Current Compliance Status
Real-time calculation based on patient data
0
CMS-13 Compliant Patients
0
Total Patients
0.0%
Compliance Rate
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CMS-13 Qualifying Diagnostic Categories
Enter the number of patients in each category
Non-CMS-13 Compliant Patients
Patients who do not fall into any of the 13 qualifying categories
Understanding the 60% Rule
The 60% Rule requires that at least 60% of an IRF's total patient population be treated for one or more of 13 qualifying medical conditions (CMS-13 list). This is a critical compliance requirement that is tested annually by Medicare Administrative Contractors (MACs).
Presumptive Compliance
MACs use a "presumptive methodology" to conduct initial compliance reviews by accessing IRF-PAI data submitted for Medicare and Medicare Advantage patients. If the electronic data shows 60% or more compliance, the IRF is presumed compliant for the entire population.
Consequences of Non-Compliance
- • Loss of Medicare certification as an IRF
- • Repayment of prior year's Medicare revenues
- • Potential facility closure
- • Damage to reputation and referral relationships
Best Practices
- • Monitor compliance weekly, not just annually
- • Maintain a buffer above 60% (aim for 65%+)
- • Ensure accurate coding of primary diagnoses
- • Verify IGC codes match CMS-13 requirements
- • Document medical necessity for all admissions