(Medicare Claims Processing Manual)

Payment return codes:     00 Final payment where no outlier applies  01 Final payment where outlier applies  02 Final payment where outlier applies, but is not payable due to limitation.  03 Not used.  04 Not used.  05 Not used.  06 LUPA payment only     07 Not used.     08 Not used.     09 Final payment, partial period payment     11 Final payment, partial period payment with outlier     12 Not used.     13 Not used.     14  LUPA payment, add -on payment applies     Error return codes:     10 Invalid TOB  15 Invalid PEP days  16 Invalid HRG days, greater than 30  20 PEP indicator invalid  25 Med review indicator invalid  30 Invalid CBSA code  31 Invalid/missing County Code  35 Invalid Initial Payment Indicator  40 Dates before January 2020 or invalid  70 Invalid HRG code  75 No HRG present in 1st occurrence  80 Invalid revenue code     85 No revenue code present on adjustment TOB  404-408 9(5) REVENUE - SUM 1 -6-QTY- ALL  Output item:  The total number of visits used by the Pricer to determine if the claim must be paid as a LUPA.  This amount will be the total of all the covered visit quantities input with all six HH discipline revenue codes.  409-417 9(7)V9(2)  OUTLIER - PAYMENT  Output item:  The outlier payment amount determined by the Pricer to be due on the claim in addition to any HRG payment amounts.  Added to the claim as a value code 17 amount.  File Position  Format  Title  Description  418-426 9(7)V9(2)  TOTAL - PAYMENT  Output item:  The total payment determined by the Pricer to be due on the claim.  427-435 S9(7)V9(2)  VBP -ADJ-AMT  Output item: The HHVBP adjustment amount, determined by subtracting the HHVBP adjustment total payment from the HH PPS payment that would otherwise apply to the claim.  Added to the claim as a value code QV amount.  436-444 9(7)V9(2)  PPS-STD -VALUE  Output item:  Standardized payment amount  the HH PPS payment without applying any provider -specific adjustments.  Informational only.  Subject to additional calculations before entered on the claim in PPS -STNDRD -VALUE field.  445-452 X(8)  RECEIPT -DATE  Input item: The receipt date of the corresponding NOA for this claim.  Date format must be CCYYMMDD.   453 X OVERRIDE -IND Input item:  An indicator of whether an exception request to the late filing penalty has been granted by the MAC.  Valid values:  Y = Exception has been granted, no late filing penalty will be calculated  N = No exception applies, calculate late filing penalty, if applicable.  454-462 9(7)V9(2)  LATE -SUB -PENALTY -AMT  Output item: The late submission penalty amount, determined by subtracting the total payment after the late submission penalty from the HH PPS payment that would otherwise apply to the claim.  Added to the claim as a value code QF amount.  463-650 X(188)  FILLER     Input records on claims must include all input items.  Output records will contain all input and output items.  If an output item does not apply to a particular record, Pricer will return zeroes.   The Medicare claims processing system will move the following Pricer output items to the claim record.  The return code will be placed in the claim header.  The HRG -PAY amount for the HIPPS code will be placed in the revenue code 0023 line.  The OUTLIER -PAYMENT amount, if any, will be placed in a value code 17 amount.  If the return code is 06 or 14 (indicating a low utilization payment adjustment), the Medicare claims processing system will apportion the REVENUE -COST amounts to the appropriate line items in order for the per -visit payments to be accurately reflected on the remittance advice.  If the return code is 14, the Medicare claims processing system will apply the H -HHA- REVENUE -ADD- ON-VISIT -AMT to the earliest line item with the corresponding revenue code.  70.3 - RESERVED  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  70.4 - Decision Logic Used by the Pricer on Claims (Rev. 10919, Issued:08- 06-21, Effective:01 -01-22, Implementation: 01- 03-22)  On input records with TOB 329, 327, 32F, 32G, 32H, 32I, 32J, 32K, 32M, 32Q, 33Q or 32P (that is, all provider submitted claims and provider or A/B MAC (HHH) initiated adjustments), Pricer will perform the following calculations in the numbered order.   If the SERV -FROM -DATE is on or after January 1, 2020, the Pricer shall perform the following:   Prior to these calculations, determine the applicable Federal standard rate to apply by reading the value in INIT -PAY- QRP -INDICATOR.  If the value is 0, use the full standard rate in subsequent calculations.  If the value is 2, use the standard rate whic h has been reduced by 2 percent due to the failure of the provider to report required quality data.   1. Low Utilization Payment Adjustment (LUPA) calculation.   1.1 If the REVENUE -SUM1 -6-QTY -ALL is less than the LUPA threshold associated with the HRG -INPUT -CODE (e.g. threshold is 6, sum is 5 or less), read the national standard per visit rates for each of the six REVENUE -QTY- COV -VISITS fields from the revenue code table for the calendar year in which the SERV -THRU- DATE falls.  Multiply each quantity by the corresponding rate.  