crosswalk

Revisions to CMS-437A Form

Rehabilitation Unit Criteria Worksheet (CMS-437A)

Current Section Number, Section Title,

Data Field Text and Location

Revised Section Number, Section Title, Data Field Text & Location

Description of Changes Made

Reasons for Changes Made

NOTES:

Revised and new text is identified in bolded and yellow highlighted text.

Deleted text is identified on bolded and green highlighted text

IRF Unit Demographic Information Section of CMS-437A

Existing Page Number: 1

Existing Section Number: NA

Existing Section:

IRF Unit Demographic Information

Existing Data Field Text:

“Related Provider Medicare Number”

Existing Locations: Row 1, column 1

Revised Page Number: 1

Revised Section Number: NA

Revised Section:

IRF Unit Demographic Information

Revised Data Field Text:

“IRF Unit’s Name”

Revised Location: Row 1, column 1

We have changed the following text:

“Related Provider Medicare Number”

in the existing CMS-437A form

to

“Name of IRF Unit”

in the revised CMS-437A form

The existing CMS-437A form does not request the CCN number for the IRF unit, but only requests the CCN number for the facility in which the IRF unit is located.

We have made this change because we do not believe that it is important to have the Medicare number for the facility in which the IRF unit is located. Instead, it is important to obtain the information IRF unit itself.

Therefore, we have deleted the text in row 1, column 1 of this section and added “IRF Unit’s Name” instead.

Existing Page Number: 1

Existing Section Number: NA

Existing Section:

IRF Unit Demographic Information

Existing Data Field Text:

“Room Numbers In Unit”

Existing Locations: Row 1, column 2

Revised Page Number: 1

Revised Section Number: NA

Revised Section:

IRF Unit Demographic Information

Revised Data Field Text:

“IRF Unit CCN Number”

Revised Location: Row 1, column 2

1. We have changed the following text:

“Room Numbers In Unit”

in the existing CMS-437A form

to

"IRF Unit’s CCN:”

in the revised CMS-437A form

2. We added a new data field for “Number of Beds in Unit” at Row 2, column 2 in the revised CMS-437A form.

In the existing CMS-437A form, there is no data field which collects the CCN number of the IRF unit, To correct this, we have renamed this data field from “Number of Rooms in Unit” to “IRF Unit’s CCN Number.” However, we have added a new data field for the number of beds in the IRF unit in a new location in this section.

Existing Page Number: 1

Existing Section Number: NA

Existing Section:

IRF Unit Demographic Information

Existing Data Field Text:

“Facility Name and Address (City, State, Zip Code)”

Existing Locations: Rows 1 & 2, Column 3

Revised Page Number: 1

Revised Section Number: NA

Revised Section:

IRF Unit Demographic Information

Revised Data Field Text:

“Date of Last Survey”

Revised Location: Row 1, Column 3

1. We have changed the following text:

“Facility Name and Address (City, State, Zip Code)” in the existing CMS-437A form

to

“Date of Last IRF Unit Survey”

in the revised CMS-437A form

2. We have also made the following changes in the revised CMS-437A form:

1. added a separate data field for the IRF’s name at row 1, column 1;

2. added a new separate data field for Street address for the IRF unit at row 2, columns 1 & 2;

3. added additional new separate data fields for the IRFs city, state & zip code at row 3, columns 1,2 and 3.

The CMS-437A form provides only a small space in which the person completing the for must fill in the name and location (city, state and zip code ) of the IRF.

We have converted the CMS-437A form to a .pdf fillable format. This will allow for the data to be exported from the form. However, if several types of data are combined into one data field, it cannot be exported into an Excel spreadsheet and the data searched by these pieces of data separately. For example, with the name and location are combined in the same data field and exported as one data field into a spread sheet, one would not be able to search by IRF name or IRF location separately.

Also, we believe that it is important to collect the complete address for the IRF, and not only the city, state and zip code,

To correct these issues, we have added separate data fields for the name of the IRF, street address, city, state and zip code.

We have changed the text of the data field which is intended to collect the date of the last IRF unit survey date from “Survey Date” in the existing CMS-437A form to “Date of Last IRF Unit Survey” in the revised CMS-437 form.

