(Medicare Claims Processing Manual)

30.4.2  SNF PPS Rate Components (Rev. 10880, Issued: 08- 06-21, Effective: 11 -08-21, Implementation: 11- 08-21)  The SNF PPS rate for each RUG group consists of 3 components:  a nursing component, a therapy component and a non- case- mix adjusted component.  The following describes the rate components used for SNF PPS:    The nursing per diem amount is a standard amount which includes direct nursing care and the cost of non- therapy ancillary services required by Medicare beneficiaries.    The nursing index is based on the amount of staff time, weighted by salary levels, associated with each RUG group.  This index represents the amount of nursing time associated with caring for beneficiaries who qualify for the group.   The nursing per diem amount is case -mix adjusted by applying the nursing index.  The result is the nursing component for that RUG group.   The therapy per diem amount is a standard amount which includes physical, occupational, and speech- language therapy services provided to beneficiaries in a Part A stay.  Payment varies based on the actual therapy resource minutes received by the beneficiar y and reported on the MDS;    The therapy index is based on the amount of staff time, weighted by salary levels, associated with each RUG group.  This index represents the amount of rehabilitation treatment time associated with caring for beneficiaries who qualify for the group.   If the RUG group is in the Rehabilitation plus Extensive Services or Rehabilitation category, the therapy per diem amount is case- mix adjusted by applying the therapy index.  The result is the therapy component for that Rehabilitation RUG group.   The non- case- mix therapy component is a standard amount to cover the cost of therapy assessments of beneficiaries who were determined not to need continued therapy services.   If the RUG group is not in the Rehabilitation plus Extensive Services or Rehabilitation category, this payment is added to the rate as therapy component for that RUG group.    The non- case- mix component is also a standard amount added to the rate for each RUG group to cover administrative and capital -related costs.   This standard amount is added to all RUG groups.  As of October 1, 2019, SNF PDPM changes are effective (see 120ff.).  30.4.3 - Decision Logic Used by the Pricer on Claims  (Rev. 4409, Issued: 10- 04-19, Effective: 11-05-19, Implementation: 11-05-19)  A. Claims for services furnished prior to October 1, 2019, under RUG -IV  The SNF Pricer shall calculate the rate for each line item with revenue code 0022 on a SNF claim.  The SNF Pricer shall determine the rate using the following information:  - HIPPS-CODE on line item 0022; -CBSA  - Per diem amounts defined within the Pricers as types of rate based on the statement covers THRU -DATE:   Inpatient rate = Nursing case mix component  General service rate = Non -case-mix component  Therapy rate = Therapy non -case mix component   Rehabilitation rate = Therapy case-mix component - Labor and non labor percentages based on the statement covers THRU-DATE;  - Wage index, SNF -FED BLEND year, and SNF -FACILITY RATE based on the statement covers THRU_DATE  - Rate adjustments applicable to the specific RUG code;  - Nursing index based on the RUG code; - Therapy index based on the rehabilitation RUG code;  On input records with TOB 21x (that is, all provider submitted claims and provider or A/B MAC (A) initiated adjustments), Pricer will perform the following calculations in numbered order for each RUG code:  (1) Multiply the applicable urban or rural inpatient rate depending on CBSA by the nursing index;  (2) Multiply the applicable urban or rural rehab rate by the therapy index, add to (1);  (3) For the top 23 RUG categories, add the general service rate to the sum of (1) and (2) for the (non- wage-adjusted) total PPS rate and proceed to step (4); OR for the lower 43 RUG categories, add the general service rate to the therapy rate to the sum of (1) and (2) for the (non- wage - adjusted) total PPS rate and proceed to step (4);  (4) Multiply the sum of (3) by the labor percentage then multiply the product by the applicable wage index and round;  (5) Multiply the sum of (3) by the non- labor percentage and round;  (6) Add the product of (5) to the non-labor product in (4) for the (wage-adjusted) total PPS rate.   Conditional Steps completed if applicable after (6):  (6a) If ICD -10-CM diagnosis code B20 (or, for services furnished prior to October 1, 2015, ICD-9-CM diagnosis code 042) is present, multiply (6) by 2.28.  B. Claims for services furnished on or after October 1, 2019, under the SNF PDPM  The SNF PDPM Pricer shall calculate the rate for each line item with revenue code 0022 on a SNF claim.   The SNF PDPM Pricer shall determine the rate using the following information: SNF PRICER uses the REGION IND, HIPPS CODE, QRP -IND & AIDS ADD- ON-IND to CALCULATE THE HCPPS RATES.                          1.    CBSA   a.    URBAN = 5 numeric characters  b.    RURAL = 3 spaces & 2 digit state code c.    SPECIAL = APPLY SPECIAL WAGE INDEX "IN LIEU" OF CBSA WAGE INDEX                                                                   i.     