Wage index adjust each value and report the payment in the associated REVENUE -COST field.   1.2 If the following conditions are met, calculate an additional LUPA add- on payment:   the dates in the SERV -FROM -DATE and ADMIT -DATE fields match   the first position of the HIPPS code is a 1 or a 2   the value in LUPA -SRC- ADM is not a B AND   the value in RECODE -IND is not a 2.   Compare the earliest line item dates for revenue codes 042x, 044x and 055x and select the revenue code with the earliest date.   If the earliest date for revenue codes 042x, 043x (CY 2022 and after) or 044x match the revenue code 055x date, select revenue code 055x.   If the earliest date for revenue codes 042x and 044x match and revenue code 055x is not present, select revenue code 042x.  For claims with Through dates on or after January 1, 2022:   If the earliest date for revenue codes 042x and 043x match and revenue code 055x is not present, select revenue code 042x.  If the earliest date for revenue codes 043x and 044x match and revenue code 055x is not present, select revenue code 043x.  1.3  Apply the appropriate LUPA add- on factor to the selected earliest dated line.   If revenue code 055x, multiply the national per -visit amount by 1.8451.  If revenue code 042x, multiply the national per -visit amount by 1.6700.  If revenue code 043x, multiply the national per -visit amount by 1.6700.  If revenue code 044x, multiply the national per -visit amount by 1.6266.  Return the resulting payment amount in the REVENUE -ADD- ON-VISIT -AMT field.   1.4  Return the sum of all REVENUE -COST amounts and the REVENUE -ADD- ON-VISIT -AMT amount, if applicable, in the TOTAL -PAYMENT field.  If the LUPA payment includes LUPA add- on amount, return 14 in the PAY -RTC field.  Otherwise, return 06 in the PAY -RTC field.  No further calculations are required.   1.5  If REVENUE -SUM1 -6-QTY- ALL is greater than or equal to the LUPA threshold associated with the HRG -INPUT -CODE, proceed to the HRG payment calculation in step 2.  2. HRG payment calculations.   2.1. If the PEP -IND is an N:   Find the weight for the HRG -INPUT -CODE from the weight table for the calendar year in which the SERV -THRU- DATE falls.  Multiply the weight times the applicable period of care rate for the calendar year in which the SERV -THRU -DATE falls.  The product is the case- mix adjusted rate.     Multiply the case -mix adjusted rate by the current labor -related percentage to determine the labor portion.  Multiply the labor portion by the wage index corresponding to the CBSA field.  Multiply the case -mix adjusted rate by the current nonlabor -related percentage to determine the nonlabor portion.  Sum the labor and nonlabor portions.  The sum is the wage index and case -mix adjusted payment for this HRG.  Proceed to the outlier calculation in step 3.    2.2. If the PEP -INDICATOR is a Y:   Perform the calculation of the case- mix and wage index adjusted payment for the HRG amount, as in 3.1.  Determine the proportion to be used to calculate this PEP by dividing the PEP -DAYS amount by 30.  Multiply the case -mix and wage index adjusted payment by this proportion.  The result is the partial period payment due on the claim.  Proceed to the outlier calculation in step 3.   3. Outlier calculation:   3.1. Wage index adjust the outlier fixed loss amount for the Federal fiscal year in which the SERV -THRU -DATE falls, using the CBSA code in the CBSA field.  Add the resulting wage index adjusted fixed loss amount to the total dollar amount resulting from the HRG payme nt calculation.  This is the outlier threshold for the period.   3.2. For each quantity in the six REVENUE -QTY - OUTLIER -UNITS fields, read the national standard per unit rates from the revenue code table for the year in which the SERV -THRU- DATE falls.  Multiply each quantity by the corresponding rate.  Sum the six r esults and wage index adjust this sum as described above, using the CBSA code in the CBSA field.  The result is the wage index adjusted imputed cost for the period.   3.3. Subtract the outlier threshold from the imputed cost.  3.4. If the result determined in step 3.3 is greater than $0.00, calculate .80 times the result.  This is the outlier payment amount.   3.5. Determine whether the outlier payment is subject to the 10% annual limitation on outliers as follows:    Multiply the amount in the PROV -PAYMENT -TOTAL field by 10 percent to determine the HHAs outlier limitation amount.    Deduct the amount in the PROV -OUTLIER -PAY -TOTAL from the outlier limitation amount.   This result is the available outlier pool for the HHA.    If the available outlier pool is greater than or equal to the outlier payment amount calculated in step 3.4, return the outlier payment amount in the OUTLIER -PAYMENT field.  Add this amount to the total dollar amount resulting from HRG payment calculatio n.  Return the sum in the TOTAL -PAYMENT field, with return code 01.    If the available outlier pool is less than the outlier payment amount calculated in step 3.4, return no payment amount in the OUTLIER -PAYMENT field.  Assign return code 02 to this record.