Medicare Claims Processing Manual
Chapter 3 - Inpatient Hospital Billing
Table of Contents
(Rev. 12575; Issued: 04-11-24)
Transmittals for Chapter 3
10 - General Inpatient Requirements
10.1 - Claim Formats
10.2 - Focused Medical Review (FMR)
10.3 - Spell of Illness
10.4 - Payment of Nonphysician Services for Inpatients
10.5 - Hospital Inpatient Bundling
20 - Payment Under Prospective Payment System (PPS) Diagnosis Related Groups (DRGs)
20.1 - Hospital Operating Payments Under PPS
20.1.1 - Hospital Wage Index
20.1.2 - Outliers
20.1.2.1 - Cost to Charge Ratios
20.1.2.2 - Statewide Average Cost to Charge Ratios
20.1.2.3 - Threshold and Marginal Cost
20.1.2.4 - Transfers
20.1.2.5 - Reconciliation
20.1.2.6 - Time Value of Money
20.1.2.7 - Procedure for Medicare contractors to Perform and Record Outlier
Reconciliation Adjustments
20.1.2.8 - Specific Outlier Payments for Burn Cases
20.1.2.9 - Medical Review and Adjustments
20.1.2.10 - Return Codes for Pricer
20.2 - Computer Programs Used to Support Prospective Payment System
20.2.1 - Medicare Code Editor (MCE)
20.2.1.1 - Paying Claims Outside of the MCE
20.2.1.1.1 - Requesting to Pay Claims Without MCE Approval
20.2.1.1.2 - Procedures for Paying Claims Without Passing through the MCE
20.2.2 - DRG GROUPER Program
20.2.3 - PPS Pricer Program
20.2.3.1 - Provider-Specific File
20.3 - Additional Payment Amounts for Hospitals with Disproportionate Share of Low-Income
Patients
20.3.1 - Clarification of Allowable Medicaid Days in the Medicare Disproportionate Share
Hospital (DSH) Adjustment Calculation
20.3.1.1 - Clarification for Cost Reporting Periods Beginning On or After January 1,
2000
20.3.1.2 - Hold Harmless for Cost Reporting Periods Beginning Before January 1, 2000
20.3.1.3 - Disproportionate Share Hospital (DSH) Policy Changes Effective for Cost
Reporting Periods beginning on or after October 1, 2009
20.3.1.4 - Disproportionate Share Hospital (DSH) Policy Changes Effective for Cost
Reporting Periods beginning on or after October 1, 2012
20.3.2 - Updates to the Federal Fiscal Year (FY) 2001
20.3.2.1 - Inpatient Hospital Payments and Disproportionate Share Hospital (DSH)
Thresholds and Adjustments
20.3.3 - Prospective Payment Changes for Fiscal Year (FY) 2003
20.3.4 - Prospective Payment Changes for Fiscal Year (FY) 2004 and Beyond
20.4 - Hospital Capital Payments Under PPS
20.4.1 - Federal Rate
20.4.2 - Hold Harmless Payments
20.4.3 - Blended Payments
20.4.4 - Capital Payments in Puerto Rico
20.4.5 - Old and New Capital
20.4.6 - New Hospitals
20.4.7 - Capital PPS Exception Payments
20.4.8 - Capital Outliers
20.4.9 - Admission Prior to and Discharge After Capital PPS Implementation Date
20.4.10 - Market Basket Update
20.5 - Rural Referral Centers (RRCs)
20.6 - Criteria and Payment for Sole Community Hospitals and for Medicare Dependent Hospitals
20.7 - Billing Applicable to PPS
20.7.1- Stays Prior to and Discharge After IPPS Implementation Date
20.7.2 - Split Bills
20.7.3 - Payment for Blood Clotting Factor Administered to Hemophilia Inpatients
20.7.4 - Cost Outlier Bills With Benefits Exhausted
20.8 - Payment to Hospitals and Units Excluded from IPPS for Direct Graduate Medical Education
(DGME) and Nursing and Allied Health (N&AH) Education for Medicare Advantage (MA) Enrollees
30 - Medicare Rural Hospital Flexibility Program and Critical Access Hospitals (CAHs)
30.1 - Requirements for CAH Services, CAH Skilled Nursing Care Services and Distinct Part Units
30.1.1 - Payment for Inpatient Services Furnished by a CAH
30.1.1.1 - Payment for Inpatient Services Furnished by an Indian Health Service (IHS)
or tribal CAH
30.1.2 - Payment for Post-Hospital SNF Care Furnished by a CAH
30.1.3 - Costs of Emergency Room On-Call Providers
30.1.4 - Costs of Ambulance Services
40 - Billing Coverage and Utilization Rules for PPS and Non-PPS Hospitals
40.1 - "Day Count" Rules for All Providers
40.2 - Determining Covered/Noncovered Days and Charges
40.2.1 - Noncovered Admission Followed by Covered Level of Care
40.2.2 - Charges to Beneficiaries for Part A Services
40.2.3 - Determining Covered and Noncovered Charges - Pricer and PS&R
40.2.4 - IPPS Transfers Between Hospitals
40.2.5 - Repeat Admissions
40.2.6 - Leave of Absence
40.3 - Outpatient Services Treated as Inpatient Services
40.3.1 - Billing Procedures to Avoid Duplicate Payments
50 - Adjustment Bills
50.1 - Tolerance Guidelines for Submitting Adjustment Requests
50.2 - Claim Change Reasons
50.3 - Late Charges
60 - Swing-Bed Services
70 - All-Inclusive Rate Providers
70.1 - Providers Using All-Inclusive Rates for Inpatient Part A Charges
80 - Hospitals That Do Not Charge
80.1 - Medicare Summary Notice (MSN) for Services in Hospitals That Do Not Charge
90 - Billing Transplant Services
90.1 - Kidney Transplant - General
90.1.1 - The Standard Kidney Acquisition Charge
90.1.2 - Billing for Kidney Transplant and Acquisition Services
90.1.3 - Billing for Donor Post-Kidney Transplant Complication Services
90.2 - Heart Transplants
90.3 - Stem Cell Transplantation
90.3.1 - Allogeneic for Stem Cell Transplantation
90.3.2 - Autologous Stem Cell Transplantation (AuSCT)
90.4 - Liver Transplants
90.4.1 - Standard Liver Acquisition Charge
90.4.2 - Billing for Liver Transplant and Acquisition Services
90.5 - Pancreas Transplants With Kidney Transplants
90.5.1 - Pancreas Transplants Alone (PA)
90.6 - Intestinal and Multi-Visceral Transplants
100 - Billing Instructions for Specific Situations
100.1 - Billing for Abortion Services
100.2 - Payment for CRNA or AA Services
100.3 - Resident and Interns Not Under Approved Teaching Programs
100.4 - Billing for Services After Termination of Provider Agreement
100.4.1 - Billing Procedures for a Provider Assigned Multiple Provider Numbers or a Change
in Provider Number
100.5 - Review of Hospital Admissions of Patients Who Have Elected Hospice Care
100.6 - Inpatient Renal Services
100.7 - Lung Volume Reduction Surgery
100.8 - Replaced Devices Offered Without Cost or With a Credit
100.9 – Requirements for Processing Non Veterans Administration (VA) Authorized Inpatient Claims
100.10 – Requirements for Processing Programs of All-Inclusive Care for the Elderly (PACE)
Disenrollments during an Inpatient Stays
130 - Coordination With the Quality Improvement Organization (QIO)
140 - Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS)
140.1 - Medicare IRF Classification Requirements
140.1.1 - Criteria That Must Be Met By Inpatient Rehabilitation Facilities
140.1.2 - Additional Criteria That Must Be Met By Inpatient Rehabilitation Units
140.1.3 - Verification Process Used to Determine if the Inpatient Rehabilitation Facility Met
the Classification Criteria
140.1.4 - New IRFs
140.1.5 - Changes in the Status of an IRF Unit
140.1.6 - New IRF Beds
140.1.7 - Change of Ownership or Leasing
140.1.8 - Mergers
140.1.9 - Retroactive Adjustments For Provisionally Excluded IRFs or IRF Beds
140.2 - Payment Provisions Under IRF PPS
140.2.1 - Phase-In Implementation
140.2.2 - Payment Adjustment Factors and Rates
140.2.3 - Case-Mix Groups
140.2.4 - Case-Level Adjustments
140.2.5 - Facility-Level Adjustments
140.2.5.1 - Area Wage Adjustments
140.2.5.2 - Rural Adjustment
140.2.5.3 - Low-Income Patient (LIP) Adjustment: The Supplemental Security Income
(SSI)/Medicare Beneficiary Data for Inpatient Rehabilitation Facilities (IRFs) Paid
Under the Prospective Payment System (PPS)
140.2.5.4 - Teaching Status Adjustment
140.2.5.4.1 - FTE Resident Cap
140.2.5.5 - Outliers
140.2.6 - Cost-to-Charge Ratios
140.2.7- Use of a National Average Cost-to-Charge Ratio
140.2.8- Reconciling Outlier Payments for IRF
140.2.9-Time Value of Money
140.2.10 - Procedure for Medicare Contractors to Perform and Record Outlier Reconciliation
Adjustments for IRFs
140.2.11- Quality Reporting Program
140.3 - Billing Requirements Under IRF PPS
140.3.1 - Shared Systems and CWF Edits
140.3.1.1 - Actions When a Claim Does Not Match the Inpatient Rehabilitation
Facility- Patient Assessment Instrument (IRF-PAI)
140.3.2 - IRF PPS Pricer Software
140.3.3 - Remittance Advices
150 - Long Term Care Hospitals (LTCHs) PPS
150.1 - Background
150.2 - Statutory Requirements
150.3 - Affected Medicare Providers
150.4 - Revision of the Qualification Criterion for LTCHs
150.5 - Payment Provisions Under LTCH PPS
150.5.1 - Budget Neutrality
150.5.2 - Budget Neutrality Offset
150.6 - Beneficiary Liability
150.7 - Patient Classification System
150.8 - Relative Weights
150.9 - Payment Rate
150.9.1 - Case-Level Adjustments
150.9.1.1 - Short-Stay Outliers
150.9.1.2 - Interrupted Stays
150.9.1.3 - Payments for Special Cases
150.9.1.4 - Payment Policy for Co-Located Providers
150.9.1.5 - High Cost Outlier Cases
150.10 - Facility-Level Adjustments
150.10.1 - Phase-in Implementation
150.11 - Requirements for Provider Education and Training
150.12 - Claims Processing and Billing
150.12.1 - Processing Bills Between October 1, 2002, and the Implementation Date
150.13 - Billing Requirements Under LTCH PPS
150.14 - Stays Prior to and Discharge After PPS Implementation Date
150.14.1-Crossover Patients in New LTCHs
150.15 - System Edits
150.16 - Billing Ancillary Services Under LTCH PPS
150.17 - Benefits Exhausted
150.17.1 - Assumptions for Use in Examples Below
150.17.1.1 - Example 1: Coinsurance Days < Short Stay Outlier Threshold (30 Day
Stay)
150.17.1.2 - Example 2: Coinsurance Days Greater Than or Equal to Short Stay Outlier
Threshold (30 day stay)
150.17.1.3 - Example 3: Coinsurance Days Greater Than or Equal to Short Stay Outlier
Threshold (20 day stay)
150.17.1.4 - Example 4: Only LTR Days < Short Stay Outlier Threshold (30 day stay)
150.17.1.5 - Example 5: Only LTR Greater Than or Equal to Short Stay Outlier
Threshold (30 day stay)
150.18 - Provider Interim Payment (PIP)
150.19 - Interim Billing
150.20 - Intermediary Benefit Payment Report (IBPR)
150.21 - Remittance Advices (RAs)
150.22 - Medicare Summary Notices (MSNs)
150.23 - LTCH Pricer Software
150.23.1 - Inputs/Outputs to Pricer
150.24 - Determining the Cost-to-Charge Ratio
150.25 - Statewide Average Cost-to-Charge Ratios
150.26 - Reconciliation
150.27 - Time Value of Money
150.28 Procedure for Medicare contractors to Perform and Record Outlier Reconciliation Adjustments
160 - Necessary Changes to Implement Special Add-On Payments for New Technologies
160.1 - Special Add-On Payments For New Technologies
160.1.1 - Identifying Claims Eligible for the Add-On Payment for New Technology
160.1.2 - Remittance Advice Impact
170 - Billing and Processing Instructions for Religious Nonmedical Health Care Institution (RNHCI) Claims
170.1 - RNHCI Election Process
170.1.1 - Requirement for RNHCI Election
170.1.2 - Revocation of RNHCI Election
170.1.3 - Completion of the Notice of Election for RNHCI
170.1.4 - Common Working File (CWF) Processing of Elections, Revocations and Cancelled
Elections
170.2 - Billing Process for RNHCI Services
170.2.1 - When to Bill for RNHCI Services
170.2.2 - Required Data Elements on Claims for RNHCI Services
170.3 - RNHCI Claims Processing By the Medicare Contractor with RNHCI Specialty Workload
170.3.1 - RNHCI Claims Not Billed to Original Medicare
170.4 - Informing Beneficiaries of the Results of RNHCI Claims Processing
180 - Processing Claims For Beneficiaries with RNHCI Elections by Contractors without RNHCI Specialty
Workloads
180.1 - Recording Determinations of Excepted/Nonexcepted Care on Claim Records
180.2 - Informing Beneficiaries of the Results of Excepted/Nonexcepted Care Determinations by the
Non-specialty Contractor
190 - Inpatient Psychiatric Facility Prospective Payment System (IPF PPS)
190.1 - Background
190.2 - Statutory Requirements
190.3 - Affected Medicare Providers
190.4 - Federal Per Diem Base Rate
190.4.1 - Standardization Factor
190.4.2 - Budget Neutrality
190.4.2.1 - Budget Neutrality Components
190.4.3 - Annual Update
190.4.4 - Calculating the Federal Payment Rate
190.5 - Patient-Level Adjustments
190.5.1 - Diagnosis-Related Groups (DRGs) Adjustments
190.5.2 - Application of Code First
190.5.3 - Comorbidity Adjustments
190.5.4 - Age Adjustments
190.5.5 - Variable Per Diem Adjustments
190.6 - Facility-Level Adjustments
190.6.1 - Wage Index
190.6.2 - Rural Location Adjustment
190.6.3 - Teaching Status Adjustment
190.6.3.1 - Full-Time Equivalent (FTE) Resident Cap
190.6.3.2 - Reconciliation of Teaching Adjustment on Cost Report
190.6.4 - Emergency Department (ED) Adjustment
190.6.4.1 - Source of Admission for IPF PPS Claims for Payment of ED Adjustment
190.6.5 - Cost-of- Living Adjustment (COLA) for Alaska and Hawaii
190.7 - Other Payment Policies
190.7.1 - Interrupted Stays
190.7.2 - Outlier Policy
190.7.2.1 - How to Calculate Outlier Payments
190.7.2.2 - Determining the Cost-to-Charge Ratio
190.7.2.3 Outlier Reconciliation
190.7.2.4. Time Value of Money
190.7.2.5 - Procedures for Medicare Contractors to Perform and Record Outlier
Reconciliation Adjustments
190.7.3 - Electroconvulsive Therapy (ECT) Payment
190.7.4 - Stop Loss Provision (Transition Period Only)
190.8 - Transition (Phase-In Implementation)
190.8.1 - Implementation Date for Provider
190.9 - Definition of New IPF Providers Versus TEFRA Providers
190.9.1 - New Providers Defined
190.10 - Claims Processing Requirements Under IPF PPS
190.10.1 - General Rules
190.10.2 - Billing Period
190.10.3 - Patient Status Coding
190.10.4 - Reporting ECT Treatments
190.10.5 - Outpatient Services Treated as Inpatient Services
190.10.6 - Patient is a Member of a Medicare Advantage Organization for Only a Portion of a
Billing Period
190.10.7 - Billing for Interrupted Stays
190.10.8 - Grace Days
190.10.9 - Billing Stays Prior to and Discharge After PPS Implementation Date
190.10.10 - Billing Ancillary Services Under IPF PPS
190.10.11 - Covered Costs Not Included in IPF PPS Amount
190.10.12 - Same Day Transfer Claims
190.10.13 - Remittance Advice - Reserved
190.10.14 - Medicare Summary Notices and Explanation of Medicare Benefits
190.11 - Benefit Application and Limits-190 Days
190.12 - Beneficiary Liability
190.12.1 - Benefits Exhaust
190.13 - Periodic Interim Payments (PIP)
190.14 - Intermediary Benefit Payment Report (IBPR)
190.15 - Monitoring Implementation of IPF PPS Through Pulse
190.16 - IPF PPS System Edits
190.17 - IPF PPS PRICER Software
190.17.1 - Inputs/Outputs to PRICER
200 - Electronic Health Record (EHR) Incentive Payments
200.1 - Payment Calculation
200.2 - Submission of Informational Only Bills for Maryland Waiver Hospitals and Critical Access
Hospitals (CAHs)
250.18 - Incomplete Colonoscopies (Codes 44388, 45378, G0105 and G0121)
Addendum A - Provider Specific File
10 - General Inpatient Requirements
(Rev. 1, 10-01-03)
HO-400, HO-400.G, HO-403, HO-412
The hospital may bill only for services provided. If the provider billing system initiates billing based on
services ordered, the provider must confirm that the service has been provided before billing either the A/B
MAC (B) or A/B MAC (A).
The provider agreement to participate in the program requires the provider to submit all information necessary
to support claims for services. Failure to submit such information in an individual case will result in denial of
the entire claim, the charging of utilization in inpatient cases to the beneficiary record, and a prohibition
against the provider billing or collecting from the beneficiary or other person for any services on the claim. A
provider with a common practice of failing to submit necessary information in connection with its claims
subjects itself to possible termination of its participation in the program. (See chapter 1.)
State agencies will find that a significant deficiency exists in complying with the conditions of participation if
the hospital repeatedly fails to transfer appropriate medical information when patients are transferred to other
health facilities. Appropriate medical information includes the discharge summary, the physician's medical
orders, and a summary of departmental medical records. The hospital must obtain the patient's consent for the
release of medical information as soon as the decision to transfer is made, unless a blanket authorization was
obtained at admission.
10.1 - Claim Formats
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of
ICD-10, Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: September, 23 2014)
A. - Institutional Claim Formats
The ASC X12 837 institutional claim format, or where permissible, Form CMS-1450, Inpatient and/or
Outpatient Billing, is used for all provider billing, except for the professional component of physicians
services. (Refer to paragraph B for the appropriate professional claim formats.) The ASC X12 837
institutional claim format and Form CMS-1450 are processed by the provider's A/B MAC (A). See Chapter
25 for instructions for hospital services.)
Providers submitting claims on paper are responsible for purchasing their own paper forms.
B. - Professional Claim Formats
The ASC X12 837 professional claim format, or where permissible, Form CMS-1500 is the prescribed format
for claims prepared by physicians and nonphysician practitioners whether or not the claims are assigned.
Institutional providers may use the ASC X12 837 professional claim format or the Form CMS-1500 to bill the
A/B MAC (B) for the professional component of physicians' services where applicable. (For more
information about the CMS-1500 claim form, refer to Chapter 26. Information about billing for physician and
other supplier services can be found in this chapter as well as chapters throughout this manual relative to
specific policies and topics.)
Providers submitting claims on paper are responsible for purchasing their own paper forms.
C. - Form CMS-1490S Patient's Request for Medicare Payment
Only beneficiaries (or their representatives) who complete and file their own claims use this form. Providers
have no need for this form.
10.2 - Focused Medical Review (FMR)
(Rev. 1, 10-01-03)
HO-419, HH-450, HH-452, HH-462.1
This section has been moved to the Program Integrity Manual, which can be found at the following Internet
address
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html.
10.3 - Spell of Illness
(Rev. 1, 10-01-03)
A3-3622
The A/B MAC (A) or (HHH) makes spell of illness determinations in accordance with the Medicare Benefit
Policy Manual, Chapter 3, and these special instructions.
A. - Beginning a Spell of Illness in Nonparticipating Provider
The noncovered services furnished by a nonparticipating provider can begin a spell of illness only if the
provider is a qualified provider. A qualified provider is a hospital (including a psychiatric hospital) or an SNF
that meets all requirements in the definition of such an institution even though it may not be participating.
It is most unlikely that a nonparticipating hospital that is not accredited by JCAHO or a nonparticipating SNF
satisfies the conditions of participation, particularly with regard to utilization review. Therefore, for spell of
illness purposes, the A/B MAC (A) or (HHH) assumes that nonparticipating providers are not qualified
providers in the absence of evidence to the contrary. Situations that might constitute such contrary evidence
include cases where the provider recently dropped out of the program or, after a survey by the State agency,
decided not to participate even though the conditions of participation were met. Hospitals accredited by
JCAHO are deemed to meet all requirements except utilization review. For such a hospital, the A/B MAC (A)
determines through the RO whether the hospital has a utilization review plan in effect.
B. - Continuing a Spell of Illness
1. Hospital Services
For purposes of continuing a spell of illness in a hospital, the hospital in which the stay occurs need not meet
all requirements that are necessary for starting a spell of illness. If there has been a stay in a hospital that
might continue the spell of illness and the A/B MAC (A) cannot ascertain its status, the A/B MAC (A)
contacts the RO, which maintains a list of all medical facilities and their status.
2. SNF Services
For purposes of continuing a spell of illness in a SNF the spell of illness ends when the beneficiary no longer
needs or receives a Medicare covered level of care.
The A/B MAC (A) uses the following seven presumptions to determine whether the skilled level of care
standards were met during a prior SNF stay. If the information upon which to base a presumption is not
readily available, the A/B MAC (A) may, at its discretion, review the beneficiary's medical records to
determine whether the beneficiary was an inpatient of an SNF for purposes of ending a spell of illness.
These special rules for determining whether a beneficiary in a SNF is an inpatient for benefit period purposes
is applicable in all cases where a prior SNF stay affects benefit period status, not only when a beneficiary is
seeking to continue a benefit period, but also where it results in the beneficiary starting a new benefit period.
If the applicable skilled level of care standards were met during a prior SNF stay, the spell of illness is
continued with current utilization available to the beneficiary. If the applicable skilled level of care standards
were not met during a prior SNF stay, the spell of illness is not continued. A new spell of illness restores full
utilization and imposes a cash deductible.
Presumptions:
Presumption 1: A beneficiary's care in a SNF met the skilled level of care standards if a Medicare SNF claim
was paid for the care, unless such payment was made under limitation of liability rules.
Presumption 2: A beneficiary's care in a SNF met the skilled level of care standards if a SNF claim was paid
for the services provided in the SNF under the special Medicare limitation on liability rules pursuant to
placement in a noncertified bed. See Chapter 30.
Presumption 3: A beneficiary's care in a SNF did not meet the skilled level of care standards if a claim was
paid for the services provided in the SNF pursuant to the general Medicare limitation on liability rules in
Chapter 30. (This presumption does not apply to placement in a noncertified bed. For claims paid under these
special provisions, see Presumption 2.)
Presumption 4: A beneficiary's care in a Medicaid nursing facility (NF) did not meet the skilled level of care
standards if a Medicaid claim for the services provided in the NF was denied on the grounds that the services
received were not at the NF level of care (even if paid under applicable Medicaid administratively necessary
days provisions which result in payment for care not meeting the NF level of care requirements).
Presumption 5: A beneficiary's care in an SNF met the skilled level of care standards if a Medicare SNF
claim for the services provided in the SNF was denied on grounds other than that the services were not at the
skilled level of care.
Presumption 6: A beneficiary's care in an SNF did not meet the skilled level of care standards if a Medicare
claim for the services provided in the SNF was denied on the grounds that the services were not at the skilled
level of care and no limitation of liability payment was made.
Presumption 7: A beneficiary's care in a SNF did not meet the skilled level of care standards if no Medicare
or Medicaid claim was submitted by the SNF.
Rebuttal of Presumptions
Presumptions 1 through 4 cannot be rebutted. Thus, prior Medicare and Medicaid claim determinations that
necessarily required a level of care determination for the time period under consideration are binding for
purposes of a later benefit period calculation. Although Presumptions 1 through 4 are not in themselves
rebuttable, a beneficiary may seek to reverse a benefit period determination that was dictated by one of these
presumptions by timely appealing the prior Medicare or Medicaid claim determination which triggered the
presumption.
Presumptions 5 through 7 can be rebutted by beneficiary showings that the level of care needed or received
is other than that which the presumption dictates. Rebuttal showings are permitted at both A/B MAC (A)
determination levels under 42 CFR 405, Subpart G (i.e., a rebuttal showing regarding the status of a prior SNF
stay is made at the time that an inpatient claim is submitted and/or at the reconsideration level). Evaluate
rebuttal documentation even if the presumption being rebutted was triggered by a Medicaid denial. Decisions
under presumptions 5 through 7 require the A/B MAC (A) to send a notice to advise the beneficiary of the
basis for the determination and the right to present evidence to rebut the determination on reconsideration.
Presumption 6 can be rebutted because the Medicare skilled level of care definition for coverage purposes is
broader than the skilled level of care definition used here for benefit period determinations. For example,
prior hospital care related to the SNF care is included in the Medicare SNF coverage requirements but is not
included in the standard for benefit period determinations. Therefore, Medicare payment could have been
denied for an SNF stay because of noncompliance with that requirement, even though skilled level of care
requirements for benefit period determinations were in fact met by the SNF stay. Consequently, when
Medicare SNF payment is denied, the beneficiary must be given the opportunity to demonstrate that he/she
still needed and received a skilled level of care for purposes of benefit period determinations to extend a
benefit period if this would be to the beneficiary's advantage.
NOTE: Effective October 1, 1990, the levels of care that were previously covered separately under the
Medicaid SNF and intermediate care facility (ICF) benefits are combined in a single Medicaid nursing facility
(NF) benefit. Thus, the Medicaid NF benefit includes essentially the same type of skilled care covered by
Medicare's SNF benefit, but it includes less intensive care as well. This means that when a person is found
not to require at least a Medicaid NF level of care (as under Presumption 4), it can be presumed that he or she
also does not meet the Medicare skilled level of care standards. However, since the NF benefit can include
care that is less intensive than Medicare SNF care, merely establishing that a person does require NF level
care does not necessarily mean that he or she also meets the Medicare skilled level of care standards.
Determining whether an individual who requires NF level care also meets the Medicare skilled level of care
standards requires an actual examination of the medical evidence and cannot be accomplished through the
simple use of a presumption.
Medicare no payment bills submitted by an SNF result in Medicare program payment determinations (i.e.,
denials). Therefore, such no payment bills trigger the appropriate presumptions. This also applies in any
State where the Medicaid program utilizes no payment bills which lead to Medicaid program payment
determinations. If an SNF erroneously fails to submit a Medicare claim (albeit a no-pay claim) when
Medicare rules require such submission, request compliance. Once the no-pay bill is submitted and denied,
the applicable presumption (other than presumption 7) is triggered. If a patient is moving from a SNF level of
care to a non-SNF level of care in a facility certified to provide SNF care, occurrence code 22 (date active care
ended) is used to signify the beginning of the no-pay period on the bill and trigger the appropriate
presumptions.
Some of the presumptions require knowledge of Medicaid's claims processing involvement with the prior
claim. The A/B MAC (A) uses current bill data, accompanying documentation, bill history files, and
telephone contacts with the prior stay facility and/or the Medicaid agency to develop the Medicaid aspects. It
does not continue Medicaid development beyond a telephone contact. It concludes its consideration of the
presumption at this point based upon the Medicaid information available.
10.4 - Payment of Nonphysician Services for Inpatients
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of
ICD-10, Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: September, 23 2014)
All items and nonphysician services furnished to inpatients must be furnished directly by the hospital or billed
through the hospital under arrangements. This provision applies to all hospitals, regardless of whether they
are subject to PPS.
A. - Other Medical Items, Supplies, and Services
The following medical items, supplies, and services furnished to inpatients are covered under Part A.
Consequently, they are covered by the prospective payment rate or reimbursed as reasonable costs under Part
A to hospitals excluded from PPS.
• Laboratory services (excluding anatomic pathology services and certain clinical pathology services);
• Pacemakers and other prosthetic devices including lenses, and artificial limbs, knees, and hips;
• Radiology services including computed tomography (CT) scans furnished to inpatients by a
physician's office, other hospital, or radiology clinic;
• Total parenteral nutrition (TPN) services; and
• Transportation, including transportation by ambulance, to and from another hospital or freestanding
facility to receive specialized diagnostic or therapeutic services not available at the facility where the
patient is an inpatient.
The hospital must include the cost of these services in the appropriate ancillary service cost center, i.e., in the
cost of the diagnostic or therapeutic service. It must not show them separately under revenue code 0540.
EXCEPTIONS:
• Pneumococcal Vaccine - is payable under Part B only and is billed by the hospital using the ASC X12
837 institutional claim format or on the Form CMS-1450.
• Ambulance Service - For purposes of this section "hospital inpatient" means a beneficiary who has
been formally admitted it does not include a beneficiary who is in the process of being transferred
from one hospital to another. Where the patient is transferred from one hospital to another, and is
admitted as an inpatient to the second, the ambulance service is payable under only Part B. If
transportation is by a hospital owned and operated ambulance, the hospital bills separately using the
ASC X12 837 institutional claim format or on Form CMS-1450 as appropriate. Similarly, if the
hospital arranges for the ambulance transportation with an ambulance operator, including paying the
ambulance operator, it bills separately. However, if the hospital does not assume any financial
responsibility, the billing is to the A/B MAC (B) by the ambulance operator or beneficiary, as
appropriate, if an ambulance is used for the transportation of a hospital inpatient to another facility for
diagnostic tests or special treatment the ambulance trip is considered part of the DRG, and not
separately billable, if the resident hospital is under PPS.
• Part B Inpatient Services - Where Part A benefits are not payable, payment may be made to the
hospital under Part B for certain medical and other health services. See Chapter 4 for a description of
Part B inpatient services.
• Anesthetist Services "Incident to" Physician Services - If a physician's practice was to employ
anesthetists and to bill on a reasonable charge basis for these services and that practice was in effect as
of the last day of the hospital's most recent 12-month cost reporting period ending before September
30, 1983, the physician may continue that practice through cost reporting periods beginning October 1,
1984. However, if the physician chooses to continue this practice, the hospital may not add costs of
the anesthetist’s service to its base period costs for purposes of its transition payment rates. If it is the
existing or new practice of the physician to employ certified registered nurse anesthetists (CRNAs) and
other qualified anesthetists and include charges for their services in the physician bills for
anesthesiology services for the hospital's cost report periods beginning on or after October 1, 1984, and
before October 1, 1987, the physician may continue to do so.
B. - Exceptions/Waivers
These provisions were waived before cost reporting periods beginning on or after October 1, 1986, under
certain circumstances. The basic criteria for waiver was that services furnished by outside suppliers are so
extensive that a sudden change in billing practices would threaten the stability of patient care. Specific criteria
for waiver and processing procedures are in §2804 of the Provider Reimbursement Manual (CMS Pub. 15-1).
10.5 - Hospital Inpatient Bundling
(Rev. 668, Issued: 09-02-05; Effective: Ambulance claims received on or after January 3, 2006, and 4
years after initial determination for adjustments; Implementation: 01-03-06)
Hospital bundling rules exclude payment to independent suppliers of ambulance services for beneficiaries in a
hospital inpatient stay. The Common Working File (CWF) performs reject edits to incoming claims from
independent suppliers of ambulance services. The CWF searches paid claim history and compares the line
item service date on an ambulance claim to the admission and discharge dates on a hospital inpatient stay. The
CWF rejects the line item when the ambulance line item service date falls within the admission and discharge
dates on a hospital inpatient claim. Based on CWF rejects, the A/B MAC (B) must deny line items for
ambulance services billed by independent suppliers that should be bundled to the hospital.
Upon receipt of a hospital inpatient claim, CWF searches paid claim history and compares the period between
the hospital inpatient admission and discharge dates to the line item service date on an ambulance claim billed
by an independent supplier. The CWF shall generate an unsolicited response when the line item service date
falls within the admission and discharge dates of the hospital inpatient claim.
Upon receipt of the unsolicited response, the A/B MAC (B) shall adjust the ambulance claim and recoup the
payment.
Ambulance services with a date of service that is the same as the admission or discharge date on an inpatient
claim are separately payable and not subject to the bundling rules.
The CWF performs an additional edit before determining if the ambulance line item should be rejected when
the beneficiary is an inpatient of a long term care facility (LTCH), inpatient psychiatric facility (IPF) or
inpatient rehabilitation facility (IRF) and is transported via ambulance to an acute care hospital to receive
specialized services. The CWF edits the claim for the presence of occurrence span code 74 (non-covered level
of care) and the associated occurrence span code from and through dates. The CWF bypasses the reject edit
when the ambulance line item service date falls within the occurrence span code 74 from and through dates
plus one day. In this case, the ambulance line item is separately payable. The CWF rejects the ambulance line
item when the service date falls outside the occurrence span code 74 from and through dates plus one day.
20 - Payment Under Prospective Payment System (PPS) Diagnosis Related Groups
(DRGs)
(Rev. 10210, Issued: 07-10-2020, Effective: 08-10-2020 , Implementation: 08-10-2020)
A. - General
The Social Security Amendments of 1983 (P.L. 98-21) provided for establishment of a prospective payment
system (PPS) for Medicare payment of inpatient hospital services. (See §20.4 for corresponding information
for PPS capital payments and computation of capital and operating outliers for FY 1992.) Under PPS,
hospitals are paid a predetermined rate per discharge for inpatient hospital services furnished to Medicare
beneficiaries. Each type of Medicare discharge is classified according to a list of DRGs. These amounts are,
with certain exceptions, payment in full to the hospital for inpatient operating costs. Beneficiary cost-sharing
is limited to statutory deductibles, coinsurance, and payment for noncovered items and services. Section 4003
of OBRA of 1990 (P.L. 101-508) expands the definition of inpatient operating costs to include certain
preadmission services. (See §40.3.)
The statute excludes children's hospitals and cancer hospitals, hospitals located outside the 50 States. In
addition to these categorical exclusions, the statute provides other special exclusions, such as hospitals that are
covered under State reimbursement control systems. These excluded hospitals and units are paid on the basis
of reasonable costs subject to the target rate of increase limits.
In accordance with Section 1814 (b) (3) of the Act, services provided by hospitals in Maryland subject to the
Health Services Cost Review Commission (provider numbers 21000-21099) are paid at a lower percentage
rate (plus adjustments for sequestration when applicable) instead of determining the payment amount of the
claim through the Inpatient Prospective Payment System (IPPS) or the Outpatient Prospective Payment
System (OPPS).
For discharges occurring on or after April 1, 1988, separate standardized payment amounts are established for
large urban areas and rural areas. Large urban areas are urban areas with populations of more than 1,000,000
as determined by the Secretary of HHS on the basis of the most recent census population data. In addition,
any New England County Metropolitan Area (NECMA) with a population of more than 970,000 is a large
urban area.
The OBRA 1987 required payment of capital costs under PPS effective with cost reporting periods that began
October 1, 1991, or later. A 10-year transition period was provided to protect hospitals that had incurred
capital obligations in excess of the standardized national rate from major disruption. High capital cost
hospitals are known as "hold harmless" hospitals. The transition period also provides for phase-in of the
national Federal capital payment rate for hospitals with capital obligations that are less than the national rate.
New hospitals that open during the transition period are exempt from capital PPS payment for their first 2
years of operation. Hospitals and hospital distinct part units that are excluded from PPS for operating costs
are also excluded from PPS for capital costs.
Capital payments are based on the same DRG designations and weights, outlier guidelines, geographic
classifications, wage indexes, and disproportionate share percentages that apply to operating payments under
PPS. The indirect teaching adjustment is based on the ratio of residents to average daily census. The hospital
split bill, adjustment bill, waiver of liability and remaining guidelines that have historically been applied to
operating payments also apply to capital payments under PPS.
B. - Hospitals and Units Excluded
The following hospitals and distinct part hospital units (DPU) are excluded from PPS and are paid on a
reasonable cost or other basis:
• Pediatric hospitals whose inpatients are predominately under the age of 18.
Hospitals located outside the 50 States.
• Hospitals participating in a CMS-approved demonstration project or State payment control system.
• Nonparticipating hospitals furnishing emergency services have not been affected by the PPS statute
(P.L. 97-21). They are paid under their existing basis.
C. - Situations Requiring Special Handling
1. Sole community hospitals are paid in accordance with the methods used to establish the operating
prospective rates for the first year of the PPS transition for operating costs. The appropriate percentage of
hospital-specific rate and the Federal regional rate is applied by the Pricer program in accordance with the
current values for the appropriate fiscal year.
2. Hospitals have the option to continue to be reimbursed on a reasonable cost basis subject to the target
ceiling rate or to be reimbursed under PPS if the following are met:
• Recognized as of April 20, 1983, by the National Cancer Institute as comprehensive cancer
centers or clinical research centers;
• Demonstrating that the entire facility is organized primarily for treatment of, and research on,
cancer; and
• Having a patient population that is at least 50 percent of the hospital's total discharges with a
principal diagnosis of neoplastic disease.
The hospital makes this decision at the beginning of its fiscal year. The choice continues until the hospital
requests a change. If it selects reasonable cost subject to the target ceiling, it can later request PPS. No
further option is allowed.
3. Regional and national referral centers within short-term acute care hospital complexes. Rural hospitals that
meet the criteria have their prospective rate determined on the basis of the urban, rather than the rural,
adjusted standardized amounts, as adjusted by the applicable DRG weighting factor and the hospital's area
wage index.
4. Hospitals in Alaska and Hawaii have the nonlabor related portion of the wage index adjusted by their
appropriate cost-of-living factor. These calculations are made by the Pricer program and are included in the
Federal portion of the rate.
5. Kidney, heart, and liver acquisition costs incurred by approved transplant centers are treated as an
adjustment to the hospital's payments. These payments are adjusted in each cost reporting period to
compensate for the reasonable expenses of the acquisition and are not included in determining prospective
payment.
6. Religious nonmedical health care institutions are paid on the basis of a predetermined fixed amount per
discharge. Payment is based on the historical inpatient operating costs per discharge and is not calculated by
Pricer.
7. Transferring hospitals with discharges assigned to MS-DRG 789 (neonates, died or transferred to another
acute care facility) have their payments calculated by the Pricer program on the same basis as those receiving
the full prospective payment. They are also eligible for cost outliers.
8. Nonparticipating hospitals furnishing emergency services are not included in PPS.
9. Veterans Administration (VA) hospitals are generally excluded from participation. Where payments are
made for Medicare patients, the payments are determined in accordance with 38 U.S.C. 5053(d).
10. A hospital that loses its urban area status as a result of the Executive Office of Management and Budget
redesignation occurring after April 20, 1983, may qualify for special consideration by having its rural Federal
rate phased-in over a 2-year period. The hospital will receive, in addition to its rural Federal rate in the first
cost reporting period, two-thirds of the difference between its rural Federal rate and the urban Federal rate that
would have been paid had it retained its urban status. In the second reporting period, one-third of the
difference is applied. The adjustment is applied for two successive cost reporting periods beginning with the
cost-reporting period in which CMS recognizes the reclassification.
11. The payment per discharge under the PPS for hospitals in Puerto Rico is the sum of:
• 50 percent of the Puerto Rico discharge weighted urban or rural standardized rate.
• 50 percent of the national discharge weighted standardized rate.
(The special treatment of referral centers and sole community hospitals does not apply to prospective payment
hospitals in Puerto Rico.)
There are special criteria that facilities must meet in order to obtain approval for payment for heart transplants
and special processing procedures for these bills. (See §90.2.) Facilities that wish to obtain coverage of heart
transplants for their Medicare patients must submit an application and documentation showing their initial and
ongoing compliance with the criteria. For facilities that are approved, Medicare covers under Part A all
medically reasonable and necessary inpatient services.
12. Hospitals with high percentage of ESRD discharges may qualify for additional payment. These payments
are handled as adjustments to cost reports.
13. Exception payments are provided for hospitals with inordinately high levels of capital obligations. They
will expire at the end of the 10-year transition period. Exception payments ensure that for FY 1992 and FY
1993:
• Sole community hospitals receive 90 percent of Medicare inpatient capital costs:
• Urban hospitals with 100 or more beds and a disproportionate share patient percentage of at least 20.2
percent receive 80 percent of their Medicare inpatient capital costs; and
• All other hospitals receive 70 percent of their Medicare inpatient capital costs.
A limited capital exception payment is also provided during the 10-year capital transition period for hospitals
that experience extraordinary circumstances that require an unanticipated major capital expenditure. Events
such as a tornado, earthquake, catastrophic fire, or a hurricane are examples of extraordinary circumstances.
The capital project must cost at least $5 million to qualify for this exception.
D. - MS-DRG Classification
The MS-DRGs (Medicare Severity DRGs) are a patient classification system which provides a means of
relating types of patients a hospital treats (i.e., its case mix) to the costs incurred by the hospital. Payment for
inpatient hospital services is made on the basis of a rate per discharge that varies according to the MS-DRG to
which a beneficiary's stay is assigned. All inpatient transfer/discharge bills from both PPS and non-PPS
facilities, including those from waiver States, long-term care facilities, and excluded units are classified by the
Grouper software program into one of 745 diagnosis related groups (DRGs).
The following MS-DRGs receive special attention:
• MS-DRGs No. 981-983 - Represent discharges with valid data, but the surgical procedure is unrelated
to the principal diagnosis. MS-DRGs 981 (Extensive O.R. Procedure Unrelated to the Principal Diagnosis w/
MCC), 982 (Extensive O.R. Procedure Unrelated to the Principal Diagnosis w/ CC), and 983 (Extensive O.R.
Procedure Unrelated to the Principal Diagnosis w/o CC/MCC) each have relative weights assigned to them
and will be paid. The hospital must review the record on each of these MS-DRGs in the remittance record and
determine that where either the principle diagnosis or surgical procedure was reported incorrectly, prepare an
adjustment bill. The A/B MAC (A) may elect to avoid the adjustment bill by returning the bill to the hospital
prior to payment.
• MS-DRG No. 998 - Represents a discharge reporting a principle diagnosis that is invalid as a principal
diagnosis. Examples include a diagnosis of diabetes mellitus or an infection of the genitourinary tract during
pregnancy, both unspecified as to episode of care. These diagnoses may be valid, but they are not sufficient to
determine the principal diagnosis for MS-DRG assignment purposes. A/B MACs (A) will return the claims.
The hospital must enter the corrected principal diagnosis for proper MS-DRG assignment and resubmit the
claim.
• MS-DRG No. 999 - Represents a discharge with invalid data, making it ungroupable. A/B MACs (A)
return the claims for correction of data elements affecting proper MS-DRG assignment. The hospital
resubmits the corrected claim.
When the bills are processed in conjunction with the MCE (see §20.2.1) coding inconsistencies in the
information and data are identified.
The MCE must be run before Grouper to identify inconsistencies before the bills are processed through the
Grouper.
E. - Difference in Age/Admission Versus Discharge
HO-415.4
When a beneficiary's age changes between the date of admission and date of discharge, the DRG and related
payment amount are determined from the patient's age at admission.
20.1 - Hospital Operating Payments Under PPS
(Rev. 1816; Issued: 09-17-09; Effective Date: Discharges on or after October 1, 2009; Implementation
Date: 10-05-09)
Section 1886(d) of the Social Security Act (the Act) sets forth a system of payment for the operating costs of
acute care hospital inpatient stays under Medicare Part A (Hospital Insurance) based on prospectively set
rates. Under the PPS, Medicare payment for hospital inpatient operating costs is made at predetermined,
specific rates for each hospital discharge. Discharges are classified according to a list of diagnosis-related
groups (DRGs).
The base payment rate is comprised of a standardized amount that is divided into a labor-related share and a
nonlabor-related share. The labor-related share is adjusted by the wage index applicable to the area where the
hospital is located; and if the hospital is located in Alaska or Hawaii, the nonlabor-related share is adjusted by
a cost-of-living adjustment factor. This base payment rate is multiplied by the DRG relative weight.
If the hospital treats a high percentage of low-income patients, it receives a percentage add-on payment
applied to the DRG-adjusted base payment rate. This add-on payment, known as the disproportionate share
hospital (DSH) adjustment, provides for a percentage increase in Medicare payments to hospitals that qualify
under statutory formulas designed to identify hospitals that serve a disproportionate share of low-income
patients. For qualifying hospitals, the amount of this adjustment may vary based on the outcome of the
statutory calculations.
If the hospital is an approved teaching hospital, it receives a percentage add-on payment for each case paid
under the PPS (known as the indirect medical education (IME) adjustment). This percentage varies, depending
on the ratio of residents to beds.
Additional payments may be made for cases that involve new technologies that have been approved for
special add-on payments. To qualify, a new technology must demonstrate that it is a substantial clinical
improvement over technologies otherwise available, and that, absent an add-on payment, it would be
inadequately paid under the regular DRG payment.
The costs incurred by the hospital for a case are evaluated to determine whether the hospital is eligible for an
additional payment as an outlier case. This additional payment is designed to protect the hospital from large
financial losses due to unusually expensive cases. Any outlier payment due is added to the DRG-adjusted base
payment rate, plus any DSH, IME, and new technology add-on adjustments.
Although payments to most hospitals under the PPS are made on the basis of the standardized amounts, some
categories of hospitals are paid based on the higher of a hospital-specific rate determined from their costs in a
base year as specified in the statute, or the PPS rate based on the standardized amount. For example, sole
community hospitals (SCHs) are the sole source of care in their areas, and small rural Medicare-dependent
hospitals (MDHs) are a major source of care for Medicare beneficiaries in their areas. Both of these categories
of hospitals are afforded this special payment protection in order to maintain access to services for
beneficiaries (although the statutory payment formulas for SCHs and MDHs differ as described below in
section 20.6).
The existing regulations governing payments to hospitals under the PPS are located in 42 CFR Part 412,
Subparts A through M.
20.1.1 - Hospital Wage Index
(Rev. 70, 01-23-04)
Section 1886(d)(3)(E) of the Act requires that, as part of the methodology for determining prospective
payments to hospitals, the Secretary must adjust the standardized amounts “for area differences in hospital
wage levels by a factor (established by the Secretary) reflecting the relative hospital wage level in the
geographic area of the hospital compared to the national average hospital wage level.” This adjustment factor
is the wage index. CMS defines hospital geographic areas (labor market areas) based on the definitions of
urban (e.g., Metropolitan Statistical Areas (MSAs)) and rural areas issued by the Office of Management and
Budget.
The Act further requires the wage index to be updated annually, based on a survey of wages and wage-related
costs of short-term, acute care hospitals. These data are collected on Worksheet S-3, Parts II and III of the
Medicare Cost Report (Form CMS-2552). To ensure the accuracy of the wage index, fiscal intermediaries are
required to perform annual desk reviews of hospitals’ wage data. CMS also publishes the wage data, and
allows hospitals an opportunity to review and request corrections to the data, before the wage index is
finalized.
In computing the wage index, CMS derives an average hourly wage for each labor market area (total wage
costs divided by total hours for all hospitals in the geographic area) and a national average hourly wage (total
wage costs divided by total hours for all hospitals surveyed in the nation). A labor market area’s wage index
value is the ratio of the area’s average hourly wage to the national average hourly wage. If a labor market
area’s average hourly wage is greater than the national average, the area’s wage index value will be greater
than 1.0000. If an area’s average hourly wage is less than the national average, the area’s wage index value
will be less than 1.0000. The wage index adjustment factor is applied only to the labor portion of the
standardized amounts.
Section 4410 of Public Law 105-33 provides that, for discharges on or after October 1, 1997, the area wage
index value applicable to any hospital that is located in an urban area may not be less than the area wage index
value applicable to hospitals located in rural areas in that State. Furthermore, this wage index floor is to be
implemented in such a manner as to ensure that aggregate prospective payment system payments are not
greater or less than those that would have been made in the year if this section did not apply.
20.1.2 - Outliers
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of
ICD -10, Implementation: ICD -10: Upon Implementation of ICD -10, ASC X12: September, 23 2014)
§1886(d)(5)(A) of the Act provides for Medicare payments to Medicare-participating hospitals in addition to
the basic prospective payments for cases incurring extraordinarily high costs. This additional payment known
as an “Outlier” is designed to protect the hospital from large financial losses due to unusually expensive cases.
To qualify for outlier payments, a case must have costs above a fixed-loss cost threshold amount (a dollar
amount by which the costs of a case must exceed payments in order to qualify for outliers), which is published
in the annual Inpatient Prospective Payment System final rule. The regulations governing payments for
operating costs under the IPPS are located in 42 CFR Part 412. The specific regulations governing payments
for outlier cases are located at 42 CFR 412.80 through 412.86.
The actual determination of whether a case qualifies for outlier payments is made by the Medicare contractor
using Pricer, which takes into account both operating and capital costs and Medicare severity-diagnostic
related group (MS-DRG) payments. That is, the combined operating and capital costs of a case must exceed
the fixed loss outlier threshold to qualify for an outlier payment. The operating and capital costs are computed
separately by multiplying the total covered charges by the operating and capital cost-to-charge ratios. The
estimated operating and capital costs are compared with the fixed-loss threshold after dividing that threshold
into an operating portion and a capital portion (by first summing the operating and capital ratios and then
determining the proportion of that total comprised by the operating and capital ratios and applying these
percentages to the fixed-loss threshold). The thresholds are also adjusted by the area wage index (and capital
geographic adjustment factor) before being compared to the operating and capital costs of the case. Finally,
the outlier payment is based on a marginal cost factor equal to 80 percent of the combined operating and
capital costs in excess of the fixed-loss threshold (90 percent for burn MS-DRGs). Any outlier payment due is
added to the MS-DRG adjusted base payment rate, plus any DSH, IME and new technology add-on payment.
For a more detailed explanation on the calculation of outlier payments, visit the CMS Web site at
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html
The Medicare contractor may choose to review outliers if data analysis deems it a priority.
The IPPS outliers are not applicable to non-PPS hospitals. The Pricer program makes all outlier
determinations except for the medical review determination. Outlier payments apply only to the Federal
portion of a capital PPS payment.
20.1.2.1 - Cost to Charge Ratios
(Rev. 4390, Issued: 09-06-19, Effective: 10-01-19, Implementation: 10-07-19)
For discharges before August 8, 2003, Medicare contractors used the latest final settled cost report to
determine a hospital’s cost-to-charge ratios (CCRs). For those hospitals that met the criteria in part I. A. of
PM A-03-058 (July 3, 2003), effective for discharges occurring on or after August 8, 2003 Medicare
contractors are to use alternative CCRs rather than one based on the latest settled cost report when
determining a hospital’s CCR (to download PM A-03-058, visit our Web site at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/CMS-Program-Memoranda.
http://www.cms.hhs.gov/Transmittals/Downloads/A03058.pdf). For all other hospitals, effective October 1,
2003, Medicare contractors are to use CCRs from the latest final settled cost report or from the latest tentative
settled cost report (whichever is from the later period) to determine a hospital’s operating and capital CCRs.
A. - Calculating a Cost-to-Charge Ratio
For IPPS outlier calculations, Medicare’s portion of hospital costs is determined by using hospital specific
cost-to-charge ratios (CCRs). At the end of the cost reporting period, the hospital prepares and submits a cost
report to its Medicare contractor, which includes Medicare allowable costs and charges. The Medicare
contractor completes a preliminary review of the as-submitted cost report and issue a tentative settlement.
The cost report is later final settled, which may be based on a subsequent review, and an NPR is issued.
The Medicare contractor shall update the PSF using the CCR calculated from the final settled cost report or
from the latest tentative settled cost report (whichever is from the later period).
Effective November 7, 2005, the following methodology shall be used to calculate a hospital’s operating and
capital CCRs.
Inpatient PPS Operating CCR
1) Identify total Medicare inpatient operating costs from the Medicare cost report, from Worksheet D-1,
Part II, line 53. (If a positive amount is reported on line 42 for nursery costs, subtract this amount on line 42
from the amount on line 53).
2) Identify total Medicare inpatient operating charges (the sum of routine and ancillary charges), from
Worksheet D-4, column 2, the sum of lines 25 through 30 and line 103.
3) Determine the Inpatient PPS operating CCR by dividing the amount in step 1 by the amount in step 2.
Inpatient Capital CCR
1) Identify total Medicare inpatient capital cost from Worksheet D Part 1, column 10, sum of lines 25
through 30, plus column 12, sum of lines 25 through 30 plus Medicare inpatient ancillary capital costs from
Worksheet D Part II, column 6, line 101 plus column 8 line 101.
2) Identify total Medicare inpatient capital charges (the sum of routine and ancillary charges), from
Worksheet D-4, column 2, the sum of lines 25 through 30 and line 103.
3) Determine the Inpatient PPS capital CCR by dividing the amount in step 1 by the amount in step 2.
B. - Use of Alternative Data in Determining CCRs For Hospitals
Effective August 8, 2003, the CMS Central Office may direct Medicare contractors to use an alternative CCR
if CMS believes this will result in a more accurate CCR. Also, if the Medicare contractor finds evidence that
indicates that using data from the latest settled or tentatively settled cost report would not result in the most
accurate CCR, then the Medicare contractor shall notify the CMS Regional Office and CMS Central Office to
seek approval to use a CCR based on alternative data. For example, CCRs may be revised more often if a
change in a hospital’s operations occurs which materially affects a hospital’s costs and/or charges. The CMS
Regional Office, in conjunction with the CMS Central Office, must approve the Medicare contractor’s request
before the Medicare contractor may use a CCR based on alternative data. Revised CCRs will be applied
prospectively to all IPPS claims processed after the update. Medicare contractors shall send notification to the
Central Office via email at [email protected].
C. - Ongoing CCR Updates Using CCRs From Tentative Settlements For Hospitals Subject to the IPPS
The Medicare contractor shall continue to update a hospital’s operating and capital CCRs (in the Provider
Specific File) each time a more recent cost report is settled (either final or tentative). Revised CCRs shall be
entered into the Provider Specific File not later than 30 days after the date of the latest settlement used in
calculating the CCRs.
Subject to the approval of CMS, a hospital’s operating and/or capital CCR may be revised more often if a
change in a hospital’s operations occurs which materially affects a hospital’s costs or charges. A revised CCR
will be applied prospectively to all hospital claims processed after the update.
D. - Request for use of a Different CCR by CMS, the Medicare Contractor or the Hospital
Effective August 8, 2003, CMS (or the Medicare contractor) may specify an alternative CCR if it believes that
the CCR being applied is inaccurate. In addition, a hospital will have the opportunity to request that a
different CCR be applied in the event it believes the CCR being applied is inaccurate. The hospital is required
to present substantial evidence supporting its request. Such evidence should include documentation regarding
its costs and charges that demonstrate its claim that an alternative ratio is more accurate. After the Medicare
contractor has evaluated the evidence presented by the hospital, the Medicare contractor notifies the CMS
regional office and CMS Central Office of any such request. The CMS Regional Office, in conjunction with
the CMS Central Office, will approve or deny any request by the hospital or Medicare contractor for use of a
different CCR. Medicare contractors shall send requests to the CMS Central Office via email at
[email protected].
E. - Notification to Hospitals Under the IPPS of a Change in the CCR
The Medicare contractor shall notify a hospital whenever it makes a change to its CCR. When a CCR is
changed as a result of a tentative settlement or a final settlement, the change to the CCR can be included in the
notice that is issued to each provider after a tentative or final settlement is completed. Medicare contractors
can also issue separate notification to a hospital about a change to their CCR(s).
F. - Hospital Mergers, Conversions, and Errors with CCRs
Effective November 7, 2005, for hospitals that merge, Medicare contractors shall continue to use the operating
and capital CCRs calculated from the Medicare cost report associated with the surviving provider number. If
a new provider number is issued, as explained in §20.1.2.2 below, Medicare contractors may use the
Statewide average CCR because a new provider number indicates the creation of a new hospital (as stated in
42 CFR 412.84 (i)(3)(i), a new hospital is defined as an entity that has not accepted assignment of an existing
hospital’s provider agreement). For non-IPPS hospitals (e.g., long term care, psychiatric, or rehabilitation
hospitals) that convert to IPPS status, or IPPS hospitals that maintain their IPPS status but receive a new IPPS
provider number the Statewide average CCR may be applied to that hospital. However, as noted in part C
above, the Medicare contractor or the hospital may request use of a different CCR, such as a CCR based on
the cost and charge data from the hospital’s cost report before it converted to IPPS status, or received a new
provider number. The Medicare contractor must verify the cost and charge data from that cost report. Use of
the alternative CCR is subject to the approval of the CMS Central and Regional Offices.
In instances where errors related to CCRs and/or outlier payments are discovered, Medicare contractors shall
contact the CMS Central Office to seek further guidance. Medicare contractors may contact the CMS Central
Office via email at [email protected].
If a cost report is reopened after final settlement and as a result of this reopening there is a change to the CCR,
Medicare contractors should contact the CMS Regional and Central Office for further instructions. Medicare
contractors may contact the CMS Central Office via email at [email protected].
G. - Maintaining a History of CCRs and Other Fields in the Provider Specific File
When reprocessing claims due to outlier reconciliation, Medicare contractors shall maintain an accurate
history of certain fields in the provider specific file (PSF). This history is necessary to ensure that claims
already processed (from prior cost reporting periods that have already been settled) will not be subject to a
duplicate systems adjustment in the event that claims need to be reprocessed. As a result, the following fields
in the PSF can only be altered on a prospective basis: -23 -Intern to Bed Ratio -24 --Bed Size -25 -Operating
Cost to Charge Ratio -27 -SSI Ratio -28 -Medicaid Ratio -47 -Capital Cost to Charge Ratio 49 -Capital IME
and 21 -Case Mix Adjusted Cost Per Discharge. A separate history outside of the PSF is not necessary. The
only instances a Medicare contractor retroactively changes a field in the PSF is to update the operating or
capital CCR when using the FISS Lump Sum Utility for outlier reconciliation or otherwise specified by the
CMS Regional Office or Central Office.
20.1.2.2 - Statewide Average Cost-to-Charge Ratios
(Rev. 2111, Issued: 12-03-10, Effective: 04-01-11, Implementation: 04-04-11)
For discharges prior to August 8, 2003, Statewide average CCRs are used in those instances in which a
hospital’s operating or capital CCRs fall above or below reasonable parameters. CMS sets forth these
parameters and the Statewide average CCRs in each year’s annual notice of prospective payment rates.
For discharges occurring on or after August 8, 2003, the Medicare contractor may use a Statewide average
CCR if it is unable to determine an accurate operating or capital CCR for a hospital in one of the following
circumstances:
1. New hospitals that have not yet submitted their first Medicare cost report. (For this purpose, a new
hospital is defined as an entity that has not accepted assignment of an existing hospital’s provider
agreement in accordance with 42 CFR 489.18.)
2. Hospitals whose operating or capital CCR is in excess of 3 standard deviations above the
corresponding national geometric mean. This mean is recalculated annually by CMS and published in
the annual notice of prospective payment rates issued in accordance with § 412.8(b) of the CFR.
3. Other hospitals which accurate data with which to calculate either an operating or capital CCR (or
both) are not available.
However, the policies of §20.1.2.1 part C and part E can be applied as an alternative to the Statewide average.
For those hospitals assigned the Statewide average operating and/or capital CCRs, these CCRs must be
updated every October 1 based on the latest Statewide average CCRs published in each year’s annual notice of
prospective payment rates until the hospital is assigned a CCR based on the latest tentative or final settled cost
report or a CCR based on the policies of §20.1.2.1 part C of this manual.
A hospital is not assigned the Statewide average CCR if its CCR falls below 3 standard deviations from the
national mean CCR. In such a case, the hospital’s actual operating or capital CCR is used.
20.1.2.3 - Threshold and Marginal Cost
(Rev. 2111, Issued: 12-03-10, Effective: 04-01-11, Implementation: 04-04-11)
The Medicare contractor, using Pricer, determines an appropriate additional payment for inpatient services
where hospital charges for covered services furnished to the beneficiary, adjusted for cost, are extraordinarily
high. CMS annually determines, and includes in the annual IPPS Final Rule and in Pricer, the threshold
beyond which a cost outlier is paid. The additional payment amount is the difference between the estimated
cost for the discharge (determined by multiplying the hospital specific CCR by the hospital’s charges for the
discharge) and the threshold criteria established for the applicable DRG multiplied by a marginal cost factor of
80 percent. (The marginal cost factor for burn cases is 90 percent, as described in §20.1.2.8.) CMS includes
the marginal cost factor in Pricer. For more explanation on the calculation of outliers visit our Web site at
http://www.cms.hhs.gov/AcuteInpatientPPS/04_outlier.asp#TopOfPage
20.1.2.4 - Transfers
(Rev. 2111, Issued: 12-03-10, Effective: 04-01-11, Implementation: 04-04-11)
A. Transfers Between IPPS Hospitals
For transfers between IPPS hospitals, the transferring hospital is paid based upon a per diem rate. The
transferring hospital may be paid a cost outlier payment. The outlier threshold for the transferring hospital is
equal to the outlier threshold for non-transfer cases, divided by the geometric mean length of stay for the
DRG, multiplied by a number equal to the length of stay for the case plus one day.
The payment to the final discharging hospital is made at the full prospective payment rate. The outlier
threshold and payment are calculated the same as any other discharge without a transfer. For further
information on transfers between IPPS hospitals, see §40.2.4 part A of this manual.
B. - Transfers from an IPPS Hospital to Hospitals or Units Excluded from IPPS that do not Fall within
a DRG that is Subject to the Postacute Care Transfer Policy
For transfers from an IPPS hospital to a hospital or unit excluded from IPPS with a DRG that is not subject to
the postacute care transfer policy, the transferring hospital is paid the full IPPS rate. The transferring hospital
may be paid a cost outlier payment. The outlier threshold and payment are calculated the same as any other
discharge without a transfer.
The payment to the final discharging hospital or unit is made at the rate of its respective payment system. For
further information on transfers from an IPPS hospital to hospitals or units excluded from IPPS that do not fall
within a DRG that is subject to the postacute care transfer policy, see §40.2.4 part B of this manual.
C. - Transfers from an IPPS Hospital to Hospitals or Units Excluded from IPPS that Fall within a DRG
that is Subject to the Postacute Care Transfer Policy
For transfers from an IPPS hospital to a hospital or unit excluded from IPPS with a DRG that is subject to the
postacute care transfer policy, the transferring hospital is paid based upon a per diem rate. The transferring
hospital may be paid a cost outlier payment. In general, the outlier threshold for the transferring hospital is
equal to the outlier threshold for non-transfer cases, divided by the geometric mean length of stay for the
DRG, multiplied by a number equal to the length of stay for the case plus one day. If a discharge is assigned
to a special pay DRG subject to the post acute care transfer policy the outlier threshold is equal to the fixed-
loss cost outlier threshold for non-transfer cases, divided by the geometric mean length of stay for the DRG,
multiplied by 0.5 plus the product of the 0.5 multiplied by a number equal to the length of stay plus one day
multiplied by 0.5.
The payment to the final discharging hospital or unit is made at the rate of its respective payment system. For
further information on transfers from an IPPS hospital to hospitals or units excluded from IPPS that fall within
a DRG subject to the postacute care transfer policy, see §40.2.4 part C and D.
20.1.2.5 - Reconciliation
(Rev. 4390, Issued: 09-06-19, Effective: 10-01-19, Implementation: 10-07-19)
A. - General
Under 42 CFR §412.84(i)(4), for discharges occurring on or after August 8, 2003, high cost outlier payments
may be reconciled upon cost report settlement to account for differences between the CCR used to pay the
claim at its original submission by the provider, and the CCR determined at final settlement of the cost
reporting period during which the discharge occurred. This new regulation was implemented in two phases
(further explanation on these two phases is provided below). Hospitals that Medicare contractors identified
using the criteria in §I.A. of PM A-03-058 (under which Medicare contractors identified hospitals whose
charges appeared to have been increasing at an excessive rate) are subject to the reconciliation policies
described in this section for discharges occurring on or after August 8, 2003. For all other hospitals,
reconciliation is effective beginning with discharges occurring in a hospital’s first cost reporting period
beginning on or after October 1, 2003.
Subject to the approval of the CMS Central Office, a hospital’s outlier claims will be reconciled at the time of
cost report final settlement if they meet the following criteria:
1. The actual operating CCR is found to be plus or minus 10 percentage points from the CCR used
during that time period to make outlier payments, and
2. Total outlier payments in that cost reporting period exceed $500,000.
To determine if a hospital meets the criteria above, the Medicare contractor shall incorporate all the
adjustments from the cost report, run the cost report, calculate the revised CCR and compute the actual
operating CCR prior to issuing a Notice of Program Reimbursement (NPR). If the criteria for reconciliation
are not met, the cost report shall be finalized. If the criteria for reconciliation are met, Medicare contractors
shall follow the instructions below in §20.1.2.7. The NPR cannot be issued nor can the cost report be
finalized until outlier reconciliation is complete.
The first criterion requires a 10 percentage point fluctuation in the operating CCR only (and not the capital
CCR). However, if a hospital meets both criteria, claims will be reconciled using the operating and capital
CCRs from the final settled cost report.
As stated above, if a cost report is reopened after final settlement and as a result of this reopening there is a
change to the CCR (which could trigger or affect outlier reconciliation and outlier payments), Medicare
contractors shall notify the CMS Regional and Central Office for further instructions. Notification to the
CMS Central Office shall be sent via email to outliers[email protected].
Even if a hospital does not meet the criteria for reconciliation, subject to approval of the Regional and Central
Office, the Medicare contractor has the discretion to request that a hospital’s outlier payments in a cost
reporting period be reconciled if the hospital’s most recent cost and charge data indicate that the outlier
payments to the hospital were significantly inaccurate. The Medicare contractor sends notification to the
Central Office via email at [email protected]. Upon approval of the CMS Regional and Central
Office that a hospital’s outlier claims need to be reconciled, Medicare contractors should follow the
instructions in §20.1.2.7.
B. - Reconciling Outlier Payments for those Hospitals Identified in PM A-03-058
As stated above, for a hospital that met the criteria in §I.A. of PM A-03-058, reconciliation begins for
discharges occurring on or after August 8, 2003. To establish whether a hospital’s outlier payments are
subject to reprocessing, Medicare contractors determine if the CCR and total outlier payments from the entire
cost reporting period meet the two criteria in part A of this section. However, if both criteria for reconciliation
are met, only the discharges that occurred between August 8, 2003 and the end of the cost reporting period
will be reconciled. These hospitals will be subject to reconciliation in subsequent cost reporting periods if
they meet the two criteria outlined in part A of this section. See example A below.
The Medicare contractors shall notify the CMS Regional Office and CMS Central Office of any hospital that
meets the criteria for reconciliation. Notification to the CMS Central Office shall be sent via email to
[email protected]. Further instructions for Medicare contractors on reconciliation and the time value
of money are provided below in §§20.1.2.6 and 20.1.2.7.
EXAMPLE A:
Cost Reporting Period: 09/01/2002-08/31/2003
Operating CCR used to pay original claims submitted during cost reporting period: 0.40 (In this example, this
CCR is from the tentatively or final settled 2002 cost report)
Final settled operating CCR from 09/01/2002-08/31/2003 cost report: 0.50
Total outlier payout in 09/01/2002-08/31/2003 cost reporting period: $600,000
Because the CCR of 0.40 used at the time the claim was originally paid changed to 0.50 at the time of final
settlement, and the provider received greater than $500,000 in outlier payments during that cost reporting
period, the provider’s claims for discharges from August 8, 2003 through August 31, 2003 shall be reconciled
using the correct CCR of 0.50. The same criteria shall be applied to the cost report beginning on 09/01/2003
to determine whether reconciliation of outlier payments for that cost reporting period is necessary. For details
on how to apply multiple CCRs in a cost reporting period, see example C below.
C. - Reconciling Outlier Payments for those Hospitals Not Identified in PM A-03-058
Beginning with the first cost reporting period starting on or after October 1, 2003, all hospitals are subject to
the reconciliation policies set forth in this section. If a hospital meets the criteria in part A of this section, the
Medicare contractor shall notify the CMS Regional Office and Central Office via email at
[email protected]. Further instructions for Medicare contractors on reconciliation and the time value
of money are provided below in §§20.1.2.6 and 20.1.2.7.
The following examples demonstrate how to apply the criteria for reconciliation:
EXAMPLE B:
Cost Reporting Period: 01/01/2004-12/31/2004
Operating CCR used to pay original claims submitted during cost reporting period: 0.40 (In this example, this
CCR is from the tentatively settled 2002 cost report)
Final settled operating CCR from 01/01/2004-12/31/2004 cost report: 0.50
Total outlier payout in 01/01/2004-12/31/2004 cost reporting period: $600,000
Because the CCR of 0.40 used at the time the claim was originally paid changed to 0.50 at the time of final
settlement, and the provider received greater than $500,000 in outlier payments during that cost reporting
period, the criteria has been met to trigger reconciliation, and therefore, the Medicare contractor shall notify
the CMS Regional Office and Central Office. The provider’s outlier payments for this cost reporting period
will be reconciled using the correct CCR of 0.50.
In the event that multiple CCRs are used in a given cost reporting period, Medicare contractors should
calculate a weighted average of the CCRs in that cost reporting period. (See Example C below for
instructions on how to weight the CCRs). The Medicare contractor shall then compare the weighted CCR to
the CCR determined at the time of final settlement of the cost reporting period to determine if reconciliation is
required. Again, total outlier payments for the entire cost reporting period must exceed $500,000 in order to
trigger reconciliation.
EXAMPLE C:
Cost Reporting Period: 01/01/2004-12/31/2004
Operating CCR used to pay original claims submitted during cost reporting period:
- 0.40 from 01/01/2004-03/31/2004 (This CCR could be from the tentatively settled 2001 cost
report)
- 0.50 from 04/01/2004-12/31/2004 (This CCR could be from the tentatively settled 2002 cost
report)
Final settled operating CCR from 01/01/2004-12/31/2004 cost report: 0.35
Total Outlier payout in 01/01/2004-12/31/2004 cost reporting period: $600,000
Weighted Average CCR: 0.474
CCR
Days
Weight
Weighted CCR
0.40
91
0.248 (91 Days / 366 Days)
(a) 0.099=
(0.40 * 0.248)
0.50
275
0.751 (275 Days / 366 Days )
(b) 0.375=
(0.50 * 0.751)
TOTAL
*366
(a)+(b) =0.4742
*NOTE: There are 366 days in the year because 2004 was a leap year.
The hospital meets the criteria for reconciliation in this cost reporting period because the weighted average
CCR at the time the claim was originally paid changed from 0.474 to 0.35 (which is greater than 10
percentage points) at the time of final settlement, and the provider received an outlier payment greater than
$500,000 for the entire cost reporting period.
20.1.2.6 - Time Value of Money
(Rev. 4390, Issued: 09-06-19, Effective: 10-01-19, Implementation: 10-07-19)
Effective for discharges occurring on or after August 8, 2003, at the time of any reconciliation under
§20.1.2.5, outlier payment may be adjusted to account for the time value of money of any adjustments to
outlier payments as a result of reconciliation. The time value of money is applied from the midpoint of the
hospital’s cost reporting period being settled to the date on which the CMS Central Office receives
notification from the Medicare contractor that reconciliation should be performed.
If a hospital’s outlier payments have met the criteria for reconciliation, CMS will calculate the aggregate
adjustment using the instructions below concerning reprocessing claims and determine the additional amount
attributable to the time value of money of that adjustment. The index that will be used to calculate the time
value of money is the monthly rate of return that the Medicare trust fund earns. This index can be found at
http://www.ssa.gov/OACT/ProgData/newIssueRates.html.
The following formula will be used to calculate the rate of the time value of money.
(Rate from Web site as of the midpoint of the cost report being settled / 365) * # of days from that midpoint
until date of reconciliation. NOTE: The time value of money can be a positive or negative amount depending
if the provider is owed money by CMS or if the provider owes money to CMS.
For purposes of calculating the time value of money, the “date of reconciliation” is the day on which the CMS
Central Office receives notification via email from the Medicare contractor.
The following is an example of the computation of the adjustment to account for the time value of money:
EXAMPLE
Cost Reporting Period: 01/01/2004-12/31/2004
Midpoint of Cost Reporting Period: 07/01/2004
Date of Reconciliation: 12/31/2005
Number of days from Midpoint until date of Reconciliation: 549
Rate from Social Security Web site: 4.625%
Operating CCR used to pay actual original claims in cost reporting period: 0.40 (This CCR could be from the
tentatively settled 2002 or 2003 cost report)
Final settled operating CCR from 01/01/2004-12/31/2004 cost report: 0.50
Total outlier payout in 01/01/2004-12/31/2004 cost reporting period: $600,000.
Because the CCR fluctuated from .40 at the time the claims were originally paid to 0.50 at the time of final
settlement and the provider has total outlier payments greater than $500,000, the criteria have been met to
trigger reconciliation. The Medicare contractor notifies the CMS Regional and Central Office.
The Medicare contractor reprocesses and reconciles the claims. The reprocessing indicates the revised outlier
payments are $700,000.
Using the values above, determine the rate that will be used for the time value of money: (4.625 / 365) * 549 =
6.9565%
Based on the claims reconciled, the provider is owed $100,000 ($700,000-$600,000) for the reconciled
amount and $6,956.50 ($100,000 * 6.9565 %) for the time value of money.
20.1.2.7 - Procedure for Medicare Contractors to Perform and Record Outlier
Reconciliation Adjustments
(Rev. 4390, Issued: 09-06-19, Effective: 10-01-19, Implementation: 10-07-19)
The following is a step-by-step explanation of the procedures that Medicare contractors are to follow if a
hospital is eligible for outlier reconciliation:
1) The Medicare contractor shall send notification to the CMS Central Office (not the hospital), via
email to outliersI[email protected] and regional office that a hospital has met the criteria for
reconciliation. Medicare contractors shall include in their notification the provider number, provider
name, cost reporting begin date, cost reporting end date, total operating and capital outlier payments
in the cost reporting period, the operating CCR or weighted average operating CCR from the time
the claims were paid during the cost reporting period eligible for reconciliation and the final settled
operating and capital CCR.
2) If the Medicare contractor receives approval from the CMS Central Office that reconciliation is
appropriate, the Medicare contractor follows steps 3-14 below. NOTE: Hospital cost reports will
remain open until their claims have been processed for outlier reconciliation.
3) The Medicare contractor shall notify the hospital and copy the CMS Regional Office and Central
Office via email at [email protected] that the hospital’s outlier claims are to be reconciled.
4) Prior to running claims in the *Lump Sum Utility, Medicare contractors shall update the applicable
provider records in the Inpatient Provider Specific File (IPSF) by entering the final settled operating
and capital CCR from the cost report in the operating and capital CCR fields. Specifically, for
hospitals paid under the IPPS, Medicare contractors shall enter the revised operating CCR in PSF
field 25 -Operating Cost to Charge Ratio and the revised capital CCR in PSF field 47 -Capital Cost
to Charge Ratio. No other elements in the IPSF (such as elements related to the DSH and IME
adjustments) shall be updated for the applicable provider records in the IPSF that span the cost
reporting period being reconciled aside from the elements for the operating and capital CCRs.
*NOTE: The FISS Lump Sum Utility is a Medicare contractor tool that, depending on the elements
that are input, will produce an extract that will calculate the difference between the original PPS
payment amounts and revised PPS payment amounts into a Microsoft Access generated report. The
Lump Sum Utility calculates the original and revised payments offline and will not affect the original
claim payment amounts as displayed in various CMS systems (such as NCH).
5) Medicare contractors shall ensure that, prior to running claims through the FISS Lump Sum Utility,
all pending claims (e.g., appeal adjustments) are finalized for the applicable provider.
6) Medicare contractors shall only run claims in the Lump Sum Utility that meet the following criteria:
• Type of Bill (TOB) equals 11X
• Previous claim is in a paid status (P location) within FISS
• Cancel date is ‘blank’
7) The Medicare contractor reconciles the claims through the applicable IPPS Pricer software and not
through any editing or grouping software.
8) Upon completing steps 3 through 7 above, the Medicare contractor shall run the claims through the
Lump Sum Utility. The Lump Sum Utility will produce an extract, according to the elements in
Table 1 below. NOTE: The extract must be importable by Microsoft Access or a similar software
program (Microsoft Excel).
9) Medicare contractors shall upload the extract into Microsoft Access or a similar software program to
generate a report that contains elements in Table 1. Medicare contractors shall ensure this report is
retained with the cost report settlement work papers.
10) For hospitals paid under the IPPS, the Lump Sum Utility will calculate the difference between the
original and revised operating and capital outlier amounts. If the difference between the original and
revised operating and capital outlier amounts (calculated by the Lump Sum Utility) is positive, then a
credit amount (addition) shall be issued to the provider. If the difference between the original and
revised operating and capital amounts (calculated by the Lump Sum Utility) is negative, then a debit
amount (deduction) shall be issued to the provider. NOTE: The difference between the original and
revised operating outlier amounts and the difference between the original and revised capital outlier
amounts are two distinct amounts calculated by the lump sum utility and are recorded on two
separate lines on the cost report.
11) The operating and capital time value of money amounts are two distinct calculations that are
recorded separately on the cost report. Medicare contractors shall determine the applicable time
value of money amount by using the calculation methodology in §20.1.2.6. If the difference between
the original and revised operating and capital outlier amounts is a negative amount then the time
value of money is also a negative amount. If the difference between the original and revised
operating and capital outlier amounts is a positive amount then the time value of money is also a
positive amount. Similar to step 10, if the time value of money is positive, then a credit amount
(addition) shall be issued to the provider. If the time value of money is negative, then a debit amount
(deduction) shall be issued to the provider. NOTE: The time value of money is applied to the
difference between the original and revised operating and capital outlier amounts.
12) For cost reporting periods beginning before May 1, 2010, under cost report 2552-96, the Medicare
contractor shall record the original operating and capital outlier amounts, the operating and capital
outlier reconciliation adjustment amount (the difference between the original and revised operating
and capital outlier amounts calculated by the Lump Sum Utility), the operating and capital time
value of money and the rate used to calculate the time value of money on lines 50-56, of Worksheet
E, Part A of the cost report (NOTE: the amounts recorded on lines 50-53 and 55 thru 56 can be
positive or negative amounts per the instructions above). The total outlier reconciliation adjustment
amount (the difference between the original and revised operating and capital outlier amount
(calculated by the Lump Sum Utility) plus the time value of money) shall be recorded on line 24.99
of Worksheet E, Part A. For complete instructions on how to fill out these lines please see § 3630.1
of the Provider Reimbursement Manual, Part II. NOTE: Both the operating and capital amounts are
combined and recorded on line 24.99 of Worksheet E, Part A.
For cost reporting periods beginning on or after May 1, 2010, under cost report 2552-10, the
Medicare contractor shall record the original operating and capital outlier amounts, the operating and
capital outlier reconciliation adjustment amounts (the difference between the original and revised
operating and capital outlier amounts calculated by the Lump Sum Utility), the operating and capital
time value of money and the rate used to calculate the time value of money on lines 90-96, of
Worksheet E, Part A of the cost report (NOTE: the amounts recorded on lines 90-93 and 95 thru 96
can be positive or negative amounts per the instructions above). The total outlier reconciliation
adjustment amount (the difference between the original and revised operating and capital outlier
amount (calculated by the Lump Sum Utility) plus the time value of money) shall be recorded on line
69 of Worksheet E, Part A. NOTE: Both the operating and capital amounts are combined and
recorded on line 69 of Worksheet E, Part A.
13) The Medicare contractor shall finalize the cost report, issue a NPR and make the necessary
adjustment from or to the provider.
14) After determining the total outlier reconciliation amount and issuing a NPR, Medicare contractors
shall restore the operating and capital CCR(s) elements to their original values (that is, the CCRs
used to pay the claims) in the applicable provider records in the IPSF to ensure an accurate history is
maintained. Specifically, for hospitals paid under the IPPS, Medicare contractors shall enter the
original operating CCR in PSF field 25 -Operating Cost to Charge Ratio and the original capital
CCR in PSF field 47 -Capital Cost to Charge Ratio.
If the Medicare contractor has any questions regarding this process it should contact the CMS Central Office
via the address and email address provided in §20.1.2.1 (B).
Table 1: Data Elements for FISS Extract
List of Data Elements for FISS Extract
Provider #
Health Insurance Claim (HIC) Number
Document Control Number (DCN)
Type of Bill
Original Paid Date
Statement From Date
Statement To Date
Original Reimbursement Amount (claims page 10)
Revised Reimbursement Amount (claim page 10)
Difference between these amounts
Original Deductible Amount, Payer A, B, C (Value Code A1, B1, C1)
Revised Deductible Amount, Payer A, B, C (Value Code A1, B1, C1)
Difference between these amounts
Original Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2)
Revised Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2)
Difference between these amounts
Original Medicare Lifetime Reserve Amount in the first calendar year period (Value
Code 08)
List of Data Elements for FISS Extract
Revised Medicare Lifetime Reserve Amount in the first calendar year period (Value
Code 08)
Difference between these amounts
Original Medicare Coinsurance Amount in the first calendar year period (Value Code 09)
Revised Medicare Coinsurance Amount in the first calendar year period (Value Code 09)
Difference between these amounts
Original Medicare Lifetime Reserve Amount in the second calendar year period (Value
code 10)
Revised Medicare Lifetime Reserve Amount in the second calendar year period (Value
code 10)
Difference between these amounts
Original Medicare Coinsurance Amount in the second calendar year period (Value code
11)
Revised Medicare Coinsurance Amount in the second calendar year period (Value code
11)
Difference between these amounts
Original Outlier Amount (Value Code 17)
Revised Outlier Amount (Value Code 17)
Difference between these amounts
Original DSH Amount (Value Code 18)
Revised DSH Amount (Value Code 18)
Difference between these amounts
Original IME Amount (Value Code 19)
Revised IME Amount (Value Code 19)
Difference between these amounts
Original New Tech Add-on (Value Code 77)
Revised New Tech Add-on (Value Code 77)
Difference between these amounts
Original Device Reductions (Value Code D4)
Revised Device Reductions (Value Code D4)
Difference between these amounts
TOT CHRG – total billed charges (claim page 3)
COV CHRG – total covered charges (claim page 3)
Original Hospital Portion (claim page 14)
Revised Hospital Portion (claim page 14)
Difference between these amounts
Original Federal Portion (claim page 14)
Revised Federal Portion (claim page 14)
Difference between these amounts
Original C TOT PAY (claim page 14)
Revised C TOT PAY (claim page 14)
Difference between these amounts
Original C FSP (claim page 14)
Revised C FSP (claim page 14)
Difference between these amounts
Original C OUTLIER (claim page 14)
Revised C OUTLIER (claim page 14)
Difference between these amounts
List of Data Elements for FISS Extract
Original C DSH ADJ (claim page 14)
Revised C DSH ADJ (claim page 14)
Difference between these amounts
Original C IME ADJ (claim page 14)
Revised C IME ADJ (claim page 14)
Difference between these amounts
Original Pricer Amount
Revised Pricer Amount
Difference between these amounts
Original PPS Payment (claim page 14)
Revised PPS Payment (claim page 14)
Difference between these amounts
Original PPS Return Code (claim page 14)
Revised PPS Return Code (claim page 14)
Original UNCOMP CARE AMT (claim page 40)
Revised UNCOMP CARE AMT (claim page 40)
Difference between these amounts
Original VAL PURC ADJ AMT (claim page 40)
Revised VAL PURC ADJ AMT (claim page 40)
Difference between these amounts
Original READMIS ADJ AMT (claim page 40)
Revised READMIS ADJ AMT (claim page 40)
Difference between these amounts
Original HAC PAYMENT AMT (claim page 40)
Revised HAC PAYMENT AMT (claim page 40)
Difference between these amounts
Original EHR PAY ADJ AMT (claim page 40)
Revised EHR PAY ADJ AMT (claim page 40)
Difference between these amounts
Original PPS-ISLET-ADD-ON-AMT (Value Code Q7)
Revised PPS-ISLET-ADD-ON-AMT (Value Code Q7)
Difference between these amounts
DRG
MSP Indicator (Value Codes 12-16 & 41-43 – indicator indicating the claim is MSP; ‘Y’
= MSP, ‘blank’ = no MSP
Reason Code
HMO-IME Indicator
Filler
20.1.2.8 - Special Outlier Payments for Burn Cases
(Rev. 707, Issued: 10-12-05; Effective/Implementation Dates: 11-07-05)
For discharges occurring on or after April 1, 1988, the additional payment amount for the DRGs related to
burn cases, which are identified in the most recent annual notice of prospective payment rates is computed
using the same methodology (as stated above in section 20.1.2.3) except that the payment is made using a
marginal cost factor of 90 percent instead of 80 percent.
20.1.2.9 - Medical Review and Adjustments
(Rev. 1571; Issued: 08-07-08; Effective Date: 08-01-08; Implementation Date: 08-15-08)
Effective April 1, 2008, QIOs are no longer performing the majority of medical review for payment of acute
inpatient prospective payment system (IPPS) hospital and long term care hospital (LTCH) claims. These
reviews are the responsibility of the A/B MACs (A). An exception occurs when a provider requests a higher-
weighted DRG review from the QIO. The QIO will continue to perform those reviews.
The A/B MAC (A) may review a sample of cost outlier cases after payment. The charges for any services
identified as non-covered through this review are denied and any outlier payment made for these services is
recovered, as appropriate, after a determination as to the provider’s liability has been made.
If the A/B MAC (A) finds a pattern of inappropriate utilization by a hospital, all cost outlier cases from that
hospital may be subject to medical review, and this review may be conducted prior to payment until the A/B
MAC (A) determines that appropriate corrective actions have been taken.
When the A/B MAC (A) reviews cost outlier cases, they shall do so using the medical records and itemized
charges, to verify the following:
1. The admission was medically necessary and appropriate;
2. Services were medically necessary and delivered in the most appropriate setting;
3. Services were ordered by the physician, actually furnished, and not duplicatively billed; and
4. The diagnostic and procedural coding are correct.
Where the A/B MAC (A)’s decision changes previously processed bills, an adjustment bill is prepared to
correct the bill.
When the hospital provides the A/B MAC (A) with medical records for cost outlier review, the hospital must
indicate the precise revenue code for each charge billed. In case adjustments are needed, revenue codes are
necessary to ensure proper accounting for cost report purposes. It is not acceptable for the hospital to merely
provide listings of revenue codes expecting the A/B MAC (A) to assign the charges to the appropriate code. If
the correct revenue codes are not provided, the A/B MAC (A) will deny the bill.
20.1.2.10 - Return Codes for Pricer
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of
ICD-10, Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: September, 23 2014)
The following return codes are calculated by PRICER and passed back to the calling program. Depending on
the type of payment and case, return codes 30, 44, 33, 40 and 42 indicate that an outlier would be paid if the
cost-to-charge ratio would rise by 20 percentage points. If a provider(s) (CCR rises by 10 percentage points
and) meets the criteria of reconciliation, the CMS Central Office uses return codes 30, 44, 33, 40 and 42 to
determine a smaller pool of claims for reprocessing claims due to outlier reconciliation.
Acute Care
Return Code 00: Paid normal DRG payment.
Return Code 02: Paid normal DRG payment plus a cost outlier.
Return Code 14: Paid normal DRG payment with per diem days equal or greater than geometric mean length
of stay.
Return Code 16: Paid normal DRG payment plus a cost outlier with per diem days equal to or greater than
geometric mean length of stay.
Return Code 30: Paid normal DRG payment and indicates an outlier payment would be necessary if the CCR
would increase by 20 percentage points.
Return Code 44: Paid normal DRG payment with per diem days equal or greater than geometric mean length
of stay and indicates an outlier payment would be necessary if the CCR would increase by 20 percentage
points.
Transfer Cases
Return Code 03: Paid a per diem payment to the transferring IPPS hospital (when the patient transfers to an
IPPS hospital) up to and including the full DRG payment if the covered days are less than the geometric mean
length of stay for the DRG. If covered days equal or exceed the geometric mean length of stay, the standard
payment is calculated.
Return Code 05: Paid a per diem payment to the transferring IPPS hospital (when the patient transfers to an
IPPS hospital) up to and including the full DRG payment if the covered days are less than the geometric mean
length of stay for the DRG. If covered days equal or exceed the geometric mean length of stay, the standard
payment is calculated. Also indicates case qualified for a cost outlier payment.
Return Code 06: Paid a per diem payment to the transferring IPPS hospital (when the patient transfers to an
IPPS hospital) up to and including the full DRG payment if the covered days are less than the geometric mean
length of stay for the DRG. If covered days equal or exceed the geometric mean length of stay, the standard
payment is calculated. Also indicates provider refused cost outlier payment.
Return Code 33: Paid a per diem payment to the transferring IPPS hospital (when the patient transfers to an
IPPS hospital) up to and including the full DRG payment if the covered days are less than the geometric mean
length of stay for the DRG. If covered days equal or exceed the geometric mean length of stay, the standard
payment is calculated. Also indicates an outlier payment would be necessary if the CCR increased by 20
percentage points.
Postacute Transfer Cases
Return Code 10: Makes payment to the transferring IPPS hospital (when the patient transfers to a non-IPPS
hospital) for postacute transfer DRGs (that have double the payment on the 1
st
day for purposes of the
postacute care transfer policy) as published in the annual IPPS Final Rule. Will calculate a per diem payment
based on the standard DRG payment if the covered days are less than the geometric mean length of stay for
the DRG. If covered days equal or exceed the geometric mean length of stay the standard payment is also
calculated. The cost outlier portion of the payment is calculated if the adjusted charges on the bill exceed the
outlier threshold.
Return Code 12: Makes payment to the transferring IPPS hospital (when the patient transfers to a non-IPPS
hospital) for postacute transfer DRGs (that receive 50 percent of the prospective payment on the 1
st
day of the
stay for purposes of the postacute care transfer policy) as published in the annual IPPS Final Rule. Will
calculate a per diem payment based on the standard DRG payment if the covered days are less than the
geometric mean length of stay for the DRG. If covered days equal or exceed the geometric mean length of
stay, the standard payment is calculated. The cost outlier portion of the payment is calculated if the adjusted
charges on the bill exceed the outlier threshold.
Return Code 40: Makes payment to the transferring IPPS hospital (when the patient transfers to a non-IPPS
hospital) for postacute transfer DRGs (that have double the payment on the 1
st
day for purposes of the
postacute care transfer policy) as published in the annual IPPS Final Rule. Will calculate a per diem payment
based on the standard DRG payment if the covered days are less than the geometric mean length of stay for
the DRG. If covered days equal or exceed the geometric mean length of stay, the standard payment is
calculated. Also indicates an outlier payment would be necessary if the CCR increased by 20 percentage
points.
Return Code 42: Makes payment to the transferring IPPS hospital (when the patient transfers to a non-IPPS
hospital) for postacute transfer DRGs (that receive 50 percent of the prospective payment on the 1
st
day of the
stay for purposes of the postacute care transfer policy) as published in the annual IPPS Final Rule. Will
calculate a per diem payment based on the standard DRG payment if the covered days are less than the
geometric mean length of stay for the DRG. If covered days equal or exceed the geometric mean length of
stay, the standard payment is calculated. Also indicates an outlier payment would be necessary if the CCR
increased by 20 percentage points.
20.2 - Computer Programs Used to Support Prospective Payment System
(Rev. 11140, Issued:12-02-21, Effective:01-04-22, Implementation: 01-04-22)
Medicare Code Editor
The Medicare Code Editor (MCE) is a front-end software program that edits claims to detect incorrect billing
data. The MCE addresses three basic types of edits which will support the DRG assignment. They include
correct diagnosis and procedure coding, coverage, and clinical edits.
Built into the MCE, which is the first portion of the Grouper program, are edits which reject incomplete or
impossible codes. Claims submitted with valid diagnoses and valid diagnoses-surgical procedure
combinations but are incorrect in that they do not represent the actual diagnosis or procedure, cannot be
detected. The responsibility for accuracy rests with the hospital. However, a post claim approval review may
be conducted by the A/B MACs (A), using medical records and the approved claim.
Grouper Program
The Grouper program determines the DRG from data elements the hospital reported. It is used on all inpatient
discharge/transfer bills received from both PPS and non-PPS facilities, including those from waiver States,
long-term care hospitals, and excluded units.
Pricer Program
The Pricer program determines the amount to pay under prospective payment.
The Pricer program applies the DRG relative weights, hospital urban or rural and census division location,
hospital specific data, and beneficiary hospital data from the bill to determine the amount payable for each
PPS discharge bill.
Most hospitals should not need a Pricer program because only one rate per DRG applies unless the claim
results in a cost outlier for a beneficiary whose benefits are exhausted during the stay. For those claims, the
provider must identify the outlier threshold to properly bill covered days on an inpatient claim. See §20.7.4
below.
20.2.1 - Medicare Code Editor (MCE)
(Rev. 11059; Issued: 10-21-21; Effective: 04-01-22; Implementation: 04-04-22)
A. - General
The MCE edits claims to detect incorrect billing data. In determining the appropriate MS-DRG for a
Medicare patient, the age, sex, discharge status, principal diagnosis, secondary diagnosis, and procedures
performed must be reported accurately to the Grouper program. The logic of the Grouper software assumes
that this information is accurate and the Grouper does not make any attempt to edit the data for accuracy.
Only where extreme inconsistencies occur in the patient information will a patient not be assigned to a MS-
DRG. Therefore, the MCE is used to improve the quality of information given to Grouper.
The MCE addresses three basic types of edits which will support the MS-DRG assignment:
• Code Edits - Examines a claim for the correct use of diagnosis and procedure codes. They include
basic consistency checks on the interrelationship among a patient's age, sex, and diagnoses and
procedures reported.
• Coverage Edits - Examines the type of patient and procedures performed to determine if the services
are covered.
• Clinical Edits - Examines the clinical consistency of the diagnostic and procedural information on the
claim to determine if they are clinically reasonable and, therefore, should be paid.
B. - Implementation Requirements
The A/B MAC (A) processes all inpatient Part A discharge/transfer claims for both PPS and non-PPS facilities
(including waiver States, long-term care hospitals, and excluded units) through the MCE. It processes claims
that have been reviewed by the QIO prior to billing through the MCE only for edit types 1, 2, 3, 4, 7, and 12.
It does not process the following kinds of claims through the MCE:
• Where no Medicare payment is due (amounts reported by value codes 12, 13, 14, 15, or 16 equal or
exceed charges).
• Where no Medicare payment is being made. Where partial payment is made, editing is required.
• Where QIO reviewed prior to billing (condition code C1 or C3). It may process these exceptions
through the program and ignore development codes or bypass the program.
The MCE software contains multiple versions. The version of the MCE accessed by the program depends
upon the patient discharge date entered on the claim.
C. - Bill System/MCE Interface
The A/B MAC (A) installs the MCE online, if possible, so that prepayment edit requirements identified in
subsection C can be directed to hospitals without clerical handling.
The MCE needs the following data elements to analyze the claim:
• Age;
• Sex;
• Discharge status;
• Diagnosis (25 maximum - principal diagnosis and up to 24 additional diagnoses);
• Procedures (25 maximum); and
• Discharge date.
The MCE provides the A/B MAC (A) an analysis of "errors" on the claim as described in subsection D. The
A/B MAC (A) develops its own interface program to provide data to MCE and receive data from it.
The MCE Installation Manual describes the installation and operation of the program, including data base
formats and locations.
D. - Processing Requirements
The hospital must follow the procedure described below for each error code. For claims returned to the
provider, the A/B MAC (A) considers the claim improperly completed for control and processing time
purposes. (See chapter 1.)
NOTE: The following instructions are based on ICD-9-CM diagnosis and procedure codes, ICD-10-CM and
ICD-10-PCS codes.
1. Invalid Diagnosis or Procedure Code
The MCE checks each diagnosis code, including the admitting diagnosis, and each procedure code against a
table of valid diagnosis and procedure codes. An admitting diagnosis, a principal diagnosis, and up to 24
additional diagnoses may be reported. Up to 25 total procedure codes may be reported on an inpatient claim.
If the recorded code is not in this table, the code is invalid, and the A/B MAC (A) returns the claim to the
provider.
For a list of valid diagnosis or procedure codes see the "International Classification of Diseases” revision
applicable to the date of the inpatient discharge or other service and the "Addendum/Errata" and new codes
furnished by the A/B MAC (A). The hospital must review the medical record and/or face sheet and enter the
correct diagnosis/procedure codes before returning the claim.
2. External Cause of Injury Code as Principal Diagnosis
External Cause of Injury codes describe the circumstances that caused an injury, not the nature of the injury,
and therefore are not recognized by the Grouper program as acceptable principal diagnoses. In ICD-9-CM the
external cause of injury diagnosis codes begin with the letter E. In ICD-10-CM the external cause of injury
codes begin with the letters V, W, X and Y. For a list of all External cause of injury codes, see International
Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), and the International
Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). The hospital must review the
medical record and/or face sheet and enter the correct diagnosis before returning the claim.
3. Duplicate of Principal Diagnosis
Any secondary diagnosis reported on the claim that is the same code as the principal diagnosis reported on the
claim is identified as a duplicate of the principal diagnosis. This is unacceptable because the secondary
diagnosis may cause an erroneous assignment to a higher severity level MS-DRG. Hospitals may not repeat a
diagnosis code. The A/B MAC (A) will delete the duplicate secondary diagnosis and process the claim.
4. Age Conflict
The MCE detects inconsistencies between a patient's age and any diagnosis on the patient's record. Examples
are:
• A 5-year-old patient with benign prostatic hypertrophy.
• A 78-year-old who delivers a baby.
In the above cases, the diagnosis is clinically impossible in a patient of the stated age. Therefore, either the
diagnosis or age is presumed to be incorrect. Four age code categories are described below.
• A subset of diagnoses is intended only for “perinatal/newborn.” These are diagnoses that occur during
the perinatal or newborn period of age 0.
• Certain diagnoses are considered reasonable only for children between the ages of 0 and 17. These are
"Pediatric" diagnoses.
• Diagnoses identified as "Maternity" are coded only for patients between the ages of 9 and 64.
• A subset of diagnoses is considered valid only for patients over the age of 14. These are "Adult"
diagnoses. For "Adult" diagnoses the age range is 15 through 124.
The list of diagnoses that are acceptable for each age category can be located in the most current version of the
Definition of Medicare Code Edits manual which is posted at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/MS-DRG-
Classifications-and-Software
Prior versions of the manual can be located at:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS
and select the final rule for the applicable Fiscal Year (FY) from the list on the left. Then select the
FY(CCYY) Final Rule Data Files, and scroll down to the Definition of Medicare Code Edits link.
If the A/B MAC (A) edits online, it will return claims for a proper diagnosis or correction of age as applicable.
If the A/B MAC (A) edits in batch operations after receipt of the admission query response, it uses the age
based on CMS records and returns claims that fail this edit. The hospital must review the Electronic Health
Record (EHR), paper medical record, and/or face sheet and enter the proper diagnosis or patient’s age before
returning the claim.
5. Sex Conflict
The MCE detects inconsistencies between a patient's sex and a diagnosis or procedure on the patient's record.
Examples are:
• Male patient with cervical cancer (diagnosis).
• Male patient with a hysterectomy (procedure).
In both instances, the indicated diagnosis or the procedure conflicts with the stated sex of the patient.
Therefore, either the patient's diagnosis, procedure or sex is incorrect.
The MCE contains listings of male and female related diagnosis and procedure codes and the corresponding
English descriptions. The hospital should review the EHR, paper medical record, and/or face sheet and enter
the proper sex, diagnosis, and procedure before returning the claim.
6. Manifestation Code as Principal Diagnosis
A manifestation code describes the manifestation of an underlying disease, not the disease itself, and
therefore, cannot be a principal diagnosis. The MCE contains listings of diagnosis codes identified as
manifestation codes. The hospital should review the EHR, paper medical record, and/or face sheet and enter
the proper diagnosis before returning the claim.
7. Nonspecific Principal Diagnosis
Effective October 1, 2007 (FY 2008), the non-specific principal diagnosis edit was discontinued and is only
applicable when processing claims using MCE version 2.0-23.0 only.
8. Questionable Admission
There are some diagnoses which are not usually sufficient justification for admission to an acute care hospital.
The MCE contains a listing of diagnosis codes identified as "Questionable Admission" when used as principal
diagnosis.
The A/B MACs (A) may review on a post-payment basis all questionable admission cases. Where the A/B
MAC (A) determines the denial rate is sufficiently high to warrant, it may review the claim before payment.
9. Unacceptable Principal Diagnosis
There are selected codes that describe a circumstance which influences an individual's health status but is not
a current illness or injury; therefore, they are unacceptable as a principal diagnosis. For example, the
diagnosis code for family history of a certain disease would be an unacceptable principal diagnosis since the
patient may not have the disease.
In a few cases, there are codes that are acceptable as a principal diagnosis if a secondary diagnosis is coded. If
no secondary diagnosis is present the message "requires secondary dx" will be returned by the MCE. The A/B
MAC (A) may review claims with codes from the Unacceptable Principal Diagnosis section and a secondary
diagnosis. A/B MACs (A) may choose to review as a principal diagnosis if data analysis deems it a priority.
If codes from the unacceptable principal diagnosis edit code list are identified without a secondary diagnosis,
the A/B MAC (A) returns the claim to the hospital and requests that the applicable secondary diagnosis be
entered. Also, any claims containing other "unacceptable principal diagnosis" codes are returned.
The hospital reviews the EHR, paper medical record, and/or face sheet and enters the appropriate principal
diagnosis that describes the illness or injury before resubmitting the claim.
10. Nonspecific O.R. Procedures
Effective October 1, 2007 (FY 2008), the non-specific O.R. procedure edit was discontinued and is only
applicable when processing claims using MCE version 2.0-23.0 only.
11. Noncovered O.R. Procedures
There are some O.R. procedures for which Medicare does not provide payment.
The A/B MAC (A) will return the claim requesting that the non-covered procedure and its associated charges
be removed from the claim, Type of Bill (TOB) 11X. If the hospital wishes to receive a Medicare denial, etc.,
the hospital may submit a non-covered claim, TOB 110, with the non-covered procedure/charges. (For more
information on billing non-pay claims, see Chapter 1 of this Manual, Section 60.1.4).
12. Open Biopsy Check
Effective October 1, 2010, the open biopsy check edit was discontinued and is only applicable when
processing claims using MCE version 2.0 - 26.0.
13. Bilateral Procedure
Effective October 1, 2015, the bilateral procedure edit was discontinued and is only used when processing
claims using MCE version 2.0-33.0.
14. Invalid Age
If the hospital reports an age over l24, the A/B MAC (A) requests the hospital confirm if it made a claim
preparation error. If the beneficiary's age is confirmed to be over l24, the hospital enters 123.
15. Invalid Sex
A patient's sex is sometimes necessary for appropriate MS-DRG assignment. The sex code reported must be
either 1 (male) or 2 (female).
16. Invalid Discharge Status
A patient's discharge status is sometimes necessary for appropriate MS-DRG assignment. Discharge status
must be coded according to the Form CMS-1450 and UB-04 conventions. See Chapter 25.
17. Limited Coverage
For certain procedures whose medical complexity and serious nature incur extraordinary associated costs,
Medicare limits coverage to a portion of the cost.
18. Wrong Procedure Performed
Certain external causes of morbidity codes indicate that the wrong procedure was performed.
19. Procedure inconsistent with length of stay (LOS)
The following procedure code should only be coded on claims when the respiratory ventilation is provided for
greater than four consecutive days during the length of stay.
Effective with discharges on and after October 1, 2015, ICD-10-PCS code, 5A1955Z - Respiratory
Ventilation, Greater than 96 Consecutive Hours
Prior to this date, discharges on and after October 1, 2012, ICD-9-CM procedure code, 96.72, Continuous
invasive mechanical ventilation for 96 consecutive hours or more
20. Unspecified Code
Unspecified codes exist for circumstances when documentation in the medical record does not provide the
level of detail needed to support reporting a more specific code. However, in the inpatient setting, there should
generally be very limited and rare circumstances for which the laterality (right, left, bilateral) of a condition is
unable to be documented and reported.
Effective April 1, 2022, the Unspecified Code edit will be triggered for certain unspecified diagnoses codes
currently designated as either a Complication or Comorbidity (CC) or Major Complication or Comorbidity
(MCC), that include other codes available in that code subcategory that further specify the anatomic site, when
entered on the claim. This edit message indicates that a more specific code is available to report. It is the
provider’s responsibility to determine if a more specific code from that subcategory is available in the medical
record documentation by a clinical provider.
If, upon review, additional information to identify the laterality from the available EHR or paper medical
record, or documentation by any other clinical provider is unable to be obtained or there is documentation in
the record that the physician is clinically unable to determine the laterality because of the nature of the
disease/condition, then the provider must enter that information into the remarks section.
The provider should submit the billing note/remarks that best identifies the primary reason why specificity
could not be determined:
Billing Note/Remarks
Definition
UNABLE TO DET LAT 1
Provider is unable to obtain additional information to
specify laterality.
UNABLE TO DET LAT 2
Physician is clinically unable to determine laterality.
20.2.1.1 - Paying Claims Outside of the MCE
(Rev. 1649; Issued: 12-18-08; Effective/Implementation Date: 11-25-08)
All institutional inpatient claims are routed through the MCE before they are processed to payment. There
may be special circumstances, however, when it is necessary to pay claims bypassing MCE edits. The CMS
will notify the contractor of these instances. They include:
• New coverage policies are enacted by Congress with effective dates that preclude making the
necessary changes timely; and
• Errors are discovered that cannot be corrected timely.
