(Medicare Claims Processing Manual)

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, Part B, line 1.02 (prior to the inclusion of line 54 of Worksheet E, Part B), the outlier  reconciliation adjustment amount (the difference between the original and revised outlier amount (calculated by the Lump Sum Utility),  the total time value of money, the rate used to calculate the time value of money and the sum of lines 51 and 53 on line s 50- 54, of Worksheet E, Part B of the cost report (NOTE :  the amounts recorded on lines 50, 51, 53 and 54 can be positive or negative amounts per the instructions above).  The total outlier reconciliation amount (Worksheet E, Part B, line 54) shall be included on Worksheet E, Part B, line 1.02.  For complete i nstructions on how to fill out these lines see 3630.2 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, Part B, line 4 (prior to the inclusion of line 94 of Worksheet E, Part B), the outli er reconciliation adjustment amount (the difference between the original and revised outlier amount (calculated by the Lump Sum Utility),  the total time value of money, the rate used to calculate the time value of money and the sum of lines 91 and 93 on lines 90- 94, of Worksheet E, Part B of the cost report (NOTE : the amounts recorded on lines 90, 91, 93 and 94 can be positive or negative amounts per the instructions above).  The total outlier reconciliation amount (Worksheet E, Part B, line 94) shall be included on Worksheet E, Part B, line 1.02.   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) elements 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 OPPS, 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 10.11.3.1 with any questions regarding this process.   Table 1:  Data Elements for FISS Extract   List of Data Elements for FISS Extract  Provider #  Medicare beneficiary identifier  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)  Revised DSH Amount (Value Code 18)  Difference between these amounts  Original IME Amount (Value Code 19)  Revised IME Amount (Value Code 19)  List of Data Elements for FISS Extract  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  HMO -IME Indicator  Filler    10.8 - Geographic Adjustments  (Rev. 1, 10- 03-03) A-01-93  Adjustments for differences in wages across geographical areas are made using inpatient hospital PPS wage index (post -reclassification, post -floor).   It is estimated that 60 percent of the group payment represents labor -related costs and are subject to the geographic adjustment.  10.8.1 - Wage Index Changes  (Rev. 1, 10- 03-03) A-02-026 XIII, A -01-144  Refer to the CMS Web site http://www.cms.gov/medicare/hopsmain.htm  for wage index change information.  10.9 - Updates  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)    Section 1833(t) of the Social Security Act (the Act) as amended by 4533 of the  Balanced Budget Act (BBA) of 1997, authorizes CMS to implement a Medicare prospective payment system for hospital outpatient services, including partial hospitalization and intensive outpatient  services; Certain Part B services furnished to hospital inpatients who have no Part A coverage; Partial hospitalization and intensive outpatient  services furnished by CMHCs; Hepatitis B vaccines and their administration, splints, cast, and antigens provided by HHAs that provide medical and other health services; Hepatitis B vaccines and their administration provided by CORFs; and Splints, casts, a nd antigens provided to hospice patients for treatment of non-terminal illness.    By statute, CMS is required to review and revise the APC groups, relative payment rates, wage adjustments, outlier payments and other adjustments required under the OPPS on an annual basis.  These annual updates are made final through the publication of pr oposed and final rules in the Federal Register.  The annual update Federal Register rules can be accessed on the OPPS Web site at:   http://www.cms.gov/Medicare/Medicare -Fee-for-Service -Payment/HospitalOutpatientPPS/    In addition to the annual update at the beginning of each calendar year, we also update the OPPS on a quarterly basis to account for mid- year changes such as adding new passthrough drugs and/or devices, adding new treatments and procedures to the new techn ology APCs, removing procedures from the inpatient list, and recognizing new HCPCS codes that may be added during the year.  The quarterly updates are issued as Recurring Update Notifications.  The quarterly Recurring Update Notifications can be found in P ub. 100- 21, Recurring Update Notification, which can be accessed at the  following Web site:  http://www.cms.gov/Regulations -andGuidance/Guidance/Manuals/Internet -Only -Manuals -IOMs.html     10.10 - Biweekly Interim Payments for Certain Hospital Outpatient Items and Services That Are Paid on a Cost Basis, and Direct Medical Education Payments, Not Included in the Hospital Outpatient Prospective Payment System (OPPS)  (Rev. 1, 10- 03-03) A-01-32  For hospitals subject to the OPPS, payment for certain items that are not paid under the OPPS, but which are reimbursable in addition to OPPS, are made through biweekly interim payments subject to retrospective adjustment based on a settled cost report.  These payments include:    Direct medical education payments;   Costs of nursing and allied health programs;    Costs associated with interns and residents not in an approved teaching program as described in 42 CFR 415.202;    Teaching physicians costs attributable to Part B services for hospitals that elect cost-based reimbursement for teaching physicians under 42 CFR 415.160;    CRNA services;    For hospitals that meet the requirements under 42 CFR 412.113(c) , the reasonable costs of anesthesia services furnished to hospital outpatients by qualified nonphysician anesthetists (i.e., certified registered nurse anesthetists and anesthesiologists assistants) employed by the hospital or obtained under arrangements ;   Bad debts for uncollectible deductibles and coinsurance;    Organ acquisition costs paid under Part B.   For hospitals that are paid under the OPPS, interim payments for these items attributable to both hospital outpatients, as well as inpatients whose services are paid under Part B of the Medicare program are made on a biweekly basis.  The A/B MAC (A) determ ines the amount of the biweekly payment by estimating a hospitals reimbursement amount for these items for the cost reporting period by using:    Medicare principles of cost reimbursement for cost -based items; and    Medicare rules for determining payment for graduate medical education for direct medical education, and dividing the total annual estimated amount for these items into 26 equal biweekly payments.  The estimated annual amount is based on the most current data available.  Biweekly interim payments are reviewed and, if necessary, adjusted at least twice during the reporting period, with final settlement based on a submitted cost report.  Because hospitals subject to the OPPS have not received payment for these items attributable to services furnished on or after August 1, 2000, the date the OPPS was implemented, the first payment to each hospital included all the payments due to the hospital retroactive to August 1, 2000.  Thereafter, A/B MACs (A) continue to make payment on a biweekly basis.  Each payment is made two weeks after the end of a  biweekly period of services.  The A/B MAC (A) was required to make retroactive payments and begin making biweekly interim payments to all hospitals that are due these payments no later than 60 days after March 8, 2001.  These biweekly payments may be combined with the inpatient biweekly payments that the A/B MAC (A) makes under 2405.2 of the Medicare Provider Reimbursement Manual (CMS Pub.15- I).  However, if a single payment is made, for purposes of final cost report set tlement, they must maintain records to separately identify the amount of the hospitals combined payment that is paid out of the Part A or Part B trust fund.  10.11 - Calculation of Overall Cost -to-Charge Ratios (CCRs) for Hospitals Paid Under the Outpatient Prospective Payment System (OPPS) and Community Mental Health Centers (CMHCs) Paid Under the Hospital OPPS  (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  10.11.1 - Requirement to Calculate CCRs for Hospitals Paid under OPPS and for CMHCs  (Rev. 2296, Issued: 09- 02-11, Effective: 10 -01-11, Implementation: 10- 03-11)