(Medicare Claims Processing Manual)

NOTE: E ffective January 1, 2011, do not r eport the service date for the revenue code 0024 line.  Instead, use  occurrence code 50 in pl ace of the service date to report the d efault discharge date for informational only claims.   Effective October 1, 201 1, report the Revenue Code 0024 line  containing the CMG from the  IRF-PAI and the transmission da te of the IRF-PAI in the  occurrence code 50 and da te field (as is r equired for FFS claims).   All oth er 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 facilit y, provider number , SSI days, covered Medicare days, and the  ratio of  Medicare Part A pa tient da ys attributable to SSI recipients.  A/B MACs (A) will use  this in formation to upda te 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 d ata to deter mine  an initia l PPS payment amount, and if applicable, to det ermine  a final outlier payment amount for IRFs whose discharge s are during a sp ecific cost re porting per iod.  A/B MACs (A) m ake a det ermination of the amount of this p ercenta ge to compute the f inal LIP adjustment which a llows the  year-end settlement of a facilitys cost re port.  When the A/B MAC (A)  se ttles a cost re port for a specific fiscal ye ar, that settled cost re port will d etermine  the f inal SSI ra tio th at is associated with th at cost report.  The A/B MAC (A)  use s the most recently se ttled SSI ratio to s ettle the current cost re port.  Once the fina l SSI ratio is d etermined for the actua l fiscal year the cost repor t corre sponds to, a re trospective adjustment may be made to account for the di fference betw een the actu al lip adjustment amount a nd the  initia l PPS lip adjustment payment amount.  A - Cla rification of Allowab le Medicaid Days in Cal culating the Dis proport ionate Share Va riable  Background  Under the IRF PPS, facilitie s receive additiona l payment amounts to accou nt for the cost of furnishing care to low- income pa tients. This is done by making adjustme nts to  the prospective  payment ra te. Under 1886(d )(5)(F) of the Act, the Medi care DS H percenta ge is m ade up of two computations. The re sults of th ese two computations ar e added toge ther to d etermine  the DS H percentage. First, the pa tient d ays of pa tients who, during a given month, w ere entitled to b oth M edicare Part A and SSI (excluding those patients who received only Sta te supplementa tion) is divid ed by the number of cov ered patient day s utilized by pa tients under Medi care P art A for th at same period. S econd, a determination is made regarding the patient days a ssociate d with  benef iciaries who w ere eligible for medical assistance (Medi caid) under a Sta te plan approved under Title  XIX but who w ere not e ntitle d to M edicare Part A (See 42 CFR 412.106(b)(4)) is d etermined. This number is divid ed by the total number of pa tient days for tha t same period. The SSI data is updated on an a nnual basis and the se data are one of the components used to determine the DS H variable th at is p art of the appropria te LIP adjustment for each IRF.  Included Days  In calcula ting the number of Medi caid day s, the  hospit al must d etermine  whether the patient wa s elig ible for Medi caid under a Sta te plan approved under Title  XIX on the day of service.  If the pa tient was so e ligible, the day counts in the Medi care dispropor tionate share adjustment calculation.  The st atutory formula  for "Medi caid day s" refl ects seve ral key concepts.  First, the focus is on the pa tient's e ligibility for Medi caid benef its as determined by the State, not the hospital' s "eligibility " for some form of Medi caid payment.  S econd, the focus is on the pa tient's e ligibility for me dical assistance under an approve d Title  XIX Sta te plan, not the pa tient's e ligibility for gene ral assi stance under a State-only progra m.  Third, the focus is on e ligibility for medi cal assistance under an approve d Title  XIX Sta te plan, not medi cal assistance under a State-only program or othe r program.  Thus, f or a day to be  counted, the patient must be  eligible on that day for medical assistance benefits unde r the Federal-State coope rative program known as Medicaid ( unde r an approved Title  XIX State plan).  In othe r words, for purposes of the Medicare dispr oportionate share adjustm ent cal culation, the  term "Medicaid days" refers to da ys on whi ch the  patient is e ligible for medical assistance benefits unde r an approved Title  XIX State plan.  The term "Medicaid d ays" does not ref er to all days that have some relation to the  Medicaid program, th rough a matching payment or otherwise; if a patient is not e ligible for medical assistance benefits unde r an approved Title  XIX State plan, the patient da y cannot b ecome  a "Medicaid da y" simply by virtue of some  other association with the  Medicaid pr ogram.  Medicaid da ys, for purposes of the Medicare dispr oportionate share adjustm ent calculation, inc lude all days during whi ch a patient is e ligible, unde r a State plan approved unde r Title  XIX, for Medicaid be nefits, e ven if Medicaid did not m ake payment for any services.  