We made this change because we believe that the existing title of “Survey Date” is vague and does not clearly communicate what data is being sought. For example, is this data field requesting a date the hospital, in which the IRF unit is located was surveyed? Or, is it requesting a date the IRF was surveyed? Also, it does not specify which survey this information is requested. For example, does it address the most recent survey, or a previous survey? We have removed these questions with the revised data field title of “Date of Last IRF Unit Survey.”

Existing Page Number: 1

Existing Section Number: NA

Existing Section:

IRF Unit Demographic Information

Existing Data Field Text:

“Number of Beds in Unit”

Existing Locations: Row 2, Column 1

Revised Page Number: 1

Revised Section Number: NA

Revised Section:

IRF Unit Demographic Information

Revised Data Field Text:

“IRF Unit’s Street Address”

Revised Location: Row 2, Columns 1 & 2

1. We have changed the following text:

“Number of Beds in Unit”

in the existing CMS-437A form

to

“IRF Unit’s Street Address”

in the revised CMS-437A form

2. We have also added a new data field for “Number of Beds in Unit” at Row 2, column 2 in the revised CMS-437A form.

See the explanation above for the change made.

Existing Page Number: 1

Existing Section Number: NA

Existing Section:

IRF Unit Demographic Information

Existing Data Field Text:

“Survey Date:”

Existing Locations: Row 2, Column 2

Revised Page Number: 1

Revised Section Number: NA

Revised Section:

IRF Unit Demographic Information

Revised Data Field Text:

“IRF Unit’s Street Address”

Revised Location: Row 2, columns 1 & 2

1. We have changed the following text:

“Survey Date:”

in the existing CMS-437A form

to be

“IRF Unit’s Street Address”

in the revised CMS-437A form

2. We have also added a new data field for “Date of Last Survey” at row 1, column 3 in the revised CMS-437A form,

See the explanation above for the change made

Existing Page Number: 1

Existing Section Number: NA

Existing Section:

IRF Unit Demographic Information

Existing Data Field Text:

“Request for Exclusion for Reporting Period”

Existing Locations: Row 3, Column 1

Revised Page Number: 1

Revised Section Number: NA

Revised Section:

IRF Unit Demographic Information

Revised Data Field Text:

“Dates of Reporting Periods for Which Exclusion Is Requested”

Revised Location: Row 3, column 1

We have changed the following text:

“Request for Exclusion for Reporting Period” in the existing CMS-437A form

to

“Dates of Reporting Periods for Which Exclusion Is Requested” in the revised CMS-437A form

We believe that the text in the existing CMS-437A form of Request for Exclusion for Reporting Period” is confusing.

We have changed this text to “Dates of Reporting Periods for Which Exclusion Is Requested” to clarify this data field.

Existing Page Number: 1

Existing Section Number: NA

Existing Section:

IRF Unit Demographic Information

Existing Data Field Text:

“Verified By:”

Existing Locations: Row 3, Column 2

Revised Page Number: 1

Revised Section Number: NA

Revised Section:

IRF Unit Demographic Information

Revised Data Field Text:

“Telephone Number”

Revised Location: Row 3, column 4

We have changed the following text:

“Verified By:”

in the existing CMS-437A form

to

“IRF Unit’s Telephone Number”

in the revised CMS-437A form

We do not believe that it is necessary to have the data field “verified by” because there is a signature line at the end of the form and the person signing the form must attest to the following:

“I hereby certify that the responses in this form are true and correct to the best of my knowledge, information and belief. Whoever knowingly and willfully makes or causes to be made a false statement or representation on this statement, may be prosecuted under applicable federal and state laws.”

We have replaced “Verified by” with “Telephone Number” because we believe it is important to have the full contact information for the IRF.

Existing Page Number: 1

Existing Section Number: NA

Existing Section:

IRF Unit Demographic information

Existing Data Field Text:

None

Existing Locations: Row 3, column 4

Revised Page Number: 1

Revised Section Number: NA

Revised Section:

IRF Unit Demographic information

Revised Data Field Text:

“Telephone Number”

Revised Location: Row 3, Column 4

We have added a new data field for “Telephone Number” for the IRF unit to the revised CMS-437A form at row 3, column 4:

The existing CMS-437A does not request the telephone number for the IRF unit. We believe that collecting complete contact information for the IRF is important because if the responses on the form are incomplete or the CMS Location or SA has questions about the IRF units’ responses, they will be able to contact them be telephone to get further information or clarification.