A/B MACs (A) are responsible for reporting problems timely.
20.2.1.1.1 - Requesting to Pay Claims Without MCE Approval
(Rev. 1649; Issued: 12-18-08; Effective/Implementation Date: 11-25-08)
The contractor may also request approval from the RO in specific situations to pay claims without first
sending them through the MCE. Examples of such situations are:
• A systems error cannot be corrected timely, and the provider's cash flow will be substantially
impacted; and/or
• Administrative Law Judge (ALJ) decisions, court decisions, and CMS instructions in particular cases
may necessitate that payment be made outside the normal process.
20.2.1.1.2 - Procedures for Paying Claims Without Passing through the MCE
(Rev. 2117, Issued: 12-10-10, Effective: 01-12-11, Implementation: 01-12-11)
Before an inpatient claim may be paid without first going through the MCE, the contractor shall obtain
approval from CMS Central Office or the RO.
Note: In certain situations, contractors bypass the MCE through an established, CMS-instructed claim
processing procedure (e.g., to verify a facility is certified to perform a specified service after a MCE limited
coverage edit is applied). Such scenarios do not require approval from the RO as the approval for such a
bypass was inherently implied when the established procedure was first implemented.
In all instances involving payment outside the normal inpatient editing process, the contractor applies the
following procedures:
• Contractors shall submit the claim overriding the MCE using the appropriate field in FISS.
• Pay interest accrued through the date payment is made on clean claims. Do not pay any additional
interest.
• Maintain a record of payment and implement controls to be sure that incorrect payment is not made,
i.e., when the claim is paid without being subject to normal editing.
• Monitor MCE software to determine when the impediment to processing is removed.
• Consider the claim processed for workload and expenditure reports when it is paid.
• Submit to the RO Consortium Contractor Manager (CCM) by the 20th of each month a report of all
inpatient claims paid without processing through the MCE with the exception of override situations
explained in the Note above (e.g., for limited coverage edits). The list of claims paid outside of the
MCE is to include the following information:
o HIC
o DCN
o TOB
o DOS (From/Through)
o Provider Number
o MCE/OCE OVR (Claim/Line)
o Reimbursement Amount
o Receipt Date
o Process Date
o Paid Date
Also, include summary data for each edit code showing claim volume and payment. Any override approvals
received and/or relevant JSM references should be annotated on the reports.
20.2.2 - DRG GROUPER Program
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of
ICD-10, Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: September, 23 2014)
The A/B MAC (A) pays for inpatient hospital services on the basis of a rate per discharge that varies
according to the MS-DRG to which a beneficiary's stay is assigned. Each MS-DRG represents the average
resources required to care for a case in that particular MS-DRG relative to the national average of resources
consumed per case. The MS-DRG weights used to calculate payment are in the Pricer DRGX file.
The A/B MAC (A) uses the GROUPER program to assign the MS-DRG number. GROUPER determines the
MS-DRG from data elements reported by the hospital. This applies to all inpatient discharge/transfer bills
received from both PPS and non-PPS facilities, including those from waiver States, long-term care hospitals,
and excluded units.
The Pricer (PPSMAIN) driver program calls the correct fiscal year GROUPER based upon the discharge date.
If the A/B MAC (A) or shared system writes its own driver program, it must access the GROUPER for the
correct FY based on discharge date. GROUPER does not determine the MS-DRG price. GROUPER
input/output are specified below. The A/B MAC (A) determines the best place in its total system to place the
GROUPER program.
Grouper requires the following items:
1. Principal and up to 24 other diagnoses
2. Principal and up to 24 additional procedures
3. Age at last birthday at admission
4. Sex (1=male and 2=female)
5. Discharge destination (patient status code from the claim)
The claim sex coding is M for male and F for female while GROUPER is l for male and 2 for female.
Discharge destination codes are similar to claim definitions for patient status except codes 20-29 are
summarized as 20. The A/B MAC (A) calculates age at admission. GROUPER needs age rather than date of
birth.
Grouper responds with the following information:
1. Major diagnostic category
2. MS-DRG number
3. Grouper return code (a one position code indicating the action taken by the program)
4. Procedure code used in determining the MS-DRG
5. Diagnosis code used in determining the MS-DRG
6. Secondary diagnosis code used in determining the MS-DRG, if applicable
20.2.3 - PPS Pricer Program
(Rev. 1, 10-01-03)
A3-3615.3, A3-3656.3
The CMS provides a Pricer program to determine the price upon which to base payment under prospective
payment. A separate Pricer installation guide is provided. The A/B MAC (A) uses the Pricer appropriate for
the date of discharge.
After GROUPER determines the DRG, the A/B MAC (A) 's system calls the Pricer program. Pricer
determines the price to pay and prepares a report.
Four data files are included. CMS maintains three:
• DRGX file - contains DRG weights, average length of stay and outlier cutoff points.
• MSAX file - contains urban and rural wage indexes used in calculating payment. CMS may request
that the A/B MAC (A) make interim changes to this file when index changes are issued for individual
hospitals after issuance of Pricer for the period.
• RATE file - contains census division values and updating amounts used in calculating payment.
The A/B MAC (A) maintains the provider-specific file, (PROV file). This contains information about the
facts specific to the provider that affect computations, e.g., effective dates for PPS, type of provider (for
application of special computation rules), census division, MSA, adjusted cost per discharge, disproportionate
share adjustment percentage, and capital data.
Pricer also calculates the disproportionate share adjustment and adds it to the DRG payment. Correct
calculation depends upon the accuracy of related information the A/B MAC (A) includes in the PRICER
PROV file.
The Pricer program applies the DRG relative weights, hospital urban or rural and census division location,
provider-specific data, and beneficiary hospital data from the bill to determine the amount payable for each
PPS discharge bill.
Pricer uses the Intern-to-Bed ratio in calculating the indirect teaching adjustment for operating costs for the
A/B MAC (A) to accumulate and use in related payments. Pricer uses the intern-to-average daily census ratio
to calculate the indirect teaching adjustment for capital costs. The A/B MAC (A) ensures that these ratios are
available for Pricer to compute payment for teaching hospitals. It includes the ratios in its PROV file to
ensure that cost outliers are not overpaid to its teaching hospitals.
Pricer does not calculate utilization days required for the PS&R, CWF, or cost report. It does not determine
the amount to pay after deduction for deductible, coinsurance, or the primary payment where Medicare is
secondary. The A/B MAC (A) must calculate the price and make adjustments to the price furnished before
making payment.
The A/B MACs (A) use the Pricer implementation guide for information concerning Pricer processing reports,
input parameters and data requirements.
20.2.3.1 - Provider-Specific File
(Rev. 3836, Issued: 08-18-17, Effective: 11-21-17, Implementation: 11-21-17)
The PROV file contains needed information about each provider to enable the pricing software to calculate the
payment amount. The FI maintains the accuracy of the data in accordance with the following criteria.
Whenever the status of any element changes, the FI prepares an additional record showing the effective date.
For example, when a hospital's FY beginning date changes as a result of a change in ownership or other "good
cause," the FI makes an additional record showing the effective date of the change.
The format and data required by the PRICER program and by the provider-specific file is found in Addendum
A.
The FIs submit a file of provider-specific payment data to CMS CO every three months for PPS and non-PPS
hospitals, inpatient rehabilitation hospitals or units (referred to as IRFs), long term care hospitals (LTCHs),
inpatient psychiatric facilities (IPFs), SNFs, and hospices, including those in Maryland. Regional home health
FIs (RHHIs) submit a file of provider specific data for all home health agencies. FIs serving as the audit FI
for hospital based HHAs do not submit a file of provider specific data for HHAs.
The FIs create a new record any time a change occurs for a provider. Data must be reported for the following
periods: October 2 - January 1, January 2 - April 1, April 2 - July 1, and July 2 - October 1. This file must be
received in CO within seven business days after the end of the period being reported.
NOTE: FIs submit the latest available provider-specific data for the entire reporting period to CO by the
seven-business day deadline. If CO fails to issue applicable instructions concerning changes or additions to
the file fields by 10 calendar days before the end of the reporting period, the FI may delay reporting of data
related to the CO instructions until the next file due date. For example, if CO instructions changing a file field
are issued on or after September 21 with an effective date of October 1, the FI may exclude the October 1 CO-
required changes from the file submitted by October 9. The FI includes the October 1 CO-required changes,
and all subsequent changes through January 1 in the file submitted in January.
A. PPS Hospitals
The FIs submit all records (past and current) for all PPS providers every three months. Duplicate the provider
file used in the "PRICER" module of the claims processing system.
B. Non-PPS Hospitals and Exempt Units
The FIs create a provider specific history file using the listed data elements for each non-PPS hospital and
exempt hospital unit. Submit the current and the preceding fiscal years every three months. Code Y in
position 49 (waiver code) to maintain the record in the PRICER PROV file.
C. Hospice
The FIs create a provider specific history file using the following data elements for each hospice. Submit the
current and the preceding fiscal years every three months. Data elements 3, 4, 5, 6, 9, 10, 13, and 17 are
required. All other data elements are optional for this provider type.
Effective October 1, 2005, data element 13 is no longer applicable to payment applications but is still
required. Data element 35 is required for all hospices. Data elements 33 and 38 are optional and may be
populated if needed.
Effective October 1, 2013, data element 34 (Hospital Quality Indicator) is required.
D. Skilled Nursing Facility (SNF)
The FIs create a provider specific history file using the following data elements for each SNF beginning with
their first cost reporting period that starts on or after July 1, 1998.
The FIs submit the current and the preceding fiscal years every three months. For PPS-exempt providers,
code Y in position 49 (waiver code) to maintain the record in the PRICER PROV file. Data elements 3, 4, 5,
6, 9, 10, 13, 19, and 21 are required. All other data elements are optional for this provider type.
Effective October 1, 2005, data element 13 is no longer applicable to payment applications but is still
required. Data element 35 is required for all SNFs. Data elements 33 and 38 are required if there is a special
wage index. Effective October 1, 2005, through September 30, 2006, data elements 33 and 38 are required
since there is a special wage index.
E. Home Health Agency (HHA)
The FIs create a provider specific history file using the following data elements for each HHA. Regional
home health FIs (RHHIs) submit the current and the preceding fiscal years every three months. Data elements
3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 19 and 30 are required. All other data elements are optional for this provider
type. All fields must be zero filled if not completed. Update the effective date in data element 4 annually.
Ensure that the current census division in data element 11 is not zero. Ensure that the waiver indicator in data
element 8 is N. Ensure that the MSA code reported in data element 13 is a valid MSA code.
F. Inpatient Rehabilitation Facilities (IRFs)
The FIs create a provider specific history file using the following data elements for each IRF beginning with
their first cost reporting period that starts on or after January 1, 2002. FIs submit the current and the preceding
fiscal years every three months. For PPS-exempt providers, code Y in position 49 (waiver code) to maintain
the record in the PRICER PROV file. Data elements 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 18, 19, 21, 25, 27, 28,
and 42 are required. All other data elements are optional for this provider type.
Effective October 1, 2005, data element 13 is no longer applicable to payment applications but is still
required. Data element 35 is required for all IRFs. Data elements 17, 33, 38, and 49 are required if applicable
to the IRF.
Effective October 1, 2013, data element 34 (Hospital Quality Indicator) is required.
G. Long Term Care Hospital (LTCH)
The FIs create a provider specific history file using the following data elements for each LTCH beginning
with their first cost reporting period that starts on or after October 1, 2002. FIs submit the current and the
preceding fiscal years every three months. For PPS-exempt providers, code Y in position 49 (waiver code) to
maintain the record in the PRICER PROV file. Data elements 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14, 18, 19,
21, 22, and 25 are the minimum required fields for entering a provider under LTCH PPS.
Effective July 1, 2005, data element 35 is required. Data elements 33 and 38 are optional and may be
populated if needed. Data elements 12, 13, and 14 are no longer applicable.
Effective July 1, 2006, data elements 23, 24, 27, 28, and 49 are required.
Effective October 1, 2013, data element 34 (Hospital Quality Indicator) is required.
H. Inpatient Psychiatric Facilities (IPF)
The FIs create a provider specific history file using the following data elements for each IPF beginning with
their first cost reporting period that starts on or after January 1, 2005.
The FIs submit the current and the preceding fiscal years every three months. For PPS-exempt providers,
code Y in position 49 (waiver code) to maintain the record in the PRICER PROV file. Data elements 1, 2, 3,
4, 5, 6, 7, 8, 9, 10, 13, 17, 18, 19, 21, 22, 23, 25, 33, 35, 38, and 48 are required. All other data elements are
optional for this provider type. Although data element 25 refers to the operating cost to charge ratio, ensure
that both operating and capital cost-to-charge ratio are entered in data element 25 for IPFs. Ensure that data
element 21 (Facility Specific Rate) will be determined using the same methodology to determine the interim
payment per discharge under the TEFRA system.
Effective July 1, 2006, data element 13 is no longer required. Data elements 33 and 38 are optional and may
be populated if needed.
Effective October 1, 2013, data element 34 (Hospital Quality Indicator) is required.
NOTE: All data elements, whether required or optional, must have a default value of “0” (zero) if numerical,
or a blank value if alphanumerical.
The provider specific file (PSF) should be transferred to CO using the Network Data Mover (NDM) system,
COPY TO and RUN JOB statements, which will notify CO of PSF file transfer. FIs must set up an NDM
transfer from the FI's system for which it is responsible. It is critical that the provider specific data is copied
to the CMS Data Center using the following input data set names ("99999" should be changed to the FI's 5-
digit number):
Data set Name ---COPY TO: --[email protected]
DCB=(HCFA1.MODEL,BLKSIZE=2400,LRECL=2400,RECFM=FB)
Data set Name ---RUN JOB: --[email protected](intermediary99999)
20.3 - Additional Payment Amounts for Hospitals with Disproportionate Share of Low-
Income Patients
(Rev. 2393, Issued: 01-25-12, Effective: 10-01-11, Implementation: 07-02-12)
The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, (Public Law: 99-272), provides for
an additional payment to an urban hospital of 100 or more beds that serves a disproportionate share of low-
income patients.
Adjustments are made in the Federal portion of the operating cost DRG payment to increase payments to
hospitals serving a disproportionate share of low-income patients. The additional payment equals the Federal
portion of the operating cost DRG payment and outlier payments, but excludes any additional payments for
the costs of indirect medical education multiplied by an adjustment percentage.
If a hospital meets the disproportionate share hospital (DSH) definition, an additional operating cost payment
will be made for discharges occurring on or after May 1, 1986. The DSH adjustment is applied only to the
Federal portion of the operating cost DRG payment (including outlier payments). It is basically a year-end
lump sum adjustment. However, the A/B MAC (A) will identify hospitals that are eligible to receive the DSH
adjustment and make interim payments subject to a year-end settlement based upon the hospital's DSH
percentage for the cost reporting period. The DRG payment a hospital receives includes the interim operating
cost DSH payment and an interim operating indirect medical education adjustment.
For services on or after October 1, 1997, the DSH percentage is not applied to outlier payments.
The Supplemental Security Income (SSI)/Medicare Beneficiary Data for IPPS hospitals is located at the
following CMS web address:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/dsh.html
The data is used for settlement purposes for hospitals.
Note that CMS issues a Recurring Update Notification prior to the Federal Fiscal Year beginning date to
provide contractors with the updated SSI file information.
A. - Regular Calculation of DSH Percentage
The operating DSH percentage is the sum of:
• The percentage of the hospital's total Medicare Part A patient days attributable to Medicare patients
who are also SSI recipients (this percentage will be supplied to the A/B MAC (A) by CMS). Since the
SSI/Medicare percentages are determined by CMS on a fiscal year basis, hospitals will be afforded the
option (for settlement purposes) of determining their SSI/Medicare percentage based upon data from
their own cost reporting period. If a hospital avails itself of this option, it must furnish its FI, in a
manner and format prescribed by CMS, data on its Medicare patients for the cost reporting period.
CMS will match these data to data supplied by SSA to determine the patients dually entitled to
Medicare Part A and SSI for the hospital's cost reporting period. The hospital bears the full cost of this
process, including the cost of verification by SSA.
Consistent with the regulations at 42 CFR 412.106(b)(2)(i) and 412.106(b)(2)(iii), patients who are
enrolled in Medicare Advantage (administered through Medicare Part C) should also be included in the
Medicare fraction. These days will be included in the Medicare/SSI fraction, but in order for them to be
counted, the hospital must submit an informational only bill (TOB 111) which includes Condition Code 04
to their Medicare contractor. This will ensure that these days are included in the hospital’s SSI ratio for
Fiscal Year 2007 and beyond.
Acute Care hospitals that received DSH during FY 2006 are also required to submit informational only
bills for their Medicare Advantage patients.
For MA patients, Long Term Care Hospitals are also required to submit informational only bills (TOB
111) with Condition Code 04.
For MA patients, Inpatient Rehabilitation Facilities are also required to submit informational only bills
(TOB 111) with both Condition Code 04 and the Case Mix Group (CMG) from the IRF PAI. Refer to
section 140.2.4.3 for the requirements for Inpatient Rehabilitation Facilities.
(Teaching hospitals do not need to submit additional claims with Condition Code 04 as they already
submit claims for Indirect Medical Education for MA beneficiaries with Condition Codes 04 and 69. We
will capture SSI information from these claims.)
• The percentage of total patient days attributable to patients entitled to Medicaid, but not to Medicare
Part A. (Medicaid days and total days are available on the cost report.)
For operating DSH payments:
For discharges between May 1, 1986, and March 31, 1990, a hospital qualifies for an operating cost DSH
adjustment if it has a DSH percentage of:
• At least 15 percent for an urban hospital with 100 or more beds;
• At least 40 percent for an urban hospital with less than 100 beds; or
• At least 45 percent for a rural hospital, with fewer than 500 beds.
For discharges on and after October 1, 1986, the hospital qualifies for an operating cost DSH adjustment if it
has a DSH percentage of at least 15 percent, is located in a rural area, and has 500 or more beds.
For discharges between April 1, 1990 and December 31, 1995, a hospital qualifies for an operating DSH
adjustment if it has a DSH percentage of:
• At least 15 percent for an urban hospital with 100 or more beds, or a rural hospital with 500 or more
beds;
• At least 40 percent for an urban hospital with fewer than 100 beds;
• At least 45 percent for a rural hospital with 100 beds or fewer, if it is not also classified as a sole
community hospital; or
• At least 30 percent for a rural hospital with more than 100 beds which is classified as a sole
community hospital.
A hospital qualifies for a capital DSH adjustment if it is located in a large urban or other urban area, has at
least 100 beds, and has a DSH percentage greater than 0.
For the DSH determination, the number of beds in a hospital is determined by counting the number of
inpatient care bed days available during the cost reporting period, excluding beds assigned to newborns,
custodial care, and PPS excluded distinct part hospital units, and dividing that number by the number of days
in the cost reporting period. Inpatient care bed days available should be the same as Indirect Medical
Education (IME) bed days. Available beds may not match the number of licensed beds.
B. - Determination of Operating DSH Adjustment Percentage
Hospitals that meet the DSH percentage criteria are entitled to adjustments to the Federal portion of their
operating cost DRG payments (including the Federal portion of outlier payments) as follows. For hospitals
that qualify for DSH payment, Pricer calculates the DSH adjustment percentage. (See §20.2.3.) The
following procedures are used to calculate the DSH adjustment.
For the period May 1, 1986 - September 30, 1988:
Urban hospitals with 100 or more beds and rural hospitals with 500 or more beds - The lesser of 15
percent or the percentage determined by using the following formula:
(DSH % - 15)(.5) + 2.5
EXAMPLES:
Hospital A is an urban hospital with 200 beds and has a DSH percentage of 21. Its DSH payment factor is
computed:
(21 - 15)(.5) + 2.5 = 5.5%
DSH adjustment factor = 5.5% (.0550)
Hospital B is an urban hospital with 250 beds and has a DSH percentage of 45. Its DSH payment adjustment
factor is computed:
(45 - 15)(.5) + 2.5 = 17.5%
DSH adjustment factor = 15% (.1500) (the maximum adjustment under the law)
• Urban hospitals with fewer than 100 beds - 5 percent.
• Rural hospitals with fewer than 500 beds - 4 percent.
For the period October 1, 1988 - March 31, 1990:
• Urban hospitals with 100 or more beds and rural hospitals with 500 or more beds - the following
formula is used:
(DSH % - 15) (.5) + 2.5
EXAMPLES:
Hospital A is an urban hospital with 200 beds and has a DSH percentage of 21 percent. Its DSH payment
factor is computed:
(21-15)(.5) + 2.5 = 5.5%
DSH adjustment factor = 5.5% (.0550)
Hospital B is an urban hospital with 250 beds and has a DSH percentage of 45 percent. Its DSH payment
adjustment factor is computed:
(45-15) (.5) + 2.5 = 17.5%
DSH adjustment factor = 17.5% (.1750, the limit was removed effective 10/1/88)
• Urban hospitals with fewer than 100 beds - 5 percent.
• Rural hospitals with fewer than 500 beds - 4 percent.
For the period April 1, 1990 - December 31, 1995:
• Urban hospitals with 100 or more beds and rural hospitals with 500 or more beds whose DSH
percentage is greater than 20.2 - the following formula is used:
Through December 31, 1990 - (DSH % - 20.2) (.65) + 5.62
January 1, 1991, and later - (DSH % - 20.2) (.7) + 5.62
EXAMPLES:
Hospital A is an urban hospital with 200 beds and has a DSH percentage of 21 percent. Its December 1990
DSH payment factor is computed:
(21 - 20.2) (.65) + 5.62 = 6.14%
DSH adjustment factor = 6.14% (.0614)
Hospital B is an urban hospital with 250 beds and has a DSH percentage of 45 percent. Its December 1990
DSH payment adjustment factor is computed:
(45 - 20.2) (.65) + 5.62% = 21.74%
DSH adjustment factor = 21.74% (.2174)
Urban hospitals with 100 or more beds and rural hospitals with 500 or more beds whose DSH percentage
is equal to or less than 20.2 - the following formula is used:
(DSH % - 15) (.6) + 2.5
• Urban hospitals with fewer than 100 beds - 5 percent.
• Rural hospitals that are RRCs and sole community hospitals - the greater of 10 percent or the
percentage determined using the following formula:
(DSH % - 30) (.6) + 4.0
EXAMPLES:
Hospital C is a rural hospital that is an RRC and a sole community hospital, and has a DSH percentage of 35
percent. Its DSH payment factor is computed:
(35 - 30) (.6) + 4.0 = 7%
DSH adjustment factor = 10% (.1000)
Hospital D is a rural hospital which is a RRC and a sole community hospital. It has a DSH percentage of 45
percent. Its DSH payment factor is computed:
(45 - 30) (.6) + 4.0 = 13%
DSH adjustment factor is 13% (.1300)
• Rural hospitals that are RRCs, but are not sole community hospitals-the following formula is
used:
(DSH % - 30) (.6) + 4.0
• Rural hospitals that are sole community hospitals, but are not RRCs - 10 percent.
• Rural hospitals not described above with 100 beds or less - 4 percent if DSH percentage is 45
percent or more.
• Rural hospitals not described above with more than 100 beds but fewer than 500 beds - 4 percent
if DSH percentage is 30 percent or more.
• Urban hospitals with 100 or more beds whose DSH percentage is less than or equal to 20.2 - the
following formula is used:
(DSH % - 15) (.6) + 2.5
For the period October 1, 1993, through September 30, 1994:
• Urban hospitals with 100 or more beds whose DSH percentage is greater than 20.2-the following
formula is used:
(DSH % - 20.2) (.8) + 5.88
• Urban hospitals with 100 or more beds whose DSH percentage is less than or equal to 20.2 - the
following formula is used:
(DSH % - 15) (.6) + 2.5
• Rural hospitals that are RRCs and sole community hospitals - the greater of 10 percent or the
percentage determined using the following formula:
(DSH % - 30) (.6) + 4.0
EXAMPLES:
Hospital C is a rural hospital that is a RRC and a sole community hospital. It has a DSH percentage of 35
percent. The DSH payment factor is computed:
(35 - 30) (.6) + 4.0 = 7%
DSH adjustment factor = 10% (.1000), the greater payment
Hospital D is a rural hospital that is a RRC and a sole community hospital. It has a DSH percentage of 45
percent. Its DSH payment factor is computed:
(45 - 30) (.6) + 4.0 = 13%
DSH adjustment factor = 13% (.1300)
Rural hospitals that are RRCs and are not sole community hospitals - the percentage is determined using
the following formula:
(DSH % - 30) (.6) + 4.0
• Rural hospitals that are sole community hospitals and are not RRCs - 10 percent.
• Rural hospitals not described above - 4 percent.
For discharges after September 30, 1994:
• Urban hospitals with 100 or more beds and rural hospitals with 500 or more beds whose DSH
percentage is greater than 20.2 - the percentage is determined using the following formula:
(DSH % - 20.2) (.825) + 5.88
• Urban hospitals with 100 or more beds whose DSH percentage is less than or equal to 20.2 - the
following formula is used:
(DSH % - 15) (.65) + 2.5
• Rural hospitals that are RRCs and sole community hospitals - the greater of 10 percent or the
percentage determined with the following formula:
(DSH % - 30) (.6) + 4.0
EXAMPLES:
Hospital C is a rural hospital that is an RRC and a sole community hospital. It has a DSH percentage of 35
percent. Its October 1994 DSH payment factor is computed:
(35 - 30) (.6) + 4.0 = 7%
DSH adjustment factor = 10% (.1000), the greater rate
Hospital D is a rural hospital that is an RRC and a sole community hospital. It has a DSH percentage of 45
percent. Its October 1994 DSH payment factor is computed:
(45 - 30) (.6) + 4.0 = 13%
DSH adjustment factor = 13% (.1300)
• Rural hospitals that are RRCs, but not sole community hospitals - Use the following formula:
(DSH % - 30) (.6) + 4.0
• Rural hospitals that are sole community hospitals and are not RRCs - 10 percent.
• Rural hospitals not described above - 4 percent.
The amount of the operating cost DSH adjustment is computed by multiplying the Federal portion of the
hospital's operating cost DRG revenues by the appropriate DSH adjustment factor.
EXAMPLE: Hospital A's DSH payment adjustment factor is 5.5 percent (.0550). The Federal portion of its
DRG revenues including appropriate outlier payments, but excluding any payments for indirect medical
education costs, equals $100,000.
Federal DRG revenues x DSH adjustment factor = DSH adjustment amount $100,000 x .055 = $5,500
The A/B MAC (A) will accumulate a record of the DSH amount paid, the Federal portion of the operating cost
DRG and any outlier amount for hospital discharges after April 30, 1986, to use at cost settlement.
C. - Computation of DSH Adjustment
Compute the amount of the DSH adjustment by multiplying the Federal portion of the hospital's DRG
revenues by the appropriate DSH adjustment factor.
EXAMPLE: Hospital A's DSH payment adjustment factor is 5.5 percent (or .0550). The Federal portion of
its DRG revenues (including appropriate outlier payments, but excluding any payments for indirect medical
education costs) equals $100,000.
Federal DRG revenues x DSH adjustment factor = DSH adjustment amount $100,000 x .055 = $5,500
D. - DSH Exception
The law contains a provision whereby a hospital can qualify for an operating cost DSH adjustment of:
• 15 percent for discharges prior to October 1, 1988;
• 25 percent for discharges between October 1, 1988, and April 1, 1990;
• 30 percent for discharges from April 1, 1990, through September 31, 1991;
• 35 percent for discharges on or after October 1, 1991, if:
° It is located in an urban area and has 100 or more beds; and
° It demonstrates that, during its cost reporting period, more than 30 percent of its total inpatient care
revenues were derived from State and local government payments for indigent care furnished to
patients not covered by Medicare or Medicaid.
It is incumbent upon the hospital to demonstrate that more than 30 percent of its total inpatient care revenues
are from State and local government sources and that they are specifically earmarked for the care of indigents
(that is, none of the money may be used for any purpose other than indigent care). The following are the types
of care that are not included as indigent care:
• Free care furnished to satisfy a hospitals Hill-Burton obligation.
• Free care or care a hospital furnished at reduced rates to its employees or by a government hospital to
any category of public employee.
• Funds furnished to a hospital to cover general operating deficits.
• The adjustment is not automatic from year to year but must be applied for on an annual basis.
Documentation to support the application includes the hospital's complete audited financial statements and
their accompanying notes. The hospital must provide detailed schedules related to State and local revenue
appropriations and outline their purpose.
Unless the appropriations are specifically earmarked for indigent patient care, the A/B MAC (A) shall assume
that a portion of the funds was intended to cover the costs of other uncompensated care, such as bad debts for
non-indigent patients, free care to employees, etc., as well as to cover general operating deficits. The A/B
MAC (A) shall calculate the percentage of charity care included in all uncompensated care and apply the
percentage to the appropriate funds to determine the amount appropriated for charity care.
Hospitals must submit documentation to support amounts claimed as indigent patient care. This includes a
copy of their procedures for determining indigence, steps used to verify a patient's financial information, and
methods used to distinguish bad debts from indigence.
The A/B MAC (A) shall review the documentation submitted in support of the provider's request for a
disproportionate share adjustment under 42 CFR 412.106(c)(2) of the regulations. Beginning with Federal
Fiscal Year (FY) 2011 A/B MACs (A) shall submit to CMS annually by February 28 documentation for the
hospitals they determine meet the qualifying standards for receiving disproportionate share hospital (DSH)
payments under section 42 CFR 412.106(c)(2). This review can be accomplished in conjunction with the
audit/settlement of the cost report for the period subject to the adjustment. At a minimum, the A/B MAC (A)
shall:
• Verify total inpatient revenues;
• Verify that State and local government appropriations on the financial statements are consistent with
amounts contained in governmental appropriations bills;
• Review, on the basis of a sample of cases, the provider's implementation of procedures for identifying
indigent patients. Ensure that amounts for "indigent" patients do not include charges associated with:
° Titles XIX and XVIII patient care;
° Hill-Burton care;
° Free care to employees; and
° Bad debts for patients who are not indigent.
E. - Reporting for PS&R and CWF
The A/B MAC (A) 's PPS Pricer identifies the amount of the DSH adjustment on each bill. The A/B MAC
(A) reports this amount with value code 18 to its PS&R, and to CWF.
20.3.1 - Clarification of Allowable Medicaid Days in the Medicare Disproportionate
Share Hospital (DSH) Adjustment Calculation
(Rev. 1, 10-01-03)
20.3.1.1 - Clarification for Cost Reporting Periods Beginning On or After January 1,
2000
(Rev. 1, 10-01-03)
PM A-01-03
Under §1886(d)(5)(F) of the Social Security Act (the Act), the Medicare disproportionate share patient
percentage is made up of two computations. The first computation includes patient days that were furnished
to patients who, during a given month, were entitled to both Medicare Part A and Supplemental Security
Income (SSI) (excluding State supplementation). This number is divided by the number of covered patient
days utilized by patients under Medicare Part A for that same period. The second computation includes
patient days associated with beneficiaries who were eligible for medical assistance (Medicaid) under a State
plan approved under Title XIX but who were not entitled to Medicare Part A. (See 42 CFR 412.106(b)(4).)
This number is divided by the total number of patient days for that same period.
Included Days
In calculating the number of Medicaid days, the hospital must determine whether the patient was eligible for
Medicaid under a State plan approved under Title XIX on the day of service. If the patient was so eligible, the
day counts in the Medicare disproportionate share adjustment calculation. The statutory formula for
"Medicaid days" reflects several key concepts. First, the focus is on the patient's eligibility for Medicaid
benefits as determined by the State, not the hospital's "eligibility" for some form of Medicaid payment.
Second, the focus is on the patient's eligibility for medical assistance under an approved Title XIX State plan,
not the patient's eligibility for general assistance under a State-only program. Third, the focus is on eligibility
for medical assistance under an approved Title XIX State plan, not medical assistance under a State-only
program or other program. Thus, for a day to be counted, the patient must be eligible on that day for medical
assistance benefits under the Federal-State cooperative program known as Medicaid (under an approved Title
XIX State plan). In other words, for purposes of the Medicare disproportionate share adjustment calculation,
the term "Medicaid days" refers to days on which the patient is eligible for medical assistance benefits under
an approved Title XIX State plan. The term "Medicaid days" does not refer to all days that have some relation
to the Medicaid program, through a matching payment or otherwise; if a patient is not eligible for medical
assistance benefits under an approved Title XIX State plan, the patient day cannot become a "Medicaid day"
simply by virtue of some other association with the Medicaid program.
Medicaid days, for purposes of the Medicare disproportionate share adjustment calculation, include all days
during which a patient is eligible, under a State plan approved under Title XIX, for Medicaid benefits, even if
Medicaid did not make payment for any services. Thus, Medicaid days include, but are not limited to, days
that are determined to be medically necessary but for which payment is denied by Medicaid because the
provider did not bill timely, days that are beyond the number of days for which a State will pay, days that are
utilized by a Medicaid beneficiary prior to an admission approval but for which a valid enrollment is
determined within the prescribed period, and days for which payment is made by a third party. In addition, we
recognize in the calculation days that are utilized by a Medicaid beneficiary who is eligible for Medicaid
under a State plan approved under Title XIX through a managed care organization (MCO) or health
maintenance organization (HMO). However, in accordance with 42 CFR 412.106(b)(4), a day does not count
in the Medicare disproportionate share adjustment calculation if the patient was entitled to both Medicare Part
A and Medicaid on that day. Therefore, once the eligibility of the patient for Medicaid under a State plan
approved under Title XIX has been verified, the A/B MAC (A) must determine whether any of the days are
dual entitlement days and, to the extent that they are, subtract them from the other days in the calculation.
Excluded Days
Many States operate programs that include both State-only and Federal-State eligibility groups in an
integrated program. For example, some States provide medical assistance to beneficiaries of State-funded
income support programs. These beneficiaries, however, are not eligible for Medicaid under a State plan
approved under Title XIX, and, therefore, days utilized by these beneficiaries do not count in the Medicare
disproportionate share adjustment calculation. If a hospital is unable to distinguish between Medicaid
beneficiaries and other medical assistance beneficiaries, then it must contact the State for assistance in doing
so.
In addition, if a given patient day affects the level of Medicaid DSH payments to the hospital but the patient is
not eligible for Medicaid under a State plan approved under Title XIX on that day, the day is not included in
the Medicare DSH calculation.
It should be noted that the types of days discussed above are not necessarily the only types of excluded days.
Please see the chart in 140.2.4.1, which summarizes some, but not necessarily all, of the types of days to be
excluded from (or included in) the Medicare DSH adjustment calculation.
To provide consistency in both components of the calculation, any days that are added to the Medicaid day
count must also be added to the total day count, to the extent that they have not been previously so added.
Regardless of the type of allowable Medicaid day, the hospital bears the burden of proof and must verify with
the State that the patient was eligible under one of the allowable categories during each day of the patient's
stay. The hospital is responsible for and must provide adequate documentation to substantiate the number of
Medicaid days claimed. Days for patients that cannot be verified by State records to have fallen within a
period wherein the patient was eligible for Medicaid as described in this memorandum cannot be counted.
20.3.1.2 - Hold Harmless for Cost Reporting Periods Beginning Before January 1, 2000
(Rev. 1, 10-01-03)
In accordance with the hold harmless position communicated by CMS on October 15, 1999, for cost reporting
periods beginning before January 1, 2000, hospitals are not to disallow, within the parameters discussed
below, the portion of Medicare DSH adjustment payments previously made to hospitals attributable to the
erroneous inclusion of general assistance or other State-only health program, charity care, Medicaid DSH,
and/or ineligible waiver or demonstration population days in the Medicaid days factor used in the Medicare
DSH formula. This is consistent with CMS' determination that hospitals and A/B MACs (A) relied, for the
most part, on Medicaid days data obtained from State Medicaid agencies to compute Medicare DSH payments
and that some of those agencies commingled the types of otherwise ineligible days listed above with Medicaid
Title XIX days in the data transmitted to hospitals and/or A/B MACs (A). Although CMS has decided to
allow the hospitals to be held harmless for receiving additional payments resulting from the erroneous
inclusion of these types of otherwise ineligible days, this decision is not intended to hold hospitals harmless
for any other aspect of the calculation of Medicare DSH payments or any other Medicare payments.
Hospitals That Received Payments Reflecting the Erroneous Inclusion of Days at Issue
In practical terms this means that the A/B MAC (A) is not to reopen any cost reports for cost reporting periods
beginning before January 1, 2000, to disallow the portions of Medicare DSH payments attributable to the
erroneous inclusion of general assistance or other State-only health program charity care, Medicaid DSH,
and/or ineligible waiver or demonstration population days if the hospital received payments for those days
based on those cost reports. If, prior to the issuance of this Program Memorandum, a hospital reopened a
settled cost report to disallow the portion of Medicare DSH payment attributable to the inclusion of these
types of days, reopen that cost report again and refund the amounts (including interest) collected. Do not,
however, pay the hospitals interest on the amounts previously recouped as result of the disallowance.
Furthermore, on or after October 15, 1999, the A/B MAC (A) is not to accept reopening requests for
previously settled cost reports or amendments to previously submitted cost reports pertaining to the inclusion
of these types of days in the Medicare DSH formula.
For cost reporting periods beginning before January 1, 2000, hospitals are to continue to allow these types of
days in the Medicare DSH calculation for all open cost reports only in accordance with the practice followed
for the hospital at issue before October 15, 1999, (i.e., for open cost reports, the A/B MAC (A) allows only
those types of otherwise ineligible days that the hospital received payment for in previous cost reporting
periods settled before October 15, 1999). For example, if, for a given hospital, a portion of Medicare DSH
payment was attributable to the erroneous inclusion of general assistance days for only the out-of-State or
HMO population in cost reports settled before October 15, 1999, the A/B MAC (A) is to include the ineligible
waiver days for only that population when settling open cost reports for cost reporting periods beginning
before January 1, 2000. However, the actual number of general assistance and other State-only health
program, charity care, Medicaid DSH, and/or ineligible waiver or demonstration days, as well as Medicaid
Title XIX days that the A/B MAC (A) allows for the open cost reports must be supported by auditable
documentation provided by the hospital.
Hospitals That Did Not Receive Payments Reflecting the Erroneous Inclusion of Days at Issue
If a hospital did not receive any payment based on the erroneous inclusion of general assistance or other State-
only health program, charity care, Medicaid DSH, and/or waiver or demonstration population days for cost
reports that were settled before October 15, 1999, and the hospital never filed a jurisdictionally proper appeal
to the Provider Reimbursement Review Board (PRRB) on this issue, the A/B MAC (A) is not to pay the
hospital based on the inclusion of these types of days for any open cost reports for cost reporting periods
beginning before January 1, 2000. Furthermore, on or after October 15, 1999, the A/B MAC (A) is not to
accept reopening requests for previously settled cost reports or amendments to previously submitted cost
reports pertaining to the inclusion of these types of days in the Medicare DSH formula.
If, for cost reporting periods beginning before January 1, 2000, a hospital that did not receive payments
reflecting the erroneous inclusion of otherwise ineligible days filed a jurisdictionally proper appeal to the
PRRB on the issue of the exclusion of these types of days from the Medicare DSH formula before October 15,
1999, the A/B MAC (A) will reopen the cost report at issue and revise the Medicare DSH payment to reflect
the inclusion of these types of days as Medicaid days. If there are any questions or concerns regarding the
qualifications for a "jurisdictionally proper appeal," the A/B MAC (A) submits them in writing before
rendering a decision in a specific case to:
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Office of Financial Management
Financial Services Group
Location C3-14-16
Baltimore, Maryland 21244-1850.
Where, for cost reporting periods beginning before January 1, 2000, a hospital filed a jurisdictionally proper
appeal to the PRRB on the issue of the exclusion of these types of days from the Medicare DSH formula on or
after October 15, 1999, reopen the settled cost report at issue and revise the Medicare DSH payment to reflect
the inclusion of these types of days as Medicaid days, but only if the hospital appealed, before October 15,
1999, the denial of payment for the days in question in previous cost reporting periods. The actual number of
these types of days that are used in this revision must be properly supported by adequate documentation
provided by the hospital. Do not reopen a cost report and revise the Medicare DSH payment to reflect the
inclusion of these types of days as Medicaid days if, on or after October 15, 1999, a hospital added the issue of
the exclusion of these types of days to a jurisdictionally proper appeal already pending before PRRB on other
Medicare DSH issues or other unrelated issues.
Continue to pay the Medicare DSH adjustment reflecting the inclusion of general assistance or other State-
only health program, charity care, Medicaid DSH, and/or waiver or demonstration population days for all
open cost reports for cost reporting periods beginning before January 1, 2000, to any hospital that, before
October 15, 1999, filed a jurisdictionally proper appeal to the PRRB specifically for this issue on previously
settled cost reports.
Finally, if a hospital has filed a jurisdictionally proper appeal with respect to the CMS 97-2 ruling and the
hospital has otherwise received payment for the portion of Medicare DSH adjustment attributable to the
inclusion of general assistance or other State-only health programs, charity care, Medicaid DSH, and/or
ineligible waiver or demonstration population days based on its paid Medicaid days, include these types of
unpaid days in the Medicare DSH formula when revising the cost reports affected by the CMS 97-2 appeal.
TYPE OF DAY DESCRIPTION
ELIGIBLE
TITLE XIX
DAY
General Assistance
Patient Days
Days for patients covered under a State-only (or county-
only) general assistance program (whether or not any
payment is available for health care services under the
program). These patients are not Medicaid-eligible
under the State plan.
No.
Other State-Only Health
Program Patient Days
Days for patients covered under a State-only health
program. These patients are not Medicaid-eligible
under the State plan.
No.
Charity Care Patient
Days
Days for patients not eligible for Medicaid or any other
third-party payer, and claimed as uncompensated care
by a hospital. These patients are not Medicaid-eligible
under the State plan.
No.
Actual 1902(r)(2) and
1931(b) Days
Days for patients eligible under a State plan based on a
1902(r)(2) or 1931(b) election. These patients are
Medicaid-eligible under the Title XIX State plan under
the authority of these provisions, which is exercised by
the State in the context of the approved State plan.
Yes.
Medicaid Optional
Targeted Low-Income
Children (CHIP-related)
Days
Days for patients who are Title XIX-eligible and who
meet the definition of "optional targeted low-income
children" under
§1905(u)(2). The difference between
these children and other Title XIX children is the
enhanced FMAP rate available to the State. These
children are fully Medicaid-eligible under the State
plan.
Yes.
TYPE OF DAY DESCRIPTION
ELIGIBLE
TITLE XIX
DAY
Separate CHIP Days
Days for patients who are eligible for benefits under a
non-Medicaid State program furnishing child health
assistance to targeted low-income children. These
children are, by definition, not Medicaid-eligible under
a State plan.
No.
§1915(c) Eligible Patient
(the "217" group) Days
Days for patients in the eligibility group under the State
plan for individuals under a Home and Community
Based Services waiver. This group includes individuals
who would be Medicaid-eligible if they were in a
medical institution. Under this special eligibility group,
they are Medicaid-eligible under the State plan.
Yes.
Retroactive Eligible Days
Days for patients not enrolled in the Medicaid program
at the time of service, but found retroactively eligible
for Medicaid benefits for the days at issue. These
patients are Medicaid-eligible under the State plan.
Yes.
Medicaid Managed Care
Organization Days
Days for patients who are eligible for Medicaid under a
State plan when the payment to the hospital is made by
an MCO for the service. An MCO is the financing
mechanism for Medicaid benefits, and payment for the
service through the MCO does not affect eligibility.
Yes.
Medicaid DSH Days
Days for patients who are not eligible for Medicaid
benefits, but are considered in the calculation of
Medicaid DSH payments by the State. These patients
are not Medicaid-eligible.
Sometimes Medicaid State plans specify that Medicaid
DSH payments are based upon a hospital's amount of
charity care or general assistance days. This, however,
is not "payment" for those days, and does not mean that
the patient is eligible for Medicaid benefits or can be
counted as such in the Medicare formula.
No.
20.3.1.3 – Disproportionate Share Hospital (DSH) Policy Changes Effective for Cost
Reporting Periods beginning on or after October 1, 2009
(Rev. 2627, Issued 01-04-13, Effective 10-01-12, Implementation 10-01-12)
Observation Days
For cost reporting periods beginning on or after October 1, 2009, observation days for patients later admitted as an
inpatient will no longer be included in the Medicare disproportionate patient percentage (DPP). In addition,
observation bed days for patients later admitted as an inpatient will no longer be counted towards a hospital’s
available bed day count for DSH and IME. Between October 1, 2003, and October 1, 2009, hospitals had reported
on their cost report the Medicaid observation patient days for admitted patients and total observation patient days
for admitted patients for inclusion in the Medicaid fraction of the Medicare DPP, and for the determination of the
available bed day count for DSH and IME. However, effective for cost reporting periods beginning on or after
October 1, 2009, observation patient days are no longer included in the DPP, and observation bed days will no
longer be counted towards the available bed day count for DSH or IME.
Labor and Delivery Patient Days
For cost reporting periods beginning on or after October 1, 2009, we will include in the Medicare disproportionate
patient percentage (DPP) patient days associated with maternity patients who were admitted as inpatients and were
receiving ancillary labor and delivery services at the time the inpatient routine census is taken, regardless of
whether the patient occupied a routine bed prior to occupying an ancillary labor and delivery bed and regardless of
whether the patient occupies a “maternity suite” in which labor, delivery, recovery and postpartum care all take
place in the same room. Prior to October 1, 2009, patient days associated with beds used for ancillary labor and
deliver were not counted in the DPP. However, for cost reporting periods beginning on or after October 1, 2009,
but before cost reporting periods beginning on or after October 1, 2012, if a patient, admitted to the hospital as
an inpatient, occupies an ancillary bed for labor and delivery, the patient days associated with the ancillary
labor/delivery services will be counted in the DPP. For cost reporting periods beginning on or after October 1,
2009 but before cost reporting periods beginning on or after October 1, 2012, this policy applies only to
counting patient days, and does not change the policy of determining the number of available beds in 42 CFR
412.106(a). Beds associated with ancillary labor/delivery services are not included in the available bed day count.
Reporting Inpatient Days in the Numerator of the Medicaid Fraction
Hospitals can report days in the numerator of the Medicaid fraction by one of three methodologies. For cost
reporting periods beginning on or after October 1, 2009, hospitals can report Medicaid-eligible days based on date
of discharge, date of admission, or dates of service. A hospital is required to notify CMS (through the fiscal
intermediary or MAC) in writing if the hospital chooses to change its methodology of counting days in the
numerator of the Medicaid fraction. The written notification should be submitted at least 30 days prior to the
beginning of the cost reporting period to which the change would apply. The written notification must specify the
changed methodology the hospital wishes to use and the cost reporting period for which the methodology would
apply. The change in methodology would be effective on the first day of the specified cost reporting period for the
entire cost reporting period. The change would be effective for all future cost reporting periods unless the hospital
submits a subsequent written notification to change its methodology.
20.3.1.4 – Disproportionate Share Hospital (DSH) Policy Changes Effective for Cost
Reporting Periods beginning on or after October 1, 2012
(Rev. 2627, Issued 01-04-13, Effective 10-01-12, Implementation 10-01-12)
Labor and Delivery Bed Days
Effective for cost reporting periods beginning on or after October 1, 2012, we will include bed days associated
with ancillary labor/delivery services to determine the number of beds in 42CFR412.105(b), which is cross-
referenced in 42 CFR412.106(a)(1)(i) for the purposes of determining the DSH payment adjustment. Bed days
associated with ancillary labor/delivery services will be included to determine the number of beds for DSH
and IME. For cost reporting periods beginning before October 1, 2012, bed days associated with ancillary
labor and delivery services were not counted in the available bed day count for DSH and IME.
20.3.2 - Updates to the Federal Fiscal Year (FY) 2001
(Rev. 1, 10-01-03)
PM A-01-47
20.3.2.1 - Inpatient Hospital Payments and Disproportionate Share Hospital (DSH)
Thresholds and Adjustments
(Rev. 1, 10-01-03)
The new FY 2001 operating standardized amounts are effective April 1, 2001, as required by §301 of BIPA
2000 (P.L. 106-554), and the new DSH thresholds and adjustments are required by §211 of BIPA 2000. In
conjunction with the new standardized amount, the new capital rates and outlier adjustment factor thresholds
are effective April 1, 2001.
The following standardized amounts effective for discharges occurring on or after April 1, 2001, and before
October 1, 2001, are:
Final FY 2001 Operating Rates
Designation
Large Urban
Areas
Large Urban
Areas
Other Areas
Other Areas
Labor-
Related
Nonlabor-
Related
Labor-
Related
Nonlabor-
Related
+National
$2,925.82
$1,189.26
$2,879.51
$1,170.43
National PR
$2,900.64
$1,179.02
$2,900.64
$1,179.02
Puerto Rico
$1,402.79
$564.66
$1,380.58
$555.72
SCHs
$2,895.02
$1,176.74
$2,849.20
$ 1,158.11
Final FY 2001 Capital Rates
National
$380.85
Puerto Rico
$184.61
Due to the changes to the standardized amounts, CMS recalculated the fixed loss cost outlier threshold
applicable for discharges on or after April 1, 2001, and before October 1, 2001. The new thresholds are equal
to the prospective payment rate for the DRG plus the IME and DSH payments plus $16,350 ($14,940 for
hospitals that have not yet entered the prospective payment system for capital-related costs).
In addition, §211 of BIPA 2000 revised the thresholds by which certain classes of hospitals qualify for the
disproportionate share adjustment, effective for discharges occurring on or after April 1, 2001. Section 211
also revised the adjustment computations for these hospitals.
The specific changes are identified below.
Hospital Type
Qualifying DSH
Percent
Adjustment Computation
Urban Hospitals
0-99 Beds
≥15%, <19.3%
≥19.3%
2.5% + [.65 x (DSH pct.-15)]
5.25%
100+ Beds (No Change in Law)
≥15%,<20.2%
≥20.2%
2.5% + [.65 x (DSH pct.-15%)]
5.88% + [.825 x (DSH pct.-20.2%)]
Rural Hospitals
Sole Community Hospitals (SCH)
≥15%, <19.3%
≥19.3%,<30%
≥30%
2.5% + [.65 x (DSH pct.-15%)]
5.25%
10%
Rural Referral Centers (RRC)
≥15%,<19.3%
≥19.3%,<30%
≥30%
2.5% + [.65 x (DSH pct.-15%)]
5.25%
5.25% + [.6 x (DSH pct.-30%)]
Both SCH and RRC
≥15%
higher of SCH or RRC adjustment
Other Rural Hospitals
0-499Beds
≥15%,<19.3%
≥19.3%
2.5% + [.65 x (DSH pct.-15%)]
5.25%
500+ Beds (No Change in Law)
≥15%,<20.2%
≥20.2%
2.5% + [.65 x (DSH pct.-15%)]
5.88% + [.825 x (DSH pct. -20.2%)]
These new rates as well as changes to the DSH adjustments are incorporated into Pricer 01.2. The formulas
are spelled out in the statute.
20.3.3 – Prospective Payment Changes for Fiscal Year (FY) 2003
(Rev. 1, 10-01-03)
A-02-084
The PPS changes for FY2003 were published in the Federal Register on August 1, 2002. All changes are
effective for hospital discharges occurring on or after October 1, 2002, unless otherwise noted.
ICD-9-CM coding changes are effective October 1, 2002. The new ICD-9-CM codes are listed, along with
their diagnosis-related group (DRG) classifications in Tables 6a and 6b in the final rule for PPS changes for
FY 2003. The ICD-9-CM codes that have been replaced by expanded codes or other codes, or have been
deleted are included in Tables 6c and 6d. The revised code titles are in Tables 6e and 6f of the same final rule.
GROUPER 20.0 assigns each case into a DRG on the basis of the diagnosis and procedure codes and
demographic information (that is age, sex, and discharge status) and is effective with discharges occurring on
or after October 1, 2002. Medicare Code Editor (MCE) 19.0 and Outpatient Code Editor (OCE) versions 18.0
and 3.20 use the new ICD-9-CM codes to validate coding for discharges and outpatient services effective
October 1, 2002.
Additional changes for FY 2003 are:
• The standardized amount update factor is 2.95 percent for all hospitals.
• The hospital specific update factor is 2.95 percent for all hospitals.
• The common fixed loss cost outlier threshold in FY 2003 is equal to the PPS rate for the DRG, Indirect
Medical Education (IME), and Disproportionate Share Hospital (DSH) plus $33,560.
• The marginal cost factor for cost outliers remains 80 percent.
• The 2003 Federal capital rate is $407.01 and the Puerto Rico capital rate is $198.29.
• The FY 2003 outlier adjustment factor is 0.948999 for the operating standardized amount.
• The FY 2003 outlier adjustment factor for Puerto Rico is 0.981651 for the operating standardized
amount. Also new for FY 03, there is an outlier adjustment factor of 0.965325 for operating
national/Puerto Rican blend.
• Payments under the DSH provision are not reduced in FY 2003.
• The IME formula is 1.35*[(1+ resident-to-bed ratio)**. 405-1] for FY 2003.
• The revised hospital wage indexes and geographic adjustment factors are contained in Tables 4a
(urban areas), 4b (rural areas) and 4c (redesignated hospitals) of section VI of the addendum to the
PPS final rule.
• Grouper 20.0 and MCE 19.0 for discharges occurring on or after October 1, 2002 replace earlier
versions of the software.
See Addendum: Hospital Reclassifications and Redesignations by Individual Hospital - FY2003.
20.3.4 – Prospective Payment Changes for Fiscal Year (FY) 2004 and Beyond
(Rev. 3431, Issued: 12-29-15, Effective: 10-01-15, Implementation: 10-05-15)
The IPPS changes for FY 2004 were published in the Federal Register on August 1, 2003. All changes are
effective for hospital discharges occurring on or after October 1, 2003. Additional changes were listed in a
Correction Notice to the Federal Register on October 6, 2003, and a One Time Notification (Pub. 100-20,
Transmittal 16, published on October 31, 2003).
Fiscal year changes to the inpatient prospective payment system occur every October. Specific instructions
will be published shortly after the publication of the IPPS Final Rule each year. In addition, other changes to
the inpatient prospective payment system may occur in January, April or July as necessary.
20.4 - Hospital Capital Payments Under PPS
(Rev. 1, 10-01-03)
A3-3611
The Omnibus Budget Reconciliation Act of 1987 established an effective date of October 1, 1991, for capital
PPS. Capital PPS will pay hospitals a fixed amount for each Medicare admission upon completion of a 10-
year transition period.
Hospitals and hospital distinct part units that are excluded from PPS for operating costs are also excluded
from PPS for capital costs. They continue to be paid for capital-related costs on a reasonable cost basis.
Capital payments are based on the same DRG designations and weights, outlier guidelines, geographic
classifications, wage indexes, and disproportionate share percentages that apply to PPS for operating costs.
The indirect teaching adjustment is based on the ratio of residents to average daily census. The hospital split
bill, adjustment bill, waiver of liability and remaining guidelines in §§40, also apply to capital PPS payments.
Outlier thresholds and computation methods have been combined effective with FY 1993 for operating and
capital costs.
Capital transfer cases are paid on a per diem basis analogous to the manner in which operating PPS payments
are made for transfer cases.
Beneficiary deductible and coinsurance obligations do not apply to capital costs. Ancillary costs paid under
Part B do not impact capital PPS payments. The 10-year transition period was established to protect hospitals
that had incurred capital obligations in excess of the standardized national rate from major disruption. These
high capital cost hospitals are known as "hold harmless" hospitals. The transition period also provides for
phase-in of the national rate for those hospitals with capital obligations that are less than the national rate.
A combined payment is made for both operating costs and capital costs under PPS, but the value of the
payment for each must be separately identified in the remittance advice for accounting purposes.
20.4.1 - Federal Rate
(Rev. 1, 10-01-03)
A3-3611.1
The standard Federal capital payment for FY 1992 and later years is based on the projected national average
Medicare capital costs per discharge for each of the fiscal years. The Federal rate is adjusted for each
hospital's case mix, day and cost outliers and wage index location. A hospital qualifies for a capital DSH
adjustment if it is located in a large urban or other urban area, has at least 100 beds, and has a disproportionate
share (DSH) percentage greater than 0.
The Federal rate is adjusted annually to reflect changes in these factors.
An adjustment is also provided to the Federal rate for indirect costs of medical education of interns and
residents. The A/B MAC (A) calculates the adjustment by dividing the hospital's full-time equivalent total of
interns and residents by the hospital's total patient days (line 8, column 6 of worksheet S3 of the CMS Form
2552-89, minus the total of the lines 1B, 1C, 1D, and 7, divided by the number of days in the cost reporting
period.) It reviews the hospital's records and makes any needed changes in the count at the end of the cost
reporting period. It enters the indirect medical education adjustment ratio in positions 184-188 of the
provider-specific file for use by Pricer.
20.4.2 - Hold Harmless Payments
(Rev. 1, 10-01-03)
A3-3611.2
In FY 1992, hospitals with a hospital-specific rate for capital that is above the Federal PPS rate for the cost
reporting period that ended in FY 1990 can receive the higher of:
• The hold harmless-old capital rate, which is 100 percent of the reasonable costs of old capital for sole
community hospitals, or 85 percent of the reasonable costs associated with old capital for all other
hospitals, plus a payment for new capital (see §20.4.5 for the definitions of old and new capital); or
• The hold harmless - 100 percent Federal rate.
The A/B MAC (A) adjusts the hospital-specific rate in the cost report for the period ending in FY 1990 for
case mix. It updates the rate to FY 1992 levels using the projected increase in national average capital costs
per discharge to initially determine whether a hospital should be paid under the hold harmless or the fully
prospective methodology. The type of methodology is entered in the provider-specific file. (See §20.2.3.)
Hospitals paid under the fully prospective methodology may change to the hold harmless methodology if
justified by the addition of obligated capital and other changes in remaining old capital costs subsequent to the
base period. This option is available through the later of a hospital's cost reporting period beginning in FY 94
or after obligated capital has been put in use. Hospitals must request an extension from the A/B MAC (A) by
the later of January 1, 1993, or within 180 days of the event causing the delay, if they will be unable to put an
asset in use for inpatient care by October 1, 1996. The new hospital-specific rate reflects the disposal of old
assets and the addition of obligated capital costs, but not new capital acquisitions. If the recalculated hospital-
specific rate exceeds the Federal rate, the hospital will be paid under the hold harmless methodology. The
payment methodology in effect for FY 94 (or after the obligated capital has been put in use, if later)
determines the payment methodology applicable for the remainder of the transition period under either
transition payment methodology.
The A/B MAC (A) does not hold harmless a hospital for increased costs resulting from a lease arrangement
entered into after December 31, 1990.
If a hospital has such low Medicare utilization in its original capital base period that it is not required to file a
cost report, its hospital-specific rate will be based on its old capital costs per discharge in the first 12-month
cost reporting period for which a cost report is filed.
The A/B MAC (A) converts a reasonable cost/hold harmless hospital to the 100 percent Federal payment rate
when:
• Advantageous due to reductions in depreciation and/or the allowable percentage of old capital;
• A hospital elects to be paid at 100 percent of the Federal rate; or
• A hospital does not maintain adequate records to identify its old capital related costs.
The A/B MAC (A) enters the payment methodology change in the provider-specific file.
An adjustment is also provided to the Federal rate for indirect costs of medical education of interns and
residents. The A/B MAC (A) calculates the adjustment by dividing the hospital's full-time equivalent total of
interns and residents by the hospital's total patient days (line 8, column 6 of worksheet S3 of the CMS Form
2552-89, minus the total of the lines 1B, 1C, 1D, and 7, divided by the number of days in the cost reporting
period). It reviews the hospital's records and makes any needed changes in the count at the end of the cost
reporting period. It enters the indirect medical education adjustment ratio in positions 184-188 of the
provider-specific file for use by Pricer.
20.4.3 - Blended Payments
(Rev. 1, 10-01-03)
A3-3611.3
Hospitals with a FY 1990 hospital-specific rate for capital below the Federal rate are paid a fully prospective
capital rate based on a blend of their hospital-specific rate and the Federal rate. The payment for discharges
occurring during a cost-reporting period that began in FY 1992 is based on a blend of 90 percent of the
hospital-specific rate and 10 percent of the Federal rate. The payment for discharges occurring during a cost-
reporting period that began in FY 1993 is based on a blend of 80 percent of the hospital-specific rate and 20
percent of the Federal rate. The Federal portion of the payment increases by 10 percent each year and the
hospital-specific portions decreases by 10 percent each year, culminating in payment at 100 percent of the
Federal rate in the tenth year.
20.4.4 - Capital Payments in Puerto Rico
(Rev. 1, 10-01-03)
A3-3611.4
A special standard rate applies to Puerto Rico. It is a combination of 50 percent of the Federal capital amount
and 50 percent of the Puerto Rican capital amount. It is used in lieu of the Federal rate to compute hold
harmless and fully prospective payments for PPS hospitals in Puerto Rico.
20.4.5 - Old and New Capital
(Rev. 1, 10-01-03)
A3-3611.5
Old capital is a hospital asset that:
• Has been put in use for patient care on or before December 31, 1990; or
• Has been legally committed to by an enforceable contract entered into on or before December 31,
1990, and put in patient use before October 1, 1994.
All other assets are considered new for Medicare purposes.
20.4.6 - New Hospitals
(Rev. 1, 10-01-03)
A3-3611.6
New hospitals that open during the national 10-year transition are exempt from capital PPS payment for their
first two years of operation. A new hospital is one that does not have a 12-month cost reporting period that
ended on or before September 30, 1990. The new hospital exemption does not apply to:
• A new acute care hospital that operated as a PPS excluded hospital for 2 or more years before its
transition to PPS;
• A hospital which has been open more than 2 years, but has participated in Medicare fewer than 2
years;
• A hospital that closes and reopens within 2 years under the same or different ownership; or
• A hospital that builds a new or replacement facility at the same or a new location, even if a change of
ownership or new leasing arrangements are involved.
A new hospital is paid 85 percent of its reasonable costs for capital during the exemption period. The
hospital's second year of operation is the base period for determination of the hospital-specific rate and old
capital assets. Effective with its third year of operation, the hospital is paid:
• The fully prospective methodology if the hospital-specific rate is less than the Federal rate. The A/B
MAC (A) uses the blend rate applicable to the Federal FY in which the base period begins. For
example, a new hospital with a hospital-specific rate less than the Federal rate and a base year
beginning in FY 1995 is paid 70 percent of its hospital-specific rate and 30 percent of the Federal rate;
or
• The hold harmless methodology if the hospital-specific rate is greater than the Federal rate. Hold
harmless payments may continue for up to 8 years. They may continue beyond the first cost reporting
period that begins on or after October 1, 2000.
20.4.7 - Capital PPS Exception Payments
(Rev. 1, 10-01-03)
A3-3611.7, 42 CFR 412.348
Exception payments are provided for hospitals with inordinately high levels of capital obligations. Payment is
made to a hospital paid under either the fully prospective payment methodology, or the hold-harmless
payment methodology. Exception payments will expire at the end of the 10-year transition period. Exception
payments ensure that:
• Sole community hospitals receive 90 percent of their Medicare inpatient capital costs;
• Urban hospitals with 100 or more beds and a disproportionate share patient percentage of at least 20.2
percent receive 80 percent of their Medicare inpatient capital costs; and
• All other hospitals receive 70 percent of their Medicare inpatient capital costs.
Pricer adds interim exception payments to the basic capital payment, using the rate entered in positions 189-
194 of the provider-specific file. The A/B MAC (A) adjusts these interim payments, as needed, at cost report
settlement.
A hospital is entitled to an additional payment if its capital payments for the cost reporting period would
otherwise be less than the applicable minimum payment level. The additional payment equals the difference
between the applicable minimum payment level and the capital payments that the hospital would otherwise
receive minus any offset amount.
A limited exception is also provided during the 10-year transition period for hospitals that experience
unanticipated extraordinary circumstances that require an unanticipated major capital expenditure. Events
such as a tornado, earthquake, catastrophic fire, or a hurricane are examples of extraordinary circumstances.
The capital project must cost at least $5 million (net of proceeds from other payment sources such as
insurance, litigation decisions and other State, local or Federal government funding programs) to qualify for
this exception. An eligible hospital's minimum payment level under this exception is 85 percent of costs
associated with the unanticipated capital expenditure and the applicable minimum payment level for its other
Medicare inpatient capital costs.
Total estimated payments under the exception process may not exceed 10 percent of the total estimated capital
prospective payments (exclusive of hold-harmless payments for old capital) for the same fiscal year.
These limited exceptions must be approved by CMS prior to payment. If approved, the A/B MAC (A)
includes the limited exception payment amount per discharge in the exception field of the provider specific
file.
20.4.8 - Capital Outliers
(Rev. 1, 10-01-03)
A3-3611.8
Total Federal PPS payments are reduced by an amount equal to anticipated outlier payments for the year to
fund capital and operating outlier payments. Outlier payments apply only to the Federal portions of capital
payments. Pricer calculates outlier payments.
Pricer used a combined methodology to determine the day outlier payment rate for capital and operating day
outliers (Day outliers were eliminated after FY 1997). A second combined methodology is used to
determine the cost outlier payment rate for capital and operating costs. A capital or operating cost outlier is
paid only if both capital and operating costs related to an admission exceed the combined outlier threshold.
Pricer pays the higher of the combined total cost outlier payment or the total day outlier payment. An
exception applies to a transferring hospital. A transferring hospital may be paid a cost outlier, but may not be
paid a day outlier unless DRG 385 or 456 applies. The outlier computation methodology is contained in the
A/B MAC (A) Pricer installation guide. (See §20.7 for the common thresholds that apply to both operating
and capital outliers.)
20.4.9 - Admission Prior to and Discharge After Capital PPS Implementation Date
(Rev. 1, 10-01-03)
A3-3611.9
The capital payment issued for an inpatient hospital stay that begins prior to and ends after the onset of capital
PPS is the amount determined by Pricer for that DRG. No reasonable cost capital pass through payment is
payable for the portion of the stay that pre-dates capital PPS. The A/B MAC (A) may not split a bill for the
periods before and after the onset of capital PPS that fall into the same billing period.
It bases any outlier payment due on the entire stay, not only that portion of the stay that began after the start of
capital PPS.
20.4.10 - Market Basket Update
(Rev. 1, 10-01-03)
A3-3611.10
For FY 1992 through FY 1995, the update to the Federal and the hospital-specific rates is based on actual
increases in capital-related costs per discharge adjusted for case mix change. For example, FY 1993 rate
updates are based on a comparison of inpatient capital costs per case in Medicare cost reports beginning in FY
1990 and the costs per case in the cost reports beginning in FY 1988. The update computation will be
modified after FY 1995 to reflect the capital market basket index, changes in capital requirements and new
technology. Annual updates for periods after FY 1992 will be effective October 1 for all PPS hospitals, rather
than the start of cost report periods that begin during that FY.
20.5 - Rural Referral Centers (RRCs)
(Rev. 1, 10-01-03)
A3-3610.16, HO-415.17
Section 1886(d)(5)(C) of the Act provides for exceptions and adjustments to the standardized prospective
payment amounts to take into account the special needs of RRCs. The adjustment allowed for approved RRCs
is that they are paid based upon the urban, rather than rural, prospective payment rates as adjusted by the
applicable DRG weighting factor and the rural area index. In addition, OBRA 89 (P.L. 101-239) extended
RRC status through cost reporting periods beginning before October 1992 to any hospital classified as an RRC
as of September 30, 1989.
To retain status as an RRC effective with the cost reporting period beginning on or after October 1, 1992, a
hospital must have met the criteria for classification as an RRC in at least two of the prior three years, or
qualify on the basis of the requirements for initial RRC certification for the current year. The A/B MAC (A)
will not review the RRC status of a hospital before the end of its third full cost reporting year as an RRC. It
will limit review of RRCs in operation more than three years at the beginning of FY 1993 to a hospital's most
recent three years. RRCs that pass review as meeting RRC status for at least two of the last three years
receive a 3-year extension of their RRC status.
The rates in Pricer include a reduction in the adjusted standardized amounts for all hospitals to ensure that
total PPS payment neither increase nor decrease as a result of the increase in payments to RRCs.
To qualify for initial RRC status for cost reporting periods beginning on or after October 1, 1992, a rural
hospital must have had at least 275 beds, or the hospital must have met one of three criteria in 42 CFR
412.96(c) (3), (4) and (5), and both of the following requirements:
• The hospital's case-mix index value for FY 91 must have been at least 1.2760, or equal to the median
case-mix index value for urban hospitals (excluding hospitals with approved teaching programs)
calculated by CMS for the census region in which the hospital is located, if fewer.
• For its cost reporting period that began during FY 1991, the hospital must have had at least 5000
discharges, or equal to the median number of discharges for urban hospitals in that census region, if
fewer, or if an osteopathic hospital, must have had at least 3000 discharges.
The CMS publishes the median case-mix index value and the median number of discharges annually in the
PPS update in the "Federal Register."
20.6 - Criteria and Payment for Sole Community Hospitals and for Medicare Dependent
Hospitals
(Rev. 1816; Issued: 09-17-09; Effective Date: Discharges on or after October 1, 2009; Implementation
Date: 10-05-09)
A. - Criteria for Sole Community Hospitals (SCHs)
A sole community hospital (SCH) is a hospital that is paid under the Medicare hospital inpatient prospective
payment system (IPPS) and is either located more than 35 miles from other like hospitals or is located in a
rural area, and meets the criteria for SCH status as specified at 42 CFR 412.92 (Title 42 of the Code of Federal
Regulations, Section 412.92, Special treatment: Sole community hospitals). A hospital may be designated as
an SCH effective with cost reporting periods beginning on or after October 1, 1990.
B. - Criteria for Medicare Dependent Hospitals (MDHs)
A Medicare-dependent, small rural hospital (MDH) is a hospital that is paid under the Medicare hospital
inpatient prospective payment system (IPPS) and meets the criteria for MDH status as specified at 42 CFR
412.108 (Title 42 of the Code of Federal Regulations, Section 412.108 Special treatment: Medicare-
dependent, small rural hospitals). A hospital may be designated as an MDH effective with cost reporting
periods beginning on or after April 1, 1990, and ending on or before March 31, 1993, and for discharges
occurring on or after October 1, 1997, and before October 1, 2011.
C. - Payment to SCHs and MDHs
SCHs and MDHs are paid based on either the Federal rate or their hospital-specific (HSP) rate, whichever will
result in the greatest payment. The HSP rate is the hospital’s rate based on their updated costs per discharge
for a particular fiscal year (FY) as specified in statute. Like all IPPS hospitals paid, SCHs and MDHs are paid
for their discharges based on the diagnosis-related DRG classification and weights regardless of whether
payment based on the Federal rate or the hospital’s HSP rate results in the greatest payment.
SCHs will be paid based on their HSP rate for either FY 1982, 1987, 1996 (for cost reporting periods
beginning on or after October 1, 2000) or 2006 (for cost reporting periods beginning on or after January 1,
2009) if this results in a greater payment than the Federal rate. For more detail, see 42 CFR 412.92(d) and 42
CFR 412.73, 412.75, 412.77, and 412.78, respectively, for determining the HSP rates for FYs 1982, 1987,
1996 and 2006.
MDHs will be paid based on their HSP rate for either FY 1982, 1987, or 2002 (for cost reporting periods
beginning on or after October 1, 2006) if this results in a greater payment than the Federal rate. For more
detail, see 42 CFR 412.108(c) and 42 CFR 412.73, 412.75, and 412.79, respectively, for determining the HSP
rates for FYs 1982, 1987, and 2002.
In addition, qualifying SCHs and MDHs that experience a significant decrease in its number of discharges
may receive an additional payment as specified at 42 CFR 412.92(e) and 42 CFR 412.108(d), respectively.
In general, the HSP rates for both SCHs and MDHs are updated annually. The HSP rates are updated for
inflation by the applicable market basket increase for each FY after the base period year, and are also adjusted
by a budget neutrality factor to account for the annual DRG reclassification and recalibration for each year
from FY 1993 forward, regardless of the year of the base period. (For reference purposes, the budget
neutrality adjustment factors are listed below at the end of this section.) For the inflation update, beginning
FY 2005, if the hospital did not submit quality data, the market basket update is reduced by a percentage
specified in statute for the applicable FY consistent with section 1886(b)(3)(B)(viii) of the Act.
Applicable Fiscal Year
Budget Neutrality Adjustment Factors
1993
0.999851
1994
0.999003
1995
0.998050
1996
0.999306
1997
0.998703
1998
0.997731
1999
0.998978
2000
0.997808
2001
0.997174
Applicable Fiscal Year
Budget Neutrality Adjustment Factors
2002
0.995821
2003
0.993111
2004
1.002608
2005
0.999876
2006
0.998993
2007
0.997395
2008
0.995743
2009
0.998795
2010
0.997941
D. - Claims Processing
The Qualifying DSH Percent uses the following provider type codes to enable Pricer to calculate the
appropriate rates for these facilities:
• 14 for a MDH that is not an RRC;
• 15 for a MDH that is also an RRC;
• 16 for a rebased SCH that is not an RRC; and
• 17 for a rebased SCH that is also an RRC.
The A/B MAC (A) calculates the HSP rate and determines the greatest HSP rate (for SCHs, FY 1982, 1987,
1996 or 2006; for MDHs, FY 1982, 1987 or 2002). Then the A/B MAC (A) updates the HSP rate to the
applicable FY and enters that amount in the PPS Facility Specific Rate of the Provider-Specific File (PSF), for
the applicable effective date. The HSP rate is to be entered even if the Federal rate is expected to result in
higher payments than the applicable HSP rate. Preloading the applicable HSP rate before the effective date is
acceptable as long as the correct effective date is used for the PSF record. The A/B MAC (A) leaves the field
blank if the hospital was not in operation during any of the applicable HSP base years.
Pricer will calculate the payment based on the higher of the Federal rate or the HSP rate. Where the HSP rate
is higher, Pricer reports the amount of the difference in the hospital-specific field. The A/B MAC (A) carries
this amount forward in the hospital-specific payment field to its PS&R record for use at cost settlement.
20.7 - Billing Applicable to PPS
(Rev. 1, 10-01-03)
20.7.1- Stays Prior to and Discharge After IPPS Implementation Date
(Rev. 1, 10-01-03)
A3-3610.4, HO-415.7
When the admission is before the hospital's PPS effective date and the discharge is later than that date
(transition claims), the Medicare payment for the period before PPS is on a reasonable cost basis and the
payment for the period after PPS is on a DRG basis.
The hospital must submit two bills. The first bill is for the period before the PPS effective date and is
processed and paid in accordance with requirements in effect before the hospital's PPS effective date. The
second bill is processed under PPS but the amount of payment on the first bill is subtracted from it. A/B
MACs (A) make the adjustment by subtracting the interim payment from the prospective payment (before any
deduction for deductible or coinsurance) for the inpatient operating costs applicable to the days in the prior
period. The interim payment applicable to the prior period is adjusted to exclude estimated costs related to
capital and direct medical education, kidney acquisition costs, and for bad debts for uncollectible deductible
and coinsurance. A/B MACs (A) will make an estimate if necessary.
For hospitals previously receiving interim payment on the basis of an average cost per diem or under PIP, the
A/B MAC (A) determines and removes a per diem amount for the excluded costs for that period from the
interim payments before reducing the prospective payment amount applicable to the discharge in the
subsequent period under PPS. Similarly, for hospitals that received a percentage of billed charges, the portion
of the percentage applicable to the excluded cost items is removed. The net percentage to the charges billed in
the prior period (cut-off bill) is applied. The resulting amount is subtracted from the PPS payment applicable
to the discharge in the subsequent period.
For transition claims, payment must not exceed the higher of what would have been paid under PPS including
the outlier adjustment or any earlier cost payment. The final amount is not reduced to less than zero. No
further adjustments are appropriate.
The interim payments used to reduce the prospective payment amounts are considered to represent fairly the
inpatient operating costs incurred and fair payment for the portion of the stay occurring in the prior period.
Therefore, the adjustment is final and not subject to further modification.
On bills covering two cost reporting periods:
• Each bill includes charges and covered days that apply to the period covered.
• The cut-off bill for the cost period is completed per Chapter 25.
• The PPS bill contains principal diagnosis and surgical procedures for the entire stay.
• The PPS bill shows the admission date, but the period covered begins with the first day of the new
accounting year.
• Where discharge is on the first day of the new accounting year, a PPS bill is still due. Some payment
may be due the provider, and the open admission must be closed on CMS' records. There are no
accommodation charges on the day of discharge; the hospital will report ancillary charges for the day
of discharge on the prior bill.
• Coinsurance days and related amounts are applied separately to each bill, i.e., the proper deduction for
coinsurance days reported on the second bill is taken from that bill.
20.7.2 - Split Bills
(Rev. 1, 10-01-03)
A3-3610.6, HO-415.9
Under PPS, split billing is not needed for cost reporting purposes; however, it is necessary to show on the bill
the coinsurance days in each calendar year for proper application of the coinsurance amount.
For admissions prior to the cost reporting year under IPPS with a discharge after the beginning of the
prospective payment year, the DRG payment for the discharge is reduced by the cost of services furnished in
the prior period.
The hospital uses the day or charge statistics on the bill representing the portion of the stay in the prior period
to determine the cost of the services furnished. Split bills are not needed at the end of the government's fiscal
year or the calendar year as changes in DRG prices are determined by the date of discharge. This is shown in
value codes 09 (first year coinsurance) and 11 (second year coinsurance). (See Chapter 25.)
PPS days on the cost report are allocated to the year of the discharge. Hospitals not on IPPS, LTCHPPS, or
IRFPPS continue to submit split bills at the end of their fiscal years and allocate the days to the hospital year
in which they occurred.
When split billing applies, DRG payments are made only on bills that show a discharge date and status. No
DRG payment is made on PPS bills that show "still patient" status.
The hospital may not split a bill for the periods before and after the onset of capital PPS that fall into the same
billing period. Capital payment issued for an inpatient hospital stay that begins prior to and ends after the
onset of capital PPS is the amount determined by Pricer for that DRG. No reasonable cost capital pass
through payment is payable for the portion of the stay that pre-dates capital PPS.
20.7.3 - Payment for Blood Clotting Factor Administered to Hemophilia Inpatients
(Rev. 12380; Issued:11-24-23; Effective:10-01-22; Implementation:04-01-24)
Section 6011 of Public Law (P.L.) 101-239 amended §1886(a)(4) of the Social Security Act (the Act) to
provide that prospective payment system (PPS) hospitals receive an additional payment for the costs of
administering blood clotting factor to Medicare hemophiliacs who are hospital inpatients. Section 6011(b) of
P.L. 101.239 specified that the payment be based on a predetermined price per unit of clotting factor
multiplied by the number of units provided. This add-on payment originally was effective for blood clotting
factors furnished on or after June 19, 1990, and before December 19, 1991. Section 13505 of P. L. 103-66
amended §6011 (d) of P.L. 101-239 to extend the period covered by the add-on payment for blood clotting
factors administered to Medicare inpatients with hemophilia through September 30, 1994. Section 4452 of
P.L. 105-33 amended §6011(d) of P.L. 101-239 to reinstate the add-on payment for the costs of administering
blood-clotting factor to Medicare beneficiaries who have hemophilia and who are hospital inpatients for
discharges occurring on or after October 1, 1998.
A/B MACs (B) shall process non-institutional blood clotting factor claims.
The A/B MACs (A) shall process institutional blood clotting factor claims payable under either Part A or Part
B.
A. - Inpatient Bills
Under the Inpatient Prospective Payment System (IPPS), hospitals receive a special add-on payment for the
costs of furnishing blood clotting factors to Medicare beneficiaries with hemophilia, admitted as inpatients of
PPS hospitals. The clotting factor add-on payment is calculated using the number of units (as defined in the
HCPCS code long descriptor) billed by the provider under special instructions for units of service.
The PPS Pricer software does not calculate the payment amount. The Fiscal Intermediary Shared System
(FISS) calculates the payment amount and subtracts the charges from those submitted to Pricer so that the
clotting factor charges are not included in cost outlier computations.
Blood clotting factors not paid on a cost or PPS basis are priced as a drug/biological under the Medicare Part
B Drug Pricing File effective for the specific date of service. As of January 1, 2005, the average sales price
(ASP) plus 6 percent shall be used.
If a beneficiary is in a covered Part A stay in a PPS hospital, the clotting factors are paid in addition to the
DRG/HIPPS payment (For FY 2004, this payment is based on 95 percent of average wholesale price.) For a
SNF subject to SNF/PPS, the payment is bundled into the SNF/PPS rate.
For SNF inpatient Part A, there is no add-on payment for blood clotting factors.
The codes for blood-clotting factors are found on the Medicare Part B Drug Pricing File. This file is
distributed on a quarterly basis.
For discharges occurring on or after October 1, 2000, and before December 31, 2005, report HCPCS Q0187
based on 1 billing unit per 1.2 mg. Effective January 1, 2006, HCPCS code J7189 replaces Q0187 and is
defined as 1 billing unit per 1 microgram (mcg).
The examples below include the HCPCS code and indicate the dosage amount specified in the descriptor of
that code. Facilities use the units field as a multiplier to arrive at the dosage amount.
EXAMPLE 1
HCPCS
Drug
Dosage
J7189
Factor VIIa
1 mcg
Actual dosage: 13,365 mcg
On the bill, the facility shows J7189 and 13,365 in the units field (13,365 mcg divided by 1 mcg = 13,365
units).
NOTE: The process for dealing with one international unit (IU) is the same as the process of dealing with
one microgram.
EXAMPLE 2
HCPCS
Drug
Dosage
J9355
Trastuzumab
10 mg
Actual dosage: 140 mg
On the bill, the facility shows J9355 and 14 in the units field (140 mg divided by 10mg = 14 units).
When the dosage amount is greater than the amount indicated for the HCPCS code, the facility rounds up to
determine units. When the dosage amount is less than the amount indicated for the HCPCS code, use 1 as the
unit of measure.
EXAMPLE 3
HCPCS
Drug
Dosage
J3100
Tenecteplase
50 mg
Actual Dosage: 40 mg
The provider would bill for 1 unit, even though less than 1 full unit was furnished.
At times, the facility provides less than the amount provided in a single use vial and there is waste, i.e.; some
drugs may be available only in packaged amounts that exceed the needs of an individual patient. Once the
drug is reconstituted in the hospital’s pharmacy, it may have a limited shelf life. Since an individual patient
may receive less than the fully reconstituted amount, we encourage hospitals to schedule patients in such a
way that the hospital can use the drug most efficiently. However, if the hospital must discard the remainder of
a vial after administering part of it to a Medicare patient, the provider may bill for the amount of drug
discarded plus the amount administered.
Example 1:
Drug X is available only in a 100-unit size. A hospital schedules three Medicare patients to receive drug X on
the same day within the designated shelf life of the product. An appropriate hospital staff member administers
30 units to each patient. The remaining 10 units are billed to Medicare on the account of the last patient.
Therefore, 30 units are billed on behalf of the first patient seen and 30 units are billed on behalf of the second
patient seen. Forty units are billed on behalf of the last patient seen because the hospital had to discard 10
units at that point.
Example 2:
An appropriate hospital staff member must administer 30 units of drug X to a Medicare patient, and it is not
practical to schedule another patient who requires the same drug. For example, the hospital has only one
patient who requires drug X, or the hospital sees the patient for the first time and did not know the patient’s
condition. The hospital bills for 100 units on behalf of the patient, and Medicare pays for 100 units.
When the number of units of blood clotting factor administered to hemophiliac inpatients exceeds 99,999, the
hospital reports the excess as a second line for revenue code 0636 and repeats the HCPCS code. One hundred
thousand fifty (100,050) units are reported on one line as 99,999, and another line shows 1,051.
Revenue Code 0636 is used. It requires HCPCS. Some other inpatient drugs continue to be billed without
HCPCS codes under pharmacy.
No changes in beneficiary notices are required. Coverage is applicable to hospital Part A claims only.
Coverage is also applicable to inpatient Part B services in SNFs and all types of hospitals, including CAHs.
Separate payment is not made to SNFs for beneficiaries in an inpatient Part A stay.
B. - A/B MAC (A) Action
The contractor is responsible for the following:
• It accepts HCPCS codes for inpatient services;
• It edits to require HCPCS codes with Revenue Code 0636. Multiple iterations of the revenue code are
possible with the same or different HCPCS codes. It does not edit units except to ensure a numeric
value;
• It reduces charges forwarded to Pricer by the charges for hemophilia clotting factors in revenue code
0636. It retains the charges and revenue and HCPCS codes for CWF; and
• It modifies data entry screens to accept HCPCS codes for hospital (including CAH) swing bed, and
SNF inpatient claims (bill types 11X, 12X, 18x, 21x and, 22x).
The September 1, 1993, IPPS final rule (58 FR 46304) states that payment will be made for the blood clotting
factor only if diagnosis code for hemophilia is included on the bill.
Inpatient blood-clotting factors are covered only for beneficiaries with hemophilia. One of the following
hemophilia diagnosis codes must be reported on the claim for payment to be made for blood clotting factors.
Table 1 - Effective for discharges September 1 1993 through the implementation of ICD-10
ICD-9-
CM
code
Description
286.0
Congenital factor VIII disorder
286.1
Congenital factor IX disorder
286.2
Congenital factor XI deficiency
286.3
Congenital deficiency of other clotting factors
286.4
von Willebrands' disease
Table 2 - Effective for discharges August 1, 2001 through the implementation of ICD-10, payment may
be made if a diagnosis codes from either Table 1 or Table 2 is reported is reported:
ICD-9-
CM code
Description
286.5
Hemorrhagic disorder due to intrinsic circulating anticoagulants (terminate
effective September 30, 2011)
286.7
Acquired coagulation factor deficiency
Table 3 - Effective for discharges on October 1, 2011, through the implementation of ICD-10 payment
may be made if a diagnosis code from any of Table 1, Table 2 or Table 3 is reported:
ICD-9-
CM
code
Description
286.52
Acquired hemophilia
286.53
Antiphospholipid antibody with hemorrhagic disorder
286.59
Other hemorrhagic disorder due to intrinsic circulating anticoagulants,
antibodies, or inhibitors
Effective for discharges on or after the implementation of ICD-10-CM and prior to October 1, 2022, the
following codes are applicable, and payment may be made for blood clotting factors only if one of the
following hemophilia diagnosis codes from the range D66 - D68.4 is reported.
A crosswalk of ICD 9 to ICD10 hemophilia diagnosis codes follows:
ICD-9-
CM Code
Description
ICD-10-
CM
Code
Description
286.0
Congenital factor VIII
disorder
D66
Hereditary factor VIII
deficiency
286.1
Congenital factor IX disorder
D67
Hereditary factor IX
deficiency
286.2
Congenital factor XI
deficiency
D68.1
Hereditary factor XI
deficiency
286.3
Congenital deficiency of
other clotting factors
D68.2
Hereditary deficiency of other
clotting factors
286.4
von Willebrands' disease
D68.0
Von Willebrand's disease
286.5
Hemorrhagic disorder due to
intrinsic circulating
anticoagulants (terminate
effective September 30,
2011)
N/A
286.52
Acquired hemophilia
D68.311
Acquired hemophilia
286.53
Antiphospholipid antibody
with hemorrhagic disorder
D68.312
Antiphospholipid antibody
with hemorrhagic disorder
286.59
Other hemorrhagic disorder
due to intrinsic circulating
anticoagulants, antibodies, or
inhibitors
D68.318
Other hemorrhagic disorder
due to intrinsic circulating
anticoagulants, antibodies, or
inhibitors
286.7
Acquired coagulation factor
deficiency
D68.32
Antiphospholipid antibody
with hemorrhagic disorder
286.7
Acquired coagulation factor
deficiency
D68.4
Acquired coagulation factor
deficiency
(Note, ICD-10-CM Code D68.32 (Hemorrhagic disorder due to extrinsic circulating anticoagulants) is no
longer eligible for payment for blood clotting factors effective July 1, 2018; however, payment may be made
for blood clotting factors when ICD-10-CM Code D68.32 is reported on discharges on or after the
implementation of ICD-10-CM and on or before July 1, 2018.)
Effective for discharges on or after October 1, 2022, D68.0 (Von Willebrand’s disease) is no longer
eligible for payment for blood clotting factors; however, payment may be made for blood clotting
factors when ICD-10-CM Code D68.0 is reported on discharges on or after the implementation of ICD-
10-CM and on or before September 30, 2022.
Effective for discharges on or after October 1, 2022, the following codes are applicable, and payment may be
made for blood clotting factors only if one of the following hemophilia diagnosis codes from the range D66 -
D68.4 is reported.
ICD-10-
CM
Code
Description
D66
Hereditary factor VIII deficiency
D67
Hereditary factor IX deficiency
D68.00
Von Willebrand disease, unspecified
D68.01
Von Willebrand disease, type 1
D68.020
Von Willebrand disease, type 2A
D68.021
Von Willebrand disease, type 2B
D68.022
Von Willebrand disease, type 2M
D68.023
Von Willebrand disease, type 2N
D68.029
Von Willebrand disease, type 2,
unspecified
D68.03
Von Willebrand disease, type 3
D68.04
Acquired von Willebrand disease
D68.09
Other von Willebrand disease
D68.1
Hereditary factor XI deficiency
D68.2
Hereditary deficiency of other clotting
factors
D68.311
Acquired hemophilia
D68.312
Antiphospholipid antibody with
hemorrhagic disorder
D68.318
Other hemorrhagic disorder due to
intrinsic circulating anticoagulants,
antibodies, or inhibitors
D68.4
Acquired coagulation factor deficiency
C. - Part A Remittance Advice
For remittance reporting PIP and/or non-PIP payments, the Hemophilia Add On is included in the overall
claim payment (Provider Reimbursement, CLP04).
If an inpatient claim has a Hemophilia Add On payment, the payment to the provider is increased in the PLB
segment with a PLB adjustment HM. The Hemophilia Add On amount will always be included in the CLP04
Claim Payment Amount.
For remittance reporting PIP payments, the Hemophilia Add On will also be reported in the provider level
adjustment (element identifier PLB) segment with the provider level adjustment reason code HM. For
remittances reporting PIP payments, the sum of inpatient claims, CLP04, is backed out at PLB with PI/PA. If
an inpatient claim has a Hemophilia Add On payment, the payment to the provider is increased in the PLB
segment with a PLB adjustment HM.
D. - Standard Hard Copy Remittance Advice
For paper remittances reporting non-PIP payments involving Hemophilia Add On, add a "Hemophilia Add
On" category to the end of the "Pass Thru Amounts" listings in the "Summary" section of the paper
remittance. Enter the total of the Hemophilia Add On amounts due for the claims covered by this remittance
next to the Hemophilia Add On heading.
The following reflects the remittance advice messages and associated codes that will appear when processing
claims under this policy. The CARC below is not included in the CAQH CORE Business Scenarios.
Group Code: OA
CARC: 94
RARC: MA103
MSN: N/A
This will be the full extent of Hemophilia Add On reporting on paper remittance notices; providers wishing
more detailed information must subscribe to the Medicare Part A specifications for the ASC X12 835
remittance advice, where additional information is available.
See chapter 22, for detailed instructions and definitions.
20.7.4 - Cost Outlier Bills With Benefits Exhausted
(Rev. 1, 10-01-03)
PM - A-99-17 (CR-749)
Providers under IPPS, LTCH PPS, and IRF PPS follow this scenario when benefits are exhausted.
The methodology for using benefit days and reimbursing cost outliers is based on the beneficiary having a
lifetime reserve (LTR) benefit day which the beneficiary elects to use or a regular benefit (regular or
coinsurance) day beginning the day after the day covered charges are incurred in an amount that results in a
cost outlier payment for the provider. Additional charges are considered covered for every day thereafter for
which a beneficiary has, and elects to use, an available benefit day.
DRG claims with cost outlier payments with discharge dates on or after October 1, 1997, must have an
Occurrence Code (OC) 47 on the claim unless there are enough full and/or coinsurance days to cover all the
medically necessary days or the only available benefits are LTR days and there are enough LTR days to cover
all the medically necessary days. DRG claims without cost outlier payments can never have regular benefit
days combined with LTR benefit days.
Once the cost outlier threshold is known, providers must add the daily covered charges for the claim until they
determine the day that covered charges reach the cost outlier threshold. Providers must exclude days and
covered charges during noncovered spans, e.g., during Occurrence Span Code (OSC) 74, 76, or 79 dates.
Providers must then submit the date of the first full day of cost outlier status (the day after the day that
covered charges reach the cost outlier threshold) on the bill using OC 47. The OC 47 date cannot be equal to
or during OSC 74, 76, or 79 dates. Providers must determine the amount of regular, coinsurance, and LTR
days the beneficiary has available per CWF inquiry or their FI.
Any nonutilization days after the beneficiary exhausts coinsurance or LTR days before the OC 47 date will be
identified using OSC 70. LTR days should be used as necessary and as elected by the beneficiary. If
coinsurance days are exhausted during the inlier portion of the stay and there is a period of nonutilization
indicated by the presence of OSC 70 and the beneficiary elects not to use LTR days, covered charges are
limited to the exact amount of the cost outlier threshold and both OC A3, which shows the last covered day,
and OC 47, which shows the following day which is the first full day of cost outlier status, must be shown.
When coinsurance and/or LTR days are exhausted during the cost outlier portion of the stay, OC A3 should be
used as appropriate to report the date benefits are exhausted. Covered charges should be accrued to reflect the
entire period of the bill if the bill is fully covered or the entire period up to and including the date benefits
were exhausted, if benefits were exhausted.
Assumptions for all of the following examples:
1. Cost outlier threshold amount is $50,000.
2. Threshold amount is reached on the 25th day.
3. Billed charges are $1,000 each day thereafter.
4. Beneficiary elects to use any available LTR days.
EXAMPLE 1: LTR Days Cover Cost Outlier
Date of Service:
1/1 - 1/31 discharge
Medically necessary days
30
Covered charges
$55,000
Benefits available
30 LTR
Covered days
30
Noncovered days
0
Cost report days
30
All charges for Medicare approved revenue codes billed as covered
No OC 47 needed
Reimbursement:
Full DRG plus cost outlier based on $55,000 covered
charges
EXAMPLE 2: LTR Days Exhaust in the Cost Outlier
Dates of service:
1/1 - 2/10 discharge
Medically necessary days:
40
Covered charges:
$65,000
Benefits available:
30 LTR
Covered days:
30
Noncovered days:
10
Cost report days:
30
30 days covered charges for Medicare approved revenue codes and 10 days noncovered
charges.
OC 47:
1/26
OC A3:
1/30
Reimbursement:
Full DRG plus cost outlier based on $55,000 covered
charges ($50,000 inlier and $5,000 outlier
EXAMPLE 3: LTR Days Exhaust Prior to Cost Outlier
Dates of service:
1/1 - 1/31 discharge
Medically necessary days:
30
Covered charges:
$55,000
Benefits available:
20 LTR
Covered days:
20
Noncovered days:
10
Cost report days:
25
25 days covered charges for Medicare approved revenue codes and 5 days noncovered
charges
OC 47:
1/26
OC A3
1/25
OSC 70:
1/21 -1/25
Reimbursement:
Full DRG payment, no cost outlier
EXAMPLE 4: Coinsurance Days Exhaust Prior to Cost Outlier and No LTR Days Are Available
Date of Service:
1/1 - 1/31 discharge
Medically necessary days
30
Covered charges
$55,000
Benefits available:
20 coinsurance
Covered days:
20
Noncovered days:
10
Cost report days:
25
25 days covered charges for Medicare approved revenue codes and 5 days noncovered
charges
OC 47:
1/26
OC A3:
1/25
OSC 70:
1/21 - 1/25
Reimbursement:
Full DRG payment, no cost outlier
EXAMPLE 5: Coinsurance Days Exhaust Prior to Cost Outlier. LTR Days Exhausts in the Cost
Outlier
Date of Service:
1/1 - 2/10 discharge
Medically necessary days
40
Covered charges
$65,000
Benefits available:
20 coinsurance and 10 LTR
Covered days:
30
Noncovered days:
10
Cost report days:
35
35 days covered charges for Medicare approved revenue codes and 5 days noncovered
charges
OC 47:
1/26
OC A3:
2/4
OSC 70:
1/21 - 1/25
Reimbursement:
Full DRG payment, plus cost outlier based on $60,000
covered charges ($50,000 inlier, $10,000 outlier, $5,000
noncovered)
EXAMPLE 6: Full and Coinsurance Days Cover Cost Outlier
Date of Service:
1/1 - 1/31 discharge
Medically necessary days
30
Covered charges
$55,000
Benefits available:
10 full and 20 coinsurance
Covered days:
30
Noncovered days:
0
Cost report days:
30
All charges for Medicare approved revenue codes billed as covered.
OC 47:
Not needed
Reimbursement:
Full DRG payment plus cost outlier based on $55,000
covered charges.
EXAMPLE 7: Coinsurance Days and LTR Days Exhaust in the Cost Outlier
Date of Service:
1/1 - 2/28 discharge
Medically necessary days
58
Covered charges
$83,000
Benefits available:
10 full, 30 coinsurance and 10 LTR
Covered days:
50
Noncovered days:
8
Cost report days:
50
50 days covered charges for Medicare approved revenue codes and 8 days noncovered
charges
OC 47:
1/26
OC A3:
2/19
Reimbursement:
Full DRG payment, plus cost outlier based on $75,000
covered charges ($50,000 inlier, $25,000 outlier, $8,000
noncovered)
EXAMPLE: 8: LTR Days Exhaust Prior to Cost Outlier and Noncovered Span(s) Present
Dates of service:
1/1 - 1/31 discharge
Medically necessary days:
28
OSC 76
1/10 - 1/11
Covered charges:
$55,000
Benefits available:
20 LTR
Covered days:
20
Noncovered days:
10
Cost report days:
25
25 days covered charges for Medicare approved revenue codes and 5 days noncovered
charges
OC 47:
1/28
OC A3
1/27
OSC 70:
1/23 -1/27
Reimbursement:
Full DRG payment, no cost outlier
20.8 - Payment to Hospitals and Units Excluded from IPPS for Direct Graduate Medical
Education (DGME) and Nursing and Allied Health (N&AH) Education for Medicare
Advantage (MA) Enrollees
(Rev. 1472, Issued: 03-06-08, Effective: 05-23-07, Implementation: 04-07-08)
During the period January 1, 1998 through December 31, 1998, hospitals received 20 percent of the fee-for-
service DGME and operating IME payment. This amount increased by 20 percentage points each consecutive
year until it reached 100 percent in calendar year (CY) 2002.
Non-IPPS hospitals and units may submit their MA claims to their respective A/B MACs (A) to be processed
as no-pay bills so that the MA inpatient days can be accumulated on the Provider Statistics & Reimbursement
Report (PS&R) (report type 118) for DGME payment purposes through the cost report.
This applies to the following hospitals and units excluded from the IPPS:
• Rehabilitation units
• Psychiatric units
• Rehabilitation hospitals
• Psychiatric hospitals
• Long-term Care hospitals
• Children’s hospitals
• Cancer hospitals
In addition, this applies to all hospitals that operate a nursing or an allied health (N&AH) program and qualify
for additional payments related to their MA enrollees under 42 CFR §413.87(e). These providers may
similarly submit their MA claims to their respective A/B MACs (A) to be processed as no-pay bills so that the
MA inpatient days can be accumulated on the PS&R (report type 118) for purposes of calculating the MA
N&AH payment through the cost report.
Non-IPPS hospitals, hospitals with rehabilitation and psychiatric units, and hospitals that operate an approved
N&AH program must submit claims to their regular A/B MAC (A) with condition codes 04 and 69. The
provider uses Condition code 69 to indicate that the claim is being submitted as a no-pay bill to the PS&R
report type 118 for MA enrollees in non-IPPS hospitals and non-IPPS units to capture MA inpatient days for
purposes of calculating the DGME and/or N&AH payment through the cost report.
The A/B MAC (A) submits the claim to the Common Working File (CWF). The CWF determines if the
beneficiary is a MA enrollee and what his/her plan number and effective dates are. The plan must be a MA
plan, per 42 CFR §422.4. Upon verification from CWF that the beneficiary is a MA enrollee, the A/B MAC
(A) adds the MA plan number and an MA Pay Code of “0” to the claim. For fee-for-service claims that were
previously paid and posted to history for the same period (due to late posting of MA enrollment data), an L-
1002 Automatic Cancellation Adjustment Report will be sent to the A/B MAC (A) when a DGME-only or a
N&AH-only claim from a non-IPPS hospital or unit is accepted for payment by CWF. No deductible or
coinsurance is to be applied against this claim nor is the beneficiary's utilization updated by CWF for this stay.
If CWF enrollment records do not indicate that the beneficiary is a MA enrollee, CWF rejects the claim and
the A/B MAC (A) notifies the hospital of this reason. The hospital may resubmit the claim after 30 days to
see if the enrollment data has been updated. No interim bills should be submitted for DGME-only or N&AH-
only claims and no Medicare Summary Notices should be prepared for these claims.
The DGME payments are made using the same interim payment calculation A/B MACs (A) currently employ.
Specifically, A/B MACs (A) must calculate the additional DGME payments using the inpatient days
attributable to MA enrollees. As with DGME and N&AH education payments made under fee-for-service, the
sum of these interim payment amounts is subject to adjustment upon settlement of the cost report. Note that
these DGME and/or N&AH payments apply both to IPPS and non-IPPS hospitals and units.
Teaching hospitals that operate GME programs (see 42 CFR §413.86) and/or hospitals that operate approved
N&AH education programs (see 42 CFR §413.87) must submit separate bills for payment for MA enrollees.
The MA inpatient days are recorded on PS&R report type 118. For services provided to MA enrollees by
hospitals that do not have a contract with the enrollee’s plan, non-IPPS hospitals and units are entitled to any
applicable DGME and/or N&AH payments under these provisions. Therefore, such hospitals and units should
submit bills to their A/B MAC (A) for these cases in accordance with this section’s instructions. In addition to
submitting the claims to the PS&R report type 118, hospitals must properly report MA inpatient days on the
Medicare cost report, Form 2552-96, on worksheet S-3, Part I, line 2 column 4, and worksheet E-3, Part IV,
lines 6.02 and 6.06.
30 - Medicare Rural Hospital Flexibility Program and Critical Access Hospitals (CAHs)
(Rev. 68, 10-16-04)
A3-3610.19, HO-415.19, A3-3610.20, HO-415.20
The Medicare law allows establishment of a Medicare rural hospital flexibility program by any State that has
submitted the necessary assurances and complies with the statutory requirements for designation of hospitals
as critical access hospitals (CAHs).
To be eligible as a CAH, a facility must be a currently participating Medicare hospital, a hospital that ceased
operations on or after November 29, 1989, or a health clinic or health center that previously operated as a
hospital before being downsized to a health clinic or health center. The facility must be located in a rural area
of a State that has established a Medicare rural hospital flexibility program, or must be located in a
Metropolitan Statistical Area (MSA) of such a State and be treated as being located in a rural area based on a
law or regulation of the State, as described in 42 CFR 412.103. It also must be located more than a 35-mile
drive from any other hospital or critical access hospital unless it is designated by the State, prior to January 1,
2006, to be a "necessary provider". In mountainous terrain or in areas with only secondary roads available,
the mileage criterion is 15 miles. In addition, the facility must make available 24-hour emergency care
services, provide not more than 25 beds for acute (hospital-level) inpatient care or in the case of a CAH with a
swing bed agreement, 60used for SNF-level care. The CAH maintains a length of stay, as determined on an
annual average basis, of no longer than 96 hours.
The facility is also required to meet the conditions of participation for CAHs
(42 CFR Part 485, Subpart F). Designation by the State is not sufficient for CAH status. To participate and
be paid as a CAH, a facility must be certified as a CAH by CMS.
A. - Grandfathering Existing Facilities
As of October 1, 1997, no new Essential Access Community Hospital (EACH) designations can be made.
The EACHs designated by CMS before October 1, 1997, will continue to be paid as sole community hospitals
for as long as they comply with the terms, conditions, and limitations under which they were designated as
EACHs.
30.1 - Requirements for CAH Services, CAH Skilled Nursing Care Services and Distinct
Part Units
(Rev. 771, Issued: 12-02-05, Effective: 01-03-06, Implementation: 01-03-06)
A CAH may provide acute inpatient care for a period that does not exceed, as determined on an annual
average basis, 96 hours per patient. The CAH's length of stay will be calculated by their A/B MAC (A) based
on patient census data and reported to the CMS regional office (RO). If a CAH exceeds the length of stay
limit, it will be required to develop and implement a corrective action plan acceptable to the CMS RO, or face
termination of its Medicare provider agreement.
Items and services that a CAH provides to its inpatients are covered if they are items and services of a type
that would be covered if furnished by an acute care hospital to its inpatients. A CAH may use its inpatient
facilities to provide post-hospital SNF care and be paid for SNF-level services if it meets the following
requirements:
1. The facility has been certified as a CAH by CMS;
2. The facility operates up to 25 beds for either acute (CAH) care or SNF swing bed care (any bed of a
unit of the facility that is licensed as a distinct-part SNF is not counted under paragraph (1) of this section);
and
3. The facility has been granted swing-bed approval by CMS.
A CAH that participated in Medicare as a rural primary care hospital (RPCH) on September 30, 1997, and on
that date had in effect an approval from CMS to use its inpatient facilities to provide post-hospital SNF care,
may continue in that status under the same terms, conditions, and limitations that were applicable at the time
those approvals were granted.
