AMRPA, others ask CMS to change 75 percent rule

They cite potential problems under PPS

Among the many onerous rules and regulations governing rehab facilities has been the 75 percent rule, which is one of the exclusion criteria used to determine whether a rehab facility qualifies for exclusion from the inpatient acute prospective payment system (PPS).

The nearly 20-year-old rule specifies that free-standing rehabilitation hospitals or rehabilitation units of hospital systems qualify for exclusion from PPS if 75% of their patients have diagnoses that fall within the following 10 categories, which have remained the same since 1984:

  • stroke;
  • spinal cord injury;
  • congenital deformity;
  • major multiple trauma;
  • fracture of femur;
  • amputations;
  • brain injury;
  • polyarthritis (including rheumatoid arthritis);
  • neurological disorders (including multiple sclerosis, motor neuron disease, polyneuropathy, muscular dystrophy, and Parkinson’s disease);
  • burns.

Now the American Medical Rehabilitation Providers Association (AMRPA) of Washington, DC, the American Hospital Association (AHA) of Chicago, and several other organizations, including the American Academy of Neurology of St. Paul, MN, the American Academy of Physical Medicine and Rehabilitation of Chicago, and the Federation of American Hospitals of Washington, DC, have asked the Centers for Medicare and Medicaid Services (CMS) to change the rule.

"Currently, inpatient rehabilitation facilities provide intensive rehabilitation services to patients with other conditions, including cardiac conditions, pulmonary conditions, and pain," wrote the organizations in a letter addressed to Thomas Scully, CMS administrator, on April 17, 2002.

The letter states that conditions typical of rehabilitation facilities have significantly changed since the mid-1980s, so the time to revise exclusion criteria is at hand.

Because the new inpatient rehabilitation facility PPS, implemented in 2002, replaces the Tax Equity and Fiscal Responsibility Act system, there are now more data available about how patients are classified. For instance, the new assessment tool provides data for classifying each Medicare Part A fee-for-service patient into a rehabilitation impairment category (RIC) and then into a case-mix group, according to the letter.

"In the interest of administrative efficiency and greater clarity to the regulated parties, the undersigned organizations respectfully request that CMS adopt an administrative presumption’ whereby if 75 percent of a rehabilitation hospital or unit’s Medicare patients were in 20 of the 21 RICs, then it would be presumed to be in compliance with the 75 percent rule," the letter states.

"The one RIC not included in the administrative presumption would be RIC 20 (Miscellaneous)," the letter continues.

AMRPA and the other organizations also requested that CMS place a moratorium on qualifying 75 percent audits, including those being conducted in New Jersey and Tennessee.

"If these audits remain in place, facilities risk losing their status as rehabilitation hospitals and units and patients will have less access to the high quality rehabilitation services they need," the letter concludes.

The 75 percent rule has been a concern of AMRPA’s since IRF-PPS was implemented Jan. 1. In a letter to CMS dated March 5, 2002, AMRPA provided public input on regulatory reform to Christy Schmidt, executive coordinator of the Regulatory Reform Initiative of the Office of the Assistance Secretary for Planning and Evaluation of the Department of Health and Human Services in Washington, DC.

That letter’s second key point was that CMS had not bothered to change the 75 percent rule since changing the way rehab facilities are paid.

"This impairs access to rehabilitation services for Medicare beneficiaries requiring services that are excluded from the list of 10 conditions, but are still necessary medical rehabilitation services," writes Robert P. Main, chairman of the board of AMRPA and president and chief executive officer of Siskin Hospital for Physical Rehabilitation in Chattanooga, TN.