Form CMS-437 A CMS-437 A REHABILITATION UNIT CRITERIA WORK SHEET

FORM APPROVED
OMB NO. 0938-0986

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

REHABILITATION UNIT 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)

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to
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MM DD YYYY
MM DD YYYY

VERIFIED BY

ALL CRITERIA UNDER SUBPART B OF PART 412 OF THE REGULATIONS MUST BE MET FOR EXCLUSION FROM
MEDICARE’S ACUTE CARE HOSPITAL PROSPECTIVE PAYMENT SYSTEM OR FROM THE PAYMENT SYSTEM USED TO PAY CRITICAL ACCESS HOSPITALS.

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REGULATION

GUIDANCE

THE HOSPITAL REPRESENTATIVE WHO
COMPLETES THIS ENTIRE FORM

• Verification of hospital attestations may be done
by CMS surveyors or MACs as applicable.

The hospital representative is expected to answer all
questions accurately.
The representative should verify the answers with
the director of rehabilitation, physician, medical
records office, or any applicable department to
ensure correct responses to this form.
A “yes” response means the hospital is in
compliance with the applicable regulation.

§412.25 Excluded hospital units: Common
requirements.
(a) Basis for exclusion. In order to be excluded
from the prospective payment systems specified in
§412.1(a)(1), a rehabilitation unit must meet the
following requirements in addition to the all criteria
under Subpart B of Part 412 of the regulations:

Form CMS-437A (06/12)

In the case of § 412.25 and § 412.29, as related to
IRF units, the term hospital includes Critical Access
Hospitals.

YES

NO

N/A

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(1) Be part of an institution that has in effect an
agreement under Part 489 to participate as a
hospital, and is not excluded in its entirety from the
prospective payment systems, and has enough beds
that are not excluded to permit the provision of
adequate cost.

• The surveyor will verify, through the regional
office (RO), that the hospital has an agreement
to partici­pate in the Medicare program, and the
hospital is not already excluded in its entirety
from IPPS, such as a rehabilitation hospital. In
other words, the unit seeking exclusions cannot
comprise the entire hospital

THE HOSPITAL REPRESENTATIVE WHO
COMPLETES THIS ENTIRE FORM

YES

NO

N/A

Representative to ensure the hospital has a
Medicare provider agreement.

• The hospital must be sufficiently staffed,
maintained and IPPS beds utilized that are not
part of the rehabilitation unit.
• Verification of this information may be done by
CMS surveyors or MACs.
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(2) Have written admission criteria that are applied
uniformly to both Medicare and non-Medicare
patients.

• Verify that the hospital has preadmission criteria
for the rehabilitation unit.

Representative to verify the rehab unit has
preadmission criteria.

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(3) Have admission & discharge records that are
separately identified from those of the hospital in
which it is located and are readily available.

• Verify that rehabilitation unit medical records
are separate and not commingled with other
hospital records and are readily available for
review.

Representative to verify that the rehab unit houses
only the records of the rehab patients.

A3503

(4) Have policies specifying that necessary clinical
information is transferred to the unit when a patient
of the hospital is transferred to the unit.

• Verify that the hospital has a policy detailing
the prompt transfer of information, and that it is
being followed.

Representative to verify the hospital has a policy
regarding the transfer of information, and the
hospital adheres to the policy.

• Conduct an open and closed record review to
determine whether the approved preadmission
criteria is applied equally to all patients.

• Review rehabilitation unit clinical records to
ensure that the clinical information that should
be transferred with the record is actually in the
medical record.

Form CMS-437A (06/12)

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REGULATION
(5) Meet applicable State licensure laws.

GUIDANCE
• Verify and document that all applicable State
licensure laws are met.
• Document all unmet State licensure
requirements.

THE HOSPITAL REPRESENTATIVE WHO
COMPLETES THIS ENTIRE FORM

YES

NO

N/A

Representative to verify that all applicable State
laws are being met and that all applicable licenses
are current.

• Verify the hospital has current licenses for its
professional staff.
• Are the licenses issued by the State in which the
rehabilitation unit is located?
• Does the unit meet special licensing
requirements issued by the State?
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(6) Have utilization review standards applicable for
the type of care offered in the unit.