A CAH may establish psychiatric and rehabilitation distinct part units effective for cost reporting periods
beginning on or after October 1, 2004. The CAH distinct part units must meet the following requirements:
1. The facility distinct part unit has been certified as a CAH by CMS;
2. The distinct part unit meets the conditions of participation requirements for hospitals;
3. The distinct part unit must also meet the requirements, other than conditions of participation
requirements, that would apply if the unit were established in an acute care hospital;
4. Services provided in these distinct part units will be paid under the payment methodology that
would apply if the unit was established in an acute care (non-CAH) hospital paid under the hospital inpatient
PPS; Inpatient Rehabilitation Facilities in CAHs are paid under the Inpatient Rehabilitation Facility PPS (see
Pub 100-04, Chapter 3, Section 140 for billing requirements) and the Inpatient Psychiatric Units in CAHs are
paid on a reasonable cost basis until a prospective payment system is created (expected in 2005);
5. Beds in these distinct part units are excluded from the 25 bed count limit for CAHs;
6. The bed limitations for each distinct part unit is 10; and
If a distinct part unit does not meet applicable requirements with respect to a cost reporting period, no
payment may be made to the CAH for services furnished in the unit during that period. Payment may resume
only after the CAH has demonstrated that the unit meets applicable requirements.
30.1.1 - Payment for Inpatient Services Furnished by a CAH
(Rev. 530, Issued: 04-22-05; Effective: 01-05-04 - HPSA Bonus; 01-03-05 - Physician Scarcity; 07-01-01;
Implementation: 07-05-05)
For cost reporting periods beginning after October 1, 1997, payment for inpatient services of a CAH is the
reasonable cost of providing the services. Effective for cost reporting periods beginning after January 1, 2004,
payment for inpatient services of a CAH is 101 percent of the reasonable cost of providing the services, as
determined under applicable Medicare principles of reimbursement, except the following principles do not
apply:
• The lesser of costs or charges (LCC) rule;
• Ceilings on hospital operating costs;
• The reasonable compensation equivalent (RCE) limits for physician services to hospitals; and
• The payment window provisions for preadmission services treated as inpatient services under §40.3.
(Because CAHs are exempt from the 1- and 3-day window provisions, services rendered by a CAH to
a beneficiary who is an outpatient prior to that beneficiary’s admission to the CAH as an inpatient, are
not bundled on the inpatient bill. Outpatient CAH services must be billed as such and on a separate
bill (85x TOB) from inpatient services. CWF and the shared system shall bypass the CAH provider
numbers when applying the edits that compare hospital outpatient and inpatient bills to apply the
window provisions. Outpatient services rendered on the date of admission to an inpatient setting are
still billed and paid separately as outpatient services in a CAH.)
Low Osmolar Contrast Material (LOCM) furnished as part of medically necessary imaging procedures for
inpatients is paid for based on bill type 11X (for LOCM furnished during an inpatient stay covered under Part
A), or 12X(for LOCM furnished to an inpatient where payment is under Part B because the stay is not covered
under Part A). Bills must include revenue code 636 along with one of the following HCPCS codes as
appropriate:
A4644 Supply of low osmolar contrast material (100 - 199 mgs of iodine);
A4645 Supply of low osmolar contrast material (200 - 299 mgs of iodine); or
A4646 Supply of low osmolar contrast material (300 - 399 mgs of iodine).
Payment for inpatient CAH services is subject to Part A deductible and coinsurance requirements. Inpatient
services should be billed on an 11X type of bill.
30.1.1.1 - Payment for Inpatient Services Furnished by an Indian Health Service (IHS) or
Tribal CAH
(Rev. 231, Issued 07-23-04, Effective: 01-01-04, Implementation: 01-03-05)
Reimbursement to IHS or Tribal CAHs for covered inpatient services is based on a facility specific per diem
rate that is established on a yearly basis from the most recently filed cost report information.
Payment for inpatient IHS or Tribal CAH services is at 100% of the facility specific per diem rate less
applicable deductible and coinsurance. Inpatient services should be billed on an 11X type of bill.
Beginning January 1, 2004, IHS or Tribal CAHs are paid 101% of the facility specific per diem rate.
30.1.2 - Payment for Post-Hospital SNF Care Furnished by a CAH
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of
ICD-10, Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: September, 23 2014)
The SNF-level services provided by a CAH, are paid at 101% of reasonable cost. Since this is consistent with
the reasonable cost principles, A/B MACs (A) will now pay for those services at 101% reasonable cost.
Hospitals must follow the rules for payment in §60 for swing-bed services.
Coinsurance and deductible are applicable for inpatient CAH payment.
All items on the ASC X12 837 institutional claim format are completed in accord with the implementation
guide applicable to the dates of the stay. All items on Form CMS-1450 are completed in accordance with
Chapter 25.
30.1.3 - Costs of Emergency Room On-Call Providers
(Rev. 803, Issued: 01-03-06, Effective: 04-03-06, Implementation: 04-03-06)
For dates of service on or after January 1, 2005, the reasonable costs of outpatient CAH services may include
the reasonable compensation and related costs for an emergency room provider who is on call but not present
at the premises of the CAH, if the provider is not otherwise furnishing provider services and is not on call at
any other provider or facility. The costs are allowable only if they are incurred under a written contract that
requires the provider to come to the CAH when the provider’s presence is medically required. An emergency
room provider must be a doctor of medicine or osteopathy, physician assistant, nurse practitioner, or clinical
nurse specialist who is immediately available by telephone or radio contact, and available on site, on a 24-
hour a day basis, within 30 minutes, or within 60 minutes in areas described in 42 CFR 1395(g)(5).
For dates of service from October 1, 2001, through December 31, 2004, this provision covers only emergency
room physicians. An emergency room physician must be a doctor of medicine or osteopathy.
30.1.4 - Costs of Ambulance Services
(Rev. 1, 10-01-03)
Effective for services furnished on or after December 21, 2000, payment for ambulance services furnished by
a CAH or by an entity that is owned and operated by a CAH is, under certain circumstances, the reasonable
cost of the CAH or the entity in furnishing those services. Payment is made on this basis only if the CAH or
the entity is the only provider or supplier of ambulance services located within a 35-mile drive of the CAH or
the entity. Reasonable cost will be determined without regard to any per-trip limits or fee schedule that would
otherwise apply.
The distance between the CAH or entity and the other provider or supplier of ambulance services will be
determined as the shortest distance in miles measured over improved roads between the CAH or the entity and
the site at which the vehicles of the nearest provider or supplier of ambulance services are garaged. An
improved road is any road that is maintained by a local, State, or Federal government entity and is available
for use by the general public. An improved road includes the paved surface up to the front entrance of the
CAH and the front entrance of the garage.
40 - Billing Coverage and Utilization Rules for PPS and Non-PPS Hospitals
(Rev. 2388, Issued: 01-20-12, Effective: 04-22-12, Implementation: 04-22-12)
A. - General
Days of utilization are charged based upon actual days of coverage including grace and waiver days. The
number of covered days used are maintained by CMS to track the beneficiary's eligible days in a benefit
period. The hospital collects the coinsurance, if applicable, for only the number of days charged against the
beneficiary's utilization record maintained by CMS. For example, if the mean length of stay for a DRG is 10
days and the beneficiary is discharged after 3, only 3 days of utilization is charged. In a like situation, if the
DRG mean length of stay is 10 days and the beneficiary is discharged after 15, the 15 days are charged against
the utilization record.
NOTE: There are some exceptions to this rule under LTCH PPS. See §150.4.
Coinsurance, if applicable, is payable by the beneficiary for the number of days used. The hospital subtracts
the coinsurance amount from the DRG payment. Days after benefits are exhausted are not charged against the
beneficiary's utilization even though the hospital may receive the full DRG payment.
The basic prospective payment amount will be paid if:
• There is at least l day of utilization left at the time of admission and that day is also a day of
entitlement (e.g., a day before the beneficiary discontinued voluntary Part A entitlement by not paying
the premium).
• There is at least l day for which payment may be made under the guarantee of payment. (If benefits
are exhausted prior to admission and no payment may be made under guarantee of payment, only Part
B benefits are available.)
• The beneficiary becomes entitled after admission. The hospital may not bill the beneficiary or other
persons for days of care preceding entitlement except for days in excess of the outlier threshold.
Utilization is not counted for any days treated as noncovered, except as described below:
• Utilization is not counted for any nonentitlement days, or days after benefits are exhausted (including
guarantee of payment days), even if those days are treated as covered for outlier calculation or treated
as Medicare patient days for the cost report.
• The length of stay exceeds the day/cost outlier threshold (Day outliers were discontinued at the end of
FY 1997), utilization is counted for medically unnecessary days which are noncovered but for which
the hospital may not charge the beneficiary because the requirements of §40.2 were not met. See
§40.2.2 for identification of these days.
• If the adjusted cost of the stay exceeds the cost outlier threshold, utilization is counted for any
medically unnecessary days on which all Part A services are treated as noncovered under §40.2.B and
for which the hospital may not charge the beneficiary. (Where only ancillary services are denied, all
days are counted as covered.)
Lifetime reserve days (LTR) for an inpatient hospital stay for which prospective payment may be made is
subject to the following:
If the beneficiary had one or more regular benefit days (full or coinsurance days) remaining in the spell of
illness when admitted, there is no advantage in using lifetime reserve days. The beneficiary is deemed to have
elected not to use lifetime reserve days for the nonoutlier (Day outliers were discontinued at the end of FY
1997) portion of the stay. IPPS uses Occurrence Span code 70 for the covered non-utilization period after
regular benefit days are exhausted or when only LTR days are exhausted. For example:
EXAMPLE 1: No Cost Outlier, only LTR Days available and Exhaust prior to discharge
Dates of Service
01/05 - 01/16
Medically necessary days
11
Benefit days available VC 83
1 LTR
Covered days VC 80
1
Noncovered days VC 81
10
Cost report days
11
OC A3
01/15(includes covered non-utilization
period)
OSC 70
01/06 - 01/15
Room & Board revenue code
11 Total & Covered units
Medicare approved revenue codes
Charges in covered
Reimbursement
Full DRG payment, no cost outlier
Beneficiary Liability:
LTR copayment amount
EXAMPLE 2: No Cost Outlier, Coinsurance Days available and Exhaust prior to discharge
Dates of Service
01/05 - 01/16
Medically necessary days
11
Benefit days available VC 82
3 Coinsurance
Covered days VC 80
3
Noncovered days VC 81
8
Cost report days
11
OSC 70
01/08 - 01/15
Room & Board revenue code
11 Total & Covered units
Medicare approved revenue codes
Charges in covered
Reimbursement
Full DRG payment, no cost outlier
Beneficiary Liability
Coinsurance copayment amount
After regular benefits have been exhausted, lifetime reserve days will be used automatically for outlier days
unless the beneficiary elects not to use them, or the average daily charges for outlier days to be reimbursed as
lifetime reserve days do not exceed the lifetime reserve day coinsurance amount. (In the latter case the
beneficiary is deemed to have elected not to use lifetime reserve days for outlier days.) An election not to use
lifetime reserve for outlier days applies to all outlier days in an admission.
• If the beneficiary had no regular benefit days remaining when admitted, available lifetime reserve days
are used automatically for each day of the stay. Exceptions exist if the beneficiary elects not to use
lifetime reserve days, or the charges for which the beneficiary is liable, if electing not use lifetime
reserve days, do not exceed the charges for which the beneficiary would be liable if the lifetime
reserve days were used. Using lifetime reserve days, the beneficiary would be responsible for the sum
of the coinsurance amounts for the lifetime reserve days that would be used plus the total charges for
outlier days, if any, for which no lifetime reserve days are available. (In the latter case the beneficiary
will be deemed to have elected not to use any lifetime reserve days.)
An election by the beneficiary not to use lifetime reserve days applies to the entire stay and precludes any
payment for the stay. A deemed election not to use lifetime reserve days applies to the entire stay and
precludes any payment for the stay unless payment may be made under the guarantee of payment.
The number of days for which utilization is charged may be different from the number used in Pricer to
compute outlier status or the number of Medicare patient days shown on the cost report.
40.1 - "Day Count" Rules for All Providers
(Rev. 1, 10-01-03)
A3-3620
See §40.2.A for general rules on counting days.
A. - Day of Admission
For all hospitals, the A/B MAC (A) counts the day of admission for the cost report and for utilization. For
PPS hospitals, it counts the day of admission for Pricer purposes unless the rules for same day transfer apply.
B. - Day of Discharge, Death, or Beginning a Leave of Absence
The A/B MAC (A) does not count the day of discharge or death for cost report, utilization or Pricer purposes
unless the admission and discharge day are the same day. Where admission and discharge occur on the same
day, it counts one day for cost report, utilization and Pricer purposes. If the patient is admitted with the
expectation that the patient will remain overnight, but is discharged or dies before midnight, it counts the day
for the cost report, utilization and Pricer. It does not count any days in a leave of absence (occurrence span
code 74), for cost report, utilization or Pricer purposes.
C. - Same Day Transfer From Participating Hospital to Nonparticipating Hospital or Nonparticipating
Distinct Part of Hospital
If the beneficiary is admitted to a PPS hospital with the expectation that the beneficiary will remain overnight,
but is transferred to a nonparticipating provider or a nonparticipating distinct part of the same provider before
midnight, the A/B MAC (A) counts the day for the cost report, utilization and Pricer. If the beneficiary is
admitted to a non-PPS hospital with the expectation that the beneficiary will remain overnight, but is
transferred to a nonparticipating hospital or a nonparticipating distinct part of a hospital before midnight, the
A/B MAC (A) counts the day for cost report and utilization purposes.
D. - Same Day Transfer From Participating Hospital to Participating Hospital
If the beneficiary is transferred to a participating hospital or distinct part of a participating hospital, the A/B
MAC (A) counts the day, if it is determined to be covered, for the cost report and for Pricer at both hospitals.
However, it charges utilization on the bill only for the later admission to avoid charging the beneficiary twice
for the same day. The earlier admission, for which the A/B MAC (A) does not charge utilization, can be
recognized by condition code 40 (same day transfer), and the same date entered in the "From" and "Through"
dates in CWF.
E. - Guarantee of Payment Days
There can be up to fourteen guarantee of payment days (8 days plus weekends and Federal holidays)
beginning with the date in occurrence code 20. The A/B MAC (A) does not charge utilization, as the
beneficiary has no days remaining, but counts guarantee of payment days for the cost report and Pricer.
F. - Provider Liability Issue
When the A/B MAC (A) or the QIO finds the provider liable, the A/B MAC (A) or the QIO determines the
cause for provider liability prior to making any decision regarding utilization. If the provider is technically
liable, i.e., liable for reasons other than custodial care or medical necessity of the services, the A/B MAC (A)
shows the dates of provider liability in occurrence span code 77, and counts the days for utilization, but not for
cost report or Pricer purposes. If the provider is liable because services were not medically necessary or were
custodial care, the A/B MAC (A) shows the dates of provider liability in occurrence span code 79 and does
not count the days for cost report, utilization or Pricer purposes.
G. - Special Rules Which Differ for PPS and Other Providers
If Part A payment may be made for a hospital stay under PPS (i.e., there is at least one Medicare patient day,
guarantee of payment day, or day for which the program is liable to the hospital under the limitation of
liability provision), the A/B MAC (A) treats all days as covered for cost report purposes, except as provided
below. It applies this same rule when per diem payments are made to a transferring PPS hospital, whether for
all or part of a stay, or when a PPS hospital requests outlier payment, whether or not such payment is made.
For non-PPS hospitals, PPS exempt units and SNFs, it counts the number of days available to the beneficiary
for all purposes.
Where outlier status is involved and there are either pre-entitlement days or days after benefits were
exhausted, the A/B MAC (A) reduces cost report days by the lesser of the number of pre-entitlement/post-
benefits exhausted days or the number of days in the stay in excess of the outlier threshold.
1. Length of Stay Does Not Exceed the Day Outlier Threshold (Day outliers discontinued after FY 97)
The A/B MAC (A) counts all days (including day of admission, but not the day of discharge or death, unless it
is also the day of admission) as covered for cost report and Pricer purposes. It does not count those medically
unnecessary days for which the provider meets notice requirements and other conditions for charging the
beneficiary. (See §40.2.2 C and D.) It does not count those medically unnecessary days for cost report or
Pricer purposes. It counts the actual number of days available to the beneficiary for utilization.
2. Length of Stay Exceeds the Day Outlier Threshold (Day outliers discontinued after FY 97)
The A/B MAC (A) counts all days (including the day of admission, but not the day of discharge or death
unless it is also the day of admission) in the stay for cost report and Pricer purposes except as follows:
a. Pre-entitlement Days
The A/B MAC (A) does not count pre-entitlement days for the cost report or for utilization in non-PPS
hospitals, exempt units or SNFs. For PPS hospitals, it does not count pre-entitlement days for utilization or
for Pricer. The number of days counted as noncovered for the cost report is limited to the number of days in
the stay in excess of the day outlier threshold. To determine which preentitlement days are counted as
noncovered, the A/B MAC (A) begins at the end of the stay (the day before the day of discharge, death, etc.)
and working backward, counts off days identified as pre-entitlement days until it has counted all
preentitlement days or, until the number of days counted equals the total number of days in excess of the
outlier threshold.
b. Post-Exhaustion of Benefit Days
The A/B MAC (A) treats post-exhaustion of benefit days exactly like pre-entitlement days.
To resolve any Medicare Secondary Payor (MSP) issues, see the Medicare Secondary Payer Manual.
40.2 - Determining Covered/Noncovered Days and Charges
(Rev. 1231; Issued: 04-27-07; Effective: 12-03-07; Implementation: 12-03-07)
The CMS must record a day or charge as either covered or noncovered because of the following:
Beneficiary utilization is recorded based upon days during which the patient received hospital or SNF
accommodations, including days paid by Medicare and days for which the provider was held liable for reasons
other than medical necessity or custodial care. Days denied as not medically necessary or as custodial care are
not charged against a beneficiary's utilization record when the provider is determined to be liable.
The provider may claim credit on its cost report only for covered accommodations, days and charges for
which actual payment is made, i.e., provider liable days and charges are not included. Data from the bill
payment process are used in preparing the cost report.
The number of days and charges provided to the Pricer program affects the day and cost outlier determinations
and the DRG payment amount. Non-PPS provider days are excluded from Pricer consideration.
It is possible to use a different number of days on a single bill for each of the above purposes, although the
same number of days will generally apply in actual practice. For example, if the beneficiary had at least 1 day
of eligibility remaining at admission, days that occur after benefits are exhausted up through the day outlier
threshold for the applicable DRG are counted for cost reporting purposes under IPPS (see section190.12.1 for
IPF and section 150.17 for LTCH benefits exhaust claims processing).
A. - General Rule on Counting of Days
These following are general rules for counting days. However, these rules are also subject to special rules for
determining day of admission, discharge, death, beginning a leave of absence, same day transfer, guarantee of
payment days, provider liability issues and outlier days for PPS outliers. See §40.1 and §40.1.G for an
explanation of these special rules.
The provider calculates and enters on the bill the number of claimable Medicare patient days on the cost
report. (Medicare patient days always refer to cost report days.) For PPS facilities the A/B MAC (A) counts,
for the cost report, utilization and Pricer purposes, all days for which Part A payment may be made to the
hospital. This includes days for which the provider is not liable under the limitation of liability provision. It
does not count days for which no Part A payment may be made for cost report, utilization or Pricer purposes.
For non-PPS providers, the A/B MAC (A) does not count the days for Pricer purposes, because DRG payment
or outlier calculations are not made.
B. - Medically Unnecessary Days for Which the Provider May Charge the Beneficiary
Days on which the hospital furnished no covered Part A services are not charged to utilization and are not
counted as Medicare patient days.
If the hospital or SNF stay includes any medically unnecessary days for which the provider has met the
requirements of §§40.2.2 C or D for charging the beneficiary, the A/B MAC (A) counts those days as
noncovered under Part A for cost report, utilization and Pricer purposes.
Since the provider may not be aware of the date benefits are exhausted or when the outlier threshold is
reached, the A/B MAC (A) verifies the provider's counts. If, for any reason, the A/B MAC (A) or the QIO
determines fewer days are claimable (e.g., if the A/B MAC (A) or the QIO indicates that benefits are
exhausted), the A/B MAC (A) will adjust cost report days for its PS&R system. If the A/B MAC (A) or the
QIO determines fewer days are claimable for the cost report, it determines the proper number of days of
utilization to charge the beneficiary and the proper number of days for the length of stay used by Pricer. It
uses the factors in §40.1 and §40.1G to make these calculations.
C. - Medically Unnecessary Outlier Costs for Which the Hospital May Not Charge
If the hospital requests payment for cost outlier, and the Medicare covered charges converted to cost exceed
the cost outlier threshold, the services which are not reasonable and necessary (or constitute custodial care)
which are noncovered, but for which the hospital may not charge the beneficiary are determined as follows:
• The hospital determines the lesser of the following:
° The cost of the medically unnecessary services (converting the charges for the medically
unnecessary services to cost); or
° The amount by which the adjusted cost of the stay exceeds the cost outlier threshold.
Ancillary services, which are not required to be furnished on an inpatient basis, are treated as medically
unnecessary, but nevertheless may be covered under Part B.
• If the costs in excess of the outlier threshold exceed the cost of the medically unnecessary services, the
cost of all of the medically unnecessary services are treated as noncovered costs. If these costs exceed
the costs in excess of the cost outlier threshold, beginning with the cost of the last medically
unnecessary service in the stay, the hospital must identify, and add on, in reverse order, the cost of
other medically unnecessary services until the total cost of medically unnecessary services reaches the
costs in excess of the cost outlier threshold. If the cost of the last service to be added on in this manner
brings the cost of medically unnecessary services over the amount of costs in excess of the cost outlier
threshold, only the portion of the cost of that last medically unnecessary service (in the order of the
addition) needed to bring the total of the medically unnecessary costs up to the costs in excess of the
cost outlier threshold is added on. In this case, the costs in excess of the cost outlier threshold are
treated as the noncovered costs.
• Once the costs of medically unnecessary services to be treated as noncovered are determined, convert
them to charges for each applicable service/revenue category, e.g., accommodations, radiology,
pharmacy, by dividing the costs treated as not medically necessary in each category by 72 percent.
The medically unnecessary charges determined are treated as noncovered charges. Days for which all
costs are found to be noncovered are treated as noncovered days.
• The hospital determines which medically unnecessary services and days treated as noncovered are
services and days for which the beneficiary can be charged under §40.2.2C or E. The remainder of the
services and days are the medically unnecessary services and days treated as noncovered even though
the hospital may not charge the beneficiary. However, the distinction between medically unnecessary
services and days for which the hospital may charge, and those for which it may not, will not be
reflected in the charges shown on the inpatient hospital billing. Both are combined and shown as
noncovered services and days.
The determination of medically unnecessary cost outliers is not affected by non-entitlement days or days after
benefits are exhausted. If the stay is covered or treated as covered, the beneficiary is treated as entitled to Part
A, and as having benefits available throughout the stay.
40.2.1 - Noncovered Admission Followed by Covered Level of Care
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of
ICD-10, Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: September, 23 2014)
Where a beneficiary receives noncovered care at admission, and is notified as such, but subsequently is
furnished covered level of care during the same hospital stay, the admission is deemed to have occurred when
covered services became medically needed and rendered. This is applicable to PPS and non-PPS billings.
The following billing entries identify this situation:
• Admission date (not the deemed date).
• Occurrence code "31" and the date the hospital provided notice to the beneficiary.
• Occurrence span code 76 indicates the noncovered span from admission date through the day before
covered care started.
• Value code 31 is used to indicate the amount which was charged the beneficiary for noncovered
services.
• Noncovered charges related to the noncovered services.
• The principal diagnosis is shown as the diagnosis that caused the covered level of care.
• Only procedures performed during the covered level of care are shown on the bill.
If a no payment bill for the noncovered level of care has been processed, the hospital prepares and forwards a
new initial bill.
40.2.2 - Charges to Beneficiaries for Part A Services
(Rev. 1495; Issued: 05-02-08; Effective Date: 10-01-08; Implementation Date: 10-06-08)
The hospital submits a bill even where the patient is responsible for a deductible which covers the entire
amount of the charges for non-PPS hospitals, or in PPS hospitals, where the DRG payment amount will be
less than the deductible.
A hospital receiving payment for a covered hospital stay (or PPS hospital that includes at least one covered
day, or one treated as covered under guarantee of payment or limitation on liability) may charge the
beneficiary, or other person, for items and services furnished during the stay only as described in subsections
A through H. If limitation of liability applies, a beneficiary's liability for payment is governed by the
limitation on liability notification rules in Chapter 30 of this manual. For related notices for inpatient
hospitals, see CMS Transmittal 594, Change Request3903, dated June 24, 2005.
A. - Deductible and Coinsurance
The hospital may charge the beneficiary or other person for applicable deductible and coinsurance amounts.
The deductible is satisfied only by charges for covered services. The A/B MAC (A) deducts the deductible
and coinsurance first from the PPS payment. Where the deductible exceeds the PPS amount, the excess will
be applied to a subsequent payment to the hospital. (See Chapter 3 of the Medicare General Information,
Eligibility, and Entitlement Manual for specific policies.)
B. - Blood Deductible
The Part A blood deductible provision applies to whole blood and red blood cells, and reporting of the number
of pints is applicable to both PPS and non-PPS hospitals. (See Chapter 3 of the Medicare General Information,
Eligibility, and Entitlement Manual for specific policies.) Hospitals shall report charges for red blood cells
using revenue code 381, and charges for whole blood using revenue code 382.
C. - Inpatient Care No Longer Required
The hospital may charge for services that are not reasonable and necessary or that constitute custodial care.
Notification may be required under limitation of liability. See CMS Transmittal 594, Change Request3903,
dated June 24, 2005, section V. of the attachment, for specific notification requirements. Note this transmittal
will be placed in Chapter 30 of this manual at a future point. Chapter 1, section 150 of this manual also
contains related billing information in addition to that provided below.
In general, after proper notification has occurred, and assuming an expedited decision is received from a
Quality Improvement Organization (QIO), the following entries are required on the bill the hospital prepares:
• Occurrence code 3l (and date) to indicate the date the hospital notified the patient in accordance with
the first bullet above;
• Occurrence span code 76 (and dates) to indicate the period of noncovered care for which it is charging
the beneficiary;
• Occurrence span code 77 (and dates) to indicate the period of noncovered care for which the provider
is liable, when it is aware of this prior to billing; and
• Value code 3l (and amount) to indicate the amount of charges it may bill the beneficiary for days for
which inpatient care was no longer required. They are included as noncovered charges on the bill.
D. - Change in the Beneficiary's Condition
If the beneficiary remains in the hospital after receiving notice as described in subsection C, and the hospital,
the physician who concurred in the hospital's determination, or the QIO, subsequently determines that the
beneficiary again requires inpatient hospital care, the hospital may not charge the beneficiary or other person
for services furnished after the beneficiary again required inpatient hospital care until proper notification
occurs (see subsection C).
If a patient who needs only a SNF level of care remains in the hospital after the SNF bed becomes available,
and the bed ceases to be available, the hospital may continue to charge the beneficiary. It need not provide the
beneficiary with another notice when the patient chose not to be discharged to the SNF bed.
E. - Admission Denied
If the entire hospital admission is determined to be not reasonable or necessary, limitation of liability may
apply. See 2005 CMS transmittal 594, section V. of the attachment, for specific notification requirements.
NOTE: This transmittal will be placed in Chapter 30 of this manual at a future point.
In such cases the following entries are required on the bill:
• Occurrence code 3l (and date) to indicate the date the hospital notified the beneficiary.
• Occurrence span code 76 (and dates) to indicate the period of noncovered care for which the
hospital is charging the beneficiary.
• Occurrence span code 77 (and dates) to indicate any period of noncovered care for which the
provider is liable (e.g., the period between issuing the notice and the time it may charge the
beneficiary) when the provider is aware of this prior to billing.
• Value code 3l (and amount) to indicate the amount of charges the hospital may bill the beneficiary
for hospitalization that was not necessary or reasonable. They are included as noncovered charges
on the bill.
F. - Procedures, Studies and Courses of Treatment That Are Not Reasonable or Necessary
If diagnostic procedures, studies, therapeutic studies and courses of treatment are excluded from coverage as
not reasonable and necessary (even though the beneficiary requires inpatient hospital care) the hospital may
charge the beneficiary or other person for the services or care according the procedures given in CMS
Transmittal 594, Change Request3903, dated June 24, 2005.
The following bill entries apply to these circumstances:
• Occurrence code 32 (and date) to indicate the date the hospital provided the notice to the beneficiary.
• Value code 3l (and amount) to indicate the amount of such charges to be billed to the beneficiary.
They are included as noncovered charges on the bill.
G. - Nonentitlement Days and Days after Benefits Exhausted
If a hospital stay exceeds the day outlier threshold, the hospital may charge for some, or all, of the days on
which the patient is not entitled to Medicare Part A, or after the Part A benefits are exhausted (i.e., the hospital
may charge its customary charges for services furnished on those days). It may charge the beneficiary for the
lesser of:
• The number of days on which the patient was not entitled to benefits or after the benefits were
exhausted; or
• The number of outlier days. (Day outliers were discontinued at the end of FY 1997.)
If the number of outlier days exceeds the number of days on which the patient was not entitled to benefits, or
after benefits were exhausted, the hospital may charge for all days on which the patient was not entitled to
benefits or after benefits were exhausted. If the number of days on which the beneficiary was not entitled to
benefits, or after benefits were exhausted, exceeds the number of outlier days, the hospital determines the days
for which it may charge by starting with the last day of the stay (i.e., the day before the day of discharge) and
identifying and counting off in reverse order, days on which the patient was not entitled to benefits or after the
benefits were exhausted, until the number of days counted off equals the number of outlier days. The days
counted off are the days for which the hospital may charge.
H. - Contractual Exclusions
In addition to receiving the basic prospective payment, the hospital may charge the beneficiary for any
services that are excluded from coverage for reasons other than, or in addition to, absence of medical
necessity, provision of custodial care, non-entitlement to Part A, or exhaustion of benefits. For example, it
may charge for most cosmetic and dental surgery.
I. - Private Room Care
Payment for medically necessary private room care is included in the prospective payment. Where the
beneficiary requests private room accommodations, the hospital must inform the beneficiary of the additional
charge. (See the Medicare Benefit Policy Manual, Chapter 1.) When the beneficiary accepts the liability, the
hospital will supply the service, and bill the beneficiary directly. If the beneficiary believes the private room
was medically necessary, the beneficiary has a right to a determination and may initiate a Part A appeal.
J. - Deluxe Item or Service
Where a beneficiary requests a deluxe item or service, i.e., an item or service which is more expensive than is
medically required for the beneficiary's condition, the hospital may collect the additional charge if it informs
the beneficiary of the additional charge. That charge is the difference between the customary charge for the
item or service most commonly furnished by the hospital to private pay patients with the beneficiary's
condition, and the charge for the more expensive item or service requested. If the beneficiary believes that the
more expensive item or service was medically necessary, the beneficiary has a right to a determination and
may initiate a Part A appeal.
K - Inpatient Acute Care Hospital Admission Followed By a Death or Discharge Prior To Room
Assignment
A patient of an acute care hospital is considered an inpatient upon issuance of written doctor’s orders to that
effect. If a patient either dies or is discharged prior to being assigned and/or occupying a room, a hospital may
enter an appropriate room and board charge on the claim. If a patient leaves of their own volition prior to
being assigned and/or occupying a room, a hospital may enter an appropriate room and board charge on the
claim as well as a patient status code 07 which indicates they left against medical advice. A hospital is not
required to enter a room and board charge, but failure to do so may have a minimal impact on future DRG
weight calculations.
40.2.3 - Determining Covered and Noncovered Charges - Pricer and PS&R
(Rev. 1, 10-01-03)
Accommodation charges for days covered by Medicare are covered charges. Ancillary charges incurred on
these days are also covered charges as long as these services are covered under Medicare. The A/B MAC (A)
enters them into its PS&R unless it or the QIO denies them as exclusions from coverage or as medically
unnecessary. For PPS hospitals, the A/B MAC (A) counts these charges for Pricer unless the charges are
included as pass-through costs.
The A/B MAC (A) does not count for Pricer or the PS&R:
• Charges the provider has shown as noncovered. (If the provider has complied with the notice
requirements in Chapter 30, it may bill the beneficiary.);
• Services on noncovered days;
• Charges for personal comfort and/or convenience items;
• Accommodations and routine charges for the day of discharge, death, or beginning of a leave of
absence, unless it is also the day of admission; and
• Charges for ancillary services on the day of discharge, death, or beginning of a leave of absence if the
preceding day is noncovered under §40.2.B.
MSP Issues
The A/B MAC (A) resolves any MSP issues not handled by §40.1.G using the instructions in the Medicare
Secondary Payer Manual specific for reasonable cost providers and the instructions in specifically for PPS
providers.
Determining Covered and Noncovered Charges - Part B
The A/B MAC (A) counts as covered under Part B, for cost report and deductible purposes, the charges for
which Part B payment may be made, except as follows:
• It counts as covered for deductible, but not cost report purposes, those charges for which the provider
is liable for technical reasons; and
• It does not count charges for which the provider is liable because services are not medically necessary
for either deductible or cost report purposes.
40.2.4 - IPPS Transfers Between Hospitals
(Rev.10952, Issued:08-19-2021, Effective: 09-20-2021, Implementation:09-20-2021)
A discharge of a hospital inpatient is considered to be a transfer if the patient is admitted the same day to
another hospital. A transfer between acute inpatient hospitals occurs when a patient is admitted to a hospital
and is subsequently transferred from the hospital where the patient was admitted to another hospital for
additional treatment once the patient's condition has stabilized or a diagnosis established. The following
procedures apply. See §20.2.3 for proper Pricer coding to ensure that these requirements are met.
Note: CMS established Common Working File Edits (CWF) edits in January 2004 to ensure accurate coding
and payment for discharges and/or transfers.
A. - Transfers Between IPPS Prospective Payment Acute Care Hospitals
For discharges occurring on or after October 1, 1983, when a hospital inpatient is discharged to another acute
care hospital, as described in 42 CFR 412.4(b), payment to the transferring hospital is based upon a graduated
per diem rate (i.e., the prospective payment rate divided by the geometric mean length of stay for the specific
MS-DRG into which the case falls; hospitals receive twice the per diem rate for the first day of the stay and
the per diem rate for every following day up to the full MS-DRG amount). If the stay is less than l day, l day is
paid. A day is counted if the patient was admitted with the expectation of staying overnight. However, this
day does not count against the patient's Medicare days (utilization days), since this Medicare day is applied at
the receiving hospital. Deductible or coinsurance, where applicable, is also charged against days at the
receiving hospital (see §40.1.D). If the patient is treated in the emergency room without being admitted and
then transferred, only Part B billing is appropriate. Payment is made to the final discharging hospital at the
full prospective payment rate.
The prospective payment rate paid is the hospital's specific rate. Similarly, the wage index values and any
other adjustments are those that are appropriate for each hospital. Where a transfer case results in treatment in
the second hospital under a MS-DRG different than the MS-DRG in the transferring hospital, payment to each
is based upon the MS-DRG under which the patient was treated. For transfers on or after October 1, 1984, the
transferring hospital may be paid an outlier payment. For further information on outlier payments for transfer
cases, see section 20.1.2.4 of this manual.
An exception to the transfer policy applies to MS-DRG 789. The weighting factor for this MS-DRG assumes
that the patient will be transferred, since a transfer is part of the definition. Therefore, a hospital that transfers
a patient classified into this MS-DRG is paid the full amount of the prospective payment rate associated with
the DRG rather than the per diem rate, plus any outlier payment, if applicable.
Effective for discharges on or after October 1, 2003, patients who leave against medical advice (LAMA), but
are admitted to another inpatient PPS hospital on the same day as they left, will be treated as transfers and the
transfer payment policy will apply.
An acute care transfer occurs when a Medicare patient in an IPPS Hospital (with any MS-DRG) is:
• Transferred to another acute care IPPS hospital or unit for related care (Patient Discharge Status Code
02 or Planned Acute Care Hospital Inpatient Readmission Patient Discharge Status Code 02).
• Admitted to another IPPS on the same day after leaving their designated IPPS hospital against medical
advice (Patient Discharge Status Code 07).
• Discharged but then readmitted on the same day to another IPPS hospital (unless the readmission is
unrelated to the initial discharge).
B. - Transfers from an IPPS Acute Care Hospital to Hospitals or Hospital Units Excluded from the
IPPS
When patients are transferred to hospitals or units excluded from IPPS, the full inpatient prospective payment
is made to the transferring hospital. The receiving hospital is paid on the basis of reasonable costs or is made
at the rate of its respective payment system (see exceptions in paragraph C of this section).
A transfer payment is made to the transferring hospital when patients are transferred to a hospital that would
ordinarily be paid under prospective payment, but that is excluded because of participation in a state or area
wide cost control program. Also, a transfer payment is made where a patient is transferred to a hospital or
hospital unit that has not been officially determined as being excluded from PPS and certain hospitals that are
excluded from IPPS. These include:
• An acute care hospital that would otherwise be eligible to be paid under the IPPS, but does not have an
agreement to participate in the Medicare program (Patient Discharge Status Code 02 or Planned Acute
Care Hospital Inpatient Readmission Patient Discharge Status Code 82).
• A critical access hospital (Patient Discharge Status Code 66 or Planned Acute Care Hospital
Readmission Patient Discharge Status Code 94).
C. - Postacute Care Transfers
(Previously Special 10 DRG Rule)
For discharges occurring on or after October 1, 1998, a discharge of a hospital inpatient is considered to be a
transfer for purposes of this part when the patient's discharge is assigned, as described in 42 CFR 412.4(c), to
one of the qualifying Postacute MS-DRGs referenced in paragraph (D) of this section and the discharge is
made under any of the following circumstances:
• To a hospital or distinct part hospital unit excluded from the inpatient prospective payment system
(under subpart B of 42 CRF 412). Facilities excluded from IPPS are inpatient rehabilitation facilities
and units (Patient Discharge Status Code 62 or Planned Acute Care Hospital Inpatient Readmission
Patient Discharge Status Code 90), long term care hospitals (Patient Discharge Status Code 63 or
Planned Acute Care Hospital Inpatient Readmission Patient Discharge Status Code 91), psychiatric
hospitals and units (Patient Discharge Status Code 65 or Planned Acute Care Hospital Inpatient
Readmission Patient Discharge Status Code 93), children’s hospitals, and cancer hospitals (Patient
Discharge Status Code 05 or Planned Acute Care Hospital Inpatient Readmission Patient Discharge
Status Code 85).
• To a skilled nursing facility (Patient Discharge Status Code 03 or Planned Acute Care Hospital
Inpatient Readmission Patient Discharge Status Code 83).
• To Hospice care at home (Patient Discharge Status Code 50) or Hospice Medical Facility (Certified)
Providing Hospice Level of Care (Patient Discharge Status Code 51).
• To home under a written plan of care for the provision of home health services from a home health
agency and those services begin within 3 days after the date of discharge (Patient Discharge Status
Code 06 or Planned Acute Care Hospital Inpatient Readmission Patient Discharge Status Code 86).
Specific transfer cases under this paragraph qualify for payment under an alternative methodology. These
include transfer cases in which the patient’s discharge is assigned, as described in 42 CFR 412.4(f)(2), (f)(5)
and (f)(6), to one of the qualifying Special Pay MS-DRGs referenced in paragraph (D) of this section. For
these cases, the transferring hospital is paid 50 percent of the appropriate inpatient prospective payment rate
and 50 percent of the appropriate transfer payment.
Medicare’s IPPS Postacute care transfer policy requires hospitals to apply the correct Patient Discharge Status
Code to claims where patients receive Home Health (HH) services within 3 days of discharge. This includes
the resumption of HH services in place prior to the inpatient stay.
Medicare’s claims processing system reviews all line item dates of service on HH claims to determine if the
Postacute care transfer payment policy should apply when any HH service dates are within 3 days after the
IPPS discharge date.
In addition to the correct Patient Discharge Status Code, the IPPS hospital may add one of the following
condition codes to the claim, as appropriate, to receive the full MS-DRG payment:
• Condition Code 42 - used if a patient is discharged to home with HH services, but the continuing
care is not related to the condition or diagnosis for which the individual received inpatient hospital
services.
• Condition Code 43 – used if the continuing care is related, but no HH services are furnished
within 3 days of hospital discharge.
If an acute care hospital submits a bill based on its belief that it is discharging a patient to home or another
setting not included in the Postacute care transfer policy but subsequently learns that Postacute care was
provided, the hospital should submit an adjusted bill.
D. - Qualifying MS-DRGs
Refer to Table 5 of the applicable Fiscal Year IPPS Federal Register for the list of qualifying Postacute MS-
DRGs and Special Pay Postacute MS-DRGs.
40.2.5 - Repeat Admissions
(Rev. 2627, Issued 01-04-13, Effective 10-01-12, Implementation 10-01-12)
A patient who requires follow-up care or elective surgery may be discharged and readmitted or may be placed
on a leave of absence.
Hospitals may place a patient on a leave of absence when readmission is expected and the patient does not
require a hospital level of care during the interim period. Examples could include, but are not limited to,
situations where surgery could not be scheduled immediately, a specific surgical team was not available,
bilateral surgery was planned, or when further treatment is indicated following diagnostic tests but cannot
begin immediately. Institutional providers must not use the leave of absence billing procedure when the
second admission is unexpected.
The A/B MACs (A) may choose to review claims if data analysis deems it a priority. AB/MACs (A) will
review the claim selected, based on the medical record associated with that claim and make a payment
determination on that claim. They will then refer the claim to the QIO, in accordance with IOM 100-08,
chapter 6, §6.5.7.
The QIOs may review acute care hospital admissions occurring within 30 days of discharge from an acute
care hospital if both hospitals are in the QIO’s jurisdiction and if it appears that the two confinements could be
related. Two separate payments would be made for these cases unless the readmission or preceding admission
is denied.
NOTE: The QIO’s authority to review and to deny readmissions when appropriate is not limited to
readmissions within 30 days. The QIO has the authority to deny the second admission to the same or another
acute PPS hospital, no matter how many days elapsed since the patient's discharge.
Placing a patient on a leave of absence will not generate two payments. Only one bill and one DRG payment
is made. The A/B MACs (A) do not consider leave of absence bills as two admissions. It may select such
bills for review for other reasons.
When a patient is discharged/transferred from an acute care Prospective Payment System (PPS) hospital, and
is readmitted to the same acute care PPS hospital on the same day for symptoms related to, or for evaluation
and management of, the prior stay’s medical condition, hospitals shall adjust the original claim generated by
the original stay by combining the original and subsequent stay onto a single claim.
Services rendered by other entities during a combined stay must be paid by the acute care PPS hospital. The
acute care PPS hospital is responsible for the other entity’s services per common Medicare practice.
NOTE: Medicare does not reimburse other entities for services performed during two inpatient acute care
PPS stays that are combined onto a single claim. However, the other entity’s services may be considered and
billed as covered services, when appropriate, by the acute care PPS hospital.
When a patient is discharged/transferred from an acute care PPS hospital and is readmitted to the same acute
care PPS hospital on the same day for symptoms unrelated to, and/or not for evaluation and management of,
the prior stay’s medical condition, hospitals shall place condition code (CC) B4 on the claim that contains an
admission date equal to the prior admissions discharge date.
Upon the request of A/B MACs (A), hospitals must submit medical records pertaining to the readmission.
For Non-PPS acute care hospitals, such as Maryland waiver hospitals, the readmission bill (if related to
original admission) does not have to be combined with the original bill if the stay spans a month. However,
the original bill would have to be adjusted to change the patient status code to a 30 (still a patient).
Subsequent monthly bills for this admission would be billed as interim bills, 112, 113 or 114.
40.2.6 - Leave of Absence
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of
ICD-10, Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: September, 23 2014)
Providers submit one bill for covered days and days of leave when the patient is ultimately discharged.
The provider bills for covered days with days of leave included in Noncovered Days. Noncovered charges for
leave of absence days (holding a bed) may be omitted from the bill or may be shown under revenue code
018x. Providers will be instructed by their A/B MAC (A) on which billing method to use. Occurrence span
code 74 is used to report the dates the leave began and ended. Although the Medicare program may not be
billed for days of leave, the provider is not permitted to charge a beneficiary for them.
Where a patient on leave of absence from a non-PPS hospital who was shown as "Still Patient" (patient status
code 30) on an interim bill:
• Has not returned within 60 days, including the day leave began, or
• Has been admitted to another institution at any time during the leave of absence, submit an adjusted
bill.
The hospital shows the day the patient left the hospital as the date of discharge. (A beneficiary cannot be an
inpatient of two institutions at the same time.)
NOTE: Home health or outpatient services provided during a leave of absence do not affect the leave and no
discharge bill is required unless the above events occur.
40.3 - Outpatient Services Treated as Inpatient Services
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of
ICD-10, Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: September, 23 2014)
A. - Outpatient Services Followed by Admission Before Midnight of the Following Day (Effective For
Services Furnished Before October 1, 1991)
When a beneficiary receives outpatient hospital services during the day immediately preceding the hospital
admission, the outpatient hospital services are treated as inpatient services if the beneficiary has Part A
coverage. Hospitals and A/B MACs (A) apply this provision only when the beneficiary is admitted to the
hospital before midnight of the day following receipt of outpatient services. The day on which the patient is
formally admitted as an inpatient is counted as the first inpatient day.
When this provision applies, services are included in the applicable PPS payment and not billed separately.
When this provision applies to hospitals and units excluded from the hospital PPS, services are shown on the
bill and included in the Part A payment. See Chapter 1 for A/B MAC (A) requirements for detecting duplicate
claims in such cases.
B. - Preadmission Diagnostic Services (Effective for Services Furnished On or After January 1, 1991)
Diagnostic services (including clinical diagnostic laboratory tests) provided to a beneficiary by the admitting
hospital, or by an entity wholly owned or wholly operated by the admitting hospital (or by another entity
under arrangements with the admitting hospital), within 3 days prior to and including the date of the
beneficiary's admission are deemed to be inpatient services and included in the inpatient payment, unless there
is no Part A coverage. For example, if a patient is admitted on a Wednesday, outpatient services provided by
the hospital on Sunday, Monday, Tuesday, or Wednesday are included in the inpatient Part A payment.
This provision does not apply to ambulance services and maintenance renal dialysis services (see the
Medicare Benefit Policy Manual, Chapters 10 and 11, respectively). Additionally, Part A services furnished
by skilled nursing facilities, home health agencies, and hospices are excluded from the payment window
provisions.
For services provided before October 31, 1994, this provision applies to both hospitals subject to the hospital
inpatient prospective payment system (IPPS) as well as those hospitals and units excluded from IPPS.
For services provided on or after October 31, 1994, for hospitals and units excluded from IPPS, this provision
applies only to services furnished within one day prior to and including the date of the beneficiary's
admission. The hospitals and units that are excluded from IPPS are: psychiatric hospitals and units; inpatient
rehabilitation facilities (IRF) and units; long-term care hospitals (LTCH); children’s hospitals; and cancer
hospitals.
The 3-day (or 1-day) payment window policy does not apply when the admitting hospital is a critical access
hospital (CAH). Therefore outpatient diagnostic services rendered to a beneficiary by a CAH, or by an entity
that is wholly owned or operated by a CAH, during the payment window, must not be bundled on the claim
for the beneficiary’s inpatient admission at the CAH. However, outpatient diagnostic services rendered to a
beneficiary at a CAH that is wholly owned or operated by a non-CAH hospital, during the payment window,
are subject to the 3-day (or 1-day) payment window policy.
The technical portion of any outpatient diagnostic service rendered to a beneficiary at a hospital-owned or
hospital-operated physician clinic or practice during the payment window is subject to the 3-day (or 1-day)
payment window policy (see MCPM, chapter 12, sections 90.7 and 90.7.1).
The 3-day (or 1-day) payment window policy does not apply to outpatient diagnostic services included in the
rural health clinic (RHC) or Federally qualified health center (FQHC) all-inclusive rate (see MCPM, chapter
19, section 20.1).
Outpatient diagnostic services furnished to a beneficiary more than 3 days (for a non-subsection (d) hospital,
more than 1 day) preceding the date of the beneficiary’s admission to the hospital, by law, are not part of the
payment window and must not be bundled on the inpatient bill with other outpatient services that were
furnished during the span of the 3-day (or 1-day) payment window, even when all of the outpatient services
were furnished during a single, continuous outpatient encounter. Instead, the outpatient diagnostic services
that were furnished prior to the span of the payment window may be separately billed to Part B.
An entity is considered to be "wholly owned or operated" by the hospital if the hospital is the sole owner or
operator. A hospital need not exercise administrative control over a facility in order to operate it. A hospital
is considered the sole operator of the facility if the hospital has exclusive responsibility for implementing
facility policies (i.e., conducting or overseeing the facility's routine operations), regardless of whether it also
has the authority to make the policies.
For purposes of the 3-day (or 1-day) payment window policy, a “sponsorship” is treated the same as an
“ownership”, and a “non-profit” or “not-for-profit” entity is treated the same as a “for-profit” entity. Thus,
outpatient diagnostic services provided by the admitting not-for-profit hospital, or by an entity that is wholly
sponsored or operated by the admitting not-for-profit hospital, to a beneficiary during the 3 days (or 1 day)
immediately preceding and including the date of the beneficiary’s inpatient admission are deemed to be
inpatient services and must be bundled on the claim for the beneficiary’s inpatient stay at the not-for-profit
hospital.
For this provision, diagnostic services are defined by the presence on the bill of the following revenue and/or
CPT codes:
Code
Description
0254
Drugs incident to other diagnostic services
0255
Drugs incident to radiology
030X
Laboratory
031X
Laboratory pathological
032X
Radiology diagnostic
0341, 0343
Nuclear medicine, diagnostic/Diagnostic
Radiopharmaceuticals
035X
CT scan
0371
Anesthesia incident to Radiology
0372
Anesthesia incident to other diagnostic services
040X
Other imaging services
Code
Description
046X
Pulmonary function
0471
Audiology diagnostic
0481, 0489
Cardiology, Cardiac Catheter Lab/Other
Cardiology with CPT codes 93451-93464, 93503,
93505, 93530-93533, 93561-93568, 93571-93572,
G0275, and G0278 diagnostic
0482
Cardiology, Stress Test
0483
Cardiology, Echocardiology
053X
Osteopathic services
061X
MRT
062X
Medical/surgical supplies, incident to radiology or
other diagnostic services
073X
EKG/ECG
074X
EEG
0918-
Testing- Behavioral Health
092X
Other diagnostic services
The CWF rejects services furnished January 1, 1991, or later when outpatient bills for diagnostic services with
through dates or last date of service (occurrence span code 72) fall on the day of admission or any of the 3
days immediately prior to admission to an IPPS or IPPS-excluded hospital. This reject applies to the bill in
process, regardless of whether the outpatient or inpatient bill is processed first. Hospitals must analyze the
two bills and report appropriate corrections. For services on or after October 31, 1994, for hospitals and units
excluded from IPPS, CWF will reject outpatient diagnostic bills that occur on the day of or one day before
admission. For IPPS hospitals, CWF will continue to reject outpatient diagnostic bills for services that occur
on the day of or any of the 3 days prior to admission. Effective for dates of service on or after July 1, 2008,
CWF will reject diagnostic services when the line item date of service (LIDOS) falls on the day of admission
or any of the 3 days immediately prior to an admission to an IPPS hospital or on the day of admission or one
day prior to admission for hospitals excluded from IPPS.
Hospitals in Maryland that are under the jurisdiction of the Health Services Cost Review Commission are
subject to the 3-day payment window.
C. - Other Preadmission Services (Effective for Services Furnished On or After October 1, 1991 and Before
June 25, 2010)
Nondiagnostic outpatient services that are related to a beneficiary’s hospital admission and that are provided
by the admitting hospital, or by an entity that is wholly owned or wholly operated by the admitting hospital (or
by another entity under arrangements with the admitting hospital), to the patient during the 3 days
immediately preceding and including the date of the beneficiary’s admission are deemed to be inpatient
services and are included in the inpatient payment. Effective March 13, 1998, we defined nondiagnostic
preadmission services as being related to the admission only when there is an exact match (for all digits)
between the principal diagnosis code assigned for both the preadmission services and the inpatient stay. Thus,
whenever Part A covers an admission, the hospital may bill nondiagnostic preadmission services to Part B as
outpatient services only if they are not related to the admission. The A/B MAC (A) shall assume, in the
absence of evidence to the contrary, that such bills are not admission related and, therefore, are not deemed to
be inpatient (Part A) services. If there are both diagnostic and nondiagnostic preadmission services and the
nondiagnostic services are unrelated to the admission, the hospital may separately bill the nondiagnostic
preadmission services to Part B. This provision applies only when the beneficiary has Part A coverage. This
provision does not apply to ambulance services and maintenance renal dialysis. Additionally, Part A services
furnished by skilled nursing facilities, home health agencies, and hospices are excluded from the payment
window provisions.
For services provided before October 31, 1994, this provision applies to both hospitals subject to IPPS as well
as those hospitals and units excluded from IPPS (see section B above).
For services provided on or after October 31, 1994, for hospitals and units excluded from IPPS, this provision
applies only to services furnished within one day prior to and including the date of the beneficiary's
admission.
Hospitals must not include on a claim for an inpatient admission any outpatient nondiagnostic services that are
not payable under Part B. For example, oral medications that are considered self-administered drugs under
Part B are not payable under the outpatient prospective payment system (OPPS) and must not be bundled on
an inpatient claim for purposes of the 3-day (or 1-day) payment window policy.
The 3-day (or 1-day) payment window policy does not apply when the admitting hospital is a critical access
hospital (CAH). Therefore, outpatient nondiagnostic services rendered to a beneficiary by a CAH, or by an
entity that is wholly owned or operated by a CAH, during the payment window, must not be bundled on the
claim for the beneficiary’s inpatient admission at the CAH. However, admission-related outpatient
nondiagnostic services rendered to a beneficiary at a CAH that is wholly owned or operated by a non-CAH
hospital, during the payment window, are subject to the 3-day (or 1-day) payment window policy.
The technical portion of any admission-related outpatient nondiagnostic service rendered to a beneficiary at a
hospital-owned or hospital-operated physician clinic or practice during the payment window is subject to the
3-day (or 1-day) payment window policy (see MCPM, chapter 12, sections 90.7 and 90.7.1).
The 3-day (or 1-day) payment window policy does not apply to outpatient nondiagnostic services that are
included in the rural health clinic (RHC) or Federally qualified health center (FQHC) all-inclusive rate (see
MCPM, chapter 19, section 20.1).
Outpatient nondiagnostic services furnished to a beneficiary more than 3 days (for a non-subsection (d)
hospital, more than 1 day) preceding the date of the beneficiary’s admission to the hospital, by law, are not
part of the payment window and must not be bundled on the inpatient bill with other outpatient services that
were furnished during the span of the 3-day (or 1-day) payment window, even when all of the outpatient
services were furnished during a single, continuous outpatient encounter. Instead, the outpatient
nondiagnostic services that were furnished prior to the span of the payment window may be separately billed
to Part B.
An entity is considered to be "wholly owned or operated" by the hospital if the hospital is the sole owner or
operator. A hospital need not exercise administrative control over a facility in order to operate it. A hospital
is considered the sole operator of the facility if the hospital has exclusive responsibility for implementing
facility policies (i.e., conducting or overseeing the facility's routine operations), regardless of whether it also
has the authority to make the policies.
For purposes of the 3-day (or 1-day) payment window policy, a “sponsorship” is treated the same as an
“ownership”, and a “non-profit” or “not-for-profit” entity is treated the same as a “for-profit” entity. Thus,
admission-related outpatient nondiagnostic services provided by the admitting not-for-profit hospital, or by an
entity that is wholly sponsored or operated by the admitting not-for-profit hospital, to a beneficiary during the
3 days (or 1 day) immediately preceding and including the date of the beneficiary’s inpatient admission are
deemed to be inpatient services and must be bundled on the claim for the beneficiary’s inpatient stay at the
not-for-profit hospital.
Hospitals in Maryland that are under the jurisdiction of the Health Services Cost Review Commission are
subject to the 3-day payment window.
Effective for dates of service on or after July 1, 2008 and before June 25, 2010, CWF will reject claims for
nondiagnostic services when the following is met:
1) There is an exact match (for all digits) between the principal diagnosis code assigned for both the
preadmission services and the inpatient stay, and
2) The line item date of service (LIDOS) falls on the day of admission or any of the 3 days
immediately prior to an admission to an IPPS hospital (or on the day of admission or one day prior to
admission for hospitals excluded from IPPS).
D. - Other Preadmission Services (Effective for Services Furnished On or After June 25, 2010)
Beginning on or after June 25, 2010, the definition of “other services related to the admission” (i.e.,
admission-related outpatient “nondiagnostic” services) is revised for purposes of the 3-day (or 1-day) payment
window policy. Except for the following changes, the other requirements in section 40.3.C continue to be
applicable.
For outpatient nondiagnostic services furnished on or after June 25, 2010, all outpatient nondiagnostic
services, other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity
wholly owned or wholly operated by the hospital) on the date of a beneficiary’s inpatient admission are
deemed related to the admission, and thus, must be billed with the inpatient stay. Also, outpatient
nondiagnostic services, other than ambulance and maintenance renal dialysis services, provided by the
hospital (or an entity wholly owned or wholly operated by the hospital) on the first, second, and third calendar
days for a subsection (d) hospital paid under the IPPS (first calendar day for non-subsection (d) hospitals)
preceding the date of a beneficiary’s inpatient admission are deemed related to the admission, and thus, must
be billed with the inpatient stay, unless the hospital attests to specific nondiagnostic services as being
unrelated to the hospital claim (that is, the preadmission nondiagnostic services are clinically distinct or
independent from the reason for the beneficiary’s admission) by adding a condition code 51 (definition “51 -
Attestation of Unrelated Outpatient Non-diagnostic Services”) to the separately billed outpatient non-diagnostic
services claim
. Beginning on or after April 1, 2011, providers may submit outpatient claims with condition code
51 for outpatient claims that have a date of service on or after June 25, 2010.
Hospitals must include on a Medicare claim for a beneficiary’s inpatient stay the diagnoses, procedures, and
charges for all preadmission outpatient diagnostic services and all preadmission outpatient nondiagnostic
services that meet the above requirements. For purposes of the Present on Admission Indicator (POA), even if
the outpatient services are bundled with the inpatient claim, hospitals shall code any conditions the patient has
at the time of the order to admit as an inpatient as POA irrespective of whether or not the patient had the
condition at the time of being registered as a hospital outpatient. In combining on the inpatient bill the
diagnoses, procedures, and charges for the outpatient services, a hospital must convert CPT codes to ICD
procedure codes and must only include outpatient diagnostic and admission-related nondiagnostic services
that span the period of the payment window.
Outpatient nondiagnostic services provided during the payment window that are unrelated to the admission
and are covered by Part B may be separately billed to Part B. Hospitals must maintain documentation in the
beneficiary’s medical record to support their claim that the preadmission outpatient nondiagnostic services are
unrelated to the beneficiary’s inpatient admission.
Effective for dates of service on or after June 25, 2010, CWF will reject outpatient claims for nondiagnostic
services when the following occurs:
1) Condition code 51 (definition “51 - Attestation of Unrelated Outpatient Non-diagnostic Services”) is not
included on the outpatient claim, and
2) The line item date of service (LIDOS) falls on the day of admission or any of the 3 days
immediately prior to an admission to an IPPS hospital (or on the day of admission or one day prior to
admission for hospitals excluded from IPPS).
40.3.1 - Billing Procedures to Avoid Duplicate Payments
(Rev. 1, 10-01-03)
HO-400H
The hospital must install adequate billing procedures to avoid submission of duplicate claims. This includes
duplicate claims for the same service and outpatient bills for nonphysician services considered included in the
DRG for a related inpatient admission in the facility or in another hospital.
Where the hospital bills separately for nonphysician services provided to a patient either on the day before
admission to a PPS hospital or during a patient's inpatient stay, the claim will be rejected by the A/B MAC (A)
as a duplicate and the hospital may be subject to sanction penalties per §1128A of the Act.
50 - Adjustment Bills
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of
ICD -10, Implementation: ICD -10: Upon Implementation of ICD -10, ASC X12: September, 23 2014)
Adjustment bills are the most common mechanism for changing a previously accepted bill. They are required
to reflect the results of A/B MAC (A)’s medical review. Adjustments may also be requested by CMS via
CWF if it discovers that bills have been accepted and posted in error other than the omission of a charge.
Adjustments may be initiated as a result of OIG and MSP requests. The A/B MAC (A) will ask the provider
to submit an adjustment request for certain situations.
For hard copy Form CMS-1450 adjustment requests, the provider places the ICN/DCN of the original bill for
Payer A, B, or C.
Where payment is handled through the cost reporting and settlement processes, the provider accumulates a log
for those items not requiring an adjustment bill. For cost settlement, the A/B MAC (A) pays on the basis of
the log. This log must include:
• Patient name;
• HICN;
• Dates of admission and discharge, or from and thru dates;
• Adjustment in charges (broken out by ancillary or routine service); and
• Any unique numbering or filing code necessary for the hospital to associate the adjustment charge with
the original billing.
Providers in Maryland, which are not paid under PPS or cost reports, submit an adjustment bill for inpatient
care of $500 or more, and keep a log as described above for lesser amounts. Because there are no adjustment
bills, the A/B MAC (A) enters the payment amounts from the summary log into the PPS waiver simulation
and annually pays the items on the log after the cost report is filed.
NOTE: Information regarding the claim form locators that correspond with these fields on the Form CMS-
1450 is found in chapter 25.
An original bill does not have to be accepted by CMS prior to making related adjustments to the provider.
However, for all adjustments other than QIO adjustments (e.g., provider submitted and/or those the A/B MAC
(A) initiates), the A/B MAC (A) submits an adjustment bill to CWF following its acceptance of the initial bill.
To verify CMS' acceptance, it takes one or both of the following actions:
A. - General Rules for Submitting Adjustment Requests
Adjustment requests that only recoup or cancel a prior payment are "credits" and must match the original in
the following fields:
• A/B MAC (A) control number (ICN/DCN);
• Surname;
• HICN;
When a definite match cannot be made on the 3 fields above, the provider's A/B MAC (A) will use the fields
below as needed. Note that for older claims, ICN/DCN probably will not match.
• Date of birth;
• Admission date (Start of Care Date for Home Health), unless changed by this adjustment requests;
and
• From/thru dates (Date of First Visit/Date of Last Visit for Home Health), unless changed by this
adjustment request.
Cancel-only adjustment requests must be submitted only in cases of incorrect provider identification numbers
and incorrect HICNs. After the cancel-only request for the incorrect bill is resolved, the provider must submit
correct information as a new bill.
The provider must submit all other adjustment requests as debits only. It shows the ICN/DCN of the bill to be
adjusted as described above, with the bill type shown as XX7. It submits adjustment requests to its A/B MAC
(A) either electronically or on hard copy. Electronic submission is preferred.
The A/B MAC (A) must enter the following bill types that relate to the entity generating the adjustment
request:
Bill
Type
Description
XX7
Provider (debit)
XX8
Provider (cancel)
XXF
Beneficiary
XXG
CWF
XXH
CMS
XXI
A/B MAC (A)
XXM
MSP
XXP
QIO/QIO
XXJ
Other
XXK
OIG
The provider submits adjustment requests as bill type XX7 or XX8. Since several different sources can
initiate an adjustment for MSP purposes, the A/B MAC (A) will change the bill type to XXM, which takes
priority over any other source of an adjustment except OIG. These priorities refer only to the designation of
the source of the adjustment. The difference between CWF generating the adjustment request and CMS
generating the request is:
An adjustment is CWF-generated if the A/B MAC (A) receives a CWF alert or a CMS-L1002.
The A/B MAC (A) prepares an adjustment if instructed by CO or RO to make a change. Typically, the A/B
MAC (A) receives such direction from CMS when it decides to retroactively change payment for a class or
other group of bills. Occasionally, CMS will discover an error in the processing of a single bill and direct the
A/B MAC (A) to correct it.
If the A/B MAC (A) furnished the A/B MAC (B) a copy of the original bill which is being adjusted, it must
furnish them a copy of the adjusted bill.
If adjustment bills are rejected by CWF for additional corrections, they need to be corrected and resubmitted.
Even if the adjustment action is requested by letter from CMS, the A/B MAC (A) must submit the adjustment
bill in its CWF record. If a rejected adjustment bill is determined to be unnecessary, the A/B MAC (A) stops
the adjustment action upon receipt of correction.
Where an adjustment bill changes subsequent utilization, the A/B MAC (A) notes this and processes
adjustments to subsequent bills if it services the provider.
If the A/B MAC (A) does not service the provider, CMS will contact the A/B MACs (A), which submitted
bills with subsequent billing dates that are affected by the adjustments via an SSA-L389 or SSA-L1001 upon
receipt of the adjusted bills in CWF. (An indicator is set by CMS on its records upon advising an A/B MAC
(A) of the appropriate adjustment actions.)
B. - Adjustment Bills Involving Time Limitation for Filing Claims
If a provider fails to include a particular item or service on its initial bill, an adjustment bill(s) to include such
an item(s) or service(s) is not permitted after the expiration of the time limitation for filing a claim. However,
to the extent that an adjustment bill otherwise corrects or supplements information previously submitted on a
timely claim about specified services or items furnished to a specified individual, it is subject to the rules
governing administrative finality, rather than the time limitation for filing.
Under prospective payment, adjustment requests are required from the hospital where errors occur in
diagnoses and procedure coding that change the DRG, or where the deductible or utilization is affected. A
hospital is allowed 60 days from the date of the A/B MAC (A) payment notice for adjustment bills where
diagnostic or procedure coding was in error. Adjustments reported by the QIO have no corresponding time
limit and are adjusted automatically by the A/B MAC (A) without requiring the hospital to submit an
adjustment bill. However, if diagnostic and procedure coding errors have no effect on the DRG, adjustment
bills are not required.
Under PPS, for long-stay cases, hospitals may bill 60 days after an admission and every 60 days thereafter if
they choose. The A/B MAC (A) processes the initial bill through Grouper and Pricer. The provider must
submit an adjustment to cancel the original interim bill(s) and rebill the stay from the admission date through
the discharge date. When the adjustment bill is received, it processes it as an adjustment. In this case, the 60-
day requirement for correction does not apply.
Where payment is handled through cost reporting and settlement processes, the provider accumulates a log for
those items not requiring an adjustment bill. Maryland inpatient hospital providers also keep a log of late
charges when the amount is under $500. They submit the log with their cost reports. After cost reports are
filed, the A/B MAC (A) makes a lump sum payment to cover these charges as shown on the summary log.
The provider uses the summary log for late charges only under cost settlement (outpatient hospital), except in
Maryland.
Maryland and cost providers are required to meet the 27-month timeframe for timely filing of claims,
including late charges.
NOTE: Providers in Maryland which are not paid under PPS or cost reports, submit an adjustment bill for
inpatient care of $500 or more, and submit a log for the lesser amounts.
50.1 - Tolerance Guidelines for Submitting Adjustment Requests
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of
ICD-10, Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: September, 23 2014)
When a bill is submitted and the hospital or the A/B MAC (A) discovers an error, the hospital submits an
adjustment request using the ASC X12 837 institutional claim format or the Form CMS-1450, if the error is a
change in the:
• Number of inpatient days (including a change in the length of stay, or a different allocation of
covered/non-covered days;
• Blood deductible;
• Inpatient cash deductible of more than $1;
• Servicing provider;
• Discharge status in a PPS hospital;
• Diagnosis or Procedures that impact the assigned DRG code; or
• Outlier payment amount.
The provider submits most adjustment requests as debits, using bill type XX7.
Also, it submits a debit-only adjustment request to the A/B MAC (A) if the hospital previously submitted an
interim bill for a PPS hospital stay or wishes to change the number of days in any inpatient stay.
The A/B MAC (A) then submits the adjustment to CWF. An adjustment from the QIO for any of the above
also requires a submission to CMS via CWF.
If PPS is involved and the DRG has been changed as a result of medical review after an original bill has been
forwarded to CMS, adjustment debit/credit bills are required. The corrected bill must be an exact duplicate of
the original, except for any changed fields including diagnostic and procedure codes.
50.2 - Claim Change Reasons
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of
ICD-10, Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: September, 23 2014)
A. - Claim Change Reason Codes
The provider submits one of the following claim change reason codes to its A/B MAC (A) with each debit-
only or cancel-only adjustment request:
Bill
Type
Reason
Code
Explanation
XX7
D0 (zero)
Change to service dates
XX7
D1
Change in charges
XX7
D2
Change in revenue codes/HCPCS
XX7
D3
Second or subsequent interim PPS bill - inpatient only
XX7
D4
Change in GROUPER input (diagnoses or procedures) -
inpatient only
XX8
D5
Cancel-only to correct a HICN or provider identification
number
XX8
D6
Cancel-only to repay a duplicate payment or OIG overpayment
(includes cancellation of an outpatient bill containing services
required to be included on the inpatient bill.)
XX7
D7
Change to make Medicare the secondary payer
XX7
D8
Change to make Medicare the primary payer
XX7
D9
Any other change
XX7
E0 (zero)
Change in patient status
The provider may not submit more than one claim change reason code per adjustment request. It must choose
the single reason that best describes the adjustment it is requesting. It should use claim change reason code
D1 only when the charges are the only change on the claim. Other claim change reasons frequently change
charges, but the provider may not "add" reason code D1 when this occurs.
The claim change reason code is entered as a condition code on the ASC X12 837 institutional claim format or
on the hard copy Form CMS-1450 For reason codes D0-D4 and D7-D9, submit a debit-only adjustment
request, bill type XX7. For reason codes D5 and D6, submit a cancel-only adjustment request, bill type XX8.
B. - Edits on Claim Change Reason Codes
The following edits are based on the claim change reason code. The A/B MAC (A) must apply them to each
incoming adjustment request.
• If the type of bill is equal to XX7 and the claim change reason code is not equal to D0-D4, D7-D9, or
E0, the A/B MAC (A) rejects the request back to the provider with the following error message,
"Claim change reason code must be present and equal to D0-D4, D7-D9, or E0 for a debit-only
adjustment request."
• If the type of bill is equal to XX8 and the claim change reason code is not equal to D5-D6, the A/B
MAC (A) rejects the request back to the provider with the following error message, "Claim change
reason code must be present and equal to D5-D6 for a cancel-only adjustment request."
• If the type of bill is equal to XX7 or XX8 and the ICN/DCN of the claim being adjusted is not present,
the A/B MAC (A) rejects the request back to the provider with the following message, "ICN/DCN of
the claim being adjusted is required for an adjustment request."
• If more than one claim change reason code is present on the provider's request, the A/B MAC (A)
rejects the request back to the provider with the following message, "only one claim change reason
code may apply to a single adjustment request from a provider. Choose the single claim change reason
code that best describes the reason for the provider's request and resubmit."
• If the provider submits an adjustment request as type of bill not equal to XX7 or XX8, the A/B MAC
(A) rejects the request back to the provider with the message, "Provider submitted adjustment request
must use type of bill equal to XX7 or XX8."
• If the claim change reason code is equal to D0, the A/B MAC (A) compares the beginning and ending
dates on the provider's request to those on the claim to be adjusted on its history. If these dates are the
same, it rejects the request back to the provider with the message, "Dates of service must change for
claim change reason code D0."
• If the claim change reason code is equal to D1, the A/B MAC (A) compares the total and line item
charges on the provider's request to those on the claim to be adjusted on its history. If these changes
are the same, the A/B MAC (A) rejects the request back to the provider with the message, "Charges
must be changed for claim change reason code D1."
• If the claim change reason code is equal to D2, the A/B MAC (A) compares revenue codes/HCPCS on
the provider's request to those on the claim to be adjusted on its history. If these codes are the same, it
rejects the request back to the provider with the message, "Revenue codes/HCPCS must change for
claim change reason code D2."
• If the claim change reason code is equal to D3, the A/B MAC (A) compares the ending date on the
provider's request to that on the claim to be adjusted on its history. If these dates are the same, it
rejects the request back to the provider with the message, "Thru dates must change for the claim
change reason code D3."
• If the claim change reason code is equal to D4, the A/B MAC (A) compares diagnosis and procedure
codes on the provider's request to those on the claim to be adjusted on its history. If these codes are
the same and are in the same sequence, it rejects the request back to the provider with the message,
"Diagnoses and/or procedures must change for claim change reason code D4."
• If the claim change reason code is equal to D5 or D6, type of bill must be equal to XX8 on the
provider's request. If type of bill is not equal to XX8, the A/B MAC (A) rejects the request back to the
provider with the message, "Type of bill must be equal to XX8 for claim change reason codes D5 or
D6."
• If the claim change reason code is equal to D7, an MSP value code (12-16, 41-43, or 47) must be
present, if a value code, 12-16, 41-43, or 47, is not present, the A/B MAC (A) rejects the request back
to the provider with the message, "An MSP value code (12-16, 41-43, or 47) must be present for claim
change reason code D7."
• If the claim change reason code is equal to D7, and one or more of value codes 12-16, 41-43, and/or 47
is present but each value amount is equal to 0 (zero) or spaces, the A/B MAC (A) rejects the request
back to the provider with the message, "invalid value amount for claim change reason code D7."
• If the claim change reason code is equal to D8, and a value code 12-16, 41-43, or 47 is present, the
A/B MAC (A) rejects the claim back to the provider with the message, "Invalid value code for claim
change reason D8."
• If the claim change reason code is equal to E0, the A/B MAC (A) compares patient status on the
provider's request to that on the claim to be adjusted. If patient status is the same, the A/B MAC (A)
rejects the request back to the provider with the message, "Patient status must change for claim change
reason E0."
If an adjustment the provider initiates results in a change to a higher weighted DRG, the A/B MAC (A) edits
the adjustment request to insure it was submitted within 60 days of the date of the remittance for the claim to
be adjusted. If it is, the A/B MAC (A) processes the claim for payment. If the remittance date is more than 60
days prior to the receipt date of the adjustment request and results in a change to a lower weighted DRG, the
A/B MAC (A) processes the claim for payment and forwards it to CWF.
The A/B MAC (A) must suspend for investigation all adjustment requests with claim change reason codes D4,
D8, and D9. Providers that consistently use D9 will be investigated and, if a pattern of abuse is evident, may
be reported to the OIG.
C. - Additional edits
The A/B MAC (A) must perform the following additional edits and investigate adjustment requests the
provider submits:
• A full denial once the bill is paid, except to accomplish retraction of a duplicate payment;
• A change in DRG based on a change in age or sex;
• A change in deductible;
• An adjustment request that changes a previously submitted QIO adjustment request;
• An adjustment of a bill due to a change in utilization or spell data on another bill;
• A reopening to change a no-payment bill to a payment bill;
• A reopening to pay a previously denied line item;
• An adjustment request the provider initiates with a claim change reason code equal to D7, with the
Medicare payment amount equal to or greater that the previously paid amount; or
• An adjustment request with a claim change reason code equal to E0, and the claim is for a PPS
provider. The A/B MAC (A) must investigate if the change is from patient status 02, transferred to
another acute care facility.
50.3 - Late Charges
(Rev. 1, 10-01-03)
HO-411.3, HO-IM411.3
Providers billing under Inpatient Hospital PPS, Outpatient PPS, SNF PPS, or HHA PPS may not bill late
charges, nor will the contractor accept such bills, for any type of PPS service, inpatient or outpatient. Charges
omitted from the original bill must be submitted on an adjustment bill that contains all pertinent charges
including those billed earlier. When the provider submits late charges on bills to the A/B MAC (A) as bill
type XX5, these bills contain only additional charges. Adjustment requests and not late charge bills should be
submitted for
• Services on the same day as outpatient surgery subject to the ASC limit,
• ESRD services paid under the composite rate,
• All inpatient accommodation charges, and
• All inpatient PPS ancillaries as adjustment requests.
The provider may submit the following charges omitted from the original paid bill to the A/B MAC (A) as late
charges:
• Any outpatient services other than the exceptions stated in this paragraph. This includes late charges
for HHA services under either Part A or Part B, hospice services, hospital outpatient services except
those on the day of ambulatory surgery subject to the ASC payment limitation, RHC services, OPT
services, SNF outpatient services, CORF services, FQHC services, CHMC services, and ESRD
services not included in the composite rate; and
• Any inpatient SNF ancillaries or inpatient hospital ancillaries other than from PPS hospitals. The
hospital may not submit late charges (XX5) for inpatient accommodations. The hospital must submit
these as adjustments (bill type XX7).
The A/B MAC (A) has the capability to accept XX5 bill types electronically and process them as initial bills
except as described in the following paragraph.
The A/B MAC (A) also performs the following edit routines on any XX5 type bills received:
• Pass all initial bill edits, including duplicate checks.
• Must not be for any of: Inpatient PPS ancillaries, inpatient accommodations in any facility, services on
the same day as outpatient surgery subject to the ASC payment limitation, or ESRD services included
in the composite rate. These are rejected back to the hospital with the message, “This change requires
an XX7 debit-only or XX8 cancel-only request from you. Late charges are not acceptable for inpatient
PPS ancillaries, inpatient accommodations in any facility, services on the same day as outpatient
surgery subject to the ASC payment limitation, or ESRD services included in the composite rate.”
• When an XX5 suspends as a duplicate, (dates of service equal or overlapping, provider ID equal,
HICNs equal, and patient surname equal), the A/B MAC (A) must determine the status of the original
paid bill. If it is denied, the A/B MAC (A) must deny the late charge bill.
• If an xx5 does not suspend as a potential duplicate, the A/B MAC (A) rejects it back to the provider
with the message, “No original bill paid. Please combine and submit a single original bill (XX1).”
• If the original bill was approved and paid, the A/B MAC (A) compares the revenue codes on the
original paid bill with the associated late charge bill:
° For all providers (any bill type), if any are the same, and are revenue codes 041x, 042x, 043x,
044x, 063x, 076x, or 091x, the A/B MAC (A) or (HHH) rejects the bill back to the provider
with the message, “You must submit an adjustment (7) to the original paid bill. Revenue
codes subject to utilization review are duplicated on the late charge bill.”
° For HHAs (bill type 32X, 33X, or 34X), the A/B MAC (HHH) must apply the same logic for
the following additional revenue codes. If any are the same and are revenue codes 0291, 0293,
055x, 056x, 057x, 058x, 059x, 060x, 066x, the A/B MAC (HHH) rejects the bill back to the
provider with the message, "You must submit an adjustment (xx7) to the original paid bill.
Revenue codes subject to utilization review are duplicated on the late charge bill."
° For hospital outpatient services (bill type 13X only), the A/B MAC (A) must apply the same
logic for the following additional revenue codes. If any are the same and are revenue codes
0255, 032x, 033x, 034x, 035x, 040x, 062x, 073x, 074x, 092x, or 0943, the A/B MAC (A)
rejects the bill back to the hospital with the message, "You must submit an adjustment (xx7) to
the original paid bill. Revenue codes subject to utilization review are duplicated on the late
charge bill."
° For RDFs (bill type 72X or 73X), the A/B MAC (A) must apply the same logic for the
following additional revenue codes; if any are the same and are revenue codes 0634, 0635,
082x, 083x, 084x, 085x, or 088x, the A/B MAC (A) rejects the bill back to the provider with
the message, “You must submit an adjustment (XX7) to the original paid bill. Revenue codes
subject to utilization review are duplicated on the late charge bill.”
• If the late charges bill relates to two or more "original" paid bills, and one of these is denied, the A/B
MAC (A) must suspend and investigate the late charge bill.
• The A/B MAC (A) must compare total charges on the original paid bill with those on the associated
late charge bill, and suspend and investigate any XX5 bill type with total charges in excess of those on
the original paid bill. This edit suggests the provider may have rebilled the already paid services.
The A/B MAC (A) may decide to perform additional edits on late charge bills.
60 - Swing-Bed Services
(Rev. 11396, Issued:05-04-22, Effective:10-01-22, Implementation:10-03-22)
Swing-bed services must be billed separately from inpatient hospital services. Swing-bed hospitals use one
provider number when billing for hospital services to identify hospital swing-bed SNF bills. The following
alpha letters identify hospital swing-bed SNF bills (for CMS use only, effective May 23, 2007, providers are
required to submit only their NPI. NOTE: The swing-bed NPI will be mapped to the 6-digit alpha-numeric
CMS Certification Number (CCN.)
"U" = short-term/acute care hospital swing-bed;
"W" = long-term hospital swing-bed;
"Y" = rehabilitation hospital swing-bed; and
”Z”=CAH swing-bed.
Note that CAHs are exempt from the SNF PPS and instead are paid based on 101 percent of reasonable cost
for swing-bed services. CAHs are subject to the hospital bundling requirements at section 1862(a)(14) of the
Social Security Act and 42 CFR § 411.15(m), and therefore, all services provided to a CAH swing-bed patient
must be included on the CAH swing-bed bill (subject to the exceptions at 42 CFR § 411.15(m)(3)). Certified
registered nurse anesthetist services paid on a pass-through basis are also to be included on the CAH swing-
bed bill.
A. - Inpatient Hospital Services in a Swing-Bed
The patient status code of 03 is inserted on the claim when the beneficiary swings from acute to SNF level of
care. (This constitutes a discharge for purposes of Medicare payment for inpatient hospital services under
PPS.) The A/B MAC (A) indicates in the Statement Covers Through Date the last day of care at the hospital
level.
If the beneficiary is discharged from a Medicare swing-bed and remains in the hospital, there is no need for a
no-pay bill. However, if a beneficiary continues to receive care after completing their stay in a SNF swing-
bed, in a NF swing-bed, the hospital must submit covered claims to Medicare.
B. - SNF Services in a Swing-Bed
Services are billed, in accordance with Chapter 25 with the following exceptions:
• The date of admission on the swing-bed SNF bill is the date the patient began to receive SNF level of
care services;
• State level agreements may call for varying types of bill coding Type of Bill. The CMS does not
perform edits on type of bill coding on bills with 8 in the 2nd digit (bill classification), in FL 18 of the
CWF inpatient record if the record is identified in FL 1 as hospital or SNF. Therefore, the A/B MAC
(A) accepts, with subsequent conversion, any bill type agreed to at the State level to identify swing-bed
billing, i.e., 18X or 21X. It must be sure the record identification of CWF FL 1 is consistent with the
provider number shown.
70 - All-Inclusive Rate Providers
(Rev. 1, 10-01-03)
A3-3660.4
70.1 - Providers Using All-Inclusive Rates for Inpatient Part A Charges
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of
ICD-10, Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: September, 23 2014)
Some providers have been approved to bill a flat fee charge for inpatient services based on either a daily basis
or total stay basis for services furnished. This is an "All-Inclusive Rate." These charges may cover room and
board, including ancillary services, or room and board only. These instructions explain the essential data
entries that must be made using the ASC X12 837 institutional claim format or on the Form CMS-1450 by
providers that use all-inclusive rates as charges. All-inclusive rate providers are identified by one of the
following charge structures:
• One total all-inclusive charge rate for both accommodations and ancillary services, including the cost
of blood in the rate;
• One total all-inclusive charge rate for both accommodations and ancillary services, not including the
cost of blood in the rate;
• One all-inclusive charge rate for accommodations and another for ancillary services, including the cost
of blood in the all-inclusive rate; or
• One all-inclusive charge rate for accommodations and another for ancillary services, not including the
cost of blood in the all-inclusive rate.
Providers follow these special instructions for completing of the billing format or form.
A. - Accommodations
Revenue Codes - Codes that identify the accommodations furnished, ancillary services provided or billing
calculation are entered in this field. The code indicates whether the rate includes charges for ancillary services
or only room and board.
If the patient was furnished more than one type of accommodation, the loops or lines for each type of
accommodation are completed. This is necessary whether or not the provider charges an all-inclusive rate
according to accommodations.
Where the all-inclusive rate varies with the type of accommodation, the Remarks field is annotated for a five-
or-more bed accommodation showing the reason for the accommodation.
Unit of Service - A quantitative measure for services furnished, by revenue category, to or for the patient
which includes items such as the number of accommodation days, pints of blood, or renal dialysis treatments,
is entered.
Total Charges - The total charges pertaining to the related revenue code for the current billing period is
entered.
Noncovered Charges - The total non-covered charges pertaining to the related revenue code for the current
billing period is entered.
B. - Ancillary Services
One All-Inclusive Charge Rate - Hospitals with one all-inclusive charge rate, including ancillary services,
are reflected in the revenue code. The total charge reflects the charge for both accommodations and ancillary
services.
Separate Ancillary All-Inclusive Rate - Some providers segregate charges for ancillary services for billing
purposes. Where a separate flat rate charge for ancillary services is incurred either on a daily or total stay
basis, the provider enters separate codes for the services. These codes indicate whether the total charge
includes only ancillary cost or includes other costs (i.e., blood).
If applicable, the following additional billing instructions are applied:
• Blood
Whenever whole blood is furnished the patient, value codes and amounts are completed. If the all-
inclusive rate does not include the charge for whole blood or packed cells, revenue codes, rates,
service dates, units, and total charges are completed in the same way a provider not using all-inclusive
rates would complete them. When the provider discounts its customary charges for unreplaced blood
to which the deductible is applicable, it shows the charges before the discount.
If the all-inclusive rate covers the cost of providing blood whenever a patient needs it, the number of
pints furnished, replaced, not replaced, and the estimated cost per pint is entered in value codes and
amounts. No amount can be shown in the Total Charges column since the rate includes the cost of
blood. It is not necessary to show the cost for any replaced blood.
• All-Inclusive Charges According to Disease, Injury, or Type of Treatment
Providers that have a charge system based on the patient's illness or injury or type of treatment
complete the applicable loops or line(s) for type of accommodation furnished showing number of days,
rate, and total charges. The rate amount and total amounts must be the same. Blood entries are
indicated as above.
• Physician's Component
As with providers having a schedule of charges for individual services, the amount of any physician's
component included in the all-inclusive charge is removed from the total covered charges before
applying the inpatient deductible or coinsurance.
• Combined Billing
CMS does not encourage the all-inclusive rate provider to combine bill. However, if it does, it must
develop the capability and indicate in the Remarks field, the number and type of each service it is
combined billing. To identify such cases, the remark "Combined Billing" must be written in the
Remarks field.
NOTE: Combined billing was eliminated with Outpatient PPS.
80 - Hospitals That Do Not Charge
(Rev. 1, 10-01-03)
A3-3660.5
Participating hospitals that do not charge individuals and also meet the exceptions to the law that normally
exclude payment for expenses paid for directly or indirectly by a governmental entity, may be reimbursed the
reasonable cost of furnishing covered services to Medicare beneficiaries. The following special procedures
apply to their bills.
• Part A Services
Computing Medicare Billing Rate
The Medicare billing rate per day is determined by the following equation:
Total allowable inpatient cost = cost per day per patient
Total inpatient days
Thus, the billing rate that appears is the average inpatient cost per day per inpatient as calculated from entries
on the latest cost settlement report approved by Medicare. Where this is the provider's first year in the
program, the A/B MAC (A) determines this rate based on the provider's books and records the appropriate
billing rate for services rendered to Medicare beneficiaries.
Computing Medicare Billing Rate (Inpatient)
The Medicare billing rate is determined in the following manner:
Total available inpatient cost = Cost per day per patient
Total inpatient days
The A/B MAC (A) multiplies the cost per day per patient by 93 percent for short-term hospitals and by 98
percent for long-term hospitals. (See §2208.lE of the Provider Reimbursement Manual, Part I, for definitions
of "short-term" and "long-term" hospitals.) Then it applies the following fixed percentages. The result is the
Medicare billing rate.
Computing Medicare Billing Rate (Outpatient)
The Medicare billing rate is determined by the following equation:
Total allowable outpatient cost = average cost per visit
Total visits (occasions of service)
Thus, the billing rate is the average cost per outpatient visit as calculated from entries on the latest cost
settlement report approved by Medicare. Where this is the provider's first year in the program, the A/B MAC
(A) determines this rate based on the provider's books and records the appropriate billing rate for services
rendered to Medicare beneficiaries.
80.1 - Medicare Summary Notice (MSN) for Services in Hospitals That Do Not Charge
(Rev. 1, 10-01-03)
A3-3660.5.A
Where the hospital does not charge for outpatient services, the A/B MAC (A) does not send the individual an
MSN. This avoids confusion and the appearance that the beneficiary is liable for services received.
90 - Billing Transplant Services
(Rev. 1571; Issued: 08-07-08; Effective Date: 08-01-08; Implementation Date: 08-15-08)
Medicare covers the following organ transplants: kidney, heart, lung, heart/lung, liver, pancreas,
pancreas/kidney, and intestinal/multi-visceral. Medicare also covers stem cell transplants for certain
conditions.
On March 30, 2007, the Department of Health and Human Services (DHHS) established a regulation
authorizing the survey and certification of organ transplant programs. The Centers for Medicare & Medicaid
Services (CMS) is the Federal agency responsible for monitoring compliance with the Medicare conditions of
participation. All hospital transplant programs covered by the regulation (does not include stem cell
transplants), whether currently approved by CMS or seeking initial approval, must submit a request for
approval under the new regulations to CMS by December 26, 2007 (180 days from the effective date of the
regulation.)
http://www.cms.hhs.gov/CertificationandComplianc/20_Transplant.asp#TopOfPage
Transplant hospitals should review the above Web site and send applications to the following address:
Centers for Medicare and Medicaid Services
Survey and Certification Group
7500 Security Blvd.
Mailstop: S2-12-25
Baltimore, MD 21244
The A/B MACs (A) may choose to review claims if data analysis deems it a priority.
90.1 - Kidney Transplant - General
(Rev. 1341, Issued: 09-21-07, Effective: 06-28-07, Implementation: 10-22-07)
A3-3612, HO-E414
A major treatment for patients with ESRD is kidney transplantation. This involves removing a kidney, usually
from a living relative of the patient or from an unrelated person who has died, and surgically placing the
kidney into the patient. After the beneficiary receives a kidney transplant, Medicare pays the transplant
hospital for the transplant and appropriate standard acquisition charges. Special provisions apply to payment.
For the list of approved Medicare certified transplant facilities, refer to the following Web site:
http://www.cms.hhs.gov/CertificationandComplianc/20_Transplant.asp#TopOfPage
A transplant hospital may acquire cadaver kidneys by:
• Excising kidneys from cadavers in its own hospital; and
• Arrangements with a freestanding organ procurement organization (OPO) that provides cadaver
kidneys to any transplant hospital or by a hospital based OPO.
A transplant hospital that is also a certified organ procurement organization may acquire cadaver kidneys by:
• Having its organ procurement team excise kidneys from cadavers in other hospitals;
• Arrangements with participating community hospitals, whether they excise kidneys on a regular or
irregular basis; and
• Arrangements with an organ procurement organization that services the transplant hospital as a
member of a network.
When the transplant hospital also excises the cadaver kidney, the cost of the procedure is included in its
kidney acquisition costs and is considered in arriving at its standard cadaver kidney acquisition charge. When
the transplant hospital excises a kidney to provide another hospital, it may use its standard cadaver kidney
acquisition charge or its standard detailed departmental charges to bill that hospital.
When the excising hospital is not a transplant hospital, it bills its customary charges for services used in
excising the cadaver kidney to the transplant hospital or organ procurement agency.
If the transplanting hospital's organ procurement team excises the cadaver kidney at another hospital, the cost
of operating such a team is included in the transplanting hospital's kidney acquisition costs, along with the
reasonable charges billed by the other hospital of its services.
90.1.1 - The Standard Kidney Acquisition Charge
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of
ICD-10, Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: September, 23 2014)
There are two basic standard charges that must be developed by transplant hospitals from costs expected to be
incurred in the acquisition of kidneys:
• The standard charge for acquiring a live donor kidney; and
• The standard charge for acquiring a cadaver kidney.
The standard charge is not a charge representing the acquisition cost of a specific kidney; rather, it is a charge
that reflects the average cost associated with each type of kidney acquisition.
When the transplant hospital bills the program for the transplant, it shows its standard kidney acquisition
charge on revenue code 081X. Kidney acquisition charges are not considered for the IPPS outlier calculation.
Acquisition services are billed from the excising hospital to the transplant hospital. A billing form is not
submitted from the excising hospital to the FI. The transplant hospital keeps an itemized statement that
identifies the services furnished, the charges, the person receiving the service (donor/recipient), and whether
this is a potential transplant donor or recipient. These charges are reflected in the transplant hospital's kidney
acquisition cost center and are used in determining the hospital's standard charge for acquiring a live donor's
kidney or a cadaver's kidney. The standard charge is not a charge representing the acquisition cost of a
specific kidney. Rather, it is a charge that reflects the average cost associated with each type of kidney
acquisition. Also, it is an all-inclusive charge for all services required in acquisition of a kidney, i.e., tissue
typing, post-operative evaluation.
A. - Billing For Blood And Tissue Typing of the Transplant Recipient Whether or Not Medicare
Entitlement Is Established
Tissue typing and pre-transplant evaluation can be reflected only through the kidney acquisition charge of the
hospital where the transplant will take place. The transplant hospital includes in its kidney acquisition cost
center the reasonable charges it pays to the independent laboratory or other hospital which typed the potential
transplant recipient, either before or after his entitlement. It also includes reasonable charges paid for
physician tissue typing services, applicable to live donors and recipients (during the pre-entitlement period
and after entitlement, but prior to hospital admission for transplantation).
B. - Billing for Blood and Tissue Typing and Other Pre-Transplant Evaluation of Live Donors
The entitlement date of the beneficiary who will receive the transplant is not a consideration in reimbursing
for the services to donors, since no bill is submitted directly to Medicare. All charges for services to donors
prior to admission into the hospital for excision are "billed" indirectly to Medicare through the live donor
acquisition charge of transplanting hospitals.
C. - Billing Donor And Recipient Pre-Transplant Services (Performed by Transplant Hospitals or
Other Providers) to the Kidney Acquisition Cost Center
The transplant hospital prepares an itemized statement of the services rendered for submittal to its cost
accounting department. Regular Medicare billing forms are not necessary for this purpose, since no bills are
submitted to the A/B MAC (A) at this point.
The itemized statement should contain information that identifies the person receiving the service
(donor/recipient), the health care insurance number, the service rendered and the charge for the service, as
well as a statement as to whether this is a potential transplant donor or recipient. If it is a potential donor, the
provider must identify the prospective recipient.
EXAMPLE:
Mary Jones
Health care insurance number
200 Adams St.
Anywhere, MS
Transplant donor evaluation services for recipient:
John Jones
Health care insurance number
200 Adams St.
Anywhere, MS
Services performed in a hospital other than the potential transplant hospital or by an independent laboratory
are billed by that facility to the potential transplant hospital. This holds true regardless of where in the United
States the service is performed. For example, if the donor services are performed in a Florida hospital and the
transplant is to take place in a California hospital, the Florida hospital bills the California hospital (as
described in above). The Florida hospital is paid by the California hospital, which recoups the monies through
the kidney acquisition cost center.
D. - Billing for Cadaveric Donor Services
Normally, various tests are performed to determine the type and suitability of a cadaver kidney. Such tests
may be performed by the excising hospital (which may also be a transplant hospital) or an independent
laboratory. When the excising-only hospital performs the tests, it includes the related charges on its bill to the
transplant hospital or to the organ procurement agency.
When the tests are performed by the transplant hospital, it uses the related costs in establishing the standard
charge for acquiring the cadaver kidney. The transplant hospital includes the costs and charges in the
appropriate departments for final cost settlement purposes.
When the tests are performed by an independent laboratory for the excising-only hospital or the transplant
hospital, the laboratory bills the hospital that engages its services or the organ procurement agency. The
excising-only hospital includes such charges in its charges to the transplant hospital, which then includes the
charges in developing its standard charge for acquiring the cadaver kidney. It is the transplant hospitals'
responsibility to assure that the independent laboratory does not bill both hospitals.
The cost of these services cannot be billed directly to the program, since such tests and other procedures
performed on a cadaver are not identifiable to a specific patient.
E. - Billing For Physicians' Services Prior to Transplantation
Physicians' services applicable to kidney excisions involving live donors and recipients (during the pre-
entitlement period and after entitlement, but prior to entrance into the hospital for transplantation) as well as
all physicians' services applicable to cadavers are considered Part A hospital services (kidney acquisition
costs).
F. - Billing for Physicians' Services After Transplantation
All physicians' services rendered to the living donor and all physicians' services rendered to the transplant
recipient are billed to the Medicare program in the same manner as all Medicare Part B services are billed.
All donor physicians' services must be billed to the account of the recipient (i.e., the recipient's Medicare
number). Modifier Q3 (Live Kidney Donor and Related Services) appears on the claim. For services
performed on or after January 1, 2011 CWF shall allow Edit 5211 to be overridden at the contractor level.
Also, contractors shall override Edit 5211 when this modifier appears on claims for donor services it receives
when the recipient is deceased (See Publication 100-02, Chapter 11, Section 80.4).
NOTE: For institutional claims, contractors may manually override the CWF edit as necessary.
G. - Billing For Physicians' Renal Transplantation Services
To ensure proper payment when submitting a Part B bill for the renal surgeon's services to the recipient, the
appropriate HCPCS codes must be submitted, including HCPCS codes for concurrent surgery, as applicable.
The bill must include all living donor physicians' services, e.g., Revenue Center code 081X.
90.1.2 - Billing for Kidney Transplant and Acquisition Services
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of
ICD-10, Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: September, 23 2014)
Applicable standard kidney acquisition charges are identified separately by revenue code 0811 (Living Donor
Kidney Acquisition) or 0812 (Cadaver Donor Kidney Acquisition). Where interim bills are submitted, the
standard acquisition charge appears on the billing form for the period during which the transplant took place.
This charge is in addition to the hospital's charges for services rendered directly to the Medicare recipient.
The contractor deducts kidney acquisition charges for PPS hospitals for processing through Pricer. These
costs, incurred by approved kidney transplant hospitals, are not included in the kidney transplant prospective
payment. They are paid on a reasonable cost basis. Interim payment is paid as a "pass through" item. (See
the Provider Reimbursement Manual, Part 1, §2802 B.8.) The contractor includes kidney acquisition charges
under the appropriate revenue code in CWF.
Bill Review Procedures
The Medicare Code Editor (MCE) creates a Limited Coverage edit for kidney transplant procedure codes.
Where these procedure codes are identified by MCE, the contractor checks the provider number to determine
if the provider is an approved transplant center, and checks the effective approval date. The contractor shall
also determine if the facility is certified for adults and/or pediatric transplants dependent upon the patient’s
age. If payment is appropriate (i.e., the center is approved and the service is on or after the approval date) it
overrides the limited coverage edit.
90.1.3 - Billing for Donor Post-Kidney Transplant Complication Services
(Rev. 2334, Issued: 10-28-11; Effective: Policy Effective date: November 28, 2011; Claims Processing
Effective date: April 1, 2012; Implementation: April 2, 2012)
Expenses incurred for complications that arise with respect to the donor are covered and separately billable
only if they are directly attributable to the donation surgery.
All covered services (both institutional and professional) for complications from a Medicare covered
transplant that arise after the date of the donor’s transplant discharge will be billed under the recipient’s health
insurance claim number and are billed to the Medicare program in the same manner as all Medicare Part B
services are billed.
• All covered donor post-kidney transplant complication services must be billed to the account of the
recipient (i.e., the recipient's Medicare number)
• Modifier Q3 (Live Kidney Donor and Related Services) appears on each covered line of the claim that
contains a HCPCS code.
Institutional claims will be required to also include:
• Occurrence Code 36 (Date of Inpatient Hospital Discharge for covered transplant patients)
• Patient Relationship Code 39 (Organ Donor)
Contractors shall override Edit 5211 when modifier Q3 appears on claims for donor services it receives when
the recipient is deceased (See Pub. 100-02, chapter 11, section 80.4).
NOTE: For institutional claims which do not require modifiers, contractors may manually override the CWF
edit as necessary.
90.2 - Heart Transplants
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of
ICD -10, Implementation: ICD -10: Upon Implementation of ICD -10, ASC X12: September, 23 2014)
Cardiac transplantation is covered under Medicare when performed in a facility which is approved by
Medicare as meeting institutional coverage criteria. On April 6, 1987, CMS Ruling 87-1, "Criteria for
Medicare Coverage of Heart Transplants" was published in the "Federal Register." For Medicare coverage
purposes, heart transplants are medically reasonable and necessary when performed in facilities that meet
these criteria. If a hospital wishes to bill Medicare for heart transplants, it must submit an application and
documentation, showing its ongoing compliance with each criterion.
If a contractor has any questions concerning the effective or approval dates of its hospitals, it should contact
its RO.
For a complete list of approved transplant centers, visit:
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/downloads/ApprovedTransplantPrograms.pdf
A. - Effective Dates
The effective date of coverage for heart transplants performed at facilities applying after July 6, 1987, is the
date the facility receives approval as a heart transplant facility. Coverage is effective for discharges October
17, 1986 for facilities that would have qualified and that applied by July 6, 1987. All transplant hospitals will
be recertified under the final rule, Federal Register / Vol. 72, No. 61 / Friday, March 30, 2007, / Rules and
Regulations.
The CMS informs each hospital of its effective date in an approval letter.
B. - Drugs
Medicare Part B covers immunosuppressive drugs following a covered transplant in an approved facility.
C. - Noncovered Transplants
Medicare will not cover transplants or re-transplants in facilities that have not been approved as meeting the
facility criteria. If a beneficiary is admitted for and receives a heart transplant from a hospital that is not
approved, physicians' services, and inpatient services associated with the transplantation procedure are not
covered.
If a beneficiary received a heart transplant from a hospital while it was not an approved facility and later
requires services as a result of the noncovered transplant, the services are covered when they are reasonable
and necessary in all other respects.
D. - Charges for Heart Acquisition Services
The excising hospital bills the OPO, who in turn bills the transplant (implant) hospital for applicable services.
It should not submit a bill to its contractor. The transplant hospital must keep an itemized statement that
identifies the services rendered, the charges, the person receiving the service (donor/recipient), and whether
this person is a potential transplant donor or recipient. These charges are reflected in the transplant hospital's
heart acquisition cost center and are used in determining its standard charge for acquiring a donor's heart. The
standard charge is not a charge representing the acquisition cost of a specific heart; rather, it reflects the
average cost associated with each type of heart acquisition. Also, it is an all inclusive charge for all services
required in acquisition of a heart, i.e., tissue typing, post-operative evaluation, etc.
Acquisition charges shall be billed on a 081X revenue code. Such charges are not considered for the IPPS
outlier calculation when billed for a heart transplant.
E. - Bill Review Procedures
The contractor takes the following actions to process heart transplant bills. It may accomplish them manually
or modify its MCE and Grouper interface programs to handle the processing.
1. MCE Interface
The MCE creates a Limited Coverage edit for heart transplant procedure codes. Where these procedure codes
are identified by MCE, the contractor checks the provider number to determine if the provider is an approved
transplant center, and checks the effective approval date. The contractor shall also determine if the facility is
certified for adults and/or pediatric transplants dependent upon the patient’s age. If payment is appropriate
(i.e., the center is approved and the service is on or after the approval date) it overrides the limited coverage
edit.
2. Handling Heart Transplant Billings From Nonapproved Hospitals
Where a heart transplant and covered services are provided by a nonapproved hospital, the bill data processed
through Grouper and Pricer must exclude transplant procedure codes and related charges.
90.3 - Stem Cell Transplantation
(Rev.11348; Issued: 04-07-22; Effective: 05-09-22; Implementation: 05-09-22)
A. General
Stem cell transplantation is a process in which stem cells are harvested from either a patient’s (autologous)
or donor’s (allogeneic) bone marrow or peripheral blood for intravenous infusion. Autologous stem cell
transplantation (AuSCT) is a technique for restoring stem cells using the patient's own previously stored
cells. AuSCT must be used to effect hematopoietic reconstitution following severely myelotoxic doses of
chemotherapy (HDCT) and/or radiotherapy used to treat various malignancies. Allogeneic hematopoietic
stem cell transplantation (HSCT) is a procedure in which a portion of a healthy donor's stem cell or bone
marrow is obtained and prepared for intravenous infusion. Allogeneic HSCT may be used to restore
function in recipients having an inherited or acquired deficiency or defect.
Hematopoietic stem cells are multi-potent stem cells that give rise to all the blood cell types; these stem
cells form blood and immune cells. A hematopoietic stem cell is a cell isolated from blood or bone
marrow that can renew itself, differentiate to a variety of specialized cells, can mobilize out of the bone
marrow into circulating blood, and can undergo programmed cell death, called apoptosis - a process by
which cells that are unneeded or detrimental will self-destruct.
The Centers for Medicare & Medicaid Services (CMS) is clarifying that bone marrow and peripheral
blood stem cell transplantation is a process which includes mobilization, harvesting, and transplant of
bone marrow or peripheral blood stem cells and the administration of high dose chemotherapy or
radiotherapy prior to the actual transplant.
When bone marrow or peripheral blood stem cell transplantation is covered, all necessary steps are
included in coverage. When bone marrow or peripheral blood stem cell transplantation is non-covered,
none of the steps are covered.
