CMS-437B Rehabilitation Hospital Criteria Worksheet

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED

OMB NO. 0938-0986

REHABILITATION HOSPITAL CRITERIA WORK SHEET

RELATED MEDICARE PROVIDER NUMBER

ROOM NUMBERS IN THE UNIT

NUMBER OF BEDS IN THE UNIT

SURVEY DATE

REQUEST FOR EXCLUSION FOR COST REPORTING PERIOD:

FACILITY NAME AND ADDRESS (City, State, Zip Code)

/ /
to
/ /
VERIFIED BY
MM DD YYYY MM DD YYYY

ALL CRITERIA UNDER SUBPART B OF PART 412 OF THE REGULATIONS MUST BE MET FOR EXCLUSION FROM MEDICARE'S ACUTE CARE HOSPITAL INPATIENT PROSPECTIVE PAYMENT SYSTEM

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GUIDANCE TO SURVEYORS

YES NO

EXPLANATORY STATEMENT

§412.23 Excluded hospitals:
(b) Rehabilitation hospitals. In order to be excluded
from the Medicare’s Acute Care Hospital
Inpatient Prospective Payment System (IPPS)
and to be paid under the Inpatient Rehabilitation
Facility Prospective Payment System, a
rehabilitation hospital must meet the following
requirements in addition to all the criteria
under subpart B of part 412 of the regulations:
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(1) Have a provider agreement under part 489
to participate as a hospital.

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(2) Except in the case of a newly participating • Has the Fiscal Intermediary verified the rehab
hospital seeking classification under this
hospital meets the 75% rule?
paragraph as a rehabilitation hospital for its
first 12-month cost reporting period, as
described in paragraph (b)(8) of this section,
a hospital must show that during its most
recent consecutive and appropriate12-month
time period (as defined by CMS or the fiscal
intermediary), it served an inpatient
population that meets the criteria under
paragraph (b)(2)(i) or (b)(2)(ii) of this section:
(i) For cost reporting periods beginning
on or after July 1, 2004 and before
July 1, 2005, the hospital has served an
inpatient population of whom at least
50 percent, and for cost reporting periods
beginning on or after July 1, 2005 and
before July 1, 2006, the hospital has
served an inpatient population of whom
at least 60 percent, and for cost reporting
periods beginning on or after July 1, 2006
and before July 1, 2007, the hospital
has served an inpatient population of

Form CMS-437B (03/06) EF 06/2006

• The surveyor should check State Agency (SA)
records and/or verify with the Regional Office
(RO) to ensure the hospital has an agreement to
participate in the Medicare program.

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EXPLANATORY STATEMENT

whom at least 65 percent, required
intensive rehabilitative services for
treatment of one or more of the
conditions specified at paragraph
(b)(2)(iii) of this section. A patient with a
comorbidity, as defined at §412.602, may
be included in the inpatient population
that counts towards the required
applicable percentage if–
(A) The patient is admitted for inpatient
rehabilitation for a condition that
is not one of the conditions
specified in paragraph (b)(2)(iii) of
this section;
(ii) For cost reporting periods beginning on
or after July 1, 2007, the hospital has
served an inpatient population of whom
at least 75 percent required intensive
rehabilitative services for treatment of
one or more of the conditions specified
in paragraph (b)(2)(iii) of this section. A
patient with comorbidity as described in
paragraph (b)(2)(i) is not included in
the inpatient population that counts
towards the required 75 percent.
(iii) List of conditions
(A) Stroke.
(B) Spinal cord injury.
(C) Congenital deformity.
(D) Amputation.
(E) Major multiple trauma.
(F) Fracture of femur (hip fracture).
(G) Brain injury.
(H) Neurological disorders.
(I) Burns.
(J) Active polyarticular
reheumatoid arthritis.
(K) Systemic vasculidities with joint
inflammation, resulting in significant
functional impairment of ambulation
and other activities of daily living.
(L) Severe or advanced osteoarthritis.
(M) Knee or hip joint replacement.

Form CMS-437B (03/06) EF 06/2006

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(3) Have in effect a preadmission screening
procedure under which each prospective
patient’s condition and medical history are
reviewed to determine whether the patient
is likely to benefit significantly from an
intensive inpatient hospital program
or assessment.

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(4) Ensure that the patients receive close
• Verify that every patient is under the care of a
medical supervision and furnish, through
physician and has signed orders in the chart.
the use of qualified personnel, rehabilitation, • If the State issues licenses, verify that all licenses
nursing, physical therapy, and occupational
are current and are issued by the State in which
therapy, plus, as needed, speech therapy,
qualified personnel are providing services.
social services or psychological services,
• Determine that the hospital has a means of
and orthotic and prosthetic services.
ensuring that its personnel remain qualified/
competent?
• Refer to State laws and hospital policies to
determine the qualifications of personnel
providing rehabilitation services.
• Review medical charts if patients have been
admitted.

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(5) Have a director of rehabilitation who —

EXPLANATORY STATEMENT

• Review the pre-admission screening protocol and
verify the protocol is applied to each potential
admission (through record review, etc).

Verify the rehab unit has a director of rehab.

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(i) Provides services to the hospital and
its inpatients on a full time basis;

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(ii) Is a doctor of medicine or osteopathy; Ensure license is current and issued by the State in
which the service is being provided.

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(iii) Is licensed under State law to practice Ensure license is current and issued by the State in
medicine or surgery; and
which the service is being provided.

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(iv) Has had, after completing a 1-year
hospital internship, at least 2 years
of training or experience in the
medical management of inpatients
requiring rehabilitation services.

Form CMS-437B (03/06) EF 06/2006

YES NO

The full time hours may be any combination of
patient services and administration. A director of
rehabilitation hours cannot be substituted by a
Physician Assistant. Verify the full time hours
through review of personnel time cards/logs, etc.

Review personnel files.

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(6) Have a plan of treatment (POT) for each
inpatient that is established, reviewed, and
revised as needed by a physician in
consultation with other professional
personnel who provide services to
the patient.

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Review hospital policy regarding multidisciplinary
(7) Use a coordinated multidisciplinary team
team meetings, frequency, and medical record
approach in the rehabilitation of each
documentation.
inpatient, as documented by periodic
clinical entries made in the patient’s
medical record to note the patient’s status
in relationship to goal attainment, and that
team conferences are held at every 2
weeks to determine the appropriateness
of treatment.
(8) A hospital that seeks classification under
this paragraph as a rehabilitation hospital
for the first full 12-month cost reporting
period that occurs after it becomes a
Medicare-participating hospital may provide
a written certification that the inpatient
population it intends to serve meets the
requirements of paragraph (b)(2) of this
section, instead of showing that it has
treated that population during its most
recent 12-month cost reporting period. The
written certification is also effective for
any cost reporting period of not less than
one month and not more than 11 months
occurring between the date of hospital
began participating in Medicare and the
start of the hospital’s regular 12-month
cost reporting period.

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YES NO

EXPLANATORY STATEMENT

Ensure that all patients have a POT in their medical
record. Verify the physician and other professional
personnel participate in the establishment, review, and
revision of the POT. (This could be a signature, a
record of a conference, or record of consultation.)

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Form CMS-437B (03/06)

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