(Medicare Claims Processing Manual)

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 Parkinsons 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 excl uded 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 recei ve 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 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 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 patients 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-of-Stay  Variable Per Diem Payment Adjustment*  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 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 providers wage index from that providers 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 IPFs FTE resident cap is determined based on the IPFs 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 ne w 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 F TE 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 IPFs 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 ca p) 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 adjustm ent 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.