Allogeneic and autologous stem cell transplants are covered under Medicare for specific diagnoses.
Effective October 1, 1990, these cases were assigned to MS-DRG 009, Bone Marrow Transplant.
The A/B MAC (A)'s Medicare Code Editor (MCE) will edit stem cell transplant procedure codes against
diagnosis codes to determine which cases meet specified coverage criteria. Cases with a diagnosis code for
a covered condition will pass (as covered) the MCE noncovered procedure edit. When a stem cell
transplant case is selected for review based on the random selection of beneficiaries, the QIO will review
the case on a post-payment basis to assure proper coverage decisions.
Bone marrow transplant codes that are reported with an ICD-9-CM that is “not otherwise specified” are
returned to the hospital for a more specific procedure code. ICD-10-PCS codes are more precise and
clearly identify autologous and nonautologous stem cells.
The A/B MAC (A) may choose to review if data analysis deems it a priority.
B.
Nationally Covered Indications
I.
Allogeneic Hematopoietic Stem Cell Transplantation (HSCT)
a.
General
• Allogeneic stem cell transplantation ( ICD-10-PCS codes 30230G2,30230G3, 30230Y2,
30230Y3, 30233G2, 30233G3, 30233Y2, 30233Y3, 30240G2, 30240G3, 30240Y2, 30240Y3,
30243G2, 30243G3, 30243Y2, and 30243Y3) is a procedure in which a portion of a healthy
donor's stem cells are obtained and prepared for intravenous infusion to restore normal
hematopoietic function in recipients having an inherited or acquired hematopoietic deficiency or
defect. See Pub. 100-03, National Coverage Determinations (NCD) Manual, chapter 1, section
110.23, for further information about this policy, and Pub. 100-04, chapter 32, section 90, for
information on coding.
Expenses incurred by a donor are a covered benefit to the recipient/beneficiary but, except for
physician services, are not paid separately. Services to the donor include physician services,
hospital care in connection with screening the stem cell, and ordinary follow-up care.
NOTE: Please note that effective September 30, 2021 PCS codes for Allogeneic SCT 30230G2,
30230G3, 30230Y2, 30230Y3, 30240G2, 30240G3, 30240Y2, 30240Y3 and PCS codes for
Autologous SCT 30230C0, 30230G0, 30230Y0, 30240C0, 30240G0, 30240Y0 are end-dated.
b.
Covered Conditions
i.
Effective for services performed on or after August 1, 1978:
For the treatment of leukemia, leukemia in remission, or aplastic anemia when it is
reasonable and necessary;
ii.
Effective for services performed on or after June 3, 1985:
For the treatment of severe combined immunodeficiency disease (SCID), and for the
treatment of Wiskott-Aldrich syndrome;
iii.
Effective for services performed on or after August 4, 2010:
For the treatment of Myelodysplastic Syndromes (MDS) pursuant to Coverage with
Evidence Development (CED) in the context of a Medicare- approved, prospective clinical
study.
iv.
Effective for claims with dates of service on or after January 27, 2016:
1.
Allogeneic HSCT for multiple myeloma is covered by Medicare only for beneficiaries
with Durie-Salmon Stage II or III multiple myeloma, or International Staging System
(ISS) Stage II or Stage III multiple myeloma, and participating in an approved
prospective clinical study.
2.
Allogeneic HSCT for myelofibrosis (MF) is covered by Medicare only for beneficiaries
with Dynamic International Prognostic Scoring System (DIPSSplus) intermediate-2 or
High primary or secondary MF and participating in an approved prospective clinical
study.
3.
Allogeneic HSCT for sickle cell disease (SCD) is covered by Medicare only for
beneficiaries with severe, symptomatic SCD who participate in an approved prospective
clinical study.
II.
III.
Autologous Stem Cell Transplantation (AuSCT)
a.
General
• Autologous stem cell transplantation (ICD-10-PCS codes 30230C0, 30230G0, 30230Y0, 30233G0,
30233C0, 30233Y0, 30240C0, 30240G0, 30240Y0, 30243C0, 30243G0, and 30243Y0) is a technique
for restoring stem cells using the patient's own previously stored cells. AuSCT must be used to effect
hematopoietic reconstitution following severely myelotoxic doses of chemotherapy (high dose
chemotherapy (HDCT)) and/or radiotherapy used to treat various malignancies. Refer to Pub. 100-03,
NCD Manual, chapter 1, section 110.23, for further information about this policy, and Pub. 100-04,
chapter 32, section 90, for information on coding.
NOTE: Please note that effective September 30, 2021 PCS codes for Allogeneic SCT 30230G2, 30230G3,
30230Y2, 30230Y3, 30240G2, 30240G3, 30240Y2, 30240Y3 and PCS codes for Autologous SCT
30230C0, 30230G0, 30230Y0, 30240C0, 30240G0, 30240Y0 are end-dated.
b.
Covered Conditions
1.
Effective for services performed on or after April 28, 1989:
Acute leukemia in remission who have a high probability of relapse and who have no human
leucocyte antigens (HLA)-matched;
Resistant non-Hodgkin's lymphomas or those presenting with poor prognostic features following
an initial response;
Recurrent or refractory neuroblastoma; or,
Advanced Hodgkin's disease who have failed conventional therapy and have no HLA-matched
donor.
2.
Effective for services performed on or after October 1, 2000:
Single AuSCT is only covered for Durie-Salmon Stage II or III patients that fit the following
requirements:
• Newly diagnosed or responsive multiple myeloma. This includes those patients with previously
untreated disease, those with at least a partial response to prior chemotherapy (defined as a 50%
decrease either in measurable paraprotein [serum and/or urine] or in bone marrow infiltration,
sustained for at least 1 month), and those in responsive relapse; and
• Adequate cardiac, renal, pulmonary, and hepatic function.
3.
Effective for services performed on or after March 15, 2005:
When recognized clinical risk factors are employed to select patients for transplantation, high dose
melphalan (HDM) together with AuSCT is reasonable and necessary for Medicare beneficiaries of
any age group with primary amyloid light chain (AL) amyloidosis who meet the following criteria:
• Amyloid deposition in 2 or fewer organs; and,
• Cardiac left ventricular ejection fraction (EF) greater than 45%.
C.
Nationally Non-Covered Indications
I.
Allogeneic Hematopoietic Stem Cell Transplantation (HSCT)
Effective for claims with dates of service on or after May 24, 1996, through January 26, 2016,
allogeneic HSCT is not covered as treatment for multiple myeloma. Refer to Pub. 100-03, NCD
Manual, chapter 1, section 110.23, for further information about this policy, and Pub. 100-04, chapter
32, section 90, for information on coding.
II.
Autologous Stem Cell Transplantation (AuSCT)
Insufficient data exist to establish definite conclusions regarding the efficacy of AuSCT for the
following conditions:
a)
Acute leukemia not in remission;
b)
Chronic granulocytic leukemia;
c)
Solid tumors (other than neuroblastoma);
d)
Up to October 1, 2000, multiple myeloma;
e)
Tandem transplantation (multiple rounds of AuSCT) for patients with multiple myeloma;
f)
Effective October 1, 2000, non primary AL amyloidosis; and,
g)
Effective October 1, 2000, through March 14, 2005, primary AL amyloidosis for Medicare
beneficiaries age 64 or older.
In these cases, AuSCT is not considered reasonable and necessary within the meaning of
§l862(a)(1)(A) of the Act and is not covered under Medicare. Refer to Pub. 100-03, NCD Manual,
chapter 1, section 110.23, for further information about this policy, and Pub. 100-04, chapter 32,
section 90, for information on coding.
D.
Other
All other indications for stem cell transplantation not otherwise noted above as covered or non-covered
remain at local Medicare Administrative Contractor discretion.
90.3.1 - Allogeneic for Stem Cell Transplantation
(Rev. 11113; Issued: 11-16-21; Effective: 12-17-21; Implementation: 12-17-21)
A. Definition of Acquisition Charges for Allogeneic Stem Cell Transplants
1. Effective for Cost Reporting Periods Beginning Prior to October 1, 2020
Acquisition charges for allogeneic stem cell transplants include, but are not limited to, charges for the
costs of the following services:
• National Marrow Donor Program fees, if applicable, for stem cells from an unrelated donor;
• Tissue typing of donor and recipient;
• Donor evaluation;
• Physician pre-admission/pre-procedure donor evaluation services;
• Costs associated with harvesting procedure (e.g., general routine and special care services,
procedure/operating room and other ancillary services, apheresis services, etc.);
• Post-operative/post-procedure evaluation of donor; and
• Preparation and processing of stem cells.
Payment for these acquisition services is included in the MS-DRG payment for the allogeneic stem cell
transplant when the transplant occurs in the inpatient setting, and in the OPPS APC payment for the
allogeneic stem cell transplant when the transplant occurs in the outpatient setting.
The Medicare contractor does not make separate payment for these acquisition services, because hospitals
may bill and receive payment only for services provided to the Medicare beneficiary who is the recipient of
the stem cell transplant and whose illness is being treated with the stem cell transplant. Unlike the acquisition
costs of solid organs for transplant (e.g., hearts and kidneys), which are paid on a reasonable cost basis,
acquisition costs for allogeneic stem cells are included in prospective payment.
Acquisition charges for stem cell transplants apply only to allogeneic transplants, for which stem cells are
obtained from a donor (other than the recipient himself or herself). Acquisition charges do not apply to
autologous transplants (transplanted stem cells are obtained from the recipient himself or herself), because
autologous transplants involve services provided to the beneficiary only (and not to a donor), for which the
hospital may bill and receive payment (see Pub. 100-04, chapter 4, §231.10 and paragraph B of this section
for information regarding billing for autologous stem cell transplants).
2. Effective for Cost Reporting Periods Beginning On or After October 1, 2020
Allogeneic hematopoietic stem cell acquisition costs are as follows:
• Registry fees from a national donor registry described in 42 U.S.C. 274k, if applicable, for stem cells
from an unrelated donor.
• Tissue typing of donor and recipient.
• Donor evaluation.
• Physician pre-admission/pre-procedure donor evaluation services.
• Costs associated with the collection procedure (for example, general routine and
special care services, procedure/operating room and other ancillary services, apheresis services), and
transportation costs of stem cells if the recipient hospital incurred or paid such costs.
• Post-operative/post-procedure evaluation of donor.
• Preparation and processing of stem cells derived from bone marrow, peripheral blood stem cells, or
cord blood (but not including embryonic stem cells).
Effective for cost reporting periods beginning on or after October 1, 2020, a subsection (d) hospital that
furnishes an allogeneic hematopoietic stem cell transplant to an individual during such a period, payment to
such hospital for hematopoietic stem cell acquisition shall be made on a reasonable cost basis.
Payment for allogeneic hematopoietic stem cell acquisition services continues to be included in the OPPS
APC payment when the transplant occurs in the outpatient setting.
Acquisition charges for stem cell transplants apply only to allogeneic transplants, for which stem cells are
obtained from a donor (other than the recipient himself or herself). Acquisition charges do not apply to
autologous transplants (transplanted stem cells are obtained from the recipient himself or herself), because
autologous transplants involve services provided to the beneficiary only (and not to a donor), for which the
hospital may bill and receive payment (see Pub. 100-04, chapter 4, §231.10 and paragraph B of this section
for information regarding billing for autologous stem cell transplants).
B. Billing for Acquisition Services
The hospital bills and shows acquisition charges for allogeneic stem cell transplants based on the status
of the patient (i.e., inpatient or outpatient) when the transplant is furnished. See Pub. 100-04, chapter 4,
§231.11 for instructions regarding billing for acquisition services for allogeneic stem cell transplants that
are performed in the outpatient setting.
When the allogeneic stem cell transplant occurs in the inpatient setting, allogeneic bone marrow/stem cell
acquisition charges shall be billed using revenue code 0815. Revenue code 0815 (Allogeneic Stem Cell
Acquisition/Donor Services) charges should include all services required to acquire stem cells from a donor,
as defined above. Effective for discharges occurring on or after October 1, 2021, such charges are not
considered for the IPPS outlier calculation when billed for an allogeneic stem cell transplant.
On the recipient’s transplant bill, the hospital reports the acquisition charges, cost report days, and utilization
days for the donor’s hospital stay (if applicable) and/or charges for other encounters in which the stem cells
were obtained from the donor. The donor is covered for medically necessary inpatient hospital days of
care or outpatient care provided in connection with the allogeneic stem cell transplant under Part A.
Expenses incurred for complications are paid only if they are directly and immediately attributable to
the stem cell donation procedure. The hospital reports the acquisition charges on the billing form for the
recipient, as described in the first paragraph of this section. It does not charge the donor's days of care
against the recipient's utilization record. For cost reporting purposes, it includes the covered donor days and
charges as Medicare days and charges.
The transplant hospital keeps an itemized statement that identifies the services furnished in collecting
allogeneic hematopoietic stem cells including all invoices or statements for purchased services for all donors
and their service charges. Records must be for the person receiving the service (donor or recipient).
Beginning October 1, 2020, for all donor sources, the hospital must identify the prospective recipient and
include the recipient’s Medicare beneficiary identification number. These charges will be reflected in the
transplant hospital's stem cell/bone marrow acquisition cost center. For allogeneic stem cell acquisition
services in cases that do not result in transplant, due to death of the intended recipient or other causes,
hospitals include the costs associated with the acquisition services on the Medicare cost report.
The hospital shows charges for the transplant itself in revenue center code 0362 or another appropriate cost
center. The hospital shows charges for acquiring allogeneic hematopoietic stem cells for transplant
in revenue code 0815.
90.3.2 - Autologous Stem Cell Transplantation (AuSCT)
(Rev.11348; Issued: 04-07-22; Effective: 05-09-22; Implementation: 05-09-22)
A. - General
Autologous stem cell transplantation (AuSCT) is a technique for restoring stem cells using the patient's
own previously stored cells. AuSCT must be used to effect hematopoietic reconstitution following
severely myelotoxic doses of chemotherapy (high dose chemotherapy (HDCT)) and/or radiotherapy used
to treat various malignancies.
If ICD-10-PCS is applicable, use the following Procedure Codes and Descriptions -
30230C0
Transfusion of Autologous Hematopoietic Stem/Progenitor Cells,
Genetically Modified into Peripheral Vein, Open Approach
30230G0
Transfusion of Autologous Bone Marrow into Peripheral Vein, Open
Approach
30230Y0
Transfusion of Autologous Hematopoietic Stem Cells into Peripheral
Vein, Open Approach
30233G0
Transfusion of Autologous Bone Marrow into Peripheral Vein,
Percutaneous Approach
30233C0
Transfusion of Autologous Hematopoietic Stem/Progenitor Cells,
Genetically Modified into Peripheral Vein, Percutaneous Approach
30233Y0
Transfusion of Autologous Hematopoietic Stem Cells into Peripheral
Vein, Percutaneous Approach
30240C0
Transfusion of Autologous Hematopoietic Stem/Progenitor Cells,
Genetically Modified into Central Vein, Open Approach
30240G0
Transfusion of Autologous Bone Marrow into Central Vein, Open
Approach
30240Y0
Transfusion of Autologous Hematopoietic Stem Cells into Central Vein,
Open Approach
30243C0
Transfusion of Autologous Hematopoietic Stem/Progenitor Cells,
Genetically Modified into Central Vein, Percutaneous Approach
30243G0
Transfusion of Autologous Bone Marrow into Central Vein, Percutaneous
Approach
30243Y0
Transfusion of Autologous Hematopoietic Stem Cells into Central Vein,
Percutaneous Approach
NOTE: Please note that effective September 30, 2021 PCS codes for Allogeneic SCT 30230G2, 30230G3,
30230Y2, 30230Y3, 30240G2, 30240G3, 30240Y2, 30240Y3 and PCS codes for Autologous SCT 30230C0,
30230G0, 30230Y0, 30240C0, 30240G0, 30240Y0 are end-dated.
B. - Covered Conditions
1.
Effective for services performed on or after April 28, 1989:
For acute leukemia in remission for patients who have a high probability of relapse and who have no
human leucocyte antigens (HLA)-matched, the following diagnosis codes are reported:
If ICD-10-CM is applicable, use the following Diagnosis Codes and Descriptions -
Diagnosis
Code
Description
C91.01 Acute lymphoblastic leukemia, in remission
C92.01 Acute myeloblastic leukemia, in remission
C92.41 Acute promyelocytic leukemia, in remission
C92.51 Acute myelomonocytic leukemia, in remission
C92.61 Acute myeloid leukemia with 11q23-abnormality in remission
C92.A1 Acute myeloid leukemia with multilineage dysplasia, in remission
C93.01 Acute monoblastic/monocytic leukemia, in remission
C94.01 Acute erythroid leukemia, in remission
C94.21 Acute megakaryoblastic leukemia, in remission
C95.01 Acute leukemia of unspecified cell type, in remission
For resistant non-Hodgkin's lymphomas or those presenting with poor prognostic features following an
initial response the following diagnosis codes are reported:
If ICD-10-CM is applicable use the following, code ranges C82.01 - C85.29, C85.81 - C86.6, C96.4, and
C96.Z - C96.9.
Recurrent or refractory neuroblastoma (see ICD-10-CM codes Neoplasm by site, malignant
for the appropriate diagnosis code)
following ranges are reported: C00 - C96, and D00 - D09 Resistant non- Hodgkin’s
lymphomas); or,
Advanced Hodgkin's disease who have failed conventional therapy and have no HLA-matched
donor (ICD-10-CM codes C81.01 - C81.99).
2. Effective for services performed on or after October 1, 2000:
Durie-Salmon Stage II or III that fit the following requirement are covered: Newly diagnosed or
responsive multiple myeloma (if ICD-10-CM is applicable, diagnosis codes C90.00, C90.01, C90.02,
and D47.Z9). This includes those patients with previously untreated disease, those with at least a
partial response to prior chemotherapy (defined as a 50% decrease either in measurable paraprotein
[serum and/or urine] or in bone marrow infiltration, sustained for at least 1 month), and those in
responsive relapse, and adequate cardiac, renal, pulmonary, and hepatic function.
3.
Effective for Services On or After March 15, 2005
Effective for services performed on or after March 15, 2005, when recognized clinical risk factors are
employed to select patients for transplantation, high-dose melphalan (HDM), together with AuSCT, in
treating Medicare beneficiaries of any age group with primary amyloid light-chain (AL) amyloidosis who
meet the following criteria:
• Amyloid deposition in 2 or fewer organs ; and,
• Cardiac left ventricular ejection fraction (EF) of 45% or greater.
NOTE: Please note that effective April 01, 2022 unspecified ICD-10-DX codes C47.9, C72.50, C72.9,
C81.91, C81.92, C81.93, C81.94, C81.95, C81.96, C81.97, C81.98, C81.99, C85.91, C85.92, C85.93, C85.94,
C85.96, C85.97, C85.98, C85.99, C91.91, C92.91, C93.91, C95.91, C96.20, C96.9 are end-dated.
C. – Non-covered Conditions
Insufficient data exist to establish definite conclusions regarding the efficacy of autologous stem cell
transplantation for the following conditions:
a) Acute leukemia not in remission prior to October 1, 2000 ( if ICD-10-CM is applicable, ICD-10-CM
codes C91.00, C92.00, C93.00, C94.00, and C95.00)
b) Chronic granulocytic leukemia prior to October 1, 2000 (if ICD-10-CM is applicable, ICD-10-CM
code C92.10);
c) Solid tumors prior to October 1, 2000 (other than neuroblastoma) (if ICD-10-CM is applicable, ICD-
10-CM codes C00.0 – C80.2 and D00.0 – D09.9);
d) Multiple myeloma prior to October 1, 2000 (if ICD-10-CM is applicable, ICD-10-CM codes C90.00,
C90.01, C90.02 and D47.Z9);
e) Tandem transplantation, on or after October 1, 2000 (if ICD-10-CM is applicable, ICD-10-CM codes
C90.00, C90.01, C90.02, and D47.Z9) ;
f) Non- primary amyloidosis on or after 10/01/00, for all Medicare beneficiaries
g) Primary AL amyloidosis effective October 1, 2000, through March 14, 2005 for Medicare
beneficiaries age 64. (if ICD-10-CM is applicable, ICD-10-CM codes E85.4, E85.81, E85.9, and E85.89);
NOTE: Coverage for conditions other than these specifically designated as covered or non- covered is left
to the discretion of the A/B MAC (A).
D. Billing for Autologous Stem Cell Transplantation (AuSCT)
The hospital bills and shows all charges for autologous stem cell harvesting, processing, and transplant
procedures based on the status of the patient (i.e., inpatient or outpatient) when the services are furnished.
It shows charges for the actual transplant, in revenue center code 0362 or another appropriate cost center.
ICD-10-PCS codes are used to identify inpatient procedures.
The HCPCS codes describing autologous stem cell harvesting procedures may be billed and are separately
payable under the OPPS when provided in the hospital outpatient setting of care. Autologous harvesting
procedures are distinct from the acquisition services described in Pub. 100-04, chapter 4, §231.11 and
section 90.3.1-A above for allogeneic stem cell transplants, which include services provided when stem
cells are obtained from a donor and not from the patient undergoing the stem cell transplant. The HCPCS
codes describing autologous stem cell processing procedures also may be billed and are separately payable
under the OPPS when provided to hospital outpatients. Payment for autologous stem cell harvesting
procedures performed in the hospital inpatient setting of care, with transplant also occurring in the
inpatient setting of care, is included in the MS-DRG payment for the autologous stem cell transplant.
90.4 - Liver Transplants
(Rev. 2513, Issued: 08-03-12, Effective: 06-21-12, Implementation: 09-04-12)
A. Background
For Medicare coverage purposes, liver transplants are considered medically reasonable and necessary for
specified conditions when performed in facilities that meet specific criteria. Coverage guidelines may be
found in Publication 100-03, Section 260.1.
Effective for claims with dates of service June 21, 2012 and later, contractors may, at their discretion cover
adult liver transplantation for patients with extrahepatic unresectable cholangiocarcinoma (CCA), (2) liver
metastases due to a neuroendocrine tumor (NET) or (3) hemangioendothelimo (HAE) when furnished in an
approved Liver Transplant Center (below). All other nationally non-covered malignancies continue to remain
nationally non-covered.
To review the current list of approved Liver Transplant Centers, see http://www.cms.gov/Medicare/Provider-
Enrollment-and-Certification/CertificationandComplianc/Transplant.html
90.4.1 - Standard Liver Acquisition Charge
(Rev. 1, 10-01-03)
A3-3615.1, A3-3615.3
Each transplant facility must develop a standard charge for acquiring a cadaver liver from costs it expects to
incur in the acquisition of livers.
This standard charge is not a charge that represents the acquisition cost of a specific liver. Rather, it is a
charge that reflects the average cost associated with a liver acquisition.
Services associated with liver acquisition are billed from the organ procurement organization or, in some
cases, the excising hospital to the transplant hospital. The excising hospital does not submit a billing form to
the A/B MAC (A). The transplant hospital keeps an itemized statement that identifies the services furnished,
the charges, the person receiving the service (donor/recipient), and the potential transplant donor. These
charges are reflected in the transplant hospital's liver acquisition cost center and are used in determining the
hospital's standard charge for acquiring a cadaver's liver. The standard charge is not a charge representing the
acquisition cost of a specific liver. Rather, it is a charge that reflects the average cost associated with liver
acquisition. Also, it is an all-inclusive charge for all services required in acquisition of a liver, e.g., tissue
typing, transportation of organ, and surgeons' retrieval fees.
90.4.2 - Billing for Liver Transplant and Acquisition Services
(Rev.11035, Issued:10-13-21, Effective: 11-17-21; Implementation: 11-17-21)
The inpatient claim is completed in accordance with instructions in chapter 25 for the beneficiary who
receives a covered liver transplant. Applicable standard liver acquisition charges are identified separately by
revenue code 081X. Where interim bills are submitted, the standard acquisition charge appears on the billing
form for the period during which the transplant took place. This charge is in addition to the hospital's charge
for services furnished directly to the Medicare recipient.
The contractor deducts liver acquisition charges for IPPS hospitals prior to processing through Pricer. Costs of
liver acquisition incurred by approved liver transplant facilities are not included in the liver transplant
prospective payment. They are paid on a reasonable cost basis. This item is a "pass-through" cost for which
interim payments are made. (See the Provider Reimbursement Manual, Part 1, §2802 B.8.) The contractor
includes liver acquisition charges under revenue code 081X in the HUIP record that it sends to CWF and the
QIO.
MCE Interface
The MCE contains a limited coverage edit for liver transplant procedures using below ICD-10-CM codes if
ICD-10-CM is applicable.
Nationally Covered Diagnosis Codes
Diagnosis
Code
Description
B16.0
Acute hepatitis B with delta-agent with hepatic coma
B16.1
Acute hepatitis B with delta-agent without hepatic coma
B16.2
Acute hepatitis B without delta-agent with hepatic coma
B16.9
Acute hepatitis B without delta-agent and without hepatic coma
B17.0
Acute delta-(super) infection of hepatitis B carrier
B17.10
Acute hepatitis C without hepatic coma
B17.11
Acute hepatitis C with hepatic coma
B17.2
Acute hepatitis E
B17.8
Other specified acute viral hepatitis
B17.9
Acute viral hepatitis, unspecified
B18.0
Chronic viral hepatitis B with delta-agent
B18.1
Chronic viral hepatitis B without delta-agent
B18.2
Chronic viral hepatitis C
B18.8
Other chronic viral hepatitis
B18.9
Chronic viral hepatitis, unspecified
B19.0
Unspecified viral hepatitis with hepatic coma
B19.10
Unspecified viral hepatitis B without hepatic coma
B19.11
Unspecified viral hepatitis B with hepatic coma
B19.20
Unspecified viral hepatitis C without hepatic coma
B19.21
Unspecified viral hepatitis C with hepatic coma
B19.9
Unspecified viral hepatitis without hepatic coma
C22.0
Liver cell carcinoma
E70.1
Other hyperphenylalaninemias
E70.20
Disorder of tyrosine metabolism, unspecified
E70.21
Tyrosinemia
E70.29
Other disorders of tyrosine metabolism
E70.30
Albinism, unspecified
E70.310
X-linked ocular albinism
E70.311
Autosomal recessive ocular albinism
E70.318
Other ocular albinism
E70.319
Ocular albinism, unspecified
E70.320
Tyrosinase negative oculocutaneous albinism
E70.321
Tyrosinase positive oculocutaneous albinism
E70.328
Other oculocutaneous albinism
E70.329
Oculocutaneous albinism, unspecified
E70.330
Chediak-Higashi syndrome
E70.331
Hermansky-Pudlak syndrome
E70.338
Other albinism with hematologic abnormality
E70.339
Albinism with hematologic abnormality, unspecified
E70.39
Other specified albinism
E70.40
Disorders of histidine metabolism, unspecified
E70.41
Histidinemia
E70.49
Other disorders of histidine metabolism
E70.5
Disorders of tryptophan metabolism
E70.81
Aromatic L-amino acid decarboxylase deficiency
E70.89
Other disorders of aromatic amino-acid metabolism
E70.9
Disorder of aromatic amino-acid metabolism, unspecified
E71.0
Maple-syrup-urine disease
E71.110
Isovaleric acidemia
E71.111
3-methylglutaconic aciduria
E71.118
Other branched-chain organic acidurias
E71.120
Methylmalonic acidemia
E71.121
Propionic acidemia
E71.128
Other disorders of propionate metabolism
E71.19
Other disorders of branched-chain amino-acid metabolism
E71.2
Disorder of branched-chain amino-acid metabolism, unspecified
E71.30
Disorder of fatty-acid metabolism, unspecified
E71.310
Long chain/very long chain acyl CoA dehydrogenase deficiency
E71.311
Medium chain acyl CoA dehydrogenase deficiency
E71.312
Short chain acyl CoA dehydrogenase deficiency
E71.313
Glutaric aciduria type II
E71.314
Muscle carnitine palmitoyltransferase deficiency
E71.318
Other disorders of fatty-acid oxidation
E71.32
Disorders of ketone metabolism
E71.39
Other disorders of fatty-acid metabolism
E71.40
Disorder of carnitine metabolism, unspecified
E71.41
Primary carnitine deficiency
E71.42
Carnitine deficiency due to inborn errors of metabolism
E71.43
Iatrogenic carnitine deficiency
E71.440
Ruvalcaba-Myhre-Smith syndrome
E71.448
Other secondary carnitine deficiency
E71.50
Peroxisomal disorder, unspecified
E71.510
Zellweger syndrome
E71.511
Neonatal adrenoleukodystrophy
E71.518
Other disorders of peroxisome biogenesis
E71.520
Childhood cerebral X-linked adrenoleukodystrophy
E71.521
Adolescent X-linked adrenoleukodystrophy
E71.522
Adrenomyeloneuropathy
E71.528
Other X-linked adrenoleukodystrophy
E71.529
X-linked adrenoleukodystrophy, unspecified type
E71.53
Other group 2 peroxisomal disorders
E71.540
Rhizomelic chondrodysplasia punctata
E71.541
Zellweger-like syndrome
E71.542
Other group 3 peroxisomal disorders
E71.548
Other peroxisomal disorders
E72.00
Disorders of amino-acid transport, unspecified
E72.01
Cystinuria
E72.02
Hartnup's disease
E72.03
Lowe's syndrome
E72.04
Cystinosis
E72.09
Other disorders of amino-acid transport
E72.10
Disorders of sulfur-bearing amino-acid metabolism, unspecified
E72.11
Homocystinuria
E72.12
Methylenetetrahydrofolate reductase deficiency
E72.19
Other disorders of sulfur-bearing amino-acid metabolism
E72.20
Disorder of urea cycle metabolism, unspecified
E72.21
Argininemia
E72.22
Arginosuccinic aciduria
E72.23
Citrullinemia
E72.29
Other disorders of urea cycle metabolism
E72.3
Disorders of lysine and hydroxylysine metabolism
E72.4
Disorders of ornithine metabolism
E72.50
Disorder of glycine metabolism, unspecified
E72.51
Non-ketotic hyperglycinemia
E72.52
Trimethylaminuria
E72.53
Primary hyperoxaluria
E72.59
Other disorders of glycine metabolism
E72.81
Disorders of gamma aminobutyric acid
E72.89
Other specified disorders of amino-acid metabolism
E72.9
Disorder of amino-acid metabolism, unspecified
E80.0
Hereditary erythropoietic porphyria
E80.29
Other porphyria
E83.00
Disorder of copper metabolism, unspecified
E83.01
Wilson's disease
E83.09
Other disorders of copper metabolism
E83.110
Hereditary hemochromatosis
E83.111
Hemochromatosis due to repeated red blood cell transfusions
E83.118
Other hemochromatosis
E83.119
Hemochromatosis, unspecified
E85.0
Non-neuropathic heredofamilial amyloidosis
E85.1
Neuropathic heredofamilial amyloidosis
E85.2
Heredofamilial amyloidosis, unspecified
E85.3
Secondary systemic amyloidosis
E85.4
Organ-limited amyloidosis
E85.89
Other amyloidosis
E88.01
Alpha-1-antitrypsin deficiency
E88.02
Plasminogen deficiency
I82.0
Budd-Chiari syndrome
K70.0
Alcoholic fatty liver
K70.10
Alcoholic hepatitis without ascites
K70.11
Alcoholic hepatitis with ascites
K70.2
Alcoholic fibrosis and sclerosis of liver
K70.30
Alcoholic cirrhosis of liver without ascites
K70.31
Alcoholic cirrhosis of liver with ascites
K70.40
Alcoholic hepatic failure without coma
K70.41
Alcoholic hepatic failure with coma
K70.9
Alcoholic liver disease, unspecified
K71.0
Toxic liver disease with cholestasis
K71.10
Toxic liver disease with hepatic necrosis, without coma
K71.11
Toxic liver disease with hepatic necrosis, with coma
K71.2
Toxic liver disease with acute hepatitis
K71.3
Toxic liver disease with chronic persistent hepatitis
K71.4
Toxic liver disease with chronic lobular hepatitis
K71.50
Toxic liver disease with chronic active hepatitis without ascites
K71.51
Toxic liver disease with chronic active hepatitis with ascites
K71.6
Toxic liver disease with hepatitis, not elsewhere classified
K71.7
Toxic liver disease with fibrosis and cirrhosis of liver
K71.8
Toxic liver disease with other disorders of liver
K72.00
Acute and subacute hepatic failure without coma
K72.01
Acute and subacute hepatic failure with coma
K72.10
Chronic hepatic failure without coma
K72.11
Chronic hepatic failure with coma
K72.90
Hepatic failure, unspecified without coma
K72.91
Hepatic failure, unspecified with coma
K73.1
Chronic lobular hepatitis, not elsewhere classified
K73.2
Chronic active hepatitis, not elsewhere classified
K73.8
Other chronic hepatitis, not elsewhere classified
K73.9
Chronic hepatitis, unspecified
K74.01
Hepatic fibrosis, early fibrosis
K74.02
Hepatic fibrosis, advanced fibrosis
K74.1
Hepatic sclerosis
K74.2
Hepatic fibrosis with hepatic sclerosis
K74.3
Primary biliary cirrhosis
K74.4
Secondary biliary cirrhosis
K74.5
Biliary cirrhosis, unspecified
K74.60
Unspecified cirrhosis of liver
K74.69
Other cirrhosis of liver
K75.0
Abscess of liver
K75.1
Phlebitis of portal vein
K75.2
Nonspecific reactive hepatitis
K75.3
Granulomatous hepatitis, not elsewhere classified
K75.4
Autoimmune hepatitis
K75.81
Nonalcoholic steatohepatitis (NASH)
K75.89
Other specified inflammatory liver diseases
K75.9
Inflammatory liver disease, unspecified
K76.0
Fatty (change of) liver, not elsewhere classified
K76.1
Chronic passive congestion of liver
K76.2
Central hemorrhagic necrosis of liver
K76.3
Infarction of liver
K76.4
Peliosis hepatis
K76.5
Hepatic veno-occlusive disease
K76.6
Portal hypertension
K76.7
Hepatorenal syndrome
K76.81
Hepatopulmonary syndrome
K76.89
Other specified diseases of liver
K77
Liver disorders in diseases classified elsewhere
K83.01
Primary sclerosing cholangitis
K83.09
Other cholangitis
K83.1
Obstruction of bile duct
K83.5
Biliary cyst
K83.8
Other specified diseases of biliary tract
K83.9
Disease of biliary tract, unspecified
K91.82
Postprocedural hepatic failure
Q44.1
Other congenital malformations of gallbladder
Q44.2
Atresia of bile ducts
Q44.3
Congenital stenosis and stricture of bile ducts
Q44.4
Choledochal cyst
Q44.6
Cystic disease of liver
T86.40
Unspecified complication of liver transplant
T86.41
Liver transplant rejection
T86.42
Liver transplant failure
T86.43
Liver transplant infection
T86.49
Other complications of liver transplant
Local Discretion Covered Diagnosis Codes
C24.0
Malignant neoplasm of extrahepatic bile duct
C7B.02
Secondary carcinoid tumors of liver
D37.6
Neoplasm of uncertain behavior of liver, gallbladder and bile ducts
Nationally NON-Covered Diagnosis Codes
C22.1
Intrahepatic bile duct carcinoma
C22.3
Angiosarcoma of liver
C22.7
Other specified carcinomas of liver
C78.7
Secondary malignant neoplasm of liver and intrahepatic bile duct
C7A.1
Malignant poorly differentiated neuroendocrine tumors
C7A.8
Other malignant neuroendocrine tumors
C7B.8
Other secondary neuroendocrine tumors
D01.5
Carcinoma in situ of liver, gallbladder and bile ducts
D18.00
Hemangioma unspecified site
D18.01
Hemangioma of skin and subcutaneous tissue
D18.02
Hemangioma of intracranial structures
D18.03
Hemangioma of intra-abdominal structures
D18.09
Hemangioma of other sites
D3A.8
Other benign neuroendocrine tumors
The MCE contains a limited coverage edit for liver transplant procedures using ICD- 10-PCS codes, if ICD-
10-PCS code is applicable.
0FY00Z0- Transplantation of Liver, Allogeneic, Open Approach 0FY00Z1-Transplantation of Liver,
Syngeneic, Open Approach
Where a liver transplant procedure code is identified by the MCE, the contractor shall check the provider
number and effective date to determine if the provider is an approved liver transplant facility at the time of the
transplant. Contractors shall use claims data to determine that the coverage criteria specified in Publication
100-03, Section 260.1 have been met. If payment is appropriate (i.e., the facility is approved, the service is
furnished on or after the approval date, and the beneficiary has a covered condition), the contractor sends the
claim to Grouper and Pricer.
If none of the diagnosis’s codes are for a covered condition, or if the provider is not an approved liver
transplant facility, the contractor denies the claim.
NOTE: Some noncovered conditions are included in the covered diagnostic codes. (The diagnostic codes are
broader than the covered conditions. Do not pay for noncovered conditions.
Grouper
If the bill shows a discharge date before March 8, 1990, the liver transplant procedure is not covered. If the
discharge date is March 8, 1990 or later, the contractor processes the bill through Grouper and Pricer. If the
discharge date is after March 7, 1990, and before October 1, 1990, Grouper assigned CMS DRG 191 or 192.
The contractor sent the bill to Pricer with review code 08. Pricer would then overlay CMS DRG 191 or 192
with CMS DRG 480 and the weights and thresholds for CMS DRG 480 to price the bill. If the discharge date
is after September 30, 1990, Grouper assigns CMS DRG 480 and Pricer is able to price without using review
code 08. If the discharge date is after September 30, 2007, Grouper assigns MS-DRG 005 or 006 (Liver
transplant with MCC or Intestinal Transplant or Liver transplant without MCC, respectively) and Pricer is able
to price without using review code 08.
Liver Transplant Billing From Non-approved Hospitals
Where a liver transplant and covered services are provided by a non-approved hospital, the bill data processed
through Grouper and Pricer must exclude transplant procedure codes and related charges.
When CMS approves a hospital to furnish liver transplant services, it informs the hospital of
the effective date in the approval letter. The contractor will receive a copy of the letter
90.5 - Pancreas Transplants Kidney Transplants
(Rev. 3481, Issued: 03-18-16. Effective: 06-20-16, Implementation: 06-20-16)
A. - Background
Effective July 1, 1999, Medicare covered pancreas transplantation when performed
simultaneously with or following a kidney transplant if ICD-9 is applicable, ICD-9-CM
procedure code 55.69. If ICD-10 is applicable, the following ICD-10-PCS codes will be
used:
0TY00Z0,
0TY00Z1,
0TY00Z2,
0TY10Z0.
0TY10Z1, and
0TY10Z2.
Pancreas transplantation is performed to induce an insulin independent, euglycemic state in
diabetic patients. The procedure is generally limited to those patients with severe secondary
complications of diabetes including kidney failure. However, pancreas transplantation is
sometimes performed on patients with labile diabetes and hypoglycemic unawareness.
Medicare has had a policy of not covering pancreas transplantation. The Office of Health
Technology Assessment performed an assessment on pancreas-kidney transplantation in
1994. They found reasonable graft survival outcomes for patients receiving either
simultaneous pancreas-kidney (SPK) transplantation or pancreas after kidney (PAK)
transplantation. For a list of facilities approved to perform SPK or PAK, refer to the
following Web site: https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/downloads/ApprovedTransplantPrograms.pdf
B. - Billing for Pancreas Transplants
There are no special provisions related to managed care participants. Managed care plans are
required to provide all Medicare covered services. Medicare does not restrict which
hospitals or physicians may perform pancreas transplantation.
The transplant procedure and revenue code 0360 for the operating room are paid under these
codes. Procedures must be reported using the current ICD procedure codes for pancreas and
kidney transplants. Providers must place at least one of the following transplant procedure
codes on the claim:
If ICD-9 Is Applicable
52.80
Transplant of pancreas
52.82
Homotransplant of pancreas
The Medicare Code Editor (MCE) has been updated to include 52.80 and 52.82 as limited
coverage procedures. The contractor must determine if the facility is approved for the
transplant and certified for either pediatric or adult transplants dependent upon the age of the
patient.
Effective October 1, 2000, ICD-9-CM code 52.83 was moved in the MCE to non-covered.
The contractor must override any deny edit on claims that came in with 52.82 prior to
October 1, 2000 and adjust, as 52.82 is the correct code.
If the discharge date is July 1, 1999, or later: the contractor processes the bill through
Grouper and Pricer.
If ICD-10 is applicable, the following procedure codes (ICD-10-PCS) are:
• 0FYG0Z0 Transplantation of Pancreas, Allogeneic, Open Approach
• 0FYG0Z1 Transplantation of Pancreas, Syngeneic, Open Approach
Pancreas transplantation is reasonable and necessary for the following diagnosis codes.
However, since this is not an all-inclusive list, the contractor is permitted to determine if any
additional diagnosis codes will be covered for this procedure.
If ICD-9-CM is applicable, Diabetes Diagnosis Codes and Descriptions
ICD-9-
CM
Code
Description
250.00
Diabetes mellitus without mention of complication, type II (non-insulin
dependent) (NIDDM) (adult onset) or unspecified type, not stated as
uncontrolled.
250.01
Diabetes mellitus without mention of complication, type I (insulin
dependent) (IDDM) (juvenile), not stated as uncontrolled.
250.02
Diabetes mellitus without mention of complication, type II (non-insulin
dependent) (NIDDM) (adult onset) or unspecified type, uncontrolled.
250.03
Diabetes mellitus without mention of complication, type I (insulin
dependent) (IDDM) (juvenile), uncontrolled.
250.1X
Diabetes with ketoacidosis
250.2X
Diabetes with hyperosmolarity
250.3X
Diabetes with coma
250.4X
Diabetes with renal manifestations
250.5X
Diabetes with ophthalmic manifestations
250.6X
Diabetes with neurological manifestations
250.7X
Diabetes with peripheral circulatory disorders
250.8X
Diabetes with other specified manifestations
250.9X
Diabetes with unspecified complication
NOTE: X=0-3
If ICD-10-CM is applicable, the diagnosis codes are: E10.10 - E10.9
Hypertensive Renal Diagnosis Codes and Descriptions if ICD-9-CM is applicable :
ICD-9-CM
Code
Description
403.01
Malignant hypertensive renal disease, with renal failure
403.11
Benign hypertensive renal disease, with renal failure
403.91
Unspecified hypertensive renal disease, with renal failure
404.02
Malignant hypertensive heart and renal disease, with renal failure
404.03
Malignant hypertensive heart and renal disease, with congestive heart
failure or renal failure
404.12
Benign hypertensive heart and renal disease, with renal failure
404.13
Benign hypertensive heart and renal disease, with congestive heart
failure or renal failure
404.92
Unspecified hypertensive heart and renal disease, with renal failure
404.93
Unspecified hypertensive heart and renal disease, with congestive heart
failure or renal failure
585.1 - 585.6,
585.9
Chronic Renal Failure Code
If ICD-10-CM is applicable, diagnosis codes and descriptions are:
ICD-10-CM
code
Description
I12.0
Hypertensive chronic kidney disease with stage 5 chronic kidney
disease or end stage renal disease
I13.11
Hypertensive heart and chronic kidney disease without heart failure,
with stage 5 chronic kidney disease, or end stage renal disease
I13.2
Hypertensive heart and chronic kidney disease with heart failure and
with stage 5 chronic kidney disease, or end stage renal disease
N18.1
Chronic kidney disease, stage 1
N18.2
Chronic kidney disease, stage 2 (mild)
N18.3
Chronic kidney disease, stage 3 (moderate)
N18.4
Chronic kidney disease, stage 4 (severe)
N18.5
Chronic kidney disease, stage 5
N18.6
End stage renal disease
N18.9
Chronic kidney disease, unspecified
NOTE: If a patient had a kidney transplant that was successful, the patient no longer has
chronic kidney failure, therefore it would be inappropriate for the provider to bill ICD-9-CM
codes 585.1 - 585.6, 585.9 or, if ICD-10-CM is applicable, the diagnosis codes N18.1 -
N18.9 on such a patient. In these cases one of the following codes should be present on the
claim or in the beneficiary's history.
The provider uses the following ICD-9-CM status codes only when a kidney transplant was
performed before the pancreas transplant and ICD-9 is applicable:
ICD-9-
CM code
Description
V42.0
Organ or tissue replaced by transplant kidney
V43.89
Organ tissue replaced by other means, kidney or pancreas
If ICD-10-CM is applicable, the following ICD-10-CM status codes will be used:
ICD-10-
CM code
Description
Z48.22
Encounter for aftercare following kidney transplant
Z94.0
Kidney transplant status
NOTE: If a kidney and pancreas transplants are performed simultaneously, the claim should
contain a diabetes diagnosis code and a renal failure code or one of the hypertensive renal
failure diagnosis codes. The claim should also contain two transplant procedure codes. If
the claim is for a pancreas transplant only, the claim should contain a diabetes diagnosis code
and a status code to indicate a previous kidney transplant. If the status code is not on the
claim for the pancreas transplant, the contractor will search the beneficiary's claim history for
a status code indicating a prior kidney transplant.
C. - Drugs
If the pancreas transplant occurs after the kidney transplant, immunosuppressive therapy will
begin with the date of discharge from the inpatient stay for the pancreas transplant.
D. - Charges for Pancreas Acquisition Services
A separate organ acquisition cost center has been established for pancreas transplantation.
The Medicare cost report will include a separate line to account for pancreas transplantation
costs. The 42 CFR 412.2(e)(4) was changed to include pancreas in the list of organ
acquisition costs that are paid on a reasonable cost basis.
Acquisition costs for pancreas transplantation as well as kidney transplants will occur in
Revenue Center 081X. The contractor overrides any claims that suspend due to repetition of
revenue code 081X on the same claim if the patient had a simultaneous kidney/pancreas
transplant. It pays for acquisition costs for both kidney and pancreas organs if transplants are
performed simultaneously. It will not pay for more than two organ acquisitions on the same
claim. In addition, the contractor remove acquisition charges prior to sending the claims to
Pricer so such charges are not included in the outlier calculation.
E. - Medicare Summary Notices (MSN) and Remittance Advice Messages
If the provider submits a claim for simultaneous pancreas kidney transplantation or pancreas
transplantation following a kidney transplant, and omits one of the appropriate
diagnosis/procedure codes, the contractor shall reject the claim.
The following reflects the remittance advice messages and associated codes that will appear
when rejecting/denying claims under this policy. This CARC/RARC combination is
compliant with CAQH CORE Business Scenario 3.
Group Code: CO
CARC: B15
RARC: N/A
MSN: 16.32
If no evidence of a prior kidney transplant is presented, then the contractor shall deny the
claim.
The following reflects the remittance advice messages and associated codes that will appear
when rejecting/denying claims under this policy. This CARC/RARC combination is
compliant with CAQH CORE Business Scenario 3.
Group Code: CO
CARC: 50
RARC: MA126
MSN: 15.4
90.5.1 - Pancreas Transplants Alone (PA)
(Rev. 3481, Issued: 03-18-16. Effective: 06-20-16, Implementation: 06-20-16)
A. - General
Pancreas transplantation is performed to induce an insulin-independent, euglycemic state in
diabetic patients. The procedure is generally limited to those patients with severe secondary
complications of diabetes, including kidney failure. However, pancreas transplantation is
sometimes performed on patients with labile diabetes and hypoglycemic unawareness.
Medicare has had a long-standing policy of not covering pancreas transplantation, as the
safety and effectiveness of the procedure had not been demonstrated. The Office of Health
Technology Assessment performed an assessment of pancreas-kidney transplantation in
1994. It found reasonable graft survival outcomes for patients receiving either simultaneous
pancreas-kidney transplantation or pancreas-after-kidney transplantation.
B. - Nationally Covered Indications
CMS determines that whole organ pancreas transplantation will be nationally covered by
Medicare when performed simultaneous with or after a kidney transplant. If the pancreas
transplant occurs after the kidney transplant, immunosuppressive therapy will begin with the
date of discharge from the inpatient stay for the pancreas transplant.
C. - Billing and Claims Processing
Contractors shall pay for Pancreas Transplantation Alone (PA) effective for services on or
after April 26, 2006 when performed in those facilities that are Medicare-approved for
kidney transplantation. Approved facilities are located at the following address:
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/downloads/ApprovedTransplantPrograms.pdf
Contractors who receive claims for PA services that were performed in an unapproved
facility, should reject such claims.
The following reflects the remittance advice messages and associated codes that will appear
when rejecting/denying claims under this policy. This CARC/RARC combination is
compliant with CAQH CORE Business Scenario 3.
Group Code: CO
CARC: 58
RARC: N/A
MSN: 16.2
Payment will be made for a PA service performed in an approved facility, and which meets
the coverage guidelines mentioned above for beneficiaries with type I diabetes.
All-Inclusive List of Covered Diagnosis Codes for PA if ICD-9-CM is applicable
(NOTE: “X” = 1 and 3 only)
ICD-9-CM
code
Description
250.0X
Diabetes mellitus without mention of complication, type I (insulin
dependent) (IDDM) (juvenile), not stated as uncontrolled.
250.1X
Diabetes with ketoacidosis
250.2X
Diabetes with hyperosmolarity
250.3X
Diabetes with coma
250.4X
Diabetes with renal manifestations
250.5X
Diabetes with ophthalmic manifestations
250.6X
Diabetes with neurological manifestations
250.7X
Diabetes with peripheral circulatory disorders
250.8X
Diabetes with other specified manifestations
250.9X
Diabetes with unspecified complication
If ICD-10-CM is applicable, , the provider uses the following range of ICD-10-CM
codes:
E10.10 – E10.9.
Procedure Codes
If ICD-9 CM is applicable
52.80 - Transplant of pancreas
52.82 - Homotransplant of pancreas
If ICD-10 is applicable, the provider uses the following ICD-10-PCS codes:
0FYG0Z0 Transplantation of Pancreas, Allogeneic, Open Approach
0FYG0Z1 Transplantation of Pancreas, Syngeneic, Open Approach
Contractors who receive claims for PA that are not billed using the covered diagnosis/procedure
codes listed above shall reject such claims. The MCE edits to ensure that the transplant is
covered based on the diagnosis. The MCE also considers ICD-9-CM codes 52.80 and 52.82 and
ICD-10-PCS codes 0FYG0Z0 and 0FYG0Z1 as limited coverage dependent upon whether the
facility is approved to perform the transplant and is certified for the age of the patient.
The following reflects the remittance advice messages and associated codes that will appear
when rejecting/denying claims under this policy. This CARC/RARC combination is
compliant with CAQH CORE Business Scenario 3.
Group Code: CO
CARC: 50
RARC: N/A
MSN: 15.4
Contractors shall hold the provider liable for denied\rejected claims unless the hospital issues
a Hospital Issued Notice of Non-coverage (HINN) or a physician issues an Advanced
Beneficiary Notice (ABN) for Part-B for physician services.
D. - Charges for Pancreas Alone Acquisition Services
A separate organ acquisition cost center has been established for pancreas transplantation.
The Medicare cost report will include a separate line to account for pancreas transplantation
costs. The 42 CFR 412.2(e)(4) was changed to include PA in the list of organ acquisition
costs that are paid on a reasonable cost basis.
Acquisition costs for PA transplantation are billed in Revenue Code 081X. The contractor
removes acquisition charges prior to sending the claims to Pricer so such charges are not
included in the outlier calculation.
90.6 - Intestinal and Multi-Visceral Transplants
(Rev. 10210, Issued: 07-10-2020, Effective: 08-10-2020, Implementation: 08-10-2020)
A. - Background
Effective for services on or after April 1, 2001, Medicare covers intestinal and multi-visceral
transplantation for the purpose of restoring intestinal function in patients with irreversible
intestinal failure. Intestinal failure is defined as the loss of absorptive capacity of the small
bowel secondary to severe primary gastrointestinal disease or surgically induced short bowel
syndrome. Intestinal failure prevents oral nutrition and may be associated with both mortality
and profound morbidity. Multi-Visceral transplantation includes organs in the digestive
system (stomach, duodenum, liver, and intestine). See §260.5 of the National Coverage
Determinations Manual for further information.
B. - Approved Transplant Facilities
Medicare will cover intestinal transplantation if performed in an approved facility. The
approved facilities are located at: https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/downloads/ApprovedTransplantPrograms.pdf
C. - Billing
If ICD-9-CM is applicable, ICD-9-CM procedure code 46.97 is effective for discharges on or
after April 1, 2001. If ICD-10 is applicable, the ICD-10-PCS procedure codes are 0DY80Z0,
0DY80Z1, 0DYE0Z0, and 0DYE0Z1. The Medicare Code Editor (MCE) lists these codes as
limited coverage procedures. The contractor shall override the MCE when this procedure
code is listed and the coverage criteria are met in an approved transplant facility, and also
determine if the facility is certified for adults and/or pediatric transplants dependent upon the
patient’s age.
For these procedures where the provider is approved as a transplant facility and certified for
the adult and/or pediatric population, and the service is performed on or after the transplant
approval date dependent on patient’s age, contractors shall use claims data to determine that
the coverage criteria specified in Publication 100-03, Section §260.5 have been met.
If payment is appropriate (i.e., the facility is approved, the service is furnished on or after the
approval date, and the beneficiary has a covered condition), the contractor sends the claim to
Grouper and Pricer.
If ICD-9-CM is applicable, charges for ICD-9-CM procedure code 46.97, and, if ICD-10 is
applicable, the ICD-10-PCS procedure codes 0DY80Z0, 0DY80Z1, 0DYE0Z0, or 0DYE0Z1
should be billed under revenue code 0360, Operating Room Services.
For discharge dates on or after October 1, 2001, acquisition charges are billed under revenue
code 081X, Organ Acquisition. For discharge dates between April 1, 2001, and September
30, 2001, hospitals were to report the acquisition charges on the claim, but there was no
interim pass-through payment made for these costs.
Bill the procedure used to obtain the donor's organ on the same claim, using appropriate ICD
procedure codes.
The 11X bill type should be used when billing for intestinal transplants.
Immunosuppressive therapy for intestinal transplantation is covered and should be billed
consistent with other organ transplants under the current rules.
If ICD-9-CM is applicable, there is no specific ICD-9-CM diagnosis code for intestinal
failure. Diagnosis codes exist to capture the causes of intestinal failure. Some examples of
intestinal failure include but are not limited to the following conditions and their associated
ICD-9-CM codes:
• Volvulus 560.2,
• Volvulus gastroschisis 756.79, other [congenital] anomalies of abdominal
wall,
• Volvulus gastroschisis 569.89, other specified disorders of intestine,
• Necrotizing enterocolitis 777.5, necrotizing enterocolitis in fetus or newborn,
• Necrotizing enterocolitis 014.8, other tuberculosis of intestines, peritoneum,
and mesenteric,
• Necrotizing enterocolitis and splanchnic vascular thrombosis 557.0, acute
vascular insufficiency of intestine,
• Inflammatory bowel disease 569.9, unspecified disorder of intestine,
• Radiation enteritis 777.5, necrotizing enterocolitis in fetus or newborn, and
• Radiation enteritis 558.1.
If ICD-10-CM is applicable, some diagnosis codes that may be used for intestinal failure are:
• Volvulus K56.2,
• Enteroptosis K63.4,
• Other specified diseases of intestine K63.89,
• Other specified diseases of the digestive system K92.89,
• Postsurgical malabsorption, not elsewhere classified K91.2,
• Other congenital malformations of abdominal wall Q79.59,
• Necrotizing enterocolitis in newborn, unspecified P77.9,
• Stage 1 necrotizing enterocolitis in newborn P77.1,
• Stage 2 necrotizing enterocolitis in newborn P77.2, and
• Stage 3 necrotizing enterocolitis in newborn P77.3.
D. - Acquisition Costs
A separate organ acquisition cost center was established for acquisition costs incurred on or
after October 1, 2001. Therefore, acquisition charges billed on revenue code 081x are
removed from the claim’s total covered charges so as to not be included in the IPPS outlier
calculation. The Medicare Cost Report will include a separate line to account for these
transplantation costs.
For intestinal and multi-visceral transplants performed between April 1, 2001, and October 1,
2001, the DRG payment was payment in full for all hospital services related to this
procedure.
E. - Medicare Summary Notices (MSN), Remittance Advice Messages, and Notice of
Utilization Notices (NOU)
If an intestinal transplant is billed by an unapproved facility after April 1, 2001, the
contractor shall deny the claim.
The following reflects the remittance advice messages and associated codes that will appear
when rejecting/denying claims under this policy. This CARC/RARC combination is
compliant with CAQH CORE Business Scenario 3.
Group Code: CO
CARC: 171
RARC: N/A
MSN: 21.6 or 21.18 or 16.2
100 - Billing Instructions for Specific Situations
(Rev. 1, 10-01-03)
100.1 - Billing for Abortion Services
100.1 - Billing for Abortion Services
(Rev. 3481, Issued: 03-18-16. Effective: 06-20-16, Implementation: 06-20-16)
Effective October 1, 1998, abortions are not covered under the Medicare program except for
instances where the pregnancy is a result of an act of rape or incest; or the woman suffers
from a physical disorder, physical injury, or physical illness, including a life endangering
physical condition caused by the pregnancy itself that would, as certified by a physician,
place the woman in danger of death unless an abortion is performed.
A. - "G" Modifier
The "G7" modifier is defined as "the pregnancy resulted from rape or incest, or pregnancy
certified by physician as life threatening."
Beginning July 1, 1999, providers should bill for abortion services using the new Modifier
G7. This modifier can be used on claims with dates of services October 1, 1998, and after.
CWF will be able to recognize the modifier beginning July 1, 1999.
B. - A/B MAC (A) Billing Instructions
1. Hospital Inpatient Billing
Hospitals use bill type 11X. Medicare will pay only when one of the following condition
codes is reported:
Condition
Code
Description
AA
Abortion Performed due to Rape
AB
Abortion Performed due to Incest
AD
Abortion Performed due to life endangering physical condition
With one of the following:
If ICD-9-CM Is Applicable:
• an appropriate ICD principal diagnosis code that will group to DRG 770 (Abortion W
D&C, Aspiration Curettage Or Hysterotomy) or
• an appropriate ICD principal diagnosis code and one of the following ICD-9-CM
operating room procedure that will group to DRG 779 (Abortion W/O D&C):69.01,
69.02, 69.51, 74.91.
If ICD-10-CM is applicable, one of the following ICD-10-PCS codes are used:
ICD-10-
PCS code
Description
10A07ZZ
Abortion of Products of Conception, Via Natural or Artificial Opening
10A08ZZ
Abortion of Products of Conception, Via Natural or Artificial Opening
Endoscopic
10D17ZZ
Extraction of Products of Conception, Retained, Via Natural or Artificial
Opening
10D18ZZ
Extraction of Products of Conception, Retained, Via Natural or Artificial
Opening Endoscopic
10A07ZZ
Abortion of Products of Conception, Via Natural or Artificial Opening
10A08ZZ
Abortion of Products of Conception, Via Natural or Artificial Opening
Endoscopic
10A00ZZ
Abortion of Products of Conception, Open Approach
10A03ZZ
Abortion of Products of Conception, Percutaneous Approach
10A04ZZ
Abortion of Products of Conception, Percutaneous Endoscopic Approach
Providers must use ICD-9-CM codes 69.01 and 69.02 if ICD-9-CM is applicable, or, if ICD-
10-CM is applicable, the related 1CD-10-PCS codes to describe exactly the procedure or
service performed.
The A/B MAC (A) must manually review claims with the above ICD-9-CM/ICD-10-PCS
procedure codes to verify that all of the above conditions are met.
2. Outpatient Billing
Hospitals will use bill type 13X and 85X. Medicare will pay only if one of the following
CPT codes is used with the "G7" modifier.
59840
59851
59856
59841
59852
59857
59850
59855
59866
C. - Common Working File (CWF) Edits
For hospital outpatient claims, CWF will bypass its edits for a managed care beneficiary who
is having an abortion outside their plan and the claim is submitted with the "G7" modifier
and one of the above CPT codes.
For hospital inpatient claims, CWF will bypass its edits for a managed care beneficiary who
is having an abortion outside their plan and the claim is submitted with one of the above
inpatient procedure codes.
D. - Medicare Summary Notices (MSN)/Explanation of Your Medicare Benefits
Remittance Advice Message
If a claim is submitted with one of the above CPT procedure codes but no "G7" modifier, the
claim is denied.
The following reflects the remittance advice messages and associated codes that will appear
when rejecting/denying claims under this policy. This CARC/RARC combination is
compliant with CAQH CORE Business Scenario 3.
Group Code: CO
CARC: 272
RARC: N/A
MSN: 21.21
100.2 - Payment for CRNA or AA Services
(Rev. 4157, Issued: 11-02-18, Effective: 04-01-19, Implementation: 04-01-19)
This section discusses reasonable cost-based payment for CRNA services (42 CFR §
412.113(c)). Note that effective January 1, 2013, qualifying rural hospitals and CAHs are
eligible to receive CRNA pass-through payments for services that the CRNA is legally
authorized to perform in the state in which the services are furnished.
Anesthesia services furnished on or after January 1, 1989, and before January 1, 1990, at a
rural hospital or CAH by a qualified hospital employed or contracted CRNA or AA can be
paid on a reasonable cost basis. The A/B MAC (A) determines the hospital's qualification
using the following criteria:
• The hospital or CAH must be located in a rural area (as defined for PPS
purposes) to be considered.
• As of January 1, 1988, the hospital or CAH employed or contracted with a
CRNA or AA. The hospital or CAH may employ or contract with more than
one CRNA or AA; however, the total number of hours of service furnished by
the anesthetists may not exceed 2,080 hours per year.
• The hospital or CAH must demonstrate that during the 1987 calendar year, its
volume of surgical procedures (inpatient and outpatient) requiring anesthesia
services did not exceed 250 procedures.
• Each qualified CRNA or AA employed or under contract with the hospital or
CAH must agree in writing not to bill on a reasonable charge basis for his or
her patient care to Medicare beneficiaries in that hospital or CAH.
In addition to the criteria described above, to maintain eligibility for reasonable cost-based
payment for services furnished on or after January 1, 1990, a hospital or CAH must provide
data for its entire patient population to demonstrate that during calendar year 1987 and the
year immediately preceding its election of reasonable cost payments, its volume of surgical
procedures requiring anesthesia services did not exceed 500 procedures. Effective October
1, 2002, the hospital or CAH must provide data for its entire patient population to
demonstrate that during calendar year 1987 and the year immediately preceding its election
of reasonable cost payments, its volume of surgical procedures requiring anesthesia services
did not exceed 800 procedures.
If a hospital or CAH did not qualify for reasonable cost-based payment for CRNA or AA
services in calendar year 1989, it can qualify in subsequent years if it demonstrates to the
Medicare Contractor prior to the start of the calendar year that it met these criteria noted
below:
• The hospital or CAH must be located in a rural area (as defined for PPS
purposes) to be considered.
• As of January 1, 1988, the hospital or CAH employed or contracted with a
CRNA or AA. The hospital or CAH may employ or contract with more than
one CRNA or AA; however, the total number of hours of service furnished by
the anesthetists may not exceed 2,080 hours per year.
• Each qualified CRNA or AA employed or under contract with the hospital or
CAH has agreed in writing not to bill on a reasonable charge basis for his or
her patient care to Medicare beneficiaries in that hospital or CAH.
• The hospital or CAH must provide data for its entire patient population to
demonstrate that during calendar year 1987 and the year immediately preceding its
election of reasonable cost payments, its volume of surgical procedures (inpatient and
outpatient) requiring anesthesia services did not exceed 500 procedures. Effective
October 1, 2002, the hospital or CAH must provide data for its entire patient
population to demonstrate that during calendar year 1987 and the year immediately
preceding its election of reasonable cost payments, its volume of surgical procedures
(inpatient and outpatient) requiring anesthesia services did not exceed 800
procedures.
Effective for calendar years beginning January 1, 1991, the A/B MAC (A) determines the
number of surgical procedures for the immediately preceding year by summing the number
of surgical procedures for the 9-month period ending September 30, annualized for a 12-
month period.
Effective December 2, 2010, in addition to a hospital or CAH that is located in a rural area
(as defined for PPS purposes), a hospital or CAH may be eligible to be paid based on
reasonable cost for CRNA or AA services, if the hospital or CAH has reclassified as rural
under 42 Code of Federal Regulations 412.103.
To prevent duplicate payments, the A/B MAC (A) informs A/B MACs (B) of the names of
CRNAs or AAs, the hospitals and/or CAHs with which they have agreements, and the
effective dates of the agreements. If the CRNA or AA bills Part B for anesthesia services
furnished after the hospital's and/or CAH’s election of reasonable cost payments, the A/B
MAC (B) must recover the overpayment from the CRNA or AA.
Since a swing-bed is a bed that is available for use to provide acute inpatient care or SNF-
level care and the CRNA/AA pass-through provision applies to hospital inpatients, CRNA
and AA services provided to hospital and CAH swing-bed patients under the pass-through
provision must be included on the hospital or CAH swing-bed bill.
100.3 - Resident and Interns Not Under Approved Teaching Programs
(Rev. 1, 10-01-03)
A3-3669
A. - General
A provider's cost for the services furnished by residents and interns not under approved
teaching programs (including physicians employed by the provider who are authorized to
practice only in a provider setting) are covered under Part B. (Part A covers only the costs of
services performed for inpatients by residents and interns who are under approved teaching
programs.) See the Medicare Benefit Policy Manual, Chapter 6 for further information on the
coverage of these services.
The provider determines that part of the inpatient charges which represents the cost of the
services of residents and interns who are not under approved teaching programs and bills
these separately under Part B, using type of bill code 121 and revenue code 096X, 097X, or
098X as applicable.
B. - Provider Procedures
The cost of Part B residents' and interns' services to inpatients is calculated on a per diem
basis by the hospital in consultation with its A/B MAC (A). The A/B MAC (A) apportions
the total cost of such services (including fringe benefits, etc.) between inpatient and
outpatient services on the basis of the time spent on each. It obtains the inpatient per diem
figure by dividing the total annual inpatient cost for these services by the estimated annual
number of inpatient days for all patients.
For the patients who are enrolled under Part B, regardless of whether Part A benefits are
payable, the provider is reimbursed for 80 percent of the cost of providing these services.
The provider collects or bills the complementary insurer for 20 percent of the per diem rate
for the services of residents and interns covered under Part B times the number of inpatient
days provided. The administrative cost of determining Part B deductible status involving the
cost of query, response, recording, and accounting on an individual basis in the aggregate,
exceeds the potential patient deductible obligation. Therefore, as long as the patient is
entitled to Part A benefits no determination of the patient's deductible liability need to be
made for inpatient Part B interns' and residents' services.
Patients not enrolled under Part B are liable for the entire cost of intern and resident services.
The provider maintains a record of the inpatient days of these individuals so that this cost
may be excluded from the amount of program obligation at the time of final cost settlement.
C. - A/B MAC (A) Procedures
Its A/B MAC (A) assists the provider in arriving at the inpatient per diem rate for the cost of
services covered under Part B provided by residents and interns. (See the Provider
Reimbursement Manual, Part I, §2120 for apportioning costs between inpatient and
outpatient per diem and §2406 for establishing interim rates.) The normal interim
reimbursement rate applied to other provider services applies to Part B residents' and interns'
services.
100.4 - Billing for Services After Termination of Provider Agreement
(Rev. 1, 10-01-03)
HO-404, HH-433
An agreement with a hospital is not time-limited and has no fixed expiration date.
A. - Part A Billing
A hospital whose provider agreement terminates (voluntarily or involuntarily), may be
reimbursed for covered Part A inpatient services for up to 30 days for services furnished on
or after the effective date of termination for beneficiaries who were admitted prior to the
termination date.
EXAMPLE:
Termination date: 6/30/01
Beneficiary admitted on or before 6/29/01
Payment can be made: 6/30/01, up to and including 7/29/01
B. - Assuring That Hospitals Continue to Bill for Covered Services
Upon cessation of a hospital's participation in the program, it supplies the Regional Office
the names and HICNs of Medicare beneficiaries entitled to have payment made on their
behalf, and continues to bill for covered services in accordance with subsection A. It
continues to submit "no-payment" death or discharge bills for Medicare beneficiaries
admitted prior to the termination of the provider's agreement.
C. - Part B Billing
Following termination of its agreement, a hospital is considered to be a "nonparticipating
hospital." An inpatient of such a hospital who has Part B coverage, but for whom Part A
benefits have been exhausted, or are otherwise not available, is entitled to reimbursement for
those services that are covered in a nonparticipating institution. Services, if rendered, must
be billed on Form CMS-1500 and sent to the A/B MAC (B). If a hospital has been billing on
the CMS-1554 for physician services, it continues to do so.
If a terminated hospital meets the necessary criteria, it may be certified to provide emergency
services, and will be assigned an emergency provider number (E suffix). This procedure is
not automatic, however, and hospitals which are terminated for Life Safety Code violations
may never be able to qualify as emergency providers. Should a terminated hospital later
qualify as an emergency provider, billings are handled by the designated emergency FI.
100.4.1 - Billing Procedures for a Provider Assigned Multiple Provider
Numbers or a Change in Provider Number
(Rev. 267, Issued 07-30-04, Effective: 10-01-04, Implementation: 01-03-05)
Where a multiple-facility provider is assigned separate provider numbers for each component
facility or where a provider is assigned a different number, it is required to use the new
number for all notices of admission, start of care notices, bills, etc., beginning with the date
the new number is effective.
A. - Inpatient
The component provider to which the new number is assigned must apportion costs for all
patients who are inpatients in that component as of the first day of the next fiscal period
when the new provider number goes in effect. The hospital must submit a discharge bill with
the old provider number and an admission notice with the new. The date of discharge and
the date of admission are the same date, which is the first day of the new fiscal period. All
subsequent billings are submitted under the new provider number. If a no-payment situation
where the entire billing period represents charges for which no Part A payment can be made,
it is not necessary to submit a discharge bill and admission notice. In this situation, only a
final no-payment bill with a discharge date is submitted under the old provider number.
Services furnished during the "no-payment" period may subsequently be determined to be
covered. Where such covered services were furnished before the date of change in provider
number, the hospital submits one corrected bill covering the entire period showing the old
provider number. However, where services subsequently determined to be covered were
furnished after the date of change, the hospital submits a corrected discharge bill with the
old provider number and a new admission notice and billing with the new provider number.
Effective October 1, 2004, there are new rules pertaining to long term care hospitals. (See
section 150.14.1).
B. - Outpatient Services, Part B Ancillary Services and Home Health Agency Services
For outpatient services and Part B ancillary services, and home health agency services, the
provider uses the old provider number for services provided up through the day before the
effective date of the new provider number. Thereafter, it uses the new number when
submitting bills.
100.5 - Review of Hospital Admissions of Patients Who Have Elected
Hospice Care
(Rev. 1, 10-01-03)
HO-418
Review of admissions to inpatient general hospitals of beneficiaries who have elected
hospice care assures that:
• Nonhospice Medicare coverage is provided to those beneficiaries only when the
hospitalization was for a condition not related to the terminal illness, and
• When inpatient hospital services were provided as a hospice benefit, the services
rendered were stipulated in the individual's plan of care as established by the
hospice's interdisciplinary group.
A. - Review for Nonrelated Hospital Admissions
To assure that nonhospice Medicare coverage is provided to beneficiaries who have elected
hospice care only when hospitalization was for a condition not related to the terminal illness,
the medical review agent reviews all inpatient hospital claims for these beneficiaries.
Appropriate medical records will be requested and a determination made as to whether or not
services were related to the individual's terminal illness.
Many illnesses may occur when an individual is terminally ill which are brought on by the
patient's underlying condition. For example, it is not unusual for a terminally ill patient to
develop pneumonia or some other illness as a result of a weakened condition. Similarly, the
setting of bones after fractures which occur in a bone cancer patient would be treatment of a
related condition.
If the review reveals hospitalization to be unrelated to the individual's terminal illness, a
determination as to the medical necessity and appropriateness of the admission is made.
Payment will be totally denied or totally approved based on the finding. If, after review, the
admission should have been totally denied, consideration under the limitation of liability
provision (§1879 of the Act) applies.
If the review of medical records reveals hospitalization to be related to the individual's
terminal illness, the claim is denied as services waived through the hospice election.
Limitation on liability provision does not apply.
B. - Review for Related Hospital Admissions
To assure that beneficiaries who have elected hospice care are receiving services as provided
in the plans of care established by the hospice's interdisciplinary groups, the medical review
agent reviews all inpatient hospital claims submitted by the hospice for these beneficiaries.
Appropriate medical records (including the plans of care) are requested and a determination
made as to whether or not services provided were related to the individual's terminal illness
and stipulated in the plan of care.
If the review reveals that services provided were medically necessary and appropriate for the
control of pain or acute or chronic symptom management as outlined in the individual's plan
of care, the claim is approved.
If the review reveals that services provided to the hospice beneficiary were not stipulated in
the plan of care as established by the hospice's interdisciplinary group, the claim is denied.
Limitation on liability does not apply.
100.6 - Inpatient Renal Services
(Rev. 1, 10-01-03)
HO-E400
Section 405.103l of Subpart J of Regulation 5 stipulates that only approved hospitals may
bill for ESRD services. Hence, to allow hospitals to bill and be reimbursed for inpatient
dialysis services furnished under arrangements, both facilities participating in the
arrangement must meet the conditions of 405.2120 and 405.2160 of Subpart U of Regulation
5. In order for renal dialysis facilities to have a written arrangement with each other to
provide inpatient dialysis care both facilities must meet the minimum utilization rate
requirement, i.e., two dialysis stations with a performance capacity of at least four dialysis
treatments per week.
Dialysis may be billed by an SNF as a service if: (a) it is provided by a hospital with which
the facility has a transfer agreement in effect, and that hospital is approved to provide staff-
assisted dialysis for the Medicare program; or (b) it is furnished directly by an SNF meeting
all nonhospital maintenance dialysis facility requirements, including minimum utilization
requirements. (See §§1861(h)(6), 1861(h)(7), title XVIII.)
100.7 - Lung Volume Reduction Surgery
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon
Implementation of ICD-10, Implementation: ICD-10: Upon Implementation of ICD-10,
ASC X12: September, 23 2014)
Lung Volume Reduction Surgery (LVRS) (also known as reduction pneumoplasty, lung
shaving, or lung contouring) is an invasive surgical procedure to reduce the volume of a
hyperinflated lung in order to allow the underlying compressed lung to expand, and thus,
establish improved respiratory function.
Effective for discharges on or after January 1, 2004, Medicare will cover LVRS under
certain conditions as described in §240 of Pub. 100-03, “National Coverage Determinations”.
The Medicare Code Editor (MCE) creates a Limited Coverage edit for ICD-9-CM procedure
code 32.22. This procedure code has limited coverage due to the stringent conditions that
must be met by hospitals. Where this procedure code is identified by MCE, the A/B MAC
(A) shall determine if coverage criteria is met and override the MCE if appropriate.
Effective with the implementation of ICD-10 there will not be an MCE edit for lung volume
reduction surgery.
The LVRS can only be performed in the facilities listed on the following Web site:
http://www.cms.gov/Medicare/Medicare-General-
Information/MedicareApprovedFacilitie/Lung-Volume-Reduction-Surgery-
LVRS.htmlMedicare previously only covered LVRS as part of the National Emphysema
Treatment Trial (NETT). The study was limited to 18 hospitals, and patients were
randomized into two arms, either medical management and LVRS or medical management.
The study was conducted by The National Heart, Lung, and Blood Institute of the National
Institutes of Health and coordinated by Johns Hopkins University (JHU). Hospital claims for
patients in the NETT were identified by the presence of Condition Code EY. The JHU
instructed hospitals of the correct billing procedures for billing claims under the NETT.
100.8 – Replaced Devices Offered Without Cost or With a Credit
(Rev. 2627, Issued 01-04-13, Effective 10-01-12, Implementation 10-01-12)
Background
To identify and track claims billed for replacement devices, CMS issued CR 4058 on
November 4, 2005. This CR provided instructions for billing and processing claims with the
following condition codes:
• 49 Product Replacement within Product Lifecycle—Replacement of a product
earlier than the anticipated lifecycle due to an indication that the product is not
functioning properly.
• 50 Product Replacement for Known Recall of a Product—Manufacturer or FDA
has identified the product for recall and therefore replacement.
Policy
Beginning with discharges on or after October 1, 2008, CMS reduces Medicare payment
when a replacement device is received by the hospital at a reduced cost or with a credit that
is 50 percent or greater than the cost of the device, and when the assigned MS-DRG for the
claim is one of the MS-DRGs applied to this policy.
For a list of MS-DRGs for which this policy applies to, please see the IPPS Final Rule.
This adjustment is consistent with section 1862(a)(2) of the Act, which excludes from
Medicare coverage an item or service for which neither the beneficiary, nor anyone on his or
her behalf, has an obligation to pay.
Billing Procedures (Discharges on or after October 1, 2008)
To correctly bill for a replacement device that was provided with a credit or no cost,
hospitals must use the combination of condition code 49 or 50, along with value code
FD. The condition code 49 or 50 will identify a replacement device while value code FD
will communicate to Medicare the amount of the credit, or cost reduction, received by the
hospital for the replaced device.
Payment (Discharges on or after October 1, 2008)
Medicare deducts the partial/full credit amount, reported in the amount for value code FD,
from the final IPPS reimbursement when the assigned MS-DRG is one of the MS-DRGs
applied to this policy.
Reminder about Charging for Recalled Devices
As a reminder, section 2202.4 of the Provider Reimbursement Manual, Part I states, “charges
should be related consistently to the cost of the services and uniformly applied to all patients
whether inpatient or outpatient.” Accordingly, hospital charges with respect to medical
devices must be reasonably related to the cost of the medical device. If a hospital receives a
credit for a replacement medical device, the charges to Medicare should also be
appropriately reduced.
100.9 – Requirements for Processing Non Veterans Administration (VA)
Authorized Inpatient Claims
(Rev. 3779, Issued: 05-24-17, Effective: 10-01-13, Implementation: 04-03-17)
Medicare is precluded from making payment for services or items that are paid for directly or
indirectly by another government entity. For inpatient claims where the VA is the Payer, the
covered VA services are exclusions to the Medicare program per Section 1862 of the Social
Security Act. If the VA doesn’t approve all the services, any Medicare covered services not
considered by the VA may be billed to the Medicare program.
When a VA- eligible beneficiary chooses to receive services in a Medicare Certified Facility
for which the VA has not authorized, the facility shall use Condition Code 26 to indicate the
patient is a VA eligible patient and chooses to receive services in a Medicare Certified
provider instead of a VA facility and value code 42 with the amount of the VA payment for
the authorized days.
100.10 – Requirements for Processing Programs of All-Inclusive Care for
the Elderly (PACE) Disenrollments during an Inpatient Stays
(Rev. 12148; Issued: 07-21-23; Effective: 01-01-24; Implementation:01-02-24)
Medicare is precluded from making payment for services or items that are paid for
directly or indirectly by another government entity. For inpatient claims where the
PACE is the Payer, the covered PACE services are exclusions to the Medicare
program per Section 1862 of the Social Security Act. If the PACE doesn’t approve all
the services due to disenrollment from the program, any Medicare covered services
not considered by the PACE program may be billed to the Medicare program. The
provider should identify PACE in the group name and or the PACE taxonomy code
251T00000X in the group number.
When a PACE beneficiary is inpatient and has been disenrolled in PACE, the facility
shall use Condition Code 35 to indicate the patient is a PACE eligible patient that
has disenrolled during an inpatient stay and value code 42 with the amount of the
PACE payment for the authorized days during enrollment in the PACE program.
130 - Coordination With the Quality Improvement Organization (QIO)
(Rev. 632, Issued: 07-29-05, Effective: 01-03-06, Implementation: 01-03-06)
Instructions regarding hospital interactions with QIOs have been relocated as follows:
• Instructions regarding HINNs are found in CMS Transmittal 594, which precedes the
placement of full instructions in Chapter 30.
• Instructions regarding hospital billing for cases involving QIO review can be found in
Chapter 1, section 150.2.
• Related instructions for QIOs can be found in the Medicare Quality Improvement
Organization Manual, Publication 100-10, Chapter 7.
140 - Inpatient Rehabilitation Facility Prospective Payment System (IRF
PPS)
(Rev. 2673, Issued: 03-14-13, Effective: 04-22-13, Implementation: 04-22-13)
Section 1886(j) of the Social Security Act (the Act) authorizes the implementation of a per
discharge prospective payment system (PPS) for inpatient rehabilitation hospitals and
inpatient rehabilitation units of a hospital now jointly referred to as inpatient rehabilitation
facilities (IRFs).
The IRF PPS is effective for cost reporting periods beginning on or after January 1, 2002.
IRF PPS payment rates include all costs of furnishing covered IRF services (routine,
ancillary, and capital-related costs) other than costs associated with operating approved
educational activities as defined in
http://www.gpo.gov/fdsys/browse/collectionCfr.action?collectionCode=CFR, select the
applicable year. Then select Title 42, Chapter IV. Select the TOC for Section 413 and
choose §413.75 and §413.85 for educational activities. You may also search the TOC for
bad debts, and other costs not covered under the PPS.
Effective for cost reporting periods beginning on or after October 1, 2004, the Medicare
Modernization Act of 2003, Public Law 108-173, section 405(g) established that CAHs may
open rehabilitation distinct part units. These IRFs will also be paid under the IRF PPS.
140.1 - Medicare IRF Classification Requirements
(Rev. 12575; Issued:04-11-24; Effective: 07-12-24; Implementation: 07-12-24)
Section 1886(j) of the Social Security Act (the Act) provides for the implementation of a
prospective payment system (PPS) under Medicare for inpatient hospital services furnished
by a rehabilitation hospital or a rehabilitation unit of a hospital (referred to as an inpatient
rehabilitation facility (IRF)). Section 1886(d)(1)(B)(ii) of the Act gives the Secretary the
discretion to define an IRF. The regulations at 42 CFR §§ 412.25 and 412.29 specify the
criteria for a provider to be excluded from the inpatient prospective payment system (IPPS)
specified in 42 CFR §412.1(a)(1) and instead be paid under the IRF PPS. 42 CFR 412.29
A facility paid under the IRF PPS is always subject to verification that it continues to meet the
criteria for exclusion from the IPPS. The fiscal intermediary (FI) or the Part A/B Medicare
Administrative Contractor (MAC) provides the Regional Office (RO) now referred to as the
Office of Program Operations and Local Engagement (OPOLE) with data for determining the
classification status of each facility and OPOLE reviews the IRF’s classification status each
year. Additionally, updates were made to 42 CFR § 412.25(c)(1) to allow a hospital to open a
new IRF unit anytime within the cost reporting year, as long as the hospital notifies OPOLE
and the MAC in writing of the change at least 30 days before the date of the change for
making a determination that a facility either is or is not classified as an IRF. This change
applies to the entire cost reporting period. We maintain the current requirements of
§ 412.25(c)(2), which specify that, if an excluded unit becomes not excluded during a cost
reporting year, the hospital must notify the MAC and OPOLE in writing before the change,
and this change would remain in effect for the rest of the cost reporting year.
If a facility fails to meet the criteria necessary to be paid under the IRF PPS, but meets the
criteria to be paid under the IPPS, it may be paid under the IPPS.
If a patient is admitted to a facility that is being paid under the IRF PPS, but is discharged
from the facility when it is no longer being paid under the IRF PPS, then payment to the
facility will be made from the applicable payment system that is in effect for the facility at the
time the patient is discharged.
IRFs that are being paid under the IRF PPS need not reapply to be classified for payment
under the IRF PPS each year. However, under CMS’s new attestation process, an IRF must
self-attest to meeting all of the criteria, except for the criteria specified below in §140.1.1B-D,
for being excluded from the IPPS and paid under the IRF PPS every 3 years. The A/B MACs
(A) are responsible for verifying annually that each IRF meets the criteria specified below in
§140.1.1B-D. IRFs are notified in writing by OPOLE of the required self-attestation
procedures and the time-frames for submitting the required self-attestation forms. The ROs
will also notify the IRFs in writing of any other procedures and requirements that apply to
them. However, the A/B MACs (A) are not responsible for monitoring or enforcing the IRF
self-attestation procedures, which are the responsibility of the State agencies.
All IRFs must notify their A/B MACs (A) and OPOLE in writing before making any changes
to their operations (i.e. increasing their bed size or square footage, moving to a new location,
changing ownership, merging, or other similar changes to the ownership or operations of the
facility).
140.1.1 - Criteria That Must Be Met By Inpatient Rehabilitation Facilities
(Rev. 12575; Issued:04-11-24; Effective: 07-12-24; Implementation: 07-12-24)
An inpatient rehabilitation hospital or an inpatient rehabilitation unit of a hospital (otherwise
referred to as an IRF) is excluded from the IPPS and is eligible for payment under the IRF
PPS if it meets all of the criteria listed below. Note that in order for an individual IRF claim
to receive Medicare payment under the IRF PPS, it must meet all of the IRF coverage
requirements in 42 CFR 412.622(a)(3), (4), and (5), as further clarified in Chapter 1, Section
110 of the Medicare Benefit Policy Manual (Pub. 100-02.
A. - The IRF must have (or be part of a hospital that has) a provider agreement under 42 CFR
Part 489 to participate in Medicare as a hospital.
B. - During the most recent, consecutive, and appropriate 12-month time period (as
defined by CMS or the A/B MAC (A)) the IRF must have treated an inpatient population
that met or exceeded the following percentages:
1. For cost reporting periods beginning on or after July 1, 2004, and before July 1, 2005,
the hospital must have served an inpatient population of whom at least 50 percent
required intensive rehabilitative services for treatment of one or more of the medical
conditions specified below at § 140.1.1C.
2. For cost reporting periods beginning on or after July 1, 2005, the IRF must have
served an inpatient population of whom at least 60 percent required intensive
rehabilitative services for treatment of one or more of the medical conditions specified
below at § 140.1.1C.
C. - List of Medical Conditions:
1. Stroke.
2. Spinal cord injury.
3. Congenital deformity.
4. Amputation.
5. Major multiple trauma.
6. Fracture of femur (hip fracture).
7. Brain injury.
8. Neurological disorders, including multiple sclerosis, motor neuron diseases,
polyneuropathy, muscular dystrophy, and Parkinson’s disease.
9. Burns.
10. Active, polyarticular rheumatoid arthritis, psoriatic arthritis, and seronegative
arthropathies resulting in significant functional impairment of ambulation and other
activities of daily living that have not improved after an appropriate, aggressive, and
sustained course (as defined below) of outpatient therapy services or services in other
less intensive rehabilitation settings, but have the potential to improve with more
intensive rehabilitation.
11. Systemic vasculidites with joint inflammation, resulting in significant functional
impairment of ambulation and other activities of daily living that have not improved
after an appropriate, aggressive, and sustained course (as defined below) of outpatient
therapy services or services in other less intensive rehabilitation settings, but would have
the potential to improve with more intensive rehabilitation.
12. Severe or advanced osteoarthritis (osteoarthrosis or degenerative joint disease)
involving two or more major weight bearing joints (elbow, shoulders, hips, or knees, but
not counting a joint with a prosthesis) with joint deformity and substantial loss of range
of motion, atrophy of muscles surrounding the joint, significant functional impairment
of ambulation and other activities of daily living that have not improved after the patient
has participated in an appropriate, aggressive, and sustained course (as defined below) of
outpatient therapy services or services in other less intensive rehabilitation settings, but
would have the potential to improve with more intensive rehabilitation. (A joint
replaced by a prosthesis no longer is considered to have osteoarthritis, or other arthritis,
even though this condition was the reason for the joint replacement.)
13. Knee or hip joint replacement, or both, during a hospitalization immediately
preceding the IRF stay and also meets one or more of the following specific criteria:
a. The patient underwent bilateral knee or bilateral hip joint replacement surgery
during the hospital admission immediately preceding the IRF admission.
b. The patient is extremely obese with a Body Mass Index of at least 50 at the time
of admission to the IRF.
c. The patient is age 85 or older at the time of admission to the IRF.
Definition of “an appropriate, aggressive, and sustained course of outpatient therapy services
or services in other less intensive rehabilitation settings”
For the medical conditions specified above in subsections 10, 11, and 12, an appropriate,
aggressive, and sustained course of outpatient therapy services or services in other less
intensive rehabilitation settings must consist of a course of rehabilitation therapy of at least 3
weeks minimum duration with at least two individual (non-group) therapy sessions per week
targeting all clinically impaired joints supported by documentation in the medical record of all
such services with periodic assessments for clinical functional improvement, within 20
calendar days of an acute hospitalization preceding immediately an IRF stay, or 20 calendar
days immediately preceding an IRF admission. However, there may be cases when, in the
A/B MAC (A)’s judgment, the preceding interpretation of what is considered an appropriate,
aggressive, and sustained course of outpatient therapy services or services in other less
intensive rehabilitation settings should not be used. In these cases, the A/B MAC (A) has the
discretion to develop, document, and use another interpretation, which is based upon local
practices and more current clinical information, that interprets or defines what the A/B MAC
(A) considers is an appropriate, aggressive, and sustained course of outpatient therapy
services or services in other less intensive rehabilitation settings. Regardless of which
interpretation or definition is used by the A/B MAC (A) with respect to what is considered an
appropriate, aggressive, and sustained course of outpatient therapy services or services in
other less intensive rehabilitation settings, the course of therapy itself should have the goal of
completing the rehabilitation, not preparing a patient for surgery. The outpatient therapy
services (or services in other less intensive settings) must immediately precede the IRF
admission or result from a systemic disease activation immediately before admission.
The A/B MAC (A) has the discretion to review documentation to assure that the patient has
completed an appropriate, aggressive, and sustained course of therapy or services in less
intensive rehabilitation settings. CMS expects that the IRF will obtain copies of the therapy
notes from the outpatient therapy or from the therapy services provided in another less
intensive setting and include these in the patient’s medical record at the IRF (in a section
for prior records). CMS believes that these prior records will be used by therapists and
others caring for the patient in the IRF, and will also be available to the A/B MAC (A) staff
who review the medical records for compliance with the requirements specified above in
§140.1.1B-D.
D. - Comorbidities.—A comorbidity is a specific patient condition that is secondary to the
patient’s principal diagnosis. A patient with a comorbidity may be counted as part of the
inpatient population that counts towards the required applicable percentage specified above in
§140.1.1B-D if:
1. The patient is admitted for inpatient rehabilitation for a medical condition that is not
one of the conditions specified above in sub-section 140.1.1C.
2. The patient has a comorbidity that falls in one of the medical conditions specified above
in sub-section 140.1.1C; and
3. The comorbidity has caused significant decline in functional ability in the individual
such that, even in the absence of the admitting condition, the individual would require the
intensive rehabilitation treatment that is unique to inpatient rehabilitation facilities paid
under the IRF PPS.
E. - For the first cost reporting period during which a facility first begins being paid under the
IRF PPS as a “new” IRF, a facility seeking to be paid under the IRF PPS must provide a
written certification to the A/B MAC (A) that the inpatient population it intends to serve
meets the requirements specified above in §140.1.1B-D. However, if CMS discovers that the
facility did not actually meet the requirements specified above in §140.1.1B-D during any
cost reporting period for which the facility provided such written certification of its intent to
meet the requirements in §140.1.1B-D, then CMS will adjust the payments associated with
that cost reporting period as described below in §140.1.9.
F. - The IRF has in effect a preadmission screening procedure under which each
prospective patient's condition and medical history are reviewed to determine whether the
patient is likely to benefit significantly from an intensive inpatient hospital rehabilitation
program. This procedure must ensure that the preadmission screening is reviewed and
approved by a rehabilitation physician prior to the patient’s admission to the IRF.
G. - The IRF has in effect a procedure to ensure that patients receive close medical
supervision, as evidenced by at least 3 face-to-face visits per week by a licensed physician
with specialized training and experience in inpatient rehabilitation to assess the patient both
medically and functionally, as well as to modify the course of treatment as needed to
maximize the patient’s capacity to benefit from the rehabilitation process. Beginning with the
second week of admission to the IRF, a non-physician practitioner who is determined by the
IRF to have specialized training and experience in inpatient rehabilitation may conduct 1 of
the 3 required face-to-face visits with the patient per week, provided that such duties are
within the non-physician practitioner’s scope of practice under applicable state law.
H. - The IRF furnishes, through the use of qualified personnel, rehabilitation nursing,
physical therapy, and occupational therapy, plus, as needed, speech-language pathology,
social services, psychological services (including neuropsychological services), and
orthotic and prosthetic services.
I. - The IRF has one physician who serves as director of rehabilitation and who—
(1) Provides services to the IRF hospital or its inpatients on a full-time basis or, in the case
of a rehabilitation unit, at least 20 hours per week;
(2) Is a doctor of medicine or osteopathy;
(3) Is licensed under State law to practice medicine or surgery; and
(4) Has had, after completing a one-year hospital internship, at least 2 years of training or
experience in the medical management of inpatients requiring rehabilitation services.
If an IRF serves both inpatients and outpatients, the time spent by the director in performing
administrative duties for the entire facility counts toward the direction requirement since it is
not feasible to prorate this administrative time between inpatients and outpatients. However,
any time spent in furnishing direct patient care can count toward the direction requirement
only if the care is furnished to inpatients.
J. - The IRF has a plan of treatment for each inpatient that is established, reviewed, and
revised, as needed, by a physician in consultation with other professional personnel who
provide services to the patient.
K. - The IRF uses a coordinated interdisciplinary team approach in the rehabilitation of each
inpatient, as documented by periodic clinical entries made in the patient's medical record to
note the patient's status in relationship to goal attainment and discharge plans. The IRF must
also ensure that team conferences are held at least once per week to determine the
appropriateness of treatment.
140.1.2 - Additional Criteria That Must Be Met By Inpatient Rehabilitation
Units
(Rev. 12575; Issued:04-11-24; Effective: 07-12-24; Implementation: 07-12-24)
In addition to the requirements specified above in §140.1.1, an inpatient rehabilitation unit
shall meet the additional criteria in paragraphs A through M below in order to be excluded
from the IPPS and be paid instead under the IRF PPS.
A. - The inpatient rehabilitation unit must be a part of an institution that has in effect an
agreement to participate as a hospital that is not excluded in its entirety from the IPPS.
B. - The inpatient rehabilitation unit must have written admission criteria that are applied
uniformly to both Medicare and non-Medicare patients.
C. - The inpatient rehabilitation unit must have admission and discharge records that are
separately identified from those of the hospital in which it is located and are readily
retrievable. The record must indicate the dates of the admission and discharge for patients of
the unit. The IRF must also have a process in place to ensure that each patient’s medical
record at the IRF meets the hospital conditions of participation in 42 CFR Part 482 and all of
the documentation requirements specified in 42 CFR §412.622 (a)(3), (4), and (5). Further
guidance on the IRF documentation requirements is available in chapter 1, section 110 of the
Medicare Benefit Policy Manual (Pub. 100-02). The inpatient rehabilitation unit's policies
must provide that necessary clinical information is transferred to the unit when a patient of the
hospital is admitted to the inpatient rehabilitation unit, as described further in chapter 1,
section 110.1.1 of the Medicare Benefit Policy Manual (Pub. 100-02).
D. - If state law provides special licensing requirements for rehabilitation units, the inpatient
rehabilitation unit must be licensed in accordance with the applicable requirements.
E. - The hospital's utilization review plan must include separate standards for the type of care
offered by the inpatient rehabilitation unit.
F. - The beds assigned to the inpatient rehabilitation unit must be physically separate from
(i.e., not co-mingled with) beds not included in the unit. This means that patients from other
parts of the hospital may not be treated in the beds assigned to the inpatient rehabilitation unit.
G. - The hospital must have enough beds not excluded from the IPPS to permit the provision
of adequate cost information. The A/B MAC (A) has discretion as to how to apply generally
accepted accounting principles when making this analysis.
H. - The inpatient rehabilitation unit and the hospital in which it is located must be serviced
by the same A/B MAC (A).
I. - The inpatient rehabilitation unit must be treated as a separate cost center for cost finding
and apportionment purposes.
J. - The accounting system of the hospital in which the inpatient rehabilitation unit is located
must provide for the proper allocation of costs and maintain statistical data that are adequate
to support the basis of allocation.
Compliance with the criteria in items H, I, and J above may be determined based on the
hospital's most recently filed cost report or, if necessary, by the hospital's presentation of
evidence that shows, to the satisfaction of the A/B MAC (A), that the hospital has the
accounting capability to meet these criteria for the cost reporting period for which the
exclusion from the IPPS, if approved, applies.
K. - The cost report for the hospital must include the costs of the inpatient rehabilitation unit,
covering the same fiscal period as the hospital, and use the same method of cost
apportionment as the hospital.
L. - As of the first day of the first cost reporting period for which all other exclusion
requirements are met, the inpatient rehabilitation unit must be fully equipped, staffed, and
must be capable of providing hospital inpatient rehabilitation care regardless of whether there
are any inpatients in the unit on that date.
M. - Each hospital may have only one unit of each type (psychiatric and rehabilitation)
excluded from the IPPS.
The criteria specified in paragraphs A through M above are used to determine whether a part
of a hospital qualifies for exclusion from the IPPS. An excluded unit must be established as a
separate cost entity for cost reporting purposes.
If a hospital wishes to have an IRF unit, it must notify OPOLE and the A/B MAC in writing
of the change at least 30 days before the date of the change currently in regulation at
§ 412.25(c)(1) to allow a hospital to open a new IRF unit anytime within the cost reporting
year. OPOLE will notify the hospital if they approve of the opening or not of the following:
(1) the particular areas that it has designated as the unit, and (2) the square footage and
number of beds in the unit. The A/B MAC (A) or OPOLE will inform the IRF of the proper
procedures. The hospital’s notification of its intent to have a unit excluded from the IPPS
must be sent to the A/B MAC (A) at the same time that it is sent to OPOLE, and it must
identify the designated space for the excluded unit through the use of room numbers and/or
bed numbers. OPOLE will then determine, based on information obtained from the State
Survey Agency and the hospital’s A/B MAC (A), whether the unit qualifies for exclusion
from the IPPS. If OPOLE rejects the hospital’s request to have the unit excluded from the
IPPS, it will notify the A/B MAC (A), CMS, and the hospital. If OPOLE approves the
hospital’s request to have the unit excluded from the IPPS, it will notify the hospital, and will
also notify the A/B MAC (A) of the unit’s exclusion from the IPPS and of the new unit’s new
provider identification number.
The hospital must self-attest that it meets all of the applicable criteria for having a unit that is
excluded from the IPPS. This self-attestation is subject to verification by OPOLE, the State
Agency, and the A/B MAC (A).
After the initial classification as an IRF, changes in the amount of space occupied by the unit,
or in the number of beds in the unit, are allowed to be made one time during a cost reporting
period if the hospital notifies its Medicare contractor and OPOLE in writing of the planned
change at least 30 days before the date of the change. A change in bed size or a change in
square footage may occur at any time during a cost reporting period and must remain in effect
for the remainder of that cost reporting period.
140.1.3 - Verification Process Used To Determine If The Inpatient
Rehabilitation Facility Met The Classification Criteria
(Rev. 12575; Issued:04-11-24; Effective: 07-12-24; Implementation: 07-12-24)
A.
- Determination of the Compliance Review Time Period
This section provides an overview of the guideline to determine the compliance review
period. In general, the OPOLE, and A/B MAC (A) will use data from the most recent,
consecutive, and appropriate 12-month time period (as defined by CMS) that starts on or
after July 1, 2004, to determine if a facility is in compliance with all of the criteria used to
classify a facility as an IRF. OPOLE and A/B MAC (A) will notify the facility of the time
period that will be utilized. OPOLE and A/B MAC (A) will begin reviewing data 4 months
prior to the start of the facility’s next cost reporting period.
For Cost Reporting Periods Starting from July 1, 2004 to July 1, 2006 Only
The compliance review periods are determined based on the following:
1.
Guidelines for Determining Compliance Review Periods For IRFs With
Cost Reporting Periods That Start Between July 1, 2004 and October 31,
2004.
Data prior to July 1, 2004 will not be used to determine an IRF’s compliance with the
requirements in §140.1.1B-D. Thus, for IRFs with cost reporting periods beginning on
or after July 1, 2004 and before November 1, 2004, less than 12 months of data will be
used in their first compliance review period after July 1, 2004. Refer to the first 5 rows
of the Table of Compliance Review Periods (below) for an illustration of this.
2.
Guidelines for Determining an IRF’s Compliance Percentage When the
Required Compliance Percentage Threshold Differs Across Two Cost
Reporting Periods
When a cost reporting period starts on or after July 1, 2005, but not later than June 30,
2006, and the compliance review period spans two cost reporting periods, the
compliance percentage is calculated using either of the following two methods. The
IRF must have a patient population in each of the two portions of time in order to use
either of the two methods described below.
(A)
The IRF must meet the applicable compliance percentage threshold in each of
the two portions of the compliance review period separately, as illustrated in the
example below.
The following is an example of how this first method would be applied:
The compliance review period for an IRF that has a cost reporting period from July
1, 2005 through June 30, 2006 is March 1, 2005 to February 28, 2006.
The IRF must meet a compliance threshold of 50 percent for the cost reporting
period of July 1, 2004 to June 30, 2005.
The IRF must meet a compliance threshold of 60 percent for the cost reporting
period of July 1, 2005 to June 30, 2006.
In this example, the first portion of the compliance review period (from March 1,
2005 to June 30, 2005) is part of the IRF’s cost reporting period that started on
July 1, 2004 and ends on June 30, 2005. The second portion of the compliance
review period (from July 1, 2005 to February 28, 2006) is part of the IRF’s cost
reporting period that starts on July 1, 2005 and ends on June 30, 2006.
Therefore, for the portion of the compliance review period from March 1, 2005 to
June 30, 2005, the compliance percentage threshold that the IRF must meet is 50
percent.
For the portion of the compliance review period from July 1, 2005 to February 28,
2006, the compliance percentage threshold that the IRF must meet is 60 percent.
If the IRF does not meet the compliance percentage threshold of 50 percent for the
March 1, 2005 to June 30, 2005 portion of the compliance review time period, or
the compliance percentage threshold of 60 percent for the July 1, 2005 to February
28, 2006 portion of the compliance review time period, it will be determined that
the IRF failed to meet the compliance percentage threshold for the entire
compliance review period consisting of March 1, 2005 to February 28, 2006.
(B)
The A/B MAC (A) computes one weighted average compliance percentage for
the entire 12-month compliance review period. The resulting weighted average
compliance percentage will be used to determine if the facility met the compliance
threshold requirements in §140.1.1B-D.
The following is an example of how this second method would be applied: The
compliance review period for an IRF that has a cost reporting period from
August 1, 2005 to July 31, 2006 is April 1, 2005 to March 31, 2006. However, the
compliance review period is divided into two portions: April 1, 2005 to July 31,
2005 and August 1, 2005 to March 31, 2006.
In the following hypothetical example, 45 percent of the cases met at least one of
the medical conditions listed above in §140.1.1C from April 1, 2005 to July 31,
2005, and 80 percent of the cases met at least one of the medical conditions listed in
§140.1.1C from August 1, 2005 to March 31, 2006. The weighted average
compliance percentage from the two portions of time must be calculated as follows
for compliance review periods beginning on or after January 1, 2013.
4/12 = 0.333 which is rounded to 0.33
8/12 = 0.666 which is rounded to 0.67
0.33 X 45% = 0.1485
0.67 X 80% = 0.5360
0.1485 + 0.5360 = 0.6845 which is rounded to 68%
Based on this result of 68 percent from the weighted average calculation, it will be
determined that the IRF met the compliance percentage threshold for the
compliance review period starting on April 1, 2005.
The table below entitled “Examples of Compliance Review Periods” provides
examples of compliance review periods associated with various cost reporting
periods.
Examples of Compliance Review Periods. For a facility that has been classified as
an IRF, but is not a “new” IRF as defined below in 140.1.4, the following table
provides examples of the compliance review periods associated with different cost
reporting periods.
Examples of Compliance Review Periods
Start Date of the Cost
Reporting Period for
Which a Facility Will
(or Will Not) be
Classified (or Retain
Classification) as an
IRF
Compliance
Review
Period:
(Admissions
or Discharges
During)
# of
Months
in
Review
Period
Compliance Percentage
Threshold
07/01/2005
07/01/2004 -
02/28/2005
8
50%
08/01/2005
07/01/2004 -
03/31/2005
9
50%
09/01/2005
07/01/2004 -
04/30/2005
10
50%
10/01/2005
07/01/2004 -
05/31/2005
11
50%
11/01/2005
07/01/2004 -
06/30/2005
12
50%
07/01/2006
03/01/2005 -
02/28/2006
12
03/01/2005 to 06/30/2005: 50 %
07/01/2005 to 02/28/2006: 60 %
08/01/2006
04/01/2005-
03/31/2006
12
04/01/2005 to 07/31/2005: 50 %
08/01/2005 to 03/31/2006: 60 %
09/01/2006
05/01/2005-
04/30/2006
12
05/01/2005 to 08/31/2005: 50 %
09/01/2005 to 04/30/2006: 60 %
10/01/2006
06/01/2005-
05/31/2006
12
06/01/2005 to 09/30/2005: 50 %
10/01/2005 to 05/31/2006: 60 %
11/01/2006
07/01/2005-
06/30/2006
12
07/01/2005 to 10/31/2005: 50 %
11/01/2005 to 06/30/2006: 60 %
12/01/2006
08/01/2005-
07/31/2006
12
08/01/2005 to 11/30/2005: 50%
12/01/2005 to 07/31/2006: 60%
For Cost Reporting Periods Starting After July 1, 2006
The compliance review periods are determined based on the following:
1. Guidelines for Determining an IRF’s Compliance Percentage When the Required
Compliance Percentage Threshold Is the Same for the Entire Compliance Review
Period
To minimize the level of effort required by Medicare contractors and IRFs, contractors
must review one continuous 12-month period if the compliance percentage threshold is
the same throughout the entire compliance review period for all compliance review
periods beginning on or after January 1, 2013.
