CMS 13 Conditions Quick Cards

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CMS 13 QUALIFYING CONDITIONS

IRF 60% Compliance Rule Quick Reference | UMRH New Orleans

Auto-Qualifies
Criteria Required
60% RULE - QUALIFYING CONDITIONS
1 Stroke
2 Spinal Cord Injury
3 Congenital Deformity
4 Amputation
5 Major Multiple Trauma
6 Hip Fracture
7 Brain Injury
8 Neurological Disorders
(MS, Parkinson's, etc.)
9 Burns
10 Arthritis - Must be active, polyarticular (multiple joints), with functional impairment
11 Hip Replacement - Bilateral OR BMI ≥50 OR Age ≥85
12 Knee Replacement - Bilateral OR BMI ≥50 OR Age ≥85
13 Systemic Vasculidities - Active, with joint inflammation & functional impairment
40% CATEGORY - OTHER QUALIFYING DIAGNOSES
  • Debility / Generalized Weakness - Post-ICU, post-sepsis, failure to thrive
  • Cardiac - Post-CABG, heart failure, post-transplant
  • Pulmonary - COPD, respiratory failure, COVID recovery
  • Single Joint Replacement - Not meeting 60% criteria
  • Cancer-Related - Post-surgery deconditioning
  • Other Medical - Renal failure, liver disease

⚠️ COMPLIANCE REMINDER

60% of admissions must have one of the 13 qualifying conditions. If compliance falls below 60% in a calendar year, the facility risks losing IRF designation and Medicare reimbursement.

UMRH New Orleans
504-433-5535
Admissions
Rosa (Director): 504-251-5065 | rmills@umrhospital.com
Anya (Business Dev): 954-825-6409 | anya@umrhospital.com
1

Stroke

Auto-Qualifies for 60%

Common Presentations

  • Ischemic stroke (CVA)
  • Hemorrhagic stroke
  • Transient ischemic attack with residual deficits
  • Hemiparesis/hemiplegia
  • Aphasia, dysarthria, dysphagia

Key Talking Points

  • JAMA study: 43% lower mortality at IRF vs SNF for stroke patients
  • Critical 72-hour window for intensive therapy
  • 15+ hours/week therapy vs 5-9 at SNF
  • Neuro Program Medical Director: Dr. Lionel A. Branch Jr., MD
UMRH New Orleans | 504-433-5535 Admissions: Rosa 504-251-5065 | Anya 954-825-6409
2

Spinal Cord Injury

Auto-Qualifies for 60%

Common Presentations

  • Complete or incomplete spinal cord injury
  • Paraplegia or tetraplegia
  • Traumatic or non-traumatic etiology
  • Spinal cord compression

Key Talking Points

  • Specialized equipment and trained staff
  • Bowel/bladder management programs
  • Skin integrity protocols
  • Mobility training with adaptive equipment
UMRH New Orleans | 504-433-5535 Admissions: Rosa 504-251-5065 | Anya 954-825-6409
3

Congenital Deformity

Auto-Qualifies for 60%

Common Presentations

  • Spina bifida
  • Cerebral palsy
  • Muscular dystrophy
  • Congenital limb deficiencies

Key Talking Points

  • Specialized pediatric and adult programs
  • Adaptive equipment training
  • Functional independence maximization
  • Family education and training
UMRH New Orleans | 504-433-5535 Admissions: Rosa 504-251-5065 | Anya 954-825-6409
4

Amputation

Auto-Qualifies for 60%

Common Presentations

  • Lower extremity amputation (BKA, AKA)
  • Upper extremity amputation
  • Traumatic or vascular etiology
  • Diabetic-related amputation

Key Talking Points

  • Prosthetic training and fitting coordination
  • Gait training and balance
  • Phantom limb management
  • ADL adaptation and independence
UMRH New Orleans | 504-433-5535 Admissions: Rosa 504-251-5065 | Anya 954-825-6409
5

Major Multiple Trauma

Auto-Qualifies for 60%

Common Presentations

  • Motor vehicle accidents
  • Multiple fractures
  • Polytrauma with multiple system involvement
  • Combined orthopedic and neurological injuries

Key Talking Points

  • Coordinated multi-disciplinary care
  • Complex medical management
  • Weight-bearing progression protocols
  • 24/7 physician oversight
UMRH New Orleans | 504-433-5535 Admissions: Rosa 504-251-5065 | Anya 954-825-6409
6

