CR 14635 IRF manual update: all required therapies start in the 36-hour window, first IDT meeting by day 4

On October 15, 2026, CMS issued Transmittal R14001BP, Change Request 14635, which updates chapter 1 of the Medicare Benefit Policy Manual (Pub. 100-02) for inpatient rehabilitation facility (IRF) services. The CR is effective October 1, 2026, with a November 17, 2026 implementation date. CMS says the revisions "address IRF documentation, therapy, and interdisciplinary team requirements."

The manual now carries two coverage requirements CMS finalized in the FY 2027 IRF PPS final rule (91 FR 48982, August 3, 2026). Every required therapy treatment or evaluation ordered at admission has to start inside the 36-hour window, and the first interdisciplinary team (IDT) meeting is due by day 4. For IRF HIM, coding, and pre-bill review staff, both are date-and-time checks on the record.

CR 14635 at a glance

The CR says CMS will release provider education through the MLN Connects newsletter "shortly after we issue the CR."

Old manual text vs. R14001BP

The 36-hour rule: every required therapy, not just one

The final rule explains why the wording changed. CMS says sub-regulatory guidance it posted in 2010 "may have created ambiguous interpretation" of whether only one therapy or all therapies had to start within 36 hours. CMS also says the plural "treatments" in the prior regulation already "means that all treatments shall be included," and the revision codifies that. The revised regulation reads: "All required therapy treatments and/or therapy evaluations ordered must begin no later than 36 hours from midnight on the day of admission to the IRF."

How CMS counts the window:

• The clock starts at the midnight that follows the admission. CMS's example: a patient admitted at 2:00 p.m. on Tuesday must have all therapy treatments and/or therapy evaluations started by 12:00 p.m. on Thursday.
• A therapy evaluation counts as the start of that therapy. The manual says evaluations "are generally considered to constitute the beginning of the required therapy services."
• The 36-hour requirement covers therapy treatments and/or therapy evaluations ordered at admission. Those orders can come from the rehabilitation physician's concurrence with the therapies identified in the preadmission screening (PAS) or from additional therapies the physician orders at admission. Per question 7 of the CMS FY 2027 IRF final rule FAQ (September 2026), therapies ordered after the rehabilitation physician's initial concurrence with the PAS and admission orders "are not subject to the 36-hour requirement." CMS still encourages IRFs to start those additional therapies as soon as possible, and asks that the record show when each additional therapy was ordered and when it began.
• CMS did not finalize flexibilities for smaller IRFs or IRFs with staffing shortages.

On enforcement, the final rule says CMS will "continue to determine compliance by conducting audits of IRFs' medical record documentation," and that IRF claims for admitted patients who cannot tolerate an intensive therapy program "may be denied by CMS."

First IDT meeting by day 4, then every 7 days

The revised regulation, 42 CFR 412.622(a)(5)(ii), requires the initial IDT meeting "on or before 4 days from the date the patient is admitted." CMS counts the day of admission as day 1. Its example: a patient admitted on a Thursday needs the initial IDT meeting before the end of the day on Sunday. The rule applies to admissions on or after October 1, 2026.

Enforcement discretion through March 31, 2027. On its IRF PPS page, CMS says it is exercising enforcement discretion on the timing of the initial IDT meeting for IRF admissions from October 1, 2026 through March 31, 2027. During that period, MACs will not deny or non-affirm a claim based solely on the timing of the initial IDT meeting if an IDT meeting occurs at least once per week throughout the patient's stay, and they will apply the initial-meeting timing requirement that was in effect during FY 2026. All other IRF coverage and documentation requirements stay in effect. The discretion covers only the timing of the initial IDT meeting. It does not change the regulation and does not apply to the 36-hour therapy requirement.

Some details that matter on review:

• CMS proposed counting the 4 days "from midnight" on the admission date and did not finalize that version. The final count runs from the date of admission.
• Commenters asked to move a weekend or holiday day 4 to the next business day. CMS did not adopt that request in the final rule.
• The date of the initial meeting sets the schedule. Each later meeting must occur at least once per week after the prior meeting, and the regulation now defines a week as "a period of 7 consecutive calendar days."
• The rehabilitation physician leads the meeting, in person or remotely, and must document concurrence with all decisions made at each meeting. The final rule says only rehabilitation physicians may join remotely, and all other team members must attend in person.
• The manual says documentation of each team conference should generally include the names and professional designations of the participants. Signatures other than the rehabilitation physician's concurrence are not required.

The day 4 deadline also matches the plan of care. R14001BP says the overall plan of care must be completed within the first 4 days, "with the day of admission being day 1." The manual drops its old line that holding the first IDT meeting within 4 days "may be good practice" and states the requirement instead.

What did not change in the preadmission screening

CMS proposed requiring the preadmission screening (PAS) to document the patient's current functional status. The final rule says CMS "will not be finalizing this proposal." The section 110.1.1 edits in R14001BP are wording: the manual now abbreviates preadmission screening as PAS and adds "as applicable" after the list of needed treatments. The 48-hour PAS window and the rehabilitation physician's documented concurrence before admission stay the same.

What this is not

It is not a payment rate update. The FY 2027 IRF rates and case-mix group relative weights come from the final rule and its October 1, 2026 correction notice (CMS-1845-CN). CMS says that notice corrects wage index and related technical errors and "does not make substantive changes to the policies or payment methodologies."

CR 14635 does not change ICD-10-CM codes, case-mix group assignments, or HCCs. The final rule also summarized comments on a request for information about future IRF payment reform, including diagnosis-based grouping similar to the SNF Patient Driven Payment Model. That was a request for information, not an FY 2027 payment change.

It is not an NCCI update.

For ICD-10-CM wording on the diagnoses in an IRF record, use the encoder or code book. The 36-hour and IDT rules come from 42 CFR 412.622 and Medicare Benefit Policy Manual chapter 1, section 110, not from a code lookup.