2. Guidelines for Determining the Compliance Review Period of a Facility Classified
as a New IRF. According to the regulations in §412.25(c), a new IRF can only
begin being paid under the IRF PPS at the start of a cost reporting period. If the IRF
begins treating patients prior to the start of a cost reporting period, it may receive
payment under the IPPS until the start of the next cost reporting period, at which
point it can begin receiving payment under the IRF PPS if it meets all of the
applicable requirements in §412.25 and §412.29. A new IRF will have a compliance
review period that starts immediately when its cost reporting period starts, and ends
four months before the start of its next cost reporting period. For example, if a
facility has a cost reporting period that starts on July 1, 2022 and is a new IRF, its
compliance review period would start on July 1, 2022 and end on February 28,
2023. Thus, a facility classified as a new IRF will have an initial compliance review
period that is 8 months in length, in order to allow OPOLE and A/B MAC (A) a 4-
month time period to make and administer a compliance determination.
3. Guidelines for Determining an IRF’s Compliance When the IRF Expands its Bed
Capacity. Effective October 1, 2011, as long as an IRF meets all of the applicable
requirements in §412.25(b) and 412.29(c)(2), it may add new beds one time, at any
time, during a cost reporting period. The IRF must provide written certification that
the inpatient population it intends to serve (including the patients served in the new
beds) meets the requirements in §412.29(b). In addition, the new IRF beds will be
included in the compliance review calculations under§412.29(b) from the time that
they are added to the IRF.
4. Guidelines for Determining the Compliance Review Period of a Facility That
Changes Its Cost Reporting Period. A facility that changes its cost reporting period
will have a new compliance review period that is based on its new cost reporting
period. For example, if an IRF changes the start of its cost reporting period from
July 1, 2011 to October 1, 2011, then the start date of its compliance review period
will also change from March 1,2011 to June 1, 2011. Excessive changes to cost
reporting periods are not permitted.
NOTE:
For cost reporting periods beginning on or after July 1, 2006, the compliance threshold
that must be met is 60 percent as discussed in the FY 2009 IRF PPS proposed rule (73
FR 22674, 22687 through 22688) and finalized in the FY 2009 IRF PPS Final Rule ( 73
46388). Thus, for all compliance review periods beginning on or after January 1, 2013
(except in the case of new IRFs, as described in section 140.3.4 above), the compliance
review period will be one continuous 12-month time period beginning 4 months before the
start of a cost reporting period and ending 4 months before the beginning of the next cost
reporting period.
Patient comorbidities that satisfy the criteria specified in 42 CFR 412.23(b)(2)(i) shall be
included in the calculations used to determine whether an IRF meets the 60 percent
compliance percentage for cost reporting periods beginning on or after July 1, 2007.
B.
- Types of Data Used to Determine Compliance with the Classification
Criteria
1.
Starting on July 1, 2004, the A/B MAC (A) will use the verification procedures
specified below in subsection C which is entitled “Verification of the Medical Condition
Criterion Using the Inpatient Rehabilitation Facility-Patient Assessment Instrument
(IRF-PAI) Data Records” or subsection D which is entitled “Verification of the Medical
Condition Criterion Using the Inpatient Rehabilitation Facility’s Total Inpatient
Population” to verify that an IRF has complied with the requirements specified above in
§140.1.1B-D.
2.
The verification procedure specified below in subsection C (that is, verification using
the IRF-PAI data) will only be used if the A/B MAC (A) has verified that the IRF’s
Medicare Part A fee-for-service inpatient population is at least 50 percent of the IRF’s
total inpatient population. Effective for compliance review periods beginning on or
after October 1, 2009, A/B MACs (A) must include the IRF’s Medicare Part C
(Medicare Advantage) inpatient population, along with the IRF’s Medicare Part A fee-
for-service inpatient population, in determining whether at least 50 percent of the IRF’s
total inpatient population is made up of Medicare patients.
3.
General Guideline Regarding Submission of a List of the Inpatients in Each IRF: In
order to verify that an IRF’s Medicare Part A fee-for-service and Medicare Part C
(Medicare Advantage) inpatient populations (combined) reflect the IRF’s total inpatient
population, the A/B MAC (A) in writing will instruct the IRF to send the A/B MAC (A),
by a specific date, a list showing the hospital patient number of each inpatient IRF
admission during the IRF’s 12-month compliance review period. Note that the term
“hospital patient number” used throughout this section refers to a unique patient
identifier used internally within the hospital for patient identification and record-
keeping purposes. For each inpatient on the list, the IRF must include the payer the IRF
can bill, or has billed, for treatment and services furnished to the inpatient. If an
inpatient on the list has multiple payers that the IRF can bill, or has billed, the IRF must
include and specify each type of payer. In addition, for each inpatient on the list, the
IRF must include the IRF admission and discharge dates.
Exception to the General Guideline: The Secretary of Health and Human Services can
declare a Public Health Emergency under section 319 of the Public Health Service Act
or another appropriate statute, and the President can declare either a National
Emergency under the National Emergencies Act or a Major Disaster under the RobertT.
Stafford Disaster Relief and Emergency Assistance Act, or other appropriate law. In
accordance with such declarations, certain regulations or operational policies may be
waived in specific geographic areas for limited and defined periods of time. If
applicable, in accordance with the waiver provisions, the IRF may be permitted to admit
patients (referred to in this section as national emergency or disaster inpatients) who
otherwise would be admitted to another inpatient setting. The national emergency or
disaster inpatients will not be included as part of the IRF’s total inpatient population
when the IRF’s compliance with the requirements specified in§140.1.1B-D is
determined by the A/B MAC (A) reading a sample of medical records. Therefore, when
the IRF submits the list of hospital patient numbers stipulated above in section
140.1.3B3, the IRF will identify each national emergency or disaster inpatient by
placing either the capital letter “E” or “D” after the patient’s unique internal hospital
identification number. The A/B MAC (A) will verify the information and, if appropriate,
exclude these patients from the list of inpatients used to select a sample of medical
records. The IRF should appropriately document in the medical record sufficient
information to identify an inpatient as a national emergency or disaster inpatient.
4.
The A/B MAC (A) will use the list of hospital patient numbers to determine the IRF’s
total inpatient population during the IRF’s compliance review period. In addition to
the above processes, the A/B MAC (A) has the discretion to sample and compare other
parameters (that is, diagnoses, procedures, length-of-stay, or any other relevant
parameter) to determine that the Medicare Part A fee-for-service and Medicare Part
C (Medicare Advantage) population (beginning on or after October 1, 2009) is
representative of the IRF’s total inpatient population.
A determination by the A/B MAC (A), in accordance with the preceding
methodologies, that the IRF’s inpatient population for the compliance review period
consisted of at least 50 percent Medicare Part A fee-for-service and Medicare Part C
(Medicare Advantage) patients (beginning on or after October 1, 2009) means that the
A/B MAC (A) can use the procedure stipulated below in subsection C to presumptively
determine if the IRF met the compliance threshold as specified above in §140.1.1B-D.
5.
The A/B MAC (A) will inform OPOLE if an IRF fails to send the list showing the
hospital patient number associated with each inpatient IRF admission during the most
recent, consecutive, and appropriate 12-month period, as defined by CMS. Further, the
A/B MAC (A) will inform OPOLE if the list of hospital patient numbers does not show
the payer or payers or the admission and discharge dates for each hospital patient
number on the list. OPOLE will notify the IRF that failure to send the A/B MAC (A)
the list within an additional 10 calendar days will result in a determination by OPOLE
that the IRF has not met the requirements specified above in §140.1.1B-D and the
facility will no longer be eligible for payment under the IRF PPS.
C.
- Verification of the Medical Condition Criteria Using the
Inpatient Rehabilitation Facility-Patient Assessment Instrument
(IRF-PAI) Data Records (The Presumptive Methodology)
1.
To determine if a facility has presumptively complied with the criteria specified
above in §140.1.1B-D, the CMS will enable the A/B MAC (A) to access the CMS' IRF-
PAI data records. Specifically, each A/B MAC (A) will be allowed to access only the
IRF-PAI information submitted by IRFs that submit claims to that A/B MAC (A).
In order to ensure that the software that matches each IRF to a particular A/B MAC (A)
is constantly updated, the A/B MAC (A) must electronically send OPOLE a table that
has at least the following title and column headings:
A/B MAC (A) List Of IRF Provider Numbers (Specify The A/B MAC (A)’s Name)
The Name of
Each IRF
That Submits
Claims To
This A/B
MAC (A)
IRF Provider
Number
IRF Cost
Reporting
Period
After checking the A/B MAC (A)’s list of IRFs for completeness and, as necessary,
communicating with the A/B MAC (A) to ensure the accuracy of the information,
OPOLE will forward the A/B MAC (A)’s list of IRFs to the CMS designated mailbox
[email protected]. The CMS contractor that maintains the IRF-
PAI database will then, if necessary, update the IRF-PAI database software used to
presumptively verify compliance with the requirements specified in §140.1.1B-D. The
A/B MAC (A) must coordinate with their CMS OPOLE to obtain access to the software
system.
The A/B MAC (A) will provide OPOLE with user information from all A/B MAC (A)
staff that are required to access the IRF-PAI data records.
When the A/B MAC (A) accesses the IRF-PAI data records, the A/B MAC (A) will be
able to generate an IRF compliance review report using the IRF-PAI information from
the IRFs on the A/B MAC (A)’s list. The Internet Quality Improvement and
Evaluation System (iQIES) system software used to generate the IRF compliance
review report will automatically use the specific diagnosis codes from the appropriate
files listed in “Presumptive Compliance” relative to the appropriate fiscal year
regulation which are available for download from the IRF PPS website at :
https://www.cms.gov/medicare/payment/prospective-payment-systems/inpatient-
rehabilitation/rules-related-files to determine if a particular IRF is presumptively in
compliance with the requirements specified in §140.1.1B-D. Prior to generating the IRF
compliance review report, the A/B MAC (A) must allow the IRF to decide whether the
IRF compliance review report will be generated using the IRF- PAI data records of
patients who were admitted during the IRF’s compliance review period (even if they
were discharged outside of the compliance review period), or the IRF-PAI data records
of patients who were discharged during the IRF’s compliance review period (even if
they were admitted outside of the compliance review period).
Below are the sections of the IRF compliance review report with example data
required for submission:
IRF Compliance Review Report
State
Provider
Number
Provider
Name
Cost Report
Start Date
Compliance Review
Period
Any
State
IRF
Number
Best
Rehab
08/01/2023
04/01/2022 To
03/31/2023
Submitted Assessments
Eligible Assessments
Percent
100
60
60%
The submitted assessments section identifies all the IRF-PAI data records that the IRF submitted
to the IRF-PAI database during the compliance review period. The eligible assessments are the
assessments submitted during the compliance review period that match one of the codes in the
associated files described as “Presumptive Compliance” relative to the appropriate fiscal year
regulation, which can be downloaded from the IRF PPS website at
https://www.cms.gov/medicare/payment/prospective-payment-systems/inpatient
rehabilitation/rules-related-files. The cost report start date shown is the start of the facility’s
next cost reporting period.
2.
If an IRF’s inpatient Medicare Part A fee-for-service and Medicare Part C (Medicare
Advantage) populations (combined) (beginning on or after October 1, 2009) are at least 50 percent
of its total inpatient population and the presumptive methodology (described above) indicates that
the IRF met or exceeded the requirements specified in §140.1.1B-D, then the IRF is presumed to
have met the requirements specified above in §140.1.1B-D. However, even when an IRF is
presumed to have met the requirements specified above in §140.1.1B-D, OPOLE and A/B MAC
(A) still have the discretion to instruct the IRF to send to OPOLE or A/B MAC (A) specific
sections of the medical records of a random sample of inpatients, or specific sections of the
medical records of inpatients identified by other means by the CMS or the A/B MAC (A).
3.
Each A/B MAC (A) must submit a report to the appropriate CMS OPOLE (with a copy to the
CMS Central Office) on at least a quarterly basis that shows each IRF’s status with respect to
compliance with the requirements specified above in §140.1.1B-D.
The associated files described as “Presumptive Compliance” relative to the appropriate fiscal
year regulation, which can be downloaded from the IRF PPS website at
https://www.cms.gov/medicare/payment/prospective-payment-systems/inpatient-
rehabilitation/rules-related-files will be used to determine presumptive compliance with the
requirements specified above in §140.1.1B-D.
The files listed in “Presumptive Methodology Files – Implementation of Changes” that is attached
to the IRF Compliance Rule Specification Files, which can be downloaded from the IRF PPS
website at http://www.cms.gov/Medicare/Medicare-Fee-for- Service-
Payment/InpatientRehabFacPPS/Criteria.html, will be used to determine presumptive compliance
with the requirements specified above in §140.1.1B-D.
D.
– Additional Verification of Arthritis Condition Criteria
Compliance with the regulatory requirements for the arthritis conditions specified above in§140.1.1 B-
D cannot be determined by the presence of an impairment group code or diagnosis code alone, but can
only be verified through review of the IRF medical record. For this reason, we removed arthritis
impairment group codes and diagnosis codes from the list of codes used to determine presumptive
compliance for compliance review periods beginning on or after October 1, 2015
However, beginning on or after October 1, 2015, we also provided for an additional item on the IRF-
PAI (item #24A) to enable IRFs to indicate whether the patient’s arthritis condition(s) meets all of the
relevant regulatory requirements specified in §140.1.1 B-D. Using the process described below, the
A/B MAC (A) must verify through medical review whether the IRF cases that would not otherwise
meet the compliance criteria, and that have a “1 – Yes” marked in item #24A, meet the severity and
prior treatment requirements in §140.1.1B-D. If so, then the A/B MAC (A) must add the appropriate
number of these cases to the cases that meet the presumptive compliance criteria.
The A/B MAC (A) shall use the following process for compliance review periods beginning on or after
October 1, 2015:
1.
If the A/B MAC (A) has determined, using the process outlined in subsection C above, that the
IRF does not presumptively meet the requirements specified above in §140.1.1B-D, then the A/B
MAC (A) must access an IRF-PAI data report called the IRF Arthritis Verification Report through the
iQIES system .
Below are the sections of the IRF Arthritis Verification Report with example data:
IRF Arthritis Verification Report
Provider
Number
Provider
Name
Patient
Name
Patient ID
IRF-PAI ID
Admission
Date
Discharge
Date
Best
Rehab
A.
Smith
B.
Jones
Z. Honey
12345678A
22345678A
32345678A
987654321
987654322
987654323
10/1/22
10/2/22
10/3/22
10/15/22
10/14/22
10/13/22
2.
The A/B MAC (A) must determine whether or not adding all of the cases listed on the IRF
Arthritis Verification Report for that IRF would be enough to increase the IRF’s compliance
percentage to equal or exceed 60 percent.
3.
If adding all of the cases listed on the IRF Arthritis Verification Report for that IRF would be
enough to increase the IRF’s compliance percentage to equal or exceed 60 percent, then the
A/B MAC (A) must use generally accepted statistical sampling techniques to obtain a
statistically valid random sample of those patients listed for the IRF on the IRF Arthritis
Verification Report. If the total number of patients listed for the IRF on the IRF Arthritis
Verification Report is less than 10, then the A/B MAC (A) will review all patients listed for
the IRF on the IRF Arthritis Verification Report. (Note that if adding all the cases listed in the
IRF Arthritis Verification Report for that IRF would not be enough to increase the IRF’s
compliance percentage to equal or exceed 60 percent, then the A/B MAC
(A)
will not proceed further with the IRF arthritis verification process and will use the
presumptive compliance percentage generated from section C above.)
4.
The A/B MAC (A) will obtain and examine the medical record sections and any other
pertinent information submitted by the IRF to determine if the patients from the random
sample obtained in step 2 meet all of the severity and prior treatment requirements specified
in §140.1.1B-D.
5.
The percentage of patients from the list that the A/B MAC (A) determines to have met the
severity and prior treatment requirements specified in §140.1.1B-D will be extrapolated to the
complete list of patients for the IRF on the IRF Arthritis Verification Report.
6.
The A/B MAC (A) shall then add the appropriate number of cases (based on the percentage
in step 4) from the IRF Arthritis Verification Report to the cases that meet the presumptive
compliance criteria, and re-calculate the IRF’s presumptive compliance percentage.
For example:
• IRF A submitted 545 IRF-PAIs in the compliance review period.
• IRF A’s presumptive compliance percentage (determined by the A/B MAC
(A)
using the steps outlined in subsection C above) was less than 60 percent.
• In this case, the A/B MAC (A) must access the IRF Arthritis Verification Report.
• The IRF Arthritis Verification Report shows 100 patients listed for IRF A.
• The A/B MAC (A) determines that inclusion of all 100 patients listed for IRF A would
increase IRF A’s presumptive compliance percentage enough to meet or exceed the 60
percent threshold.
• The A/B MAC (A) uses generally accepted statistical sampling techniques to
randomly select 10 patients from that list for medical review, and based on the
medical review determines that 7 of the 10 patients meet all of the requirements
specified in §140.1.1B-D.
• The A/B MAC (A) will then extrapolate this percentage (7/10 = 70 percent) to the full list
of patients shown on the IRF Eligibility Arthritis Verification Report for IRF A. Thus,
the A/B MAC (A) will add 70 patients (70 percent of 100) listed for IRF A on the IRF
Arthritis Verification Report to the total number of IRF A’s patients that meet the
presumptive compliance criteria.
• The A/B MAC (A) will then recalculate IRF A’s presumptive compliance percentage
with the addition of the 70 cases.
• The A/B MAC (A) will base the determination of the IRF’s presumptive compliance
with the requirements specified in §140.1.1B-D on the updated calculation of the IRF’s
presumptive compliance percentage.
• The A/B/ MAC (A) will report this updated presumptive compliance percentage,
instead of the presumptive compliance percentage from subsection C above, on the
quarterly report that the A/B MAC (A) sends to the appropriate CMS OPOLE (with a
copy to the CMS Central Office).
NOTE: Even when an IRF is presumed to have met the requirements specified above in§140.1.1B-D
using the updated presumptive methodology calculation, OPOLE and A/BMAC (A) still have the
discretion to use the medical review methodology described in subsection E below to verify the IRF’s
compliance with the requirements in §140.1.1B-D.
E.
- Verification of the Medical Condition Criteria Using the Inpatient
Rehabilitation Facility’s Total Inpatient Population (Medical Review
Methodology)
1.
The A/B MAC (A) must use the IRF’s total inpatient population to verify that the IRF has
met the requirements specified above in §140.1.1B-D if:
(i)
the IRF’s Medicare population (including Medicare Part A fee-for-service and Medicare
Part C (Medicare Advantage) patients, effective October 1, 2009) is not at least 50 percent of
its total inpatient population; or
(ii)
the A/B MAC (A) is unable to generate a valid IRF compliance review report
using the IRF-PAI database methodology specified previously; or
(iii)
the A/B MAC (A) generates an IRF compliance review report, based on the use of the
presumptive methodology, which demonstrates that the IRF has not met the requirements
specified above in §140.1.1B-D.
If the IRF’s Medicare Part A fee-for-service and Medicare Part C (Medicare Advantage)
populations (combined, effective October 1, 2009) comprise less than 50 percent of the IRF’s
total inpatient population, or the A/B MAC (A) otherwise determines that the Medicare Part A
fee-for-service and Medicare Part C (Medicare Advantage) populations (combined, effective
October 1, 2009) are not representative of the overall IRF inpatient population, or the A/B MAC
(A) is unable to generate a valid report using the presumptive methodology, the presumptive
determination is that the IRF did not meet the requirements specified above in §140.1.1B-D.
2.
As previously stated above, the A/B MAC (A) will instruct the IRF to send the A/B MAC (A)
a list showing the hospital patient number of each inpatient that the IRF admitted during the most
recent, consecutive, and appropriate 12-month period, as defined by CMS. The list of hospital
patient numbers must include the payer(s) and admission and discharge dates that correspond
with the inpatients whose hospital patient numbers are shown on the list. The A/B MAC (A) will
then use generally accepted statistical sampling techniques to obtain a random sample of
inpatients from the list. The random sample of inpatients drawn from the list must be sufficiently
large to ensure that the A/B MAC (A) can determine, with at least 95 percent confidence,
whether the IRF’s compliance percentage is below the required compliance threshold (i.e., not in
compliance) or at or above the required compliance threshold (i.e., in compliance).
For example, suppose that the required compliance threshold for an IRF to be in compliance
with the requirements specified above in §140.1.1B-D is 60 percent. The A/B MAC (A) reviews
a random sample of claims from IRF A and estimates that IRF A’s compliance percentage is 58
percent. Suppose that the standard deviation that the A/B MAC (A) calculates for IRF A’s
random sample of IRF claims is plus or minus 4 percentage points, so that the 95 percent
confidence interval in this particular example is between 54 percent and 62 percent (with 58
percent as the midpoint). In this case, the IRF is considered to be in compliance with the 60
percent rule, since 60 percent is within the 95 percent confidence interval. To verify whether the
IRF is in fact in compliance with the requirements specified above in §140.1.1B-D, the A/B
MAC (A) may need to draw a larger random sample of the IRF’s inpatients. For example, a
larger random sample of IRF A’s inpatients might have reduced the standard deviation to plus or
minus 1 percentage point, which would have led the 95 percent confidence interval to be
between 57 percent and 59 percent. This would have demonstrated with 95 percent confidence
that the IRF was not in compliance with the requirements specified above in §140.1.1B-D
(because the entire 95 percent confidence interval was below the required compliance threshold
of 60 percent).
If the compliance percentage threshold differs within the compliance review period (i.e., is 50
percent for a portion of the compliance review period and 60 percent for the other portion of the
period), then a random sample of inpatients will be drawn from each of the two time periods
separately.
The use of generally recognized statistical sampling principles may result in a determination that
it would be inappropriate to use a sample to determine the facility’s compliance percentage. If a
random sample is not appropriate in a particular case, then the A/B MAC (A) will use the IRF’s
entire inpatient population to determine the IRF’s compliance percentage. In addition, if the IRF
had 100 or fewer inpatients during the compliance review period, then the A/B MAC (A) must
use the IRF’s total inpatient population (consisting of both Medicare and non- Medicare
inpatients) to determine the IRF’s compliance percentage.
Prior to selecting the random sample of inpatients, the A/B MAC (A) must allow the IRF to
decide if the IRF wants the sample to contain either the patients who were admitted during the
IRF’s compliance review period (even if some of those patients were discharged outside of the
compliance review period) or the patients discharged during the IRF’s compliance review
period (even if some of those patients were admitted outside of the compliance review period).
If the A/B MAC (A) uses a random sample of the IRF’s inpatient population (rather than the
IRF’s total inpatient population) to determine the IRF’s compliance percentage, then the A/B
MAC (A) must ensure that an adequate sample size is used to determine (with at least a 95 percent
statistical level of confidence) whether or not the IRF has met the requirements in §140.1.1B-D. In
some cases, this will require the A/B MAC (A) to expand the size of the random sample of
inpatients selected from a particular IRF.
The A/B MAC (A) will instruct the IRF to send it copies of specific sections of the medical records
for all of the inpatients to be used in the compliance review. The A/B MAC (A) has the discretion
to decide which specific sections of the medical records to obtain, provided that the requested
medical record sections contain enough information to allow the A/B MAC (A)’s reviewers to
determine the medical condition(s) for which each inpatient received treatment in the IRF. In
addition to submitting the requested sections of the medical records, the IRF has the discretion to
send the A/B MAC (A) other clinical information regarding these same inpatients.
3.
The A/B MAC (A) will examine the medical record sections and any other information
submitted by the IRF to determine if the IRF meets the requirements specified above in
§140.1.1B-D. To determine if a specific inpatient matches one of the medical conditions
specified in §140.1.1C, the A/B MAC (A) may use the diagnosis and impairment group codes
specified in the appropriate files listed in “Presumptive Methodology Files – Implementation of
Changes” that is attached to the IRF Compliance Rule Specification Files, which can be
downloaded from the IRF PPS website at https://www.cms.gov/medicare/payment/prospective-
payment-systems/inpatient-rehabilitation/rules-related-files for general guidance. The A/B
MAC (A) is not permitted to use these codes to make a final determination as to whether or not
the specific inpatient required intensive rehabilitation services for treatment of one or more of
the medical conditions specified in §140.1.1C. The determination of whether a specific
inpatient required intensive rehabilitation services for treatment of a condition can only be
determined through careful review of that inpatient’s unique clinical characteristics and
circumstances, as reflected in the inpatient’s medical record.
4.
In general, when the A/B MAC (A) is using a sample of medical records to determine
compliance with the requirements in §140.1.1B-D, the A/B MAC (A) always has the discretion to
determine if a patient meets or does not meet any of the medical conditions listed in §140.1.1C
based upon a review of the clinical record, regardless of the results of the presumptive
methodology described previously. In other words, the compliance percentage that is determined
using the medical review methodology described in this section will supersede the compliance
percentage that was determined for the same compliance review period using the presumptive
methodology. To ensure that the compliance review process is similar for all IRFs, the A/B MAC
(A) must have written policies that describe the reasons for using a random sample of medical
records to determine an IRF’s compliance percentage when the presumptive methodology has
shown that the IRF met the compliance threshold.
5.
The A/B MAC (A) will inform OPOLE if an IRF fails to provide information in accordance
with the requirements specified above in subsection D2. OPOLE will notify the IRF that failure
to provide the A/B MAC (A) with the information in accordance with the requirements
specified above in subsection D2 will result in a determination by OPOLE that the IRF has not
met the requirements specified above in §140.1.1B-D.
F.
– Submission of Compliance Data Requirements
By the 15th day of each month, the A/B MAC (A) responsible for determining the
compliance percentage for each IRF using either of the methods specified above in
§§140.1.3C or 140.1.3D shall submit a report to CMS via e- mail to
[email protected]. Instructions regarding the format of the report, how to
complete the report, and where to send it are specified on the IRF PPS website at:
https://www.cms.gov/medicare/payment/prospective-payment-systems/inpatient-
rehabilitation/rules-related-files.
The submitted report should indicate the IRF data for the specific month and year, as well as the MAC
name. The data elements for the report must include the following:
• MAC Number,
• Name of Provider,
• City,
• State,
• Zip Code,
• Provider Number,
• Cost Report Begin Date (mm/dd/y
• Review Period From and To Dates (mm/dd/yyy),
• Percent of the Medicare Population,
• Percent of Compliance using the Presumptive Method (if the presumptive method is used),
• Percent of Compliance using Medical Review Sample (if the medical review method is used
following a failed presumptive method or at the discretion of the MAC), and
• Comments (indicating any additional relevant information).
The following demonstrates how a typical report should look. All data provided in the example report
below are fictitious.
IRF Data for the month and year of: May 2022
MAC Name: BCBS of Healthy OH
MAC
Number
Name of
Provider
City
State
Zip
Provider
Number
01234
Acme
Rehabilitation
Unit
Healthy
OH
12345
04T123
01234
Zenith
Rehabilitation
Unit
Healthy
OH
12345
04T321
Cost Report
Begin Date
(mm/dd/yyyy)
Review
Period From
and To
Dates
(mm/dd/yyyy
-
mm/dd/yyyy)
Percent of
the
Medicare
Population
Percent of
Compliance
using the
Presumptive
Method
Percent of
Compliance
using
Medical
Review
Sample
Comments
07/01/2022
01/01/2021 –
02/29/2022
50.00%
60.00%
10/01/2022
06/01/2021 –
05/31/2022
20.00%
NA
65.00%
1. The A/B MAC (A) must verify that the requirements specified above in
§140.1.1B-E and §140.1.2 G-K were met.
2. The State Agency will determine whether the criteria specified above in
§140.1.1F-K and §140.1.2 Q were met.
140.1.4 - New IRFs
(Rev. 2673, Issued: 03-14-13, Effective: 04-22-13, Implementation: 04-22-13)
An IRF hospital or IRF unit is considered new if it has not been paid under the IRF PPS
for at least 5 calendar years. A new IRF will be considered new from the point that it first
participates in Medicare as an IRF until the end of its first full 12-month cost reporting
period.
A new IRF must provide written certification that the inpatient population it intends to
serve will meet the requirements in §140.1.1B-D above. The written certification is
effective for the first full 12-month cost reporting period that occurs after the IRF begins
being paid under the IRF PPS, and for any cost reporting period of not less than 1 month
and not more than 11 months occurring between the date the IRF begins being paid under
the IRF PPS and the start of the IRF’s first full 12-month cost reporting period.
As described in section 140.1.9 below, retroactive adjustments may be made for any
period during which the hospital has self-attested to meeting the requirements specified in
§140.1.1B-D, but is shown not to have actually met these requirements during that period.
140.1.5 - Changes in the Status of an IRF Unit
(Rev. 12575; Issued:04-11-24; Effective: 07-12-24; Implementation: 07-12-24)
For purposes of payment under the IRF PPS, the status of an IRF unit may be
changed from not excluded from the IPPS to excluded from the IPPS at any time
within a cost reporting period as noted in 42 CFR §412.29. The hospital must notify
the A/B MAC (A) and OPOLE in writing of the change at least 30 days before the
date of the change. In addition, the hospital must maintain the information needed to
accurately determine which costs are and are not attributable to the IRF unit. A
change in the status of a unit from excluded to not excluded that is made during a
cost reporting period must remain in effect for the remainder of that cost reporting
period.
140.1.6 - New IRF Beds
(Rev. 2673, Issued: 03-14-13, Effective: 04-22-13, Implementation: 04-22-13)
Any IRF beds that are added to an existing IRF must meet all applicable State Certificate
of Need and State licensure laws. New IRF beds may be added one time at any time
during a cost reporting period and will be considered new for the rest of that cost reporting
period. A full 12-month cost reporting period must elapse between the delicensing or
decertification of IRF beds in an IRF hospital or IRF unit and the addition of new IRF
beds to that IRF hospital or IRF unit. Before an IRF can add new beds, it must receive
written approval from the appropriate CMS RO, so that the CMS RO can verify that a full
12-month cost reporting period has elapsed since the IRF has had beds delicensed or
decertified.
New IRF beds are included in the compliance review calculations for determining
compliance with §140.1.1B-D above from the time that they are added to the IRF.
140.1.7 - Change of Ownership or Leasing
(Rev. 2673, Issued: 03-14-13, Effective: 04-22-13, Implementation: 04-22-13)
If an IRF hospital (or a hospital that has an IRF unit) undergoes a change of ownership or
leasing, as defined in 42 CFR §489.18, the IRF hospital (or IRF unit of a hospital) retains
its excluded status and will continue to be paid under the IRF PPS before and after the
change of ownership or leasing if the new owner(s) of the IRF hospital (or the hospital
with an IRF unit) accept assignment of the previous owners’ Medicare provider agreement
and the IRF continues to meet all of the requirements for payment under the IRF PPS.
Note that an IRF’s payment status under the IRF PPS is a Medicare classification status,
which cannot be separated from its host hospital and therefore cannot be purchased
outside of the purchase of its host hospital.
If the new owner(s) do not accept assignment of the previous owners’ Medicare provider
agreement, the IRF is considered to be voluntarily terminated and the new owner(s) may
re-apply to the Medicare program to operate a new IRF, under the requirements for new
IRFs in §140.1.4 above.
If, after the change of ownership or leasing, the IRF does not continue to meet all of the
requirements for payment under the IRF PPS, then the IRF loses its excluded status and
will be paid instead under the IPPS.
140.1.8 - Mergers
(Rev. 2673, Issued: 03-14-13, Effective: 04-22-13, Implementation: 04-22-13)
If an IRF hospital (or a hospital with an IRF unit) merges with another hospital and the
owner(s) of the merged hospital accept assignment of the IRF hospital’s provider
agreement (or the provider agreement of the hospital with the IRF unit), then the IRF
hospital or IRF unit retains its excluded status and will continue to be paid under the IRF
PPS before and after the merger, as long as the IRF hospital or IRF unit continues to meet
all of the requirements for payment under the IRF PPS. Note that an IRF’s payment status
under the IRF PPS is a Medicare classification status, which cannot be separated from its
host hospital and therefore cannot be merged with another entity outside of the merger
with its host hospital.
If the owner(s) of the merged hospital do not accept assignment of the IRF hospital’s
provider agreement (or the provider agreement of the hospital with the IRF unit), then the
IRF hospital or IRF unit is considered voluntarily terminated and the owner(s) of the
merged hospital may re-apply to the Medicare program to operate a new IRF under the
requirements for new IRFs in §140.1.4 above.
140.1.9 - Retroactive Adjustments for Provisionally Excluded IRFs or
IRF Beds
(Rev. 2673, Issued: 03-14-13, Effective: 04-22-13, Implementation: 04-22-13)
For cost reporting periods beginning on or after October 1, 1991, if a new IRF (or new
beds that are added to an existing IRF) are paid under the IRF PPS for an initial cost
reporting period during which the hospital has self-attested to meeting the requirements
specified above in §140.1.1B-D, but the inpatient population actually treated in the new
unit or the beds added to the existing unit during that cost reporting period do not meet the
requirements specified above in §140.1.1B-D, CMS adjusts payments to the hospital
retroactively in accordance with the procedure specified below.
A. - If an IRF hospital, IRF unit, or group of new IRF beds is paid under the IRF PPS for a
cost reporting period based on a written certification that it will meet the requirements
specified above in §140.1.1B-D, but does not actually meet the requirement for that cost
reporting period, CMS adjusts Medicare payments to the hospital retroactively in
accordance with paragraph C below.
B. - In the case of a unit to which new beds have been added, the requirement in
§140.1.1B-D above is applied to the entire unit, including both new and existing beds. If
the entire unit is able to meet the requirement, the previously existing unit and the added
beds are presumed to meet the requirement separately and no payment adjustment as
specified below in paragraph C is made. If the unit as a whole does not meet the
requirement specified above in §140.1.1B-D, the hospital must furnish the A/B MAC (A)
or the State Agency, as specified by the RO, the information needed to determine whether
the requirement specified in §140.1.1B-D above was met by the established portion of the
unit (that is, the previously existing unit) and by the newly added beds, considered
separately. If the hospital is not able to demonstrate that the established portion of the unit
met the requirement, then that portion of the facility will not be classified as an IRF for the
following cost reporting period. Retroactive adjustments may apply.
If the added beds are shown to have met the requirement specified above in §140.1.1B-D,
then those beds are eligible to be included as part of the unit’s classification as an IRF for
the following cost reporting period. If the added beds did not meet the requirement, the
A/B MAC (A) adjusts its payment to the unit retroactively in accordance with paragraph C
below and the added beds will not be included as part of the unit classified as an IRF for
the following cost reporting period.
If the hospital does not have the records needed to discriminate between the performance
of the previously existing unit and that of the added beds, or for other reasons does not
furnish the information requested by the A/B MAC (A) or State Agency, neither the
previously existing unit nor the added beds will be classified as an IRF for the following
cost reporting period. In that case, the A/B MAC (A) adjusts its payment to the entire unit
retroactively in accordance with paragraph C below.
C. - The A/B MAC (A) adjusts payment to the hospital by calculating the difference
between the amount actually paid for services to Medicare patients in the IRF hospital,
IRF unit, or new IRF beds during the period of provisional exclusion, and the amount that
would have been paid if the IRF hospital, IRF unit, or new IRF beds had not been
excluded from the IPPS. The A/B MAC (A) then takes action to recover the resulting
overpayment, or corrects the underpayment to the hospital.
140.2 - Payment Provisions Under IRF PPS
(Rev. 11504, Issued 08-05-22; Effective:10-01-22; Implementation: 10-03-22)
Section 1886 of the BBA provides the basis for establishing the Federal payment rates
applied under PPS to IRFs. The PPS incorporates per discharge federal rates based on
average IRF costs in a base year updated for inflation to the first effective period of the
system.
IRF PPS providers are not subject to the 3-day payment window for pre-admission services,
but are subject to the 1-day payment window for pre-admission services.
Beneficiary liability will operate the same as under the current Tax Equity and Fiscal
Responsibility Act of 1982 (TEFRA) payment system. Even if Medicare payments are
below cost of care for a patient under prospective payment, the patient cannot be billed for
the difference in any case.
Below are the annual rate update Change Requests (CRs) for Fiscal Years
2003-2022:
FY 2022 – CR 12364
FY 2021 – CR 11858
FY 2020 – CR 11345
FY 2019 – CR 10826
FY 2018 – CR 10125
FY 2017 – CR 9669
FY 2016 – CR 9236
FY 2015 – CR 8788
FY 2014 – CR 8326
FY 2013 – CR 7901
FY 2012 – CR 7510
FY 2011 – CR 7076
FY 2010 – CR 7029
FY 2010 – CR 6607
FY 2009 – CR 6166
FY 2008 – CR 5694
FY 2007 – CR 5273
FY 2006 – CR 4037
FY 2005 – CR 3378
FY 2004 – CR 2894
FY 2003 – CR 2250
Change Requests can be accessed through the following CMS Transmittals Website:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/index.html
Rate and weight information used by the IRF Pricer is updated periodically, usually
annually, and is published in the “Federal Register.” Updates occur each October, to
reflect the fact that IRF PPS rates are effective for a Federal fiscal year. Updates may
also occur at other points in the year when required by legislation.
Whenever these update items change, Medicare also publishes a Recurring Update
Notification to inform providers and A/B MACs (A) about the changes. These
Recurring Update Notifications also describe how the changes will be implemented
through the IRF Pricer.
140.2.1 - Phase-In Implementation
(Rev. 2673, Issued: 03-14-13, Effective: 04-22-13, Implementation: 04-22-13)
Under the BBA, the Federal fiscal year in which a facility's cost reporting period begins
determines which transition period percentages apply. The first transition period
percentages are applicable for cost reporting periods beginning during Federal fiscal year
2001. The second transition period percentages are applicable to cost reporting periods
beginning during Federal fiscal year 2002, that is, periods beginning on or after October 1,
2001, and before October 1, 2002. For cost reporting periods beginning during Federal
fiscal year 2003 and after, payment is based on 100 percent of the adjusted Federal
prospective payment.
Since CMS is implementing the IRF PPS for discharges that occur during the IRF's cost
reporting period that begins on or after January 1, 2002, IRFs are phased directly into the
second transition period, where payment will be based on 66 2/3 percent of the PPS
payment and 33 1/3 percent of the TEFRA payment. A facility will continue to be paid
under the TEFRA (reasonable cost-based) system for its entire cost reporting period
beginning prior to January 1, 2002.
In addition, §305 of the BIPA 2000 states facilities may elect to be paid 100 percent PPS
payment, rather than payment based on the transition method. If a facility chooses not to
be paid under the transition method, they must notify their A/B MAC (A) no later than 30
days prior to its first cost reporting period for which the IRF PPS applies to the facility.
The request to make the election must be made in writing to the Medicare A/B MAC (A)
for the facility. The A/B MAC (A) must receive the request on or before the 30th day
before the applicable cost reporting period begins, regardless of any postmarks or
anticipated delivery dates. Requests received, postmarked, or delivered by other means
after the 30th day before the cost reporting period begins will not be approved. If the 30th
day before the cost reporting period falls on a day that the postal service or other delivery
sources are not open for business, the facility is responsible for allowing sufficient time
for delivery of the request before the deadline. If a facility's request is not received or not
approved, payment will be based on the transition method.
140.2.2 - Payment Adjustment Factors and Rates
(Rev. 2673, Issued: 03-14-13, Effective: 04-22-13, Implementation: 04-22-13)
Section 1886(j) of the Act sets forth the methodology for establishing the payment rates
as well as the data on which they are based. In addition, this section prescribes
adjustments to such rates based on geographic variation and case-mix and other factors
the Secretary deems necessary to ensure that payment most accurately reflects cost.
For the initial period of the IRF PPS, beginning on or after January 1, 2002, all payment
rates and associated rules were published in the "Federal Register" on August 7, 2001.
For each succeeding fiscal year, the rates will be published in the "Federal Register" on or
before August 1 of the year preceding the affected fiscal year.
140.2.3 - Case-Mix Groups
(Rev. 2673, Issued: 03-14-13, Effective: 04-22-13, Implementation: 04-22-13)
In general, a case will be grouped into a Case-Mix Group (CMG) based on the clinical
characteristics of the Medicare beneficiary. Rehabilitation Impairment Categories (RICs),
functional measurements, age, and comorbidities were used to develop the CMGs.
Specifically, RICs are used to group cases that are similar in clinical characteristics and
resource use. The RICs are codes that indicate the primary cause of the rehabilitation
hospitalization and are clinically homogeneous. In addition to the first two digits of the
CMG indicating the RIC, the CMGs are further partitioned using functional measures of
motor and cognitive scores. Age improves the explanatory power of the CMGs if some
groups are split based on this variable. Lastly, comorbidites were found to substantially
increase the average cost of a case in specific CMGs. The comorbidities are arrayed in
three categories (or tiers) based on whether the costs are considered high, medium, or low.
If a case has more than one comorbidity, the CMG payment rate will be based on the
comorbidity that results in the highest payment.
140.2.4 - Case-Level Adjustments
(Rev. 2673, Issued: 03-14-13, Effective: 04-22-13, Implementation: 04-22-13)
Payment is based on the CMGs described above, as well as possible adjustments specific
to the case and the facility characteristics. For case level adjustments, more than one case
level adjustment may apply to the same case. For ease of understanding, the case level
discussion is presented below in the same order that is used to assess whether or not they
apply. For example, a case may be classified as a transfer, but may also receive
additional payments because it meets the definition of an outlier case.
Interrupted stays are defined as those cases in which a Medicare beneficiary is
discharged from the inpatient rehabilitation facility and returns to the same inpatient
rehabilitation facility within 3 consecutive calendar days. The 3 consecutive calendar
days begin with the day of the discharge from the IRF and ends on midnight of the third
day. The length of stay for these cases will be determined by the total length of the IRF
stay including the days prior to the interruption and the days after the interruption. One
CMG payment will be made for interrupted stay cases and the payment will be based on
the initial assessment. For example, if a Medicare beneficiary is discharged on February
1, 2001, and is readmitted on February 3, the case would be considered an interrupted
stay and only one CMG payment will be made based on the initial assessment.
However, if the Medicare beneficiary was readmitted on February 4, then it would not be
considered an interrupted stay. A separate DRG payment will not be made to the acute
care hospital when the beneficiary is discharged and returns to the same IRF on the same
day. However, a DRG payment can be made if the beneficiary does not return to the
same IRF on the same day as they were discharged. If a case is determined to be an
interrupted stay, other adjustments may apply to this payment amount. For example, the
case still may meet the definition of a transfer case described below.
For the IRF PPS, transfer cases are defined as those in which a Medicare beneficiary is
transferred to either another rehabilitation facility, a long term care hospital, an inpatient
hospital, or a nursing home that accepts payment under either the Medicare program
and/or the Medicaid program AND the length of stay of the case is less than the average
length of stay for a given CMG. The transfer policy consists of a per diem payment
amount calculated by dividing the per discharge CMG payment rate by the average
length of stay for the CMG. Medicare will pay transfer cases a per diem amount and
include an additional half day payment for the first day. Transfer payments will be
calculated by first adding the length of stay of the case to 0.5 (to account for the addition
of the half day payment for the first day) and then multiplying the result by the CMG per
diem amount.
The IRF PPS also includes a payment adjustment for certain cases, such as short-stay
cases (for cases that do not meet the definition of a transfer case). A separate CMG
payment (5001) will be made for cases with a length of stay of 3 days or less, without
consideration of the clinical characteristics of the patient. Cases that expire with a length
of stay of 3 days or less, will also be classified to CMG 5001.
Separate CMGs will also be made for cases that expire with a length of stay greater than
3 days. To improve the explanatory power of the groups, four additional CMGs were
created to account for cases that expire. CMG 5101 is used for short-stay, orthopedic,
expired cases. This CMG includes those cases that would otherwise be grouped to RICs
07, 08, and 09 and the length of the stay is greater than 3 days, but less than or equal to
13 days. CMG 5102 will be used for orthopedic expired cases where the length of stay is
greater than or equal to 14 days. CMG 5103 will be used for short-stay, non-orthopedic,
expired cases. This CMG includes those cases that would not be grouped to the
orthopedic RICs and the length of the stay is greater than 3 days, but less than or equal to
15 days. CMG 5104 will be used for non-orthopedic expired cases where the length of
stay is greater than or equal to16 days.
140.2.5 - Facility-Level Adjustments
(Rev. 2673, Issued: 03-14-13, Effective: 04-22-13, Implementation: 04-22-13)
Facility-level adjustments apply to all cases and are based on the individual IRF
characteristics. The facility-level adjustments include an area wage adjustment, an
adjustment for facilities located in rural areas, an adjustment for treating low-income
patients and an adjustment for teaching facilities. Outlier payments will also be discussed
in this section. Although outlier payments are considered to be a case-level adjustment, a
case can be determined to qualify for these additional payments only after all other
facility-level adjustments are computed. Thus, for ease of understanding, the discussion of
these facility-level and outlier adjustments are presented in the same order that is used to
assess their applicability.
140.2.5.1 - Area Wage Adjustments
(Rev. 12575; Issued:04-11-24; Effective: 07-12-24; Implementation: 07-12-24)
To adjust payments for area wage differences, CMS first identifies the labor-related
portion of the prospective payment rates which is published annually in the Federal
Register. The labor-related unadjusted Federal payment is multiplied by a wage index
value to account for area wage differences. CMS uses the inpatient acute care hospital
wage data to compute the wage indices on the basis of the labor market area in which the
acute care hospital is located, but without taking into account geographic reclassification
under §§1886(d)(8) or (d)(10) of the Act and without applying the “rural floor” under
§4410 of the BBA. The wage data excludes the wages for services provided by teaching
physicians, interns and residents, and nonphysician anesthetists under Medicare part B,
because these services are not covered under the IRF PPS. For IRF PPS discharges
occurring before October 1, 2005, the IRF PPS utilizes labor market area definitions based
upon new statistical area definitions issued by the Office of Management and Budget
(OMB). The new labor market area definitions include new definitions of Metropolitan
Statistical Areas, Micropolitan Statistical Areas, and Combined Statistical Areas, more
commonly referred to as Core-Based Statistical Areas (CBSAs). CBSA-based
designations reflect the most recent available geographic classifications and more
accurately reflect current labor markets. The OMB also established New England City and
Town Areas, which are similar to the previous New England MSAs. CMS uses the
county-based areas for all MSAs in the Nation, including those in New England. Adopting
county-based labor market areas for the entire country creates consistency and stability in
the Medicare payment program because all of the labor market areas, including New
England, are defined using the same system (that is, counties), rather than different
systems in different areas of the country, and minimizes program complexity. CMS uses
the Metropolitan Divisions where applicable under the new CBSA-based labor market
area definitions to determine urban areas. Micropolitan Areas are treated as rural labor
market areas under the IRF PPS. To calculate the statewide rural wage index for each
State, CMS combines all of the counties in a State outside of designated urban areas along
with all Micropolitan Areas.
Beginning in FY 2023 a five percent cap will be applied on any decrease to a provider’s
wage index from that provider’s final wage index in the prior fiscal year. For subsequent
years, a provider's wage index would not be less than 95 percent of its wage index
calculated in the prior FY. A new IRF will be paid the wage index for the area in which it
is geographically located for its first full or partial FY with no cap applied, because a new
IRF will not have a wage index in the prior FY.
140.2.5.2 - Rural Adjustment
(Rev. 2673, Issued: 03-14-13, Effective: 04-22-13, Implementation: 04-22-13)
Payments are adjusted for facilities located in rural areas. A facility is considered to be
a rural IRF if they are located in a non-urban area.
For FY 2006 and FY 2007, a hold harmless policy applies to IRFs that meet the
definition of rural in FY 2005 in §412.602 and become urban under the FY 2006 CBSA-
based designations. The IRFs that meet the criteria described in the previous sentence
will qualify for an adjustment to their payments in FY 2006 and FY 2007 equal to some
portion of the 19.14 percent rural adjustment effective in FY 2005. This adjustment is in
addition to the one-year blended wage index described above for discharges occurring on
or after October 1, 2005 and on or before September 30, 2006.
140.2.5.3 - Low-Income Patient (LIP) Adjustment: The Supplemental
Security Income (SSI)/Medicare Beneficiary Data for Inpatient
Rehabilitation Facilities (IRFs) Paid Under the Prospective Payment
System (PPS)
(Rev. 2673, Issued: 03-14-13, Effective: 04-22-13, Implementation: 04-22-13)
The LIP adjustment accounts for differences in costs among IRFs associated with
differences in the proportion of low-income patients treated. The LIP adjustment is
calculated as (1 + disproportionate share hospital (DSH) patient percentage) raised to a
power specified in the most recent IRF PPS final rule published in the Federal
Register. To compute the DSH patient percentage the following formula is used:
DSH
=
Medicare SSI Days
+
Medicaid, Non-Medicare Days
Total Medicare Days
Total Days
This instruction provides the data for determining additional payment amounts for IRFs
with low-income patients. An SSI data file below shows the latest available IRF-specific
data to compute an IRF's SSI ratio for the associated specified fiscal year (FY). An IRF
may use this ratio as part of the formula to estimate their LIP adjustment for a cost
reporting period that begins subsequent to the FY specified by the data file. As
appropriate, a file will be updated annually (usually each October/November).
Patients who are enrolled in Medicare Advantage (administered through Medicare Part
C) should also be included in the Medicare fraction. These days will be included in the
Medicare/SSI fraction, but in order for them to be counted, the hospital must submit an
informational only bill (TOB 111), which includes both Condition Code 04 and the CMG
code from the IRF PAI, to their Medicare contractor. This will ensure that these days are
included in the IRF’s SSI ratio for Fiscal Year 2007 and beyond. Teaching IRFs do not
have to submit an additional bill with Condition Code 04. They already submit bills with
Condition Codes 04 and 69 for Indirect Medical Education payments and CMS will use
the information from these bills for the SSI ratio.
IRFs that received LIP payments during FY 2006 are also required to
submit informational only bills for their Medicare Advantage patients.
Informational Only Claim Elements:
•
Covered 111 TOB
•
Condition Code 04
•
Medicare Fee-for-Service is the primary payer
•
There is no MSP
•
Beneficiary’s Medicare HICN
•
For claims prior to October 1, 2011, report the Revenue Code 0024 line
containing CMG A9999 and, instead of inputting the transmission date of the
IRF-PAI in the service date field (as is required for FFS claims), input the
discharge date as a default for these informational only claims. The discharge date
is required on informational only claims to reduce reporting burden for IRFs who
may be submitting “old” informational only claims.
NOTE: Effective January 1, 2011, do not report the service date for the revenue code 0024
line. Instead, use occurrence code 50 in place of the service date to report the default
discharge date for informational only claims.
•
Effective October 1, 2011, report the Revenue Code 0024 line containing the CMG
from the IRF-PAI and the transmission date of the IRF-PAI in the occurrence code
50 and date field (as is required for FFS claims).
•
All other required claim elements
The SSI/Medicare beneficiary data for IRF PPS is available to A/B MACs (A)
electronically and contains the name of the facility, provider number, SSI days, covered
Medicare days, and the ratio of Medicare Part A patient days attributable to SSI
recipients. A/B MACs (A) will use this information to update their provider specific file.
The files are located at the following CMS Web site address:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ProspMedicareFeeSvcPmtGen/index.html. Select Inpatient Rehabilitation
Facility PPS, then select, from the list at the left, SSI Data.
A/B MACs (A) use this data to determine an initial PPS payment amount, and if
applicable, to determine a final outlier payment amount for IRFs whose discharges are
during a specific cost reporting period. A/B MACs (A) make a determination of the
amount of this percentage to compute the final LIP adjustment which allows the year-end
settlement of a facility’s cost report. When the A/B MAC (A) settles a cost report for a
specific fiscal year, that settled cost report will determine the final SSI ratio that is
associated with that cost report. The A/B MAC (A) uses the most recently settled SSI
ratio to settle the current cost report. Once the final SSI ratio is determined for the actual
fiscal year the cost report corresponds to, a retrospective adjustment may be made to
account for the difference between the actual lip adjustment amount and the initial PPS
lip adjustment payment amount.
A - Clarification of Allowable Medicaid Days in Calculating the Disproportionate
Share Variable
Background
Under the IRF PPS, facilities receive additional payment amounts to account for the cost
of furnishing care to low-income patients. This is done by making adjustments to the
prospective payment rate. Under §1886(d)(5)(F) of the Act, the Medicare DSH
percentage is made up of two computations. The results of these two computations are
added together to determine the DSH percentage. First, the patient days of patients who,
during a given month, were entitled to both Medicare Part A and SSI (excluding those
patients who received only State supplementation) is divided by the number of covered
patient days utilized by patients under Medicare Part A for that same period. Second, a
determination is made regarding the patient days associated with beneficiaries who were
eligible for medical assistance (Medicaid) under a State plan approved under Title XIX
but who were not entitled to Medicare Part A (See 42 CFR 412.106(b)(4)) is determined.
This number is divided by the total number of patient days for that same period. The SSI
data is updated on an annual basis and these data are one of the components used to
determine the DSH variable that is part of the appropriate LIP adjustment for each IRF.
Included Days
In calculating the number of Medicaid days, the hospital must determine whether the
patient was eligible for Medicaid under a State plan approved under Title XIX on the day
of service. If the patient was so eligible, the day counts in the Medicare disproportionate
share adjustment calculation. The statutory formula for "Medicaid days" reflects several
key concepts. First, the focus is on the patient's eligibility for Medicaid benefits as
determined by the State, not the hospital's "eligibility" for some form of Medicaid
payment. Second, the focus is on the patient's eligibility for medical assistance under an
approved Title XIX State plan, not the patient's eligibility for general assistance under a
State-only program. Third, the focus is on eligibility for medical assistance under an
approved Title XIX State plan, not medical assistance under a State-only program or other
program. Thus, for a day to be counted, the patient must be eligible on that day for
medical assistance benefits under the Federal-State cooperative program known as
Medicaid (under an approved Title XIX State plan). In other words, for purposes of the
Medicare disproportionate share adjustment calculation, the term "Medicaid days" refers
to days on which the patient is eligible for medical assistance benefits under an approved
Title XIX State plan. The term "Medicaid days" does not refer to all days that have some
relation to the Medicaid program, through a matching payment or otherwise; if a patient is
not eligible for medical assistance benefits under an approved Title XIX State plan, the
patient day cannot become a "Medicaid day" simply by virtue of some other association
with the Medicaid program.
Medicaid days, for purposes of the Medicare disproportionate share adjustment
calculation, include all days during which a patient is eligible, under a State plan approved
under Title XIX, for Medicaid benefits, even if Medicaid did not make payment for any
services. Thus, Medicaid days include, but are not limited to, days that are determined to
be medically necessary but for which payment is denied by Medicaid because the provider
did not bill timely, days that are beyond the number of days for which a State will pay,
days that are utilized by a Medicaid beneficiary prior to an admission approval but for
which a valid enrollment is determined within the prescribed period, and days for which
payment is made by a third party. In addition, CMS recognizes the calculation days that
are utilized by a Medicaid beneficiary who is eligible for Medicaid under a State plan
approved under Title XIX through a managed care organization (MCO) or health
maintenance organization (HMO). However, in accordance with 42 CFR 412.106(b)(4), a
day does not count in the Medicare disproportionate share adjustment calculation if the
patient was entitled to both Medicare Part A and Medicaid on that day. Therefore, once
the eligibility of the patient for Medicaid under a State plan approved under Title XIX has
been verified, the A/B MAC (A) must determine whether any of the days are dual
entitlement days and, to the extent that they are, subtract them from the other days in the
calculation.
Excluded Days
Many States operate programs that include both State-only and Federal-State eligibility
groups in an integrated program. For example, some States provide medical assistance to
beneficiaries of State-funded income support programs. These beneficiaries, however, are
not eligible for Medicaid under a State plan approved under Title XIX, and, therefore,
days utilized by these beneficiaries do not count in the Medicare disproportionate share
adjustment calculation. If a hospital is unable to distinguish between Medicaid
beneficiaries and other medical assistance beneficiaries, then it must contact the State for
assistance in doing so.
In addition, if a given patient day affects the level of Medicaid DSH payments to
the hospital but the patient is not eligible for Medicaid under a State plan approved
under Title XIX on that day, the day is not included in the Medicare DSH
calculation.
It should be noted that the types of days discussed above are not necessarily the
only types of excluded days. See the chart below, which summarizes some, but
not necessarily all, of the types of days to be excluded from (or included in) the
Medicare DSH adjustment calculation.
To provide consistency in both components of the calculation, any days that are
added to the Medicaid day count must also be added to the total day count, to the
extent that they have not been previously so added.
Regardless of the type of allowable Medicaid day, the hospital bears the burden
of proof and must verify with the State that the patient was eligible under one of
the allowable categories during each day of the patient's stay. The hospital is
responsible for and must provide adequate documentation to substantiate the
number of Medicaid days claimed. Days for patients that cannot be verified by
State records to have fallen within a period wherein the patient was eligible for
Medicaid cannot be counted.
Types of Days Included/Excluded in the Medicare DSH Adjustment Calculation
Type of Day
Description
Eligible
Title XIX
Day
General
Assistance
Patient Days
Days for patients covered under a State-only (or county-only) general
assistance program (whether or not any payment is available for health
care services under the program). These patients are not Medicaid-
eligible under the State plan
No
Other State-
Only Health
Program Patient
Days
Days for patients covered under a State-only health program. These
patients are not Medicaid-eligible under the State plan
No
Charity Care
Patient Days
Days for patients not eligible for Medicaid or any other third-party payer,
and claimed as uncompensated care by a hospital. These patients are not
Medicaid-eligible under the State plan.
No
Actual 1902(r)(2)
and 1931(b)
Days
Days for patients eligible under a State plan based on a 1902(r)(2) or
1931(b) election. These patients are Medicaid-eligible under the Title
XIX State plan under the authority of these provisions, which is exercised
by the State in the context of the approved State plan.
Yes
Type of Day
Description
Eligible
Title XIX
Day
Medicaid
Optional
Targeted Low-
Income
Children
(CHIP-related)
Days
Days for patients who are Title XIX-eligible and who meet the definition
of "optional targeted low-income children" under §1905(u)(2). The
difference between these children and other Title XIX children is the
enhanced FMAP rate available to the State. These children are fully
Medicaid-eligible under the State plan.
Yes
Separate CHIP
Days
Days for patients who are eligible for benefits under a non-Medicaid
State program furnishing child health assistance to targeted low-income
children. These children are, by definition, not Medicaid-eligible under
No.
140.2.5.4 - Teaching Status Adjustment
(Rev. 2673, Issued: 03-14-13, Effective: 04-22-13, Implementation: 04-22-13)
The teaching status adjustment is a facility level adjustment made to the Federal
per discharge base rate to account for the higher indirect operating costs
experienced by facilities that participate in graduate medical education. The
adjustment is made on a claim basis as an interim payment, with final payment in
full for the cost reporting period made through the cost report. Any difference
between the interim payments and the actual teaching status adjustment amount
computed in the cost report are adjusted through lump sum
payments/recoupments when the cost report is filed and later settled. The
adjustment is based on the IRF’s “teaching variable,” which is the ratio of the
number of FTE residents training in the IRF (subject to the FTE resident cap
described below) to the IRF’s average daily census (ADC).
140.2.5.4.1 - FTE Resident Cap
(Rev. 2673, Issued: 03-14-13, Effective: 04-22-13, Implementation: 04-22-13)
There is a cap on the number of FTE residents that may be counted for purposes of
calculating the teaching adjustment, not the number of residents teaching institutions can
hire or train. The FTE resident cap is identical in freestanding teaching rehabilitation
hospitals and in distinct part rehabilitation units with GME programs. The cap is the
number of FTE residents that trained in the IRF during a “base year.”
An IRF’s FTE resident cap is determined based on the final settlement of the IRF’s most
recent cost reporting period ending on or before November 15, 2004. IRFs that first began
training residents after November 15, 2004 will initially receive an FTE cap of zero. The
FTE caps for new IRFs (as well as existing IRFs) that start training residents in a new
GME program (as defined in §413.79(1)) may be subsequently adjusted in accordance
with the policies that are being applied in the IPF PPS (as described in
§412.424(d)(1)(iii)(B)(2)), which in turn are made in accordance with the policies
described in 42 CFR 413.79(e).
For other types of Medicare providers (including long-term care hospitals) that have been
training residents and are currently converting to IRFs, the fiscal intermediary will
determine an FTE resident cap for purposes of the IRF teaching status adjustment,
applicable beginning with the new IRF’s payments under the IRF PPS based on the FTE
count of residents during the predecessor facility’s most recent cost reporting period
ending on or before November 15, 2004. If the predecessor facility did not begin training
residents until after November 15, 2004, the facility would initially receive an FTE cap of
zero. The FTE caps for new IRFs (as well as existing IRFs) that start training residents
in a new GME program (as defined in §413.79(1)), may be subsequently adjusted in
accordance with the policies that are being applied in the IPF PPS (as described in
§412.424(d)(1)(iii)(B)(2)), which in turn are made in accordance with the policies
described in 42 CFR 413.79(e).
Once established, the FTE resident cap for the teaching status adjustment for the new IRF
will be subject to the same rules and adjustments as any IRF’s FTE resident cap. CMS
will monitor this policy closely to ensure that it is not being inappropriately manipulated.
IRFs are not permitted to aggregate the FTE resident caps used to compute the IRF PPS
teaching status adjustment through affiliation agreements. Residents with less than full-
time status and residents floating through the rehabilitation hospital or unit for less than a
full year are counted in proportion to the time they spend in their assignment with the IRF
(for example, a resident on a full-time, 3-month rotation to the IRF would be counted as
0.25 FTEs for purposes of counting residents to calculate the ratio). No FTE resident time
counted for purposes of the IPPS IME adjustment is allowed to be counted for purposes
of the teaching status adjustment for the IRF PPS.
The denominator used to calculate the teaching status adjustment under the IRF PPS is
the IRF’s average daily census (ADC) from the current cost reporting period. If a
rehabilitation hospital or unit has more FTE residents in a given year than in the base year
(the base year being used to establish the cap) payments are based on the lower number
(the cap amount) in that year. If a rehabilitation hospital or unit were to have fewer FTE
residents in a given year than in the base year (that is, fewer residents than its FTE
resident cap) an adjustment in payments in that year is based on the lower number (the
actual number of FTE residents the facility hires and trains).
Effective for cost reporting periods beginning on or after October 1, 2011, the IRF FTE
resident caps may be temporarily adjusted to reflect interns and residents added because of
another IRF’s closure or the closure of another IRF’s residency training program. An IRF
is only eligible for the temporary cap adjustment if training the additional interns and
residents would cause the IRF to exceed its FTE resident cap. In addition, an IRF that
closes a medical residency training program must agree to temporarily reduce its FTE cap
before other IRFs can receive temporary adjustments to their caps for training the IRF’s
interns and residents. IRFs may qualify for the temporary cap adjustment for cost
reporting periods beginning on or after October 1, 2011 if they are already training interns
and residents displaced by IRF closures or residency training program closures that
occurred prior to October 1, 2011.
140.2.5.5 - Outliers
(Rev. 2673, Issued: 03-14-13, Effective: 04-22-13, Implementation: 04-22-13)
Section 1886(j)(4) of the Act provides the Secretary with the authority to make payments
in addition to the basic IRF prospective payments for cases incurring extraordinarily high
cost. A case qualifies for outlier payment if the estimated cost of the case exceeds the
adjusted outlier threshold. CMS calculates the adjusted outlier threshold by adding the
IRF PPS payment for the case (that is, the CMG payment adjusted by all of the relevant
facility-level adjustments) and the adjusted threshold amount (also adjusted by all of the
relevant facility-level adjustments). Then, CMS calculates the estimated cost of the case
by multiplying the IRF’s overall cost-to-charge ratio (CCR) by the Medicare allowable
covered charge. If the estimated cost of the case is higher than the adjusted outlier
threshold, CMS makes an outlier payment for the case equal to 80 percent of the
difference between the estimated cost of the case and the outlier threshold.
The adjusted threshold amount and upper threshold CCR are set forth annually in the IRF
PPS notices published in the Federal Register.
140.2.6 - Cost-to-Charge Ratios
(Rev. 2323, Issued: 10-26-11, Effective: 11-28-11, Implementation: 11-28-11)
For discharges beginning on and after January 1, 2002 thru September 30, 2003, the
Medicare contractor shall use the instructions for calculating the CCR for purposes of
determining outlier payments under the IRF PPS set forth in Transmittal A-01-131.
For discharges beginning on or after October 1, 2003, the Medicare contractor shall use a
CCR from the most recent tentative settled cost report or the most recent settled cost
report (whichever is the later period), specific to freestanding IRFs or for IRFs that are
distinct part units of acute care hospitals in accordance with the formulas set forth below.
Effective October 1, 2003, if an IRF’s CCR is above the applicable ceiling set forth
annually in the IRF PPS notices published in the Federal Register it is considered to be
statistically inaccurate. As a result, CMS will assign the IRF an appropriate national
average CCR. CMS does not use a lower threshold; an IRF will receive their actual CCR,
no matter how low their ratio falls.
The IRF PPS covers operating and capital-related costs and excludes medical education
and nurse anesthetist costs paid for on a reasonable cost basis. Therefore, total Medicare
charges for IRFs will consist of the sum of the inpatient routine charges and the sum of
inpatient ancillary charges (including capital). Total Medicare costs will consist of the sum
of inpatient routine costs (net of private room differential and swingbed) plus the sum of
ancillary costs plus capital-related pass-through costs only.
The provider specific file (PSF) contains a field for the operating CCR (Field 25; file
position 102-105) and for the capital CCR (Field 42; file position 203-206). Because the
CCR computed for the IRF PPS includes routine, ancillary, and capital costs, the CCR for
freestanding IRFs, units, and new providers described below will be entered on the
provider specific file only in field 25; file position 102-105. Field 42; file position 203-206
of the provider specific file must be zero-filled.
The Medicare contractor shall continue to update the IRF’s CCR each time a more recent
cost report is settled (either final or tentative). Revised CCRs shall be entered into the PSF
not later than 30 days after the date of the latest settlement used in calculating the CCR.
A. - Calculating Medicare CCRs for Freestanding IRFs
1) Identify total Medicare costs from Worksheet D-1, Part II, line 49 minus
(Worksheet D, Part III, col. 8, lines 25 through 30 plus Worksheet D, Part IV, col.
7, line 101).
2) Identify total Medicare charges (the sum of routine and ancillary charges), from
Worksheet D-4, Column 2, the sum of lines 25 through 30 and line 103 from the
cost report; where possible, these charges should be confirmed with the PS&R
data.
3) Divide the Medicare costs by the Medicare charges to compute the CCR.
B. - Calculating Medicare CCRs for IRF Distinct Part Units
1) Identify total Medicare costs from Worksheet D-1, Part II, line 49 minus
(Worksheet D, Part III, col. 8, line 31 plus Worksheet D, Part IV, col. 7, line 101).
2) Identify total Medicare charges (the sum of routine and ancillary charges) from
Worksheet D-4, Column 2, line 31 plus line 103 from the cost report; where
possible, these charges should be confirmed with the PS&R data.
3) Divide the Medicare costs by the Medicare charges to compute the CCR.
All references to Worksheets and specific line numbers shall correspond with the sub-
provider identified as the IRF unit that has the letter "T" or “R” in the third position of the
Medicare provider number.
C. - Calculating Medicare CCRs for New IRFs
In the case of a New IRF unit (defined in 42 C.F.R. 412.30) or a New Inpatient
Rehabilitation Hospital (defined as a hospital that has never entered into a provider
agreement with the Secretary), the Medicare contractor shall use a national average CCR
based on the facility location of either urban or rural. The national average CCRs
applicable to IRFs shall be found in each year’s annual notice of prospective payment
rates published in the Federal Register.
The national average CCR will be used until the IRF’s actual CCR can be computed using
the first tentative settled or final settled cost report data, which will then be used for the
subsequent cost report periods.
We NOTE, the policies in §§ E and F below can be applied as an alternative to the
national average CCR.
For those IRFs assigned the national average CCR, the CCR must be updated every
October 1 based on the latest national average CCRs published in each year’s IRF PPS
annual notice of prospective payment rates until the IRF is assigned a CCR based on the
latest tentative or final settled cost report or a CCR based on the policies of part E and F of
this section.
D. - Mergers, Conversion and Errors with CCRs
Effective April 1, 2011, in the case of a merger, the Medicare contractor shall use the CCR
from the IRF with the surviving provider number. If a new provider number is issued (i.e.,
a new provider agreement is signed because the new owner refused assignment of the
existing provider agreement), the Medicare contractor shall use the national CCR based on
the facility location of either urban or rural.
When errors related to CCRs and/or outlier payments are discovered, Medicare
contractors shall contact the CMS Central Office to seek guidance. Likewise, when a cost
report is reopened after final settlement and as a result of this reopening there is a change
to the CCR; Medicare contractors should contact the CMS Central Office for further
instructions.
E. - Alternative CCRs
The CMS may direct the Medicare contractor to use an alternative CCR to the CCR from
the later of the latest settled cost report or latest tentative settled cost report, if it believes
this will result in a more accurate CCR. In addition, if the Medicare contractor finds
evidence that using data from the latest settled or tentatively settled cost report would not
result in the most accurate CCR, the Medicare contractor should contact the CMS
Regional Office and CMS Central Office to seek approval to use a CCR based on
alternative data. For example, CCRs may be revised more often if a change in an IRF’s
operations occurs which materially affects the IRF’s costs and/or charges. Notification to
the CMS Central Office shall be sent to the mailing address or email address provided in
Part (f) below. The CMS Regional Office, in conjunction with CMS Central Office, will
approve or deny any request by the Medicare contractor for use of an alternative CCR.
Revised CCRs will be applied prospectively to all IRF PPS claims processed after the
update.
F. - Request for Use of a Different CCR by the IRF
Also, an IRF will have the opportunity to request that a different CCR be applied in the
event it believes the CCR being applied is inaccurate. The IRF is required to present
substantial evidence supporting its request. Such evidence should include documentation
regarding its costs and charges that demonstrate its claim that an alternative ratio is more
accurate. After the Medicare contractor has evaluated the evidence presented by the IRF,
the Medicare contractor notifies the CMS Regional Office and CMS Central Office of
such a request. The CMS Regional Office, in conjunction with CMS Central Office, will
approve or deny any request by the IRF for use of a different CCR. Medicare contractors
shall send requests to the CMS Central Office at the following address or email address:
CMS
C/O Division of Institutional Post Acute Care
7500 Security Blvd
Mail Stop C5-06-27
Baltimore, MD 21244
[email protected]
Revised CCRs will be applied prospectively to all IRF PPS claims processed after the
update.
G. - Notification to Facilities Under the IRF PPS
The Medicare contractor shall notify an IRF whenever they make a change to its CCR.
When a CCR is changed as a result of a tentative settlement or a final settlement, the
change to the CCR should be included in the notice that is issued to each provider after a
tentative or final settlement is completed.
H. - Maintaining a History of CCRs and Other Fields in the Provider Specific File
When recalculating claims due to outlier reconciliation, Medicare contractors shall
maintain an accurate history of certain fields in the PSF. This history is necessary to
ensure that claims already processed (from prior cost reporting periods that have already
been settled) will not be subject to a duplicate systems adjustment in the event that claims
need to be reprocessed. As a result, the following fields in the PSF can only be altered on
a prospective basis: 21 -Case Mix Adjusted Cost Per Discharge, 24 -Bed Size, 25 -
Operating Cost to Charge Ratio, 27 -SSI Ratio, -28 -Medicaid Ratio and 49 -Capital IME.
A separate history outside of the PSF is not necessary. The only instances a Medicare
contractor retroactively changes a field in the PSF is to update the CCR when using the
FISS Lump Sum Utility for outlier reconciliation or otherwise specified by the CMS
Regional Office or Central Office.
140.2.7 - Use of a National Average Cost-to-Charge Ratio
(Rev. 2111, Issued: 12-03-10, Effective: 04-01-11, Implementation: 04-04-11)
A national average CCR based on the facility location of either rural or urban is applied in
the following situations:
• New IRFs that have not yet submitted their first Medicare cost report.
• IRFs whose overall CCR is in excess of the national CCR ceiling, as set forth
annually in the IRF PPS notices published in the Federal Register.
• Other IRFs for which accurate data to calculate an overall CCR are not available.
However, the policies of §140.2.6 part E and F can be applied as an alternative to the
national average CCR.
The national urban and rural CCRs for IRFs are set forth annually in the Federal
Register.
140.2.8 - Reconciling Outlier Payments for IRFs
(Rev. 2111, Issued: 12-03-10, Effective: 04-01-11, Implementation: 04-04-11)
A. - General
For discharges occurring in cost reporting periods beginning on or after October 1, 2003,
Medicare contractors are to reconcile IRF PPS outlier payments at the time of cost report
final settlement if:
1) Actual CCR is found to be plus or minus 10 percentage points from the CCR used
during that time period to make outlier payments, and
2) Outlier payments exceed $500,000 in that cost reporting period.
The return codes from the PRICER software may be used to identify the cases for which
outlier payments were made in a cost reporting period.
In the event that these criteria do not identify facilities that are being overpaid (or
underpaid) significantly for outliers, then, based on an analysis of the facility’s most
recent cost and charge data that indicates that the CCR for those facilities are significantly
inaccurate, Medicare contractors and the CMS Central Office also have the administrative
discretion to reconcile cost reports of those IRFs. However, Medicare contractors must
seek approval from the CMS Regional Office and CMS Central Office in the event they
intend to reconcile outlier payments for an IRF that does not meet the above-specified
criteria.
To determine if an IRF meets the criteria for outlier reconciliation, the Medicare
contractor shall perform the following steps: (1) incorporate all the adjustments from the
cost report, (2) run the cost report, (3) calculate the revised CCR and (4) compute the
actual CCR prior to issuing a Notice of Program Reimbursement (NPR). If the criteria are
not met, the cost report can be finalized. If the criteria are met, Medicare contractors shall
follow the instructions in §140.2.10. The NPR cannot be issued nor can the cost report be
finalized until outlier reconciliation is complete.
If a cost report is reopened after final settlement and as a result of this reopening there is a
change to the CCR (which could trigger or affect IRF PPS outlier reconciliation and
outlier payments), Medicare contractors shall notify the CMS Central and Regional
Offices for further instructions. Notification to the CMS Central Office shall be sent to the
mailing address or email address provided in §140.2.6(F) above.
The following examples demonstrate how to apply the criteria for reconciliation:
EXAMPLE A:
Cost Reporting Period: 01/01/2010-12/31/2010
CCR used to pay original claims submitted during cost reporting period: 0.40
(In this example, this CCR is from the tentatively or final settled 2007 cost report)
Final settled CCR from 01/01/2010-12/31/2010 cost report: 0.50
Total IRF PPS outlier payout in 01/01/2010-12/31/2010 cost reporting period: $600,000
Because the CCR of 0.40 used at the time the claim was originally paid changed to 0.50 at
the time of final settlement, and the provider received greater than $500,000 in IRF PPS
outlier payments during that cost reporting period, the criteria are met for reconciliation,
and therefore, the Medicare contractor notifies the CMS Central Office and the Regional
Office. The provider’s IRF PPS outlier payments for this cost reporting period are
reconciled using the correct CCR of 0.50.
In the event that multiple CCRs are used in a given cost reporting period to calculate
outlier payments, Medicare contractors should calculate a weighted average of the CCRs
in that cost reporting period. Example B below shows how to weight the CCRs. The
Medicare contractor shall then compare the weighted CCR to the CCR determined at the
time of final settlement of the cost reporting period to determine if IRF PPS outlier
reconciliation is required. Total IRF PPS outlier payments for the entire cost reporting
period must exceed $500,000 in order to trigger reconciliation.
EXAMPLE B:
Cost reporting period: 01/01/2010-12/31/2010
CCR used to pay original claims submitted during cost reporting period:
0.40 from 01/01/2010 to 03/31/2010 (This CCR could be from the tentatively settled 2006
cost report.)
0.50 from 04/01/2010 to 12/31/2010 (This CCR could be from the tentatively settled 2007
cost report.)
Final settled CCR from 01/01/2010 - 12/31/2010 cost report: 0.35
Total IRF outlier payout in 01/01/2010 -12/31/2010 cost reporting period: $600,000
Weighted average CCR: 0.476
CCR
DAYS
Weight
Weighted CCR
0.40
90
0.247 (90 Days / 365
Days)
(a) 0.099 = (0.40 *
0.247)
0.50
275
0.753 (275 Days /
365 Days)
(b) 0.377 = (0.50 *
0.753)
TOTAL
365
365
(a)+(b) = 0.476
The IRF meets the criteria for IRF PPS outlier reconciliation in this cost reporting period
because the variance from the weighted average CCR at the time the claim was originally
paid compared to the CCR from the cost report at the time of settlement is greater than 10
percentage points (from 0.476 to 0.35) and the provider received total IRF outlier
payments greater than $500,000 for the entire cost reporting period.
B. - Providers Already Flagged for Outlier Reconciliation
Medicare contractors shall have until April 25, 2011 to submit via email to
[email protected] a list of providers that were flagged for outlier
reconciliation prior to April 1, 2011 (NOTE: Do not send this list prior to April 1, 2011
as this list shall include all providers flagged for outlier reconciliation prior to April 1,
2011). In this list, Medicare contractors shall include the provider number, provider name,
cost reporting begin date, cost reporting end date, status of cost report (was the Notice of
Program Reimbursement (NPR) issued), date of NPR, total outlier payments in the cost
reporting period, the CCR or weighted CCR from the time the claims were paid during the
cost reporting period being reconciled and the final settled CCR. The CMS Central Office
will then review this list and grant formal approval via email for Medicare contractors to
reprice and reconcile the claims of those hospitals that have been flagged for outlier
reconciliation. Upon approval from the CMS Central Office, Medicare contractors shall
follow the procedures in §140.2.10 and complete the reconciliation process by October 1,
2011. If a Medicare contractor cannot complete the reconciliation process by October 1,
2011, the Medicare contractor shall contact the CMS Central Office for further guidance.
NOTE: Those Medicare contractors that do not have any providers flagged for outlier
reconciliation prior to April 1, 2011, shall also send an email to the address above
indicating that they have no providers flagged for outlier reconciliation prior to April 1,
2011.
140.2.9 - Time Value of Money
(Rev. 2242, Issued: 06-17-11, Effective: 07-01-11, Implementation: 07-01-11)
Effective for discharges occurring on or after September 30, 2003, at the time of any
reconciliation under §140.2.9.10, outlier payment may be adjusted to account for the time
value of money of any adjustments to outlier payments as a result of reconciliation. The
time value of money is applied from the midpoint of the IRF’s cost reporting period being
settled to the date on which the CMS Central Office receives notification from the
Medicare contractor that reconciliation should be performed.
If the IRF’s outlier payments have met the criteria for reconciliation, the Medicare
contractor shall follow the process in §140.2.10. The index that will be used to calculate
the time value of money is the monthly rate of return that the Medicare trust fund earns.
This index can be found at http://www.ssa.gov/OACT/ProgData/newIssueRates.html.
The following formula will be used to calculate the rate of the time value of money.
(Rate from Web site as of the midpoint of the cost report being settled / 365) * # of days
from that midpoint until date of reconciliation. NOTE: The time value of money can be a
positive or negative amount depending if the provider is owed money by CMS or if the
provider owes money to CMS.
For purposes of calculating the time value of money, the “date of reconciliation” is the day
on which the CMS Central Office receives notification. This date is either the postmark
from the written notification sent to the CMS Central Office via mail by the Medicare
contractor, or the date an email was received from the Medicare contractor by the CMS
Central Office, whichever is first.
The following is an example of the procedures for reconciliation and computation of the
adjustment to account for the time value of money:
EXAMPLE C:
Cost Reporting Period: 01/01/2004-12/31/2004
Midpoint of Cost Reporting Period: 07/01/2004
Date of Reconciliation: 12/31/2005
Number of days from Midpoint until date of Reconciliation: 549
Rate from Social Security Web site: 4.625%
CCR used to pay actual original claims in cost reporting period: 0.40 (This CCR could be
from the tentatively settled 2002 or 2003 cost report)
Final settled CCR from 01/01/2004-12/31/2004 cost report: 0.50
Total outlier payout in 01/01/2004-12/31/2004 cost reporting period: $600,000.
Because the CCR fluctuated from .40 at the time the claims were originally paid to 0.50 at
the time of final settlement and the provider has an outlier payout greater than $500,000,
the criteria have been met to trigger reconciliation. The Medicare contractor notifies the
CMS Regional and Central Office.
The Medicare contractor reprocesses and reconciles the claims. The reprocessing indicates
the revised outlier payments are $700,000.
Using the values above, determine the rate that will be used for the time value of money:
(4.625 / 365) * 549 = 6.9565%
Based on the claims reconciled, the provider is owed $100,000 ($700,000-$600,000) for
the reconciled amount and $6,956.50 ($100,000 * 6.9565 %) for the time value of money.
140.2.10 - Procedure for Medicare Contractors to Perform and Record
Outlier Reconciliation Adjustments for IRFs
(Rev. 2111, Issued: 12-03-10, Effective: 04-01-11, Implementation: 04-04-11)
The following is a step-by-step explanation of the procedures that Medicare contractors
are to follow if an IRF is eligible for outlier reconciliation:
1) The Medicare contractor shall send notification to the CMS Central Office (not the
IRF), via the street address or email address provided in §140.2.6 (F), and to the
Regional Office that an IRF has met the criteria for reconciliation. Medicare
contractors shall include in their notification the provider number, provider name,
cost reporting begin date, cost reporting end date, total outlier payments in the cost
reporting period, the CCR or weighted average CCR from the time the claims were
paid during the cost reporting period eligible for reconciliation and the final settled
CCR.
2) If the Medicare contractor receives approval from the CMS Central Office that
reconciliation is appropriate, the Medicare contractor shall follow steps 3-14
below. NOTE: Hospital cost reports will remain open until their claims have been
processed for outlier reconciliation.
3) The Medicare contractor shall notify the IRF and copy the CMS Regional Office
and Central Office in writing or via email (through the addresses provided in
§140.2.6 (F)) that the IRF’s outlier claims are to be reconciled.
4) Prior to running claims in the *Lump Sum Utility, Medicare contractors shall
update the applicable provider record in the Provider Specific File (PSF) by
entering the final settled CCR from the cost report in the -25 -Operating Cost to
Charge Ratio field. No other elements in the PSF shall be updated for the
applicable provider records in the PSF that span the cost reporting period being
reconciled aside from the CCR.
a. *NOTE: The FISS Lump Sum Utility is a Medicare contractor tool that,
depending on the elements that are input, will produce an extract that will
calculate the difference between the original PPS payment amounts and
revised PPS payment amounts into a Microsoft Access generated report.
The Lump Sum Utility calculates the original and revised payments offline
and will not affect the original claim payment amounts as displayed in
various CMS systems (such as NCH).
5) Medicare contractors shall ensure that, prior to running claims through the FISS
Lump Sum Utility, all pending claims (e.g., appeal adjustments) are finalized for
the applicable provider.
6) Medicare contractors shall only run claims in the Lump Sum Utility that meet the
following criteria:
7) Type of Bill (TOB) equals 11X
8) Previous claim is in a paid status (P location) within FISS
9) Cancel date is ‘blank’
10) The Medicare contractor reconciles the claims through the IRF Pricer software and
not through any editing or grouping software.
11) Upon completing steps 3 through 7 above, the Medicare contractor shall run the
claims through the Lump Sum Utility. The Lump Sum Utility will produce an
extract, according to the elements in Table 1 below. NOTE: The extract must be
importable by Microsoft Access or a similar software program (Microsoft Excel).
12) Medicare contractors shall upload the extract into Microsoft Access or a similar
software program to generate a report that contains elements in Table 1. Medicare
contractors shall ensure this report is retained with the cost report settlement work
papers.
13) For facilities paid under the IRF PPS, the Lump Sum Utility will calculate the
difference between the original outlier amount (value code 17) and the revised
outlier amount (value code 17). If the difference between the original and revised
outlier amount is positive, then a credit amount (addition) shall be issued to the
provider. If the difference between the original and revised outlier amount is
negative, then a debit amount (deduction) shall be issued to the provider.
14) Medicare contractors shall determine the applicable time value of money amount
by using the calculation methodology in §140.2.8. If the difference between the
original and revised outlier amount (calculated by the Lump Sum Utility) is a negative
amount, then the time value of money is also a negative amount.
If the difference
between the original and revised outlier amount (calculated by the Lump Sum Utility)
is a positive amount, then the time value of money is also a positive amount.
Similar
to step 10, if the time value of money is positive, then a credit amount (addition)
shall be issued to the provider. If the time value of money is negative, then a debit
amount (deduction) shall be issued to the provider. NOTE: The time value of
money is applied to the difference between the original outlier amount (value code
17) and the revised outlier amount (value code 17).
15) For cost reporting periods beginning before May 1, 2010, under cost report 2552-
96, the Medicare contractor shall record the original outlier amount from
Worksheet E-3, Part 1 line 1.05, the outlier reconciliation adjustment amount (the
difference between the original outlier amount (value code 17) and the revised
outlier amount (value code 17) calculated by the Lump Sum Utility), the total time
value of money and the rate used to calculate the time value of money on lines 50-
53, of Worksheet E-3, Part 1 of the cost report (NOTE: the amounts recorded on
lines 50, 51 and 53 can be positive or negative amounts per the instructions above).
The total outlier reconciliation amount (the difference between the original outlier
amount (value code 17) and the revised outlier amount (value code 17) calculated
by the Lump Sum Utility plus the time value of money) shall be recorded on line
15.99 of Worksheet E-3, Part 1. For complete instructions on how to fill out these
lines, see §3633.1 of the Provider Reimbursement Manual, Part II.
a. For cost reporting periods beginning on or after May 1, 2010, under cost
report 2552-10, the Medicare contractor shall record the original outlier
amount from Worksheet E-3, Part III, line 4, the outlier reconciliation
adjustment amount (the difference between the original outlier amount
(value code 17) and the revised outlier amount (value code 17) calculated
by the Lump Sum Utility), the total time value of money and the rate used
to calculate the time value of money on lines 50-53, of Worksheet E-3, Part
III of the cost report (NOTE: the amounts recorded on lines 50, 51 and 53
can be positive or negative amounts per the instructions above). The total
outlier reconciliation amount (the difference between the original outlier
amount (value code 17) and the revised outlier amount (value code 17)
calculated by the Lump Sum Utility plus the time value of money) shall be
recorded on line 30 of Worksheet E-3, Part 3.
16) The Medicare contractor shall finalize the cost report, issue a NPR and make the
necessary adjustment from or to the provider.
17) After determining the total outlier reconciliation amount and issuing a NPR,
Medicare contractors shall restore the CCR(s) to their original values (that is, the
CCR(s) used to pay the claims) in the applicable provider records in the PSF to
ensure an accurate history is maintained. Specifically, for hospitals paid under the
IRF PPS, Medicare contractors shall enter the original CCR(s) in PSF field 25 -
Operating Cost to Charge Ratio.
Medicare contractors shall contact the CMS Central Office via the mailing address or
email address provided in §140.2.6 (F) with any questions regarding this process.
Table 1: Data Elements for FISS Extract
List of Data Elements for FISS Extract
Provider #
Health Insurance Claim (HIC) Number
Document Control Number (DCN)
Type of Bill
Original Paid Date
Statement From Date
Statement To Date
Original Reimbursement Amount (claims page 10)
Revised Reimbursement Amount (claim page 10)
Difference between these amounts
Original Deductible Amount, Payer A, B, C (Value Code A1, B1, C1)
Revised Deductible Amount, Payer A, B, C (Value Code A1, B1, C1)
Difference between these amounts
Original Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2)
Revised Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2)
Difference between these amounts
Original Outlier Amount (Value Code 17)
Revised Outlier Amount (Value Code 17)
Difference between these amounts
Original DSH Amount (Value Code 18)
List of Data Elements for FISS Extract
Revised DSH Amount (Value Code 18)
Difference between these amounts
Original IME Amount (Value Code 19)
Revised IME Amount (Value Code 19)
Difference between these amounts
Original New Tech Add-on (Value Code 77)
Revised New Tech Add-on (Value Code 77)
Difference between these amounts
Original Device Reductions (Value Code D4)
Revised Device Reductions (Value Code D4)
Difference between these amounts
Original Hospital Portion (claim page 14)
Revised Hospital Portion (claim page 14)
Difference between these amounts
Original Federal Portion (claim page 14)
Revised Federal Portion (claim page 14)
Difference between these amounts
Original C TOT PAY (claim page 14)
Revised C TOT PAY (claim page 14)
Difference between these amounts
Original C FSP (claim page 14)
Revised C FSP (claim page 14)
Difference between these amounts
Original C OUTLIER (claim page 14)
Revised C OUTLIER (claim page 14)
Difference between these amounts
Original C DSH ADJ (claim page 14)
Revised C DSH ADJ (claim page 14)
Difference between these amounts
Original C IME ADJ (claim page 14)
Revised C IME ADJ (claim page 14)
Difference between these amounts
Original Pricer Amount
Revised Pricer Amount
Difference between these amounts
Original PPS Payment (claim page 14)
Revised PPS Payment (claim page 14)
Difference between these amounts
Original PPS Return Code (claim page 14)
Revised PPS Return Code (claim page 14)
DRG
MSP Indicator (Value Codes 12-16 & 41-43 - indicator indicating the claim is MSP;
‘Y’ = MSP, ‘blank’ = no MSP
Reason Code
List of Data Elements for FISS Extract
HMO-IME Indicator
Filler
140.2.11 - Quality Reporting Program
(Rev. 3039, Issued: 08-22-14, Effective: 10-01-14, Implementation: 10-06-14)
Section 1886 (j)(7)(A)(i) of the Act requires application of a 2% reduction of the
applicable market basket increase factor for IRFs that fail to comply with the quality data
submission requirements. FY 2014 is to be the first year that the mandated reduction will
be applied for IRFs that failed to comply with the data submission requirements during the
data collection period October 1, 2012 through December 31, 2012. Thus, in compliance
with 1886(j)(7)(A)(i) of the Act, we will apply a 2 percentage point reduction to the
applicable FY 2014 market basket increase factor in calculating an adjusted FY 2014
standard payment conversion factor to apply to payments for only those IRFs that failed to
comply with the data submission requirements.
Application of the 2% reduction may result in an update that is less than 0.0 for a fiscal
year and in payment rates for a fiscal year being less than such payment rates for the
preceding fiscal year. Also, reporting-based reductions to the market basket increase
factor will not be cumulative; they will only apply for the FY involved.
The adjusted FY 2014 standard payment conversion factor that will be used to compute
IRF PPS payment rates for any IRF that failed to meet the quality reporting requirements
for the period from October 1, 2012 through December 2012 will be $14,555.
After the reconsideration process has occurred and prior to October 1 of each FY, CMS
will provide the Medicare contractors with a final list of IRFs that failed to comply with
the data submission requirements. The Medicare contractors will then be responsible for
notifying each IRF that failed to comply with the quality data submission requirements
that it will receive a 2% reduction in payment. Additionally, the Medicare contractors
shall include information regarding the IRFs right to further appeal the 2% reduction via
the Provider Reimbursement Review Board (PRRB) appeals process. Contractors shall
send this second letter only to IRFs that requested a reconsideration. Medicare contractors
shall include the model language at the end of this section in their notification letter to the
IRFs.
The Medicare contractor shall update (or not update) the IRF’s provider file based on the
appropriate scenario listed below:
• If the IRF was notified that it was potentially subject to the 2% reduction, and did
not request a reconsideration, then the Medicare contractor shall set a quality
reporting indicator in the provider file that triggers Medicare systems to calculate
the 2% reduction on all of the IRF’s claims for the upcoming fiscal year.
• If the IRF was notified that it was potentially subject to the 2% reduction, and
requested a reconsideration, but on reconsideration CMS upheld the decision to
apply the 2% reduction, then the Medicare contractor shall set a quality reporting
indicator in the provider file that triggers Medicare systems to calculate the 2%
reduction on all of the IRF’s claims for the upcoming fiscal year.
• If the IRF was notified that it was potentially subject to the 2% reduction, and
requested a reconsideration, and on reconsideration CMS determined that the IRF
should not be subject to the 2% reduction (i.e., reversed its decision), then the
Medicare contractor shall not update the quality reporting indicator in the IRF’s
provider file and shall notify the IRF that they will receive their full IRF PPS
payment update for the upcoming fiscal year.
• If the IRF submitted the necessary IRF Quality Reporting data and was never
notified that it might potentially be subject to the 2% reduction, then the Medicare
contractor shall take no action regarding the quality reporting indicator in the
IRF’s provider file.
Below are the Quality Annual Rate Updates for the applicable Fiscal Years (FYs):
FY
data collection
from
data collection
through
adjusted standard
payment conversion
factor
FY 2014
10/01/2012
12/31/2012
$14,555
FY 2015
01/01/2013
12/31/2013
$14,901
140.3 - Billing Requirements Under IRF PPS
(Rev. 11140, Issued:12-02-21, Effective:01-04-22, Implementation: 01-04-22)
IRF PPS payment is contingent on the requirement that IRFs complete a patient
assessment upon admission and discharge for Medicare patients. The August 7, 2001,
Final Rule, and subsequent final rules contain detailed information regarding the
assessment schedule for the patient assessment instrument (PAI) with respect to
transmission requirements, encoding dates, and other pertinent information. Further, there
is an item-by-item guide, which specifies detailed instructions regarding the manner in
which each item on the assessment instrument needs to be completed.
Effective with cost reporting periods beginning on or after January 1, 2002, IRFs are
required to report billing data with a new revenue code and a Health Insurance PPS
(HIPPS) Rate Code on the ASC X12 837 institutional claim or, in rare cases, on the Form
CMS-1450 for all Part A inpatient claims (Type of Bill 11X) to their A/B MACs (A). The
new revenue code, 0024, is used in conjunction with the HIPPS Rate Code to identify the
CMG payment classification for the beneficiary. In addition to all entries previously
required on a Part A claim, the following additional instructions must be followed to
accurately price and pay a claim under the IRF PPS. These claims must be submitted on
Type of Bill 11X. The last four digits of the provider number for rehabilitation hospitals
is from 3025 to 3099, and for rehabilitation distinct part units the third digit will be a T if
the unit is located in an acute care hospital or an R if the unit is located in a CAH.
• The Revenue code must contain revenue code 0024. This code indicates that this
claim is being paid under the PPS. This revenue code can appear on a claim only
once.
• The following Patient Discharge Status codes are applicable under the transfer
policy for IRF PPS: 02, 03, 61, 62, 63, and 64.
NOTE: IRFs that transfer a beneficiary to a nursing home that accepts payment under
Medicare and/or Medicaid should use PS 03, discharged/transferred to a SNF. IRFs that
transfer a beneficiary to a nursing facility that does not accept Medicare or Medicaid,
should code PS 04, discharged/transferred to an ICF, until such time that a new PS code is
established to differentiate between nursing facilities that do not accept Medicare and/or
Medicaid and those that do. PS 04 does not constitute a transfer under the IRF PPS
policy.
• For typical cases, the HCPCS/Rates must contain a five digit HIPPS Rate/CMG
Code (AXXYY-DXXYY). The first position of the code is an A, B, C, or D. The
HIPPS rate code beginning with A in front of the CMG is defined as without
comorbidity. The HIPPS rate code containing a B in front of the CMG is defined
as with comorbidity for Tier 1. The HIPPS rate code containing a C in front of the
CMG is defined as with comorbidity for Tier 2. The HIPPS rate code containing a
D in front of the CMG is defined as with comorbidity for Tier 3. The (XX) in the
HIPPS rate code is the Rehabilitation Impairment Category (RIC). The (YY) in
the HIPPS rate code is the sequential numbering system within the RIC.
• For atypical cases effective January 1, 2010, the HCPCS/Rates must contain a five
digit HIPPS Rate/CMG Code A5001. An atypical case occurs under the new IRF
coverage requirements that became effective January 1, 2010, where an IRF is
eligible to receive the IRF short stay payment for 3 days or less (HIPPS Rate/CMG
A5001) if a patient’s thorough preadmission screening shows that the patient is an
appropriate candidate for IRF care but then something unexpected happens
between the preadmission screening and the IRF admission such that the patient is
no longer an appropriate candidate for IRF care on admission and the day count is
greater than 3. In this scenario only, if the patient is discharged/transferred on or
after day 4, we are instructing IRFs to bill HIPPS Rate/CMG A5001. Thus,
whether or not the IRF is able to discharge the patient to another setting of care
within 3 days, the IRF will only be eligible for and receive the IRF short stay
payment for 3 days or less (HIPPS Rate/CMG A5001).
Covered Charges should contain zero covered charges when the revenue code is 0024.
For accommodation revenue codes (010x-021x), covered charges must equal the rate
times the units. The IRF Pricer will calculate and return the payment amount for the line
item with revenue code 0024. Non-outlier payments will not be made based on the total
charges shown in Revenue Code 0001.
• IRF providers will submit one admit through discharge claim for the stay. Final
PPS payment is based upon the discharge bill.
• Should the patient's stay overlap the time in which the PPS applies to the facility,
PPS payment will still be based on discharge. If the facility submitted an interim
bill, a debit/credit adjustment must be made prior to PPS payment. If the facility
submits multiple interim bills, the provider will need to submit cancels and then
rebill once the cancels are accepted.
• IRFs can submit adjustment bills (even to correct the CMG), but late charge bills
will not be allowed (Type of bill 115).
• If a beneficiary has 1 day of Medicare coverage during their IRF stay, an entire
CMG payment will be made.
• IRFs will be paid under the IRF PPS beginning on the first day of their cost
reporting period that begins on or after January 1, 2002. Units established in a
CAH will be paid under the IRF PPS beginning with CAH cost reporting periods
on or after October 1, 2004.
For interim bills, if the stay is greater than 60 days, the interim bill should include the
lowest level of the HIPPS code from the admission assessment. The final claim will be
adjusted to reflect data from the discharge assessment.
When coding PPS bills for ancillary services associated with a Part A inpatient stay, the
traditional revenue codes will continue to be shown, e.g., 0250 - Pharmacy, 042x -
Physical Therapy, in conjunction with the appropriate entries in Service Units and Total
Charges.
• IRFs are required to report the number of units based on the procedure or service.
• IRFs are required to report the actual charge for each line item, in Total Charges.
If a beneficiary's Part A benefits exhaust during the stay, code an occurrence code A3-C3.
If benefits are exhausted prior to the stay, submit a no pay claim, which will be coded by
the A/B MAC (A) with no pay code B. Report any services that can be billed under the
Part B benefit using 12X TOB.
NOTE: For more information on outlier payments when benefits are exhausted, please
see §20.7.4. Although this references an expired instruction specific to inpatient hospital
PPS billing, the information presented provides important general information.
140.3.1 - Shared Systems and CWF Edits
(Rev. 11075; Issued: 10-28-21; Effective: 12-01-21; Implementation: 12-01-21)
To ensure that revenue code 0024 is not reported more than once on bill type 11X;
• To ensure the claim can be matched to the corresponding Inpatient Rehabilitation
Facility – Patient Assessment Instrument (IRF-PAI) assessment in the internet
Quality Improvement Evaluation System (iQIES)
• To compare applicable inpatient claims with post-acute claims that will allow
erroneous claims to be reviewed and appropriate adjustments to be made on an
ongoing basis to the discharging hospital’s inpatient claim.
• To check the incoming claims admission date to the history discharge date for the
same provider except when patient status code is 30 (CWF);
• To check the incoming claim’s discharge date to the history admission date for the
same provider (CWF);
• To reject subsequent claims with the same PPS provider on the same day (CWF);
• Ensure accurate coding of patient status codes by checking the incoming claim’s
admission date to the history discharge date;
o CWF accepts the incoming claim and sends an informational
unsolicited response to the A/B MAC (A) on the history claim if the
patient status code does not match the incoming provider number
o The A/B MAC (A) cancels the history claim to the provider
• To check incoming claim’s discharge date to the history admission date to ensure
the appropriate use of the patient status code on the incoming claim;
• CWF rejects the incoming claim if the patient status code does not match the
provider number;
• A/B MAC (A) returns the incoming claim to the provider for correction of the
patient status code.
• To insure that revenue code 0024 is only on claims submitted by IRF providers.
Bills submitted incorrectly will be returned to the provider.
• To insure that a valid HIPPS/CMG rate code is always present with revenue code
0024;
• Units entered on the 0024 must be accepted, but are not required.
• To insure that revenue code total charges line 0001 must equal the sum of the
individual total charges lines;
• To insure that the length of stay in the statement covers period, from and through
dates equals the total days for accommodations revenue codes 010x-021x,
including revenue code 018x (leave of absence)/interrupted stay,
• To insure that Occurrence Span Code 74 is present on the claim if there is an
interrupted stay < 3 days. If the interruption is greater than 3 days, the bill should
be considered a discharge. If the patient returns to the IRF by midnight of the 3rd
day, the bill continues under the same CMG. CWF will need to edit to ensure that
if another IRF bill comes in during the interrupted stay, it is rejected, as it should
be associated with the original CMG; and
• If HIPPS rate code is 5101, 5102, 5103, or 5104 patient status must be 20
(Expired)/
• The accommodation revenue code 018x (leave of absence) will continue to be used
in the current manner including the appropriate occurrence span code 74 and date
range.
140.3.1.1 - Actions When a Claim Does Not Match the Inpatient
Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI)
(Rev. 11075; Issued: 10-28-21; Effective: 12-01-21; Implementation: 12-01-21)
The following outcomes are possible when a claim does not match the IRF-PAI
HIPPS:
o A matching assessment is found. The claim HIPPS code does not match the
IRF-PAI HIPPS code, but the transmission date matches causing the
claims processing system to use the assessment HIPPS code documented in
iQIES for claims processing purposes;
o A matching assessment is found. The claim HIPPS code does not match
IRF-PAI HIPPS code, and the
transmission date is different causing the claims processing system to use
the assessment HIPPS code and date documented in iQIES for claims
processing purposes;
o A matching assessment is not found. This causes the claim to Return to
Provider (RTP) with Reason Code 37096.
IRFs should be sure to have an IRF-PAI that has completed processing at iQIES
before submitting an IRF claim to the Medicare Administrative Contractor. The
IRF can verify this by reviewing their IRF-PAI validation report.
If an IRF has inadvertently submitted their claim prior to the corresponding IRF-
PAI being accepted in iQIES and the claim has RTP’d with Reason Code 37096,
simply resubmit the claim once the IRF-PAI has completed processing. This will
require communication between the provider’s billing office and their clinical staff
that submits their IRF-PAI.
If a claim is returned because Medicare systems do not find the matching
assessment, there is no need to call the QIES Technical Support Office (QTSO)
help desk for such billing issues.
If a provider has submitted an IRF-PAI prior to submission of the claim with
information that is different from the claim submission for any of the following
information:
o Medicare Beneficiary Identifier (IRF-PAI item 2);
o Beneficiary date of birth (IRF-PAI item 6);
o Provider CCN (IRF-PAI item 1B);
o Claim statement covers through dates (IRF-PAI item 40); and
o Claim admission date (IRF-PAI item 12).
The claim or the IRF-PAI should be corrected (depending on which item had the
error) and then the claim resubmitted. If the claim is resubmitted without
correcting the appropriate information, the claim will be returned to the provider
again.
In most cases the claim is being submitted one (1) day prior to the finalization of
the IRF-PAI. IRFs may want to add an additional claim hold day(s) on their claim
submission to allow IRF-PAI completing processing and to avoid claims being
RTP’d with Reason Code 37096.
140.3.2 - IRF PPS Pricer Software
(Rev. 693, Issued: 09-30-05, Effective: 10-01-05, Implementation: 10-31-05)
The CMS has developed an IRF Pricer Program that calculates the Medicare payment rate.
Pricer will use a variety of inputs listed below to calculate the payment rate.
A. Inputs to Pricer
• Provider Specific File data (see section 20.2.3.1 and Addendum of this chapter for
required elements)
• Bill Data includes:
° Patient Status:
° Payment Modification Flag (if condition code is 66, set flag "Y" otherwise use
"N.");
° Covered Charges;
° Discharge Date;
° HIPPS/CMG Rate Code;
° Length of Stay (LOS);
° Covered Days;
° Lifetime Reserve Days (LTR)
B. Data Returned From Pricer
Pricer returns the following information:
• PPS Return Code
• MSA /CBSA (effective October 1, 2005)
• Wage Index
• Average LOS
• Relative Weight
• Total Payment Amount
• PPS Federal Payment Amount
• Facility Specific Payment Amount
• Outlier Payment Amount
• Low-Income Payment (LIP) Amount
• Teaching Amount (effective October 1, 2005)
• LOS
• Regular Days Used
• LTR Days Used
• Transfer Percentage
• Facility Specific Rate pre-blend
• Standard Payment Amount
• PPS federal amount pre-blend
• Facility costs
• Outlier threshold
• Submitted HIPPS/CMG code
• PPS Pricer CMG code
• Calculation version code
The Pricer is available electronically to the Shared Systems.