Hip Fracture

Auto-Qualifies for 60%

Common Presentations

  • Femoral neck fracture
  • Intertrochanteric fracture
  • Subtrochanteric fracture
  • Post-ORIF or hemiarthroplasty

Key Talking Points

  • Early mobilization reduces complications
  • Fall prevention programs
  • Weight-bearing progression per surgeon protocol
  • Osteoporosis management coordination
UMRH New Orleans | 504-433-5535 Admissions: Rosa 504-251-5065 | Anya 954-825-6409
7

Brain Injury

Auto-Qualifies for 60%

Common Presentations

  • Traumatic brain injury (TBI)
  • Anoxic/hypoxic brain injury
  • Post-craniotomy
  • Encephalopathy with functional deficits

Key Talking Points

  • Cognitive rehabilitation programs
  • Behavioral management expertise
  • Neuro Program Medical Director oversight
  • Family training for safe discharge
UMRH New Orleans | 504-433-5535 Admissions: Rosa 504-251-5065 | Anya 954-825-6409
8

Neurological Disorders

Auto-Qualifies for 60%

Common Presentations

  • Multiple sclerosis (MS) exacerbation
  • Parkinson's disease
  • Guillain-Barré syndrome
  • Polyneuropathy, motor neuron disease

Key Talking Points

  • Disease-specific rehabilitation protocols
  • Medication management optimization
  • Fatigue management strategies
  • Long-term functional maintenance planning
UMRH New Orleans | 504-433-5535 Admissions: Rosa 504-251-5065 | Anya 954-825-6409
9

Burns

Auto-Qualifies for 60%

Common Presentations

  • Second and third degree burns
  • Burns affecting functional areas
  • Post-skin grafting
  • Inhalation injury recovery

Key Talking Points

  • Scar management and contracture prevention
  • Range of motion preservation
  • Pain management expertise
  • Wound care coordination
UMRH New Orleans | 504-433-5535 Admissions: Rosa 504-251-5065 | Anya 954-825-6409
10

Polyarticular Inflammatory Arthritis

Criteria Required for 60%

Common Presentations

  • Rheumatoid arthritis
  • Psoriatic arthritis
  • Severe osteoarthritis (multiple joints)

⚠️ Required Criteria

  • Active - Currently symptomatic
  • Polyarticular - Affecting multiple joints
  • Functional impairment - Documented ADL limitations
UMRH New Orleans | 504-433-5535 Admissions: Rosa 504-251-5065 | Anya 954-825-6409
11

Hip Replacement

Criteria Required for 60%

Common Presentations

  • Total hip arthroplasty (THA)
  • Hip revision surgery
  • Bilateral hip replacement

⚠️ Must Meet ONE of These Criteria

  • Bilateral - Both hips replaced (same admission or staged)
  • BMI ≥ 50 - Documented body mass index
  • Age ≥ 85 - Patient is 85 years or older

If Criteria NOT Met

Patient counts toward 40% category - still appropriate for IRF if medically necessary

UMRH New Orleans | 504-433-5535 Admissions: Rosa 504-251-5065 | Anya 954-825-6409
12

Knee Replacement

Criteria Required for 60%

Common Presentations

  • Total knee arthroplasty (TKA)
  • Knee revision surgery
  • Bilateral knee replacement

⚠️ Must Meet ONE of These Criteria

  • Bilateral - Both knees replaced (same admission or staged)
  • BMI ≥ 50 - Documented body mass index
  • Age ≥ 85 - Patient is 85 years or older

If Criteria NOT Met

Patient counts toward 40% category - still appropriate for IRF if medically necessary

UMRH New Orleans | 504-433-5535 Admissions: Rosa 504-251-5065 | Anya 954-825-6409
13

Systemic Vasculidities

Criteria Required for 60%

Common Presentations

  • Rheumatoid vasculitis
  • Giant cell arteritis
  • Polyarteritis nodosa
  • Wegener's granulomatosis

⚠️ Required Criteria

  • Active - Currently symptomatic disease
  • Joint inflammation - Documented articular involvement
  • Functional impairment - Documented ADL limitations
UMRH New Orleans | 504-433-5535 Admissions: Rosa 504-251-5065 | Anya 954-825-6409