SPECIAL = SNF- SPEC -WI-IND = '1' ON SNF-INPUT -RECORD and SNF -SPEC -WI-X = 5 numeric characters                                                                  ii.     CBSA -WIR -EFFDATE = '20051001'.   2.    HIPPS CODE - 5 CHARACTERS = 4 alpha/1 numeric character. [on line item 0022] Evaluate each of the 1st four characters to select component rates:  a.    Character # 1 = component rate for Physical Therapy (PT) & Occupational Therapy (OT). There are 16 PDPM Groups A thru P.  b.    Character # 2 = component rate for Speech Language Pathology  (SLP). There are 12 PDPM Groups A thru L. c.    Character # 3 = component rate for Nursing. There are 25 PDPM Groups A thru Y.  d.    Character # 4 = component for Non-Therapy Ancillary (NTA). There are 6 PDPM Groups A thru F.  e.    Character # 5 = component for Non-Case Mix (NCM) which do not impact the rates selected, but supply information about Assessment Level.                                                           i.     5-day assessment =   1                                                          ii.      IPA   = 0    3.    Non -Case- Mix component is fixed rate based on REGION -IND & QRP -IND [4 options  URBAN, RURAL, URBAN- QRP, & RURAL -QRP applied equally to each payment)                   4.    IF SNF -FED -BLEND =1      SET QRP IND TO Y  identifies that a reduced payment component rate should be selected.   5.    Variable Per Diem adjustment factor applies to PT/OT & NTA components only based on the day- in-stay;    6.    Nursing component is adjusted by factor of 1.18 when AIDS Add -On-Indicator is set to Y ( If input field SNF -PRIN -DIAG -CODE OR [SNF -OTHER -DIAG -CODE2 thru  SNF-OTHER -DIAG -CODE25] = 'B20   '.   7. NTA component is adjusted by reassigning a new component rate when AIDS Add -On-Indicator is set to Y (( If input field SNF -PRIN -DIAG -CODE OR [SNF -OTHER -DIAG -CODE2 thru  SNF-OTHER -DIAG -CODE25] = 'B20   '.  a. If reported NTA group is NF, reassigned NTA group is NC  b. If reported NTA group is NE, reassigned NTA group is NB  c. If reported NTA group is ND, reassigned NTA group is NA  d. If reported NTA group is NC, reassigned NTA group is NA  e. If reported NTA group is NB, reassigned NTA group is NA  f. If reported NTA group is NA, no reassignment is necessary (NA represents the highest per diem component rate).    8.       SNF -PDPM -UNITS   & VBP -MULTIPLIER cannot be = zero    9.    SNF -PDPM -PRIOR DAYS > 100 NF processing HALTS & an ERROR Code is placed in SNF -RTC      On input records with TOB 21x (that is, all provider submitted claims and provider or A/B MAC (A) initiated adjustments), Pricer will perform the following calculations in numbered order  for each SNF input character:    .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .      (1)     Capture/select the applicable rate components associated with each HIPPS CODE character from rate tables determined by the Region IND, QRP -IND and AID Add -On IND (applies to Nursing only).   (2)     Compute the PT -OT-FEE ROUNDED =     HIPPS- PT-RATE -COMP + HIPPS-OT-RATE -COMP.    (3)     Compute the PT -OT-PORTION ROUNDED =    PT -OT-FEE *  PT -OT-UTIL. (Utilization Days for PT -OT is determined by summing the PT -OT Variable Per Diem factors  for Total Days (CURRENT -DAYS + PRIOR -DAYS.)).    (4)     Compute the NTA -PORTION ROUNDED =  HIPPS- NTA- RATE -COMP * NTA- UTIL.   (Utilization Days for NTA category is determined by summing the NTA Variable Per Diem factors  for Total Days (CURRENT -DAYS + PRIOR -DAYS.).    (5)     Compute NURS -SLP-NCM -PORTION ROUNDED =     (HIPPS- NURSE -RATE -COMP +     HIPPS- SLP-RATE -COMP +    HIPPS- NCM -RATE -COMP) * CURRENT -DAYS (or SNF -PDPM -UNITS).                                                   (6)     Compute TOT -PDPM -CASEMIX -PERDIEM = (PT -OT-PORTION +     NTA-PORTION +    NURS -SLP- NCM -PORTION).     ALL 3 PORTIONS ARE ADDED TOGETHER TO GET THE  TOTAL CASE MIX PER DIEM.    (7)     Compute LABOR -PORTION ROUNDED =       (TOT -PDPM -CASEMIX -PERDIEM * PERCENT- 2020- LABOR).                                                           (8)     Compute LABOR -ADJUSTED ROUNDED =    (LABOR -PORTION * AREA-WAGE -INDEX).                                                                         (9)     Compute NON -LABOR -PORTION ROUNDED =    (TOT -PDPM -CASEMIX -PERDIEM * PERCENT- 2020- NLABOR)                                                           (10)  Compute TOTAL -LABOR -ADJ-RATE ROUNDED =    (LABOR -ADJUSTED + NON- LABOR -PORTION).     (11)  Compute TOTAL -CALC -PAYMENT -RATE ROUNDED = TOTAL -LABOR -ADJ-RATE.                                                                         (12)  Apply the VBP (Value Based Purchasing Factor).            Compute SNF -PAYMENT -RATE ROUNDED =   VBP -MULTIPLIER *   TOTAL-CALC -PAYMENT -RATE.                                                                     (13)  Obtain the VBP PAY Difference  Compute VBP -PAY- DIFF ROUNDED =   SNF -PAYMENT -RATE -  TOTAL -CALC -PAYMENT -RATE.   30.5 - Annual Updates to the SNF Pricer  (Rev. 10880, Issued: 08- 06-21, Effective: 11 -08-21, Implementation: 11- 08-21)