• Verify that the hospital has a utilization
review plan that includes the review of rehab
services (No utilization review (UR) standards
are required if the QIO is conducting review
activities.)

Representative to verify that the hospital has a UR
plan and that the UR standards are being applied to
the care offered in the rehab unit.

• Verify that the hospital has written UR standards
that are applied to the care offered in the unit.

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(7) Have beds physically separate from (that is, not
commingled with) the hospital’s other beds.
NOTE: §412.25(a) (8)-(12) are verified by the FI.

• Is the space containing the rehab beds physically Representative will verify that the beds on the rehab
separate from the beds in other units of the
unit do not belong to medical/surgical patients but
hospital?
are dedicated to rehab patients only.
• There cannot be any beds that are located
within the physical confines of the excluded
rehab unit that are not excluded beds.
• The IRF unit cannot use its beds for medical
/surgical patients or any other type of
patient. Those beds are solely for the use of IRF
patients.
• If the unit doesn’t have enough patients to fill
those beds, the beds must be left empty or the
unit can decrease the number of beds in the
unit after the hospital has notified CMS of its
intent.

Form CMS-437A (06/12)

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(13) As part of the first day of the first cost reporting
period for which all other exclusion requirements
are met, the unit is fully equipped and staffed and is
capable of providing hospital inpatient rehabilitation
care regardless of whether there are any inpatients
in the unit on that date.

• Prior to scheduling the survey, verify with the
FI that the unit is operational: fully staffed and
equipped.

(b) Changes in the size of excluded units. Except in
the special cases noted at the end of this paragraph,
changes in the number of beds or square footage
considered to be part of an excluded unit under this
section are allowed one time during a cost reporting
period if the hospital notifies its Medicare contractor
and the CMS RO in writing of the planned change
at least 30 days before the date of the change.
The hospital must maintain the information needed
to accurately determine costs that are attributable to
the excluded unit. A change in bed size or a change
in square footage may occur at any time during a
cost reporting period and must remain in effect for
the rest of that cost reporting period. Changes in
bed size or square footage may be made at any time
if these changes are made necessary by relocation
of a unit to permit construction or renovation
necessary for compliance with changes in Federal,
State, or local law affecting the physical facility or
because of catastrophic events such as fires, floods,
earthquakes, or tornadoes.

• Verify that the request the IRF is making to add
beds is the first and only request during the cost
report year.

THE HOSPITAL REPRESENTATIVE WHO
COMPLETES THIS ENTIRE FORM

YES

NO

N/A

• It is not required that the unit has inpatients
on the day of the survey, but must demonstrate
capability of caring for patients.
Representative to verify that if changes were made
to the unit, both CMS and the MAC/FI were notified
prior to any change.

• A decrease in the number of beds or square
footage may occur at any time during the cost
report period. In both cases, the change must
remain in affect for the remainder of the cost
report period
• No changes can be made without notifying both
CMS RO and the FI/MAC at least 30 days prior
to the change.

§ 412.29 Classification criteria
for payment under the inpatient
rehabilitation facility prospective
payment systems. To be excluded from the
prospective payment systems described in
§ 412.1(a)(1) and to be paid under the prospective
payment system specified in § 412.(1)(a)(3), an
inpatient rehabilitation hospital or an inpatient
rehabilitation unit of a hospital (otherwise referred
to as an IRF) must meet the following requirements:
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(a) Have (or be part of a hospital that has) a
provider agreement under part 489 of this chapter
to participate as a hospital.

Form CMS-437A (06/12)

• The SA will check these provisions with the RO
prior to the survey.

Representative to ensure the hospital has a
Medicare provider agreement.

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(b) Except in the case of a “new” IRF or “new” IRF
beds, as defined in paragraph (c) of this section,
an IRF must show that, during its most recent,
consecutive, and appropriate 12-month time period
(as defined by CMS or the Medicare contractor),
it served an inpatient population that meets the
criteria outlined in § 412.29 (b)(2).

• The MAC/FI reviews the inpatient population
of the IRF. If the hospital has not demonstrated
that it served the appropriate inpatient
population as defined in § 412.29 (b)(2), the
MAC notifies the RO.