Worksheet Checklist Section of CMS-437A form

Existing Page Number: 2 & 3

Existing Section Number:

• Tag A3500 – Regulatory text

• Regulation §412.25(a)(1)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

§412.1(a) - Basis for exclusion. In order to be excluded from the prospective payment systems specified in 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:

§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:

(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.

Existing Locations: Row 3, column 2

Revised Page Number: 2 & 3

Revised Section Number:

• Tag A3500 - Regulatory text

• Regulation §412.25(a)(1)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

§412.25(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: “§412.25(a)(1) Be part of an institution that – §412.25(a)(1)(i) Has in effect an agreement under Part 489 of this chapter to participate as a hospital;

§412.25(a)(1)(ii) Prior to October 1, 2019, is not excluded in its entirety from the prospective payment systems; and §412.25(a)(1)(iii) Unless it is a unit in a critical access hospital, the hospital, in which an IRF unit is located, must have at least 10 staffed and maintained hospital beds that are paid under the applicable payment system under which the hospital is paid, or at least 1 staffed and maintained hospital bed for every 10 certified inpatient rehabilitation facility (IRF) beds, whichever number is greater. Otherwise, the IRF will be classified as an IRF hospital, rather than an IRF unit...

Revised Location: Row 3, column 2

We have revised the regulation text stated in column 2 so as to give the proper regulatory language and regulation section numbers

In row 4, column 2 of the Worksheet section of the existing CMS-437A form, the text of §412.23(a)(1) is not set forth in its entirety but is paraphrased. Also, the proper citations are not provided.

In the revised version of the CMS-437A form, we have added the text of §412.23(a)(1) in its entirety and provided proper citations to the subsection of §4412.25(a)(1).

We made this change because we believe that it is not appropriate to provide a paraphrased version of the applicable regulations on a document which required the facility to self-attest to meeting said regulations. We believe that the regulation text and numbering/lettering should be provided so that the facility staff my feel confident in their attestation that the do meet the regulations. Or, in the alternative, facilities that do not meet the requirements of a particular section of the regulations will have the complete regulatory text and citation to rely on in performing the tasks necessary to come into compliance with said regulations.

Existing Page Number: 2

Existing Section Number:

• Tag A3500 – Surveyor Guidance

• §412.25(a)(1)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

• 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 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.

Existing Locations: Row 3, Column 3

Revised Page Number: 2

Revised Section Number:

• Tag A3500 – Surveyor Guidance

• §412.25(a)(1)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

The SA or CMS surveyor or MAC will

verify the following:

• That the hospital, in which the

Inpatient Rehabilitation Facility

(“IRF”) unit is located, has an

agreement to participate in the

Medicare program, and

• That the hospital in which the IRF unit

is located, is not excluded in its

entirety from the Medicare Inpatient

Prospective Payment System(“IPPS”);

and

• That the hospital, in which the IRF

unit is located, meets one of the

following staffing ratios (whichever

is greater):

1. Has at least 10 staffed and

Maintained hospital beds that are

paid under the Medicare payment

system under which the hospital

is paid; or

2. Has at least 1 staffed and

maintained hospital bed for every

10 certified inpatient IRF unit

beds, whichever number is greater.\

Revised Location: Row 3, Column 3

We have made the changes identified to the text of row 3, column 3.

We have made the changes identified to the text of row 3, column 3 to make this text more closely resemble the requirements of §412.1(a) of the regulations.

Existing Page Number: 2

Existing Section Number:

• Tag A3500 – Actions Required

• §412.25(a)(1)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

“Representative to ensure the hospital has a Medicare provider agreement.”

Existing Locations: Row 3, Column 4

Revised Page Number: 2

Revised Section Number:

• Tag A3500 – Actions Required

• §412.25(a)(1)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

“The IRF unit representative shall verify

that:

• The hospital, in which the IRF unit is

located, has a Medicare provider

agreement;

• The hospital in which the Inpatient

Rehabilitation Unit (“IRF unit”) is

located is not excluded from the

Medicare IPPS system; and

• The hospital (that is not a CAH), in

which the IRF unit is located, meets

one of the following requirements,

whichever is greater:

1. The hospital has at least 10staffed and maintained hospital beds that are paid by Medicare under the applicable payment system; or

2. The hospital has at least 1staffed

and maintained hospital bed for

every 10 IRF unit beds.