Thus, M edicaid days include, but a re not limite d to, da ys that are determined to be medically necessary but for which payment is denied by Medicaid b ecause the provide r did not bill t imely, days that are beyond the  num ber of days for which a State will p ay, days that are utiliz ed by a Medicaid be neficiary prior to an admission a pproval but f or which a valid enrollme nt is determined within the  prescribed period, a nd days for which payment is ma de by a third par ty.  In addition, CMS  reco gnizes the calculation da ys that are utiliz ed by a Medicaid beneficiary who is e ligible for Medicaid unde r a State plan approved und er Title  XIX through a managed care organization ( MCO) or health maintenance organization ( HMO) .  Ho wever, in accordance with 42 C FR 412.106( b)(4) , a day does not c ount in the  Medicare dispr oportionate share adjustm ent cal culation if  the patient was entitle d to both M edicare Part A a nd Medicaid on tha t day.  Theref ore, onc e the eligibilit y of the patient for Medicaid unde r a State plan approved und er Title  XIX has been ver ified, the  A/B MAC (A) mu st determine  whether any of the days are dual entitlement da ys and, to the  extent that they are, subt ract them from  the othe r days in the  calculation.  Excluded Days  Many States operate  programs th at include both S tate-only and Federal-State eligibilit y groups in a n integrated program.  F or example, some  States provide  medical assistance to beneficiaries of State-funde d inc ome suppor t programs.  Th ese beneficiaries, how ever, are not e ligible for Medicaid unde r a State plan approved unde r Title  XIX, and, therefore, days utiliz ed by these beneficiaries do not c ount in the  Medicare dispr oportionate share adjustm ent cal culation.  If a hospit al is un able to distin guish be tween M edicaid beneficiaries and othe r medical assistance beneficiaries, the n it must c ontact the State for assistance in doing so.  In addition, if  a given patient da y affects the  level of Medicaid D SH payments to the hospit al but the  patient is not e ligible for Medicaid unde r a State plan approved unde r Title X IX on tha t day, the day is not in cluded in the  Medicare DSH calculation.  It should be  noted that the types of days discussed above  are not ne cessarily the only types of excluded days.  See the chart below, whi ch summar izes som e, but not necessa rily all, of the  types of days to be  excluded from ( or included in) the Medicare DSH adjustme nt cal culation.  To provide  consist ency in both c ompone nts of  the calculation, a ny days that are added to the  Medicaid da y count must a lso be  added to the  total day count, to the  extent that they have not been p revious ly so added.  Regardless of the type of allowable Medicaid da y, the hospit al bears the burden of proof and must ver ify with the  State that the patient was eligible unde r one of the allowable cat egories during e ach day of the patient's stay.  The hospit al is responsible  for and must pr ovide  adequate documentation to subst antiate the numbe r of Medicaid d ays claimed. Days for patients th at can not be  verified by State records to ha ve fallen within a  period wherein the  patient was eligible for Medicaid c annot be  counted.  Types of Days Included/Excluded in the  Medicare DSH Adjustm ent Calculation  Type of Day Description  Eligible Title  XIX Day General Assist ance Patient Days Days for patients covered und er a State-only (or county-only) general assistance program (whether or not a ny payment is a vailable for health care services unde r the program).  These patients are not M edicaid-eligible under the State plan No Other State-Only Health Program Patient Days Days for patients covered und er a State-only health program.  Th ese patients ar e not M edicaid-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 uncompe nsated care by a hospit al.  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.  The se patients are Medicaid-eligible unde r the Title XIX State plan unde r the authority of these provisions, whi ch is e xercis ed by the State in the  context of the approved State plan. Yes Type of Day Description  Eligible Title  XIX Day Medicaid Optiona l Targeted Low- Income Children (CHIP-related) Days Days for patients who are Title  XIX-eligible and who m eet the definition  of "optiona l targeted low -income children" under 1905(u)(2) .  The difference between the se children and othe r Title  XIX children is the  enhanced FMAP rate available to the  State.  Th ese children are fully Medicaid-eligible unde r the State plan. Yes Separate CHIP Days Days for patients who are eligible for benefits under a non-Medicaid State program furnishi ng child health a ssistance to targeted low -income children. Th ese children are, by definition, not M edicaid-eligible under    No.  140.2.5.4 - Teaching Status Adjustment (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)