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(c) In the case of new IRFs (as defined in
paragraph (c)(1) of this section) or new IRF beds
(as defined in paragraph (e)(2) of this section), the
IRF must provide a written certification that the
inpatient population it intends to serve meets the
requirements of paragraph (b) of this section. This
written certification will apply until the end of the
IRF’s first full 12-month cost reporting period or, in
the case of new IRF beds, until the end of the cost
reporting period during which the new beds are
added to the IRF.

• In the case of a new IRF unit, the surveyor will
verify that the hospital has not previously sought
exclusion.
• The surveyor will verify that the hospital received
approval for the unit under the appropriate
State licensure laws.

THE HOSPITAL REPRESENTATIVE WHO
COMPLETES THIS ENTIRE FORM

YES

NO

N/A

The representative completes this form (Form CMS
437A) as well as a signed attestation statement
attesting that the rehab unit’s patients it intends
to serve meets the requirements outlined in §
412.29(b)(2).

• •The IRF must submit an attestation
statement in addition to the Form CMS 437A
(rehabilitation unit worksheet) to the SA as part
of their initial application packet.
• Until the SA receives both the attestation
statement and the Form CMS 437A, the new
unit cannot be recommended for approval.

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(1) New IRFs. An IRF hospital or IRF unit is
considered new if it has not been paid under the
new IRF PPS in subpart P of this part for at least 5
calendar years. A new IRF will be considered new
from the point that it first participates in Medicare
as an IRF until the end of its first full 12-month cost
reporting period.

Form CMS-437A (06/12)

• If an IRF unit has been closed for 5 years (more
than 60 calendar months), it can open its doors
as a new unit.

The representative ensures the IRF unit has not been
paid under the IRFPPS for at least 5 calendar years.

• Verify either through the SA or RO that the
IRF unit has been closed for the 5 years before
approving the IRF unit as new.

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THE HOSPITAL REPRESENTATIVE WHO
COMPLETES THIS ENTIRE FORM

(2) New IRF beds. Any IRF beds that are added
to an existing IRF must meet all applicable State
Certificate of Need and State licensure laws. New
IRF beds may be added one time at any point during
a cost reporting period and will be considered
new for the rest of that cost reporting period. A
full 12-month cost reporting period must elapse
between the delicensing or decertification of IRF
beds in an IRF hospital or IRF unit and the addition
of new IRF beds to that IRF hospital or IRF unit.
Before an IRF can add new beds, it must receive
written approval from the appropriate CMS RO, so
that the RO can verify that a full 12-month cost
reporting period has elapsed since the IRF has had
beds declincensed or decertified. New IRF beds are
included in the compliance review calculations
under paragraph (b) of this section from the time
that they are added to the IRF.

• If the hospital added beds to its IRF unit, the
surveyor or CMS will verify that the hospital had
approval (certificate of need or State license )
before adding beds, if such approval is required.

• The representative verifies that the hospital
received State approval (certification of need or
State licensure) , if prior approval is required by
the State, prior to any IRF unit bed increase.

• The surveyor must verify that the hospital
received written CMS RO approval before
adding any new beds to its IRF unit.

• The representative verifies that the hospital
received written approval from the CMS RO
before any new beds were added to the IRF
unit.

(3) Change of ownership or leasing.
An IRF hospital or IRF unit that
undergoes a change of ownership, or
leasing as defined in § 489.18 of this
chapter, retains its excluded status
and will continue to be paid under
the prospective payment systems
specified in § 412.1(a)(3) before and
after the change of ownership or
leasing if the new owner(s) of the IRF
accept assignment of the previous
owners’ Medicare provider agreement
and the IRF continues to meet all the
requirements for payment under the IRF
prospective payment system. If the new
owner(s) do not accept assignment of
the previous owners’ Medicare provider
agreement, the IRF is considered to be
voluntarily terminated and the new
owner(s) may reapply to participate
in the Medicare program. If the IRF
does not continue to meet all of
the requirements under the new IRF
prospective payment system, then the
IRF loses its excluded status and is paid
according to the prospective payment
systems described in § 412.1(a)(1).