Revised Location: Row 3, Column 4

We have made the changes identified to the checklist requirements that the facility must meet for §412.25(a)(1).

We have made the changes identified to clarify the checklist requirements that the facility must meet for §412.25(a)(1) and make them more specific to the regulatory requirements of §412.25(a)(1)

Existing Page Number: 2

Existing Section Number:

• Tag A3501 - Surveyor Guidance

• §412.25(a)(2)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

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

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

Existing Locations: Row 4, Column 3

Revised Page Number: 3

Revised Section Number:

• Tag A3501 - Surveyor Guidance

• §412.25(a)(2)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

• Verify that the IRF unit has written

admission criteria.

• Conduct a record review to determine

whether the IRF unit’s admission

criteria are applied equally to both

Medicare and non-Medicare patients.

Revised Location: Row 4, Column 3

We have made the changes identified to the Surveyor Guidance for §412.25(a)(2).

We have simplified text of the surveyor guidance section. We have changed the reference to “the hospital” to “the IRF Unit”

Existing Page Number: 2

Existing Section Number:

• Tag A3501 – Actions Required

• §412.25(a)(2)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

“Representative to verify the rehab unit has preadmission criteria.”

Existing Locations: Row 4, Column 4

Revised Page Number: 2

Revised Section Number:

• Tag A3501 – Actions Required

• §412.25(a)(2)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

“The IRF unit representative shall verify

that:

• The IRF unit has written admission

criteria; and

• The IRF’s written admission criteria

are being applied equally to both Medicare

and non-Medicare patients.”

Revised Location: Row 4, Column 4

We have made the changes identified to the facility checklist requirements for §412.25(a)(2).

In the existing CMS-437A form, the checklist requirements for §412.25(a)(2), the IRF representative to ensure that the hospital has a Medicare provider agreement.

However, §412.25(a)(2) requires the provider to “[h]ave written admission criteria that are applied uniformly to both Medicare and non-Medicare patients.” Therefore, the stated requirement that the IRF ensure that the hospital have a Medicare Agreement is incorrect.

In the revised CMS-437A form, we have revised the checklist requirement for §412.25(a)(2) to be consistent with the regulatory requirements.

Also, the existing CMS-1561 form requires the IRF representative to verify that the rehab unit has “preadmission” criteria. This requirement is technically incorrect and not in accordance with the regulation §412.25(a)(2).

We say this because §412.25(a)(2) specifically requires that IRFs must have “written admission” criteria. This regulation does not use the prefix “pre” before the word “admission” when referring to these criteria. Also, the regulation requires that the criteria be in writing. However, the checklist instruction in column 4 does not state that the admission criteria must be written.

Our revised checklist instructions for Tag 3501 / §412.25(a)(2) have corrected these issues/errors.

Existing Page Number: 2

Existing Section Number:

• Tag A3502 – Surveyor Guidance

• §412.25(a)(3)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

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

Existing Locations: Row 5, Column 3

Revised Page Number: 3

Revised Section Number:

• Tag A3502 – Surveyor Guidance

• §412.25(a)(3)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

• “The surveyor should verify that:

1. The IRF unit has separate medical records that can be easily identified as belonging exclusively to the IRF unit and as different as from those used by the hospital in which the IRF unit is located.

2. The IRF unit medical records are not co-mingled with the medical records of the hospital in which the IRF unit is located; and

3. The IRF unit’s medical records are readily available for review.”

Revised Location: Row 5, Column 3

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 2

Existing Section Number:

• Tag A3502 – Actions Required

• §412.25(a)(3)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

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

Existing Locations: Row 5, column 4

Revised Page Number: 3

Revised Section Number:

• Tag A3502 – Actions Required

• §412.25(a)(3)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

“The IRF unit representative shall verify that:

• The IRF unit has separate medical records that can be easily identified as belonging exclusively to the IRF and as different from those of the hospital in which the IRF unit is located;

• The IRF unit's medical records are not co-mingled with the medical records of the hospital in which the IRF is located.

