Guide · Inpatient Rehabilitation
IRF Coverage & the 60% Rule
Two tests sit behind every IRF claim: the facility-level 60% Rule that lets a hospital be paid as an IRF, and the case-level medical-necessity criteria for the individual admission. Both must be met.
No PHIReferenceInformational reference — paraphrased from CMS rules and manuals, not billing or legal advice; verify against 42 CFR 412.29 and the Medicare Benefit Policy Manual (Pub. 100-02, Ch. 1, §110).
The 60% Rule (facility classification)
42 CFR 412.29To be paid under the IRF PPS, at least 60% of a facility's inpatient population must require intensive rehabilitation for one or more of 13 conditions. A case can count by its primary diagnosis or by a qualifying comorbidity.
| Who decides | the MAC, annually, at the start of each cost-reporting period |
| Presumptive method | compliance read from IRF-PAI diagnosis and impairment codes |
| Medical-review method | a sampled record review when the presumptive test is not met |
The 13 qualifying conditions
Count one or more| 1. Stroke | 8. Burns |
| 2. Spinal cord injury | 9. Active polyarthritis (incl. rheumatoid) |
| 3. Congenital deformity | 10. Systemic vasculitis with joint inflammation |
| 4. Amputation | 11. Severe or advanced osteoarthritis (multiple joints) |
| 5. Major multiple trauma | 12. Certain specified neurological conditions |
| 6. Hip fracture | 13. Knee or hip joint replacement — only if bilateral, BMI ≥ 50, or age ≥ 85 |
| 7. Brain injury |
The qualifying diagnosis lists are maintained by CMS and updated by rule; confirm the current code lists.
Medical necessity for the individual case
Coverage| Intensive therapy | reasonable expectation the patient can participate in and benefit from intensive therapy — generally 3 hours/day at least 5 days/week, or 15 hours within 7 consecutive days |
| Multiple disciplines | at least two therapy disciplines, one of which is physical or occupational therapy |
| Physician supervision | rehabilitation-physician face-to-face visits at least 3 days/week |
| Preadmission screening | by a qualified clinician designated by a rehab physician within the 48 hours before admission |
| Post-admission & plan of care | a post-admission physician evaluation and an individualized overall plan of care synthesized by the rehab physician within 4 days of admission |
| Interdisciplinary team | a coordinated team approach to the patient's care |
Facility classification and individual coverage are separate tests — meeting the 60% Rule does not make a single stay payable, and a payable stay does not by itself satisfy the 60% Rule.