• IRF status is lost if a hospital is acquired and the
new owners reject assignment of the previous
owner’s Medicare provider assignment.

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Form CMS-437A (06/12)

• The surveyor will verify that the hospital’s IRF
unit didn’t have more than one increase in beds
during a single cost reporting period.
• Surveyors must verify that if the hospital’s IRF
unit decreased beds, it didn’t thereafter add
beds unless a full 12 month cost reporting
period had elapsed.

• Only entire hospitals may be sold or leased.
• IRF units may not be sold or leased separately
from the hospital of which it is a part.

YES

NO

N/A

• The representative will verify that if the
hospital’s IRF unit decreased beds, it didn’t
thereafter add beds unless a full 12 month cost
reporting period had elapsed.
• The representative will verify that the hospital’s
IRF unit didn’t have more than one increase in
beds during a single cost reporting period.

The representative of the IRF unit, that has
undergone a change of ownership, must ensure
that the new owner(s) have accepted assignment
of the previous Medicare provider agreement. If the
new owner(s) have not accepted the assignment,
the representative cannot request continued
participation as an IPPS-excluded unit.

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(4) Mergers. If an IRF hospital (or a
hospital with an IRF unit) merges with
another hospital and the owner(s) of
the merged hospital accept assignment
of the IRF (or the hospital’s provider
agreement (or the provider agreement
of the hospital with the IRF unit), then
the IRF hospital or IRF unit retains its
excluded status and will continue to be
paid under the prospective payment
system specified in § 412.1(a)(3) before
and after the merger, as long as the IRF
hospital or IRF unit continues to meet all
the requirements for payment under the
IRF prospective payment system. If the
owner(s) of the merged hospital do not
accept assignment of the IRF hospital’s
provider agreement (or the provider
agreement of the hospital with the IRF
unit), then the IRF hospital or IRF unit is
considered voluntarily terminated and
the owner(s) of the merged hospital
may reapply to the Medicare program to
operate a new IRF.

• As with the change of ownership, the
owner of the merged hospital must accept
assignment of the hospital’s (with the IRF unit)
provider agreement to ensure uninterrupted
reimbursement.

(d) 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. This procedure must ensure that the
preadmission screening is reviewed and approved
by a rehabilitation physician prior to the patient’s
admission to the IRF.

• Review the hospital’s procedures, or other
alternative documents or records, to verify the
hospital”s rehabilitation unit has a preadmission
screening procedure in place.

Form CMS-437A (06/12)

• If the owner of the hospital to be merged
doesn’t accept assignment of the previous
owner(s) Medicare provider agreement, the new
owner(s) will not be eligible for reimbursement
until the new owner(s) reapplies to the Medicare
program to operate a new hospital and have
additionally been granted IRF status.

THE HOSPITAL REPRESENTATIVE WHO
COMPLETES THIS ENTIRE FORM

YES

NO

N/A

The representative of the IRF unit that has
undergone a merger must ensure that the new
owner(s) have accepted assignment of the
previous Medicare provider agreement. If the
new owner(s) have not accepted the assignment,
the representative cannot request continued
participation as an IPPS-excluded unit.

• IRF status is lost if a hospital is acquired and the
new owner(s) reject assignment of the previous
owner’s Medicare provider agreement. This also
applies to an acquisition that is followed by a
merger.

The representative will ensure the hospital’s
rehabilitation unit is using the preadmission
screening procedure on all patients admitted to the
rehab unit.

• A review of the clinical records should indicate
whether the IRF has such a screening procedure
and whether it is using the screening procedure.
• The purpose of the preadmission screen is to
reduce the rate of hospital readmission by
ensuring that the patients that are accepted to
the IRF will benefit from intensive rehabilitation
services.

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(e) Have in effect a procedure to ensure that
patients receive close medical supervision, as
evidenced by at least 3 face-to-face visits per week
by a licensed physician with specialized training and
experience in inpatient rehabilitation to access the
patient both medically and functionally, as well as
to modify the courses of treatment as needed to
maximize the patient’s capacity to benefit from the
rehabilitation process.