140.3.3 - Remittance Advices
(Rev. 3481, Issued: 03-18-16. Effective: 06-20-16, Implementation: 06-20-16)
A remittance advice remark code is used to notify an IRF when the CMG code was
changed.
The following reflects the remittance advice messages and associated codes that will
appear when communicating claims under this policy. The CARC below is not included
in the CAQH CORE Business Scenarios.
Group Code: N/A
CARC: N/A
RARC: Alert N69
MSN: N/A
150 - Long Term Care Hospitals (LTCHs) PPS
(Rev. 1, 10-01-03)
PM A-02-093
150.1 - Background
(Rev. 1, 10-01-03)
LTCHs are certified under Medicare as short-term acutecare hospitals that have been
excluded from the acute care hospital inpatient prospective payment system (PPS) under
§1886(d)(1)(B)(iv) of the Act and, for Medicare payment purposes, are generally defined
as having an average inpatient length of stay of greater than 25 days. This PPS replaced
the previous reasonable cost-based payment system for LTCHs.
150.2 - Statutory Requirements
(Rev. 1, 10-01-03)
The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (BBRA),
as amended by the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection
Act of 2000 (BIPA), required that a budget neutral, per discharge PPS for LTCHs based
on diagnosis-related groups (DRGs) be implemented for cost reporting periods beginning
on or after October 1, 2002.
The CMS satisfied the statutory implementation requirement by establishing October 1,
2002 as the effective date of the LTCH PPS with systems changes to follow. Payments
for LTCH services furnished for cost reporting periods beginning on or after October 1,
2002 are based on the policies set forth in the August 30, 2002 final rule (67 FR 55954).
150.3 - Affected Medicare Providers
(Rev. 11396, Issued:05-04-22, Effective:10-01-22, Implementation:10-03-22)
LTCHs are certified under Medicare as short-term acute care hospitals and, for Medicare
payment purposes, are generally defined as having an average inpatient length of stay of
greater than 25 days.
Veterans Administration Hospitals, hospitals that are reimbursed under state cost control
systems approved under 42 CFR Part 403, and hospitals that are reimbursed in accordance
with demonstration projects authorized under §402(a) of Public Law 90-248 (42 U.S.C.
1395b-1) or §222(a) of Public Law 92-603 (42 U.S.C. 1395b-1) are not included in the
LTCH PPS. (See 42 CFR §412.22(c).) Payment to foreign hospitals will be made in
accordance with the provisions set forth in 42 CFR 413.74. Currently, two of the four
Maryland LTCHs included on CMS’ Certification Number (CCN) database are presently
paid in accordance with demonstration projects (i.e., the Maryland "Waiver") and
therefore not subject to payments under the LTCH PPS: Levindale Hebrew Geriatric
Center and Deaton Hospital and Medical Center (now known as University Specialty
Hospital).
150.4 - Revision of the Qualification Criterion for LTCHs
(Rev. 208, 06-18-04)
Under the LTCH PPS, the greater than 25-day average length of stay (ALOS) calculation
is based only on a hospital's Medicare inpatients, counting total medically necessary days,
not only covered days. For cost reporting periods beginning on or after October 1, 2002,
LTCHs are required to meet this revised criteria in order to qualify as LTCHs for
Medicare payment purposes.
The average Medicare length of stay is calculated by dividing the total number of covered
and noncovered days of care provided to Medicare patients, by the Medicare discharges
occurring during that period. If the days of a stay involve days of care furnished during
two or more separate cost reporting periods, that is, an admission during one cost
reporting period and a discharge during a future cost reporting period, the total number of
days of the stay are considered to have occurred during the cost reporting period during
which the patient was discharged. For cost reporting periods beginning on or after July 1,
2004, if a hospital fails to meet the ALOS requirement under this provision, the A/B MAC
(A) will determine the ALOS for cost reporting periods beginning on or after July 1, 2004
but before July 1, 2005 by dividing the applicable total days for Medicare inpatients
during the cost reporting period when they occur, by the number of discharges occurring
during the same cost reporting period.
If the A/B MAC (A) determines that the LTCH does not qualify, A/B MACs (A) are to
follow the procedures already established in the Medicare General Information,
Eligibility, and Entitlement Manual (CMS Pub. 100-01). The new manual can be found at
http://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/index.html?redirect=/manuals/cmsindex.asp. Select
Internet-Only Manuals (IOM) from the left side of the page, then select 100-01.
The CMS requires on-going monitoring of LTCH compliance with the above requirements
as well as notification by A/B MACs (A) regarding this compliance.
150.5 - Payment Provisions Under LTCH PPS
(Rev. 1, 10-01-03)
Section 123 of Public Law 106-113(BBRA), as amended by §307 of Public Law 106-
554(BIPA), authorizes the establishment of Federal payment rates under PPS for LTCHs.
The BIPA confers broad authority on the Secretary to determine what payment system
adjustments should be included in the LTCH PPS, both on a facility level and on a case-
level, to ensure that payment most accurately reflects cost.
The CMS has established a transition to full payments under the LTCH PPS: a 5-year
phase-in during which a decreasing percentage of payments will based upon what
payments would have been under the reasonable cost-based system. LTCHs may also
elect to receive payment based on 100 percent of the "Federal payment rate." New
LTCHs are to be paid based fully on 100 percent of the Federal rate (i.e. hospitals for
which the first cost reporting period as an LTCH began on or after October 1, 2002). (See
§150.10.1.)
150.5.1 - Budget Neutrality
(Rev. 1, 10-01-03)
The BBRA requires that total payments under the PPS must equal the amount that would
have been paid if the PPS had not been implemented.
150.5.2 - Budget Neutrality Offset
(Rev. 3445, Issued: 01-29-16, Effective: 01-01-16, Implementation: 04-04-16)
A reduction factor to all Medicare payments during the transition to account for the
monetary effect of the 5-year transition from the present cost-based payment system and
the LTCH PPS, and the policy to permit LTCHs to elect payment solely under the PPS
rather than based on the blend during the transition. (See §150.10.1.)
If a LTCH is paid under the transition blend methodology, the budget neutrality offset will
be applied to both the TEFRA Rate Percentage and the Federal Rate percentage.
The budget neutrality offset equals 1 minus the ratio of the estimated TEFRA reasonable
cost-based payments that would have been made had the LTCH PPS not been
implemented to the projected total Medicare program payments that would be made under
the transition methodology and the option to elect payment based on the 100 percent of the
Federal rate.
The per discharge Federal rates under the PPS are based on average LTCH costs in a base
year updated for inflation to the first effective period of the system.
Fiscal year changes to the LTCH PPS system occur annually in October. Specific
instructions will be published shortly after the publication of the LTCH Final Rule each
year. In addition, other changes to the inpatient prospective payment system may occur in
January, April or July as necessary.
150.6 - Beneficiary Liability
(Rev. 1, 10-01-03)
Beneficiary liability will operate the same as under the former TEFRA cost-based
payment system, i.e., if Medicare payments are below the cost of care for a patient under
prospective payment, the patient cannot be billed for the difference.
As under the former TEFRA cost-based payment system, beneficiaries (or their Medigap
insurers or other private insurers, such as an employer-sponsored plan, as applicable) are
responsible for all noncovered days, where Medicare has not made a full LTC-DRG
payment.
For more detailed information regarding lifetime reserve days, refer to the Medicare
Benefit Policy Manual, chapter 5.
150.7 - Patient Classification System
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon
Implementation of ICD-10, Implementation: ICD-10: Upon Implementation of ICD-
10, ASC X12: September, 23 2014)
The BBRA required the use of diagnostic-related groups (DRGs) for patient classification
purposes in the PPS for LTCHs. In general, a case is grouped based on the clinical
characteristics of the Medicare beneficiary.
The patient classification system groupings are called LTC-DRGs, which are based on the
existing CMS DRGs used under the acute care hospital inpatient PPS. Patient discharges
are grouped using ICD diagnosis codes reported on the claim for the principal diagnosis,
up to twenty four additional diagnoses, and up to twenty five procedures performed during
the stay, as well as age, sex, and discharge status of the patient.
The same GROUPER software developed by 3M for the acute care hospital inpatient PPS,
is used but with LTCH-specific relative weights reflecting the resources used to treat the
medically complex LTCH patients).
150.8 - Relative Weights
(Rev. 1, 10-01-03)
Payment weights assigning a specific value representing the relative resource use of each
LTC DRG are determined by the hospital-specific relative value method. This
methodology normalizes charges within each hospital and then compares them across
hospitals. Relative weights are updated annually October 1 using the most recent
available claims data. Relative weights and the geometric average length of stay are in the
Pricer program.
150.9 - Payment Rate
(Rev. 1547, Issued: 07-03-08; Effective: 07-01-08; Implementation: 07-07-08)
Payments to LTCHs under the LTCH PPS are based on a single standard Federal rate for
both the inpatient operating and capital-related costs (including routine and ancillary
services), but not certain pass through costs (i.e., bad debts, direct medical education, new
technologies, and blood clotting factors). This single standard Federal rate is updated
annually by the excluded hospital with capital market basket index. The formula for an
unadjusted LTCH PPS prospective payment is as follows:
• Federal Prospective Payment = LTC-DRG Relative Weight * Standard Federal
Rate Case-Level Adjustments
Effective July 1, 2003, the annual update to the standard Federal rate is based on the
“LTCH PPS rate year” of July 1 through June 30, rather than the Federal fiscal year
(October 1 through September 30). July 1, 2008, is the final rate year; LTCH PPS is
moving back to a Federal Fiscal Year effective October 1, 2009.
150.9.1 - Case-Level Adjustments
(Rev. 1, 10-01-03)
Payments are based on the LTC-DRG described as well as possible adjustments specific to
the case. Because LTCHs are distinguished from other inpatient hospital settings by an
average length of stay of greater than 25 days, it was necessary to establish payment
categories for certain cases that have stays of considerably less than the average length of
stay. The following case-level adjustments are applied to cases that, based on length of
stay at the LTCH, receive significantly less than the full course of treatment for a specific
LTC-DRG.
150.9.1.1 - Short-Stay Outliers
(Rev. 2060, Issued: 10-01-10, Effective: 10-01-10, Implementation: 10-04-10)
• Generally, a short-stay outlier (SSO) is a case that has a covered length of stay
between 1 day and up to and including 5/6 of the average length of stay for the LTC-
DRG to which the case is grouped. Effective for LTCH PPS discharges occurring on
or before June 30, 2006, the adjusted payment for an SSO case is the least of:
• 120 percent of the cost of the case (determined using the facility-specific cost to
charge ratio (CCR) and covered charges from the bill);
• 120 percent of the LTC-DRG specific per diem payment (determined using the
LTC-DRG relative weight, the average length of stay of the LTC-DRG, and the
length of stay of the case); or
• The full LTC-DRG payment.
To compute 120% of cost:
• Charges x CCR = Cost ($13,870.33) x (0.8114) = $11,254.39
• 120% of cost = $11,254.39 x 1.2 = $13,505.27
To compute 120% of the specific LTC-DRG per diem:
• Full LTC-DRG payment / ALOS LTC-DRG x LOS of the case x 1.2
Full LTC-DRG payment:
$34,956.15 (FY 2003 standard Federal rate)
x 0.72885 (labor %)
$25,477.79 (labor share)
x 1.0301 (1/5th wage index value for FY 2003)
$26,244.67 (wage adjusted labor share)
+ 9,478.36 (non-labor share=$34,956 x 0.27115)
$35,723.03 (adjusted standard Federal rate)
x 1.4103 (LTC-DRG 113 relative weight)
$50,380.19 (full LTC-DRG payment
Per Diem = $50,380.19 / 36.9 (ALOS LTC-DRG 113) = $1365.32 per day
If LOS of case is 10 days, then 120% of per diem = $1365.32 per day x 10 days x
1.2 = $16,383.80.
In this example, the case is paid 120% of cost ($13,505.27) since it is less than $120% of
the specific LTC-DRG per diem ($16,383.80) and the full LTC-DRG payment
($50,380.19).
For discharges occurring on or after August 8, 2003, short-stay outlier payments are to be
reconciled upon cost report settlement to account for differences between the estimated
cost-to-charge-ratio and the actual cost-to-charge ratio for the period during which the
discharge occurs. For further information, refer to the June 9, 2003 High Cost Outlier
final rule (68 FR 34506 - 34513).
For RY 2007, the SSO policy was revised as follows:
• Effective for LTCH PPS discharges occurring on or after July 1, 2006, the adjusted
payment for a SSO case is equal the least of:
o 100 percent of estimated cost of the case,
o 120 percent of the LTC-DRG per diem amount,
o the full LTC-DRG payment, or
o a blend of an amount comparable to what would otherwise be paid under the IPPS,
computed as a per diem and capped at the full IPPS DRG comparable amount, and
the 120 percent LTC-DRG per diem amount.
Under the blend alternative, the percentage of the 120 percent LTC-DRG per diem amount
is based on the ratio of the (covered) length of stay of the case to the lesser of the SSO
threshold for the LTC-DRG (i.e., 5/6ths of the geometric ALOS of the LTC-DRG) or 25
days. As the length of stay reaches the lower of the five-sixths SSO threshold or 25 days,
the adjusted SSO payment is no longer be limited by this fourth option. This is because
for SSO cases with a LOS of 25 days or more, the amount determined under the blend
alternative is equal to 100 percent of the 120 percent of the LTC- DRG specific per diem
amount and 0 percent of the IPPS comparable per diem amount. In addition, the LOS in
the numerator cannot exceed the number of days in the denominator (i.e., the percentage
may not exceed 100 percent). The remaining percent of the blend alternative (that is, 100
percent minus the percentage applied to the 120 percent of the LTC-DRG per diem
amount) is applied to the IPPS comparable per diem amount (capped at the full IPPS
comparable amount).
The following examples illustrate how the blend alternative is calculated when the LTCH
patient is grouped to hypothetical DRG XYZ. For purposes of this example, for DRG
XYZ, the full LTC DRG payment is $38,597.41, the LTCH PPS geometric ALOS is 33.6
days, the LTCH PPS SSO threshold (i.e., 5/6ths of the geometric ALOS) is 28.0 days, the
full IPPS comparable amount is $8,019.82, and the IPPS geometric ALOS is 4.5 days.
SSO Example #1 - LOS equals 11 Days:
Step
Number
Description of
Step
Description of
Calculation
Example of Calculation Result
1a
Determine 120
percent of the
LTC-DRG per
diem amount
Divide the full LTC-
DRG payment by
the geometric
ALOS of LTC-DRG
XYZ and multiply
that per diem
amount by both the
covered LOS and
1.2
$38,597.41 x11 days x
1.2
33.6 days
$15,163.27
1b*
Calculate the
percentage of the
120 percent of
the LTC-DRG
per diem amount
Divide the covered
LOS by the lesser of
the 5/6
th
ALOS of
LTC-DRG XYZ or
25 days
11 days ÷ 25 days 0.44
Step
Number
Description of
Step
Description of
Calculation
Example of Calculation Result
1c
Determine the
LTC-DRG per
diem portion of
the blend
alternative
Multiply the
percentage
determined in step
(1-b) by the LTC-
DRG per diem
amount in step (1-a)
0.44 x $15,163.28 $6,671.84
2a
Calculate the
IPPS comparable
per diem amount
Divide the full IPPS
comparable amount
by the geometric
ALOS of DRG
XYZ and multiply
by the covered LOS
$8,019.82 x 11 days
4.5 days
$19,604.00
2b
Determine the
IPPS comparable
per diem amount
to be used in the
blend alternative
Compare the full
IPPS comparable
amount to the IPPS
comparable per
diem amount to
determine which is
the least amount
The full IPPS
comparable amount
($8,019.82) is lower than
the IPPS comparable per
diem amount
($19,604.00)
$8,019.82
2c
Calculate the
percentage of the
IPPS comparable
per diem amount
Subtract the
percentage
determined in step
(1-b) from 1 (i.e., 1
minus the covered
LOS divided by the
lesser of the 5/6
th
ALOS of LTC-DRG
XYZ or 25 days)
1 - 0.44 0.56
2d
Determine the
IPPS comparable
per diem portion
of the blend
alternative
Multiply the
percentage
determined in step
(2-c) by the IPPS
comparable amount
determined in step
(2-b)
0.56 x $8,019.82 $4,491.10
3
Compute the
blend alternative
Add the LTC-DRG
per diem portion
determined in step
(1-c) and the IPPS
comparable per
diem portion
determined in
step (2-d)
$6,671.84 + $4,491.10 $11,162.94
* In this example, 25 days was used in the denominator since the 5/6th ALOS of LTC
DRG XYZ (28.0 days) is greater than 25 days. If the 5/6th ALOS of LTC-DRG XYZ was
less than 25 days, that value would have been used in the denominator of this calculation.
In addition, the LOS in the numerator may not exceed the number of days in the
denominator (i.e., the percentage may not exceed 100 percent).
SSO Example #2 - LOS equals 27 Days:
Step
Number
Description of
Step
Description of
Calculation
Example of
Calculation
Result
1a
Determine 120
percent of the
LTC-DRG per
diem amount
Divide the full LTC-
DRG payment by the
geometric ALOS of
LTC-DRG XYZ and
multiply that per diem
amount by both the
covered LOS and 1.2
$38,597.41 x 27 days
33.6 days
x 1.2
$37,218.
93
1b*
Calculate the
percentage of
the 120 percent
of the LTC-
DRG per diem
amount
Divide the covered
LOS by the lesser of
the 5/6
th
ALOS of
LTC-DRG XYZ or
25 days; however,
since the LOS in the
numerator exceeds the
number of days in the
denominator, the
percentage equals 100
percent
27 days ÷ 25 days is >
1; therefore percent is
1.00
1.00
1c
Determine the
120 percent of
the LTC-DRG
per diem portion
of the blend
alternative
Multiply the
percentage
determined in step (1-
b) by the 120 percent
of the LTC-DRG per
diem amount in step
(1-a)
1.0 x $37,218.93
$37,218.
93
2a
Calculate the
IPPS
comparable per
diem amount
Divide the full IPPS
comparable amount
by the geometric
ALOS of DRG XYZ
and multiply by the
covered LOS
$8,019.82 x 11 days
4.5 days
$48,118.
92
Step
Number
Description of
Step
Description of
Calculation
Example of
Calculation
Result
2b
Determine the
IPPS
comparable per
diem amount to
be used in the
blend alternative
Compare the full
IPPS comparable
amount to the IPPS
comparable per diem
amount to determine
which is the least
amount
The full IPPS
comparable amount
($8,019.82) is lower
than the IPPS
comparable per diem
amount ($48,118.92)
$8,019.8
2
2c
Calculate the
percentage of
the IPPS
comparable per
diem amount
Subtract the
percentage
determined in step (1-
b) from 1 (i.e.,
1 minus the covered
LOS divided by the
lesser of the 5/6
th
ALOS of LTC-DRG
XYZ or 25 days)
1 - 1.00 0.00
2d
Determine the
IPPS
comparable per
diem amount
portion of the
blend alternative
Multiply the
percentage
determined in step (2-
c) by the IPPS
comparable per diem
amount determined in
step (2-b)
0.00 x $8,019.82 $0.00
3
Compute the
blend alternative
Add the 120 percent
of the LTC-DRG per
diem portion
determined in step (1-
c) and the IPPS
comparable per diem
portion determined in
step (2-d)
$37,218.93 + $0.00
$37,218.
93
**
* In this example, 25 days was used in the denominator since the 5/6th ALOS of LTC
DRG XYZ (28.0 days) is greater than 25 days. If the 5/6th ALOS of LTC-DRG XYZ was
less than 25 days, that value would have been used in the denominator of this calculation.
In addition, the LOS in the numerator may not exceed the number of days in the
denominator (i.e., the percentage may not exceed 100 percent).
** Note that, since in this example the LOS of the SSO case exceeds 25 days, the blend
percentage applicable to the 120 percent of the LTC-DRG specific per diem amount is 100
percent and the percentage applicable to the IPPS comparable per diem amount is 0
percent, therefore the amount computed under the blend option is equal to 120 percent of
the LTC-DRG specific per diem amount.
Under the blend alternative of the SSO payment formula, an amount comparable to what
would otherwise be paid under the IPPS (i.e., full IPPS comparable amount) includes
payment for the costs of inpatient operating services based on the standardized amount
determined under §412.64(c), adjusted by the applicable DRG weighting factors
determined under §412.60 as specified at §412.64(g). This amount is further adjusted to
account for different area wage levels by geographic area using the applicable IPPS labor-
related share, based on the CBSA where the LTCH is physically located as set forth at
§412.525(c) and using the IPPS wage index for non-reclassified hospitals published in the
annual IPPS final rule. (In the RY 2006 LTCH PPS final rule (70 FR 24200), we discuss
the inapplicability of geographic reclassification procedures for LTCHs.) For LTCHs
located in Alaska and Hawaii, this amount is also adjusted by the applicable proposed
COLA factor used under the IPPS published annually in the IPPS final rule. (Currently,
the same COLA factors are used under both the IPPS and the LTCH PPS.)
Additionally, an amount comparable to what would be paid under the IPPS for the case
includes a disproportionate share (DSH) adjustment (see §412.106), if applicable, and
includes an indirect medical education (IME) adjustment (see §412.105), if applicable.
For the comparable IPPS DSH adjustment, provider specific file elements 24 (Bed Size),
27 (Supplemental Security Income Ratio (SSI)), and 28 (Medicaid Ratio) are required, as
discussed below. In determining a LTCH’s SSI ratio and Medicaid ratio used in the
calculation of the comparable IPPS DSH adjustment, refer to sections 20.3.1.1 and
20.3.1.2 of this manual.
For the comparable IPPS IME adjustment, provider specific file elements 23 (Intern/Beds
Ratio) and 49 (Capital Indirect Medical Education Ratio) are required, as discussed below.
Furthermore, the IPPS comparable IME adjustment for a LTCH is determined by imputing
a limit on the number of full-time equivalent (FTE) residents that may be counted for IME
(IME cap) based on the LTCH’s direct GME cap as set forth at §413.79(c)(2) (which will
already be established for a LTCH which had residency programs). In determining the
IPPS comparable IME adjustment for a LTCH, if applicable, the use of a proxy for the
IME cap is necessary because it would not be appropriate to apply the IPPS IME rules
literally in the context of this LTCH PPS payment adjustment. The full IPPS comparable
amount used under the blend alternative in the SSO payment adjustment, also includes
payment for inpatient capital-related costs, based on the capital Federal rate at
§412.308(c), which is adjusted by the applicable IPPS DRG weighting factors. This
amount is further adjusted by the applicable geographic adjustment factors set forth at
§412.316, including wage index (based on the CBSA where a LTCH is physically located
and derived from the IPPS wage index for non-reclassified hospitals as published in the
annual IPPS final rule), and large urban location, if applicable. A LTCH PPS payment
amount comparable to what would be paid under the IPPS does not include additional
payments for extraordinarily high cost cases under the IPPS outlier policy (§412.80(a)).
Under existing LTCH PPS policy, a SSO case that meets the criteria for a LTCH PPS high
cost outlier payment at §412.525(a)(1) (i.e., if the estimated costs of the case exceeds the
adjusted LTCH PPS SSO payment plus the fixed-loss amount) will receive an additional
payment under the LTCH PPS HCO high cost outlier at §412.525(a) (67 FR 56026;
August 30, 2002). Under the revised SSO payment formula, we will continue to use the
fixed-loss amount calculated under §412.525(a), and not a fixed-loss amount based on
§412.80(a), to determine whether a SSO case receives an additional payment as a high
cost outlier case.
For RY 2008, the SSO policy was revised as follows:
Effective for LTCH PPS discharges occurring on or after July 1, 2007, and on or before
December 28, 2007
*
, the payment adjustment formula for SSO cases was revised for those
cases where the patient’s LTCH covered LOS is less than, or equal to an “IPPS-
comparable” threshold. For cases falling within this “IPPS-comparable” threshold,
Medicare payment under the SSO policy is subject to an additional adjustment.
The IPPS-comparable threshold is defined as the geometric average length of stay for the
same DRG under the IPPS plus one standard deviation (refer to Table 3 in the LTCH PPS
RY 2008 final rule (72 FR 26870 at 27019- 27029)).
If the covered LOS at the LTCH is less than or equal to the IPPS-comparable threshold for
the LTC-DRG, Medicare payment is based on the IPPS comparable per diem amount,
capped at the full IPPS comparable amount. This option replaces the “blend” amount in
the adjusted LTCH PPS SSO payment formula.
Effective for discharges occurring on or after July 1, 2007 and on or before December 28,
2007
*
, therefore, the adjusted Medicare payment for an SSO case where the covered LOS
at the LTCH is within the IPPS-comparable threshold, is equal the least of:
o 100 percent of estimated cost of the case,
o 120 percent of the LTC-DRG per diem amount,
o the full LTC-DRG payment, or
o the “IPPS comparable” per diem amount , capped at the full IPPS comparable
amount
The IPPS comparable amount is determined by the same methodology as the IPPS
comparable portion of the blend alternative, specified above in the above examples at 2a.
For SSO cases where the covered length of stay exceeds the “IPPS threshold,” payment is
made under the SSO payment formula that became effective beginning in RY 2007, as
specified above.
*
NOTE: On December 29, 2007, the Medicare, Medicaid, and SCHIP Extension Act of
2007 (MMSEA) was enacted that mandated a modification to the SSO payment
adjustment formula for a 3-year period beginning on the date of enactment of the Act.
Specifically, section 114(c)(3) of the MMSEA specifies that the revision to the SSO
policy implemented in RY 2008 shall not apply for a 3-year period beginning with
discharges occurring on or after December 29, 2007. Consequently, the fourth option in
the SSO payment adjustment formula at §412.529(c)(3)(i) will not apply during this 3-
year period, and therefore, there will be no comparison of the covered LOS of the SSO
case to the “IPPS threshold” in determining the payment adjustment for SSO cases.
Therefore, for SSO discharges occurring on or after December 29, 2007, and before
December 29, 2012, the adjusted payment for a SSO case is equal to the least of:
o 100 percent of estimated cost of the case,
o 120 percent of the LTC-DRG per diem amount,
o the full LTC-DRG payment, or
o a blend of an amount comparable to what would otherwise be paid under the IPPS,
computed as a per diem and capped at the full IPPS DRG comparable amount, and
the 120 percent LTC-DRG per diem amount.
As noted above, during this 3-year period specified by the MMSEA, all SSO cases
(including those where the covered LOS exceeds the “IPPS threshold”) are paid under the
SSO payment formula that became effective beginning in RY 2007, as described above.
Short Stay Outlier Policy for LTCHs qualifying under §1886(d)(1)(B)(II)
A “subsection (II)” hospital:
• Was excluded as a LTCH in 1986
• Has an average inpatient LOS of greater than 20 days, and
• Demonstrates that 80 percent of its annual Medicare inpatient discharges in the 12-
month reporting period ending FFY 1997 have a principal finding of neoplastic
disease.
For a “subsection (II)” hospital there is a special short-stay outlier policy effective for the
remainder of the transition period (i.e., discharges occurring on or after July 1, 2003
through December 31, 2006), where the lesser of 120 percent of cost or120 percent of the
per diem LTC-DRG in the existing short-stay outlier policy is replaced with the follow
percentages:
• Effective for discharges occurring on or after July 1, 2003 through the first year
of transition 195%;
• Effective for discharges during the second year of the transition, 193%;
• Effective for discharges during the third year of the transition, 165%;
• Effective for discharges during the fourth year of the transition, 136%; and
• Effective for discharges for the last year and thereafter, the percentage returns to
120%.
150.9.1.2 - Interrupted Stays
(Rev. 1231; Issued: 04-27-07; Effective: 12-03-07; Implementation: 12-03-07)
Beginning on July 1, 2004, there are two interruption of stay policies in effect under the
LTCH PPS.
A 3-day or less interruption of stay is a stay at an LTCH during which the beneficiary is
discharged from the LTCH to an acute care hospital, IRF, SNF, or home and readmitted to
the same LTCH within 3-days of the discharge. The 3-day or less period begins with the
date of discharge from the LTCH and ends not later than midnight of the third day.
Medicare payment for any test, procedure, or care provided on an outpatient basis or for
any inpatient treatment during the “interruption" would be the responsibility of the LTCH
“under arrangements” with one limited exception: for RY 2005 and RY 2006, if treatment
at an inpatient acute care hospital would be grouped to a surgical DRG, a separate
Medicare payment would be made under the IPPS for that care. Effective for dates of
service on or after July 1, 2006 (RY 2007), this limited exception for surgical DRGs is no
longer applicable. No further separate payment to an acute care hospital will be made.
Any tests or procedures, that were administered to the patient during that period of time of
interruption will be considered to be part of that single episode of LTCH care and bundled
into the payment to the LTCH. The LTCH will be required to pay any other providers
without additional Medicare program payment liability.
If no additional Medicare services are delivered during the3-day or less interruption (e.g.,
the patient is home and doesn’t receive any outpatient or inpatient services at an acute care
hospital or IRF or care at a SNF) prior to readmission to the LTCH, the number of days
away from the LTCH will not be included in the total length of stay for that beneficiary
stay. If care is delivered on any day during the interruption, however, that the LTCH pays
for “under arrangements,” all the days of the interruption are included in the total length of
stay for that beneficiary stay. Therefore, if a patient receives services on only one of the
days of the interruption but is away from the LTCH for 3 days, all 3 days will be deemed a
part of the total episode of care and counted towards the length of stay for that patient
stay. If an interruption of stay exceeds 3-days, the original interrupted stay policy, below,
governs payment.
• The original interrupted stay policy is now defined as “a greater than 3-day
interruption of stay” and is a stay in which a LTCH patient that is admitted upon
discharge to an inpatient acute care hospital, an inpatient rehabilitation facility
(IRF), a skilled nursing facility (SNF), or swing bed and returns to the same LTCH
within a specified period of time. The day count begins on the day of discharge
from the LTCH, which is also the admission day to the other provider, and ends on
the day of readmission to the LTCH.
o For an acute care hospital: between 4 and 9 consecutive days;
o For an IRF: between 4 and 27 consecutive days;
o For a SNF: between 4 and 45 consecutive days; and
o For a Swing Bed: between 4 and 45 consecutive days or less.
Note that although the greater than 3-day interruption of stay policy only governs when a
patient is away from the LTCH for between 4 days and the applicable provider threshold,
the day count for determining whether the threshold is met begins when the patient is
discharged. So if a patient is discharged on 9/2/04, the 3-day or less interrupted stay
policy will govern payment if the patient is readmitted to the LTCH on 9/2, 9/3, or 9/4. If
the patient is readmitted to the LTCH on 9/5, payment will be paid to, for example, the
acute care hospital which provided treatment, but the day count for determining whether
or not the stay is one interrupted stay or a whether the return to the LTCH is a separate
admission starts on 9/2. For example, if the LTCH discharges a patient to an acute care
hospital on 9/2/04, if they are readmitted to the LTCH by 9/10/04, this is an interrupted
stay. If they are readmitted on 9/11/04, it counts as a separate admission. An interrupted
stay case is treated as one discharge for the purposes of payment; only one LTCH PPS
payment is made. (The bill generated by the original stay in the LTCH should be
cancelled by the provider or they may do a debit/credit adjustment.)
Multiple interrupted stays should be entered as one claim but each interrupted stay should
be evaluated individually for the rule regarding the appropriate number of days at the
intervening facility.
If the length of stay at the "receiving" site of care exceeds the above- specified period of
time, the return to the LTCH is a new admission. This means that the original discharge to
that site is treated as a discharge for payment purposes.
For the percentage of payments that are to be made under the TEFRA system during the 5-
year transition, the A/B MAC (A) treats each segment of the interrupted stay as a separate
discharge. (A/B MACs (A) are to follow the same procedure as provided under the IRF
PPS in determining the amount of the payment under the blend that TEFRA would have
paid.)
150.9.1.3 - Payments for Special Cases
(Rev. 1816; Issued: 09-17-09; Effective Date: Discharges on or after October 1,
2009; Implementation Date: 10-05-09)
Payments for short-stay outliers are determined in the Pricer logic. Payments for
interrupted stays are based on properly submitted bills by the LTCHs, which are described
in billing instructions.
More than one case-level adjustment may apply to the same case. For example, a case
may be a short-stay outlier and also be governed by either the 3-day or less or greater than
3-day interruption of stay policy and therefore only generate 1 LTC-DRG payment to the
LTCH.
150.9.1.4 - Payment Policy for Co-Located Providers
(Rev. 2060, Issued: 10-01-10, Effective: 10-01-10, Implementation: 10-04-10)
Hospitals within hospitals (HwH), satellite facilities, and onsite SNFs:
The LTCHs that are co-located with other Medicare providers (acute care hospitals, IRFs,
SNFs) are subject to the interrupted stay policy (§150.9.1.2) but in addition, if such
discharges and readmissions exceed 5 percent of the LTCH’s total discharges during a
cost reporting period, all such readmissions during that cost reporting period are to be paid
as one discharge, regardless of the time spent at the intervening facility.
• One 5 percent calculation is applied to discharges to and readmissions from onsite
acute care hospitals and a separate 5 percent calculation is made for the combined
discharges to, and readmissions to, the LTCH from onsite IRFs, SNFs, and
psychiatric facilities.)
• Prior to triggering either of the 5 percent thresholds, such cases are to be evaluated
and paid under the interrupted stay policy. (Presently, there is no interrupted stay
policy for psychiatric facilities, so in the case of a LTCH patient who is directly
readmitted from a psychiatric facility, there will be two LTC-DRG payments
unless, and until, the number of such readmissions (counted along with
readmissions from an onsite IRF or SNF) reach the 5 percent threshold.)
The LTCHs were required to notify their A/B MACs (A) about the providers with which
they are co-located within 60 days of their first cost reporting period that began on or after
October 1, 2002. A change in co-located status must be reported to the A/B MACs (A)
within 60days of such a change. The implementation of the onsite policy is based on
information maintained by A/B MACs (A) on other Medicare providers co-located with
LTCHs. A/B MACs (A) notify the CMS RO of such arrangements.
Payments under this policy are determined at cost report settlement.
Beginning FY 2005, an additional payment adjustment was established for LTCH HwHs
and satellites of HwHs relating to the percentage of patients discharged during a specific
cost reporting period that were admitted from their host hospital. Effective for cost
reporting periods beginning on or after July 1, 2007, the payment adjustment that governs
LTCH HwHs and satellites of HwHs discharging patients from their host hospital was
extended to govern discharges from all LTCHs (not already addressed by the existing
policy) that are admitted from any referring hospital. This policy adjustment includes
discharges from “grandfathered” LTCH HwHs and LTCH satellites that were admitted
from their host hospitals; LTCH and LTCH satellite discharges from referring hospitals
that are not co-located with the discharging facility; and discharges from “free-standing”
LTCHs that were admitted from any referring hospital.
Basic Payment Formula under the 25 Percent Threshold Payment Adjustment for
Medicare Discharges from Referring Hospitals
NOTE: On December 29, 2007, the Medicare, Medicaid, and SCHIP Extension Act of
2007 (MMSEA) was enacted with mandated several modifications to this policy for a 3-
year period beginning on the date of enactment of the Act. For clarity, each modification
to the policy is specified in a bullet point immediately below the explanation of the
particular aspect of the policy as it was effective on July 1, 2007. The bullet points below
also include additional amendments made by the enactment of the American Recovery
and Reinvestment Act (ARRA) of 2009 on February 17, 2009, to the 25 percent threshold
payment adjustment. It is important to note that for those policies that operate on an
October 1 cycle (i.e. pre-MMSEA regulations at 42 CFR §412.534), the ARRA has
amended the MMSEA so that the MMSEA relief is effective for cost reporting periods
beginning on or after October 1, 2009, and before October 1, 2010. For policies that
operate on a July 1 cycle, (e.g., pre-MMSEA regulations at 42 CFR 412.534(h) and §412.
536) the ARRA amendments to the MMSEA relief are effective for cost reporting periods
beginning on or after July 1, 2007 and before July 1, 2010.
With the passage of the Affordable Care Act of 2010, all provisions of MMSEA as
amended by the ARRA affecting the LTCH PPS were extended an additional 2-years.
Therefore, provisions due to sunset on July 1, 2010, and October 1, 2010, have been
extended until July 1 2012, and October 1, 2012, respectively. The revisions to this
section (below), indicate these new dates.
• Admitted to co-located LTCHs and LTCH satellites from their host hospitals
o This policy was finalized for FY 2005
o If a LTCH HwH or satellite admits from its host hospital in excess of 25
percent or the applicable percentage) of its discharges for the LTCH’s cost
reporting period, an adjusted payment will be made of the lesser of the
otherwise full payment under the LTCH PPS and an amount that would be
equivalent to what Medicare would otherwise be paid under the IPPS. For
LTCHs and LTCH satellites subject to the transition period described
below, there is a 3-year transition to the full 25 percent threshold payment
adjustment.
As amended by the MMSEA of 2007 and further amended by the ARRA and the
ACA:
• The percentage threshold for “applicable” LTCHs and LTCH satellites
(i.e., subject to the transition described below) is raised from 25 percent to
50 percent for LTCH cost reporting periods beginning on or after October1,
2007, and before October 1, 2012. “Grandfathered” LTCH satellites are
also “applicable” for this increase, under the ARRA but on a July 1 cycle,
as noted above.
• For LTCHs with “special circumstances,” specified below, the 50 percent
threshold is raised to 75 percent for the same 3-year period.
o In determining whether a hospital meets the 25 percent criterion, patients
transferred from the host hospital that have already qualified for outlier
payments at the acute host would not count as part of the host’s allowable
percentage and therefore the payment would not be subject to the
adjustment. Those patients would be eligible for full payment under the
LTCH PPS. (Cases admitted from the host before the LTCH crosses the 25
percent or applicable threshold would be paid under the LTCH PPS.)
• Admitted to Grandfathered LTCH HwHs and LTCH Satellites from their
Host Hospitals
Prior to the enactment of the MMSEA and the ARRA, this policy was effective for
cost reporting periods beginning on or after July 1, 2007.
o Subject to the 3-year transition described below, if a grandfathered LTCH
HwH or a grandfathered satellite of a LTCH has admitted from its host
hospital in excess of 25 percent or the applicable percentage) of its
discharges for the LTCH’s cost reporting period, an adjusted payment will
be made of the lesser of the otherwise full payment under the LTCH PPS
and an amount that would be equivalent to what Medicare would otherwise
be paid under the IPPS.
o In determining whether a hospital meets the 25 percent criterion, patients
transferred from the host hospital that have already qualified for outlier
payments at the acute host would not count as part of the host’s allowable
percentage and therefore the payment would not be subject to the
adjustment. Those patients would be eligible for full payment under the
LTCH PPS. (Cases admitted from the host before the LTCH crosses the 25
percent or applicable threshold would be paid under the LTCH PPS.)
• Admitted to all LTCHs and LTCH Satellites from Referring Hospitals other
than those with which they are Co-located:
○ This policy is effective for cost reporting periods beginning on or after July
1, 2007.
○ Subject to the 3-year transition specified below, if a LTCH or LTCH
satellite admits from its host hospital in excess of 25 percent or the
applicable percentage) of its discharges for the HwH’s cost reporting
period, an adjusted payment will be made of the lesser of the otherwise full
payment under the LTCH PPS and an amount that would be equivalent to
what Medicare would otherwise be paid under the IPPS. (See details of
this payment adjustment below the discussion of the MMSEA and the
ARRA changes.)
○ In determining whether a hospital meets the 25 percent criterion, patients
transferred from the host hospital that have already qualified for outlier
payments at the acute host would not count as part of the host’s allowable
percentage and therefore the payment would not be subject to the
adjustment. Those patients would be eligible for full payment under the
LTCH PPS. (Cases admitted from the host before the LTCH crosses the 25
percent or applicable threshold would be paid under the LTCH PPS.)
As amended by the MMSEA of 2007 and further amended by the ARRA and the
ACA:
• For cost reporting periods beginning on or after July 1, 2007, and before
July 1, 2012, grandfathered LTCH HwHs are exempted from the 25 percent
threshold for admissions from co-located hospitals or referring hospitals
with which they are not co-located.
• “Freestanding” LTCHs, i.e., LTCHs not co-located with another hospital as
a HwH or as a satellite are exempted from the 25 percent threshold for
admissions from any referring hospital.
As amended by the ARRA of 2009:
• The ARRA amended the MMSEA changes to the 25 percent threshold
policy by adding another category of LTCHs that would be subject to the 3-
year delay in application of the 25 percent payment provision, i.e., LTCHs
or LTCH satellites that were co-located with provider-based locations of an
IPPS hospital that did not deliver services payable under the IPPS at those
campuses where the LTCHs or LTCH satellites were located.
The 5-year delay in the application of the percentage threshold payment adjustment for
each of the above categories is effective for cost reporting periods beginning on or after
July 1, 2007 and before July 1, 2012.
NOTE: For cost reporting periods beginning on or after July 1, 2007 and before July 1,
2012 or on or after October 1, 2007, and before October 1, 2012, as applicable (see
explanation above), this payment adjustment continues to be applicable under the specific
circumstances set forth in the MMSEA and the ARRA as amended by the ACA.
Payment adjustment under the 25 percent threshold payment policy
Under the LTCH PPS, payments for LTCH or LTCH discharges in excess of the specified
threshold percentages are based on the lesser of an amount otherwise payable under the
LTCH PPS or an amount that is equivalent to what would otherwise be paid under the
IPPS for the costs of inpatient operating services would be based on the standardized
amount adjusted by the applicable IPPS DRG weighting factors. This amount would be
further adjusted for area wage levels using the applicable IPPS labor-related share based
on the CBSA where the LTCH is physically located and the IPPS wage index for non-
reclassified hospitals published in the annual IPPS final rule. For LTCHs located in
Alaska and Hawaii, this amount would also be adjusted by the applicable COLA factors
used under the IPPS. Furthermore, an amount equivalent to what would otherwise be paid
under the IPPS for the costs of inpatient operating services would also include, where
applicable, a DSH adjustment and where applicable, an IME adjustment.
Additionally, to arrive at the payment amount equivalent to what would otherwise be
payable under the IPPS, a LTCH would also be paid under the LTCH PPS for the costs of
inpatient capital-related costs, using the capital Federal rate determined under adjusted by
the applicable IPPS DRG weighting factors. This amount would be further adjusted by
the applicable geographic adjustment factors set forth, including local cost variation
(based on the IPPS wage index for non-reclassified hospitals published in the annual IPPS
final rule), large urban location, and COLA, if applicable.
For discharges governed by this payment, an amount that is equivalent to an amount that
would otherwise be paid under the IPPS for the inpatient capital-related costs would also
include a DSH adjustment if applicable, and an equivalent IME adjustment), if applicable.
An amount equivalent to what would be paid under the IPPS would be determined based
on the sum of the amount equivalent to what would be paid under the IPPS inpatient
operating services and the amount equivalent to what would be paid under the IPPS for
inpatient capital-related costs. This is necessary since, under the IPPS, there are separate
Medicare rates for operating and capital costs to acute care hospitals, while under the
LTCH PPS, there is a single payment rate for the operating and capital costs of the
inpatient hospital’s services provided to LTCH Medicare patients.
Note that there is a difference between the policy that we have codified for adjusted
payments to LTCH HwHs and satellites of LTCHs, which is based on an amount
“equivalent” under the existing payment, and the additional component to the SSO
payment adjustment that is based on an amount “comparable” to what would otherwise be
paid under the IPPS adjustment. The distinction is that if a SSO case also qualifies as a
high cost outlier (HCO) case after the SSO payment amount is determined, the SSO
payment formula uses the LTCH PPS fixed loss amount. In contrast, under the payment
adjustment for LTCH HwHs and LTCH satellites if the amount payable by Medicare for a
specific case is equivalent to what would be otherwise payable under the IPPS and the
case also qualified as a HCO, the outlier payment for this case would be based on the IPPS
HCO policy because the resulting payment would then be more equivalent to what would
have been payable under the IPPS. Similarly, if under this payment adjustment the lesser
amount resulted in an “otherwise payable amount under the LTCH PPS,” and the stay
qualified as a HCO, Medicare would generate a HCO payment governed by the LTCH
PPS fixed loss amount calculated under the LTCH PPS and if the estimated cost of the
case exceeds the adjusted LTC-DRG plus a fixed loss amount under §412.525(a), the
LTCH would receive an additional payment based on the LTCH PPS HCO policy.
Specific Circumstances (applicable to all of the above scenarios)
NOTE: MMSEA changes described above, as amended by the ARRA and
further amended by the ACA, are applicable for cost reporting periods
beginning on or after October 1, 2007, and before October 1, 2012, or on or
after July 1 2007, and before July 1, 2012..
• For LTCHs and LTCH satellites located in rural areas, instead of the 25
percent threshold, we provide for a 50 percent threshold for patients from
any individual referral hospital. In addition, in determining the percentage
of patients admitted from that referring hospital, any patient that had been
Medicare outliers at the host and then transferred to the HwH would be
considered as if they were admitted from a non-host hospital. Under
MMSEA, the 25 percentage threshold is increased to 50 percent for
applicable LTCH HwHs, satellites, and grandfathered satellites.
• For urban single or MSA dominant referring hospitals, we would allow the
LTCH or LTCH satellite to admit from the host up to the referring
hospital’s percentage of total Medicare discharges in the MSA. A floor of
25 percent and a ceiling of 51 percent applied to this variation. Under
MMSEA, the 50 percentage threshold is increased to 75 percent.
Transition Periods
For Medicare discharges from referring hospitals:
• Admitted to co-located LTCHs and LTCH satellites from their host hospitals
o This policy was finalized for FY 2005.
This payment adjustment will be phased-in over 4 years for existing LTCH HwHs and
also for LTCHs-under-formation that satisfy the following two-prong requirement:
o On or before October 1, 2004 they have certification as acute care hospitals,
under Part 489; and
o Before October 1, 2005 designation as a LTCH.
For purposes of full payment under the LTCH PPS during the transition period, the
percentage of discharges from the LTCH HwH originating from the host hospital
for each applicable cost reporting period, may not exceed the percentage of
discharges during the hospital’s cost reporting period during FY 2004 that were
admitted from the host hospital.
Year 1 -- (cost reporting periods beginning on or after October 1, 2004 through September
30, 2005) a “hold harmless”
o Payments will be made under the LTCH PPS but the percentage of LTCH
HwH discharges originating from the host may not exceed the percentage for
such patients established for cost reporting periods during FY 2004.
Year 2 -- (cost reporting periods beginning on or after October 1, 2005 through September
30, 2006)
o LTCH HwHs will be paid under the otherwise unadjusted LTCH PPS for the
percentage of discharges originating from their host hospital that do not exceed
the lesser of the percentage of those patients for their FY 2004 cost reporting
period or 75 percent.
o For discharges in excess of that threshold, the payments will be determined
under “the basic payment formula” specified above.
Year 3 -- (cost reporting periods beginning on or after October 1, 2006 through September
30, 2007)
o LTCH HwHs will be paid under the otherwise unadjusted LTCH PPS for the
percentage of discharges originating from their host hospital that do not exceed
the lesser of the percentage of those patients for their FY 2004 cost reporting
period or 50 percent.
o For discharges in excess of that threshold, the payments will be determined
under “the basic payment formula” specified above.
Year 4 -- (cost reporting periods beginning on or after October 1, 2007 through September
30, 2008)
o LTCH HwHs will be paid under the otherwise unadjusted LTCH PPS for the
percentage of discharges originating from their host hospital that do not exceed
the 25 percent or the applicable percentage described for “specific
circumstances above.”
o For discharges in excess of that threshold, the payments will be determined
under “the basic payment formula” specified above.
Transition Period for all LTCHs affected by the Above Described Regulations for
cost reporting periods beginning on or after July 1, 2008.
NOTE: MMSEA as amended by the ARRA and further amended by the ACA
changes described above applicable for cost reporting periods beginning on or
after July 1, 2007, and before July 1, 2012 for “grandfathered” LTCH HwHs
and “freestanding” LTCHs.
The full payment threshold adjustment will be phased in over 3-years as follows:
Year 1 - (for cost reporting periods beginning on or after July 1, 2007 through June 30,
2008)
o LTCHs and LTCH satellites will be paid under the otherwise unadjusted
LTCH PPS for the percentage of discharges originating from a referring
hospital that do not exceed the lesser of the percentage of those patients for
their RY 2005 cost reporting period or 75 percent.
o For discharges in excess of that threshold, the payments will be determined
under “the basic payment formula” specified above.
Year 2 - (for cost reporting periods on or after July 1, 2008 through June 30, 2009),
o LTCHs and LTCH satellites will be paid under the otherwise unadjusted
LTCH PPS for the percentage of discharges originating from a referring
hospital that do not exceed the lesser of the percentage of those patients for
their RY 2005 cost reporting period or 50 percent.
o For discharges in excess of that threshold, the payments will be determined
under “the basic payment formula” specified above.
Year 3 - (for cost reporting periods on or after July 1, 2009)
o All LTCHs and LTCH satellites subject to the payment threshold policy
effective for RY 2008, will be subject to the 25 percent (or applicable
percentage) threshold.
o For discharges in excess of that threshold, the payments will be determined
under “the basic payment formula” specified above.
Implementation:
• The payment threshold policy for discharges from co-located LTCH HwHs
and LTCH satellites admitted from their hosts (including grandfathered
LTCH HwHs and satellites) is determined based on a location-specific
basis.
• The payment threshold policy for discharges from LTCHs and LTCH
satellites admitted from referring hospitals with which they are not co-
located is determined based upon provider numbers for both the LTCH and
the referring hospital.
For LTCHs and LTCH satellites subject to both the FY 2005 and the RY 2008
threshold payment adjustment policies
• If a co-located LTCH or a co-located referring hospital (host) shares a
provider number with a hospital or satellite at another location, threshold
determinations will continue to be location-specific for the co-located
LTCH and host. The threshold percentage determinations will be applied
to all other location or campus of either a LTCH or referring hospital in the
aggregate. For example, when the policy finalized for RY 2008 is fully
phased in, a co-located LTCH (LTCH A) and host (referring hospital A)
will have a 25 percent threshold under the policy finalized for FY 2005. If
referring hospital A shares a provider number with a remote location (RH
A’), then another 25 percent threshold will be applied to patients
discharged from LTCH A that were admitted RH A’.
• We note that for cost reporting periods beginning on or after October 1,
2007, non-grandfathered co-located LTCHs, are fully phased-in to the full
25 percent (or applicable percentage threshold) for discharges admitted
from their co-located hosts (under the initial 25 percent payment threshold
established for FY 2005)s.
• However, for discharges admitted from non-co-located referring hospitals,
these LTCH HwHs and satellites are governed by the policy finalized for
RY 2008. Therefore, for cost reporting periods beginning on or after July
1, 2007 through June 30, 2008, the 75 percent threshold will apply, and the
50 percent threshold will apply for cost reporting periods beginning on or
after July 1, 2008 through June 30, 2009 as described above in this
response.)
• Furthermore, under our finalized policy for RY 2008, grandfathered LTCH
HwHs and satellites will be subject to the 3-year transition that we are
finalizing under this new policy for all their discharges, both admitted from
their co-located host and from other non-co-located referring hospitals.
When both policies apply:
If a patient discharged from a LTCH HwH or satellite was originally admitted from the
host hospital and immediately prior to that admission to the host, the patient was being
treated at the same LTCH HwH or LTCH satellite, both of the policies described in this
section, the 5 percent on-site policy as well as the 25 percent policy are applicable. In such
a case, the following procedures should be followed keeping in mind that the 5 percent
rule affects number of discharges and the 25 percent rule affects payment.
• The on-site 5 percent computation is first in order to determine the real number of
discharges.
• Focusing on the relationship between an acute host and a LTCH HwH/satellite, if the
number of revolving door discharges between these two facilities exceeds 5 percent
during a CR period, this policy will collapse the number of discharges within that CR
period, halving the # of revolving door LTCH stays where the intervening stay
exceeded the threshold and eliminating from consideration those host stays that were
bracketed by two LTCH stays. All such stays for the entire cost reporting period will
be paid as one LTCH PPS stay.
• The next issue is to determine which of these stays will be paid an unadjusted LTCH
PPS rate and which will be paid an amount equivalent to what would otherwise be
paid under the IPPS. Cases prior to tripping the 25 percent threshold will be paid the
otherwise unadjusted LTCH PPS rate and those after the threshold that had not
achieved outlier status at the host it will be paid based on the adjustment.
• Because of the 5 percent policy that collapsed the discharges from the LTCH, for
purposes of the 25 percent policy, we are focusing on fewer discharges in total from
the LTCH and we need to determine what percent of these discharges originated in the
host so that we can apply the payment adjustment.
BUT, in the event that the 5 percent is not tripped during that cost reporting period, each
acute-->LTCH-->acute--> LTCH cycle, which will count as two LTCH discharges
originating in the host for purposes of the 25 percent policy, since both the first and
second LTCH admission were from the host.
150.9.1.5 - High Cost Outlier Cases
(Rev. 1547, Issued: 07-03-08; Effective: 07-01-08; Implementation: 07-07-08)
Additional payments are made for those cases that are considered high cost outliers. A
case falls into this category if the estimated cost of the case exceeds the outlier threshold
(the LTC-DRG payment plus a fixed loss amount). (Short-stay outliers, described above,
are also eligible for outlier payments if their costs exceed the outlier threshold. The
applicable short-stay outlier payment is used to determine the outlier threshold for short-
stay outlier cases.)
The fixed loss amount is determined annually on July 1 such that projected outlier
payments are equal to 8 percent of total LTCH PPS payments. July 1, 2008, is the final
rate year; LTCH PPS is moving back to a Federal Fiscal Year effective October 1, 2009.
If the estimated cost of the case is greater than the outlier threshold an additional payment
is added to the LTC-DRG payment amount.
The outlier payment is 80 percent of the difference between the estimated cost of the case
and the outlier threshold (the LTC-DRG payment plus a fixed loss amount).
The estimated cost of the case is calculated by multiplying the Medicare allowable charge
on the claim by the LTCH's overall cost-to-charge ratio obtained from the latest settled
cost report.
For discharges occurring on or after August 8, 2003, (high cost outlier payments may be
reconciled upon cost report settlement to account for differences between the estimated
cost-to-charge-ratio and the actual cost-to-charge ratio for the period during which the
discharge occurs. For further information, refer to the June 9, 2003 High Cost Outlier
final rule (68 FR 34506 - 34513).
150.10 - Facility-Level Adjustments
(Rev. 1547, Issued: 07-03-08; Effective: 07-01-08; Implementation: 07-07-08)
Facility-level adjustments are based on individual LTCH characteristics. The BIPA
confers broad authority on the Secretary to include "appropriate adjustments to the long-
term hospital payment system."
Variables examined include an area wage adjustment, adjustment for geographic
reclassification, disproportionate share patient (DSH) percentage, and an adjustment for
indirect medical education (IME).
• The system includes an area wage adjustment that is being phased in over 5 years.
• The wage adjustment is made by multiplying the labor-related share of the
standard Federal rate by the applicable wage index value.
• A LTCH's wage index is based on the Metropolitan Statistical Area (MSA) or rural
area in which the hospital is physically located, without regard to geographic
reclassification under http://www.ssa.gov/OP_Home/ssact/title18/1886.htm
§§1886(d)(8) - (10) of the Act. Effective July 1, 2005, an LTCH wage index is
based on the Core-Based Statistical Area (CBSA).
• The phase-in of the wage index adjustment is as follows:
Cost Reporting
Periods Beginning
During
Applicable Wage Index Value
FY 2003
1/5
th
of the value of the
applicable pre-reclassification,
no floor hospital inpatient wage
index
FY 2004
2/5
ths
of the value of the
applicable pre-reclassification,
no floor hospital inpatient wage
index
FY 2005
3/5
ths
of the value of the
applicable pre-reclassification,
no floor hospital inpatient wage
index
FY 2006
4/5
ths
of the value of the
applicable pre-reclassification,
no floor hospital inpatient wage
index
FY 2007
Full value (5/5
ths
) of the value
of the applicable pre-
reclassification, no floor
hospital inpatient wage index
Based on analyses of patient charge data from FYs 2000 and 2001 MedPAR data and cost
report data from FY 1998 and 1999 HCRIS data, there is no empirical evidence to support
other adjustments. Therefore, for the present, there are no adjustments for DSH, IME, or
geographic reclassification.
There is a cost-of-living adjustment (COLA) for LTCHs located in Alaska and Hawaii.
• The adjustment is made by multiplying the nonlabor-related portion of the
unadjusted standard Federal rate by the applicable COLA factor from OPM based
on the county that the LTCH is located (similar to the COLA under the acute care
hospital inpatient PPS).
• Annual updates for the LTCH PPS appear in Federal Register publications: for
payment rates and associated adjustments, see the LTCH PPS final rule with an
effective date of July 1. Annual updates of the LTC-DRGs are published in the
IPPS final rule with an effective date of October 1.
• The COLA factors effective July 1, 2004 are the same as under the acute care
hospital inpatient PPS and are as follows:
Area COLA
Alaska:
All Areas 1.25
Hawaii:
Honolulu 1.25
Hawaii County 1.165
Kauai County 1.2325
Maui County 1.2375
Kalawao County 1.2375
Cost-of-Living Adjustment Factors: Alaska and Hawaii Hospitals Area Cost of
Living Adjustment Factor effective for discharges on and after October 1, 2008.
Alaska:
City of Anchorage and 80-kilometer (50-mile) radius by road 1.24
City of Fairbanks and 80-kilometer (50-mile) radius by road 1.24
City of Juneau and 80-kilometer (50-mile) radius by road 1.24
Rest of Alaska 1.25
Hawaii:
City and County of Honolulu 1.25
County of Hawaii 1.17
County of Kauai 1.25
County of Maui and County of Kalawao 1.25
150.10.1 - Phase-in Implementation
(Rev. 1, 10-01-03)
The PPS for LTCHs is to be phased-in over a five- year period from cost-based
reimbursement to Federal prospective payment. During this transition period, payment is
based on an increasing percentage of the LTCH prospective payment and a decreasing
percentage of each LTCH's cost-based reimbursement rate for each discharge as follows:
Cost Reporting Periods Beginning
On or After
LTCH PPS
Federal Rate
Percentage
TEFRA
Rate
Percentage
October 1, 2002, through September 30, 2003
20
80
October 1, 2003, through September 30, 2004
40
60
October 1, 2004, through September 30, 2005
60
40
October 1, 2005, through September 30, 2006
80
20
October 1, 2006
100
0
The LTCHs can exercise a one-time irrevocable option to elect payment based on 100
percent of the Federal rate rather than transition from cost-based reimbursement to
prospective payment. To exercise this option, for cost reporting periods beginning on or
after October 1, 2002, and before December 1, 2002, the LTCH was to notify its A/B
MAC (A) of this election in writing, and it was to be received by the A/B MAC (A) no
later than November 1, 2002. To exercise this option, for cost reporting periods beginning
on or after December 1, 2002, the LTCH must notify its A/B MAC (A) in writing 30 days
prior to the start of the LTCH's next cost reporting period.
Payments to new LTCHs, i.e., a hospital that has its first cost reporting period as a LTCH
beginning on or after October 1, 2002, are made based on 100 percent of the standard
Federal rate.
NOTE: under the BIPA, during cost reporting periods beginning during FY 2001, target
amounts under TEFRA were increased by 25 percent. This increase will continue to be in
effect for the TEFRA portion of transitions payments.
150.11 - Requirements for Provider Education and Training
(Rev. 1, 10-01-03)
Training resources are available for A/B MAC (A) staff to use in training providers about
the Long Term Care Hospital Prospective Payment System (LTCH PPS). The train-the-
trainer process for LTCH PPS does not include in- person instruction for A/B MACs (A).
Instead, CMS provides various educational resources for A/B MACs (A) to learn about
LTCH PPS.
The CMS provides the following LTCH PPS education resources for A/B MACs (A):
• A training guide is available on; http://www.cms.gov/Medicare/Medicare-Fee-for-
Service-Payment/LongTermCareHospitalPPS/ltch_train.html, the actual Training
Guide can then be downloaded;
• A training video was mailed to A/B MACs (A);
• A PowerPoint presentation for training providers is available on
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/LongTermCareHospitalPPS/ltch_train.html, the actual Power Point
presentation can then be downloaded; and
• An e-mail mailbox was established to address questions. Send questions to:
LTCHPPS@cms.gov .
150.12 - Claims Processing and Billing
(Rev. 1, 10-01-03)
150.12.1 - Processing Bills Between October 1, 2002, and the
Implementation Date
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon
Implementation of ICD-10, Implementation: ICD-10: Upon Implementation of ICD-
10, ASC X12: September, 23 2014)
Claims submitted prior to implementation were processed under the current methodology.
On or after January 1, 2003, submit mass adjust claims under the PPS payment
methodology by April 30, 2003. The shared systems is creating a mass adjustment
program.
Beginning October 16, 2003, all LTCHs are required to comply with the HIPAA
Administrative Simplification Standards, unless they have obtained an extension in
compliance with the Administrative Compliance Act to submit claims in compliance with
the standards at 42 CFR 162.1002 and 45 CFR 162.1192 using the ICD. All ICD coding
must be used for LTCH providers with cost reporting period beginning on or after October
1, 2002.
150.13 - Billing Requirements Under LTCH PPS
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon
Implementation of ICD-10, Implementation: ICD-10: Upon Implementation of ICD-
10, ASC X12: September, 23 2014)
Billing LTCH PPS Services
Effective with cost reporting periods beginning on or after October 1, 2002, LTCHs are to
incorporate the following so that A/B MACs (A) accurately price and pay a claim under
the LTCH PPS. These claims must be submitted on Type of Bill 11X.
This is a DRG- based payment system; therefore the LTCH DRG is determined by the
grouping of diagnosis codes reported on the claim for the principal diagnosis, up to
twenty four additional diagnoses, and up to twenty five procedures performed during the
stay, as well as age, sex, and discharge status of the patient on the claim. Grouper
software will determine DRG assignment.
Each bill from an LTCH must contain the complete diagnosis and procedure coding for
purposes of the GROUPER software. Normal adjustments will be allowed. LTCH
providers submit one admit through discharge claim for the stay. Final PPS payment is
based upon the discharge bill (note that the day in which benefits exhaust is considered a
“discharge” for payment purposes).
Effective December 3, 2007, once a patient’s Medicare benefit’s exhaust, the LTCH is
allowed to submit no-pay bills until physical discharge or death.
150.14 - Stays Prior to and Discharge After PPS Implementation Date
(Rev. 1, 10-01-03)
If the patient's stay begins prior to and ends on or after the provider's first fiscal year begin
date under LTCH PPS, payment to the facility is based on LTCH PPS rates and rules.
There is no split billing. If the facility submitted an interim bill, a debit/credit adjustment
must be made prior to PPS payment. If the facility submits multiple interim bills, the
provider needs to submit cancels for all bills and then rebill once the cancels are accepted.
150.14.1 - Crossover Patients in New LTCHs
(Rev. 267, Issued 07-30-04, Effective: 10-01-04, Implementation: 01-03-05)
When a hospital undergoes a change in ownership or a change in classification from an
acute care hospital to a LTCH, payment issues arise for “cross-over” patients who were
admitted prior to the change in classification who are still hospitalized under the new
provider number. Since all LTCHs are required to be certified as hospitals and generally
be paid under the IPPS, for 6 months prior to designation as a LTCH, in 42 CFR
412.23(e), there are “cross-over patients,” at the creation of every LTCH, who were
admitted to the facility when it was an acute care hospital. The policy was to discharge
the patient under the acute provider number and readmit the patient under the new LTCH
provider number (see section 100.4.1 of this chapter). Medicare paid twice for what was
really one episode of care since separate payment would be made to both the acute
hospital and the LTCH. Effective October 1, 2004, Medicare will issue one discharge-
based payment to the LTCH that discharges the patient, under the applicable payment
system.
In the regulations at 42 CFR 412.521(e) we provide a payment methodology for such
cases in which Medicare will consider all the days of the patient stay in the facility (both
prior to and following the date of LTCH designation) to be a single episode of LTCH care.
Payment for this single episode of care will include the day and cost data for that patient at
both the acute care hospital and the LTCH in determining the payment to the LTCH under
the LTCH PPS. Furthermore, the days of the patient’s stay both prior to and following
designation as a LTCH are counted in determining the patient’s total length of stay at the
LTCH both for payment purposes as well as for the LTCH’s average length of stay
(ALOS) calculation under 42 CFR 412.23(e)(2) and (3).
Bills paid to the facility for crossover patients when the facility was paid under IPPS must
be canceled, so that the entire stay can be billed under the LTCH provider number and
paid for under LTCH PPS.
150.15 - System Edits
(Rev. 1472, Issued: 03-06-08, Effective: 05-23-07, Implementation: 04-07-08)
The Shared systems and/or Common Working File (CWF) must ensure:
• That revenue code total charges line 0001 must equal the sum of the individual
total charges lines;
• That the length of stay in the statement covers period, from and through dates
equals the total days for accommodations revenue codes 010x-021x, including
revenue code 018x (leave of absence)/interrupted stay;
• That Occurrence Span Code 74 is present on the claim when there is an interrupted
stay (the beneficiary has returned to the LTCH in a specified amount of time). See
section 150.9.1.2.
If the interruption is greater than the specified number of days applicable to the specific
provider, the bill is considered a discharge and two bills would exist if the beneficiary
returns to the same LTCH, otherwise it is considered an interruption with one DRG
payment associated. CWF will edit for both of these situations.
Payments under the onsite discharge and readmittance policy are to be reconciled at cost
report settlement, at which time it is possible to determine the total number of such cases
that have occurred during that cost reporting period.
The accommodation revenue code 018X, (leave of absence) continues to be used in the
current manner in terms of Occurrence Span code 74 and date range.
150.16 - Billing Ancillary Services Under LTCH PPS
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon
Implementation of ICD-10, Implementation: ICD-10: Upon Implementation of ICD-
10, ASC X12: September, 23 2014)
When coding PPS bills for ancillary services associated with a Part A inpatient stay, the
traditional revenue codes are shown, in conjunction with the appropriate entries in Service
Units and Total Charges.
• LTCHs are required to report the number of units based on the procedure or
service.
• LTCHs are required to report the actual charge for each line item, in Total
Charges.
• In general the current policy applies for billing ancillary services and nothing
changes with the implementation of this PPS.
150.17 - Benefits Exhausted
(Rev. 1472, Issued: 03-06-08, Effective: 05-23-07, Implementation: 04-07-08)
The day benefits exhaust is considered a “discharge” for payment purposes under LTCH
PPS.
If a beneficiary's Part A benefits exhaust during the stay, providers code an Occurrence
Code A3-C3. If benefits are exhausted prior to the stay, hospitals submit a no-pay claim
that is to be coded by the A/B MAC (A) with no pay code B.
LTCH PPS uses Occurrence Code 47 to indicate the first full day of cost outlier status and
also uses Occurrence Span Code 70 for covered non-utilization periods beyond the short-
stay outlier threshold. There is an exception if there are not enough regular days to reach
the short-stay outlier threshold point. For the beneficiary to continue coverage, LTR days
must be utilized for the remainder of the entire stay, as available. Similarly, for the
beneficiary to continue coverage, if only LTR days are available, they must be used on a
continuous basis throughout the entire stay, as available.
150.17.1 - Assumptions for Use in Examples Below
(Rev. 1, 10-01-03)
1. Cost outlier threshold amount is $50,000
2. Threshold amount is reached on the 25th day
3. The DRG ALOS equals 12 days, therefore, the Short Stay Threshold equals 10
days
4. Billed charges are $3,000 per day for the first 12 days, $2,000 on the 13th day and
$1,000 each day thereafter
5. Beneficiary elects to use any available LTR days
150.17.1.1 - Example 1: Coinsurance Days < Short Stay Outlier
Threshold (30 Day Stay)
(Rev. 1, 10-01-03)
1a.
Date of service: 1/1/03 - 1/31/03
Medically necessary days: 30
Covered charges: $55,000
Benefits available: 9 coinsurance and 60 LTR
Covered days: 30
Noncovered days: 0
Coinsurance days used: 9
LTR days used: 21
Cost report days: 30
Reimbursement: Full DRG payment plus cost outlier based on $55,000 covered
charges
1b.
Date of service: 1/1/03 - 1/31/03
Medically necessary days: 30
Covered charges: $27,000
Benefits available: 9 coinsurance and 0 LTR
Covered days: 9
Noncovered days: 21
Coinsurance days used: 9
LTR days used: 0
Cost report days: 9
OC A3: 1/09/03
Reimbursement: Short stay outlier
1c.
Date of service: 1/1/03 - 1/31/03
Medically necessary days: 30
Covered charges: $50,000
Benefits available: 9 coinsurance and 10 LTR
Covered days: 19
Noncovered days: 11
Coinsurance days used: 9
LTR days used: 10
Cost report days: 25
OC 47: 1/26/03
OC A3: 1/25/03
OSC 70: 1/20/03 - 1/25/03
Reimbursement: Full DRG payment
150.17.1.2 - Example 2: Coinsurance Days Greater Than or Equal to
Short Stay Outlier Threshold (30 day stay)
(Rev. 1, 10-01-03)
2a.
Date of service: 1/1/03 - 1/31/03
Medically necessary days: 30
Covered charges: $55,000
Benefits available: 15 coinsurance and 60 LTR
Covered days: 20
Noncovered days: 10
Coinsurance days used: 15
LTR days used: 5
Cost report days: 30
OC 47: 1/26/03
OSC 70: 1/16/03 - 1/25/03
Reimbursement: Full DRG payment plus cost outlier based on $55,000 covered
charges
2b.
Date of service: 1/1/03 - 1/31/03
Medically necessary days: 30
Covered charges: $53,000
Benefits available: 15 coinsurance and 3 LTR
Covered days: 18
Noncovered days: 12
Coinsurance days used: 15
LTR days used: 3
Cost report days: 28
OC 47: 1/26/03
OC A3: 1/28/03
OSC 70: 1/16/03 - 1/25/03
Reimbursement: Full DRG payment plus cost outlier based on $53,000 covered
charges
2c.
Date of service: 1/1/03 - 1/31/03
Medically necessary days: 30
Covered charges: $50,000
Benefits available: 15 coinsurance and 0 LTR
Covered days: 15
Noncovered days: 15
Coinsurance days used: 15
LTR days used:0
Cost report days: 25
OC 47: 1/26/03
OC A3: 1/25/03
OSC 70: 1/16/03 - 1/25/03
Reimbursement: Full DRG payment
150.17.1.3 - Example 3: Coinsurance Days Greater Than or Equal to
Short Stay Outlier Threshold (20 day stay)
(Rev. 1, 10-01-03)
Date of service: 1/1/03 - 1/21/03
Medically necessary days: 20
Covered charges: $45,000
Benefits available: 15 coinsurance and 0 LTR
Covered days: 15
Noncovered days: 5
Coinsurance days used: 15
LTR days used: 0
Cost report days: 20
OSC 70: 1/16/03 - 1/20/03
Reimbursement: Full DRG payment
150.17.1.4 - Example 4: Only LTR Days < Short Stay Outlier Threshold
(30 day stay)
(Rev. 1, 10-01-03)
Date of service: 1/1/03 - 1/31/03
Medically necessary days: 30
Covered charges: $27,000
Benefits available: 9 LTR
Covered days: 9
Noncovered days: 21
Coinsurance days used: 0
LTR days used: 9
Cost report days: 9
OC A3: 1/09/03
Reimbursement: Short stay outlier payment
150.17.1.4 - Example 4: Only LTR Days < Short Stay Outlier Threshold
(30 day stay)
(Rev. 1, 10-01-03)
Date of service: 1/1/03 - 1/31/03
Medically necessary days: 30
Covered charges: $27,000
Benefits available: 9 LTR
Covered days: 9
Noncovered days: 21
Coinsurance days used: 0
LTR days used: 9
Cost report days: 9
OC A3: 1/09/03
Reimbursement: Short stay outlier payment
150.17.1.5 - Example 5: Only LTR Greater Than or Equal to Short Stay
Outlier Threshold (30 day stay)
5a.
Date of service: 1/1/03 - 1/31/03
Medically necessary days: 30
Covered charges: $50,000
Benefits available: 12 LTR
Covered days: 12
Noncovered days: 18
Coinsurance days used: 0
LTR days used: 12
Cost report days: 25
OC 47: 1/26/03
OC A3: 1/25/03
OSC 70: 1/13/03 - 1/25/03
Reimbursement: Full DRG payment
5b.
Date of service: 1/1/03 - 1/31/03
Medically necessary days: 30
Covered charges: $55,000
Benefits available: 60 LTR
Covered days: 30
Noncovered days: 0
Coinsurance days used: 0
LTR days used: 30
Cost report days: 30
Reimbursement: Full DRG payment plus cost outlier based on $55,000 covered
charges
5c.
Date of service: 1/1/03 - 1/31/03
Medically necessary days: 30
Covered charges: $53,000
Benefits available: 28 LTR
Covered days: 28
Noncovered days: 2
Coinsurance days used: 0
LTR days used: 28
Cost report days: 28
OC 47: 1/26/03
OC A3: 1/28/03
Reimbursement: Full DRG payment plus cost outlier based on $53,000 covered
charges
150.18 - Provider Interim Payment (PIP)
(Rev. 1, 10-01-03)
PIP applies to LTCH PPS. Outlier payments in regards to PIP are handled the way they
currently are under other inpatient PPS systems.
150.19 - Interim Billing
(Rev. 1231; Issued: 04-27-07; Effective: 12-03-07; Implementation: 12-03-07)
Interim bills are allowed every 60 days. Refer to Chapter 1, section 50.2 for specifics on
interim billing under PPS.
Effective December 3, 2007, LTCHs are allowed to submit no-pay bills (TOB 110) once
benefit’s exhaust, every 60 days. They do not have to continually adjust bills until
physical discharge or death once benefit’s exhaust. The last bill shall contain a discharge
patient status code.
150.20 – Intermediary Benefit Payment Report (IBPR)
(Rev. 1, 10-01-03)
The IBPR report changes to reflect the payments for LTCHs going to PPS free-standing
hospitals.
150.21 - Remittance Advices (RAs)
(Rev. 1, 10-01-03)
Reason and remark codes already in existence for inpatient hospital PPS apply under this
PPS.
150.22 - Medicare Summary Notices (MSNs)
(Rev. 1, 10-01-03)
Use existing notices for inpatient hospital PPS for LTCH PPS.
150.23 - LTCH Pricer Software
(Rev. 1, 10-01-03)
The CMS developed a LTCH Pricer program that calculates the Medicare payment rate.
Pricer software is electronically supplied to the Shared systems. Pricer pays a short-stay
outlier if the stay is between 1 day and up to and including 5/6 of the average length of
stay for the LTC-DRG.
• Pricer incorporates the five-year phase-in period for those providers that
choose to be paid on the blended rate.
150.23.1 - Inputs/Outputs to Pricer
(Rev. 1231; Issued: 04-27-07; Effective: 12-03-07; Implementation: 12-03-07)
Inputs
• Provider Specific File Data; Fields-1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14, 18,
19, 21, 22, and 25 (although this field refers to the operating cost/charge ratio,
for LTCH, entered here will be a combined operating and capital cost/charge
ratio). Effective July 1, 2005, A/B MACs (A) shall no longer populate fields
12, 13, or 14. Field 35 must be populated for all LTCHs. Fields 33 and 38
shall be populated if applicable. Effective July 1, 2006, data elements 23, 24,
27, 28, and 49 are required. See the section "Determining the Cost-to-Charge
Ratio" below for determining the cost/charge ratio.
• The facility-specific rate (Field 21) will be determined using the same
methodology that would be used to determine the interim payment per
discharge under the TEFRA system if the LTCH PPS were not being
implemented.
• Bill Data
o Provider #
o Patient Status
o Covered Charges
o Discharge Date (or benefit’s exhaust date if present (Occurrence Code
A3, B3, or C3))
o Length of Stay (LOS)
o Covered Days
o Lifetime Reserve Days (LTR)
o DRG (from Grouper)
Outputs
• PPS Return Code
• MSA/CBSA (CBSAs will be returned for discharges on or after July 1, 2005).
• Wage Index
• Average LOS
• Relative Weight
• Final Payment Amount
• DRG Adjusted Payment Amount
• Federal Payment Amount
• Outlier Payment Amount
• Payment Amount
• Facility Costs
• LOS
• Regular Days Used
• LTR Days Used
• Blend Year, 1-5
• Outlier Threshold
• DRG
• COLA
• Calculation Version Code
• National Labor Percent
• National Non-Labor Percent
• Standard Federal Rate
• Budget Neutral Rate
• New Facility-specific Rate
150.24 - Determining the Cost-to-Charge Ratio
(Rev. 4390, Issued: 09-06-19, Effective: 10-01-19, Implementation: 10-07-19)
For all LTCHs, effective October 1, 2003, Medicare contractors are to use a CCR from the
latest final settled cost report or from the latest tentative settled cost report (whichever is
from the later period) to determine a LTCH’s CCR.
A. - Calculating an overall LTCH Medicare Cost-to-Charge Ratio
For the LTCH PPS outlier calculations (short stay and high cost), Medicare’s portion of
hospital costs are determined by using a hospital’s overall Medicare cost-to-charge ratio
(CCR). At the end of the cost reporting period, the hospital prepares and submits a cost
report to its Medicare contractor, which includes Medicare allowable costs and charges.
The Medicare contractor completes a preliminary review of the as-submitted cost report
and issues a tentative settlement. The cost report is later final settled, which may be based
on a subsequent review, and a Notice of Program Reimbursement (NPR) is issued.
The Medicare contractor shall update the PSF using the CCR calculated from the final
settled cost report or from the latest tentative settled cost report (whichever is from the
later period).
Under the LTCH PPS, the following methodology shall be used to calculate a hospital’s
overall Medicare cost-to-charge ratio:
1) Identify total Medicare inpatient costs from Worksheet D-1, Part II, line 49 minus
(Worksheet D, Part III, col. 8, lines 25 through 30 plus Worksheet D, Part IV, col.
7, line 101)
2) Identify total Medicare inpatient charges obtained from Worksheet D-4, Column 2,
lines 25 through 30 plus line 103 from the cost report (where possible, these
charges should be confirmed with the PS&R data).
3) Determine the LTCH’s overall Medicare CCR by dividing the amount in step 1 by
the amount in step 2.
B. - Use of Alternative Data in Determining CCRs For LTCHs
Effective August 8, 2003, the CMS Central Office may direct Medicare contractors to use
an alternative CCR if CMS believes this will result in a more accurate CCR. Also, if the
Medicare contractor finds evidence that indicates that using data from the latest settled or
tentatively settled cost report would not result in the most accurate CCR, then the
Medicare contractor shall notify the CMS Regional Office and CMS Central Office to
seek approval to use a CCR based on alternative data. For example, a CCR may be
revised more often if a change in a LTCHs operations occurs which materially affects a
LTCH’s costs and/or charges. The CMS Regional Office, in conjunction with the CMS
Central Office, must approve the Medicare contractor’s request before the Medicare
contractor may use a CCR based on alternative data. Revised CCRs will be applied
prospectively to all LTCH claims processed after the update. Medicare contractors shall
send notification to the CMS Central Office via email to [email protected].
C. - Ongoing CCR Updates Using CCRs From Tentative Settlements For Hospitals
Subject to the LTCH PPS
Medicare contractors shall continue to update a LTCH’s CCR (in the Provider Specific
File) each time a more recent cost report is settled (either final or tentative). A revised
CCR shall be entered into the Provider Specific File not later than 30 days after the date of
the latest settlement used in calculating the CCR.
D. - Request for use of a Different CCR by CMS, the Medicare Contractor or the
LTCH
Effective August 8, 2003, CMS (or the Medicare contractor) may specify an alternative
CCR if it believes that the CCR being applied is inaccurate. In addition, a LTCH will
have the opportunity to request that a different CCR be applied in the event it believes the
CCR being applied is inaccurate. The LTCH is required to present substantial evidence
supporting its request. Such evidence should include documentation regarding its costs
and charges that demonstrate its claim that an alternative ratio is more accurate. After the
Medicare contractor has evaluated the evidence presented by the LTCH, the Medicare
contractor notifies the CMS Regional Office and CMS Central Office of any such request.
The CMS Regional Office, in conjunction with the CMS Central Office, will approve or
deny any request by the LTCH or Medicare contractor for use of a different CCR.
Medicare contractors shall send requests via email to the CMS Central at
[email protected].
E. - Notification to Hospitals Under the LTCH PPS of a Change in the CCR
The Medicare contractor shall notify a LTCH whenever it makes a change to its CCR.
When a CCR is changed as a result of a tentative settlement or a final settlement, the
change to the CCR can be included in the notice that is issued to each provider after a
tentative or final settlement is completed. Medicare contractors can also issue separate
notification to a LTCH about a change to their CCR.
F. - Mergers, Conversions and Errors with CCRs
Effective April 1, 2011, for LTCHs that merge, Medicare contractors shall continue to use
the CCR from the LTCH with the surviving provider number. If a new provider number is
issued, as explained in §150.25 below, Medicare contractors should use the Statewide
average CCR because a new provider number indicates the creation of a new hospital (as
stated in 42 CFR §§ 412.525(a)(4)(iv)(C)(1) and 412.529(c)(3)(iv)(C)(1), a new hospital is
defined as an entity that has not accepted assignment of an existing hospital’s provider
agreement). However, the policy of §150.24 part B and C can be applied to determine an
alternative to the Statewide average CCR.
For newly classified LTCHs, that is those hospitals (e.g., short term acute, psychiatric, or
rehabilitation hospitals) that meet the requirements set forth in 42 CFR 412.23(e), or
LTCHs that receive a new LTCH provider number, the Statewide average CCR should be
used until a CCR can be computed from the LTCH’s cost report data, as described in part
A of this section. However, as noted in part C above, the Medicare contractor or the
LTCH may request use of a different CCR, such as a CCR based on the cost and charge
data from the hospital’s cost report immediately preceding its classification as a LTCH or
receiving a new LTCH provider number. The Medicare contractor must verify the cost
and charge data from that cost report. Use of the alternative CCR is subject to the approval
of the CMS Central and Regional Offices. NOTE: A newly classified LTCH must
request an alternative CCR and receive approval from the CMS Central Office prior
to the effective date of the hospital’s classification as a LTCH in order for that
alternative CCR to be effective beginning on the date of classification (as a LTCH).
If the request and approval for an alternative CCR occurs after the effective date of
the LTCH classification, then the use of the alternative CCR will be effective
prospectively beginning with the date of the approval of the alternative CCR request.
In instances where errors related to CCRs and/or outlier payments are discovered,
Medicare contractors shall contact the CMS Central Office to seek further guidance.
Medicare contractors may contact the CMS Central Office via email at
[email protected].
If a cost report is reopened after final settlement and as a result of this reopening there is a
change to the CCR, Medicare contractors shall contact the CMS regional and Central
Office for further instructions. Medicare contractors may contact the CMS Central Office
via email at [email protected].
G. - Maintaining a History of CCRs and Other Fields in the Provider Specific File
When reprocessing claims due to outlier reconciliation, Medicare contractors shall
maintain an accurate history of certain fields in the provider specific file (PSF). This
history is necessary to ensure that claims already processed (from prior cost reporting
periods that have already been settled) will not be subject to a duplicate systems
adjustment in the event that claims need to be reprocessed. As a result, the following
fields in the PSF can only be altered on a prospective basis: 21 -Case Mix Adjusted Cost
Per Discharge, 23 -Intern to Bed Ratio, 24 -Bed Size, 25 -Operating Cost to Charge Ratio,
27 -SSI Ratio and 28 -Medicaid Ratio. A separate history outside of the PSF is not
necessary. (NOTE: PSF elements 23, 24, 27, 28 and 49 are only required for LTCHs
effective 7/11/06.). The only instances a Medicare contractor retroactively changes a field
in the PSF is to update the CCR when using the FISS Lump Sum Utility for outlier
reconciliation or otherwise specified by the CMS Regional Office or Central Office.
150.25 - Statewide Average Cost-to-Charge Ratios
(Rev. 2111, Issued: 12-03-10, Effective: 04-01-11, Implementation: 04-04-11)
For discharges prior to August 8, 2003, the Statewide average CCR is used in those
instances in which a LTCH’s CCR falls above or below reasonable parameters. CMS sets
forth these parameters and the Statewide average CCRs in each year’s IPPS annual notice
of prospective payment rates.
For discharges occurring on or after August 8, 2003, the Medicare contractor should use a
Statewide average CCR if it is unable to determine an accurate CCR for a LTCH in one of
the following circumstances:
1. New hospitals that have not yet submitted their first Medicare cost report. (For this
purpose, a new hospital is defined as an entity that has not accepted assignment of
an existing hospital’s provider agreement in accordance with 42 CFR 489.18.)
2. LTCHs whose overall CCR is in excess of 3 standard deviations above the
corresponding national geometric mean. Effective 10/1/2006, this mean is
recalculated annually by CMS and published in the annual notice of prospective
payment rates issued in accordance with §§412.525(a)(4)(iv)(c)(2) and
412.529(c)(3)(iv)(c)(2) of the CFR.
3. Other LTCHs for whom accurate data with which to calculate an overall CCR are
not available.
However, the policies of §150.24 part B and C can be applied as an alternative to the
Statewide average CCR.
For those LTCHs assigned the Statewide average CCR, the CCR must be updated every
October 1 based on the latest Statewide average CCRs published in each year’s IPPS
annual notice of prospective payment rates (Table 8C for LTCHs) until the hospital is
assigned a CCR based on the latest tentative or final settled cost report or a CCR based on
the policies of §150.24 part B and C of this manual. A hospital is not assigned the
Statewide average CCR if its CCR falls below 3 standard deviations from the national
mean CCR. In such a case, the LTCH CCR is used.
150.26 - Reconciliation
(Rev. 4390, Issued: 09-06-19, Effective: 10-01-19, Implementation: 10-07-19)
A. - General
For all LTCHs, reconciliation is effective beginning with discharges occurring in a
hospital’s first cost reporting period beginning on or after October 1, 2003.
Subject to the approval of the CMS Central Office, Medicare contractors shall reconcile a
LTCHs outlier claims at the time of cost report final settlement if they meet the following
criteria:
1. The actual CCR is found to be plus or minus 10 percentage points from the CCR
used during that cost reporting period to make outlier payments, and
2. Applicable outlier payments exceed $500,000 in that cost reporting period.
For the purposes of determining whether outlier payments meet the $500,000 threshold,
MACs shall combine the following applicable payments depending on the cost reporting
period:
a. For cost reporting periods beginning before October 1, 2015, high cost outlier
payments made under 42 CFR §412.525 and short-stay outlier payments made
under 42 CFR §412.529 (“OUTLIER” and “SHORT STAY OUTLIER
PAYMENTS” on PS&R Report 11S);
b. For cost reporting periods beginning on or after October 1, 2015 and ending before
October 1, 2017, high cost outlier payments made under 42 CFR §412.525 (that is,
both high cost outlier payments made to site neutral payment rate discharges
described under 42 CFR §412.522(a)(1) and to standard payment rate discharges
described under 42 CFR §412.522(a)(2)), and short-stay outlier payments made
under 42 CFR §412.529 (“OUTLIER” and “SSO STANDARD PAYMENTS” on
PS&R Report 11S);
c. For cost reporting periods beginning on or after October 1, 2015 and ending after
October 1, 2017
i. For discharges before October 1, 2017, high cost outlier payments
made under 42 CFR §412.525 (that is, both high cost outlier payments
made to site neutral payment rate discharges described under 42 CFR
§412.522(a)(1) and to standard payment rate discharges described
under 42 CFR §412.522(a)(2)), and short-stay outlier payments made
under 42 CFR §412.529 (“OUTLIER” and “SSO STANDARD
PAYMENTS on PS&R Report 11S);
ii. For discharges after October 1, 2017, high cost outlier payments made
under 42 CFR §412.525 (that is, both high cost outlier payments made
to site neutral payment rate discharges described under 42 CFR
§412.522(a)(1) and to standard payment rate discharges described
under 42 CFR §412.522(a)(2)) (“OUTLIER” on PS&R Report 11S); or
d. For cost reporting periods beginning on or after October 1, 2017, high cost outlier
payments made under 42 CFR §412.525 (that is, both high cost outlier payments
made to site neutral payment rate discharges described under 42 CFR
§412.522(a)(1) and to standard payment rate discharges described under 42 CFR
§412.522(a)(2)) (“OUTLIER” on PS&R Report 11S).
To determine if a LTCH meets the criteria above, the Medicare contractor shall
incorporate all the adjustments from the cost report, run the cost report, calculate the
revised CCR and compute the actual CCR prior to issuing a Notice of Program
Reimbursement (NPR). If the criteria for reconciliation are not met, the cost report shall
be finalized. If the criteria for reconciliation are met, Medicare contractors shall follow
the instructions below in §150.28. The NPR cannot be issued nor can the cost report be
finalized until outlier reconciliation is complete. The criteria above replaces the criteria
published in §III of PM A-03-058.
As stated above, if a cost report is reopened after final settlement and as a result of this
reopening there is a change to the CCR (which could trigger or affect outlier reconciliation
and outlier payments), Medicare contractors shall notify the CMS Regional and Central
Office for further instructions. Notification to the CMS Central Office shall be sent via
email to outliersIP[email protected].
Even if a LTCH does not meet the criteria for reconciliation, subject to approval of the
CMS Regional and Central Office, the Medicare contractor has the discretion to request
that a LTCH’s outlier payments in a cost reporting period be reconciled if the LTCH’s
most recent cost and charge data indicate that the outlier payments to the hospital were
significantly inaccurate. The Medicare contractor sends notification to the CMS Central
Office via email to [email protected]. Upon approval of the CMS regional and
Central Office that a LTCH’s high cost and short stay outlier claims need to be reconciled,
Medicare contractors shall follow the instructions in §§150.27 and 150.28.
B. Reconciling Outlier Payments
Beginning with the first cost reporting period starting on or after October 1, 2003, all
LTCHs are subject to the reconciliation policies set forth in this section. If a LTCH meets
the criteria in part A of this section, the Medicare contractor shall follow the instructions
below in §150.28. Further instructions for Medicare contractors on reconciliation and the
time value of money are provided below in §§150.27 and 150.28. The following
examples demonstrate how to apply the criteria for reconciliation:
Example A
Cost Reporting Period: 01/01/2004-12/31/2004
CCR used to pay original claims submitted during cost reporting period: 0.40 (In this
example, this CCR is from the tentatively settled 2002 cost report).
Final settled CCR from 01/01/2004-12/31/2004 cost report: 0.50.
Total outlier payments (short-stay and high cost outliers combined) in 01/01/2004-
12/31/2004 cost reporting period: $600,000.
Because the CCR of 0.40 used at the time the claim was originally paid changed to 0.50
(by more than 10 percentage points) at the time of final settlement, and the provider
received greater than $500,000 in (short-stay and high cost) outlier payments during that
cost reporting period, the criteria has been met to trigger reconciliation, and therefore, the
Medicare contractor notifies the CMS Regional Office and CMS Central Office. The
provider’s outlier payments for this cost reporting period will be reconciled using the
actual CCR of 0.50.
In the event that multiple CCRs are used in a given cost reporting period, Medicare
contractor shall calculate a weighted average of the CCRs in that cost reporting period.
(See Example B below for instructions on how to weight the CCRs). The Medicare
contractor shall then compare the weighted average CCR to the CCR determined at the
time of final settlement of the cost reporting period to determine if reconciliation is
required. Again, total (combined short- stay and high cost) outlier payments for the entire
cost reporting period must exceed $500,000 in order to trigger reconciliation.
Example B
Cost Reporting Period: 01/01/2004-12/31/2004
CCR used to pay original claims submitted during cost reporting period:
- 0.40 from 01/01/2004-03/31/2004 (This CCR is from the tentatively settled 2001 cost
report)
- 0.50 from 04/01/2004-12/31/2004 (This CCR is from the tentatively settled 2002 cost
report)
Final settled CCR from 01/01/2004-12/31/2004 cost report: 0.35
Total (short-stay and high cost) outlier payout in 01/01/2004-12/31/2004 cost reporting
period: $600,000
Weighted Average CCR: 0.474, completed as follows:
CCR
Days
Weight
Weighted CCR
0.40
91
0.248 (91 Days / 366 Days)
(a) 0.099=
(0.40 * 0.248)
0.50
275
0.751 (275 Days / 366 Days )
(b) 0.375=
(0.50 * 0.751)
TOTAL
*366
(a)+(b) =0.4742
*NOTE: There are 366 days in the year because 2004 was a leap year.
The LTCH meets the criteria for reconciliation in this cost reporting period because the
weighted average CCR at the time the claim was originally paid changed (by more than
ten percentage points) from 0.474 to 0.35 at the time of final settlement, and the provider
received (combined) outlier payments greater than $500,000 for the entire cost reporting
period.
150.27 - Time Value of Money
(Rev. 2242, Issued: 06-17-11, Effective: 07-01-11, Implementation: 07-01-11)
At the time of any reconciliation under §150.26, outlier payments may be adjusted to
account for the time value of money of any adjustments to outlier payments as a result of
reconciliation. The time value of money is applied from the midpoint of the LTCH’s cost
reporting period being settled to the date on which the CMS Central Office receives
notification from the Medicare contractor that reconciliation should be performed.
If a LTCH’s outlier payments have met the criteria for reconciliation, the Medicare
contractor shall follow the process in §150.28. The index that will be used to calculate the
time value of money is the monthly rate of return that the Medicare trust fund earns. This
index can be found at
http://www.ssa.gov/OACT/ProgData/newIssueRates.html
The following formula will be used to calculate the rate of the time value of money.
(Rate from Web site as of the midpoint of the cost report being settled / 365) * # of days
from that midpoint until date of reconciliation.
NOTE: The time value of money can be a positive or negative amount depending if the
provider is owed money by CMS or if the provider owes money to CMS.
For purposes of calculating the time value of money, the “date of reconciliation” is the day
on which the CMS Central Office receives notification. This date is either the postmark
from the written notification sent to the CMS Central Office via mail by the Medicare
contractor, or the date an email was received from the Medicare contractor by the CMS
Central Office, whichever is first.
The following is an example of the procedures for reconciliation and computation of the
adjustment to account for the time value of money:
Example C
Cost Reporting Period: 01/01/2004-12/31/2004
Midpoint of Cost Reporting Period: 07/01/2004
Date of Reconciliation: 12/31/2005
Number of days from Midpoint until date of Reconciliation: 549
Rate from Social Security Web site: 4.625%
CCR used to pay actual original claims in cost reporting period: 0.40 (This CCR could be
from the tentatively settled 2002 or 2003 cost report)
Final settled CCR from 01/01/2004-12/31/2004 cost report: 0.50
Total outlier payout in 01/01/2004-12/31/2004 cost reporting period: $600,000.
Because the CCR fluctuated from 0.40 at the time the claims were originally paid to 0.50
at the time of final settlement and the provider has total outlier payments greater than
$500,000, the criteria have been met to trigger reconciliation. The Medicare contractor
notifies the CMS Regional Office and CMS Central Office.
The Medicare contractor reprices the claims in accordance with the process in §150.28
below. The repricing indicates the revised outlier payments are $700,000.
Using the values above, determine the rate that will be used for the time value of money:
(4.625 / 365) * 549 = 6.9565%
Based on the claims reconciled, the provider is owed $100,000 ($700,000-$600,000) for
the reconciled amount and $6,956.50 ($100,000 * 6.9565 %) for the time value of money.
150.28 - Procedure for Medicare Contractors to Perform and Record
Outlier Reconciliation Adjustments
(Rev. 4390, Issued: 09-06-19, Effective: 10-01-19, Implementation: 10-07-19)
The following is a step-by-step explanation of the procedures that Medicare contractors
are to follow if a LTCH is eligible for outlier reconciliation:
1) The Medicare contractor shall send notification to the CMS Central Office (not the
hospital), via email to outliersIP[email protected] and CMS Regional Office that a
hospital has met the criteria for reconciliation. Medicare contractors shall include
in their notification the provider number, provider name, cost reporting begin date,
cost reporting end date, total short stay and high cost outlier payments in the cost
reporting period, the CCR or weighted average CCR from the time the claims were
paid during the cost reporting period eligible for reconciliation and the final settled
CCR.
2) If the Medicare contractor receives approval from the CMS Central Office that
reconciliation is appropriate, the Medicare contractor shall follow steps 3-14
below. NOTE: Hospital cost reports will remain open until their claims have been
processed for outlier reconciliation.
3) The Medicare contractor shall notify the hospital and copy the CMS Regional
Office and Central Office via email at out[email protected] that the
hospital’s outlier claims are to be reconciled.
4) Prior to running claims in the *Lump Sum Utility, Medicare contractors shall
update the applicable provider record in the Provider Specific File (PSF) by
entering the final settled CCR from the cost report in the -25 -Operating Cost to
Charge Ratio field. No other elements in the PSF shall be updated for the
applicable provider records in the PSF that span the cost reporting period being
reconciled aside from the CCR.
*NOTE: The FISS Lump Sum Utility is a Medicare contractor tool that,
depending on the elements that are input, will produce an extract that will
calculate the difference between the original PPS payment amounts and
revised PPS payment amounts into a Microsoft Access generated report. The
Lump Sum Utility calculates the original and revised payments offline and
will not affect the original claim payment amounts as displayed in various
CMS systems (such as NCH).
5) Medicare contractors shall ensure that, prior to running claims through the FISS
Lump Sum Utility, all pending claims (e.g., appeal adjustments) are finalized for
the applicable provider.
6) Medicare contractors shall only run claims in the Lump Sum Utility that meet the
following criteria:
7) Type of Bill (TOB) equals 11X
8) Previous claim is in a paid status (P location) within FISS
9) Cancel date is ‘blank’
10) The Medicare contractor reconciles the claims through the applicable LTCH Pricer
software and not through any editing or grouping software.
11) Upon completing steps 3 through 7 above, the Medicare contractor shall run the
claims through the Lump Sum Utility. The Lump Sum Utility will produce an
extract, according to the elements in Table 1 below. NOTE: The extract must be
importable by Microsoft Access or a similar software program (Microsoft Excel).
12) Medicare contractors shall upload the extract into Microsoft Access or a similar
software program to generate a report that contains elements in Table 1. Medicare
contractors shall ensure this report is retained with the cost report settlement work
papers.
13) For hospitals paid under the LTCH PPS, the difference between the Original PPS
Payment Amount and Revised PPS Payment Amount from the Lump Sum Utility
will reflect the difference between the total original short-stay and high cost outlier
payment amount and the revised short-stay and high cost outlier payment amount.
If the difference between the original and revised PPS Payment Amount is
positive, then a credit amount (addition) shall be issued to the provider. If the
difference between the original and revised PPS Payment is negative, then a debit
amount (deduction) shall be issued to the provider.
14) Medicare contractors shall determine the applicable time value of money amount
by using the calculation methodology in §150.27. If the difference between the
Original PPS Payment Amount and Revised PPS Payment Amount from the Lump
Sum Utility is a negative amount then the time value of money is also a negative
amount. If the difference between the Original PPS Payment Amount and Revised
PPS Payment Amount from the Lump Sum Utility is a positive amount then the
time value of money is also a positive amount. Similar to step 10, if the time value
of money is positive, then a credit amount (addition) shall be issued to the
provider. If the time value of money is negative, then a debit amount (deduction)
shall be issued to the provider. NOTE: The time value of money is applied to the
difference between the original PPS Payment Amount and Revised PPS Payment
Amount.
15) For cost reporting periods beginning before May 1, 2010, under cost report 2552-
96, the Medicare contractor shall record the original PPS amount by summing
lines 1.02 and 1.05 from Worksheet E-3, Part I, the outlier reconciliation
adjustment amount (the difference between the Original PPS Payment Amount and
Revised PPS Payment Amount from the Lump Sum Utility), the total time value of
money and the rate used to calculate the time value of money on lines 50-53, of
Worksheet E-3, Part I of the cost report (NOTE: the amounts recorded on lines 50,
51 and 53 can be positive or negative amounts per the instructions above). The
total outlier reconciliation amount (the difference between the original PPS
Payment Amount and Revised PPS Payment Amount (from the Lump Sum Utility)
plus the time value of money) shall be recorded on line 15.99 of Worksheet E-3,
Part I. For complete instructions on how to fill out these lines please see §3633.1
of the Provider Reimbursement Manual, Part II.
16) For cost reporting periods beginning on or after May 1, 2010, under cost report
2552-10, the Medicare contractor shall record the original PPS amount from
Worksheet E-3, Part IV line 3, the outlier reconciliation adjustment amount (the
difference between the Original PPS Payment Amount and Revised PPS Payment
Amount from the Lump Sum Utility), the total time value of money and the rate
used to calculate the time value of money on lines 50-53, of Worksheet E-3, Part
IV of the cost report (NOTE: the amounts recorded on lines 50, 51 and 53 can be
positive or negative amounts per the instructions above). The total outlier
reconciliation amount (the difference between the original PPS Payment Amount
and Revised PPS Payment Amount (from the Lump Sum Utility) plus the time
value of money) shall be recorded on line 20 of Worksheet E-3, Part IV.
17) The Medicare contractor shall finalize the cost report, issue a NPR and make the
necessary adjustment from or to the provider.
18) After determining the total outlier reconciliation amount and issuing a NPR,
Medicare contractors shall restore the CCR(s) to their original values (that is, the
CCRs used to pay the claims) in the applicable provider records in the PSF to
ensure an accurate history is maintained. Specifically, for hospitals paid under the
LTCH PPS, Medicare contractors shall enter the original CCR(s) in PSF field 25 -
Operating Cost to Charge Ratio.
If the Medicare contractor has any questions regarding this process it should contact the
Central Office, via email at [email protected].
Table 1: Data Elements for FISS Extract
List of Data Elements for FISS Extract
Provider #
Health Insurance Claim (HIC) Number
Document Control Number (DCN)
Type of Bill
Original Paid Date
Statement From Date
Statement To Date
Original Reimbursement Amount (claims page 10)
List of Data Elements for FISS Extract
Revised Reimbursement Amount (claim page 10)
Difference between these amounts
Original Deductible Amount, Payer A, B, C (Value Code A1, B1, C1)
Revised Deductible Amount, Payer A, B, C (Value Code A1, B1, C1)
Difference between these amounts
Original Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2)
Revised Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2)
Difference between these amounts
Original Outlier Amount (Value Code 17)
Revised Outlier Amount (Value Code 17)
Difference between these amounts
Original DSH Amount (Value Code 18)
Revised DSH Amount (Value Code 18)
Difference between these amounts
Original IME Amount (Value Code 19)
Revised IME Amount (Value Code 19)
Difference between these amounts
Original New Tech Add-on (Value Code 77)
Revised New Tech Add-on (Value Code 77)
Difference between these amounts
Original Device Reductions (Value Code D4)
Revised Device Reductions (Value Code D4)
Difference between these amounts
Original Hospital Portion (claim page 14)
Revised Hospital Portion (claim page 14)
Difference between these amounts
Original Federal Portion (claim page 14)
Revised Federal Portion (claim page 14)
Difference between these amounts
Original C TOT PAY (claim page 14)
Revised C TOT PAY (claim page 14)
Difference between these amounts
Original C FSP (claim page 14)
Revised C FSP (claim page 14)
Difference between these amounts
Original C OUTLIER (claim page 14)
Revised C OUTLIER (claim page 14)
Difference between these amounts
Original C DSH ADJ (claim page 14)
Revised C DSH ADJ (claim page 14)
Difference between these amounts
Original C IME ADJ (claim page 14)
Revised C IME ADJ (claim page 14)
Difference between these amounts
List of Data Elements for FISS Extract
Original Pricer Amount
Revised Pricer Amount
Difference between these amounts
Original PPS Payment (claim page 14)
Revised PPS Payment (claim page 14)
Difference between these amounts
Original PPS Return Code (claim page 14)
Revised PPS Return Code (claim page 14)
DRG
MSP Indicator (Value Codes 12-16 & 41-43 - indicator indicating the claim is MSP;
‘Y’ = MSP, ‘blank’ = no MSP
Reason Code
HMO-IME Indicator
Filler
160 - Necessary Changes to Implement Special Add-On Payments for
New Technologies
(Rev. 1, 10-01-03)
A-02-124
160.1 - Special Add-On Payments For New Technologies
(Rev. 1, 10-01-03)
Section 533(b) of the Medicare, Medicaid, and State Children's Health Insurance Program
(SCHIP) Benefits Improvement and Protection Act of 2000 (BIPA) amended section
1886(d)(5) of the Act to add subparagraphs (K) and (L) and establish a process of
identifying and ensuring adequate payment for new medical services and technologies
under Medicare. In the September 7, 200l, final rule (66 FR 46902), CMS established that
cases using approved new technology would be appropriate candidates for an additional
payment when: the technology represents an advance in medical technology that
substantially improves, relative to technologies previously available, the diagnosis or
treatment of Medicare beneficiaries; the payment for such cases can be demonstrated to be
inadequately paid otherwise under the diagnosis-related group (DRG) system; and data
reflecting the costs of the technology would be unavailable to use to recalibrate the DRG
weights.