• The IRF unit admission and discharge records are readily available for review.

Revised Location: Row 5, column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 2

Existing Section Number:

• Tag A3503 – Surveyor Guidance

• §412.25(a)(4)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

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

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

Existing Locations: Row 6, Column 3

Revised Page Number: 4

Revised Section Number:

• Tag A3503 – Surveyor Guidance

• §412.25(a)(4)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

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

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

Revised Location: Row 6, Column 3

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 2

Existing Section Number:

• Tag A3503– Actions Required

• §412.25(a)(4)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

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

Existing Locations: Row 6, Column 4

Revised Page Number: 4

Revised Section Number:

• Tag A3503– Actions Required

• §412.25(a)(4)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

“The IRF unit representative shall verify that:

• The hospital has a policy specifying the necessary clinical information (medical records) that should be sent with a hospital patient that is transferred to the IRF unit; and

• The hospital adheres to this policy; and,

• The clinical records that should be sent with a hospital patient being transferred to the IRF unit are actually in the patient’s IRF medical record.”

Revised Location: Row 6, Column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 3

Existing Section Number:

• Tag A3504 – Surveyor Guidance

• §412.25(a)(5)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

• Verify and document that all applicable State licensure laws are met.

• Document all unmet State licensure requirements.

• 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?

Existing Locations: Row 7, Column 3

Revised Page Number: 5

Revised Section Number:

• Tag A3504 – Surveyor Guidance

• §412.25(a)(5)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

“The IRF surveyor will:

• Verify and document that all applicable State licensure laws are met.

• Document all unmet State licensure requirements.

• Verify that IRF unit professional staff have current licensure issued by the state in which the IRF unit is located.

• Are there any State licenses required for the IRF unit?

• If so, does the IRF unit meet these State licensing requirements?

Revised Location: Row 7, Column 3

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 3

Existing Section Number:

• Tag A3504– Actions Required

• §412.25(a)(5)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

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

Existing Locations: Row 7, Column 4

Revised Page Number: 5

Revised Section Number:

• Tag A3504– Actions Required

• §412.25(a)(5)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

“The IRF unit representative shall verify that:

• All applicable state laws are being met; and

• All applicable licensure and certification requirement for IRF professional staff are current.”

Revised Location: Row 7, Column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 3

Existing Section Number:

• Tag A3505– Actions Required

• §412.25(a)(6)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

“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.“

Existing Locations: Row 8, Column 4

Revised Page Number: 5

Revised Section Number:

• Tag A3505– Actions Required

• §412.25(a)(6)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

The IRF unit representative shall verify that:

• The hospital in which the IRF unit is located has a Utilization Review (UR) plan; and

• The UR standards are applicable to the type of care offered in the IRF unit.

Revised Location: Row 8, Column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 3

Existing Section Number:

• Tag A3506– Actions Required

• §412.25(a)(7)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

Representative will verify that the beds on the rehab unit do not belong to medical/surgical patients but are dedicated to rehab patients only.

Existing Locations: Row 9, Column 4

Revised Page Number: 6

Revised Section Number:

• Tag A3506– Actions Required

• §412.25(a)(7)

,

Revised Section:

Worksheet checklist section

Revised Data Field Text:

The IRF unit representative will verify that:

• The IRF unit beds are physically separate from and not co-mingled with the hospital beds; and,

• No beds in the IRF unit are used for hospital patients, even if the IRF unit does not have enough rehab patients to fill the IRF unit beds.

Revised Location: Row 9, Column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 4

Existing Section Number:

• Tag A3507– Actions Required

• §412.25(a)(13)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

NONE

Existing Locations: Row 10, Column 4

Revised Page Number: 7

Revised Section Number:

• Tag A3507– Actions Required

• §412.25(a)(13)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

For a new IRF unit that is requesting an IPPS payment system exclusion for the first time, the IRF unit representative must verify with the Fiscal Intermediary (FI) (i.e. – MAC) that:

As of the 1st day of the first cost reporting period for which all other IPPS exclusion requirements are met, the IRF unit is/was:

• Fully operational:

• Fully equipped;

• Fully staffed, and

• Capable of providing inpatient rehabilitation care (regardless of whether there are any inpatients in the unit on that date.)