• Review the hospital’s procedures or other
alternative documents or records to verify the
hospital has a procedure detailing close medical
supervision for patients, including at least 3
face-to-face visits per week.

(f) Furnish, through the use of qualified personnel,
rehabilitation nursing, physical therapy, and
occupational therapy, plus as needed, speechlanguage pathology, social services, psychological
services (including neuropsychological service) and
orthotic and prosthetic services.

• Review the licenses of all qualified personnel
that are required by the State to be licensed, to
verify the licenses are up-to-date.

• As part of the clincal record review, look for
documentation supporting the physician visits.

THE HOSPITAL REPRESENTATIVE WHO
COMPLETES THIS ENTIRE FORM

YES

NO

N/A

The representative will ensure the rehab unit has a
procedure or other alternative documents or records
verifying the hospital has a procedure detailing close
medical supervision that includes the rehabilitation
physician making at least 3 face-to-face visits per
week.

The representative verifies that all qualified
personnel, that are required by the State to be
licensed, have licenses that are up-to-date.

• Qualified personnel would include either
personnel that are licensed in the State in which
the services are provided or those personnel that
are recognized under reciprocity by the State in
which the services are provided.
• Determine if the hospital has and follows a
procedure to evaluate and document that
personnel are qualified and that those
personnel maintain their qualifications.

A3519

(g) Have a director of rehabilitation who —

• Verify the rehab unit has a director of
rehabilitation by reviewing personnel logs or
rosters and organization charts.

The representative will verify that the rehab unit has
a physician Director of Rehabilitation.

A3520

(1) Provides services to the rehabilitation unit and to
unit’s inpatients for at least 20 hours per week;

• The 20 hours may be any combination of patient
services and administration. Hours cannot be
substituted by a Physician Assistant or by any
other qualified professional. Verify the 20 hours
through review of personnel time cards/logs, etc.

The representative will verify that the physician
is spending 20 hours per week providing a
combination of patient services and administration
the rehab unit.

A3521 ­

(2) Is a doctor of medicine or osteopathy;

• Review the physician’s license to verify the
physician is an MD or DO.

The representative will review the physician’s license
to ensure the physican is an MD or DO.

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(3) Is licensed under State law to practice medicine
or surgery; and

• Ensure license is current and issued by the State. The representative will review the physician’s license
is current.

Form CMS-437A (06/12)

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THE HOSPITAL REPRESENTATIVE WHO
COMPLETES THIS ENTIRE FORM

A3523

(4) 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.

• Review personnel and/or credentialing files to
verify the physician’s training and experience
complies with the regulation.

The representative reviews the director of
rehabilitation’s level of training and experience.

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(h) Have a plan of treatment 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.

• Conduct a clinical record review to verify that
each IRF patient has a plan of treatment and
that the plans are updated whenever there is a
change in the patient’s condition.

The representative verifies that the rehab unit has
patient plans of treatment.

YES

NO

N/A

• The plan of treatment should include the
patient’s medical prognosis and the anticipated
interventions, functional outcomes, and
discharge destination from the IRF stay.
• The anticipated interventions detailed in the
overall plan of care should include the expected
intensity (meaning number of hours per day),
frequency (meaning number of days per week),
and duration (meaning total number of days
during the IRF stay) of physical, occupational,
speech-language pathology, and prosthetic/
orthotic therapies required by the patient during
the IRF stay.

A3525

(i) Use a coordinated interdisciplinary team
approach in the rehabilitation of each inpatient,
as documented by the periodic clinical entries
made in the patient’s medical record to note the
patient’s status in relationship to goal attainment
and discharge plans and that team conferences
are held at least once per week to determine the
appropriateness of treatment.

• Review clinical records to determine whether the
interdisciplinary team is meeting once a week to
review patient progress toward goal attainment
and discharge planning.

The representative will determine whether
interdiciplinary teams are meeting once weekly to
review patient progress and that documentation is
in the medical records.

• Determine if the documentation complies with
the regulatory requirements.

According to the Paperwork Reduction of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0986. The time required to complete this
information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

COMMENTS

Form CMS-437A (06/12)

9