(Medicare Claims Processing Manual)

Under TEFRA, the PS&R report used the benefits exhaust date as the discharge date (if present).  This changed when the IPF PPS was implemented, and the 'actual' discharge date was used.  The days stay with the year they occurred, making it easier for the P S&R report (especially during the blend period) to settle the cost report.  This means that:  1. Claims will now be settled on the appropriate cost report;  2. The appropriate PPS -TEFRA blend percentage will be paid;   3. Patients with long lengths of stay will be counted on the correct PS&R report;   4. The PRICER version used will be the one in effect at the time the services were provided (i.e., when the Medicare beneficiary actually has Medicare benefits).   190.13 - Periodic Interim Payments (PIP)  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  Medicare contractors shall pay PIP for providers who send a request to their Medicare contractor and qualify.  Outlier payments, teaching adjustment, and ECT add- on payments are not included in the PIP payment amount but are paid on the discharge claim for  ECT, and on a discharge, benefits exhaust, or last day of a Medicare covered level of care claim, for the teaching adjustment and outlier payment.   190.14 - Intermediary Benefit Payment Report (IBPR)  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  The IBPR report has been changed to reflect the payments for IPFs going to PPS psychiatric hospitals and units.   190.15  - Monitoring Implementation of IPF PPS Through Pulse  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  The FISS 620A and 620B reports will be modified to add an additional row for IPF monitoring.  The report will be modified to include a separate reporting line titled IPF PPS.  This entry will appear immediately below IPF PPS and report the total claim count and total reimbursement amount.  IPF PPS totals will include all providers with the last four digits of the provider numbers in range 4000 -  4499, xx- Sxxx, and xx- Mxxx.  190.16 - IPF PPS System Edits (Rev. 2157, Issued: 02- 11-11, Effective: 04 -01-11, Implementation: 04- 04-11)  FISS shall ensure that:    Revenue Code total charges line 0001 must equal the sum of the individual total charges lines.    The length of stay in the statement covers period, from and through dates, equals the total days for accommodations Revenue Codes 010x- 021x, including Revenue Code 018x (leave of absence)/interrupted stay.    Value Code 75 is allowed from contractor entry and not allowed from Provider entry. Also, Providers are not allowed to alter this information.   The ED adjustment is not made where a patient is discharged from an acute care hospital or CAH and admitted to the same hospitals or CAHs psychiatric unit with the application of the correct Point of Origin code D on the IPF PPS claim.  FISS and CWF shall ensure that multiple Occurrence Span Code 74s are allowed.  CWF shall ensure that:    Occurrence Span Code 74 is present on the claim when there is an interrupted stay (the beneficiary has returned to the same IPF within 3 days).   Value Code 75 is present on claims when there is an interrupted stay resulting from a discharge at another IPF (the beneficiary has returned to the different IPF within 3 days).  190.17 - IPF PPS PRICER Software  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  CMS has developed an IPF PRICER program that calculates the Medicare payment rate. PRICER software will be electronically supplied to the Standard Systems.  A Personal Computer (PC) version of this PRICER will be available on the CMS Web site in the future  at http://www.cms.hhs.gov/PCPricer.  PRICER will incorporate the 3 -year phase- in period for all current IPFs.  New IPFs will be paid completely under the new IPF PPS (i.e., there is no transition for new IPFs).  190.17.1 - Inputs/Outputs to PRICER  (Rev. 11396, Issued:05-04-22, Effective:10 -01-22, Implementation:10-03-22)  Provider Specific File Data   Data Element  Title  1 National Provider Identifier (not a mandatory entry at this time)  2 Provider CMS Certification Number (CCN)  3 Effective Date  4 Fiscal Year Begin Date  5 Report Date  6 Termination Date  7 Waiver Indicator  Data Element  Title  9 Provider Type (must be 03 or 06) Effective July 1, 2006, 06 is no longer valid.  Contractors shall use 49.  12 Actual Geographic Reclassification -MSA (no longer applicable effective July 1, 2006)  17 Temporary Relief Indicator (For IPF PPS, code Y if there is an Emergency Department)  18 Federal PPS Blend Indicator (must be 1, 2, 3, or 4)  21 Case Mix Adjusted Cost Per Discharge/PPS Facility Specific Rate (This is determined using the same methodology that would be used to determine the interim payment per discharge under the TEFRA system if the IPF PPS were not being implemented.)  22 Cost of Living Adjustment (COLA)  23 Intern/Bed Ratio  25 Combined Capital and Operating Cost to Charge Ratio  33 Special Wage Indicator (should be set to 1 if there is a change to the wage index.)  35 Actual Geographic Location  Core -Based Statistical Area (CBSA) (required July 1, 2006)  38 Special Wage Index  48 New Hospital  63 Supplemental Wage Index  64 Supplemental Wage Index Indicator   Bill Data   National Provider Identifier  Covered Charges  Provider CMS Certification Number (CCN)  Discharge Date (or benefits exhaust date if present)  Patient Age  Other Diagnosis Codes  DRG  Other Procedure Codes  Length of Stay Indicator for Occurrence Code 31, A3, B3, or C3 to apply outlier to this bill.  