Under 42 CFR 412.88 of the regulations, an add-on payment is made for discharges
involving approved new technologies, if the total covered costs of the discharge exceed
the DRG payment for the case (including adjustments for indirect medical education
(IME) and disproportionate share hospitals (DSH) but excluding outlier payments).
PRICER calculates the total covered costs for this purpose by applying the cost-to-charge
ratio (that is used for inpatient outlier purposes) to the total covered costs of the discharge.
Payment for eligible cases is equal to:
• The full DRG payment (see example 1 that follows); plus
• The lesser of
1. 50 percent of the costs of the new medical service or technology (see example
2); or
2. 50 percent of the amount by which the total covered costs (as determined above)
of the case exceed the DRG payment (see example 3); plus
• Any applicable outlier payments if the costs of the case exceed the DRG, plus
adjustments for IME and DSH, and any approved new technology payment for the
case plus the fixed loss outlier threshold. The costs of the new technology are
included in the determination of whether a case qualifies for outliers.
This instruction implements the above payment mechanism into the claims processing
systems.
Below are three illustrative examples of this policy for cases involving an eligible
technology estimated to cost $3,000 in a DRG that pays $20,000.
Example One
Applying the hospital’s cost-to-charge ratio to the total covered charges for the case, it is
determined the total cost for the case is $19,000. Medicare would pay $20,000, the full
DRG payment. Even though the case involved a new technology eligible for add-on
payments, the total covered costs of the case did not exceed the DRG payment, therefore,
no additional payment is made.
Example Two:
Applying the hospital’s cost-to-charge ratio to the total covered charges for the case, it is
determined the total cost for the case is $25,000. Because, in this case, 50 percent of the
costs of the new medical service or technology is less than 50 percent of the amount by
which the total covered costs (as determined above) of the case exceed the DRG payment,
Medicare would pay 50 percent of the costs of the new technology (in addition to the
DRG payment). Therefore, for this case, Medicare would pay $21,500 (the DRG payment
of $20,000 plus one-half of $3,000, the estimated cost of the new technology).
Example Three:
Applying the hospital’s cost-to-charge ratio to the total covered charges for the case, it is
determined the total cost for the case is $22,000. Medicare would pay one-half of the
amount by which the costs of the case exceed the DRG payment, up to the estimated cost
of the new technology. Therefore, for this case, Medicare would pay $21,000 (the DRG
payment of $20,000 plus one-half of the costs above that amount).
160.1.1 - Identifying Claims Eligible for the Add-On Payment for New
Technology
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon
Implementation of ICD-10, Implementation: ICD-10: Upon Implementation of ICD-
10, ASC X12: September, 23 2014)
Technologies eligible for add-on payments are identified based on the applicable codes
from the International Classification of Diseases, Clinical Modification. Claims submitted
with an ICD code indicating that a new technology was involved in the treatment of the
patient is then eligible for add-on payments as described above.
The system maintainers pass (if present) the "principal" and up to twenty four "other
procedure" codes to PRICER. If an eligible code is present, PRICER calculates an add-on
payment if appropriate.
Additionally, the National Uniform Billing Committee has approved value code 77 for use
on the ASC X12 837 institutional claim or Form CMS-1450 for A/B MAC (A) use only,
defined as “New Technology Add-On Payment.” This value code must be passed to CWF
and the PS&R. The amount shown in this value code must be paid to PIP providers on a
claim-by-claim basis the same as outlier payments are paid to PIP providers.
160.1.2 - Remittance Advice Impact
(Rev. 3481, Issued: 03-18-16. Effective: 06-20-16, Implementation: 06-20-16)
In order to process this special add-on payment for new technologies, and report in the
Remittance Advice (electronic and paper), contractors shall submit code ZL in the AMT
segment of the Loop 2110 AMT01 of the ASC X12 835 Transaction. Contractors shall
also submit code CS in the composite data element of the PLB segment in the 835 ASC
X12 Transaction.
For PIP payment, the contractor includes only the add-on payment on a claim-by-claim
basis.
The following reflects the remittance advice messages and associated codes that will
appear when processing claims under this policy. The CARC below is not included in the
CAQH CORE Business Scenarios.
Group Code: OA
CARC: 94
RARC: N/A
MSN: N/A
170 - Billing and Processing Instructions for Religious Nonmedical
Health Care Institution (RNHCI) Claims
(Rev. 851, Issued: 02-10-06; Effective/Implementation Dates: 05-11-06)
170.1 - RNHCI Election Process
(Rev. 851, Issued: 02-10-06; Effective/Implementation Dates: 05-11-06)
See Chapter 5, Section 40 of Pub. 100-01, Medicare General Information, Eligibility, and
Entitlement Manual for a definition of RNHCI providers. See Chapter 1, Section 130 of
Pub. 100-02, Medicare Benefit Policy Manual for more information about the RNHCI
benefit and coverage.
170.1.1 - Requirement for RNHCI Election
(Rev. 2930, Issued: 04-11-14, Effective: 07-14-14, Implementation: 07-14-14)
The RNHCI benefit provides only for Part A inpatient services. For an RNHCI to receive
payment under the Medicare program, the beneficiary must make a written election to
receive benefits under §1821 of the Act. To elect religious nonmedical health care
services, the beneficiary or the beneficiary’s legal representative must attest that the
individual is conscientiously opposed to acceptance of nonexcepted medical treatment,
and the individual’s acceptance of such treatment would be inconsistent with the
individual’s sincere religious beliefs.
All submissions regarding RNHCI services are processed by a single Medicare contractor
as a specialty workload. Currently, this specialty workload is part of Medicare
Administrative Contractor Jurisdiction 10. The completed election form must be filed
with the contractor and a copy retained by the RNHCI provider. See section 170.1.3
below for instructions on the submission of the election to the contractor.
The RNHCI provider should question each beneficiary prior to executing the election
statement to determine if the beneficiary has Medicare Part B coverage in effect via a
health plan or has recently received care (services or items, including physician-ordered
durable medical equipment) for which Medicare payment was sought. An affirmative
answer will alert the RNHCI provider that subsequent claims under the election may be
denied.
Occasionally, a Medicare beneficiary may seek services at a RNHCI that do not qualify
for Medicare coverage and for which the beneficiary may seek payment from another
insurer. The beneficiary is not required to make an election of RNHCI benefits in this
case.
If the other insurer requires a denial from Medicare before making payment for these
services, a denial notice cannot be processed by Medicare claims processing systems.
Medicare systems require submission of a Notice of Election (NOE) before any RNHCI
claims, including claims for denial, can be processed.
The RNHCI may request in writing a denial notice from the Medicare contractor. The
written request must describe the reason the beneficiary does not qualify for Medicare
coverage. It must also describe the specific services that will be provided to the
beneficiary. In response, the contractor will provide the RNHCI with a manual denial
letter. This letter may then be submitted to a secondary insurer as evidence of a prior
Medicare denial.
170.1.2 - Revocation of RNHCI Election
(Rev. 2654, Issued: 02-08-13, Effective: 05-09-13, Implementation, 05-09-13)
Under §1821(b)(3), a beneficiary may revoke an election in writing or by receiving
nonexcepted medical care. Once an election has been revoked, Medicare payment cannot
be made to an RNHCI unless a new valid election is filed. The RNHCI revocation does
not interfere with the beneficiary’s ability to seek other Medicare services within the limits
of his/her Medicare coverage. Multiple revocations may affect the beneficiary’s ability to
access the RNHCI benefit in the future (see Pub. 100-02, Medicare Benefit Policy
Manual, Chapter 1, Section 130.2.2).
Written revocations received from a beneficiary must be filed by the RHNCI with their
Medicare contractor and a copy retained by the RNHCI provider. Revocations may be
filed using the same format as elections, indicating a revocation in the type of bill code.
See section 170.1.3 below for details.
170.1.3 - Completion of the Notice of Election for RNHCI
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon
Implementation of ICD-10, Implementation: ICD-10: Upon Implementation of ICD-
10, ASC X12: September, 23 2014)
Elections, revocations and cancellations of elections may be submitted to the contractor
via the paper Form CMS-1450 or via the contractor’s Direct Data Entry (DDE) system.
Election transactions are not covered transaction under the Health Insurance Portability
and Accountability Act of 1996 (HIPAA) and therefore the HIPAA standard claim
transaction is not required. Additionally, the HIPAA standard claim transaction (ASC
X12 837 institutional claim format) does not support the data requirements of these
transactions.
This section gives detailed information only for items required for the notice of election
and related transactions. The RHNCI does not need to complete items not listed.
Provider Name, Address, and Telephone Number
Required - The minimum entry is the RNHCI’s name, city, State, and ZIP code. The post
office box number or street name and number may be included. The State may be
abbreviated using standard post office abbreviations. Five- or 9-digit ZIP codes are
acceptable. The RNHCI uses the information to reconcile provider number discrepancies.
Phone and/or FAX numbers are desirable.
Type of Bill
Required - The RNHCI enters the 3-digit numeric type of bill code. The first digit
identifies the type of facility. The second digit classifies the type of care. The third digit
(commonly referred to as a “frequency” code) indicates in this instance the nature of the
election related transaction.
The RNHCI enters type of bill 41A, 41B, or 41D as appropriate.
Valid codes for RNHCI elections:
1st Digit - Type of Facility
4- Religious Nonmedical Health Care Institution
2nd Digit - Classification (Special Facility)
1- Inpatient (Part A)
3rd Digit - Frequency
A - RNHCI election notice
B - RNHCI revocation notice
D - Cancellation
The RNHCI submits type of bill 41D to the specialty contractor as a cancellation of a
previously submitted notice of election or notice of revocation, when it was submitted in
error. In situations where the RNHCI is correcting a previously submitted date, they
submit a new type of bill 41A to the contractor for processing.
Patient’s Name
Required - The RNHCI enters the patient’s name with the surname first, first name, and
middle initial, if any.
Patient’s Address
Required - The RNHCI enters the patient’s full mailing address including street name and
number, post office box number or RFD, city, State, and ZIP code.
Patient’s Birth Date
Required - (If available) The RNHCI enters the month, day, and year of birth. If the date
of birth cannot be obtained after a reasonable effort, the field will be zero-filled.
Patient’s Sex
Required - The RNHCI enters an “M” for male or an “F” for female.
Admission Date
Required - The RNHCI enters the date of the election, revocation or cancellation. In no
instance should the date be prior to July 1, 2000.
National Provider Identifier
Required - The RNHCI enters their National Provider Identifier (NPI). During Medicare
processing, the NPI is matched to the RHNCI’s CMS Certification Number (CCN).
RNHCI CCNs are composed of a 2-digit state code and a 4-digit provider identifier in the
range 1990-99.
Insured’s Name
Required - The RNHCI enters the beneficiary’s name on line A if Medicare is the primary
payer. The RNHCI enters the name as on the beneficiary’s Medicare card. If Medicare is
the secondary payer, the RNHCI enters the beneficiary’s name on line B or C, as
applicable, and enters the insured’s name on line A.
Insured’s Unique Identification
Required - On the same lettered line (A, B, or C) that corresponds to the line on which
Medicare payer information is, the RNHCI enters the patient’s HICN. The RNHCI enters
the number as it appears on the patient’s Medicare Card, Social Security Award
Certificate, Utilization Notice, Medicare Summary Notice, Temporary Eligibility Notice,
etc., or as reported by the Social Security Office.
170.1.4 - Common Working File (CWF) Processing of Elections,
Revocations and Cancelled Elections
(Rev. 2654, Issued: 02-08-13, Effective: 05-09-13, Implementation, 05-09-13)
The Medicare contractor with RNHCI specialty workload submits all RNHCI election,
revocations and cancelled elections to CWF for approval. The CWF will notify the
contractor that these transactions were received and accepted. The CWF uses these
records to maintain a beneficiary file of all RNHCI beneficiary elections and revocations.
This file is used in processing claims for RNHCI services (see section 170.3 below) and
for other Medicare services (see section 180).
CWF rejects any notices of revocations or cancellations when:
• CWF history shows no RNHCI elections are on file;
• The submitted dates do not match the elections on file;
• The revocation date is prior to the date of the election;
• The election in question has already been revoked or cancelled; or
• CWF history indicates an RNHCI claim has been processed during the
election period to which the revocation or cancellation applies. If these
claims were submitted in error, the RNHCI must cancel the claims prior to
resubmitting the revocation or cancellation.
170.2 - Billing Process for RNHCI Services
(Rev. 851, Issued: 02-10-06; Effective/Implementation Dates: 05-11-06)
170.2.1 - When to Bill for RNHCI Services
(Rev. 2654, Issued: 02-08-13, Effective: 05-09-13, Implementation, 05-09-13)
RNHCIs submit claims to their Medicare contractor in the following situations:
• At the time of beneficiary's discharge, or death.
• At the time the beneficiary's benefits are exhausted
• On an interim basis monthly.
RNHCIs submit a claim even where the charges do not exceed the beneficiary's
deductible. See section 40 for instructions regarding reporting of utilization days.
170.2.2 - Required Data Elements on Claims for RNHCI Services
(Rev. 3075, Issued; 09-24-14, Effective: 11-12-14, ICD-10: Upon Implementation of
ICD-10, Implementation: 11-12-14, ICD-10: Upon Implementation of ICD-10)
The Social Security Act at §1862 (a)(22) requires that all claims for Medicare payment
must be submitted in an electronic form specified by the Secretary of Health and Human
Services, unless an exception described at §1862 (h) applies. The electronic form required
for billing RNHCI claims is the ASC X12 837 institutional claim transaction. Since the
data structure of the ASC X12 837 institutional claim transaction is difficult to express in
narrative form and to provide assistance to small providers excepted from the electronic
claim requirement, the instructions below are given relative to the Form CMS-1450 paper
claim.
Both the electronic claim transaction and the paper claim form are suitable for use in
billing multiple third party payers. This section details only those data elements required
for Medicare billing. When RNHCIs are billing multiple third parties, they complete all
items required by each payer who is to receive a claim for the services.
Provider Name, Address, and Telephone Number
Required - The RNHCI must enter their name, city, State, and ZIP Code. The post office
box number or street name and number may be included. The State may be abbreviated
using standard post office abbreviations. Five or 9-digit ZIP Codes are acceptable. This
information is used in connection with the Medicare provider number to verify provider
identity. Phone/Fax numbers are desirable.
Patient Control Number/Medicare Record Number
Optional - The RNHCI may report a beneficiary's control number if they assign one and
need it for association and reference purposes.
Type of Bill
Required - This 3-digit alphanumeric code gives three specific pieces of information. The
first digit identifies the type of facility. The second classifies the type of care. The third
indicates the sequence of this claim in this particular episode of care. It is a "frequency"
code.
Valid codes for RNHCI claims:
1st Digit-Type of Facility
4 - Religious Nonmedical Health Care Institution
2nd Digit Classification (Except Clinics and Special Facilities)
1 - Inpatient (Part A)
3rd Digit-Frequency Definition
0-Nonpayment/zero claims Use when you do not anticipate payment
from the payer for the bill but are merely
informing the payer about a period of
nonpayable confinement or termination
of care. The "Through" date of this bill
is the discharge date for this
confinement. Nonpayment bills are
required only to extend the "spell of
illness." See code 71 below.
l-Admit Through Discharge Claims Use for a bill encompassing an entire
inpatient confinement for which you
expect payment from the payer or for
which Medicare utilization is chargeable.
2-Interim-First Claim Use for the first of an expected series of
payment bills for the same confinement
or course of treatment for which
Medicare utilization is chargeable.
3-Interim-Continuing Claim Use when a payment bill for the same
confinement or course of treatment has
been submitted, further bills are expected
to be submitted and Medicare utilization
is chargeable.
4-Interim-Last Claim Use for a payment bill which is the last
of a series for this confinement or course
of treatment when Medicare utilization is
chargeable. The "Through" date of this
bill is the discharge date for this
confinement.
7-Replacement of Prior Claim Use to correct (other than late charges) a
previously submitted bill. This is the
code applied to the corrected or "new"
bill.
8-Void/Cancel of a Prior Claim This code indicates the bill is an exact
duplicate of an incorrect bill previously
submitted. Enter a code "7"
(Replacement of Prior Claim) showing
the correct information.
Statement Covers Period (From - Through)
Required - The RNHCI must enter the beginning and ending dates of the period covered
by this bill. Enter the date of discharge or the date of death in the space provided under
"Through." The statement covers period may not span 2 accounting years.
Patient's Name
Required - The RNHCI must enter the beneficiary's last name, first name, and middle
initial, if any.
Patient's Address
Required - The RNHCI must enter the beneficiary's full mailing address, including street
number and name, post office box number or RFD, City, State, and ZIP Code.
Patient Birth Date
Required - The RNHCI must enter the month, day, and year of birth (MM-DD-YYYY) of
the beneficiary.
Sex
Required - The RNHCI must enter an “M” for male or an “F” for female.
Admission Date
Required - The RNHCI must enter the date the beneficiary was admitted for inpatient care.
(MM-DD-YY).
Type of Admission
Required - The RNHCI must enter the code indicating the priority of this admission.
Valid codes for RNHCI claims:
3 Elective The beneficiary's condition permitted adequate
time to schedule the availability of a suitable
accommodation.
9 Information Self-explanatory
Not Available
Point of Origin for Admission
Required - The RNHCI must enter the code indicating the beneficiary’s point of origin.
The RNHCI may use any valid point of origin code that applies to the particular
admission.
Patient Discharge Status
Required - The RNHCI must enter the code indicating the patient's status as of the
"Through" date of the billing period. The RNHCI may use any valid patient status code
that applies to the discharge.
Condition Codes
Conditional - The RNHCI may enter any number of condition codes to describe conditions
that apply to the billing period. If the RNHCI is submitting an adjustment or a
cancellation claim, an applicable condition code from the ‘claim change reason’ series (D0
through D9 or E0) must be used.
If non-covered days are reported because the beneficiary’s inpatient benefits were
exhausted, the RHNCI must indicate whether the beneficiary elects to use lifetime reserve
days. The RNHCI must indicate lifetime reserve days are used on the claim by reporting
condition code 68. If the beneficiary elects not to use lifetime reserve days, the RNHCI
must report condition code 67.
Occurrence Codes and Dates
Conditional - The RNHCI may enter any number of occurrence codes and their associated
dates to define specific event(s) relating to this billing period. Occurrence codes are 2
alphanumeric digits, and are reported with a corresponding date.
If non-covered days are reported due to days not falling under the guarantee of payment
provision, the RNHCI reports occurrence code 20.
If non-covered days are reported because the beneficiary’s inpatient benefits were
exhausted, the RNHCI reports occurrence code A3.
Occurrence Span Code and Dates
Conditional - The RNHCI may enter any number of occurrence span codes and their
associated dates to define specific event(s) relating to this billing period. Occurrence span
codes are 2 alphanumeric digits, and are accompanied by from and through dates for the
period described by the code.
If non-covered days are reported because the beneficiary was on a leave of absence and
was not in the RNHCI, the RNHCI reports occurrence span code 74.
Document Control Number (DCN)
Conditional - The RNHCI must complete this field on adjustment requests (Bill Type, FL
4 = 417). An RNHCI requesting an adjustment to a previously processed claim must
insert the ICN/DCN of the claim to be adjusted.
Value Codes and Amounts
Required - The RNHCI must report utilization days using the value codes described
below.
Covered Days - The RNHCI must use value code 80 to enter the total number of covered
days during the billing period, including lifetime reserve days elected for which Medicare
payment is requested. Covered days exclude any days classified as non-covered, the day
of discharge, and the day of death.
Covered days are always in terms of whole days rather than fractional days. As a result,
the covered days do not include the day of discharge, even where the discharge was late.
The RNHCI does not deduct any days for payment made under workers' compensation,
automobile medical, no-fault, liability insurance, or an EGHP for an ESRD beneficiary or
employed beneficiaries and spouses age 65 or over. The specialty contractor will calculate
utilization based upon the amount Medicare will pay and will make the necessary
utilization adjustment.
Non-covered Days - The RNHCI must use value code 81 to enter the total number of non-
covered days in the billing period for which the beneficiary will not be charged utilization
for Part A services. Non-covered days include:
• Days not falling under the guarantee of payment provision. See section 40.1. E.
• Days not approved by the utilization review committee when the beneficiary does
not meet the need for Part A services;
• Days for which no Part A payment can be made because benefits are exhausted.
This means that either lifetime reserve days were exhausted or the beneficiary
elected not to use them.
• Days for which no Part A payment can be made because the services were
furnished without cost or will be paid for by the VA. (Pub. 100-02, Medicare
Benefit Policy Manual, Chapter 16, section 50);
• Days after the date covered services ended, such as non-covered level of care;
• Days for which no Part A payment can be made because the beneficiary was on a
leave of absence and was not in the RNHCI. See section 40.2.6;
• Days for which no Part A payment can be made because an RNHCI whose
provider agreement has terminated may only be paid for covered inpatient services
during the limited period following such termination. All days after the expiration
of this period are non-covered. See Pub. 100-01, Medicare General Information,
Eligibility and Entitlement Manual, Chapter 5, section 10.6.4;
The RNHCI enters in "Remarks" a brief explanation of any non-covered days not
described in the occurrence codes. Show the number of days for each category of non-
covered days (e.g., "5 leave days").
Day of discharge or death is not counted as a non-covered day. All hospital inpatient rules
for billing non-covered days apply to RNHCI claims.
Coinsurance Days - The RNHCI must use value code 82 to enter the number of covered
inpatient days occurring after the 60th day and before the 9lst day for this billing period.
Lifetime Reserve Days - The RNHCI must use value code 83 to enter the number of
lifetime reserve days the beneficiary elected to use during this billing period.
Lifetime reserve days are not charged where the average daily charge is less than the
lifetime reserve coinsurance amount. The average daily charge consists of charges for all
covered services furnished after the 90th day in the benefit period and through the end of
the billing period.
The RNHCI must notify the beneficiary of their right to elect not to use lifetime reserve
days before billing Medicare for services furnished after the 90th day in the spell of
illness. The determination to elect or withhold use of lifetime reserve days should be
documented and kept on file at the provider.
Conditional - The RNHCI may at their option enter any number of other value codes and
related dollar amount(s) to identify data necessary for the processing of this claim. Value
codes are 2 alphanumeric digits, and a corresponding value amount. Negative amounts
are never shown. If more than one value code is shown for a billing period, the RNHCI
must show codes in ascending numeric sequence.
Revenue Code
Required - The RNHCI must enter the appropriate revenue codes to identify specific
accommodation and/or ancillary charges. This code takes the place of fixed line item
descriptions. The 4-digit numeric revenue code on the adjacent line explains each charge.
The following revenue codes and associated descriptions are used where there are charges
billed as covered by Medicare:
Code Description
0001 Total Charges
0120 Semi-Private Room
0270 Supplies (non-religious, as covered by Medicare)
Any other revenue codes may be submitted with non-covered charges only.
Additionally, there is no fixed "Total" line in the charge area. On paper claims, the
RNHCI must enter revenue code "000l" to report a total of the charges on the claim.
The RNHCI should list revenue codes other than revenue code “0001” in ascending
numeric sequence and should not repeat revenue codes on the same claim to the extent
possible.
Units of Service
Required - The RNHCI must enter the number of days for accommodations revenue
codes.
Accommodation days are always in terms of whole days rather than fractional days. The
accommodation days do not include the day of discharge, even where the discharge was
late. Where a charge was made because the beneficiary remained in the RNHCI after
checkout time for his own convenience, it is a non-covered charge and you can bill the
beneficiary if that is your usual practice and if the beneficiary is given proper notice of
their liability. In this instance, the RNHCI will enter the additional charge in non-covered
charges.
Total Charges
Required - The RHNCI must sum the total charges (covered and non-covered) for the
billing period by revenue code and enter them on the adjacent line. On paper claims, the
last revenue code entered in revenue code "000l" represents the grand total of all charges
billed. For all lines, the total charges minus any associated non-covered charges represent
the covered charges.
Each line allows up to 9 numeric digits (0000000.00).
When submitting charges (covered/non-covered):
• Medicare is restricted by law and court order from paying for the religious portion
of care or the training of personnel that provide that care. Additionally Medicare
does not pay either based on charges or costs for training of nonmedical personnel.
RNHCIs do not receive full Medicare payment for a beneficiary’s stay since the
beneficiary is fiscally responsible for the religious aspects of care. Therefore, the
original Medicare or Medicare health plan rate may be significantly lower than the
RNHCI private pay rate that includes religious charges.
• As medical procedures are not performed in a RNHCI, the use of high cost medical
supplies are not separately payable. Supplies that require a physician order (e.g.,
specialty dressings, compression stockings, alternating pressure mattress pads) are
not separately payable in a RNHCI. The use of diapers, incontinence pads,
chux/underpads, feminine hygiene products, tissues, and the materials for simple
dressings (cleansing and bandaging) are included in the daily room and board
portion of the charges and should not be reported separately as supplies.
• Medical equipment (e.g., wheelchair, walker, crutches) are institution inventory
items for beneficiary use in the RNHCI. The use of these items during the
beneficiary stay is part of the daily interim payment to the RNHCI. To receive
Medicare payment for durable medical equipment (DME) following a RNHCI
stay, a beneficiary would need to meet all of the criteria, including medical
necessity, and obtain a physician order or prescription. A RNHCI is not authorized
as a Medicare supplier and, therefore, may not offer DME items for purchase to
beneficiaries.
• Nonmedical nursing personnel, for Medicare payment purposes, perform services
(e.g., serving meals, assisting with activities of daily living) that are strictly
nonmedical/non-religious. The statute and court order mandates only the coverage
and payment under Part A for reasonable and necessary nonmedical/non-religious
care.
• Medicare payment for religious/nonmedical nursing personnel in a RNHCI, as
other inpatient facilities, is a component of the per diem rate and is not separately
payable.
Non-Covered Charges
Required - The RHNCI must enter the total non-covered charges pertaining to the related
revenue code, if any (e.g., religious items/services or religious activities performed by
nurses or other staff, or convenience items that are not part of the Medicare daily interim
payment rate.)
Examples of non-covered charges:
• Non-covered religious items include but are not limited to religious publications,
religious recordings, any equipment for the use of those recordings, any
reproduction costs for these materials, and attendance at religious meetings.
• Religious sessions with RNHCI staff or outside associates.
• Expenses related to student programs/subsistence, staff education/training, travel,
or relocation to be factored into the development of charges for covered patient
care services.
• Stays, items, and services that are not substantiated by appropriate documentation
in the beneficiary’s utilization review file or care record.
• Convenience items (e.g., telephone, computer, beautician/barber).
Payer Identification
Required - If Medicare is the primary payer, the RNHCI must enter "Medicare" on line A.
If Medicare is entered, this indicates that the RNHCI has developed for other insurance
and has determined that Medicare is the primary payer.
All additional entries across line A supply information needed by the payer named. If
Medicare is the secondary or tertiary payer, the RNHCI may identify the primary payer on
line A and enter Medicare information on line B or C as appropriate.
National Provider Identifier
Required - The RNHCI enters their National Provider Identifier (NPI). During Medicare
processing, the NPI is matched to the RHNCI’s CMS Certification Number (CCN).
RNHCI CCNs are composed of a 2-digit state code and a 4-digit provider identifier in the
range 1990-99.
Insured’s Unique Identification
Required - On the same lettered line (A, B, or C) that corresponds to the line on which
Medicare payer information is shown, the RNHCI must enter the beneficiary's Medicare
Health Insurance Claim Number. The RNHCI must show the number as it appears on the
beneficiary's Medicare Card, Certificate of Award, Utilization Notice, Medicare Summary
Notice, Temporary Eligibility Notice, or as reported by the Social Security Office.
Principal Diagnosis Code
Required - While coding of a principal diagnosis is not consistent with the nonmedical
nature of RNHCI services, the presence of diagnosis codes is a requirement for claims
transactions under HIPAA. To satisfy this requirement on claims with Statement Covers
“Through” dates before implementation of ICD-10, the RNHCI may report ICD-9 code
799.9 (defined “other unknown and unspecified cause”). To satisfy this requirement on
claims with Statement Covers “Through” dates on or after the implementation of ICD-10,
the RNHCI may report ICD-10 code R69 (defined “illness, unspecified”).
Other Diagnosis Codes
Required - While coding of diagnoses is not consistent with the nonmedical nature of
RNHCI services, the presence of diagnosis codes is a requirement for claims transactions
under HIPAA. To satisfy this requirement on claims with Statement Covers “Through”
dates before the implementation of ICD-10, the RNHCI may report ICD-9 code V62.6
(defined “refusal of treatment for reasons of religion or conscience”). To satisfy this
requirement on claims with Statement Covers “Through” dates on or after the
implementation of ICD-10, the RNHCI may report ICD-10 code Z53.1 (defined
“procedure and treatment not carried out because of patient's decision for reasons of
belief”).
The RNHCI reports no additional diagnosis codes in the remaining fields. Similarly,
RNHCIs do not use other fields relating to medical diagnoses and medical procedures.
The RNHCI reports no additional diagnosis codes in the remaining fields. Similarly,
RNHCIs do not use other fields relating to medical diagnoses and medical procedures.
Attending Provider
Required - While the participation of an attending provider is not consistent with the
nonmedical nature of RNHCI services, reporting an attending provider is a requirement
for claims transactions under HIPAA. To satisfy this requirement, the RNHCI must report
the name and NPI of their director of nursing.
Remarks
Conditional - The RNHCI may enter any remarks needed to provide information that is
not shown elsewhere on the bill but which is necessary for proper payment.
Provider Representative Signature and Date
Required - If using the hard copy claim, an RNHCI representative makes sure the claim
record is complete and accurate before signing Form CMS-1450. A stamped signature is
acceptable on Form CMS-1450.
170.3 - RNHCI Claims Processing By the Medicare Contractor with
RNCHI Specialty Workload
(Rev. 2654, Issued: 02-08-13, Effective: 05-09-13, Implementation, 05-09-13)
Upon submission of a claim for RNHCI services, the contractor ensures that the
submission contains the complete set of required data elements according to the
instructions in §170.2. The specialty contractor ensures that the submission does not
contain data that is invalid, internally inconsistent or is not otherwise submitted in error.
If the submission is not found to be consistent with CMS instructions, it is returned to the
RNHCI for correction.
Once the claim is found to satisfy CMS instructions, the contractor ensures the claim is
not a duplicate of previously paid RNHCI services or does not demonstrate grounds for
Medicare denial for any other reason. If the claim appears appropriate for payment based
on the specialty contractors initial processing, the claim is submitted to the CMS Common
Working File (CWF) for approval.
The CWF system compares the claim submitted by the contractor to the eligibility and
utilization data for the beneficiary that received the services. The CWF ensures the
beneficiary is eligible for Part A for the dates of service (since RNHCI services are
exclusively a Part A benefit) and the beneficiary has utilization days remaining in their
current inpatient spell of illness. The CWF also compares the RNHCI claim to the
beneficiary’s file of RNHCI elections and claims. If CWF does not identify any error
conditions on the RNHCI claim, an approval message is returned to the specialty
contractor.
An RNHCI claim may be rejected by CWF if:
• No RNHCI election period is present for the dates of service of the claim;
• The RNHCI election period to which the claim would apply has been revoked (see
section 180 for procedures that lead to revocation of the election);
• The RNHCI election period to which the claim would apply has been cancelled; or
• The service dates on the claim overlap previously paid claims for RNCHI services
or other inpatient services that were processed by a Medicare contractor other than
the specialty contractor.
Claims rejected for these reasons may not be corrected and returned by the RNHCI. If the
error condition can be resolved (for instance, by the resubmission of an election period
cancelled in error), the RNHCI may submit a new original claim for the services.
Upon receipt of payment approval or rejection from CWF, the contractor may then
process the claim to completion. RNHCI claims are paid a daily interim rate as
established for each RNHCI provider under TEFRA payment rules (see Pub. 15-2,
Provider Reimbursement Manual, chapter 30). The contractor makes RNHCI payments
subject to the inpatient hospital cash deductible when applicable and, if services are for the
61
st
through 90
th
day of a benefit period or are for lifetime reserve days, subject to
coinsurance (see Pub. 100-01, Medicare General Information, Eligibility and Entitlement
Manual, Chapter 3, Sections 10.1 and 10.2).
170.3.1 - RNHCI Claims Not Billed to Original Medicare
(Rev. 2654, Issued: 02-08-13, Effective: 05-09-13, Implementation, 05-09-13)
Health Plans
A beneficiary covered by a Medicare Advantage plan (e.g., Medicare health maintenance
organization, preferred provider organization, competitive medical plan or other health
care prepayment plans.) must have prior authorization from their plan before admission to
a RNHCI to assure payment for a specified time period. Continued stay reviews must be
performed, submitted, and approved at designated intervals identified by the plan to assure
coverage by the Medicare health plan.
In the case of billing a Medicare health plan, the RNHCI charges for inpatient services
should not exceed the established interim TEFRA per diem payment amount available
under Medicare Part A. The Medicare health plan may obtain the current TEFRA per
diem rate information by calling the specialty contractor responsible for the involved
RNHCI.
Medicaid
The State agency may obtain the current Medicare rate information by calling the
Medicare contractor responsible for the RNHCI.
170.4 - Informing Beneficiaries of the Results of RNHCI Claims
Processing
(Rev. 2654, Issued: 02-08-13, Effective: 05-09-13, Implementation, 05-09-13)
Beneficiaries are informed of all Medicare payment determinations, including those for
RNHCI services, via their monthly Medicare Summary Notice (MSN). The complete set
of messages used on the MSN can be found in chapter 21, section 50.42 of this manual.
The Medicare contractor with RHNCI specialty workload uses special messages on MSNs
to reflect determinations specific to the RNHCI benefit.
• If an RNHCI claim is denied because CWF did not find record of an RNHCI
election in the beneficiaries record, the contractor uses MSN message 42.3. This
message reads: “This service is not covered since you did not elect to receive
religious nonmedical health care services instead of regular Medicare services.”
• If an RNHCI claim is denied because CWF found record of an RNHCI election in
the beneficiary’s record that had been revoked in writing, the contractor uses MSN
message 42.5. This message reads: “This service is not covered because you
requested in writing that your election to religious nonmedical health care services
be revoked.”
• If an RNHCI claim is denied because CWF found record of an RNHCI election in
the beneficiary’s record that had been revoked because the beneficiary received
nonexcepted medical care, the contractor uses MSN message 42.4. This message
reads: “This service is not covered because you received medical health care
services which revoked your election to religious nonmedical health care services.”
180 - Processing Claims For Beneficiaries With RNHCI Elections by
Contractors Without RNHCI Specialty Workloads
(Rev. 11963, Issued:04-20-23, Effective: 10-01-23, Implementation, 10-02-23)
While elections and claims for RNHCI services are processed by the Medicare contractor with
RNHCI specialty workload, all Medicare contractors (below ‘non-specialty contractors’)
must understand the nature and purpose of the RNHCI election and the definitions of
excepted and non-excepted care defined in Pub. 100-02, Medicare Benefit Policy Manual,
Chapter 1, Section 130. Non-specialty contractors may find it advisable to have an
identified specialist (or specialists) familiar with excepted and nonexcepted care used in the
review of beneficiaries with RNHCI elections, since this process is so unlike other Medicare
claims processes.
Beneficiaries may revoke their RNHCI election by submitting a written revocation request to
Medicare, but this is rare. Far more commonly, beneficiaries revoke the election simply by
receiving nonexcepted medical services and requesting Medicare payment for those services.
Any non-specialty contractor may receive a claim for services for a beneficiary with an RNHCI
election currently in place. This section provides instructions to non-specialty contractors for
the handling of such claims.
Upon receipt of a claim for payment, non-specialty contractors will not be aware that the
beneficiary has an RNHCI election in place and will process the claim normally to the point of
transmitting the claim to CWF. The CWF searches beneficiary records for all claims to
determine whether an RNHCI election is found. If an election is found, CWF takes one of two
actions on a claim for non-RNHCI services:
• If the claim is for DME, or prosthetic/orthotic devices, CWF will accept the
DMEPOS claim and revoke the RNHCI election. All DMEPOS claims are treated
as nonexcepted medical care.
• If the claim is for COVID-19 vaccine services and no other covered services, CWF will
accept the claim and leave the RNCHI election in place. All COVID-19 vaccines and
their administrations are treated as excepted medical care.
• If the claim is for any other Medicare covered services, CWF initially rejects it to
the non-specialty contractor. The non-specialty contractor must determine whether the
care was excepted or nonexcepted. The claim must never be automatically denied.
The RNHCI election revocation does not interfere with the beneficiary’s ability to seek
other Medicare services within the limits of their Medicare coverage.
The process for non-specialty contractors to follow in responding to this CWF edit is unique
among Medicare claims processes. A determination must be made whether the beneficiary’s
RNHCI election should be revoked. Therefore, unlike other CWF rejects which are processed
in an automated fashion, claims rejected by CWF due to the presence of an RNHCI election
must be suspended and developed to determine if the beneficiary received excepted care.
At differing points in time, this review consisted of a request for medical records or a series of
telephone contacts but these methods were found too workload intensive. In response to a
CWF reject due to the presence of an RNHCI election, non-specialty contractors must issue a
simple development letter asking the provider of services to respond in a yes or no fashion to
three questions:
• Whether the beneficiary paid for the services out of pocket in lieu of requesting
payment from Medicare;
• Whether the beneficiary was unable to make his/her beliefs and wishes known before
receiving the services that have been billed; and
• Whether, for a vaccination service, the vaccination performed was required by a
government jurisdiction.
Each non-specialty contractor may develop the wording and format of this letter based on their
experience effectively communicating with their community of providers.
The purpose for this development letter is to determine whether the care received is excepted
(leaving the election intact) or whether it is nonexcepted (causing a revocation of the RNHCI
election). Provider responses of ‘No’ to all questions in the letter will determine that the
services are found to be non-excepted care. Provider responses of ‘Yes’ to the questions
regarding inability to make beliefs known or regarding required vaccinations will determine
that the services are found to be excepted care. Unless reasons to deny these claims are found
during the course of claims processing, these claim will normally be paid. A provider response
of ‘Yes’ to the question regarding the beneficiary’s paying out of pocket will determine that the
services are found to be excepted care, but the claim for payment for medical care must be
denied. The claim must be denied because the beneficiary has not made a request for Medicare
payment. The beneficiary has accepted liability for these services in order to protect their
RNHCI election.
Once the non-specialty contractor makes this determination of whether the care is excepted or
nonexcepted, the claim record is annotated accordingly (see section 180.1 below) and returned
to CWF. The claim will be approved for payment and if the care was found to be nonexcepted
CWF will cause the beneficiary’s RNHCI election to be revoked.
In the event that the provider does not reply timely to the development letter, non-specialty
contractors must make an excepted/nonexcepted determination based on the evidence
presented by the claim itself. Non-specialty contractors shall apply the same timeliness
standard to these responses as to all other documentation requests. If the claim contains
durable medical equipment or prosthetic/orthotic devices, the non-specialty contractor
may make a determination of nonexcepted care on that basis alone. All such claims are
treated as nonexcepted care. For all other claims, non-specialty contractor staff with a
clinical background must make their best determination based on the diagnoses and
procedures reported on the claim whether the services were excepted or nonexcepted care.
In cases where the determination cannot be made with certainty but there is some reason
to suspect services were nonexcepted care, the non-specialty contractor shall make a
determination of nonexcepted care and annotate the claim record accordingly.
Determinations must be made within the earlier of 30 days of receipt of the provider’s
response or 30 days of the end of the timely response period.
The importance of the development of these claims lies in its effect on the beneficiary. If
the claim for medical care is denied improperly based on the presence of the RNHCI
election, the beneficiary will incur liability in error and may experience financial hardship.
Similarly, it is important that the review result in accurate determinations of nonexcepted
care since repeated revocations of this benefit can have an impact on the beneficiary’s right
to access the RNHCI benefit in the future.
180.1 - Recording Determinations of Excepted/Nonexcepted Care on Claim
Records
(Rev. 3481, Issued: 03-18-16. Effective: 06-20-16, Implementation: 06-20-16)
Once the excepted/nonexcepted care determination is made, the non-specialty contractor
resubmits the claim to CWF using the following indicators to record the determination:
• Indicator “1” - for excepted care; or
• Indicator “2” - for nonexcepted care.
NOTE: Indicator 0 (zero) presents no entry.
The following are the fields and locations for the excepted and nonexcepted indicators on
the CWF record types:
Record
Location
Field
Size
HUIP (IP hospital/SNF Claim)
84
1
823
HUOP (Outpatient)
64
1
778
HUHC (Hospice)
64
1
778
HUHH (Home Health)
64
1
778
HUBC (A/B MAC (B) Claim)
13
1
57
The screen field corresponding to these CWF fields may vary depending on the Medicare
shared system in use at a contractor’s location. Non-specialty contractors may contact
their shared system maintainer if necessary to determine the correct screen location to use
for excepted/nonexcepted care indicators.
If a claim is resubmitted with a “0” excepted care indicator in error, CWF will again reject
the claim. Upon receipt of the resubmitted claim with a valid “1” or “2” entry, CWF will
approve it for payment and revoke the beneficiary’s election if the care received was
nonexcepted. CWF will not notify either the specialty contractor or the non-specialty
contractor of any revocations as a result of claims received for nonexcepted care. Any
subsequent RNHCI claims processed at the contractor with RNHCI specialty workload
will be not approved for payment by CWF unless the beneficiary files a new election
following the prescribed time intervals between elections.
If development to make the excepted/nonexcepted care determination discovered that the
beneficiary paid out of pocket for the services and the claim for payment for medical care must
be denied as a result.
The following reflects the remittance advice messages and associated codes that will
appear when rejecting/denying claims under this policy. This CARC/RARC combination
is compliant with CAQH CORE Business Scenario 3.
Group Code: PR
CARC: 96
RARC: MA47
MSN: N/A
180.2 - Informing Beneficiaries of the Results of Excepted/Nonexcepted
Care Determinations by the Non-specialty Contractor
(Rev. 2654, Issued: 02-08-13, Effective: 05-09-13, Implementation, 05-09-13)
Beneficiaries are informed of all Medicare payment determinations, including those for
RNHCI services, via their monthly Medicare Summary Notice (MSN). The complete set
of messages used on the MSN can be found in chapter 21, section 50.42 of this manual.
Non-specialty contractors use special messages on MSNs to reflect determinations
specific to excepted or nonexcepted care.
• If a determination of excepted care is made, the non-specialty contractor uses MSN
message 42.1. This message reads: “You received medical care at a facility other
than a religious nonmedical health care institution but that care did not revoke your
election to receive benefits for religious nonmedical health care.”
• If a determination of nonexcepted care is made, the non-specialty contractor uses
MSN message 42.2. This message reads: “Since you received medical care at a
facility other than a religious nonmedical health care institution, benefits for
religious nonmedical health care services has been revoked for these services
unless you file a new election.”
If development to make the excepted/nonexcepted care determination discovered that the
beneficiary did not request Medicare payment, but instead paid for the services out of
pocket, the non-specialty contractor uses MSN message 16.41. This message reads:
“Payment is being denied because you refused to request reimbursement under your
Medicare benefits.”
190 - Inpatient Psychiatric Facility Prospective Payment System (IPF
PPS)
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
190.1 - Background
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
This section and its subsections provide instructions about the IPF PPS. The IPF PPS
replaces existing reasonable cost-based payments subject to Tax Equity and Fiscal
Responsibility Act (TEFRA) limits under section 1886 (b) of the Social Security Act (the
Act) for discharges occurring on and after the first day of the IPF's first cost reporting
period beginning on or after January 1, 2005.
The IPF PPS, codified at 42 CFR 412, Subpart N, provides payment for inpatient
psychiatric treatment when provided to an inpatient in psychiatric hospitals and distinct
part psychiatric units of acute care hospitals and critical access hospitals (CAHs).
190.2 - Statutory Requirements
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
Section 124 of the Medicare, Medicaid, and SCHIP (State Children's Health Insurance
Program) Balanced Budget Refinement Act of 1999 (BBRA) (Pub. L.106-113), mandated
that the Secretary: (1) develop a per diem PPS for inpatient hospital services furnished in
psychiatric hospitals and psychiatric units; (2) include in the PPS an adequate patient
classification system that reflects the differences in patient resource use and costs among
psychiatric hospitals and psychiatric units; (3) maintain budget neutrality; (4) permit the
Secretary to require psychiatric hospitals and psychiatric units to submit information
necessary for the development of the PPS; and (5) submit a report to the Congress
describing the development of the PPS. Section 124 of the BBRA also required that the
IPF PPS be implemented for cost reporting periods beginning on or after October 1, 2002.
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (P. L.
108-173), section 405(g) extended the IPF PPS to distinct part psychiatric units of CAHs,
effective for cost reporting periods beginning on or after October 1, 2004.
190.3 - Affected Medicare Providers
(Rev. 11396, Issued:05-04-22, Effective:10-01-22, Implementation:10-03-22)
Psychiatric hospitals and distinct part psychiatric units of acute care hospitals and CAHs
are included in the IPF PPS and are referred to in these instructions as “inpatient
psychiatric facilities” or “IPFs.” The regulations at 42 CFR 412.402 define an IPF as a
hospital that meets the requirements specified in 42 CFR 412.22, 42 CFR 412.23(a), 42
CFR 482.60, 42 CFR 482.61, and 42 CFR 482.62, and units that meet the requirements
specified in 42 CFR 412.22, 42 CFR 412.25, and 42 CFR 412.27.
IPFs are certified under Medicare as inpatient psychiatric hospitals, which means an
institution that is primarily engaged in providing, by or under the supervision of a
physician, psychiatric services for the diagnosis and treatment of mentally ill patients,
maintains clinical records necessary to determine the degree and intensity of the treatment
provided to mentally ill patients, and meets staffing requirements sufficient to carry out
active programs of treatment for individuals who are furnished care in the institution. A
distinct part psychiatric unit may also be certified if it meets the clinical record and
staffing requirements in 42 CFR 412.27 which mirror the requirements for a psychiatric
hospitals in 42 CFR 482.60, 42 CFR 482.61 and 42 CFR 482.62.
The CMS Certification Number (CCN) ranges for IPFs are from xx-4000 through xx-
4499, xx-Sxxx, and xx-Mxxx. Note that this will change with the implementation of
National Provider Identifiers (NPI).
The following hospitals are not paid under the IPF PPS:
• Veterans Administration hospitals; See 42 CFR 412.22 (c).
• Hospitals that are reimbursed under state cost control systems approved under 42
CFR Part 403; Psychiatric Hospitals (provider numbers xx-4000 - xx-4499) in the
State of Maryland are paid under the IPF PPS. Psychiatric distinct part units
located in an acute care hospital in Maryland identified by ‘S’ in the third position
of the CMS Certification Number (CCN) are waived from the IPF PPS, as is the
acute hospital in which they are located. Currently there are no CAHs in
Maryland.
• Hospitals that are reimbursed in accordance with demonstration projects
authorized under §402(a) of Pub. L. 90-248 (42 U. S. C. 1395b-1) or §222(a) of
Pub. L. 92-603 (42 U. S. C. 1395b-1); See 42 CFR 412.22 (c). IPFs in acute care
hospitals that participate in demonstration projects are paid in accordance with the
demonstration project;
• Nonparticipating hospitals furnishing emergency services to Medicare
beneficiaries are paid in accordance with 42 CFR 412. 22 (c).
• Payment to foreign hospitals is made in accordance with the provisions set forth in
42 CFR 413.74.
190.4 - Federal Per Diem Base Rate
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
Payments to IPFs under the IPF PPS are based on a single Federal per diem base rate
computed from both the inpatient operating and capital-related costs of IPFs (including
routine and ancillary services), but not certain pass-through costs (i.e., bad debts, direct
graduate medical education, and nursing and allied health education).
The Federal per diem payment under the IPF PPS is comprised of the Federal per diem
base rate (which is broken into a labor-related share and a non-labor-related share) and
applicable patient and facility adjustments that are described in §§190.5 and 190.6.
The standardized Federal per diem base rates and adjustment factors are updated July 1
every year, beginning July 1, 2006. For the updated standardized Federal per diem base
rates for subsequent years refer to the Federal Register rules and accompanying
Recurring Update Notifications. See
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/InpatientPsychFacilPPS/IPF-PPS-Regulations-and-Notices.html
190.4.1 - Standardization Factor
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
The CMS standardized the IPF PPS Federal per diem base rate in order to account for the
overall positive effects of the IPF PPS payment adjustment factors. To standardize the
IPF PPS payments, CMS compared the IPF PPS payment amounts calculated from the FY
2002 MedPAR file to the projected TEFRA payments from the FY 2002 cost report file
updated to the midpoint of the IPF PPS implementation period (that is, October 2005).
The standardization factor was calculated by dividing total estimated payments under the
TEFRA payment system by estimated payments under the IPF PPS. CMS then applied
this factor to the average per diem cost of an IPF stay.
190.4.2 - Budget Neutrality
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
The BBRA required that total payments under the PPS must equal the amount that would
have been paid if the PPS had not been implemented. Therefore, in the November 2004
IPF PPS final rule, CMS calculated the budget neutrality factor by setting the total
estimated IPF PPS payments to be equal to the total estimated payments that would have
been made under the TEFRA methodology had the IPF PPS not been implemented. CMS
calculated the final Federal per diem base rate to be budget neutral during the
implementation period under the IPF PPS using a July 1 update cycle. The
implementation period for the IPF PPS is the 18-month period of January 1, 2005 through
June 30, 2006.
190.4.2.1 - Budget Neutrality Components
(Rev. 1543; Issued: 06-27-08; Effective Date: 07-01-08; Implementation Date: 07-
07-08)
The following are the three components of the budget neutrality adjustment:
(1) Outlier Adjustment: Since the IPF PPS payment amount for each stay includes
applicable outlier amounts, CMS reduced the standardized Federal per diem base rate to
account for aggregate IPF PPS payments estimated to be made as outlier payments. The
appropriate outlier amount was determined by comparing the adjusted prospective
payment for the entire stay to the computed cost per case. If costs were above the
prospective payment plus the adjusted fixed dollar loss threshold amount, an outlier
payment was computed using the applicable risk-sharing percentages. The outlier
adjustment was calculated to be 2 percent of total IPF PPS. As a result, the standardized
Federal per diem base rate was reduced by 2 percent to account for projected outlier
payments;
(2) Stop-Loss Adjustment: CMS provides a stop-loss payment to ensure that an
IPF's total PPS payments are no less than a minimum percentage of their TEFRA
payment, had the IPF PPS not been implemented. CMS reduced the standardized Federal
per diem base rate by the percentage of aggregate IPF PPS payments estimated to be made
for stop-loss payments. As a result, the standardized Federal per diem base rate was
reduced by 0.39 percent to account for stop-loss payments. Since the transition will be
completed for RY 2009, for cost reporting periods beginning on or after January 1, 2008,
IPFs will be paid 100 percent PPS and, therefore, the stop loss provision will no longer be
applicable. The CMS has previously stated that we would remove this 0.39 percent
adjustment to the Federal per diem base rate after the transition. Therefore, for RY 2009,
the Federal per diem base rate and ECT rates will be increased by 0.39 percent.
(3) Behavioral Offset: The implementation of the IPF PPS may result in certain
changes in IPF practices especially with respect to coding for comorbid medical
conditions. As a result, Medicare may incur higher payments than assumed in the
calculations. Accounting for these effects through an adjustment is commonly known as a
behavioral offset. The behavioral offset for the IPF PPS was calculated to be 2.66 percent.
As a result, CMS reduced the standardized Federal per diem base rate by 2.66 percent to
account for behavioral changes.
190.4.3 - Annual Update
(Rev. 11543; Issued: 08-04 -2022; Effective: 10-01-22; Implementation: 10-03-22)
Prior to rate year (RY) 2012, the Inpatient Psychiatric Facility Prospective Payment
System (IPF PPS) was on a July 1
st
- June 30
th
annual update cycle. The first update to the
IPF PPS occurred on July 1, 2006 and every July 1
st
thereafter.
Effective with RY 2012, the IPF PPS payment rate update period switched from a rate
year that began on July 1
st
ending on June 30
th
to a period that coincides with a fiscal year
(FY). To transition from a RY to a FY, the IPF PPS RY 2012 covered the15 month period
from July 1
st
-September 30
th
. This change to the payment update period will allow one
consolidated annual update to both the rates and the ICD-10-CM/PCS coding changes
(MS-DRG, comorbidities, and code first). Coding and rate changes will continue to be
effective October 1
st
-September 30
th
of each year thereafter.
In accordance with 42 CFR 412.428, the annual update includes revisions to the Federal
per diem base rate, the hospital wage index, ICD-10-CM coding and Diagnosis-Related
Groups (DRGs) classification changes discussed in the annual update to the hospital IPPS
regulations, the electroconvulsive therapy (ECT) payment per treatment, the fixed dollar
loss threshold amount and the national urban and rural cost-to-charge medians and
ceilings.
Below are the Change Requests (CRs) for the applicable Rate Years (RYs) and Fiscal
Years (FYs), which are issued via a Recurring Update Notification.
RY 2009 - CR 6077
RY 2010 - CR 6461
RY 2011 - CR 6986
RY 2012 - CR 7367
FY 2013 - CR 8000
FY 2014 - CR 8395
FY 2015 - CR 8889
FY 2016 - CR 9305
FY 2017 - CR 9732
FY 2018 - CR 10214
FY 2019 - CR 10880
FY 2020 - CR 11420
FY 2021 – CR 11949
FY 2022- CR 12417
FY 2023 – CR 12859
Change Requests can be accessed through the following CMS Transmittals Website:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/InpatientPsychFacilPPS/Inpatient-Psychiatric-Facility-PPS-Transmittals.html
190.4.4 - Calculating the Federal Payment Rate
(Rev. 11140, Issued:12-02-21, Effective: 01-04-22, Implementation: 01-04-22)
To calculate an IPF PPS payment, follow the steps below:
1 - Multiply the Federal per diem base rate by the labor share.
2 - Multiply the resulting amount by the appropriate wage index factor.
3 - Multiply the Federal per diem base rate by the non-labor share.
4 - Multiply the resulting amount from this by any applicable cost-of-living adjustment
(COLA) (Alaska or Hawaii).
5 - Add the adjusted labor portion of the Rate to the adjusted non-labor portion of the Rate
(Add the results of steps 2 and 4). This is the Federal rate.
You must multiply this sum (step 5) by the all applicable facility and patient level
adjustment factors described in §§190.5 and 190.6, to calculate the final payment.
190.5 - Patient-Level Adjustments
(Rev. 1543; Issued: 06-27-08; Effective Date: 07-01-08; Implementation Date: 07-
07-08)
Patient-level adjustments include a DRG, or MS-DRG, adjustment, comorbidity
adjustment, an age adjustment, and a variable per diem adjustment.
190.5.1 - Diagnosis- Related Groups (DRGs) Adjustments
(Rev. 4104, Issued: 08-03-18, Effective: 10-01-18, Implementation: 10-01-18)
On claims with discharges before October 1, 2007, the IPF PPS provides adjustments for
15 designated DRGs. On claims with discharges on or after October 1, 2007, the IPF PPS
provides adjustments for 17 designated MS-DRGs. Payment is made under the IPF PPS
for claims with a principal diagnosis included in Chapter Five of the International
Classification of Diseases (ICD-9- or ICD-10 as applicable) or the Diagnostic and
Statistical Manual of Mental Disorders-Fourth Edition, Text Revision (DSM-IV-TR). The
language about the source of the principal diagnosis code is from our regulations at 42
CFR 412.27, and has been in place since 2006, but there have since been updates to the
versions of these code sets.
In a final rule published on September 5, 2012 (77 FR 54664), the Secretary of HHS
adopted the ICD–10–CM and ICD–10–PCS, in place of the ICD–9–CM, as the standard
medical data code sets for HIPAA covered entities. Because we are required to use the
HIPAA standards, effective October 1, 2015, IPF claims for eligible patients must have a
psychiatric principal diagnosis that is listed in the ICD–10–CM. It should be noted that the
DSM codes map to ICD-10 codes, but the mapping is not exclusive to chapter 5 of the
ICD–10–CM, as it was with ICD–9–CM.
Nevertheless, only those claims with diagnoses that group to a psychiatric DRG/MS-DRG
will receive the DRG adjustment in addition to all other applicable adjustments. Although
the IPF will not receive a DRG adjustment for a principal diagnosis not found in one of
the following psychiatric DRGs/MS-DRGs, the IPF will receive the Federal per diem base
rate and all other applicable adjustments.
IPFs must submit claims providing the principal diagnosis. To classify the case to the
appropriate DRG/MS-DRG, the GROUPER software for the hospital IPPS is used and the
IPF PRICER applies the appropriate adjustment factor to the Federal per diem base rate.
Changes to the ICD coding system are addressed annually in the IPPS proposed and final
rules published each year. The updated codes are effective October 1 of each year and
must be used to report diagnostic or procedure information.
Since the IPF PPS uses the same GROUPER as the IPPS, including the same diagnostic
code set and DRG classification system, the IPF PPS is adopting IPPS’ new MS-DRG
coding system in order to maintain that consistency. The updated codes are effective
October 1 of each year. Although the code set is being updated, note that these are the
same adjustment factors in place since implementation.
Based on changes to the IPPS, the following changes are being made to the principal
diagnosis DRGs under the IPF PPS. Below is the crosswalk of current DRGs to the new
MS-DRGs which were effective October 1, 2007:
(v24) DRG
Prior to
10/01/07
(v25) MS-
DRG From
10/01/07
MS-DRG Descriptions
Adjustment
Factor
12
056
057
Degenerative nervous system disorders w
MCC
Degenerative nervous system disorders
w/o MCC
1.05
023
080
081
Nontraumatic stupor & coma w MCC
Nontraumatic stupor & coma w/o MCC
1.07
424
876
O.R. procedure w principal diagnoses of
mental illness
1.22
425
880
Acute adjustment reaction &
psychosocial dysfunction
1.05
(v24) DRG
Prior to
10/01/07
(v25) MS-
DRG From
10/01/07
MS-DRG Descriptions
Adjustment
Factor
426
881
Depressive neuroses
0.99
427
882
Neuroses except depressive
1.02
428
883
Disorders of personality & impulse
control
1.02
429
884
Organic disturbances & mental
retardation
1.03
430
885
Psychoses
1.00
431
886
Behavioral & developmental disorders
0.99
432
887
Other mental disorder diagnoses
0.92
433
894
Alcohol/drug abuse or dependence, left
AMA
0.97
521-522
895
Alcohol/drug abuse or dependence w
rehabilitation therapy
1.02
523
896
897
Alcohol/drug abuse or dependence w/o
rehabilitation therapy w MCC
Alcohol/drug abuse or dependence w/o
rehabilitation therapy w/o MCC
0.88
190.5.2 - Application of Code First
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon
Implementation of ICD-10, Implementation: ICD-10: Upon Implementation of ICD-
10, ASC X12: September, 23 2014)
According to the ICD Official Guidelines for Coding and Reporting, when a principal
diagnosis code has a Code First notation, the provider follows the applicable coding
convention, which requires the underlying condition (etiology) to be sequenced first,
followed by the manifestation due to the underlying condition. Therefore, CMS considers
Code First diagnoses to be the principal diagnosis. The submitted claim goes through the
IPF PPS claims processing system that identifies the principal diagnosis code as non-
psychiatric and searches only the first “secondary” code for a psychiatric code to assign
the DRG/MS-DRG in order to pay Code First claims properly.
For more coding guidance, refer to the ICD-9-CM Official Guidelines for Coding and
Reporting which can be located on the CDC Web site at:
http://www.cdc.gov/nchs/icd/icd9cm.htm
The ICD-10-CM Official Guidelines are posted on the CDC’s website at:
http://www.cdc.gov/nchs/icd/icd10cm.htm
The most current Code First list is posted on the IPF PPS Web site at:
www.cms.gov/InpatientPsychFacilPPS. Select Tools and Worksheets from the column at
the left.
Code First Example - ICD-9-CM
Diagnosis code 294.11 “Dementia in Conditions Classified Elsewhere with Behavioral
Disturbances” is designated as “NOT ALLOWED AS PRINCIPAL DX” code.
Four digit code 294.1 “Dementia in Conditions Classified Elsewhere”, is designated as a
Code First diagnosis indicating that all 5 digit diagnosis codes that fall under the 294.1
category (codes 294.10 and 294.11) must follow the Code First rule. The 3 digit code 294
“Persistent Mental Disorders Due to Conditions Classified Elsewhere” appears in the ICD-
9-CM as follows:
294 - PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED
ELSEWHERE
294.1 - Dementia in Conditions Classified Elsewhere
Code First any underlying physical condition, as:
Dementia in:
Alzheimer’s disease (331.0)
Cerebral lipidosis (330.1)
Dementia with Lewy bodies (331.82)
Dementia with Parkinsonism (331.81)
Epilepsy (345.0 - 345.9)
Frontal dementia (331.19)
Frontotemporal dementia (331.19)
General paresis [syphilis] (094.1)
Hepatolenticular degeneration (275.1)
Huntington’s chorea (333.4)
Jacob-Creutzfeldt disease (046.1)
Multiple sclerosis (340)
Pick's disease of the brain (331.11)
Polyarteritis nodosa (446.0)
Syphilis (094.1)
294.10 Dementia in Conditions Classified Elsewhere Without Behavioral Disturbances
NOT ALLOWED AS PRINCIPAL DX
294.11 Dementia in Conditions Classified Elsewhere With Behavioral Disturbances
NOT ALLOWED AS PRINCIPAL DX
According to Code First requirements, the provider would code the appropriate physical
condition first, for example, 333.4 “Huntington’s Chorea” as the principal diagnosis code
and 294.11 “Dementia In Conditions Classified Elsewhere With Behavioral Disturbances”
as a secondary diagnosis or comorbidity code on the patient claim.
The purpose of this example is to demonstrate proper coding for a Code First situation.
However, in this case, the principal diagnosis groups to one of the 15 DRGs, or 17 MS-
DRGs, for which CMS pays an adjustment. Had the diagnosis code grouped to a non-
psychiatric DRG/MS-DRG, the PRICER would search the first of the other diagnosis
codes for a psychiatric code listed in the Code First list in order to assign a DRG
adjustment.
Code First Example - ICD-10-CM
Diagnosis code F02.81 “Dementia in other diseases classified elsewhere with behavioral
disturbance” is designated as “NOT ALLOWED AS PRINCIPAL DX” code.
The three digit code F02 “Dementia in other diseases classified elsewhere”, is designated
as a Code First diagnosis indicating that all diagnosis codes that fall under the F02
category (codes F02.80 and F02.81) must follow the Code First rule. The 3 digit code F02
“Dementia in other diseases classified elsewhere” appears in the ICD-10-CM as follows:
F02 Dementia in other diseases classified elsewhere
Code first the underlying physiological condition, such as:
Alzheimer's (G30.0 - G30.9)
cerebral lipidosis (E75.4)
Creutzfeldt-Jakob disease (A81.0 - A81.09)
dementia with Lewy bodies (G31.83)
epilepsy and recurrent seizures (G40 - G40.919)
frontotemporal dementia (G31.09)
hepatolenticular degeneration (E83.0)
human immunodeficiency virus [HIV] disease (B20)
hypercalcemia (E83.52)
hypothyroidism, acquired (E00 - E03.9)
intoxications (T36 - T65)
Jakob-Creutzfeldt disease (A81.00 - A81.09)
multiple sclerosis (G35)
neurosyphilis (A52.17)
niacin deficiency [pellagra] (E52)
Parkinson's disease (G20)
Pick's disease (G31.01)
polyarteritis nodosa (M30.0)
systemic lupus erythematosus (M32 - M32.9)
trypanosomiasis (B56 - B57.39)
vitamin B deficiency (E53.8)
F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance
NOT ALLOWED AS PRINCIPAL DX
F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance
NOT ALLOWED AS PRINCIPAL DX
According to Code First requirements, the provider would code the appropriate physical
condition first, for example, G20 “Parkinson’s disease” as the principal diagnosis code
and F02.81 “Dementia in other diseases classified elsewhere with behavioral disturbance”
as a secondary diagnosis or comorbidity code on the patient claim.
190.5.3 - Comorbidity Adjustments
(Rev. 4104, Issued: 08-03-18, Effective: 10-01-18, Implementation: 10-01-18)
Comorbidities are specific patient conditions that are secondary to the patient's principal
diagnosis and that require treatment during the stay. Diagnoses that relate to an earlier
episode of care and have no bearing on the current hospital stay are excluded and not
reported on IPF claims. Comorbid conditions must co-exist at the time of admission,
develop subsequently, affect the treatment received, affect the length of stay or affect both
treatment and the length of stay. IPFs enter the full codes for up to twenty four additional
diagnoses if they co-exist at the time of admission or develop subsequently.
The IPF PPS has 17 comorbidity categories, each containing codes of comorbid
conditions. Each comorbidity grouping will receive a grouping-specific adjustment.
Facilities can receive only one comorbidity adjustment per comorbidity category, but can
receive an adjustment for more than one comorbidity category on the claim. The IPF
PRICER then applies the appropriate adjustment factors to the Federal per diem base rate.
A list of the ICD-10-CM/PCS codes that are associated with each category is on the IPF
PPS Web site at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/InpatientPsychFacilPPS/index.html?redirect=/inpatientpsychfacilpps. Select
Tools and Worksheets from the column at the left.
The 17 comorbidity categories and specific adjustments are as follows:
Description of Comorbidity
Adjustment Factor
Developmental Disabilities
1.04
Coagulation Factor Deficits
1.13
Tracheostomy
1.06
Description of Comorbidity
Adjustment Factor
Renal Failure, Acute
1.11
Renal Failure, Chronic
1.11
Oncology Treatment
1.07
Uncontrolled Diabetes-Mellitus with or
without complications
1.05
Severe Protein Calorie Malnutrition
1.13
Eating and Conduct Disorders
1.12
Infectious Disease
1.07
Drug and/or Alcohol Induced Mental
Disorders
1.03
Cardiac Conditions
1.11
Gangrene
1.10
Chronic Obstructive Pulmonary Disease
1.12
Artificial Openings - Digestive and Urinary
1.08
Severe Musculoskeletal and Connective
Tissue Diseases
1.09
Poisoning
1.11
190.5.4 - Age Adjustments
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
The IPF PPS has an age adjustment with 9 age categories; under 45, over 80, and
categories in 5 year groupings in between. IPFs receive this adjustment for each day of
the stay. The age adjustment is determined based on the age at admission and does not
change regardless of the length of stay.
Age
Adjustment
Factor
Under 45
1.00
45 and under 50
1.01
50 and under 55
1.02
55 and under 60
1.04
60 and under 65
1.07
65 and under 70
1.10
70 and under 75
1.13
75 and under 80
1.15
Age
Adjustment
Factor
80 and over
1.17
190.5.5 - Variable Per Diem Adjustments
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
The variable per diem adjustments account for the ancillary and certain administrative
costs that occur disproportionately in the first days after admission to an IPF. The variable
per diem adjustments decline each day of the patient’s stay through day 21. After day 21,
the adjustments remain the same each day for the remainder of the stay.
Day-of-Stay
Variable Per Diem Payment
Adjustment*
Day 1 - Facility Without a Qualifying
Emergency Department
1.19
Day 1 - Facility With a Qualifying Emergency
Department
1.31
Day 2
1.12
Day 3
1.08
Day 4
1.05
Day 5
1.04
Day 6
1.02
Day 7
1.01
Day 8
1.01
Day 9
1.00
Day 10
1.00
Day 11
0.99
Day 12
0.99
Day 13
0.99
Day 14
0.99
Day 15
0.98
Day 16
0.97
Day 17
0.97
Day 18
0.96
Day 19
0.95
Day 20
0.95
Day 21
0.95
Day-of-Stay
Variable Per Diem Payment
Adjustment*
Over 21
0.92
*The adjustment for day 1 would be 1.31 or 1.19 depending on whether the IPF
has a qualifying emergency department or is a psychiatric unit in an acute care
hospital or CAH with a qualifying emergency department (see §190.6.4).
190.6 - Facility-Level Adjustments
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
Facility-level adjustments include the hospital wage index, a rural location adjustment, a
teaching status adjustment, an emergency department adjustment for qualifying EDs, and
a cost-of-living adjustment for IPFs located in Alaska and Hawaii.
190.6.1 - Wage Index
(Rev. 11543, Issued: 08-04-22, Effective: 10-01-22, Implementation: 10-03-22)
The wage index accounts for the geographic differences in labor costs. Prior to Fiscal Year
2020, the IPF PPS used the unadjusted, pre-floor, pre-reclassified hospital wage index
from the prior year as the basis for the IPF wage index. Beginning with Fiscal Year 2020,
the IPF PPS uses the concurrent unadjusted, pre-floor, pre-reclassified hospital wage index
as the basis for the IPF wage index. The wage index is applied to the labor-related share of
the Federal per diem base rate.
Core-Based Statistical Area (CBSA) designations are used for assigning a wage index
value for discharges occurring on or after October 1. Updates to the IPF PPS wage index
are made in a budget neutral manner. CMS calculates a budget-neutral wage index
adjustment factor by comparing estimated payments under the previous wage index to
estimated payments under the updated wage index. This factor is applied in the update to
the Federal per diem base rate.
Beginning in FY 2023 a five percent cap will be applied on any decrease to a provider’s
wage index from that provider’s final wage index in the prior fiscal year. For subsequent
years, a provider's wage index would not be less than 95 percent of its wage index
calculated in the prior FY. A new IPF will be paid the wage index for the area in which it
is geographically located for its first full or partial FY with no cap applied, because a new
IPF will not have a wage index in the prior FY.
190.6.2 - Rural Location Adjustment
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
There is a 17 percent adjustment if a facility is located in a rural area. The IPF PPS
defines urban and rural areas at 42 CFR 412.402.
190.6.3 - Teaching Status Adjustment
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
IPFs that train interns and residents receive a facility-level adjustment to the Federal per
diem base rate. The cost of direct graduate medical education (DGME) and nursing and
allied health education are not paid through the IPF PPS.
PRICER calculates the adjustment by adding 1 to the ratio of interns and residents to the
average daily census (ADC), and then raising that sum to the 0.5150 power.
The number of interns and residents is capped at the level indicated on the latest cost
report submitted by the IPF prior to November 15, 2004. (See §190.6.3.1 for more
detailed instructions for the FTE Resident Cap).
For beneficiaries enrolled in a Medicare Advantage plan, IPFs may bill for DGME and
nursing and allied health education costs. There is no authority to pay teaching status
adjustment to IPFs for Medicare Advantage beneficiaries, as is done under the IPPS.
190.6.3.1 - Full-Time Equivalent (FTE) Resident Cap
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
There is a cap on the number of FTE residents that may be counted for purposes of
calculating the teaching adjustment. There is no limit to the number of residents teaching
institutions can hire or train. There is only a limit to the number of residents who may be
counted in calculation of the IPF PPS teaching adjustment. The cap is the number of FTE
residents that trained in the IPF during a base year.
An IPF’s FTE resident cap is determined based on the IPF’s most recently filed cost
report, filed prior to November 15, 2004. IPFs that first began training residents after
November 15, 2004, will initially receive an FTE cap of zero. The FTE caps for new IPFs
(as well as existing IPFs) that start training residents in a new DGME program (as defined
in 42 CFR 413.79(1)) may be subsequently adjusted in accordance with the policies that
are being applied in the IPF PPS (as described in 42 CFR 412.424(d)(1)(iii)(B)(2)).
IPFs are not permitted to aggregate the FTE resident caps used to compute the IPF PPS
teaching status adjustment through affiliation agreements. Residents with less than full-
time status and residents rotating through the psychiatric hospital or unit for less than a
full year are counted in proportion to the time they spend in their assignment with the IPF
(for example, a resident on a full-time, 3-month rotation to the IPF would be counted as
0.25 FTEs for purposes of counting residents to calculate the ratio). No FTE resident time
counted for purposes of the IPPS Indirect Medical Education (IME) adjustment is allowed
to be counted for purposes of the teaching status adjustment under the IPF PPS.
The denominator used to calculate the teaching status adjustment under the IPF PPS is the
IPF’s ADC from the current cost reporting period. If IPFs have more FTE residents in a
given year than in the base year (the base year being used to establish the cap) payments
are based on the lower number (the cap amount) in that year. If an IPF were to have fewer
FTE residents in a given year than in the base year (that is, fewer residents than its FTE
resident cap) an adjustment in payments in that year is based on the lower number (the
actual number of FTE residents the facility trains).
190.6.3.2 - Reconciliation of Teaching Adjustment on Cost Report
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
The teaching status adjustment is made on a claim basis as an interim payment and the
final payment in full for the claim is made during the final settlement of the cost report.
The difference between those interim payments and the actual teaching adjustment amount
based on information from the cost report are adjusted through lump sum
payments/recoupments when the cost report is settled.
The teaching adjustment is calculated as follows:
1. Determine the product of the wage-adjusted Federal per diem base rate and the
applicable teaching, rural, DRG, comorbidity, and age adjustments.
2. Determine the product of the wage adjusted base rate and the applicable rural, DRG,
comorbidity, and age adjustments.
3. Determine the difference of these two products (Step 1 minus Step 2).
4. Calculate and sum the variable per diem amounts for the product in Step 2 to calculate
the Federal payment net of the teaching adjustment amount.
5. Calculate and sum the variable per diem amounts for the difference in Step 3 to
calculate the portion of the Federal payment attributable to the teaching adjustment.
6. To obtain the total Federal payment necessary for outlier calculations, etc., add Steps 4
and 5 together. Step 5 alone is the teaching adjustment portion of the Federal payment,
and can be separately identified and reconciled on the cost report.
190.6.4 - Emergency Department (ED) Adjustment
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
An adjustment is provided for IPFs that maintain a qualifying ED. This is a facility-level
adjustment that applies to all IPF admissions (with the one exception described below),
regardless of whether a particular patient receives preadmission services in the hospital’s
ED.
The ED adjustment is incorporated into the variable per diem adjustment for the first day
of each stay for IPFs with a qualifying ED. That is, IPFs with a qualifying ED receive a
31 percent adjustment as the variable per diem adjustment for day 1 of each stay. If an
IPF does not have a qualifying ED, it receives a 19 percent adjustment as the variable per
diem adjustment for day 1 of each patient stay.
A qualifying ED means an ED of psychiatric units located in a hospital or CAH with EDs
that are staffed and equipped to furnish a comprehensive array (medical as well as
psychiatric) of emergency services and meets the definition of “provider-based status” (42
CFR 413.65) and meets the definition of a “dedicated emergency department” (42 CFR
489.24).
o “Provider-based status means the relationship between a main provider and a
provider-based entity or a department of a provider, remote location of a hospital,
or satellite facility that complies with the provisions of this section.” 42 CFR
413.65
o “Dedicated emergency department means any department or facility of the
hospital, regardless of whether it is located on or off the main hospital campus, that
meets at least one of the following requirements:
(1) It is licensed by the State in which it is located under applicable
State law as an emergency room or emergency department;
(2) It is held out to the public (by name, posted signs, advertising, or
other means) as a place that provides care for emergency medical
conditions on an urgent basis without requiring a previously scheduled
appointment; or
(3) During the calendar year immediately preceding the calendar year in
which a determination under this section is being made, based on a
representative sample of patient visits that occurred during that calendar
year, it provides at least one-third of all its outpatient visits for the
treatment of emergency medical conditions on an urgent basis without
requiring a previously scheduled appointment.” See 42 CFR 489.24.
As specified in 42 CFR 412.424(d)(1)(v)(B), the ED adjustment is not made where a
patient is discharged from an acute care hospital or CAH and admitted to the same
hospital’s or CAH’s psychiatric unit. An ED adjustment is not made in these cases
because the costs associated with ED services are reflected in the DRG payment to the
acute care hospital or through the reasonable cost payment made to the CAH.
Therefore, when patients are discharged from an acute care hospital or CAH and admitted
to the same hospital’s or CAH’s psychiatric unit, the IPF receives the 1.19 adjustment
factor as the variable per diem adjustment for the first day of the patient’s stay in the IPF.
IPFs should notify their Medicare contractors 30 days before the beginning of their cost
reporting period regarding if they have a qualifying ED. Medicare contractors have the
discretion to determine how they wish to be notified and the documentation they require.
Once the Medicare contractor is satisfied that the IPF has a qualifying ED, the Medicare
contractor should enter the information in the provider-specific file within a reasonable
timeframe so that the IPF can begin to receive the ED adjustment. Application of the ED
adjustment is prospective.
Medicare contractors may also use the date the documentation was received from the IPF
to implement the ED adjustment. The provider-specific file can be updated from the date
of the attestation and claims processed from that date will receive the ED adjustment.
CMS does not intend that IPFs would have to wait until the beginning of their next cost
report period to receive the ED adjustment.
However, if an IPF no longer meets the definition of a qualified ED, the IPF must
promptly notify their Medicare contractor. The Medicare contractor would immediately
remove the flag from the provider-specific file and the provider will not receive the ED
adjustment. If the provider should once again meet the definition of a qualified ED, they
should contact their Medicare contractor immediately in order to update their file.
190.6.4.1 - Source of Admission for IPF PPS Claims for Payment of ED
Adjustment
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon
Implementation of ICD-10, Implementation: ICD-10: Upon Implementation of ICD-
10, ASC X12: September, 23 2014)
Source of admission code “D” is reported by IPFs to identify IPF patients who have been
transferred to the IPF from the same hospital or CAH. Claims with source of admission
code "D" do not receive the ED adjustment.
See Pub. 100-04, Medicare Claims Processing Manual chapter 25, §60.1, for additional
instructions for completing the CMS claim data set.
190.6.5 - Cost-of-Living Adjustment (COLA) for Alaska and Hawaii
(Rev. 11039; Issued: 10-05-21; Effective: 10-01-21; Implementation: 10-04-21)
The IPF PPS includes a payment adjustment for IPFs located in Alaska and Hawaii based
upon the area in which the IPF is located. An adjustment for IPFs located in Alaska and
Hawaii is made by multiplying the non-labor related share of the Federal per diem base
rate and ECT rate by the applicable COLA factor.
The CMS notes that the COLA areas for Alaska are not defined by county as are the
COLA areas for Hawaii. In 5 CFR §591.207, the OPM established the following COLA
areas:
(a) City of Anchorage, and 80-kilometer (50-mile) radius by road, as measured
from the Federal courthouse;
(b) City of Fairbanks, and 80-kilometer (50-mile) radius by road, as measured
from the Federal courthouse;
(c) City of Juneau, and 80-kilometer (50-mile) radius by road, as measured from
the Federal courthouse;
(d) Rest of the State of Alaska.
In FY 2018, CMS updated the IPF COLA amounts; these updated amounts will remain in
effect for FY 2018 through FY 2021.
In FY 2022, CMS updated the IPF COLA amounts; these updated amounts will remain in
effect for FY 2022 through FY 2025. For comparison purposes, CMS is showing the
COLA factors effective for FY 2018 through FY 2021 in the first column and in the
second column COLA factors effective for FY22 through FY25.
Comparison of IPF PPS Cost-of-Living Adjustment Factors: IPFs Located in Alaska
and Hawaii
Area
FY 2018
through
FY 2021
FY 2022
through
FY 2025
Alaska:
City of Anchorage and 80-kilometer (50-mile) radius by
road
1.25
1.22
City of Fairbanks and 80-kilometer (50-mile) radius by
road
1.25
1.22
City of Juneau and 80-kilometer (50-mile) radius by road
1.25
1.22
Rest of Alaska
1.25
1.24
Hawaii:
City and County of Honolulu
1.25
1.25
County of Hawaii
1.21
1.22
County of Kauai
1.25
1.25
County of Maui and County of Kalawao
1.25
1.25
190.7 - Other Payment Policies
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
190.7.1 - Interrupted Stays
(Rev. 2083, Issued: 10-29-10, Effective: 01-01-11, Implementation: 01-03-11)
An interrupted stay is a case in which a patient is discharged from an IPF and is
readmitted to the same or another IPF before midnight on the third consecutive day
following discharge from the original IPF stay.
For a patient who is discharged and readmitted to the same IPF, interrupted stays are
considered to be continuous for the purposes of applying the variable per diem adjustment
and determining if the case qualifies for an outlier payment. In other words, an interrupted
stay is treated as one stay and one discharge for the purpose of payment. Thus, the IPF
should hold the claim for 3 days to ensure there is not a readmission that soon. In this
way, the readmission is included on the original claim.
For example, if a patient leaves the IPF on 1/1 and returns to the same IPF on 1/3, this is
considered an interrupted stay and the Occurrence Span Code 74 will show 1/1 – 1/2.
Should the patient return to the IPF on 1/4, two bills are allowed.
For a patient who is discharged and readmitted to another IPF, interrupted stays are
considered to be continuous for the purposes of applying the variable per diem adjustment.
For example, if a patient is discharged from IPF “A” and within 3 days is readmitted to
IPF “B,” this is considered an interrupted stay under IPF PPS. There will be no provider
action. FISS will process the claim from IPF “B” with information received from CWF
on covered days from the claim received from IPF “A”(this information will be displayed
in FISS with a value code 75 on claim that is processed for IPF “B”).
Medicare contractors should monitor trends to ensure IPFs are not consistently admitting,
discharging, and readmitting patients in order to receive the larger variable per diem
payments associated with the first days of a patient’s stay.
190.7.2 - Outlier Policy
(Rev. 2111, Issued: 12-03-10, Effective: 04-01-11, Implementation: 04-04-11)
§124 of the Medicare, Medicaid, and SCHIP, Balance Budget Refinement Act of 1999
(BBRA) (Pub.L.106-113), mandated the development of a per diem prospective payment
system for inpatient psychiatric services furnished in hospitals and psychiatric distinct part
units of acute care hospitals. §405 (g)(2) of the Medicare Prescription Drug, Improvement,
and Modernization Act of 2003(MMA) (Pub. L. 108-173) extended the IPF PPS to distinct
part psychiatric units of critical access hospitals (CAHs). §124 of the BBRA provides the
Secretary discretion in establishing the payment methodology including payments for
cases incurring extraordinarily high costs. This additional payment known as an “outlier”
is designed to protect IPFs from large financial losses due to unusually expensive cases. If
the estimated cost of the case is greater than the adjusted fixed dollar loss threshold
amount (the fixed dollar loss threshold amount multiplied by area wage index, rural
location, teaching and COLA adjustment factors), an additional payment is added to the
IPF PPS payment amount.
The fixed dollar loss threshold amount is computed so that projected outlier payments
equal 2 percent of total IPF PPS payments to ensure that IPFs treating unusually costly
cases do not incur substantial losses and promote access to IPFs for patients who require
expensive care. The fixed dollar loss threshold amount is published in the annual IPF PPS
update notice or final rule. The specific regulations governing payments for outlier cases
are located at 42 CFR 412.424(d) (3) (i).
Under 42 CFR §412.424 (d)(3)(i), for discharges in cost reporting periods beginning on or
after January 1, 2005, high cost outlier payments may be reconciled at cost report
settlement to account for differences between the cost-to-charge ratio (CCR) used to pay
the claim at its original submission by the provider, and the CCR determined at final
settlement of the cost reporting period during which the discharge occurred. Medicare
contractors will use either the most recent settled IPF cost report or the most recent
tentatively settled IPF cost report, whichever is later, to obtain the applicable IPF CCR.
In addition, under 42 CFR § 412.424 (d)(3)(i),effective for discharges in cost reporting
periods beginning on or after January 1, 2005, at the time of reconciliation, outlier
payments may be adjusted to account for the time value of any underpayments or
overpayments based on the regulations in 42 CFR §412.84 (m), except that CMS
calculates a single overall (combined operating and capital ) CCR for IPFs and national
average IPF CCRs are used instead of statewide average CCRs.
Once the threshold amount is met, CMS will share a declining percentage of the losses for
a high cost case. The risk-sharing percentages would be 80 percent of the difference
between the cost for the case minus payment and the adjusted threshold amount for days 1
through 9 of the stay and 60 percent of the difference after the 9
th
day. Medicare
contractors will determine the total outlier amount and divide by the number of days, then
pay 80 percent for days 1-9 and 60 percent for days beyond that.
Outlier payments are not paid on interim bills, but they are calculated on a final discharge
bill, a benefits exhaust bill, or if the patient falls below a covered level of care. For a more
detailed explanation on the calculation of outlier payments, visit our Web site at
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/InpatientPsychFacilPPS/index.html?redirect=/inpatientpsychfacilpps
Medicare contractors may choose to review outliers if data analysis deems it a priority.
The Pricer program makes all outlier determinations except for the medical review
determinations.
190.7.2.1 - How to Calculate Outlier Payments
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
1 - Calculate the Adjusted Fixed Dollar Loss Threshold Amount
• Multiply the threshold amount by the labor share and the area wage index;
• Multiply the threshold amount by the non-labor share and any applicable COLA
(Alaska or Hawaii);
• Add these two products and then multiply by any applicable facility-level
adjustments (teaching, rural); and
• Add this amount to the sum of the Federal per diem payment and ECT payment to
obtain the adjusted threshold amount.
2 - Calculate Eligible Outlier Costs
• Multiply reported hospital charges by the cost-to-charge ratio to calculate cost.
• Subtract the adjusted threshold amount from the cost. This is the amount subject
to outlier payments.
• Divide this amount by the length of stay to calculate the per diem outlier amount.
• For days 1 through 9, multiply this per diem outlier amount by 0.80. For day 10
and thereafter, multiply the per diem outlier amount by 0.60. The sum of these
amounts is the total outlier payment.
190.7.2.2 - Determining the Cost-to-Charge Ratio
(Rev. 4406, Issued: 10-01-19, Effective: 10-01-19, Implementation: 10-07-19)
For discharges in cost reporting periods beginning on or after January 1, 2005, Medicare
contractors are to use a CCR from the latest settled cost report or from the latest tentative
settled cost report (whichever is from the later period) to determine the IPF’s CCR. Cost-
to-charge ratios are updated each time a subsequent cost report is settled or tentatively
settled. Total Medicare charges consist of the sum of inpatient routine charges and the sum
of inpatient ancillary charges including capital. Total Medicare costs consist of the sum of
inpatient routine costs (net of private room differential and swing bed cost) plus the sum
of ancillary costs plus capital-related pass-through costs only. Based on current Medicare
cost reports and worksheets, specific instructions are described below.
Hospitals
For IPFs that are psychiatric hospitals:
1) Identify total Medicare costs from worksheet D-1, Part II, line 49, minus
(Worksheet D, Part III, column 8, lines 25 through 30, plus Worksheet D, Part IV,
column 7, line 101).
2) Identify total Medicare charges (the sum of routine and ancillary charges) from
Worksheet D-4, column 2, the sum of lines 25 through 30 and line 103 from the
cost report; where possible, these charges should be confirmed with the PS&R
data.
3) Divide the Medicare costs by the Medicare charges to compute the CCR.
Distinct Part Units
For IPFs that are distinct part psychiatric units:
1) Identify total Medicare costs from Worksheet D-1, Part II, line 49 minus
(Worksheet D, Part III, column 8, line 31 plus Worksheet D, Part IV, column 7,
line 101).
2) Identify total Medicare charges (the sum of routine and ancillary charges) from
Worksheet D-4, Column 2, line 31 plus line 103 from the cost report; where
possible, these charges should be confirmed with the PS&R data.
3) Divide the Medicare costs by the Medicare charges to compute the CCR.
All references to Worksheets and specific line numbers shall correspond with the sub-
provider identified as the IPF unit that has the letter "S" or “M” in the third position of the
Medicare provider number.
A. - Use of Alternative Data in Determining CCRs For IPFs Subject to the IPF PPS
Under 42 CFR 412.424( d)(3)(i,), for discharges in cost reporting periods beginning on or
after January 1, 2005, CMS may direct Medicare contractors to use an alternative CCR to
the CCRs from the latest settled cost report or latest tentatively settled cost report, if CMS
believes this will result in a more accurate CCR. In addition, if the Medicare contractor
finds evidence that indicates that using data from the latest settled or tentatively settled
cost report would not result in the most accurate CCR, then the Medicare contractor shall
contact the CMS Central Office to seek approval to use a CCR based on alternative data.
B. - Request by the IPF for use of a Different CCR
For discharges in cost reporting periods beginning on or after January 1, 2005, an IPF may
request that an alternative CCR be applied in the event it believes the CCR being applied
is inaccurate. The IPF is required to present substantial evidence supporting its request.
Such evidence should include documentation regarding its costs and charges that
demonstrate its claim that an alternative ratio is more accurate. The CMS Regional Office,
in conjunction with the CMS Central Office, will approve or deny any request after
evaluation by the Medicare contractor of the evidence presented by the IPF. Revised
CCRs are applied prospectively to all IPF claims. Medicare contractors shall send
notification to the CMS Central Office via the following address and e-mail address:
CMS
C/O Division of Chronic Care Management-IPF Outlier Team
7500 Security Blvd.
Mail Stop C5-05-27
Baltimore, MD. 21244
[email protected]
C. - Application of National Median CCRs for IPFs
For discharges in cost reporting periods occurring on or after January 1, 2005, the Medicare
contractor may use the national CCRs for an IPF in one of the following circumstances:
1. New IPFs that have not yet submitted their first Medicare cost report.
2. IPFs whose CCR is in excess of 3 standard deviations above the corresponding national
geometric mean (that is, above the ceiling).
3. Other IPFs for whom the Medicare contractor obtains inaccurate or incomplete data with
which to calculate a CCR.
For new IPFs, we are using the national median CCRs until the facility’s actual CCR can be
computed using the first tentatively settled or final settled cost report, which will then be used
for the subsequent cost report period.
NOTE: IPF PPS provides two national ceilings, one for IPFs located in rural areas and one for
IPFs located in urban areas. We computed the ceilings by calculating the national average and
the standard deviation of the CCR for both urban and rural IPFs.
The policies in section E below can be applied as an alternative to the national median CCR.
For those IPFs assigned the national median CCR, the CCR must be updated every October 1
st
based on the latest national median CCRs published in each year’s IPF PPS notice or final rule
until the hospital is assigned a CCR based on the latest tentative or final settled cost report or a
CCR based on the policies of part E and F of this section.
D. - Notification to IPFs Under the IPF PPS of a Change in the CCR
The Medicare contractor shall notify an IPF whenever it makes a change to its CCR.
When a CCR is changed as a result of a tentative settlement or a final settlement, the
change to the CCR can be included in the notice that is issued to each provider after a
tentative or final settlement is completed. Medicare contractors can also issue separate
notification to an IPF about a change to their CCR(s).
E. - Ongoing CCR Updates Using CCRs From Tentative Settlements For Entities
Subject to the IPF PPS
For discharges beginning on or after January 1, 2005, Medicare contractors are to use a
CCR from the latest settled cost report or from the latest tentatively settled cost report
(whichever is from the later period) to determine the IPF’s CCR. Under the IPF PPS,
Medicare contractors must update the IPFs CCR on the Provider Specific File to reflect
the IPFs CCR from the most recent tentative settlements or final settled cost reports,
(whichever is the later period). Revised CCRs shall be entered into the Provider Specific
File not later than 30 days after the date of the latest settlement used in calculating the
CCR.
Subject to the approval of CMS, an IPF’s CCR may be revised more often if a change in a
hospital’s operations occurs which materially affects a hospital’s costs or charges. A
revised CCR will be applied prospectively to all IPF PPS claims processed after the
update.
F. - Alternative CCRs
Effective for discharges in cost reporting periods beginning on or after January 1, 2005,
the CMS Central Office may direct Medicare contractors to use an alternative CCR to the
CCR from the later of the latest settled cost report or latest tentatively settled cost report, if
CMS believes this will result in a more accurate CCR. In addition, if the Medicare
contractor finds evidence that indicates that using data from the latest settled or tentatively
settled cost report would not result in the most accurate CCR, the Medicare contractor
shall contact the CMS Central Office to seek approval to use a CCR based on alternative
data. Also, a facility will have the opportunity to request that a different CCR be applied
in the event it believes the CCR being applied is inaccurate. The IPF is required to present
substantial evidence supporting its request. Such evidence should include documentation
regarding its costs and charges that demonstrate its claim that an alternative ratio is more
accurate. The CMS Regional Office and CMS Central Office must approve any such
request after evaluation by the Medicare contractor of the evidence presented by the IPF.
G. - IPF Mergers, Ownership Changes, and Errors with CCRs
Effective April 1, 2011, in the case of a merger, the Medicare contractor shall use the CCR
from the IPF with the surviving provider number. If a new provider number (i.e., a new
provider agreement is signed because the new owner refused assignment of the existing
provider agreement) is issued the Medicare contractor shall use the national CCR based on
the facility location of either urban or rural.
In instances where errors related to CCRs and/or outlier payments are discovered,
Medicare contractors shall contact CMS Central Office to seek guidance. Medicare
contractors may contact the CMS Central Office via the address and email address listed
in part B of this section.
If a cost report is reopened after final settlement and as a result of this reopening there is a
change to the CCR, Contractors shall contact the CMS regional and Central Office for
further instructions. Contractors may contact the CMS Central Office via the address and
email address listed in part B of this section.
H. - Maintaining a History of CCRs and Other Fields in the Provider Specific File
When reprocessing claims due to outlier reconciliation, Medicare contractors shall
maintain an accurate history of certain fields in the provider specific file (PSF). This
history is necessary to ensure that claims already processed (from prior cost reporting
periods that have already been settled) will not be subject to a duplicate systems
adjustment in the event that claims need to be reprocessed. As a result, the following fields
in the PSF can only be altered on a prospective basis: -23 -Intern to Bed Ratio -24 --Bed
Size -25 -Operating Cost to Charge Ratio and 21 -Case Mix Adjusted Cost Per Discharge.
A separate history outside of the PSF is not necessary. The only instances a Medicare
contractor retroactively changes a field in the PSF is to update the CCR when using the
FISS Lump Sum Utility for outlier reconciliation or otherwise specified by the CMS
Regional Office or Central Office.
190.7.2.3 - Outlier Reconciliation
(Rev. 2242, Issued: 06-17-11, Effective: 07-01-11, Implementation: 07-01-11)
A. - General
Under §412.424 (d) (3) (i), for IPF services furnished during cost reporting periods
beginning on or after January 1, 2005, IPF outlier payments may be reconciled upon cost
report settlement to account for differences between the overall ancillary CCR used to pay
the claim at its original submission by the provider, and the CCR determined at final
settlement of the cost reporting period during which the service was furnished. IPF PPS
outlier payments are reconciled if the CMS Central Office and Regional Office confirm
that reconciliation is appropriate.
Effective for cost reporting periods beginning on or after April 1, 2011, subject to the
approval of the CMS Central Office and Regional Office, the Medicare contractor shall
reconcile an IPF’s outlier claims at the time of cost report final settlement if they meet the
following criteria:
1. The actual CCR is found to be plus or minus 10 percentage points from the CCR
used during that time period to make outlier payments, and
2. Total IPF outlier payments in that cost reporting period exceed $500,000.
To determine if an IPF meets the criteria above, the Medicare contractor shall incorporate
all the adjustments from the cost report, run the cost report, calculate the revised CCR, and
compute the actual overall ancillary CCR prior to issuing a Notice of Program
Reimbursement (NPR). If the criteria for IPF outlier reconciliation are not met, the cost
report shall be finalized. If the criteria for reconciliation are met, Medicare contractors
shall follow the instructions below in §190.7.2.5 of this chapter. The NPR cannot be
issued nor can the cost report be finalized until IPF outlier reconciliation is complete.
These IPF cost reports will remain open until their claims have been processed for IPF
PPS outlier reconciliation.
As stated above, if a cost report is reopened after final settlement and as a result of this
reopening there is a change to the CCR (which could trigger or affect IPF PPS outlier
reconciliation and outlier payments), Medicare contractors shall notify the CMS Central
and Regional Offices for further instructions. Notification to the CMS Central Office shall
be sent to the address and email address provided in §190.7.2.2(B) above.
Medicare contractors shall notify the CMS Central Office and Regional Office if a cost
report was final settled and meets the qualifications for IPF PPS outlier reconciliation.
Notification to the CMS Central Office shall be sent to the address and email address
provided in §190.7.2.2 (B).
B. - Reconciling Outlier Payments IPFs
Beginning with the first cost reporting period starting on or after January 1, 2005, IPF
outlier payments may be reconciled at cost report settlement to account for differences
between the cost-to-charge ratio (CCR) used to pay the claim at its original submission by
the provider, and the CCR determined at final settlement of the cost reporting period
during which the discharge occurred. Effective for cost reporting periods beginning on or
after April 1, 2011, if an IPF meets the criteria in part A of this section, the Medicare
contractor shall follow the instructions below in §190.7.2.5. The following examples
demonstrate how to apply the criteria for reconciliation (as discussed in part A above):
EXAMPLE A:
Cost Reporting Period: 01/01/2010-12/31/2010
Operating CCR used to pay original claims submitted during cost reporting period: 0.40
(In this example, this CCR is from the tentatively or final settled 2007 cost report)
Final settled operating CCR from 01/01/2010-12/31/2010 cost report: 0.50
Total IPF PPS outlier payout in 01/01/2010-12/31/2010 cost reporting period: $600,000
Because the CCR of 0.40 used at the time the claim was originally paid changed to 0.50 at
the time of final settlement, and the provider received greater than $500,000 in IPF PPS
outlier payments during that cost reporting period, the criteria are met for reconciliation,
and therefore, the Medicare contractor notifies the Central Office and the Regional Office.
The provider’s IPF PPS outlier payments for this cost reporting period are reconciled
using the correct CCR of 0.50.
In the event that multiple CCRs are used in a given cost reporting period to calculate
outlier payments, Medicare contractors should calculate a weighted average of the CCRs
in that cost reporting period. Example B below shows how to weight the CCRs. The
Medicare contractor shall then compare the weighted CCR to the CCR determined at the
time of final settlement of the cost reporting period to determine if IPF PPS outlier
reconciliation is required. Total IPF PPS outlier payments for the entire cost reporting
period must exceed $500,000 in order to trigger reconciliation.
EXAMPLE B:
Cost reporting period: 01/01/2010-12/31/2010
Overall CCR used to pay original claims submitted during cost reporting period:
0.40 from 01/01/2010 to 03/31/2010 (This CCR could be from the tentatively settled
2006 cost report.)
0.50 from 04/01/2010 to 12/31/2010 (This CCR could be from the tentatively settled 2007
cost report.)
Final settled operating CCR from 01/01/2010 - 12/31/2010 cost report: 0.35
Total IPF outlier payout in 01/01/2010 -12/31/2010 cost reporting period: $600,000
Weighted average CCR: 0.476
CCR
DAYS
Weight
Weighted CCR
0.40
90
0.247 (90 Days / 365
Days)
(a) 0.099 = (0.40 *
0.247)
0.50
275
0.753 (275 Days /
365 Days)
(b) 0.377 = (0.50 *
0.753)
TOTAL
365
365
(a)+(b) = 0.476
The IPF meets the criteria for IPF PPS outlier reconciliation in this cost reporting period
because the variance from the weighted average CCR at the time the claim was originally
paid compared to the CCR from the cost report at the time of settlement is greater than 10
percentage points (from 0.476 to 0.35) and the provider received total IPF outlier
payments greater than $500,000 for the entire cost reporting period.
Even if the IPF does not meet the criteria for reconciliation in §190.7.2.3, subject to
approval of the CMS Central and Regional Offices, the Medicare contractor has the
discretion to request that IPF PPS outlier payments in a cost reporting period be reconciled
if the IPF’s most recent cost and charge data indicate that the IPF PPS outlier payments to
the IPF were significantly inaccurate. The Medicare contractor sends notification to the
CMS Regional Office and Central Office via the address and email address provided in
§190.7.2.2 (B). Upon approval of the CMS Central and Regional Office that IPF’s outlier
claims need to be reconciled, Medicare contractors should follow the instructions in
§190.7.2.3.
190.7.2.4 - Time Value of Money
(Rev. 2242, Issued: 06-17-11, Effective: 07-01-11, Implementation: 07-01-11)
Effective for discharges occurring on or after January 1, 2005, at the time of any
reconciliation under §190.7.2, IPF outlier payment may be adjusted to account for the time
value of money of any adjustments to IPF outlier payments as a result of reconciliation.
The time value of money is applied from the midpoint of the IPF’s cost reporting period
being settled to the date on which the CMS Central Office receives notification from the
Medicare contractor that reconciliation should be performed.
If an IPF’s outlier payments have met the criteria for reconciliation, Medicare contractors
will calculate the aggregate adjustment using the instructions below concerning
reprocessing claims and determine the additional amount attributable to the time value of
money of that adjustment. The index that will be used to calculate the time value of
money is the monthly rate of return that the Medicare trust fund earns. This index can be
found at http://www.ssa.gov/OACT/ProgData/newIssueRates.html.
The following formula shall be used to calculate the rate of the time value of money.
(Rate from Web site as of the midpoint of the cost report being settled / 365) * # of days
from that midpoint until date of reconciliation. NOTE: The time value of money can be a
positive or negative amount depending if the provider is owed money by CMS or if the
provider owes money to CMS.
For purposes of calculating the time value of money, the “date of reconciliation” is the day
on which the CMS Central Office receives notification. This date is either the postmark
from the written notification sent to the CMS Central Office via mail by the Medicare
contractor, or the date an email was received from the Medicare contractor by the CMS
Central Office, whichever is first.
EXAMPLE C:
Cost reporting period: 01/01/2010 - 12/31/2010
Midpoint of cost reporting period: 07/01/2010
Date of reconciliation: 12/31/2010
Number of days from midpoint until date of reconciliation: 547
Rate from Social Security Web site: 4.625%
Overall ancillary CCR used to pay actual original claims in cost reporting period: 0.40
(This CCR could be from the tentatively settled 2006 or 2007 cost report.)
Final settled operating CCR from 01/01/2009 - 12/31/2009 cost report: 0.50
Total IPF outlier payout in 01/01/2009 - 12/31/2009 cost reporting period: $600,000
Because the CCR fluctuated from 0.40 at the time the claims were originally paid to 0.50
at the time of final settlement and the provider has an IPF outlier payout greater than
$500,000, the criteria have been met to trigger reconciliation. The Medicare contractor
follows the procedures in §190.7.2.4.
The reprocessing of claims indicates the revised IPF hospital outlier payments are
$700,000.
Using the values above, the rate that is used for the time value of money is determined:
(4.625 / 365) * 548 = 6.9438%
Based on the claims reconciled, the provider is owed $100,000 ($700,000 - $600,000) for
the reconciled amount and $6,943.80 for the time value of money.
190.7.2.5 - Procedures for Medicare Contractors to Perform and Record
Outlier Reconciliation Adjustments
(Rev. 2111, Issued: 12-03-10, Effective: 04-01-11, Implementation: 04-04-11)
The following is a step-by-step explanation of the procedures that Medicare contractors
are to follow if an IPF is eligible for outlier reconciliation:
1) The Medicare contractor shall send notification to the CMS Central Office (not the
hospital), via the street address and email address provided in §190.7.2.2 (B), and
CMS Regional Office that a hospital has met the criteria for reconciliation.
Medicare contractors shall include in their notification the provider number,
provider name, cost reporting begin date, cost reporting end date, total outlier
payments in the cost reporting period, the CCR or weighted average CCR from the
time the claims were paid during the cost reporting period eligible for
reconciliation and the final settled CCR.
2) If the Medicare contractor receives approval from the CMS Central Office that
reconciliation is appropriate, the Medicare contractor shall follow steps 3-14
below. NOTE: Hospital cost reports will remain open until their claims have been
processed for outlier reconciliation.
3) The Medicare contractor shall notify the hospital and copy the CMS Regional
Office and Central Office in writing and via email (through the addresses provided
in §190.7.2.2 (B)) that the hospital’s outlier claims are to be reconciled.
4) Prior to running claims in the *Lump Sum Utility, Medicare contractors shall
update the applicable provider record in the Provider Specific File (PSF) by
entering the final settled CCR from the cost report in the -25 -Operating Cost to
Charge Ratio field. No other elements in the PSF shall be updated for the
applicable provider records in the PSF that span the cost reporting period being
reconciled aside from the CCR.
*NOTE: The FISS Lump Sum Utility is a Medicare contractor tool that,
depending on the elements that are input, will produce an extract that will calculate
the difference between the original PPS payment amounts and revised PPS
payment amounts into a Microsoft Access generated report. The Lump Sum Utility
calculates the original and revised payments offline and will not affect the original
claim payment amounts as displayed in various CMS systems (such as NCH).
5) Medicare contractors shall ensure that, prior to running claims through the FISS
Lump Sum Utility, all pending claims (e.g., appeal adjustments) are finalized for
the applicable provider.
6) Medicare contractors shall only run claims in the Lump Sum Utility that meet the
following criteria:
• Type of Bill (TOB) equals 11X
• Previous claim is in a paid status (P location) within FISS
• Cancel date is ‘blank’
7) The Medicare contractor reconciles the claims through the IPF Pricer software and
not through any editing or grouping software.
8) Upon completing steps 3 through 7 above, the Medicare contractor shall run the
claims through the Lump Sum Utility. The Lump Sum Utility will produce an
extract, according to the elements in Table 1 below. NOTE: The extract must be
importable by Microsoft Access or a similar software program (Microsoft Excel).
9) Medicare contractors shall upload the extract into Microsoft Access or a similar
software program to generate a report that contains elements in Table 1. Medicare
contractors shall ensure this report is retained with the cost report settlement work
papers.
