cover cardiac rehabilitation services beyond 18 weeks.) Pending approval by the Medicare Medical Director, additional coverage may be allowed, but must not exceed a total of 72 sessions for 36 weeks.
A downloadable "Request for Cardiac Rehab Extension" 
form is available at to assist providers with the required documentation and information necessary for requesting a cardiac rehabilitation extension.
All requests for cardiac rehabilitation extensions should be submitted via overnight mailing to:
WPS Medicare
Attention: Medical Review Department/Cardiac Rehabilitation Extension
3333 Farnam Street, Suite 600
Omaha, NE 68131
The Medicare Medical Director will make a decision to approve or deny the extension of services within 30 days of receipt of documentation. A representative from the Medical Review department will contact your facility by phone with the Medical Director's decision to approve or deny the extension. This phone contact will be followed with an official notification letter that will be mailed to the facility.
For more information, please see the CMS IOM:
CMS Publication 100-3, Chapter 1, Section 20.10
Wisconsin Physicians Service (WPS) Local Coverage Determinations (LCD) for Part A
Since the announcement of the Jurisdiction 5 (J5) A/B Medicare Administrative Contract (MAC), there has been some confusion amongst providers as to which Local Coverage Determinations (LCDs) should be followed.
If you are a provider that was formerly with Mutual of Omaha Medicare and have now transitioned to Wisconsin Physicians Service (WPS) Medicare, you are considered a "Legacy Part A" provider, and should continue to utilize the LCD's posted on our Website under Part A Information. As a legacy provider, your claims and other Medicare Part A services are being provided by WPS Medicare under a Medicare Fee-For-Service (FFS) contract, not a MAC contract.
To access these LCD's, go to the WPS Medicare home page http://www.wpsmedicare.com. From the home page, choose "Part A Information" under "Provider." Accept the license agreement, and you will be taken into the Part A Legacy portion of the Website. From here, use the primary (top) navigation bar to choose Policy/Coverage. A drop-down menu will give you options for Local or National Coverage Determinations.
You will not utilize the Jurisdiction 5 MAC LCD's until you transition to the MAC environment. Exact dates for these transitions have not yet been determined.
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.
- Surface electrical stimulation
- 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).
- 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.
- Deep pharyngeal neuromuscular stimulation (DPNS)
- 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.
- 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.
- Instrinsic stimulation
- 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.
- 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.
Using Section T of the MDS to Determine RUG Rehabilitation Categories in Skilled Nursing Facilities
There has been some confusion about the use of Section T of the Minimum Data Set (MDS) to project patients into a rehab medium RUG category.
Section T may only be used if a physician orders therapy, an evaluation has been completed, and treatment has been scheduled. The intent of Section T is to recognize ordered and scheduled therapy services during the early days of the resident's stay. Often therapies are not initiated until after the end of the observation period, or the resident may have a sudden change in status and be readmitted to the hospital before therapy services start. For the Medicare 5-Day or Readmission/Return Assessment, this section provides an overall picture of the amount of therapy a resident will likely receive through the fifteenth day from admission.
The instructions for completing Section T state, "For Item T1b: Review the resident's clinical record to determine if the physician has ordered one or more of the medically necessary therapies to begin in the first 14 days of stay. Therapies include physical therapy (PT), occupational therapy (OT), and/or speech pathology services. If not, skip to Item T2. If orders exist, consult with the therapists involved to determine if the initial evaluation is completed and therapy treatment(s) has been scheduled. If therapy treatment(s) will not be scheduled, skip to Item T2."
"If the resident is scheduled to receive at least one of the therapies, have the therapist(s) calculate the total number of days through the resident's fifteenth day since admission to Medicare Part A when at least one therapy service will be delivered. Then have the therapist(s) estimate the total PT, OT, and SP treatment minutes that will be delivered through the fifteenth day of admission to Medicare Part A."
The therapist would then estimate the number of days therapy would occur through day fifteen and then estimate the number of minutes expected to be delivered.
For complete instructions, refer to the RAI Manual 
, Chapter 3, Pages 215 - 217.
Page Last Updated: Tuesday, 15-Jul-2008 10:35:51 CDT