Revised Location: 10, Column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 4

Existing Section Number:

• Tag A3508 – Surveyor Guidance

• §412.25(b)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

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

• 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 effect 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.”

Existing Locations: Row 11, column 3

Revised Page Number: 7 & 8

Revised Section Number:

• Tag A3508 – Surveyor Guidance

• §412.25(b)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

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

• A decrease in the number of beds or square footage may occur only once during a cost reporting period,

• The change must remain in effect for the remainder of the cost report period.

• Changes in the number of beds or square footage may be made at any time, during the cost reporting period 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.

• No changes can be made without notifying both the CMS RO and the FI/MAC at least 30 days prior to the change.

Revised Location: Row 11, column 3

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 4

Existing Section Number:

• Tag A3508– Actions Required

• §412.25(b)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

“Representative to verify that if changes were made to the unit, both CMS and the MAC/FI were notified prior to any change.”

Existing Locations: Row 11, column 4

Revised Page Number: 7 & 8

Revised Section Number:

• Tag A3508– Actions Required

• §412.25(b)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

If changes were or are to be made to the size of the IRF unit, the IRF unit representative will verify that:

• CMS and the MAC/FI were notified at least 30 days prior to making any changes in the size of the IRF unit.

• A change in the size of the IRF unit is only made once per cost reporting period and that the change remains in effect for the remainder of the cost report period.

• The IRF unit maintains the information needed to document changes in bed size or square footage 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.

• The hospital maintains the information needed to accurately determine costs that are attributable to the excluded unit.

Revised Location: Row 11, column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 4 & 5

Existing Section Number:

• Tag A3509– Actions Required

• §412.29(a)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

“Representative to ensure the hospital has a Medicare provider agreement. “

Existing Locations: Row 12, column 4

Revised Page Number: 9

Revised Section Number:

• Tag A3509– Actions Required

• §412.29(a)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

• The IRF unit representative shall verify the hospital in which the IRF unit is located has a Medicare provider agreement under 42 CFR part 489.

Revised Location: Row 12, column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 5

Existing Section Number:

• Tag A3510 – Surveyor Guidance

• §412.29(b)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

“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.”

Existing Locations: Row 13, column 3

Revised Page Number: 10

Revised Section Number:

• Tag A3510 – Surveyor Guidance

• §412.29(b)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

“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.

After July 1, 2005, the IRF patient population must meet the 60% rule.”

Revised Location: Row 13, column 3

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

We have also made these changes to state the requirements is a more logical order.

Existing Page Number: 5

Existing Section Number:

• Tag A3510– Actions Required

• §412.29(b)

Existing Section: Worksheet checklist section

Existing Data Field Text:

NONE

Existing Locations: Row 13, column 4

Revised Page Number: 10

Revised Section Number:

• Tag A3510– Actions Required

• §412.29(b)

Revised Section: Worksheet checklist section

Revised Data Field Text:

“For IRF units or hospitals established after 07/01/2005, the IRF representative will verify that the IRF population meets the 60% rule. (i.e. – at least 60 percent of the IRF’s population required intensive rehabilitation services for treatment of one or more of the conditions specified at paragraph § 412.29(b)(1) and § 412.29(b)(2). A patient with a comorbidity, as defined at § 412.602, may be included in the inpatient population that counts toward the required applicable percentage.)”

Revised Location: Row 13, column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

In the existing CMS-437A form, there are no requirements stated for TagA3510 for new IRF beds. However there are regulatory requirements that the IRF must meet.

Therefore, we have added the appropriate requirements.

Existing Page Number: 5

Existing Section Number:

• Tag A3511– Surveyor Actions

• §412.29(c)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

“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 IRF must submit an attestation statement in addition to the Form CMS 437A (Rehabilitation Unit Work Sheet) 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.”

Revised Page Number: 10 & 11

Revised Section Number:

• Tag A3511– Actions Required

• §412.29(c)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

• “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 IRF must provide a written attestation statement and completed & signed CMS-437A form 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.”

We have made the changes identified in the yellow bolded text in the 2 left hand columns.

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 5

Existing Section Number:

• Tag A3511– Actions Required

• §412.29(c)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

“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).”

