(Medicare Claims Processing Manual)

IRF PPS:  All IRFs are 100% Federal for cost reporting periods beginning on or after 10/01/2002. LTCH PPS:   For cost reporting periods beginning on or after 10/01/2002, enter the appropriate code for the blend ratio between federal and facility rates for the LTCH provider:    Federal %  Facility%  1 20 80 2 40 60 3 60 40 4 80 20 5 100 00  For LTCH cost reporting periods beginning on or after 10/01/2015 enter the appropriate code for the blend year representing 50% site neutral payment and 50 % standard payment.   6 Blend Year 1  (represents 50% site neutral payment and 50 % standard payment effective for all LTCH providers with cost reporting periods beginning on or after 10/01/2015 through 09/30/16)   7 - Blend Years 2 through 4  (represents 50% site neutral payment and 50 % standard payment effective for all LTCH providers with cost reporting periods beginning in FY 2017, FY 2018 or FY 2019   8 - Blank  Transition Blend no longer applies with cost reporting periods beginning in on or after 10/01/2019. Full Site Neutral payment   Data Element  File Position  Format  Title  Description  IPF PPS:  Enter the appropriate code for the blend ratio between federal and facility rates.  Effective for all IPF providers with cost reporting periods beginning on or after 1/1/2005.  Federal %  Facility%  1 25 75 2 50 50 3 75 25 4 100 00   19 76-77  9(2) State Code  Enter the 2 -digit state where the provider is located.  Enter only the first (lowest) code for a given state. For example, effective October 1, 2005, Florida has the following State Codes: 10, 68 and 69.  MACs shall enter a 10 for Floridas state code.  List of valid state codes is located in Pub. 100-07, Chapter 2, Section 2779A1.  20 78-80 X(3)  Filler  Blank.  21 81-87 9(5)V9(2)  Case Mix Adjusted Cost Per Discharge/PPS Facility Specific Rate  For PPS hospitals and waiver state non -excluded hospitals, enter the base year cost per discharge divided by the case mix index.  Enter zero for new providers.  See 20.1  for sole community and Medicare-dependent hospitals on or after 04/01/90. For inpatient PPS hospitals, verify if figure is greater than $10,000.  For LTCH, verify if figure is greater than $35,000.   22 88-91  9V9(3)   Cost of Living Adjustment (COLA)  Enter the COLA.  All hospitals except Alaska and Hawaii use 1.000. 23 92-96 9V9(4)  Intern/Beds Ratio  Enter the provider's intern/resident to bed ratio.  Calculate this by dividing the provider's full time equivalent residents by the number of available beds (as calculated in positions 97-101).  Do not include residents in anesthesiology who are employed t o replace anesthetists or those assigned to PPS excluded units.  Base the count upon the average number of full- time equivalent residents assigned to the hospital during the fiscal year.  Correct cases where there is reason to believe that Data Element  File Position  Format  Title  Description  the count is substantially in error for a particular facility.  The MAC is responsible for reviewing hospital records and making necessary changes in the count at the end of the cost reporting period. Enter zero for non-teaching hospitals. IPF PPS:  Enter the ratio of residents/interns to the hospitals average daily census.  24  97-101 9(5) Bed Size  Enter the number of adult hospital beds and pediatric beds available for lodging inpatient. Must be greater than zero.  (See the Provider Reimbursement Manual, 2405.3G.)  25 102-105 9V9(3)  Operating Cost to Charge Ratio  Derived from the latest settled cost report and corresponding charge data from the billing file.  Compute this amount by dividing the Medicare operating costs by Medicare covered charges.  Obtain Medicare operating costs from the Medicare cost repot form C MS-2552-96, Supplemental Worksheet D-1, Part II, Line 53.  Obtain Medicare covered charges from the MAC billing file, i.e., PS&R record.  For hospitals for which the MAC is unable to compute a reasonable cost- to-charge ratio, they use the appropriate urban or rural statewide average cost -to-charge ratio calculated annually by CMS and published in the " Federal Register."  These average ratios are used to calculate cost outlier payments for those hospitals where you compute cost- to-charge ratios that are not within the limits published in the "Federal Register."  For LTCH and IRF PPS, a combined operating and capital cost- to-charge ratio is entered here.  See below for a discussion of the use of more recent data for determining CCRs.  Data Element  File Position  Format  Title  Description  26 106-110  9V9(4)   Case Mix Index   The case mix index is used to compute positions 81-87 (field 21).  Zero- fill for all others.  In most cases, this is the case mix index that has been calculated and published by CMS for each hospital (based on 1981 cost and billing data) reflecting the relative cost of that hospital's mix of cases compared to the national average mix.  27 111-114 V9(4)  Supplemental Security Income Ratio   Enter the SSI ratio used to determine if the hospital qualifies for a disproportionate share adjustment and to determine the size of the capital and operating DSH adjustments.  28 115-118 V9(4)  Medicaid Ratio  Enter the Medicaid ratio used to determine if the hospital qualifies for a disproportionate share adjustment and to determine the size of the capital and operating DSH adjustments.  29 119 X(1)  Provider PPS Period  This field is obsolete as of 4/1/91.  