Source of Admission  ECT Units  Patient Status Code  Claim Number  National Provider Identifier  Covered Charges   Indicator for Value Code75 to apply variable per diem adjustment to this bill.   Outputs   In addition to returning the above bill data inputs, Pricer will return the following:   Final Payment  National Non -Labor Rate  DRG/MS -DRG Adjusted Payment  Federal Rate  Federal Adjusted Payment  Budget Neutrality Rate  Outlier Adjusted Payment  Outlier Threshold  Comorbidity Adjusted Payment  Federal Per Diem Base Rate  Per Diem Adjusted Payment  Standardized Factor  Facility Adjusted Payment  Labor Share  Age Adjusted Payment  Non-Labor Share  Rural Adjusted Payment  COLA  Teaching Adjusted Payment  Day of Stay Adjustment  ED Adjusted Payment  Age Adjustment  ECT Adjusted Payment  Comorbidity Adjustment  Return Code  DRG Adjustment  MSA/CBSA  Rural Adjustment  Wage Index  ECT Adjustment  National Labor Rate  Blend Year Calculation Version     200 - Electronic Health Record (EHR) Incentive Payments  (Rev. 2066, Issued: 10- 15-10, Effective: 10 -01-10, Implementation: 01- 03-11)  The American Recovery and Reinvestment Act of 2009 (ARRA) (Pub. L. 111- 5) provides incentive payments for acute care hospitals (subsection (d) hospitals) and critical access hospitals (CAHs) who are meaningful users of certified electronic health records (EHR) technology.  200.1 - Payment Calculation  (Rev.  2066, Issued: 10- 15-10, Effective: 10 -01-10, Implementation: 01- 03-11)  A - Incentive Payment Calculation for Subsection (d) Hospitals   [Initial Amount] x [Medicare Share] x [Transition Factor]   o Initial Amount  equals $2,000,000 + [$200 per discharge for the 1,150th - 23,000th discharge]   o Medicare Share equals Medicare/(Total*Charges), whereas:   o Medicare equals [number of Inpatient Bed Days for Part A Beneficiaries] plus [number of Inpatient Bed Days for MA Beneficiaries]   o Total  equals [number of Total Inpatient Bed Days]   o Charges  equals [Total Charges minus Charges for Charity Care*] divided by [Total Charges]   o Transition Factor   Fiscal Year  Fiscal Year that Eligible Hospital First Receives the Incentive Payment   2011 2012 2013 2014 2015 2011 1.00     2012 0.75 1.00    2013 0.50 0.75 1.00   2014 0.25 0.50 0.75 0.75  2015  0.25 0.50 0.50 0.50 2016   0.25 0.25 0.25  B - Incentive Payment Calculation for Critical Access Hospitals (CAHs)   CAH Reasonable Cost x Medicare Share*   * See Medicare Share computation in sub -section A above.   200.2 - Submission of Informational Only Bills for Maryland Waiver Hospitals and Critical Access Hospitals (CAHs)  (Rev. 2066, Issued: 10- 15-10, Effective: 10 -01-10, Implementation: 01- 03-11)  Acute care hospitals already submit informational only bills for purposes of including Part C days in the Disproportionate Share (DSH) calculations, as explained in Section 20.3 above.  However, Maryland waiver hospitals and CAHs do not currently submit informational only bills.  In order for CMS to capture Part C days for purposes of calculating EHR payments, Maryland waiver hospitals and CAHs must submit informational only claims to Medicare, effective for discharges October 1, 2010.  Informational only c laims are claims billed for patients enrolled in a Medicare Advantage (MA) Plan and contain a condition the following elements:    Covered 11X TOB (not 110)   Condition Code 04   Medicare is the primary payer   There is no MSP   Beneficiarys Medicare HICN   All other required claim elements   250.18 Incomplete Colonoscopies (Codes 44388, 45378, G0105 and G0121)  (Rev.  4153, Issued: 10- 26-18, Effective: 04 -01-19, Implementation: 04- 01-19) An incomplete colonoscopy, e.g., the inability to advance the colonoscope to the cecum or colon- small intestine anastomosis due to unforeseen circumstances, is billed and paid using colonoscopy through stoma code 44388, colonoscopy code 45378, and screening colonoscopy codes G0105 and G0121 with modifier  -53. (Code 44388 is valid with modifier 53 beginning January 1, 2016.) The Medicare physician fee schedule database has specific values for codes 44388- 53, 45378- 53, G0105- 53 and G0121- 53. An incomplete c olonoscopy performed prior to January 1, 2016, is paid at the same rate as a sigmoidoscopy. Beginning January 1, 2016, Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one -half the value of the inputs for the codes. As such, instruct CAHs that elect Method II payment to use modifier  -53 to identify an incomplete screening colonoscopy (physician professional service(s) billed in revenue code 096X, 097X, and/or 098X).  CAH Method II shall be consistent with the guidelines outlined in PUB. 100- 04, chapter 12, section 30.1 and chapter 18, section 60.2.                          Addendum A - Provider Specific File  (Rev. 12234, Issued: 08-31-23, Effective: 10-01-2023, Implementation: 10-02-2023)   Data Element  File Position  Format  Title  Description  1 1-10 X(10)  National Provider Identifier (NPI)  Alpha -numeric 10 character  NPI number.  Data Element  File Position  Format  Title  Description