Existing Locations: Row 14, column 4

Revised Page Number: 10 & 11

Revised Section Number:

• Tag A3511– Actions Required

• §412.29(c)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

For new IRF units (defined as an IRF unit that has not been paid under the new IRF PPS in subpart P of this part for at least 5 calendar years), or for new IRF beds added:

• The IRF unit must provide a written attestation statement and completed and signed CMS-437A form which states that the inpatient population it intends to serve meets the requirements of §412.29(b).

Revised Location: Row 14, column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns.

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 5

Existing Section Number:

• Tag A3512 – Actions Required

• §412.29(c) (1)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

The representative ensures the IRF unit

has not been paid under the IRF PPS for

at least 5 calendar years.

Existing Locations: Row 15, column 4

Revised Page Number: 11

Revised Section Number:

• Tag A3512 – Actions Required

• §412.29(c) (1)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

“For a new IRF certification, as required by 412.29(c) above, the IRF unit representative must verify that the IRF unit has not been paid under the Medicare Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) for at least 5 calendar years.

NOTE: 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.”

Revised Location: Row 15, column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 6

Existing Section Number:

• Tag A3513 – Actions Required

• §412.29(c)(2)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

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

• 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.”

Existing Locations: Row 16, Column 4

Revised Page Number: 12

Revised Section Number:

• Tag A3513 – Actions Required

• §412.29(c)(2)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

“If new IRF beds were added during the previous 12 months, the IRF unit representative will verify that:

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

• The IRF unit received written approval from the applicable CMS Location before the new beds were added to the IRF unit; and

• The IRF unit didn’t have more than one increase in beds during a single cost reporting period.

If IRF unit removed or decertified beds, the IRF unit representative will that:

The IRF unit didn’t thereafter add any additional beds until after a full 12-month cost reporting period had elapsed; and

• The IRF unit didn’t have more than one increase in beds during a single cost reporting period.

Revised Location: Row 16, Column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 6

Existing Section Number:

• Tag A3514 – Actions Required

• §412.29(c)(3)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

“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.”

Existing Locations: Row 17, Column 4

Revised Page Number: 13

Revised Section Number:

• Tag A3514 – Actions Required

• §412.29(c)(3)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

“The IRF unit representative will verify the following:

• Whether the hospital has or is currently undergoing a change of ownership or leasing; and,

• If so, whether the new owner(s) or leasee(s) of the hospital have accepted assignment of the hospital's existing Medicare provider agreement.

Revised Location: Row 17, Column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 7

Existing Section Number:

• Tag A3515 – Actions Required

• §412.29(c)(4)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

“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.”

Existing Locations: Row 18, Column 4

Revised Page Number: 14

Revised Section Number:

• Tag A3515 – Actions Required

• §412.29(c)(4)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

The IRF unit representative will verify the following:

• Whether the hospital in which the IRF unit is located has merged with another hospital; and

• If so, the whether the new hospital owner(s) accepted assignment of the IRF unit’s existing Medicare provider agreement.”

Revised Location: Row 18, Column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 7

Existing Section Number:

• Tag A3516 – Actions Required

• §412.29(d)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

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

Existing Locations: Row 19, Column 4

Revised Page Number: 15

Revised Section Number:

• Tag A3516 – Actions Required

• §412.29(d)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

The IRF unit representative will verify that:

• The IRF unit has 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; and,

• The IRF unit is using the preadmission screening procedure on all patients admitted to the rehab unit.

Revised Location: Row 19, Column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 8

Existing Section Number:

• Tag A3517 – Actions Required

• §412.29(e)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

“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.”

Existing Locations: Row 20, column 4

Revised Page Number: 17

Revised Section Number:

• Tag A3517 – Actions Required

• §412.29(e)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

“The IRF unit representative will verify that:

• The IRF unit has a procedure for close medical supervision of the patients, and

• That this procedure includes at least 3 face-to-face visits per week by a licensed physician with specialized training and experience in inpatient rehabilitation, for the purpose of assessing 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.

Revised Location: Row 20, column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 8

Existing Section Number:

• Tag A3518 – Actions Required

• §412.29(f)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

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

Existing Locations: Row 21, column 4

Revised Page Number: 16 & 17

Revised Section Number:

• Tag A3518 – Actions Required

• §412.29(f)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

“The IRF unit representative will verify that:

• The IRF’s patients receive rehabilitation nursing care, physical therapy, and occupational therapy, and, if needed, that they received speech-language pathology services, social services, psychological services (including neuropsychological services) and orthotic and prosthetic services; and

• All of the IRF unit professional staff that provide the above-stated services have current licenses and certifications, as applicable.”