Leave Blank for periods on or after 4/1/91.  30 120-125  9V9(5)   Special Provider Update Factor  Zero -fill for all hospitals after FY91.  This Field is obsolete for hospitals as of FY92. Effective 1/1/2018, this field is used for HHAs only.  Enter the HH VBP adjustment factor provided by CMS for each HHA. If no factor is provided, enter 1.00000.  31 126-129 V9(4)  Operating DSH  Disproportionate share adjustment Percentage.  Pricer calculates the Operating DSH effective 10/1/91 and bypasses this field.  Zero -fill for all hospitals 10/1/91 and later.  32  130-137  9(8)  Fiscal Year End   This field is no longer used.  If present, must be CCYYMMDD.  33 138  X(1)  Special Payment Indicator Enter the code that indicates the type of special payment provision that applies.  Blank = not applicable Y = reclassified  1 = special wage index indicator  2 = both special wage index indicator and reclassified  D = Dual reclassified  Data Element  File Position  Format  Title  Description  34 139 X(1)   Hospital Quality Indicator  Enter code to indicate that hospital meets criteria to receive higher payment per MMA quality standards. Blank = hospital does not meet criteria  1 = hospital quality standards have been met 35 140-144 X(5)  Actual Geographic Location  Core -Based Statistical Area (CBSA)  Enter the appropriate code for the CBSA 00001-89999, or the rural area, (blank (blank) (blank) 2 digit numeric State code such as _ _ _ 36 for Ohio, where the facility is physically located.  36   145-149  X(5)   Wage Index Location CBSA  Enter the appropriate code for the CBSA, 00001-89999, or the rural area, (blank)(blank) (blank) (2 digit numeric State code) such as _ _ _ 3 6 for Ohio, to which a hospital has been reclassified due to its prevailing wage rates.  Leave blank or enter the actual location CBSA (field 35), if not reclassified.  Pricer will automatically default to the actual location CBSA if this field is left blan k. 37 150-154  X(5)   Payment CBSA   Enter the appropriate code for the CBSA, 00001-89999 or the rural area, (blank) (blank)(blank) (2 digit numeric State code) such as _ _ _ 3 6 for Ohio, to which a hospital has been reclassified.  Leave blank or enter the actual location CBSA (field 35) if not reclassified.  Pricer will automatically default to the actual location CBSA if this field is left blank  38 155-160 9(2)V9(4)  Special Wage Index  Enter the special wage index that certain providers may be assigned.  Enter zeroes unless the Special Payment Indicator field equals a 1 or 2.  39 161-166  9(4)V9(2)   Pass Through Amount for Capital   Per diem amount based on the interim payments to the hospital.  Must be zero if location 185 = A, B, or C (See the Provider Reimbursement Manual, 2405.2).  Used for PPS hospitals prior to their cost reporting period beginning in FY 92, new hospitals during their first 2 years of operation FY 92 or later, and non -PPS Data Element  File Position  Format  Title  Description  hospitals or units.  Zero -fill if this does not apply.  40 167-172 9(4)V9(2)  Pass Through Amount for Direct Medical Education  Per diem amount based on the interim payments to the hospital (See the Provider, Reimbursement Manual, 2405.2.).  Zero-fill if this does not apply.  41 173-178  9(4)V9(2)   Pass Through Amount for Organ Acquisition   Per diem amount based on the interim payments to the hospital.  Include standard acquisition amounts for kidney, heart, lung, pancreas, intestine and liver transplants.  Do not include acquisition costs for bone marrow transplants.  (See the Provider Reimb ursement Manual, 2405.2.)  Zero-fill if this does not apply.  42 179-184  9(4)V9(2)   Total Pass Through Amount, Including Miscellaneous   Per diem amount based on the interim payments to the hospital (See the Provider Reimbursement Manual 2405.2.)  Must be at least equal to the three pass through amounts listed above.  Include pass through amount for Domestic N95 Respirator Procurement. The following are included in total pass through amount in addition to the above pass through amounts.  Certified Registered Nurse Anesthetists (CRNAs) are paid as part of Miscellaneous Pass Through for rural hospitals that perform fewer than 500 surgeries per year, and Nursing and Allied Health Professional Education when conducted by a provider in an approved program.  Do not include amounts paid for Indirect Medical Education, Hemophilia Clotting Factors, DSH adjustments, or Allogeneic Stem Cell Acquisition .  Zero -fill if this does not apply.  43 185 X(1)  Capital PPS Payment Code Enter the code to indicate the type of  capital payment methodology for hospitals: A = Hold Harmless  cost payment for old capital  B = Hold Harmless  100% Federal rate  C = Fully prospective blended rate  44 186-191 9(4)V9(2)  Hospital Specific Capital Rate  Must be present unless:  Data Element  File Position  Format  Title  Description   A "Y" is entered in the Capital Indirect Medical Education Ratio field; or   A08 is entered in the Provider Type field; or  A termination date is present in Termination Date field.  Enter the hospital's allowable adjusted base year inpatient capital costs per discharge.  This field is not used as of 10/1/02.  45 192-197  9(4)V9(2)   Old Capital Hold Harmless Rate   Enter the hospital's allowable inpatient "old" capital costs per discharge incurred for assets acquired before December 31, 1990, for capital PPS.  Update annually.  46 198-202  9V9(4)   New Capital -Hold Harmless Ratio