Baylor Rehabilitation and the "75 % Rule"

Baylor Institute for Rehabilitation and all inpatient rehabilitation facilities must meet criteria established by The Centers for Medicare and Medicaid Services (CMS) to be classified as an inpatient facility. The ruling, called the "75% Rule," requires at least a certain percentage of admissions be in one of 13 diagnostic categories. Hospitals can also admit patients with other diagnoses as long as the required percentage from these 13 categories is met. In addition, all potential patient 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 a day at least five days per week.

A version of this rule has been in place since 1983 but was updated in 2004 to expand and further define the allowed diagnostic categories. The "75% Rule" is being phased in with full compliance required by July 1, 2007.

The 13 approved diagnoses include:

• Active, polyarthricular rheumatoid arthritis, psoriatic arthritis and seronegative arthropathies resulting in significant functional impairment of ambulation and other activities of daily living which has not improved after appropriate, aggressive and sustained course of outpatient therapy services or services in other less intensive rehabilitation settings immediately preceding the inpatient rehabilitation admission or which results from a systemic disease activation immediately before admission, but has the potential to improve with more intensive rehabilitation
• Amputation
• Brain Injury
• Burns
• Congenital Deformity
• Fracture of the femur (hip fracture)
• Knee or hip joint replacement or both during an acute hospitalization immediately preceding the inpatient rehabilitation stay and also meet one or more of these criteria:
     - The patient underwent bilateral knee or bilateral hip joint replacement surgery
        during the acute hospital admission immediately preceding the inpatient
        rehabilitation admission.
     - The patient is extremely obese with a Body Mass Index of at least 50 at the time
        of admission.
     - The patient is 85 or older at the time of admission.
• Major Multiple Trauma
• Neurological Disorders including multiple sclerosis, motor neuron diseases, polyneuropathy, muscular dystrophy and Parkinson's disease
• Severe advanced osteoarthritis involving three or more major joints (elbow, shoulders, hips or knees) with joint deformity and substantial loss of range of motion, atrophy, significant functional impairment of ambulation and other activities of daily living which has not improved after an appropriate, aggressive and sustained course of outpatient therapy services or services in other less intensive rehabilitation settings immediately preceding the inpatient rehabilitation admission but has the potential to improve with more intensive rehabilitation.
• Spinal Cord Injury
• Stroke
• Systemic vasculidites with joint inflammation resulting in significant functional impairment of ambulation and other activities of daily living which has not improved after an appropriate, aggressive and sustained course of outpatient therapy services or services in other less intensive rehabilitation settings immediately preceding the inpatient rehabilitation admission or which results from a systemic disease activation immediately before admission but has the potential to improve with more intensive rehabilitation.

In compliance with this rule, Baylor must admit at least 75 percent of its inpatient rehabilitation patients from these 13 categories but will also continue to admit additional appropriate rehabilitation patients with other diagnoses after meeting these guidelines.

What types of patients may this new rule affect?
With these new criteria, some patients with a unilateral joint replacement, may no longer receive inpatient rehabilitation. Among the alternative settings for inpatient rehabilitation recommended by the CMS include acute care hospitals, skilled nursing facilities, long-term care hospitals, outpatient rehabilitation facilities and home health care.

If you have any questions about the "75 % Rule" and what it may mean to you, please call Baylor Institute for Rehabilitation at (972) 820-9300.

Source: Centers for Medicare and Medicaid Services List of IRF Regulations, Regulation No. 1480-N, "75% Rule: Changes to the Criteria for Being Classified as an IRF," Notice (70FR 36640)