The Centers for Medicare and Medicaid Services (CMS) has revised its criteria for classifying hospitals as inpatient rehabilitation facilities. Known as the "75% Rule," the new criteria focuses on medical necessity and functional capability, and require that inpatient rehabilitation hospitals (IRFs) have at least a certain percentage of their admissions fall into 13 diagnostic categories. As long as they meet the required percent threshold, hospitals can still admit other patients with diagnoses not related to one of these 13 categories. Please keep in mind that all potential admissions to an inpatient rehabilitation hospital must be clinically stable and able to tolerate, or have the potential to tolerate, at least three hours of rehabilitation therapy at least five days per week.

The 75% Rule went into effect on July 1, 2004.  On December 29, 2007, President Bush signed into law S 2449, the Medicare, Medicaid, and SCHIP Extension Act of 2007. The legislation permanently freezes the IRF services compliance threshold at 60%. Therefore, at INTEGRIS Jim Thorpe Rehabilitation Hospital, 60% of our patients must be admitted with one of the 13 diagnoses shown below. The patient may also have one of the 13 conditions as a comorbid condition and this too will count toward the qualifying percentages. 

(As defined by Stedman’s Medical Dictionary, a comorbid condition is “a concomitant [occurring with something else] but unrelated pathological or disease process.”)

• Stroke
• Spinal cord injury
• Congenital deformity
• Amputation
• Major multiple trauma
• Fracture of femur (hip fracture)
• Brain injury
• Neurological disorders (including, but not limited to, MS, MD, polyneuropathy, and Parkinson's disease)
• Burns
• Active, polyarthricular rheumatoid arthritis, psoriatic arthritis, and seronegative arthropathies
• Systemic vasculidities with joint inflammation
• Severe/advanced osteoarthritis involving two or more major weight-bearing joints (not counting joints with a prosthesis) with joint deformity, substantial loss of range of motion, and atrophy of muscles surrounding the joint. (Note: In actual CMS regulations, the diagnoses in #10, #11, and #12 include additional qualifications/limitations.)
• Knee or hip joint replacement, with one or more of the following circumstances applying:
  • The patient underwent bilateral knee or bilateral hip joint replacement surgery during acute hospitalization.
  • The patient is extremely obese with a Body Mass Index of at least 50 at time of admission to inpatient rehabilitation hospital.
  • The patient is age 85 or older at the time of admission.

Who might this new rule affect?

Under these new criteria, some patients with joint replacements, for example, may no longer receive inpatient rehabilitation. Instead, they may have a course of intensive outpatient rehabilitation therapy or home care or be sent to a skilled nursing facility. Keep in mind that the more cases we admit under the 13 qualifying categories, the more patients we can also take who do not meet those criteria.