10) For hospitals paid under the IPF PPS, the Lump Sum Utility will calculate the
difference between the original outlier amount (value code 17) and the revised
outlier amount (value code 17). If the difference between the original and revised
outlier amount (calculated by
the Lump Sum Utility) is positive, then a credit
amount (addition) shall be issued to the provider. If the difference between the
original and revised outlier amount (calculated by
the Lump Sum Utility) is negative,
then a debit amount (deduction) shall be issued to the provider.
11) Medicare contractors shall determine the applicable time value of money amount
by using the calculation methodology in §190.7.2.4. If the difference between the
original and revised outlier amount (calculated by the Lump Sum Utility) is a negative
amount then the time value of money is also a negative amount.
If the difference
between the original and revised outlier amount (calculated by the Lump Sum Utility)
is a positive amount then the time value of money is also a positive amount.
Similar to
step 10, if the time value of money is positive, then a credit amount (addition) shall
be issued to the provider. If the time value of money is negative, then a debit
amount (deduction) shall be issued to the provider. NOTE: The time value of
money is applied to the difference between the original outlier amount (value code
17) and the revised outlier amount (value code 17).
12) For cost reporting periods beginning before May 1, 2010, under cost report 2552-
96, the Medicare contractor shall record the original outlier amount from
Worksheet E-3, Part 1 line 1.09, the outlier reconciliation adjustment amount (the
difference between the original outlier amount (value code 17) and the revised
outlier amount (value code 17) calculated by Lump Sum Utility), the total time
value of money and the rate used to calculate the time value of money on lines 50-
53, of Worksheet E-3, Part 1 of the cost report (NOTE: the amounts recorded on
lines 50, 51 and 53 can be positive or negative amounts per the instructions above).
The total outlier reconciliation amount (the difference between the original outlier
amount (value code 17) and the revised outlier amount (value code 17) calculated
by the Lump Sum Utility plus the time value of money) shall be recorded on line
15.99 of Worksheet E-3, Part 1. For complete instructions on how to fill out these
lines please see § 3633.1 of the Provider Reimbursement Manual, Part II.
For cost reporting periods beginning on or after May 1, 2010, under cost report
2552-10, the Medicare contractor shall record the original outlier amount from
Worksheet E-3, Part II line 2, the outlier reconciliation adjustment amount (the
difference between the original outlier amount (value code 17) and the revised
outlier amount (value code 17) calculated by the Lump Sum Utility), the total time
value of money and the rate used to calculate the time value of money on lines 50-
53, of Worksheet E-3, Part II of the cost report (NOTE: the amounts recorded on
lines 50, 51 and 53 can be positive or negative amounts per the instructions above).
The total outlier reconciliation amount (the difference between the original outlier
amount (value code 17) and the revised outlier amount (value code 17) calculated
by the Lump Sum Utility plus the time value of money) shall be recorded on line
29 of Worksheet E-3, Part II.
13) The Medicare contractor shall finalize the cost report, issue a NPR and make the
necessary adjustment from or to the provider.
14) After determining the total outlier reconciliation amount and issuing a NPR,
Medicare contractors shall restore the CCR(s) to their original values (that is, the
CCRs used to pay the claims) in the applicable provider records in the PSF to
ensure an accurate history is maintained. Specifically, for hospitals paid under the
IPF PPS, Medicare contractors shall enter the original CCR in PSF field 25 -
Operating Cost to Charge Ratio.
Medicare contractors shall contact the CMS Central Office via the address and email
address provided in §190.7.2.2 (B) with any questions regarding this process.
Table 1: Data Elements for FISS Extract
List of Data Elements for FISS Extract
Provider #
Health Insurance Claim (HIC) Number
Document Control Number (DCN)
Type of Bill
Original Paid Date
Statement From Date
Statement To Date
Original Reimbursement Amount (claims page 10)
Revised Reimbursement Amount (claim page 10)
Difference between these amounts
Original Deductible Amount, Payer A, B, C (Value Code A1, B1, C1)
Revised Deductible Amount, Payer A, B, C (Value Code A1, B1, C1)
Difference between these amounts
Original Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2)
Revised Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2)
Difference between these amounts
Original Outlier Amount (Value Code 17)
Revised Outlier Amount (Value Code 17)
List of Data Elements for FISS Extract
Difference between these amounts
Original DSH Amount (Value Code 18)
Revised DSH Amount (Value Code 18)
Difference between these amounts
Original IME Amount (Value Code 19)
Revised IME Amount (Value Code 19)
Difference between these amounts
Original New Tech Add-on (Value Code 77)
Revised New Tech Add-on (Value Code 77)
Difference between these amounts
Original Device Reductions (Value Code D4)
Revised Device Reductions (Value Code D4)
Difference between these amounts
Original Hospital Portion (claim page 14)
Revised Hospital Portion (claim page 14)
Difference between these amounts
Original Federal Portion (claim page 14)
Revised Federal Portion (claim page 14)
Difference between these amounts
Original C TOT PAY (claim page 14)
Revised C TOT PAY (claim page 14)
Difference between these amounts
Original C FSP (claim page 14)
Revised C FSP (claim page 14)
Difference between these amounts
Original C OUTLIER (claim page 14)
Revised C OUTLIER (claim page 14)
Difference between these amounts
Original C DSH ADJ (claim page 14)
Revised C DSH ADJ (claim page 14)
Difference between these amounts
Original C IME ADJ (claim page 14)
Revised C IME ADJ (claim page 14)
Difference between these amounts
Original Pricer Amount
Revised Pricer Amount
Difference between these amounts
Original PPS Payment (claim page 14)
Revised PPS Payment (claim page 14)
Difference between these amounts
Original PPS Return Code (claim page 14)
Revised PPS Return Code (claim page 14)
DRG
MSP Indicator (Value Codes 12-16 & 41-43 - indicator indicating the claim is MSP; ‘Y’ =
MSP, ‘blank’ = no MSP
Reason Code
List of Data Elements for FISS Extract
HMO-IME Indicator
Filler
190.7.3 - Electroconvulsive Therapy (ECT) Payment
(Rev. 3575, Issued: 08-01-16, Effective: 10-01-16; Implementation: 10-03-16)
IPFs receive an additional payment for each ECT treatment furnished during the IPF stay.
The ECT base rate is based on the median hospital cost used to calculate the calendar year
2005 Outpatient Prospective Payment System amount for ECT and is updated annually by
the market basket and wage budget neutrality factor. The ECT base rate is adjusted by the
wage index and any applicable COLA factor.
In order to receive the payment, an IPF must report revenue code 0901 along with the
number of units of ECT on the claim. The units should reflect the number of ECT
treatments provided to the patient during the IPF stay. In addition, IPFs must include the
ICD-9-CM procedure code for ECT (94.27) in the procedure code field and use the date of
the last ECT treatment the patient received during their IPF stay.
Effective with the implementation of ICD-10 the following ICD-10-PCS codes apply:
ICD-10-PCS Code and Description
GZB0ZZZ - Electroconvulsive Therapy, Unilateral-Single Seizure
GZB2ZZZ - Electroconvulsive Therapy, Bilateral-Single Seizure
GZB4ZZZ – Other Electroconvulsive Therapy
It is important to note that since ECT treatment is a specialized procedure, not all
providers are equipped to provide the treatment. Therefore, many patients who need ECT
treatment during their IPF stay must be referred to other providers to receive the ECT
treatments, and then return to the IPF. In accordance with 42 CFR 412.404(d)(3), in these
cases where the IPF is not able to furnish necessary treatment directly, the IPF would
furnish ECT under arrangements with another provider. While a patient is an inpatient of
the IPF, the IPF is responsible for all services furnished, including those furnished under
arrangements by another provider. As a result, the IPF claim for these cases should reflect
the services furnished under arrangements by other providers.
190.7.4 - Stop Loss Provision (Transition Period Only)
(Rev. 1543; Issued: 06-27-08; Effective Date: 07-01-08; Implementation Date: 07-
07-08)
The IPF PPS includes a stop-loss provision during the 3-year transition. The purpose is to
ensure each facility receives an average payment per case under the IPF PPS that is no less
than 70 percent of its average payment under the TEFRA. It is calculated at cost report
settlement. New providers are not eligible for stop-loss payments. See §190.9.1.
Example of stop-loss calculation in year 3 of the transition:
1. Enter Total (100%) TEFRA payments for cases during cost reporting period
2. Enter Total (100%) PPS payments for cases during cost reporting period
3. Multiply Step 1 by 0.70.
4. If Step 3 is greater than Step 2, subtract Step 2 from Step 3. Otherwise, enter 0.
5. Add Steps 2 and 4 to calculate total PPS payments.
6. Multiply Step 1 by 0.25 to calculate the TEFRA portion.
7. Multiply Step 5 by 0.75 to calculate the PPS portion.
8. Add Steps 6 and 7 to calculate the IPF’s aggregate payments in the third year of the
IPF PPS. Determine if this amount is at least 70 percent of what would have been paid
under TEFRA, then pay the difference.
NOTE: Since the transition will be completed for RY 2009, for cost reporting periods
beginning on or after January 1, 2008, IPFs will be paid 100 percent PPS and, therefore,
the stop loss provision will no longer be applicable. The CMS has previously stated that
we would remove this 0.39 percent adjustment to the Federal per diem base rate after the
transition. Therefore, for RY 2009, the Federal per diem base rate and ECT rates will be
increased by 0.39 percent.
190.8 - Transition (Phase-In Implementation)
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
190.8.1 - Implementation Date for Provider
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
The IPF PPS is phased-in over 3 years from the cost based reimbursement to the Federal
prospective payment. All IPF providers must transition over the 3-year transition period.
There is no election of 100 percent PPS in the first year.
During the transition period, payment is based on an increasing percentage of the IPF
prospective payment and a decreasing percentage of each IPF’s TEFRA-based
reimbursement rate for each case as follows:
Transition
Year
Cost Reporting
Periods
Beginning on or After
TEFRA Rate
Percentage
IPF PPS Federal Rate
Percentage
1
January 1, 2005
75
25
2
January 1, 2006
50
50
3
January 1, 2007
25
75
January 1, 2008
0
100
The 3-year transition period is separate from the annual update cycle of the IPF PPS. The
transition is effective according to cost reporting periods, but the updates to the rates take
effect July 1 of each year. For more detailed information regarding the annual update
cycle, refer to §190.4.3-Annual Update.
Although the IPF PPS is effective January 1, 2005, an individual IPF's PPS transition year
start date is the first day of the first cost reporting period that begins on or after that date.
An IPF may begin the IPF PPS as early as January 1, 2005, or as late as December 31,
2005, should a cost reporting period begin on that date.
The IPF PPS applies to claims for discharges occurring in the IPF's first cost reporting
period beginning on or after January 1, 2005. Where the IPF has already billed interim
claims for an inpatient that has benefit days remaining after the PPS implementation date,
the provider must submit a cancel bill and re-bill under the IPF PPS so that payment for
the entire stay is made under the IPF PPS.
If the provider ever had a TEFRA limit, the IPF is not a new provider and therefore will
receive the blended payment. This includes those providers that previously closed their
psychiatric units and then re-opened the psychiatric units. If the provider had a TEFRA
limit established, that TEFRA limit is updated using the rate of increase percentages in
42 CFR 413.40.
For cost reporting periods beginning in FY 1999 through FY 2002, the applicable rate-of-
increase percentage is the market basket increase percentage minus a factor based on the
percentage by which the hospital’s operating costs exceed the hospital’s ceiling for the
most recently available cost reporting period.
To update the TEFRA limit for IPFs that were closed during FY 1999 through FY 2002
and then re-opened (including CAHs that were statutorily precluded from having a distinct
part unit), the rate-of-increase for these years would be the full market basket up to the cap
on the target amounts.
190.9 - Definition of New IPF Providers Versus TEFRA Providers
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
190.9.1 - New Providers Defined
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
A new IPF provider is one that meets the definition of an IPF in 42 CFR 412.402, and
under present or previous ownership or both, has not received payment under TEFRA for
delivery of IPF services prior to the effective date of the IPF PPS, January 1, 2005. To be
a new provider, the first cost reporting period as a psychiatric hospital, a distinct part unit
in an acute care hospital or a CAH must have begun no earlier than January 1, 2005,
coinciding with the effective date of the IPF PPS.
Change of ownership has no impact on whether an IPF is considered a new IPF provider.
190.10 - Claims Processing Requirements Under IPF PPS
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
190.10.1 - General Rules
(Rev. 3030, Issued: 08-22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon
Implementation of ICD-10, Implementation: ICD-10: Upon Implementation of ICD-
10, ASC X12: September, 23 2014)
Effective with cost reporting periods beginning on or after January 1, 2005, the following
claim preparation requirements apply to IPFs:
• Type of Bill (TOB) is 11X;
• Medicare provider number ranges for IPFs are from xx-4000 - xx-4499, xx-
Sxxx, and xx-Mxxx; (NOTE: Implementation of NPI will change this.)
• The IPF must correctly code diagnoses for the principal diagnosis, and up to
twenty four additional diagnoses, if applicable;
• The IPF must correctly code one principal procedure and up to twenty four
additional procedures performed during the stay;
• The IPF must also code age, sex, and patient (discharge) status of the patient
on the claim, using standard inpatient coding rules; and
• An IPF distinct part must code source of admission code "D" on incoming
transfers from the acute care area of the same hospital to avoid overpayment of
the emergency department adjustment when the acute area has billed or will be
billing for covered services for the same inpatient admission.
Other general requirements for processing Medicare Part A inpatient claims described in
Chapter 25 of this manual apply.
CMS' hospital inpatient GROUPER applicable to the discharge date (or effective
December 3, 2007, benefits exhaust date, if present) on the claim will determine the
DRG/MS-DRG assignment.
190.10.2 - Billing Period
(Rev. 1231; Issued: 04-27-07; Effective: 12-03-07; Implementation: 12-03-07)
When the patient has Medicare benefits, IPF providers will submit one admit through
discharge claim for the stay upon discharge. IPFs may interim bill in 60-day intervals
following the instructions in chapter 1, §50.2 of this manual should the patient’s stay be
exceptionally long. Final PPS payment is based upon the date of physical discharge or
death, or the date benefits exhausted (effective December 3, 2007).
IPFs can submit adjustment claims, but late charge claims will not be allowed, e.g., the
adjustment claim must include all charges and services and must replace the earlier
claim(s) instead of including only the additional charges and services.
In situations when a patient falls below a skilled level of care, IPFs should submit a 112
TOB with both an Occurrence Code 22 (Date active care ended) and patient status code 30
(Still a patient). IPFs should then continue to submit subsequent interim 117 TOBs, as
appropriate, with the patient status code 30 and the correct Occurrence Span Codes that
identify payment liability (codes 76 or 77).
Effective December 3, 2007, once the patient’s Medicare benefit’s exhaust, the IPF is
allowed to submit no-pay bills (TOB 110), with a Patient Status Code of 30 every 60 days,
until the patient is physically discharged or dies. The last bill shall contain a discharge
patient status code. IPFs no longer need to continually adjust claims once benefits
exhaust.
190.10.3 - Patient Status Coding
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
All patient status (i.e., discharge disposition) codes for 11X TOB are valid, but there are
no special payment policies related to transfer codes; for example, discounted or per diem
payments in transfer situations. The same patient status codes applicable under inpatient
PPS for same day transfers (with Condition Code 40) are applicable under IPF PPS.
190.10.4 - Reporting ECT Treatments
(Rev. 4104, Issued: 08-03-18, Effective: 10-01-18, Implementation: 10-01-18)
IPFs must report on their claims under Revenue Code 0901: the total number of ECT
treatments provided to the patient during their IPF stay listed under “Service Units.”
Providers will code ICD-9-CM procedure code 94.27 if ICD-9-CM is applicable, or,
effective with the implementation of ICD-10, providers will code the ICD-10-PCS codes
listed below in the procedure code field, and for the procedure date will use the date of the
last ECT treatment the patient received during their IPF stay.
ICD-10-PCS Code and Description
GZB0ZZZ - Electroconvulsive Therapy, Unilateral-Single Seizure
GZB2ZZZ - Electroconvulsive Therapy, Bilateral-Single Seizure
GZB4ZZZ - Other Electroconvulsive Therapy
190.10.5 - Outpatient Services Treated as Inpatient Services
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
IPFs are subject to the 1-day payment window for outpatient bundling rules. Refer to
chapter 3, §40.3 of this manual for more information on bundling rules.
190.10.6 - Patient is a Member of a Medicare Advantage Organization
for Only a Portion of a Billing Period
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
The payer at the time of the patient’s admission to an IPF is responsible for the cost of the
entire stay. This could occur for patients who move from traditional Medicare to a
Medicare Advantage plan or vice versa.
190.10.7 - Billing for Interrupted Stays
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
IPFs shall bill for the interrupted stay using Occurrence Span Code 74. The Occurrence
Span Code FROM date equals the day of discharge for the IPF and the THROUGH date is
the last day the patient was not present in the IPF at midnight. For example, the patient
leaves the IPF on 1/1 and returns to the IPF on 1/3. This is considered an interrupted stay
and the Occurrence Span Code 74 will show 1/1 - 1/2. Should the patient return to the IPF
on 1/4, two bills will be allowed. The accommodation Revenue Code 018X (RT 50, field
5), (SV 201), (leave of absence) will continue to be used in the current manner in terms of
Occurrence Span Code 74 (RT 40, field 22 - 27) and date range.
190.10.8 - Grace Days
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
There are no grace days allowed under IPF PPS, therefore the date the beneficiary is
notified of the provider's intent to bill (Occurrence Code 31) is the last covered day for
that patient.
190.10.9 - Billing Stays Prior to and Discharge After PPS
Implementation Date
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
If the patient’s stay begins prior to and ends on or after the provider’s first fiscal year
begin date under IPF PPS, payment to the facility is based on IPF PPS rates and rules.
There is no split billing. If the facility submitted an interim bill, a debit/credit adjustment
must be made prior to PPS payment (see chapter 1, §50.2 of this manual). If the facility
submitted multiple interim bills, the facility will need to submit cancels for all bills and
then re-bill once the cancels are accepted.
Exceptions:
If the beneficiary’s benefits were exhausted or the beneficiary is in a non-covered level of
care prior to implementation of IPF PPS, then IPF PPS is not applicable and the IPF will
continue to submit no-pay bills (TOB 110) to Medicare.
190.10.10 - Billing Ancillary Services Under IPF PPS
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
There are no special rules for billing IPF inpatient ancillary services.
190.10.11 - Covered Costs Not Included in IPF PPS Amount
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
The following covered services are not included in the IPF PPS discharge payment
amount:
o Nursing and allied health education costs are pass-through costs paid outside the
IPF PPS.
o DGME and bad debts.
190.10.12 - Same Day Transfer Claims
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
A same day transfer occurs when a patient is admitted to an IPF and is subsequently
transferred for acute care (or another type of inpatient facility care) on the same day. If
the patient is admitted to an IPF with the expectation that the patient will remain
overnight, but is discharged before midnight, the day is counted as a full day for the cost
report, but is not counted as a Medicare covered day for purposes of charging the
beneficiary utilization.
IPFs should show the same day for admission and discharge, and report Condition Code
40 (Same Day Transfer).
If the patient is admitted to an IPF and discharged (not transferred to another inpatient
setting) the same day before midnight, the day is counted as a full day for the cost report,
and is counted as a Medicare covered day for purposes of charging the beneficiary
utilization. IPFs do not report Condition Code 40 on this case.
The purpose for the variance in coding is to charge the beneficiary only 1 day utilization
where two facilities are billing. Payment will be made for 1 day.
190.10.13 - Remittance Advice - Reserved
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
Not yet available.
190.10.14 - Medicare Summary Notices and Explanation of Medicare
Benefits
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
Existing notices for inpatient hospital PPS are used.
190.11 - Benefit Application and Limits-190 Days
(Rev. 4104, Issued: 08-03-18, Effective: 10-01-18, Implementation: 10-01-18)
The psychiatric benefit lifetime maximum of 190 days of inpatient care applies to
Medicare participating psychiatric hospitals per 42 CFR 409.62. The 190-day lifetime
limitation does not apply to inpatient psychiatric care provided in certified psychiatric
units of an acute care hospital or critical access hospital. Section 409.62 states, “There is a
lifetime maximum of 190 days on inpatient psychiatric hospital services available to any
beneficiary. Therefore, once an individual receives benefits for 190 days of care in a
psychiatric hospital, no further benefits of that type are available to that individual.”
Payment may not be made for more than a total of 190 days of inpatient psychiatric
hospital services during the patient's lifetime. This limitation does not apply to inpatient
psychiatric services furnished in a non-psychiatric hospital. This limitation does not
apply to inpatient psychiatric services furnished in a hospital, a CAH or distinct part
psychiatric unit. The period spent in a psychiatric hospital prior to entitlement does not
count against the patient's lifetime limitation, even though pre-entitlement days may have
been counted against the 150 days of eligibility in the first benefit period.
The Benefit Period provisions described in Medicare Publication 100-01, Medicare
General Information, Eligibility, and Entitlement, chapter 3, §§10.4-10.4.4 are applicable
to inpatients in either a Medicare participating psychiatric hospital or a certified
psychiatric unit of an acute care hospital or critical access hospital.
The CWF keeps track of days paid for inpatient psychiatric services and informs the
Medicare contractor on claims where the 190-day limit is reached.
For a more detailed description see Pub. 100-02, Medicare Benefit Policy Manual, chapter
3, §30.C. and chapter 4, §50 for the 190-day lifetime limitation on payment for inpatient
psychiatric hospital services. For details concerning the pre-entitlement inpatient
psychiatric benefit reduction provision see Pub. 100-02, Medicare Benefit Policy Manual,
chapter 4, §§10 - 50.
190.12 - Beneficiary Liability
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
Beneficiary liability will operate the same as under the former TEFRA cost-based
payment system. An IPF may not charge a beneficiary for any services for which
payment is made by Medicare, even if the facility’s cost of furnishing services to that
beneficiary are greater than the amount the facility is paid under the prospective payment
system.
An IPF receiving payment under this subpart for a covered hospital stay (that is, a stay that
included at least 1 covered day) may charge the Medicare beneficiary or other person only
the applicable deductible and coinsurance amounts under 42 CFR 409.82, 42 CFR 409.83,
and 42 CFR 409.87 and for items or services as specified under 42 CFR 489.30.
For more detailed information regarding lifetime reserve days, refer to Pub. 100-02
Medicare Benefit Policy Manual, chapter 5.
190.12.1 - Benefits Exhaust
(Rev. 1231; Issued: 04-27-07; Effective: 12-03-07; Implementation: 12-03-07)
Effective December 3, 2007, for payment purposes, an IPF discharge occurs when benefits
exhaust and the date benefits exhaust (if present) will substitute for the ‘actual’ discharge
date. The claim is paid based on the benefits exhaust date if present rather than the
discharge date. The Pricer version used to price claims for the discharge is when the
services actually were provided (i.e., when the Medicare beneficiary has Medicare
benefits). No pay/110 TOBs are allowed instead of continually adjusting the claims (117
TOB) until actual discharge occurs once benefits exhaust.
Under TEFRA, the PS&R report used the benefits exhaust date as the discharge date (if
present). This changed when the IPF PPS was implemented, and the 'actual' discharge
date was used. The days stay with the year they occurred, making it easier for the PS&R
report (especially during the blend period) to settle the cost report. This means that:
1. Claims will now be settled on the appropriate cost report;
2. The appropriate PPS-TEFRA blend percentage will be paid;
3. Patients with long lengths of stay will be counted on the correct PS&R report;
4. The PRICER version used will be the one in effect at the time the services
were provided (i.e., when the Medicare beneficiary actually has Medicare
benefits).
190.13 - Periodic Interim Payments (PIP)
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
Medicare contractors shall pay PIP for providers who send a request to their Medicare
contractor and qualify. Outlier payments, teaching adjustment, and ECT add-on payments
are not included in the PIP payment amount but are paid on the discharge claim for ECT,
and on a discharge, benefits exhaust, or last day of a Medicare covered level of care claim,
for the teaching adjustment and outlier payment.
190.14 - Intermediary Benefit Payment Report (IBPR)
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
The IBPR report has been changed to reflect the payments for IPFs going to PPS
psychiatric hospitals and units.
190.15 - Monitoring Implementation of IPF PPS Through Pulse
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
The FISS 620A and 620B reports will be modified to add an additional row for IPF
monitoring. The report will be modified to include a separate reporting line titled “IPF
PPS.” This entry will appear immediately below “IPF PPS” and report the total claim
count and total reimbursement amount. IPF PPS totals will include all providers with the
last four digits of the provider numbers in range 4000 - 4499, xx-Sxxx, and xx-Mxxx.
190.16 - IPF PPS System Edits
(Rev. 2157, Issued: 02-11-11, Effective: 04-01-11, Implementation: 04-04-11)
FISS shall ensure that:
• Revenue Code total charges line 0001 must equal the sum of the individual total
charges lines.
• The length of stay in the statement covers period, from and through dates, equals
the total days for accommodations Revenue Codes 010x-021x, including Revenue
Code 018x (leave of absence)/interrupted stay.
• Value Code 75 is allowed from contractor entry and not allowed from Provider
entry. Also, Providers are not allowed to alter this information.
• The ED adjustment is not made where a patient is discharged from an acute care
hospital or CAH and admitted to the same hospital’s or CAH’s psychiatric unit
with the application of the correct Point of Origin code “D” on the IPF PPS claim.
FISS and CWF shall ensure that multiple Occurrence Span Code 74s are allowed.
CWF shall ensure that:
• Occurrence Span Code 74 is present on the claim when there is an interrupted stay
(the beneficiary has returned to the same IPF within 3 days).
• Value Code 75 is present on claims when there is an interrupted stay resulting
from a discharge at another IPF (the beneficiary has returned to the different IPF
within 3 days).
190.17 - IPF PPS PRICER Software
(Rev. 1101, Issued: 11-03-06, Effective: 01-01-05, Implementation: 12-04-06)
CMS has developed an IPF PRICER program that calculates the Medicare payment rate.
PRICER software will be electronically supplied to the Standard Systems. A Personal
Computer (PC) version of this PRICER will be available on the CMS Web site in the
future at http://www.cms.hhs.gov/PCPricer.
PRICER will incorporate the 3-year phase-in period for all current IPFs. New IPFs will
be paid completely under the new IPF PPS (i.e., there is no transition for new IPFs).
190.17.1 - Inputs/Outputs to PRICER
(Rev. 11396, Issued:05-04-22, Effective:10-01-22, Implementation:10-03-22)
Provider Specific File Data
Data Element
Title
1
National Provider Identifier (not a
mandatory entry at this time)
2
Provider CMS Certification Number
(CCN)
3
Effective Date
4
Fiscal Year Begin Date
5
Report Date
6
Termination Date
7
Waiver Indicator
9
Provider Type (must be 03 or 06)
Effective July 1, 2006, 06 is no longer
valid. Contractors shall use 49.
12
Actual Geographic Reclassification-
MSA (no longer applicable effective
July 1, 2006)
17
Temporary Relief Indicator (For IPF
PPS, code Y if there is an Emergency
Department)
18
Federal PPS Blend Indicator (must be 1,
2, 3, or 4)
Data Element
Title
21
Case Mix Adjusted Cost Per
Discharge/PPS Facility Specific Rate
(This is determined using the same
methodology that would be used to
determine the interim payment per
discharge under the TEFRA system if
the IPF PPS were not being
implemented.)
22
Cost of Living Adjustment (COLA)
23
Intern/Bed Ratio
25
Combined Capital and Operating Cost to
Charge Ratio
33
Special Wage Indicator (should be set to
1 if there is a change to the wage index.)
35
Actual Geographic Location
Core-Based Statistical Area (CBSA)
(required July 1, 2006)
38
Special Wage Index
48
New Hospital
63
Supplemental Wage Index
64
Supplemental Wage Index Indicator
Bill Data
National Provider Identifier
Covered Charges
Provider CMS Certification
Number (CCN)
Discharge Date (or benefits exhaust date if
present)
Patient Age
Other Diagnosis Codes
DRG
Other Procedure Codes
Length of Stay
Indicator for Occurrence Code 31, A3, B3, or
C3 to apply outlier to this bill.
Source of Admission
ECT Units
Patient Status Code
Claim Number
Indicator for Value Code75 to apply variable
per diem adjustment to this bill.
Outputs
In addition to returning the above bill data inputs, Pricer will return the following:
Final Payment
National Non-Labor Rate
DRG/MS-DRG Adjusted Payment
Federal Rate
Federal Adjusted Payment
Budget Neutrality Rate
Outlier Adjusted Payment
Outlier Threshold
Comorbidity Adjusted Payment
Federal Per Diem Base Rate
Per Diem Adjusted Payment
Standardized Factor
Facility Adjusted Payment
Labor Share
Age Adjusted Payment
Non-Labor Share
Rural Adjusted Payment
COLA
Teaching Adjusted Payment
Day of Stay Adjustment
ED Adjusted Payment
Age Adjustment
ECT Adjusted Payment
Comorbidity Adjustment
Return Code
DRG Adjustment
MSA/CBSA
Rural Adjustment
Wage Index
ECT Adjustment
National Labor Rate
Blend Year Calculation Version
200 - Electronic Health Record (EHR) Incentive Payments
(Rev. 2066, Issued: 10-15-10, Effective: 10-01-10, Implementation: 01-03-11)
The American Recovery and Reinvestment Act of 2009 (ARRA) (Pub. L. 111-5) provides
incentive payments for acute care hospitals (subsection (d) hospitals) and critical access
hospitals (CAHs) who are meaningful users of certified electronic health records (EHR)
technology.
200.1 - Payment Calculation
(Rev. 2066, Issued: 10-15-10, Effective: 10-01-10, Implementation: 01-03-11)
A - Incentive Payment Calculation for Subsection (d) Hospitals
[Initial Amount] x [Medicare Share] x [Transition Factor]
o Initial Amount equals $2,000,000 + [$200 per discharge for the 1,150
th
- 23,000
th
discharge]
o Medicare Share equals Medicare/(Total*Charges), whereas:
o Medicare equals [number of Inpatient Bed Days for Part A Beneficiaries]
plus [number of Inpatient Bed Days for MA Beneficiaries]
o Total equals [number of Total Inpatient Bed Days]
o Charges equals [Total Charges minus Charges for Charity Care*] divided
by [Total Charges]
o Transition Factor
Fiscal Year
Fiscal Year that Eligible Hospital First Receives
the Incentive Payment
2011 2012 2013 2014 2015
2011 1.00
2012 0.75 1.00
2013 0.50 0.75 1.00
2014 0.25 0.50 0.75 0.75
2015 0.25 0.50 0.50 0.50
2016 0.25 0.25 0.25
B - Incentive Payment Calculation for Critical Access Hospitals (CAHs)
CAH Reasonable Cost x Medicare Share*
* See Medicare Share computation in sub-section A above.
200.2 - Submission of Informational Only Bills for Maryland Waiver
Hospitals and Critical Access Hospitals (CAHs)
(Rev. 2066, Issued: 10-15-10, Effective: 10-01-10, Implementation: 01-03-11)
Acute care hospitals already submit informational only bills for purposes of including Part
C days in the Disproportionate Share (DSH) calculations, as explained in Section 20.3
above. However, Maryland waiver hospitals and CAHs do not currently submit
informational only bills. In order for CMS to capture Part C days for purposes of
calculating EHR payments, Maryland waiver hospitals and CAHs must submit
informational only claims to Medicare, effective for discharges October 1, 2010.
Informational only claims are claims billed for patients enrolled in a Medicare Advantage
(MA) Plan and contain a condition the following elements:
• Covered 11X TOB (not 110)
• Condition Code 04
• Medicare is the primary payer
• There is no MSP
• Beneficiary‘s Medicare HICN
• All other required claim elements
250.18 Incomplete Colonoscopies (Codes 44388, 45378, G0105 and
G0121)
(Rev. 4153, Issued: 10-26-18, Effective: 04-01-19, Implementation: 04-01-19)
An incomplete colonoscopy, e.g., the inability to advance the colonoscope to the cecum or
colon-small intestine anastomosis due to unforeseen circumstances, is billed and paid
using colonoscopy through stoma code 44388, colonoscopy code 45378, and screening
colonoscopy codes G0105 and G0121 with modifier “-53.” (Code 44388 is valid with
modifier 53 beginning January 1, 2016.) The Medicare physician fee schedule database
has specific values for codes 44388-53, 45378-53, G0105-53 and G0121-53. An
incomplete colonoscopy performed prior to January 1, 2016, is paid at the same rate as a
sigmoidoscopy. Beginning January 1, 2016, Medicare will pay for the interrupted
colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.
As such, instruct CAHs that elect Method II payment to use modifier “-53” to identify an
incomplete screening colonoscopy (physician professional service(s) billed in revenue
code 096X, 097X, and/or 098X).
CAH Method II shall be consistent with the guidelines outlined in PUB. 100-04, chapter
12, section 30.1 and chapter 18, section 60.2.
Addendum A - Provider Specific File
(Rev. 12452; Issued; 01-11-24, Effective:04-03-23; Implementation: 07-01-24)
Data
Element
File
Position
Format
Title
Description
1
1-10
X(10)
National
Provider
Identifier (NPI)
Alpha-numeric 10 character NPI number.
11-16
X(6)
Provider CMS
Certification
Number (CCN)
Alpha-numeric 6 character provider
number. Cross check to provider type.
Positions 3 and 4 of:
Provider #
Provider Type
00-08
Blanks, 00, 07-11,
13-17, 21-22;
NOTE: 14 and 15
no longer valid,
effective 10/1/12
12
18
13
23,37
20-22
02
30
04
33
05
40-44
03
50-64
32-34, 38
15-17
35
70-84, 90-99
36
Codes for special units are in the third
position of the provider CMS Certification
Number (CCN) and should correspond to
the appropriate provider type, as shown
below (NOTE: SB = swing bed):
Special Unit
Prov.
Type
M - Psych unit in CAH
49
R - Rehab unit in CAH
50
S - Psych Unit
49
T - Rehab Unit
50
U - SB for short-term hosp.
51
W - SB for LTCH
52
Y - SB for Rehab
53
Z - SB for CAHs
54
Data
Element
File
Position
Format
Title
Description
3
17-24
9(8)
Effective Date
Must be numeric, CCYYMMDD. This is
the effective date of the provider's first PPS
period, or for subsequent PPS periods, the
effective date of a change to the PROV
file. If a termination date is present for this
record, the effective date must be equal to
or less than the termination date.
Year: Greater than 82, but not greater than
current year.
Month: 01-12
Day: 01-31
4
25-32
9(8)
Fiscal Year
Beginning Date
Must be numeric, CCYYMMDD.
Year: Greater than 81, but not greater than
current year.
Month: 01-12
Day: 01-31
Must be updated annually to show the
current year for providers receiving a
blended payment based on their FY begin
date. Must be equal to or less than the
effective date.
5
33-40
9(8)
Report Date
Must be numeric, CCYYMMDD.
Date file created/run date of the PROV
report for submittal to CMS CO.
6
41-48
9(8)
Termination
Date
Must be numeric, CCYYMMDD.
Termination Date in this context is the date
on which the reporting MAC ceased
servicing the provider. Must be zeros or
contain a termination date. Must be equal
to or greater than the effective date.
If the provider is terminated or transferred
to another MAC, a termination date is
placed in the file to reflect the last date the
provider was serviced by the outgoing
MAC. Likewise, if the provider
identification number changes, the MAC
must place a termination date in the PROV
file transmitted to CO for the old provider
identification number.
7
49
X(1)
Waiver Indicator
Enter a “Y” or “N.”
Y = waived (Provider is not under PPS).
N = not waived (Provider is under PPS).
Data
Element
File
Position
Format
Title
Description
8
50-54
9(5)
Intermediary
Number
Assigned intermediary number.
9
55-56
X(2)
Provider Type
This identifies providers that require
special handling. Enter one of the
following codes as appropriate.
00 or blanks = Short Term Facility
02 Long Term
03 Psychiatric
04 Rehabilitation Facility
05 Pediatric
06 Hospital Distinct Parts
(Provider type “06” is effective until
July 1, 2006. At that point, provider
type “06” will no longer be used.
Instead, MACs will assign a hospital
distinct part as one of the following
provider types: 49, 50, 51, 52, 53, or 54)
07 Rural Referral Center
08 Indian Health Service
13 Cancer Facility
14 Medicare Dependent Hospital
(during cost reporting periods that
began on or after April 1, 1990).
15 Medicare Dependent Hospital/Referral
Center
(during cost reporting periods that
began on or after April 1, 1990. Invalid
October 1, 1994 through September 30,
1997).
16 Re-based Sole Community Hospital
17 Re-based Sole Community Hospital/
Referral Center
18 Medical Assistance Facility
21 Essential Access Community Hospital
22 Essential Access Community
Hospital/Referral Center
23 Rural Primary Care Hospital
32 Nursing Home Case Mix Quality Demo
Project – Phase II
33 Nursing Home Case Mix Quality Demo
Project – Phase III – Step 1
34 Reserved
35 Hospice
36 Home Health Agency
Data
Element
File
Position
Format
Title
Description
37 Critical Access Hospital
38 Skilled Nursing Facility (SNF) – For
non-demo PPS SNFs – effective for
cost reporting periods beginning on or
after July 1, 1998
40 Hospital Based ESRD Facility
41 Independent ESRD Facility
42 Federally Qualified Health Centers
43 Religious Non-Medical Health Care
Institutions
44 Rural Health Clinics-Free Standing
45 Rural Health Clinics-Provider Based
46 Comprehensive Outpatient Rehab
Facilities
47 Community Mental Health Centers
48 Outpatient Physical Therapy Services
49 Psychiatric Distinct Part
50 Rehabilitation Distinct Part
51 Short-Term Hospital – Swing Bed
52 Long-Term Care Hospital – Swing Bed
53 Rehabilitation Facility – Swing Bed
54 Critical Access Hospital – Swing Bed
NOTE: Provider Type values 49-54 refer
to special unit designations that are
assigned to the third position of the
provider CMS Certification Number
(CCN) (See field #2 for a special unit-to-
provider type cross-walk).
10
57
9(1)
Current Census
Division
Must be numeric (1-9). Enter the Census
division to which the facility belongs for
payment purposes. When a facility is
reclassified for the standardized amount,
MACs must change the census division to
reflect the new standardized amount
location. Valid codes are:
1 New England
2 Middle Atlantic
3 South Atlantic
4 East North Central
5 East South Central
6 West North Central
7 West South Central
8 Mountain
9 Pacific
Data
Element
File
Position
Format
Title
Description
NOTE: When a facility is reclassified for
purposes of the standard amount, the MAC
changes the census division to reflect the
new standardized amount location.
11
58
X(1)
Change Code
Wage Index
Reclassification
Enter "Y" if hospital's wage index location
has been reclassified for the year. Enter
"N" if it has not been reclassified for the
year. Adjust annually.
12
59-62
X(4)
Actual
Geographic
Location - MSA
Enter the appropriate code for the MSA
0040-9965, or the rural area, (blank)
(blank) 2 digit numeric State code such as
_ _36 for Ohio, where the facility is
physically located.
13
63-66
X(4)
Wage Index
Location - MSA
Enter the appropriate code for the MSA,
0040-9965, or the rural area, (blank)
(blank) (2 digit numeric State code) such as
_ _ 3 6 for Ohio, to which a hospital has
been reclassified due to its prevailing wage
rates. Leave blank or enter the actual
location MSA (field 13), if not reclassified.
Pricer will automatically default to the
actual location MSA if this field is left
blank.
14
67-70
X(4)
Standardized
Amount MSA
Location
Enter the appropriate code for the MSA,
0040-9965, or the rural area, (blank)
(blank) (2 digit numeric State code) such as
_ _ 3 6 for Ohio, to which a hospital has
been reclassified for standardized amount.
Leave blank or enter the actual location
MSA (field 13) if not reclassified. Pricer
will automatically default to the actual
location MSA if this field is left blank.
15
71-72
X(2)
Sole Community
or Medicare
Dependent
Hospital – Base
Year
Leave blank if not a sole community
hospital (SCH) or a Medicare dependent
hospital (MDH) effective with cost
reporting periods that begin on or after
April 1, 1990. If an SCH or an MDH,
show the base year for the operating
hospital specific rate, the higher of either
82 or 87. See §20.6. Must be completed
for any SCH or MDH that operated in 82
or 87, even if the hospital will be paid at
the Federal rate.
Data
Element
File
Position
Format
Title
Description
16
73
X(1)
Change Code for
Lugar
reclassification
Enter an "L" if the MSA has been
reclassified for wage index purposes under
§1886(d)(8)(B) of the Act. These are also
known as Lugar reclassifications, and
apply to ASC-approved services provided
on an outpatient basis when a hospital
qualifies for payment under an alternate
wage index MSA.
Leave blank for hospitals if there has not
been a Lugar reclassification.
17
74
X(1)
Temporary
Relief Indicator
Enter a “Y” if this provider qualifies for a
payment update under the temporary relief
provision, otherwise leave blank.
IPPS: Effective October 1, 2004, code a
“Y” if the provider is considered “low
volume.”
IPF PPS: Effective January 1, 2005, code
a “Y” if the acute facility where the unit is
located has an Emergency Department or if
the freestanding psych facility has an
Emergency Department.
IRF PPS: Effective October 1, 2005, code
a “Y” for IRFs located in the state and
county in Table 2 of the Addendum of the
August 15, 2005 Federal Register (70 FR
47880). The table can also be found at the
following website:
www.cms.hhs.gov/InpatientRehabFacPPS/
07DataFiles.asp#topOfPage
LTCH PPS: Effective 04/21/16 through
12/31/16, code a ‘Y’ for an LTCH that is a
grandfathered HwH (hospitals that are
described in § 412.23(e)(2)(i) that currently
meets the criteria of § 412.22(f)); and is
located in a rural area or is reclassified rural
by meeting the provisions outlined in
§412.103, as set forth in the regulations at
§412.522(b)(4).
18
75
X(1)
Federal PPS
Blend Indicator
HH PPS: For “From” dates before
1/1/2021: Enter the value to indicate if
normal percentage payments should be
made on RAP and/or whether payment
should be reduced under the Quality
Reporting Program. Valid values:
0 = Make normal percentage payment
Data
Element
File
Position
Format
Title
Description
1 = Pay 0%
2 = Make final payment reduced by 2%
3 = Make final payment reduced by 2%,
pay RAPs at 0%
NOTE: All new HHAs enrolled after
January 1, 2019 must have this value set to
1 or 3 (no RAP payments).
For “From” dates on or after 1/1/2021:
Enter the value to indicate whether
payment should be reduced under the
Quality Reporting Program. Valid values:
0 = Make normal percentage payment
2 = Make final payment reduced by 2%
IRF PPS: All IRFs are 100% Federal for
cost reporting periods beginning on or after
10/01/2002.
LTCH PPS: For cost reporting periods
beginning on or after 10/01/2002, enter the
appropriate code for the blend ratio
between federal and facility rates for the
LTCH provider:
Federal %
Facility%
1
20
80
2
40
60
3
60
40
4
80
20
5
100
00
For LTCH cost reporting periods beginning
on or after 10/01/2015 enter the
appropriate code for the blend year
representing 50% site neutral payment and
50 % standard payment.
6 –Blend Year 1 (represents 50% site
neutral payment and 50 % standard
payment effective for all LTCH providers
with cost reporting periods beginning on or
after 10/01/2015 through 09/30/16)
7 - Blend Years 2 through 4 (represents
50% site neutral payment and 50 %
Data
Element
File
Position
Format
Title
Description
standard payment effective for all LTCH
providers with cost reporting periods
beginning in FY 2017, FY 2018 or FY
2019
8 - Blank – Transition Blend no longer
applies with cost reporting periods
beginning in on or after 10/01/2019. Full
Site Neutral payment
IPF PPS: Enter the appropriate code for
the blend ratio between federal and facility
rates. Effective for all IPF providers with
cost reporting periods beginning on or after
1/1/2005.
Federal %
Facility%
1
25
75
2
50
50
3
75
25
4
100
00
19
76-77
9(2)
State Code
Enter the 2-digit state where the provider is
located. Enter only the first (lowest) code
for a given state. For example, effective
October 1, 2005, Florida has the following
State Codes: 10, 68 and 69. MACs shall
enter a “10” for Florida’s state code.
List of valid state codes is located in Pub.
100-07, Chapter 2, Section 2779A1.
20
78-80
X(3)
Filler
Blank.
21
81-87
9(5)V9(2)
Case Mix
Adjusted Cost
Per
Discharge/PPS
Facility Specific
Rate
For PPS hospitals and waiver state non-
excluded hospitals, enter the base year cost
per discharge divided by the case mix
index. Enter zero for new providers. See
§20.1 for sole community and Medicare-
dependent hospitals on or after 04/01/90.
For inpatient PPS hospitals, verify if figure
is greater than $10,000. For LTCH, verify
if figure is greater than $35,000.
22
88-91
9V9(3)
Cost of Living
Adjustment
(COLA)
Enter the COLA. All hospitals except
Alaska and Hawaii use 1.000.
23
92-96
9V9(4)
Intern/Beds
Ratio
Enter the provider's intern/resident to bed
ratio. Calculate this by dividing the
Data
Element
File
Position
Format
Title
Description
provider's full time equivalent residents by
the number of available beds (as calculated
in positions 97-101). Do not include
residents in anesthesiology who are
employed to replace anesthetists or those
assigned to PPS excluded units. Base the
count upon the average number of full-time
equivalent residents assigned to the
hospital during the fiscal year. Correct
cases where there is reason to believe that
the count is substantially in error for a
particular facility. The MAC is responsible
for reviewing hospital records and making
necessary changes in the count at the end
of the cost reporting period.
Enter zero for non-teaching hospitals.
IPF PPS: Enter the ratio of
residents/interns to the hospital’s average
daily census.
24
97-101
9(5)
Bed Size
Enter the number of adult hospital beds and
pediatric beds available for lodging
inpatient. Must be greater than zero. (See
the Provider Reimbursement Manual,
§2405.3G.)
Data
Element
File
Position
Format
Title
Description
25
102-105
9V9(3)
Operating Cost
to Charge Ratio
Derived from the latest settled cost report
and corresponding charge data from the
billing file. Compute this amount by
dividing the Medicare operating costs by
Medicare covered charges. Obtain
Medicare operating costs from the
Medicare cost repot form CMS-2552-96,
Supplemental Worksheet D-1, Part II, Line
53. Obtain Medicare covered charges from
the MAC billing file, i.e., PS&R record.
For hospitals for which the MAC is unable
to compute a reasonable cost-to-charge
ratio, they use the appropriate urban or
rural statewide average cost-to-charge ratio
calculated annually by CMS and published
in the "Federal Register." These average
ratios are used to calculate cost outlier
payments for those hospitals where you
compute cost-to-charge ratios that are not
within the limits published in the "Federal
Register."
For LTCH and IRF PPS, a combined
operating and capital cost-to-charge ratio is
entered here.
See below for a discussion of the use of
more recent data for determining CCRs.
26
106-110
9V9(4)
Case Mix Index
The case mix index is used to compute
positions 81-87 (field 21). Zero-fill for all
others. In most cases, this is the case mix
index that has been calculated and
published by CMS for each hospital (based
on 1981 cost and billing data) reflecting the
relative cost of that hospital's mix of cases
compared to the national average mix.
27
111-114
V9(4)
Supplemental
Security Income
Ratio
Enter the SSI ratio used to determine if the
hospital qualifies for a disproportionate
share adjustment and to determine the size
of the capital and operating DSH
adjustments.
28
115-118
V9(4)
Medicaid Ratio
Enter the Medicaid ratio used to determine
if the hospital qualifies for a
disproportionate share adjustment and to
determine the size of the capital and
operating DSH adjustments.
Data
Element
File
Position
Format
Title
Description
29
119
X(1)
Provider PPS
Period
This field is obsolete as of 4/1/91. Leave
Blank for periods on or after 4/1/91.
30
120-125
9V9(5)
Special Provider
Update Factor
Zero-fill for all hospitals after FY91. This
Field is obsolete for hospitals as of FY92.
Effective 1/1/2018, this field is used for
HHAs only. Enter the HH VBP
adjustment factor provided by CMS for
each HHA. If no factor is provided, enter
1.00000.
31
126-129
V9(4)
Operating DSH
Disproportionate share adjustment
Percentage. Pricer calculates the Operating
DSH effective 10/1/91 and bypasses this
field. Zero-fill for all hospitals 10/1/91 and
later.
32
130-137
9(8)
Fiscal Year End
This field is no longer used. If present,
must be CCYYMMDD.
33
138
X(1)
Special Payment
Indicator
Enter the code that indicates the type of
special payment provision that applies.
Blank = not applicable
Y = reclassified
1 = special wage index indicator
2 = both special wage index indicator and
reclassified
D = Dual reclassified
34
139
X(1)
Hospital Quality
Indicator
Enter code to indicate that hospital meets
criteria to receive higher payment per
MMA quality standards.
Blank = hospital does not meet criteria
1 = hospital quality standards have been
met
35
140-144
X(5)
Actual
Geographic
Location
Core-Based
Statistical Area
(CBSA)
Enter the appropriate code for the CBSA
00001-89999, or the rural area, (blank
(blank) (blank) 2 digit numeric State code
such as _ _ _ 36 for Ohio, where the
facility is physically located.
36
145-149
X(5)
Wage Index
Location CBSA
Enter the appropriate code for the CBSA,
00001-89999, or the rural area,
(blank)(blank) (blank) (2 digit numeric
State code) such as _ _ _ 3 6 for Ohio, to
which a hospital has been reclassified due
to its prevailing wage rates. Leave blank
or enter the actual location CBSA (field
35), if not reclassified. Pricer will
Data
Element
File
Position
Format
Title
Description
automatically default to the actual location
CBSA if this field is left blank.
37
150-154
X(5)
Payment CBSA
Enter the appropriate code for the CBSA,
00001-89999 or the rural area, (blank)
(blank)(blank) (2 digit numeric State code)
such as _ _ _ 3 6 for Ohio, to which a
hospital has been reclassified. Leave blank
or enter the actual location CBSA (field
35) if not reclassified. Pricer will
automatically default to the actual location
CBSA if this field is left blank
38
155-160
9(2)V9(4)
Special Wage
Index
Enter the special wage index that certain
providers may be assigned. Enter zeroes
unless the Special Payment Indicator field
equals a “1” or “2.”
39
161-166
9(4)V9(2)
Pass Through
Amount for
Capital
Per diem amount based on the interim
payments to the hospital. Must be zero if
location 185 = A, B, or C (See the Provider
Reimbursement Manual, §2405.2). Used
for PPS hospitals prior to their cost
reporting period beginning in FY 92, new
hospitals during their first 2 years of
operation FY 92 or later, and non-PPS
hospitals or units. Zero-fill if this does not
apply.
40
167-172
9(4)V9(2)
Pass Through
Amount for
Direct Medical
Education
Per diem amount based on the interim
payments to the hospital (See the Provider,
Reimbursement Manual, §2405.2.). Zero-
fill if this does not apply.
41
173-178
9(4)V9(2)
Pass Through
Amount for
Organ
Acquisition
Per diem amount based on the interim
payments to the hospital. Include standard
acquisition amounts for kidney, heart, lung,
pancreas, intestine and liver transplants.
Do not include acquisition costs for bone
marrow transplants. (See the Provider
Reimbursement Manual, §2405.2.) Zero-
fill if this does not apply.
Data
Element
File
Position
Format
Title
Description
42
179-184
9(4)V9(2)
Total Pass
Through
Amount,
Including
Miscellaneous
Per diem amount based on the interim
payments to the hospital (See the Provider
Reimbursement Manual §2405.2.) Must be
at least equal to the three pass through
amounts listed above. Include pass
through amount for Domestic N95
Respirator Procurement. The following are
included in total pass through amount in
addition to the above pass through
amounts. Certified Registered Nurse
Anesthetists (CRNAs) are paid as part of
Miscellaneous Pass Through for rural
hospitals that perform fewer than 500
surgeries per year, and Nursing and Allied
Health Professional Education when
conducted by a provider in an approved
program. Do not include amounts paid for
Indirect Medical Education, Hemophilia
Clotting Factors, DSH adjustments, or
Allogeneic Stem Cell Acquisition. Zero-
fill if this does not apply.
43
185
X(1)
Capital PPS
Payment Code
Enter the code to indicate the type of
capital payment methodology for hospitals:
A = Hold Harmless – cost payment for old
capital
B = Hold Harmless – 100% Federal rate
C = Fully prospective blended rate
44
186-191
9(4)V9(2)
Hospital Specific
Capital Rate
Must be present unless:
• A "Y" is entered in the Capital
Indirect Medical Education Ratio
field; or
• A“08” is entered in the Provider
Type field; or
• A termination date is present in
Termination Date field.
Enter the hospital's allowable adjusted base
year inpatient capital costs per discharge.
This field is not used as of 10/1/02.
45
192-197
9(4)V9(2)
Old Capital Hold
Harmless Rate
Enter the hospital's allowable inpatient
"old" capital costs per discharge incurred
for assets acquired before December 31,
1990, for capital PPS. Update annually.
Data
Element
File
Position
Format
Title
Description
46
198-202
9V9(4)
New Capital-
Hold Harmless
Ratio
Enter the ratio of the hospital's allowable
inpatient costs for new capital to the
hospital's total allowable inpatient capital
costs. Update annually.
47
203-206
9V9(3)
Capital Cost-to-
Charge Ratio
Derived from the latest cost report and
corresponding charge data from the billing
file. For hospitals for which the MAC is
unable to compute a reasonable cost-to-
charge ratio, it uses the appropriate
statewide average cost-to-charge ratio
calculated annually by CMS and published
in the "Federal Register." A provider may
submit evidence to justify a capital cost-to-
charge ratio that lies outside a 3 standard
deviation band. The MAC uses the
hospital's ratio rather than the statewide
average if it agrees the hospital's rate is
justified.
See below for a detailed description of the
methodology to be used to determine the
CCR for Acute Care Hospital Inpatient and
LTCH Prospective Payment Systems.
48
207
X(1)
New Hospital
Enter "Y" for the first 2 years that a new
hospital is in operation. Leave blank if
hospital is not within first 2 years of
operation.
49
208-212
9V9(4)
Capital Indirect
Medical
Education Ratio
This is for IPPS hospitals and IRFs only.
Enter the ratio of residents/interns to the
hospital's average daily census. Calculate
by dividing the hospital's full-time
equivalent total of residents during the
fiscal year by the hospital's total inpatient
days. (See §20.4.1 for inpatient acute
hospital and §§140.2.4.3 and 140.2.4.5.1
for IRFs.) Zero-fill for a non-teaching
hospital.
50
213-218
9(4)V9(2)
Capital
Exception
Payment Rate
The per discharge exception payment to
which a hospital is entitled. (See §20.4.7
above.)
51
219-219
X
VBP Participant
Enter “Y” if participating in Hospital
Value Based Purchasing. Enter “N” if not
participating. Note if Data Element 34
(Hospital Quality Ind) is blank, then this
field must = N.
Data
Element
File
Position
Format
Title
Description
52
220-231
9V9(11)
VBP Adjustment
Enter VBP Adjustment Factor. If Data
Element 51 = N, leave blank.
53
232-232
X
HRR Indicator
Enter “0” if not participating in Hospital
Readmissions Reduction program. Enter
“1” if participating in Hospital
Readmissions Reduction program and
payment adjustment is not 1.0000. Enter
“2” if participating in Hospital
Readmissions Reduction program and
payment adjustment is equal to 1.0000.
54
233-237
9V9(4)
HRR Adjustment
Enter HRR Adjustment Factor if “1” is
entered in Data Element 53. Leave blank if
“0” or “2” is entered in Data Element 53.
55
238-240
V999
Bundle Model 1
Discount
Enter the discount % for hospitals
participating in Bundled Payments for Care
Improvement Initiative (BPCI), Model 1
(demo code 61).
56
241-241
X
HAC Reduction
Indicator
Enter a ‘Y’ if the hospital is subject to a
reduction under the HAC Reduction
Program. Enter a ‘N’ if the hospital is NOT
subject to a reduction under the HAC
Reduction Program.
57
242-250
9(7)V99
Uncompensated
Care Amount
Enter the estimated per discharge
uncompensated care payment (UCP)
amount or enter the total of the estimated
per discharge UCP amount and estimated
per discharge supplemental payment
amount, calculated and published by CMS
for each hospital. Effective 10/1/2022, the
estimated per discharge supplemental
payment is for eligible Indian Health
Service/Tribal hospitals and hospitals
located in Puerto Rico.
58
251-251
X
Electronic
Health Records
(EHR) Program
Reduction
Enter a ‘Y’ if the hospital is subject to a
reduction due to NOT being an EHR
meaningful user. Leave blank if the
hospital is an Electronic Health Records
meaningful user.
59
252-258
9V9(6)
LV Adjustment
Factor
Enter the low-volume hospital payment
adjustment factor calculated in accordance
with the low-volume hospital payment
regulations at § 412.101.
60
259-263
9(5)
County Code
Enter the County Code. Must be 5 numbers.
Data
Element
File
Position
Format
Title
Description
61
264-268
9V9999
Medicare
Performance
Adjustment
(MPA)
Enter the MPA percentage calculated and
published by the Centers for Medicare &
Medicaid Services (CMS).
62
269-269
X(1)
LTCH DPP
Indicator
Enter a ‘Y’ if the LTCH is subject to the
DPP payment adjustment. Leave blank if the
LTCH is not subject to the DPP payment
adjustment.
63
270-275
9(2) V9(4)
Supplemental
Wage Index
Enter the supplemental wage index that
certain providers may be assigned. Enter
zeroes if it does not apply.
64
276-276
X(1)
Supplemental
Wage Index Flag
Enter the supplemental wage index flag that
certain providers may be assigned:
1=Prior Year Wage Index
2=Special IPPS-comparable Wage Index*
3=Future use
Enter blank if it does not apply
*Only for LTCH providers. Pricer will
override the otherwise determined IPPS-
comparable wage index with this value.
65
277-285
9(7)V99
Pass Through
Amount for
Allogeneic Stem
Cell Acquisition
Enter the per diem amount based on the
interim payments to the hospital. Include
acquisition amounts for allogeneic stem
cell transplants. Zero-fill if this does not
apply.
66
286-291
9(4)V9(2)
Pass Through
Amount for
Direct Graduate
Medical
Education
(Medicare
Advantage (MA)
Exclusion)
Per diem amount of direct graduate
medical education to be excluded from MA
capitation rates per regulation. Zero-fill if
this does not apply.
67
292-297
9(4)V9(2)
Pass Through
Amount for
Kidney
Acquisition (MA
Exclusion)
Per diem amount of kidney acquisition
costs to be excluded from MA capitation
rates per regulation. Zero-fill if this does
not apply.
Data
Element
File
Position
Format
Title
Description
68
298-306
9(7)V99
Pass Through
Amount for
Domestic N95
Respirator
Procurement
Enter the per diem amount based on the
interim payments to the hospital. Include
payment adjustments for the additional cost
for procurement of wholly domestically
made NIOSH-approved surgical N95
respirators.
69
307-310
X(4)
Filler
Transmittals Issued for this Chapter
Rev #
Issue Date
Subject
Impl Date
CR#
R12575CP
04/11/2024
Internet Only Manual Updates to Publication
100-04 to Implement Updates to Policy
(Inpatient Rehabilitation Facility (IRF)
07/12/2024
13587
R12452CP
01/11/2024
Implementation of System Edits for Direct
Graduate Medical Education (DGME) and
Kidney Acquisition Pass-
Thru Amount Fields of
the Provider Specific File (PSF)
07/01/2024
13434
11/24/2023
Diagnosis Code Update for Add-on Payments
for Blood Clotting Factor Administered to
Hemophilia Inpatients
04/01/2024
13381
R12290CP
10/05/2023
Diagnosis Code Update for Add-on Payments
for Blood Clotting Factor Administered to
Hemophilia Inpatients- Rescinded and replaced
by transmittal 12380
04/01/2024
13381
R12234CP
08/31/2023
Fiscal Year (FY) 2024 Inpatient Prospective
Payment System (IPPS) and Long-Term Care
Hospital (LTCH) PPS Changes
10/02/2023
13306
R12148CP
07/21/2023
Instructions To Process Services During
Disenrollment From The Programs Of All-
Inclusive Care For The Elderly (PACE)
01/02/2024
13248
R11963CP
04/20/2023
Religious Nonmedical Health Care Institution
Provisions of the Consolidated Appropriations
Act (CAA) of 2023
10/02/2023
13108
R11639CP
10/07/2022
Provider Specific File (PSF) changes for Direct
Medical Education (DME), Direct Graduate
Medical Education (DGME), Organ Acquisition
Cost (OAC) and Kidney Acquisition Costs
(KAC)
04/03/2023
12852
R11543CP
08/05/2022
Inpatient Psychiatric Facilities Prospective
Payment System (IPF PPS) Updates for Fiscal
Year (FY) 2023
10/03/2022
12859
R11540CP
08/05/2022
Inpatient Rehabilitation Facility (IRF) Annual
Update: Prospective Payment System (PPS)
Pricer Changes for FY 2023
10/03/2022
12807
R11396CP
05/04/2022
Update to Chapters 3, 4, 27 and 37 of
Publication (Pub.) 100-04 Medicare Claims
10/03/2022
12715
Rev #
Issue Date
Subject
Impl Date
CR#
Processing Manual to Remove Reference to the
Term "OSCAR"
R11348CP
04/07/2022
Revisions to Chapters 3, “Inpatient Hospital
Billing” of the Medicare Claims Processing
Manual (Pub 100-04), 18, “Preventive and
Screening Services” of the Medicare Claims
Processing Manual (Pub 100-04), and 32
“Billing Requirements for Special Services” of
the Medicare Claims Processing Manual (Pub
100-04) to Update Coding
05/09/2022
12602
R11140CP
12/02/2021
Update to the Internet Only Manual (IOM)
Publication 100-04, Chapters 3 and 17
01/04/2022
12525
R11059CP
10/21/2021
April 2022 Update to the Java Medicare Code
Editor (MCE) for New Edit 20- Unspecified
Code Edit
04/04/2022
12471
R11075CP
10/28/2021
Revision to Chapter 3 to Update Instructions for
Handling Inpatient Rehabilitation Facility (IRF)
Claims
12/01/2021
12500
R11035CP
10/13/2021
Revisions to Chapters 3, 18, and 32 to Update
Coding
11/17/2021
12377
R11039CP
10/05/2021
Inpatient Psychiatric Facilities Prospective
Payment System (IPF PPS) Updates for Fiscal
Year (FY) 2022
10/04/2021
12417
R11019CP
09/27/2021
Inpatient Psychiatric Facilities Prospective
Payment System (IPF PPS) Updates for Fiscal
Year (FY) 2022- Rescinded and replaced by
transmittal 11039
10/04/2021
12417
R10952CP
08/19/2021
Update to the Internet Only Manual (IOM)
Publication (Pub.) 100-04, Chapter 3, Section
40.2.4 Inpatient Prospective Payment System
(IPPS) Transfers Between Hospitals
09/20/2021
12360
R10943CP
08/11/2021
Inpatient Psychiatric Facilities Prospective
Payment System (IPF PPS) Updates for Fiscal
Year (FY) 2022
10/04/2021
12364
R10944CP
08/12/2021
Inpatient Psychiatric Facilities Prospective
Payment System (IPF PPS) Updates for Fiscal
Year (FY) 2022- Rescinded and replaced by
transmittal 11019
10/04/2021
12417
Rev #
Issue Date
Subject
Impl Date
CR#
R10696CP
03/31/2021
Penalty for Delayed Request for Anticipated
Payment (RAP) Submission
01/04/2021
11855
R10403CP
10/27/2020
Penalty for Delayed Request for Anticipated
Payment (RAP) Submission -- Implementation
Rescinded and replaced by transmittal 10696
01/04/2021
11855
R10402CP
10/20/2020
Change to the Payment of Allogeneic Stem Cell
Acquisition Services
10/05/2020
11729
R10376CP
10/02/2020
Update to the Internet Only Manual (IOM)
Publication (Pub.) 100-04, Chapter 3, Section
90.4.2 for Liver Transplants
11/03/2020
11929
R10369CP
09/24/2020
Penalty for Delayed Request for Anticipated
Payment (RAP) Submission -- Implementation
Rescinded and replaced by transmittal 10403
01/04/2021
11855
R10371CP
09/24/2020
Change to the Payment of Allogeneic Stem Cell
Acquisition Services- Rescinded and replaced
by transmittal 10402
10/05/2020
11729
R10321CP
08/28/2020
Inpatient Rehabilitation Facility (IRF) Annual
Update: Prospective Payment System (PPS)
Pricer Changes for FY 2021
10/05/2020
11858
R10312CP
08/21/2020
Inpatient Psychiatric Facilities Prospective
Payment System (IPF PPS) Updates for Fiscal
Year (FY) 2021
10/05/2020
11949
R10254CP
07/31/2020
Penalty for Delayed Request for Anticipated
Payment (RAP) Submission – Implementation -
Rescinded and replaced by Transmittal 10369
01/04/2021
11855
R10222CP
07/14/2020
Updates in the Fiscal Intermediary Shared
System (FISS) Inpatient Provider Specific Files
(PSF)
10/05/2020
11797
R10140CP
05/15/2020
Updates in the Fiscal Intermediary Shared
System (FISS) Inpatient Provider Specific Files
(PSF)- Rescinded and replaced by Transmittal
10222
10/05/2020
11797
R10121CP
05/08/2020
Updates in the Fiscal Intermediary Shared
System (FISS) Inpatient and Outpatient
Provider Specific Files (PSF)
10/05/2020
11707
07/10/2020
Change to the Payment of Allogeneic Stem Cell
Acquisition Services - Rescinded and replaced
by Transmittal 10371
10/05/2020
11729
R10210CP
07/10/2020
Update to the Internet Only Manual (IOM)
08/10/2020
11829
Rev #
Issue Date
Subject
Impl Date
CR#
Publication (Pub.) 100-04, Chapter 3, Section
20 and 90.6
R10002CP
03/20/2020
Update to the Internet Only Manual (IOM)
Publication (Pub.) 100-04, Chapter 3, Section
90.4.2
04/20/2020
11687
R4406CP
10/01/2019
Inpatient Psychiatric Facilities Prospective
Payment System (IPF PPS) Updates for Fiscal
Year (FY) 2020
10/07/2019
11420
R4390CP
09/06/2019
Fiscal Year (FY) 2020 Inpatient Prospective
Payment System (IPPS) and Long Term Care
Hospital (LTCH) PPS Changes
10/07/2019
11361
R4357CP
08/09/2019
Inpatient Psychiatric Facilities Prospective
Payment System (IPF PPS) Updates for Fiscal
Year (FY) 2020- Rescinded and replaced by
Transmittal 4406
10/07/2019
11420
R4353CP
08/02/2019
Inpatien1t Rehabilitation Facility (IRF) Annual
Update: Prospective Payment System (PPS)
Pricer Changes for FY 2020
10/07/2019
11345
R4337CP
07/18/2019
Implementation of the Medicare Performance
Adjustment (MPA) for the Maryland Total Cost
of Care (MD TCOC) Model
07/01/2019
10971
R4308CP
05/16/2019
Implementation of the Medicare Performance
Adjustment (MPA) for the Maryland Total Cost
of Care (MD TCOC) Model - Rescinded and
replaced by Transmittal 4337
07/01/2019
10971
R4257CP
03/14/2019
Implementation of the Medicare Performance
Adjustment (MPA) for the Maryland Total Cost
of Care (MD TCOC) Model- Rescinded and
replaced by Transmittal 4308
07/01/2019
10971
R4230CP
02/01/2019
Implementation of the Medicare Performance
Adjustment (MPA) for the Maryland Total Cost
of Care (MD TCOC) Model
07/01/2019
10971
R4271CP
03/29/2019
Update to the Internet-Only-Manual (IOM)
Publication (Pub.) 100-04, Chapters 1 and 3
04/29/2019
11188
R4157CP
11/02/2018
Hospital and Critical Access Hospital (CAH)
Swing-Bed Manual Revisions and Shared
Systems Changes
04/01/2019
10962
R4166CP
11/09/2018
Revisions to Medicare Claims Processing
Manual Reference to Burn Medicare Severity-
12/11/2018
11020
Rev #
Issue Date
Subject
Impl Date
CR#
Diagnostic Related Groups (MS-DRGs) for
Transfer Policy
R4153CP
10/26/2018
Incomplete Colonoscopies Billed with Modifier
53 for Critical Access Hospital (CAH) Method
II Providers
04/01/2019
10937
R4104CP
08/03/2018
Inpatient Psychiatric Facilities Prospective
Payment System (IPF PPS) Updates for Fiscal
Year (FY) 2019
10/01/2018
10880
R4144CP
10/04/2018
Fiscal Year (FY) 2019 Inpatient Prospective
Payment System (IPPS) and Long Term Care
Hospital (LTCH) PPS Changes- No Longer
Sensitive
10/01/2018
10869
09/07/2018
Fiscal Year (FY) 2019 Inpatient Prospective
Payment System (IPPS) and Long Term Care
Hospital (LTCH) PPS Changes SENSITIVE/
CONTROVERSIAL DO NOT POST-
Rescinded and replaced by Transmittal 4144
10/01/2018
10869
R4101CP
08/03/2018
Inpatient Rehabilitation Facility (IRF) Annual
Update: Prospective Payment System (PPS)
Pricer Changes for FY 2019
10/01/2018
10826
R4046CP
05/10/2018
Inpatient Prospective Payment System (IPPS)
and Long-Term Care Hospital (LTCH) PPS
Extensions per the Advancing Chronic Care,
Extenders, and Social Services (ACCESS) Act
Included in the Bipartisan Budget Act of 2018
04/02/2018
10547
R4038CP
04/27/2018
Notification of Change in Instructions for
Handling IRF Active Provider List
04/23/2018
10459
R4008CP
03/23/2018
Notification of Change in Instructions for
Handling IRF Active Provider List – Rescinded
and replaced by Transmittal 4038
04/23/2018
10459
R3836CP
08/18/2017
Home Health Value-Based Purchasing
Implementation
11/21/2017
9939
R3849CP
08/25/2017
Inpatient Rehabilitation Facility (IRF) Annual
Update: Prospective Payment System (PPS)
Pricer Changes for FY 2018
10/02/2017
10125
R3826CP
08/04/2017
Inpatient Psychiatric Facilities Prospective
10/02/2017
10214
Rev #
Issue Date
Subject
Impl Date
CR#
Payment System (IPF PPS) Fiscal Year (FY)
2018
R3795CP
06/16/2017
Updates in the Fiscal Intermediary Shared
System (FISS) Inpatient and Outpatient
Provider Specific Files (PSF)
10/02/2017
10165
R3779CP
05/24/2017
Instructions to Process Services Not Authorized
by the Veterans Administration (VA) in a Non-
VA Facility Reported With Value Code (VC) 42
04/03/2017
9818
R3750CP
04/19/2017
New Fields in the Fiscal Intermediary Shared
System (FISS) Inpatient and Outpatient
Provider Specific Files (PSF)
07/03/2017
9926
R3718CP
02/14/2017
Instructions to Process Services Not Authorized
by the Veterans Administration (VA) in a Non-
VA Facility Reported With Value Code (VC)
42-- Rescinded and replaced by Transmittal
3779
04/03/2017
9818
R3712CP
02/03/2017
New Fields in the Fiscal Intermediary Shared
System (FISS) Inpatient and Outpatient
Provider Specific Files (PSF)
07/03/2017
9926
R3635CP
10/28/2016
Instructions to Process Services Not Authorized
by the Veterans Administration (VA) in a Non-
VA Facility Reported With Value Code (VC) 42
– Rescinded and replaced by Transmittal 3718
04/03/2017
9818
R3590CP
08/01/2016
Changes to the Fiscal Intermediary Shared
System (FISS) Inpatient Provider Specific File
(PSF) for Low-Volume Hospital Payment
Adjustment Factor and New Inpatient
Prospective Payment System (IPPS) Pricer
Output Field for Islet Isolation Add-on Payment
10/03/2016
9570
R3576CP
08/05/2016
Inpatient Rehabilitation Facility (IRF) Annual
Update: Prospective Payment System (PPS)
Pricer Changes for FY 2017
10/03/2016
9669
R3575CP
08/01/2016
Update-Inpatient Psychiatric Facilities
Prospective Payment System (IPF PPS) Fiscal
Year (FY) 2017
10/03/2016
9732
R3571CP
07/29/2016
New Revenue Code 0815 for Allogeneic Stem
Cell Acquisition Services
01/03/2017
9674
R3556CP
07/01/2016
Stem Cell Transplantation for Multiple
Myeloma, Myelofibrosis, Sickle Cell Disease,
and Myelodysplastic Syndromes
10/03/2016
9620
Rev #
Issue Date
Subject
Impl Date
CR#
R3511CP
04/29/2016
Changes to the Fiscal Intermediary Shared
System (FISS) Inpatient Provider Specific File
(PSF) for Low-Volume Hospital Payment
Adjustment Factor and New Inpatient
Prospective Payment System (IPPS) Pricer
Output Field for Islet Isolation Add-on Payment
– Rescinded and replaced by Transmittal 3590
10/03/2016
9570
R3509CP
04/29/2016
Stem Cell Transplantation for Multiple
Myeloma, Myelofibrosis, Sickle Cell Disease,
and Myelodysplastic Syndromes - Rescinded
and replaced by Transmittal 3556
10/03/2016
9620
R3504CP
04/28/2016
Revision of the Method to Calculate the Length
of Stay (LOS) Edit for Continuous Invasive
Mechanical Ventilation for Greater than 96
Consecutive Hours
10/03/2016
9559
R3481CP
03/18/2016
Updates to Pub. 100-04, Chapters 3, 6, 7 and 15
to Correct Remittance Advice Messages
06/20/2016
9562
R3452CP
02/04/2016
Additional Fields Added to the Outlier
Reconciliation Lump Sum Utility
07/05/2016
9472
R3445CP
01/29/2016
Off-Cycle Update to the Long Term Care
Hospital (LTCH) Prospective Payment System
(PPS) Fiscal Year (FY) 2016 Pricer
04/04/2016
9527
R3431CP
12/29/2015
Fiscal Year (FY) 2016 Inpatient Prospective
Payment System (IPPS) and Long Term Care
Hospital (LTCH) PPS Changes
10/05/2015
9253
R3388CP
10/30/2015
Manual Updates to Clarify IRF Claims
Processing
12/02/2015
9362
R3373CP
10/14/2015
Fiscal Year (FY) 2016 Inpatient Prospective
Payment System (IPPS) and Long Term Care
Hospital (LTCH) PPS Changes –
Rescinded and
replaced by Transmittal 3431
10/05/2015
9253
R3360CP
09/24/2015
Fiscal Year (FY) 2016 Inpatient Prospective
Payment System (IPPS) and Long Term Care
Hospital (LTCH) PPS Changes –
Rescinded and
replaced by Transmittal 3373
10/05/2015
9253
R3357CP
09/18/2015
Fiscal Year (FY) 2016 Inpatient Prospective
Payment System (IPPS) and Long Term Care
Hospital (LTCH) PPS Changes –
Rescinded and
Replaced by Transmittal 3360
10/05/2015
9253
Rev #
Issue Date
Subject
Impl Date
CR#
R3332CP
08/21/2015
Update-Inpatient Psychiatric Facilities
Prospective Payment System (IPF PPS) Fiscal
Year (FY) 2016
10/05/2015
9305
R3331CP
08/21/2015
Inpatient Rehabilitation Facility (IRF) Annual
Update: Prospective Payment System (PPS)
Pricer Changes for FY 2016
10/05/2015
9236
R3199CP
02/20/2015
Revisions to Medicare Claims Processing
Manual for Foreign, Emergency and Shipboard
Claims
04/21/2015
8940
R3082CP
09/30/2014
Update-Inpatient Psychiatric Facilities
Prospective Payment System (IPF PPS) Fiscal
Year (FY) 2015
10/06/2014
8889
R3075CP
09/24/2014
Date Correction to Diagnosis Code Reporting
on Religious Nonmedical Health Care
Institution (RNHCI) Claims
11/12/2014
8857
R3054CP
08/29/2014
Ventricular Assist Devices for Bridge-to-
Transplant and Destination Therapy
09/30/2014
8803
R3039CP
08/22/2014
Inpatient Rehabilitation Facility (IRF) Annual
Update: Prospective Payment System (PPS)
Pricer Changes for FY 2015
10/06/2014
8788
R3034CP
08/22/2014
Update-Inpatient Psychiatric Facilities
Prospective Payment System (IPF PPS) Fiscal
Year (FY) 2015 – Rescinded and replaced by
Transmittal 3082
10/06/2014
8889
R3030CP
08/22/2014
Update to Pub. 100-04, Chapter 03 to Provide
Language-Only Changes for Updating ICD-10
and ASC X12
09/23/2014
8679
R3017CP
08/08/2014
Date Correction to Diagnosis Code Reporting
on Religious Nonmedical Health Care
Institution (RNHCI) Claims – Rescinded and
replaced by Transmittal 3075
11/12/2014
8857
R2933CP
04/17/2014
Addition of New Fields and Expansion of
Existing Model 1 Discount Percentage Field in
the Inpatient Hospital Provider Specific File
(PSF) and Addition of New Fields and
Renaming Payment Fields in the Inpatient
Prospective Payment System (IPPS) Pricer
Output
07/07/2014
8546
R2930CP
04/11/2014
Denial Letters for Religious Nonmedical Health
Care Institution Services Not Covered by
Medicare
07/14/2014
8559
Rev #
Issue Date
Subject
Impl Date
CR#
R2870CP
02/05/2014
Addition of New Fields and Expansion of
Existing Model 1 Discount Percentage Field in
the Inpatient Hospital Provider Specific File
(PSF) and Addition of New Fields and
Renaming Payment Fields in the Inpatient
Prospective Payment System (IPPS) Pricer
Output –
Rescinded and replaced by Transmittal
2933
07/07/2014
8546
R2819CP
11/19/2013
Fiscal Year (FY) 2014 Inpatient Prospective
Payment System (IPPS) and Long Term Care
Hospital (LTCH) PPS Changes
10/07/2013
8421
R2778CP
08/30/2013
Fiscal Year (FY) 2014 Inpatient Prospective
Payment System (IPPS) and Long Term Care
Hospital (LTCH) PPS Changes –
Rescinded and
replaced by Transmittal 2819
10/07/2013
8421
R2769CP
08/16/2013
Inpatient Rehabilitation Facility (IRF) Annual
Update: Prospective Payment System (PPS)
Pricer Changes for FY 2014
10/07/2013
8326
R2768CP
08/16/2013
Update-Inpatient Psychiatric Facilities
Prospective Payment System (IPF PPS) Fiscal
Year (FY) 2014
10/07/2013
8395
R2765CP
08/16/2013
Diagnosis Code Reporting on Religious
Nonmedical Health Care Institution Claims
01/06/2014
8350
R2722CP
06/11/2013
Changes to Contractor Designation in
Processing Foreign, Emergency and Shipboard
Claims
01/29/2012
8103
R2719CP
06/07/2013
Pass-through Payments for Certified Registered
Nurse Anesthetist Anesthesia Services and
Related Care
09/09/2013
7896
R2673CP
03/14/2013
Manual Updates to Clarify IRF Claims
Processing
04/22/2013
8127
R2674CP
03/14/2013
Changes to Contractor Designation in
Processing Foreign, Emergency and Shipboard
Claims –
Rescinded and replaced by Transmittal
2722
01/29/2013
8103
R2654CP
02/08/2013
Updates to Claims Processing Instructions
Regarding Religious Nonmedical Health Care
Institutions (RNHCI)
05/09/2013
8186
R2638CP
01/18/2013
Manual Updates to Clarify IRF Claims
Processing – Rescinded and replaced by
Transmittal 2673
04/22/2013
8127
Rev #
Issue Date
Subject
Impl Date
CR#
R2627CP
01/04/2013
Fiscal Year (FY) 2012 Inpatient Prospective
Payment System (IPPS), Long Term Care
Hospital (LTCH) PPS Changes
10/01/2012
8041
R2625CP
12/28/2012
Changes to Contractor Designation in
Processing Foreign, Emergency and Shipboard
Claims –
Rescinded and replaced by Transmittal
2674
01/29/2012
8103
R2576CP
11/01/2012
Affordable Care Act (ACA) Section 3025
Expansion of a Field in the Inpatient Provider
Specific File) PSF)
04/01/2013
8067
R2539CP
08/31/2012
Fiscal Year (FY) 2012 Inpatient Prospective
Payment System (IPPS), Long Term Care
Hospital (LTCH) PPS Changes –
Rescinded and
replaced by Transmittal 2627
10/01/2012
8041
R2520CP
08/17/2012
Update-Inpatient Psychiatric Facilities
Prospective Payment System (IPF PPS) Fiscal
Year (FY) 2013
10/01/2012
8000
R2518CP
08/10/2012
Inpatient Rehabilitation Facility (IRF) Annual
Update: Prospective Payment System (PPS)
Pricer Changes for FY 2013
10/01/2012
7901
R2513CP
08/03/2012
Liver Transplantation for Patients with
Malignancies
09/04/2012
7908
R2489CP
06/22/2012
Attending Provider Identifiers on Religious
Nonmedical Health Care Institution Claims
09/24/2012
7862
R2447CP
04/26/2012
Additional Fields Added to the Outlier
Reconciliation Lump Sum Utility
10/01/2012
7789
R2397CP
01/26/2012
Update to Abortion Condition Codes Associated
With Reason Code 32809
07/02/2012
7687
R2393CP
01/25/2012
Inpatient Rehabilitation Facility (IRF) No-Pay
Billing for Medicare Advantage (MA) Patients
Update
07/02/2012
7674
R2388CP
01/20/2012
Update to Pub. 100-04, Medicare Claims
Processing Manual, Chapter 3: Inpatient
Hospital Billing
04/22/2012
7706
R2367CP
12/09/2011
Verification of Status for all Hospitals
Qualifying for Disproportionate Share Hospital
(DSH) Payments Under 42CFR Section
412.106(c)(2), also known as the “Pickle
Amendment” – Rescinded and replaced by
Transmittal 2367
10/05/2009
6564
Rev #
Issue Date
Subject
Impl Date
CR#
R2334CP
10/28/2011
Billing for Donor Post-Kidney Transplant
Complication Services
04/02/2011
7523
R2332CP
10/28/2011
Diagnosis Code Update for Add-on Payments
for Blood Clotting Factor Administered to
Hemophilia Patients
04/02/2011
7553
R2301CP
09/13/2011
Inpatient Rehabilitation Facility (IRF) Annual
Update: Prospective Payment System (PPS)
Pricer Changes for FY 2012
10/03/2011
7510
R2285CP
08/26/2011
Attending Physician Identifiers on Religious
Nonmedical Health Care Institution Claims
11/28/2011
7542
R2275CP
08/12/2011
Inpatient Rehabilitation Facility (IRF) Annual
Update: Prospective Payment System (PPS)
Pricer Changes for FY 2012 – Rescinded and
replaced by Transmittal 2301
10/03/2011
7510
R2242CP
6/17/2011
Revision to Formula to Compute the Time
Value of Money under the Inpatient Prospective
Payment System (IPPS), Outpatient Prospective
Payment System (OPPS), Inpatient
Rehabilitation Facility (IRF PPS), Inpatient
Psychiatric Facility (IPF PPS) and Long Term
Care Hospital (LTCH PPS)
07/01/2011
7464
R2222CP
05/20/2011
Pass-through Payment for Certified Registered
Nurse Anesthetist Services
10/03/2011
7379
R2220CP
05/20/2011
Update - Inpatient Psychiatric Facilities
Prospective Payment System (IPF PPS) Rate
Year 2012
07/05/2011
7367
R2193CP
04/22/2011
Updates to Pub. 100-04, Medicare Claims
Processing Manual, Chapter 3, Inpatient
Hospital Billing
07/23/2011
7385
R2157CP
02/11/2011
Implementation of Edits for the Emergency
Department (ED) Adjustment Policy Under the
Inpatient Psychiatric Facility Prospective
Payment System (IPF PPS)
04/04/2011
7072
R2117CP
12/10/2010
Revisions to the Medicare Code Editor (MCE)
and Integrated Outpatient Code Editor(IOCE)
Reporting Requirements
01/12/2011
7246
R2111CP
12/03/2010
Outlier Reconciliation and other Outlier Manual
Updates for the Inpatient Prospective Payment
System (IPPS), Outpatient Prospective Payment
System (OPPS), Inpatient Rehabilitation
Facility (IRF) PPS, Inpatient Psychiatric Facility
04/04/2011
7192
Rev #
Issue Date
Subject
Impl Date
CR#
(IPF) PPS and Long Term Care Hospital
(LTCH) PPS
R2089CP
11/12/2010
Implementation of Edits for the Emergency
Department (ED) Adjustment Policy Under the
Inpatient Psychiatric Facility Prospective
Payment System (IPF PPS) – Rescinded and
replaced by Transmittal 2157
04/04/2011
7072
R2083CP
10/29/2010
Implementation of the Interrupted Stay Policy
under the Inpatient Psychiatric Facility
Prospective Payment System (IPF PPS)
01/03/2011
7044
R2066CP
10/15/2010
Submission of Informational Only Claims by
Maryland Waiver Hospitals and Critical Access
Hospitals (CAHs) for Electronic Health Records
(EHR) Purposes
01/03/2011
7172
R2062CP
10/08/2010
Allogeneic Hematopoietic Stem Cell
Transplantation (HSCT) for Myelodysplastic
Syndrome (MDS)
11/10/2010
7137
R2060CP
10/01/2010
Fiscal Year (FY) 2011 Inpatient Prospective
Payment System (IPPS), Long Term Care
Hospital (LTCH) PPS and Inpatient Psychiatric
Facility (IPF) PPS Changes
10/04/2010
7134
R2057CP
09/17/2010
Fiscal Year (FY) 2011 Inpatient Prospective
Payment System (IPPS), Long Term Care
Hospital (LTCH) PPS and Inpatient Psychiatric
Facility (IPF) PPS Changes – Rescinded and
replaced by Transmittal 2060
10/04/2010
7134
R2026CP
08/13/2010
Inpatient Rehabilitation Facility (IRF) Annual
Update: Prospective Payment System (PPS)
Pricer Changes for FY 2011
10/04/2010
7076
R2028CP
08/13/2010
5010 Implementation--Processing Additional
International Classification of Diseases, 9th
Revision-Clinical Modification (ICD-9-CM)
Diagnosis and Procedure Codes in Pricer,
Grouper, and the Medicare Code Editor (MCE)
01/03/2011
7004
R2016CP
07/30/2010
5010 Implementation--Processing Additional
International Classification of Diseases, 9th
Revision-Clinical Modification (ICD-9-CM)
Diagnosis and Procedure Codes in Pricer,
Grouper, and the Medicare Code Editor (MCE)
- Rescinded and replaced by Transmittal 2028
01/03/2011
7004
Rev #
Issue Date
Subject
Impl Date
CR#
R2011CP
07/30/2010
Revised Instructions for Reporting Assessment
Dates under the Inpatient Rehabilitation Facility
(IRF), Skilled Nursing Facility (SNF), and
Swing Bed (SB) Prospective Payment Systems
(PPS)
01/03/2011
7019
R2009CP
07/29/2010
Implementation of the Interrupted Stay Policy
under the Inpatient Psychiatric Facility
Prospective Payment System (IPF PPS) –
Rescinded and replaced by Transmittal 2083
01/03/2011
7044
R2008CP
07/30/2010
Common Working File (CWF) Override Edit
for Kidney Transplant Donor Claims When the
Kidney Recipient is Deceased
01/03/2011
6978
R1981CP
-6/04/2010
Update-Inpatient Psychiatric Facilities
Prospective Payment System (IPF PPS) Rate
Year 2011
07/06/2010
6986
R1895CP
01/15/2010
Processing of Non-Covered International
Classification of Diseases, Ninth Revision,
Clinical Modification (ICD-9-CM) Procedure
Codes on Inpatient Hospital Claims
04/05/2010
6547
R1890CP
01/08/2010
Processing of Non-Covered International
Classification of Diseases, Ninth Revision,
Clinical Modification (ICD-9-CM) Procedure
Codes on Inpatient Hospital Claims –
Rescinded
and replaced by Transmittal 1895
04/05/2010
6547
R1882CP
12/21/2009
January 2010 Update of the Hospital Outpatient
Prospective Payment System (OPPS)
01/04/2010
6751
R1871CP
12/11/2009
January 2010 Update of the Hospital Outpatient
Prospective Payment System (OPPS) -
Rescinded and replaced by Transmittal 1882
01/04/2010
6751
R1838CP
10/28/2009
Processing of Non-Covered International
Classification of Diseases, Ninth Revision,
Clinical Modification (ICD-9-CM) Procedure
Codes on Inpatient Hospital Claims –
Rescinded
and replaced by Transmittal 1890
04/05/2010
6547
R1828CP
10/09/2009
Verification of Status for all Hospitals
Qualifying for Disproportionate Share Hospital
(DSH) Payments Under 42CFR Section
412.106(c)(2), also known as the “Pickle
Amendment” – Rescinded and replaced by
Transmittal 2367
10/05/2009
6564
Rev #
Issue Date
Subject
Impl Date
CR#
R1816CP
09/17/2009
Fiscal Year (FY) 2010 Inpatient Prospective
Payment System (IPPS), Long Term Care
Hospital (LTCH) PPS, and Inpatient Psychiatric
Facility (IPF) PPS Changes
10/05/2009
6634
R1815CP
09/09/2009
Fiscal Year (FY) 2010 Inpatient Prospective
Payment System (IPPS), Long Term Care
Hospital (LTCH) PPS, and Inpatient Psychiatric
Facility (IPF) PPS Changes - Rescinded and
replaced by Transmittal 1816
10/05/2009
6634
R1811CP
09/04/2009
Verification of Status for all Hospitals
Qualifying for Disproportionate Share Hospital
(DSH) Payments Under 42CFR Section
412.106(c)(2), also known as the “Pickle
Amendment” – Rescinded and replaced by
Transmittal 1828
10/05/2009
6564
R1808CP
08/28/2009
Inpatient Rehabilitation Facility (IRF) Annual
Update: Prospective Payment System (PPS)
Pricer Changes for FY 2010
10/05/2009
6607
R1780CP
07/24/2009
Update-Inpatient Psychiatric Facilities
Prospective Payment System (IPF PPS) Rate
Year 2010
07/06/2009
6461
R1741CP
05/22/2009
Update-Inpatient Psychiatric Facilities
Prospective Payment System (IPF PPS) Rate
Year 2010 – Rescinded and replaced by
Transmittal 1780
07/06/2009
6461
R1702CP
03/13/2009
April 2009 Update of the Hospital Outpatient
Prospective Payment System (OPPS)
04/06/2009
6416
R1695CP
03/06/2009
Providers Submitting Information Regarding
Medicare Beneficiaries Entitled to Medicare
Advantage (MA) for Fiscal Year 2006 for the
Medicare/Supplemental Security Income (SSI)
Fraction
07/06/2009
6329
R1677CP
02/13/2009
Shipboard Services Billed to the Carrier and
Services Not Provided Within the United States.
Rescinds and fully replaces CR 6217.
03/13/2009
6327
R1649CP
12/18/2009
Procedures for Paying Claims Without Passing
Through the Integrated Outpatient Code Editor
(OCE) or Medicare Code Editor (MCE)
11/25/2008
6252
R1619CP
10/24/2008
Procedures for Paying Claims Without Passing
Through the Integrated Outpatient Code Editor
11/25/2008
6252
Rev #
Issue Date
Subject
Impl Date
CR#
(OCE) or Medicare Code Editor (MCE) -
Rescinded and replaced by Transmittal 1649
R1612CP
10/03/2008
Revision of Interim Payment Methodology for
Religious Nonmedical Health Care Institution
(RNHCI), Clarifying Existing Policy on
Training of Religious Nonmedical Nursing
Personnel, Claims Not Billed to the RNHCI
Specialty Contractor, and Statutory End of
Coverage for RNHCI Items and Services
Furnished in the Home
01/05/2009
5383
R1609CP
10/03/2008
Shipboard Services Billed to the Carrier and
Services Not Provided Within the United States
– Rescinded and replaced by CR 6327,
Transmittal 1677
01/05/2009
6217
R1592CP
09/10/2008
Artificial Hearts
12/01/2008
6185
R1585CP
09/05/2008
Inpatient Rehabilitation Facility (IRF) Annual
Update: Prospective Payment System (PPS)
Pricer Changes for FY 2009
10/06/2008
6166
R1583CP
08/29/2008
Artificial Hearts - Replaced by Transmittal 1592
10/06/2008
6185
R1571CP
08/07/2008
Transition of Responsibility for Medical Review
From Quality Improvement Organizations
(QIOs)
08/15/2008
5849
R1547CP
07/03/2008
Update Long Term Care Hospital (LTCH)
Prospective Payment System (PPS) Rate Year
2009
07/07/2008
6114
R1543CP
06/27/2008
Update-Inpatient Psychiatric Facilities
Prospective Payment System (IPF PPS) Rate
Year 2009
07/07/2008
6077
R1510CP
05/20/2008
Revision to the Inpatient Prospective Payment
System (IPPS) Post Acute Transfer Policy for
Discharges/Transfers to Home Under Care of an
Organized Home Health Service Organization in
Anticipation of Covered Skilled Care -
Rescinded and Not Replaced
10/06/2008
6012
R1509CP
05/16/2008
Adjusting Inpatient Prospective Payment
System (IPPS) Reimbursement for Replaced
Devices Offered Without Cost or With a Credit
10/06/2008
5860
R1498CP
05/02/2008
Adjusting Inpatient Prospective Payment
System (IPPS) Reimbursement for Replaced
Devices Offered Without Cost or With a Credit
– Replaced by Transmittal 1509
10/06/2008
5860
Rev #
Issue Date
Subject
Impl Date
CR#
R1495CP
05/02/2008
Billing Blood and Blood Products
10/06/2008
5867
R1479CP
03/14/2008
April 2008 Inpatient Rehabilitation Facility
(IRF) Prospective Payment System (PPS) Pricer
Changes
04/07/2008
5965
R1472CP
03/06/2008
Update of Institutional Claims References
04/07/2008
5893
R1429CP
02/01/2008
Modification of Payment Window Edits in the
Common Working File (CWF) to Look at Line
Item Dates of Service (LIDOS) on Outpatient
Claims
07/07/2008
5880
R1421CP
01/25/2008
Update of Institutional Claims References -
Rescinded and Replaced by Transmittal 1472
04/07/2008
5893
R1341CP
09/21/2007
New Web Site for Approved Transplant Centers
10/22/2007
5724
R1311CP
07/20/2007
Capturing Medicare Advantage (MA)
Beneficiary Days in the Medicare Supplemental
Security Income (SSI) Fraction for
Disproportionate Share Hospital (DSH) Data
01/07/2008
5647
R1268CP
06/15/2007
Update – Long Term Care Hospital Prospective
Payment System (LTCH PPS) Rate Year 2008
07/02/2007
5652
R1231CP
04/27/2007
The Use of Benefit's Exhaust (BE) Day as the
Day of Discharge for Payment Purposes for the
Inpatient Psychiatric Facility Prospective
Payment System (IPF PPS) and Clarification of
Discharge for Long Term Care Hospitals
(LTCH) and the Allowance of No-Pay Benefits
Exhaust Bills (TOB 110)
12/03/2007
5474
R1137CP
12/22/2006
Inpatient Rehabilitation Facility (IRF) Teaching
Status Adjustment
01/22/2007
5325
R1135CP
12/22/2006
Correction of Instructions for Calculating IRF
Compliance Percentage Threshold
03/22/2007
5303
R1105CP
11/09/2006
Swing Bed Hospital Updates
12/11/2006
5114
R1101CP
11/03/2006
Inpatient Psychiatric Facility Prospective
Payment System (IPF PPS)
12/04/2006
5287
R1072CP
10/06/2006
Inpatient Prospective Payment System (IPPS)
Outlier Reconciliation Technical Corrections
11/06/2006
5286
R982CP
06/16/2006
New Use of Hospital Issued Notices of
Noncoverage (HINNs)
09/18/2006
5070
R981CP
06/15/2006
Update-Long Term Care Hospital Prospective
Payment System (LTCH PPS) Rate Year 2007
07/03/2006
5202
Rev #
Issue Date
Subject
Impl Date
CR#
R980CP
06/14/2006
Changes Conforming to CR 3648 Instructions
for Therapy Services
10/02/2006
4014
R966CP
05/26/2006
Intestinal and Multi-Visceral Transplantation
06/26/2006
5090
R957CP
05/19/2006
Pancreas Transplants Alone (PA)
07/03/2006
5093
R941CP
05/05/2006
Changes Conforming to CR 3648 Instructions
for Therapy Services – Rescinded and replaced
by Transmittal 980
10/02/2006
4014
R938CP
05/05/2006
The Inpatient Rehabilitation Facility Prospective
Payment System (IRF PPS)
08/07/2006
5016
R903CP
04/14/2006
Payment for Blood Clotting Factors
Administered to Hemophilia Inpatients
07/14/2006
4229
R851CP
02/10/2006
Revisions to Instructions for Contractors Other
Than the Religious Nonmedical Health Care
Institutions Specialty Contractor Regarding
Claims for Beneficiaries with RNCHI Elections
05/11/2006
4218
R843CP
02/09/2006
Inpatient Admission Followed by Discharge or
Death Prior to Room Assignment
07/03/2006
4202
R836CP
02/03/2006
Inpatient Admission Followed by Discharge or
Death Prior to Room Assignment – Rescinded
and replaced by Transmittal 843
07/03/2006
4202
R817CP
01/20/2006
Update to the Inpatient Provider specific File
and the Outpatient Provider Specific File to
Retain Provider Information
04/03/2006
4279
R803CP
01/03/2006
Administration of Drugs and Biologicals in a
Method II Critical Access Hospital (CAH)-
Rescinds and Replaces CR 3911
04/03/2006
4234
R776CP
12/06/2005
Stem Cell Transplantation
01/03/2006
4173
R771CP
12/02/2005
Revisions to Pub. 100-04, Medicare Claims
Processing Manual in Preparation for the
National Provider Identifier
01/03/2006
4181
R768CP
12/02/2005
Lung Volume Reduction Surgery
03/02/2006
4149
R766CP
12/02/2005
Stem Cell Transplantation - Rescinded and
replaced by Transmittal 776
01/03/2006
4173
R714CP
10/21/2005
Payment Window Edit Corrections within the
Common Working File (CWF)
04/03/2006
4089
R707CP
10/12/2005
IPPS Outlier Reconciliation
11/07/2005
3966
R703CP
10/07/2005
IPPS Outlier Reconciliation – Rescinded and
replaced by Transmittal 703
11/07/2005
3966
Rev #
Issue Date
Subject
Impl Date
CR#
R698CP
10/07/2005
The Supplemental Security Income (SSI)
Medicare Beneficiary Data for Fiscal Year 2006
for the Inpatient Rehabilitation Facility
Prospective Payment System (IRF PPS)
11/07/2005
4065
R693CP
09/30/2005
Updates to the IRF and SNF Provider Specific
File and Changes in Inpatient Rehabilitation
Facility Prospective Payment System For FY
2006
10/31/2005
4099
R668CP
09/02/2005
Enforcement of Hospital Inpatient Bundling:
Carrier Denial of Ambulance Claims during an
Inpatient Stay
01/03/2006
3933
R654CP
08/19/2005
Services Not Provided Within United States
11/17/2005
3781
R646CP
08/12/2005
Update to the Inpatient Provider Specific File
(PSF) and the Outpatient PSF to Retain Provider
Information – Rescinded and replaced by
Transmittal 817
01/03/2006
3940
R632CP
07/29/2005
Billing and Claims Processing Instructions for
Claims Subject to Expedited Determinations
01/03/2006
3949
R622CP
07/29/2005
Enforcement of Hospital Inpatient Bundling:
Carrier Denial of Ambulance Claims during an
Inpatient Stay
01/03/2006
3933
R619CP
07/29/2005
Late IRF-PAI Data Submission Penalty Protocol
Within the Inpatient Rehabilitation Facility
Prospective Payment System
01/03/2006
3885
R594CP
06/24/2005
Preliminary Instructions: Expedited
Determinations/Reviews for Original Medicare
07/01/2005
3903
R577CP
06/03/2005
Preliminary Instructions: Expedited
Determinations/Reviews for Original Medicare
07/01/2005
3903
R530CP
04/22/2005
Billing Requirements for Physician Services
Rendered in Method II Critical Access Hospitals
(CAHs)
07/05/2005
3800
R526CP
04/15/2005
Updated Requirements for Autologous Stem
Cell Transplantation (AuSCT)
05/16/2005
3797
R478CP
02/18/2005
Clarification of the Verification Process to be
Used to Determine if the Inpatient
Rehabilitation Facility Meets The IRF
Classification Criteria
03/21/2005
3704
R465CP
02/04/2005
Billing Requirements for Physician Services in
Method II Critical Access Hospitals (CAHs)
07/05/2005
3559
Rev #
Issue Date
Subject
Impl Date
CR#
R392CP
12/10/2004
The Supplemental Security Income (SSI)
Medicare Beneficiary Data for Fiscal Year 2003
for Inpatient Rehabilitation Facility Prospective
Payment System (IRF PPS)
01/10/2005
3567
R384CP
12/01/2004
Inpatient Psychiatric Facility Prospective
Payment System (IPF PPS)
04/04/2005
3541
R383CP
11/26/2004
Inpatient Psychiatric Facility Prospective
Payment System (IPF PPS) Replaced by
Transmittal 384.
04/04/2005
3541
R379CP
11/26/2004
Low Osmolar Contrast Material/Laboratory
Tests/Payment for Inpatient Services Furnished
by a Critical Access Hospital (CAH)
04/04/2005
3439
R357CP
11/05/2004
Implementation of Coverage of Religious
Nonmedical Health Care Institution Items and
Services Furnished in the Home, MMA section
706
04/04/2005
3529
R347CP
10/29/2004
Inpatient Rehabilitation Facility (IRF)
Classification Requirements
11/29/2004
3503
R291CP
08/27/2004
Use of Transmission Date in the Service
Date/Assessment Date Field for Inpatient
Rehabilitation Facility Prospective Payment
System (IRF PPS) Claims
01/03/2005
3433
R285CP
08/27/2004
Addition of Physician Assistants, Nurse
Practitioners and Clinical Nurse Specialists as
Emergency On-Call Providers for Critical
Access Hospitals (CAHs)
01/03/2005
3228
R276CP
08/13/2004
Further Information Related to CR 3175,
Distinct Part Units of Critical Access Hospitals
(CAHs)
01/03/2005
3399
R267CP
07/30/2004
Crossover Patients in New Long Term Care
Hospitals (LTCH)
01/03/2005
3391
R266CP
07/30/2004
Revision of Common Working File (CWF)
Editing for Same-Day, Same- Provider Acute
Care Readmissions
01/03/2005
3389
R263CP
07/30/2004
Inpatient Rehabilitation Facility (IRF) Annual
Update: Prospective Payment System (PPS)
Pricer for FY 2005
10/04/2004
3378
R231CP
07/23/2004
Indian Health Service or Tribal Critical Access
Hospitals Billing for Professional Services
01/03/2005
3235
R221CP
06/25/2004
Medicare IRF Classification Requirements
07/01/2004
3334
Rev #
Issue Date
Subject
Impl Date
CR#
R208CP
06/18/2004
Long Term Care Hospital Prospective Payment
System (LTCH PPS) Fiscal Year 2005-Update
07/06/2004
3335
R161CP
04/30/2004
Informing Beneficiaries about which local
Medical Review Policy (LMRP) and /or Local
Coverage Determination (LCD) and o/or
National Coverage Determination (NCD) is
associated with their claim denial - rescinded
and replaced with Pub. 100-08, Transmittal 75.
10/04/2004
3089
R156CP
04/30/2004
Clarification of payments and billing procedures
for hospitals subject to the Maryland waiver
10/04/2004
3200
R152CP
04/30/2004
Inclusion of Core-Based Statistical Area
(CBSA) Data Elements to the Provider Specific
Files
10/04/2004
3272
R144CP
04/23/2004
Distinct Part Units for Critical Access Hospitals
10/04/2004
3175
R087CP
02/06/2004
Expansion of Transfer Policy Under Inpatient
Payment Prospective System
07/06/2004
2934
R077CP
02/06/2004
Change in Methodology for Determining
Payment for Outliers
03/08/2004
2998
R073CP
01/23/2004
MCE and IPPS Transfers Between Hospitals
N/A
2716 &
2891
R070CP
01/23/2004
Hospital Operating Payments Under PPS
02/23/2004
3038
R068CP
01/16/2004
New Requirements for Critical Access
Hospitals. These changes have been established
with the "Medicare Prescription Drug,
Improvement, and Modernization Act"
(MPDIMA) of 2003, Pub.L. 108-173
04/05/2004
3052
R039CP
12/08/2003
Low-Income Provides Adjustment: The
Supplemental Security Income Medicare
Beneficiary Data for Fiscal Year 2002 for IRFs
Paid Under the PPS
01/05/2004
2978
R026CP
11/04/2003
Lung Volume Reduction Surgery
01/05/2004
2688
R010CP
10/17/2003
Heart Transplants
10/01/2003
2958
R001CP
10/01/2003
Initial Publication of Manual
NA
NA
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