IRF-PAI Glossary

Commonly known as a stroke, it occurs when blood flow to the brain is interrupted (ischemic) or when bleeding occurs in the brain (hemorrhagic), resulting in brain damage.

An injury to the brain caused by external force (MVA, fall, assault) resulting in altered consciousness, cognitive deficits, or physical impairments.

Damage to the spinal cord resulting in loss of motor and sensory function below the level of injury. Can be complete (no function below injury) or incomplete (some function preserved).

Basic self-care activities including eating, grooming, bathing, dressing, toileting, and mobility. IRF therapy focuses on maximizing independence in ADLs.

The rehabilitation team consisting of a physician, registered nurse, physical therapist, occupational therapist, speech-language pathologist (as needed), social worker, and case manager who collaborate on patient care.

A two-digit code that classifies the primary reason for rehabilitation based on the patient's diagnosis. There are 21 IGC categories (01-21) used to determine the RIC tier and payment.

One of 21 major diagnostic categories (01-21) used to classify IRF patients based on their primary impairment. Each RIC has specific tier levels based on comorbidities.

A classification within each RIC based on the number of comorbidities: Tier 1 (0 comorbidities), Tier 2 (1-2 comorbidities), Tier 3 (3+ comorbidities). Higher tiers result in higher Medicare payment.

The current medical coding system used to classify diagnoses and procedures. IRF-PAI requires ICD-10 codes for primary diagnosis and all active comorbidities.

An additional medical condition that coexists with the primary diagnosis and requires treatment or monitoring during the IRF stay. Comorbidities determine the tier level (1, 2, or 3).

The specification of which side of the body is affected (right, left, or bilateral). Required for many ICD-10 codes to ensure specificity and avoid denials.

An ICD-10 code that lacks specificity (e.g., laterality, type, location). Unspecified codes should be AVOIDED when more specific information is documented.

A private organization contracted by CMS to process Medicare claims and conduct audits of healthcare providers, including IRFs. MACs review IRF-PAI accuracy and medical record documentation.

A CMS compliance requirement that at least 60% of an IRF's total patient population must have diagnoses from 13 specified medical conditions (CMS-13 list) to maintain IRF certification.

The 13 medical conditions specified by CMS that count toward the 60% Rule: stroke, brain injury, SCI, neurological disorders, amputation, fractures, joint replacement, burns, etc.

A method of demonstrating 60% Rule compliance by ensuring that at least 60% of patients admitted during a sample week have CMS-13 diagnoses, rather than calculating over the entire cost reporting period.

A MAC decision to refuse payment for an IRF claim due to lack of medical necessity, documentation errors, or non-compliance with IRF regulations.

The requirement that IRF admission is appropriate and reasonable based on the patient's medical condition, functional status, and need for intensive rehabilitation.

The 12-month period used to calculate the 60% Rule compliance. Most IRFs use a fiscal year (October 1 - September 30) as their cost reporting period.

A Medicare-certified hospital or hospital unit that provides intensive rehabilitation services to patients who require multidisciplinary team care and can tolerate at least 3 hours of therapy per day.

A standardized assessment tool required by CMS to collect patient data at admission and discharge from an IRF. It includes demographic information, diagnoses, comorbidities, functional status, and discharge disposition.

A required document that must be completed and signed by a rehabilitation physician BEFORE the patient is admitted to the IRF. It documents medical necessity and appropriateness for IRF-level care.

A comprehensive care plan developed by the interdisciplinary team that MUST be completed within 4 days of IRF admission. It includes rehabilitation goals, interventions, and expected outcomes.

Direct patient encounter by the rehabilitation physician. CMS requires at least 3 face-to-face visits per week, with one visit occurring within 24 hours of admission.

The date when the medical condition or injury first occurred. Required for certain diagnoses and used to determine appropriateness of IRF admission timing.

A standardized assessment tool that measures functional status in 18 areas including self-care, mobility, cognition, and communication. Scores range from 1 (total assistance) to 7 (complete independence).

The sum of FIM scores for 13 motor items (eating, grooming, bathing, dressing, toileting, bladder, bowel, transfers, locomotion, stairs). Range: 13-91 points.

The sum of FIM scores for 5 cognitive items (comprehension, expression, social interaction, problem solving, memory). Range: 5-35 points.

A payment classification system that groups IRF patients with similar clinical characteristics and resource needs. CMG determines the Medicare payment amount based on RIC, tier, age, and functional status.

Medicare's payment methodology for IRFs where payment is predetermined based on CMG assignment rather than actual costs incurred. Payment is per discharge, not per day.

The number of days a patient remains in the IRF from admission to discharge. Average LOS varies by diagnosis but typically ranges from 12-16 days.

The location where the patient is discharged after IRF stay: home, skilled nursing facility (SNF), acute care hospital, long-term acute care (LTAC), or expired.

The improvement in functional status measured by the difference between admission and discharge FIM scores. Higher functional gain indicates better rehabilitation outcomes.

CMS program requiring IRFs to submit quality measure data through the IRF-PAI. Failure to report results in a 2% reduction in Medicare payment.

Rehabilitation focused on improving mobility, strength, balance, gait, and transfers. PT is one of the core disciplines in IRF care.

Rehabilitation focused on improving independence in self-care, fine motor skills, cognitive function, and home safety. OT addresses ADLs and instrumental ADLs.

Rehabilitation focused on communication disorders (aphasia, dysarthria), swallowing disorders (dysphagia), and cognitive-communication deficits.

CMS requirement that IRF patients must be able to tolerate and benefit from at least 3 hours of therapy per day, at least 5 days per week. This is a key criterion for IRF admission.