Revised Location: Row 21, column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 8

Existing Section Number:

• Tag A3519 – Actions Required

• §412.29(g)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

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

Existing Location: Row 22, column 4

Revised Page Number: 17

Revised Section Number:

• Tag A3519 – Actions Required

• §412.29(g)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

“The IRF unit representative will verify that the IRF unit has a Director of Rehabilitation.”

Revised Location: Row 22, column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 8

Existing Section Number:

• Tag A3520 – Actions Required

• 412.29(g)(1)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

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

Existing Location: Row 23, column 4

Revised Page Number: 17

Revised Section Number:

• Tag A3520 – Actions Required

• 412.29(g)(1)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

“The IRF unit representative will verify that the IRF unit director spends at least 20 hours per week providing a combination of patient services and administration at the IRF unit.

Revised Location: Row 23, column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 8

Existing Section Number:

• Tag A3521 – Actions Required

• §412.29(g)(2)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

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

Existing Locations: Row 24, column 4

Revised Page Number: 17

Revised Section Number:

• Tag A3521 – Actions Required

• §412.29(g)(2)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

“The IRF unit representative will verify that the IRF unit director is a physician (MD or DO) with current, valid licensure as a physician in the State in which the IRF unit is located.”

Revised Location: Row 24, column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 8

Existing Section Number:

• Tag A3522 – Surveyor Guidance

• §412.29(g)(3)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

“Ensure license is current and issued by the State.”

Existing Locations: Row 25, column 3

Revised Page Number: 18

Revised Section Number:

• Tag A3522 – Surveyor Guidance

• §412.29(g)(3)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

“Ensure that the IRF unit director’s physician license is current and issued by the State in which the IRF unit is located.”

Revised Location: Row 25, column 3

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 8

Existing Section Number:

• Tag A3522 – Actions Required

• §412.29(g)(3)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

“The representative will review the physician’s license is current.”

Existing Locations: Row 25, column 4

Revised Page Number: 18

Revised Section Number:

• Tag A3522 – Actions Required

• §412.29(g)(3)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

“The IRF unit representative will verify that the Director of Rehabilitation holds current, unexpired licensure as a physician in the State in which the IRF unit is located.”

Revised Location: Row 25, column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 9

Existing Section Number:

• A3523 – Actions Required

• §412.29(g)(4)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

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

Existing Locations: Row 26, column 4

Revised Page Number: 18

Revised Section Number:

• A3523 – Actions Required

• §412.29(g)(4)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

“The IRF unit representative will verify that the director of the IRF unit has at least 2 years of training or experience in the medical management of inpatients requiring rehabilitation services (after completing 1 year of residency).”

Revised Location: Row 26, column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 9

Existing Section Number:

• Tag A3524 – Actions Required

• §412.29(h)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

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

Existing Locations: Row 27, column 4

Revised Page Number: 18 & 19

Revised Section Number:

• Tag A3524 – Actions Required

• §412.29(h)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

The IRF unit representative will verify that the IRF unit has an established plan of treatment for each inpatient, that is prepared, reviewed, and revised as needed by a physician in consultation with other professional personnel who provide services to the patient.

Revised Location: Row 27, column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Existing Page Number: 9

Existing Section Number:

• Tag A3525 – Actions Required

• §412.29(h)(i)

Existing Section:

Worksheet checklist section

Existing Data Field Text:

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

Existing Locations: Row 28, column 4

Revised Page Number: 19

Revised Section Number:

• Tag A3525 – Actions Required

• §412.29(h)(i)

Revised Section:

Worksheet checklist section

Revised Data Field Text:

“The IRF unit representative will verify that the IRF unit has an interdisciplinary team, that meets no less than once weekly to review patient progress and that documentation is in the medical records.”

Revised Location: Row 28, column 4

We have made the changes identified in the yellow bolded text in the 2 left hand columns

We have made these changes to better reflect and clarify the regulatory requirements.

Page 4 of 4