Cms-437b Rehabilitation Hospital Criteria Work Sheet

FORM APPROVED
OMB NO. 0938-0986

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

REHABILITATION HOSPITAL CRITERIA WORK SHEET
RELATED MEDICARE PROVIDER NUMBER

ROOM NUMBERS IN THE HOSPITAL

NUMBER OF BEDS IN THE HOSPITAL

SURVEY DATE

REQUEST FOR EXCLUSION FOR COST REPORTING PERIOD

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

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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

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REGULATION

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

§412.23 Excluded hospital units: Classifications.
(b) Rehabilitation hospitals. A rehabilitation hospital
must meet the requirements specified in §412.29 of this
subpart to be excluded from the prospective payment
systems specified in §412.1(a)(1) of this subpart and to
be paid under the prospective payment system specified
in §412.1(a)(3) of this subpart and in subpart P of this
part.
§412.29 Classification criteria for payment under the
inpatient rehabilitation facility prospective payment
system. 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 rehabilitataion hospital or an inpatient
rehabilitation unit of a hospital (otherwise referred to as
an IRF) must meet the following requirements:

Form CMS-437B (06/12)

THE HOSPITAL REPRESENTATIVE WHO
COMPLETES THIS ENTIRE FORM
The hospital representative is expected to answer all
questions truthfully. 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.

YES

NO

N/A

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REGULATION

GUIDANCE

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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.

The surveyor will verify, through the regional office (RO),
that the hospital has an agreement to participate in the
Medicare program.

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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 of whom at least 60 percent required intensive
rehabilitation services for treatment of one or more of the
conditions specified at paragraph (b) (2) of this section.

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 (c)(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.

• The IRF must submit a written attestation statement
as well as Form CMS 437B (rehabililtation hospital
worksheet) to the SA as part of their initial
application packet or as determined by CMS to
maintain their IPPS excluded status.

• This written certification will apply until the end
of the IRF’s first full 12-month cost report period or
in the case of new IRF beds, until the end of the cost
report period during which the new beds are added
to the IRF.
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(1) New IRFs. An IRF hospital or IRF unit is considered
new if it has not been paid under the 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 report period.

Form CMS-437B (06/12)

THE HOSPITAL REPRESENTATIVE WHO
COMPLETES THIS ENTIRE FORM

YES

NO

N/A

Representative to ensure the hospital has a Medicare
provider agreement.

The representative completes this form (Form CMS 437B)
as well as a signed attestation statement attesting that
the rehab hospital patients it intends to serve meets the
requirements outlined in §412.29(b)(2) and submits the
documentation to the State Agency.

• Until the SA receives both the attestation statement
and the Form CMS 437B the new rehabilitation
hospital cannot be recommended for approval.

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

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

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

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REGULATION

GUIDANCE

THE HOSPITAL REPRESENTATIVE WHO
COMPLETES THIS ENTIRE FORM

(1) New IRFs 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 report period. A full 12-month cost report period
must elapse between the delicensing or decertification
of IRF beds in an IRF hospital or IRF unit and the addition
of new 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 CMS RO can verify that
a full 12-month cost eporting period has elapsed since
the IRF has had beds delicensed or decertified, New IRF
beds are ncluded in the compliance review calculations
under paragraph (b) of this section from the time that
they are added to the IRF.

• If the rehabilitation hospital added beds, 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 completes this form (Form CMS 437B)
as well as a signed attestation statement attesting
that the rehab patients it intends to serve meets the
requirements outlined in § 412.29(b)(2).

(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 system 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 owner’s Medicare provider agreement,
and the IRF continues to meet all of the requirements
for payment under the IRF prospective payment system.
If the new owner(s) do not accept assignment of the
previous owner’s Medicare provider agreement, the IRF
is considered to be voluntarily terminated, and the new
owner(s) may re-apply to participate in the Medicare
program. If the IRF does not continue to meet all of the
requirements for payment under the IRF prospective
payment system, then the IRF loses its excluded status
and is paid according to the prospective payment systems
described in §412,(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-437B (06/12)

YES

NO

N/A

• The surveyor must verify that the hospital received
written CMS RO approval before adding any new
beds.
• The surveyor will verify that the hospital didn’t have
more than one increase in beds during a single cost
reporting period.
• Surveyors must verify that if the rehabilitation hospital
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,

The representative of the IRF hospital 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 rehab
hospital.

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REGULATION

GUIDANCE

(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 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 of
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 with the existing 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 has a
preadmission screening procedure in place.

(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 assess the patient both medically and
functionally, as well as to modify the course of treatment
as needed to maximize the patient’s capacity to benefit
from the rehabilitation process.

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

Form CMS-437B (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) would not be
eligible for reimbursement until the new owner(s)
reapplied 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 hospital 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 rehabilitation hospital.

• 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 is using
the preadmission screening procedure on all patients
admitted to the rehab hospital.

• A review of the clinical records should indicate
whether the IRF is using the screening procedure.

• Review the hospital’s procedures or other alternative
documents or records to verify the hospital has a
procedure detailing close medical supervision for
patients.

The representative will ensure the rehabitation hospital
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.

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REGULATION

GUIDANCE

(f) Furnish, through the use of qualified personnel,
rehabilitation nursing, physical therapy, and occupational
therapy; plus, as needed, speech-language pathology,
social services, psychological services (including
neuropsychological services), 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.

THE HOSPITAL REPRESENTATIVE WHO
COMPLETES THIS ENTIRE FORM

YES

NO

N/A

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.

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(g) Have a director of rehabilitation who-

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(1) Provides services to the IRF hospital and its inpatients
on a full-time basis.

Verifies the rehab hospital has a director
of rehabilitation by reviewing by reviewing personnel logs
or rosters and organization charts.
• The hospital will define the term “full-time” as it
applies to all of its employees,
• The full time hours may be any combination of
patient services and administration.

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

The representative will verify that the physician is full
time providing a 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.”
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(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 physician is a MD or DO.

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

Surveyor will verify the physician has a current license
issued by the State, as appropriate.

The representative verifies the physician’s license is
current.

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(4) Has had, after completing a 1-year hospital
Review personnel and/or credentialing files to
internship, at least 2 years of training or experience in the verify the physician’s training and experience complies
medical management of inpatients requiring rehabilitation with the regulation.
services.

Form CMS-437B (06/12)

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

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REGULATION
(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.

GUIDANCE
• 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 HOSPITAL REPRESENTATIVE WHO
COMPLETES THIS ENTIRE FORM

YES

NO

N/A

The representative verifies that the rehabitation hospital
has patient plans of treatment.

• The plan of treatment should include the patient’s
medical prognosis and the anticipated inteventions,
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.

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(i) Use a coordinated interdisciplinary team approach in
the rehabilitation of each 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 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.

Ul Retroactive adjustments. If a new IRF (or new beds
that are added to an existing IRF) are excluded from the
prospective payment systems specified in§ 412.1(a)(1)
and paid under the prospective payment system specified
in § 412.1(a)(3) for a cost reporting period under
paragraph (c) of this section, but the inpatient population
actually treated during that period does not meet the
requirements of paragraph (b) of this section, we adjust
payments to the IRF retroactively in accordance with the
provisions in § 412.130.

If the new IRF’s inpatient population doesn’t meet the
60% rule, the IRF will lose its IPPS exclusionary status.
The RO will send notification to the facility prior to the
beginning of the next cost report period that the facility
has lost its IPPS excluded status and will revert to acute
care hospital status.

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 requirement.

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COMMENTS

Form CMS-437B (06/12)

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