(Medicare Claims Processing Manual)

When IRF -PAI Assessments Cannot Be Submitted Within 24 Months   A Medicare beneficiary's entitlement date may sometimes be approved or changed retroactively.  Frequently, these cases result in services becoming covered for dates of service that are beyond the Medicare timely filing limit.  Retroactive entitlement is an established exception to the timely filing pe riod, so these claims may be submitted for payment (see Pub. 100-04, chapter 1, section 70.7.2).  iQIES accepts assessments for up to 24 months from the assessment date.  In rare cases, a retroactive entitlement decision may extend back beyond this 24 month period.  Each assessment that cannot be submitted to iQIES because of the 24 month limit will correspond to a Medicare claim for that IRF discharge.    To process the claims for these older dates of service, IRFs should contact their MAC to alert them to the situation and request any special instructions for the timing and coding of the claims.  In addition to any other special instructions, the IRF shall  submit the claims with a note in the Remarks field saying "IRF -PAI over 24 months."   Upon receipt of the claims, the MAC shall take the following actions:    When the untimely claims are suspended to check for exception requests, confirm the dates of service are over 24 months from the occurrence code 50 date on the claim.   Temporarily turn off the edit that triggers the iQIES finder file, process the affected claims without sending them to iQIES, then turn the edit back on.   Process the IRF claim using the provider -submitted HIPPS code for payment calculations.    140.3.2 - IRF PPS Pricer Software  (Rev. 693, Issued: 09- 30-05, Effective: 10 -01-05, Implementation: 10- 31-05)  The CMS has developed an IRF Pricer Program that calculates the Medicare payment rate.  Pricer will use a variety of inputs listed below to calculate the payment rate.   A.  Inputs to Pricer    Provider Specific File data (see section 20.2.3.1 and Addendum of this chapter for required elements)    Bill Data includes:    Patient Status:    Payment Modification Flag (if condition code is 66, set flag "Y" otherwise use "N.");   Covered Charges;    Discharge Date;    HIPPS/CMG Rate Code;    Length of Stay (LOS);    Covered Days;    Lifetime Reserve Days (LTR)   B.  Data Returned From Pricer   Pricer returns the following information:    PPS Return Code    MSA /CBSA (effective October 1, 2005)    Wage Index    Average LOS    Relative Weight    Total Payment Amount    PPS Federal Payment Amount    Facility Specific Payment Amount   Outlier Payment Amount    Low-Income Payment (LIP) Amount    Teaching Amount (effective October 1, 2005)    LOS    Regular Days Used    LTR Days Used    Transfer Percentage    Facility Specific Rate pre -blend   Standard Payment Amount    PPS federal amount pre -blend   Facility costs    Outlier threshold    Submitted HIPPS/CMG code    PPS Pricer CMG code    Calculation version code   The Pricer is available electronically to the Shared Systems.   140.3.3 - Remittance Advices  (Rev. 3481, Issued: 03- 18-16. Effective: 06 -20-16, Implementation: 06- 20-16)   A remittance advice remark code is used to notify an IRF when the CMG code was changed.   The following reflects the remittance advice messages and associated codes that will appear when communicating claims under this policy.  The CARC below is not included in the CAQH CORE Business Scenarios.   Group Code: N/A  CARC: N/A  RARC: Alert N69  MSN: N/A  150 - Long Term Care Hospitals (LTCHs) PPS  (Rev. 1, 10- 01-03) PM A -02-093  150.1 - Background  (Rev. 1, 10- 01-03)  LTCHs are certified under Medicare as short -term acutecare hospitals that have been excluded from the acute care hospital inpatient prospective payment system (PPS) under 1886(d)(1)(B)(iv)  of the Act and, for   Medicare payment purposes, are generally defined as having an average inpatient length of stay of greater than 25 days.  This PPS replaced the previous reasonable cost -based payment system for LTCHs.  150.2 - Statutory Requirements  (Rev. 1, 10- 01-03)  The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (BBRA), as amended by the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), required that a budget neutral, per discharge PPS for LTCHs based on diagnosis -related groups (DRGs) be implemented for cost reporting periods beginning on or after October 1, 2002.  The CMS satisfied the statutory implementation requirement by establishing October 1, 2002 as the effective date of the LTCH PPS with systems changes to follow.  Payments for LTCH services furnished for cost reporting periods beginning on or after October 1, 2002 are based on the policies set forth in the August 30, 2002 final rule (67 FR 55954).   150.3 - Affected Medicare Providers  (Rev. 11396, Issued:05- 04-22, Effective:10 -01-22, Implementation:10- 03-22)  LTCHs are certified under Medicare as short -term acute care hospitals and, for Medicare payment purposes, are generally defined as having an average inpatient length of stay of greater than 25 days.   Veterans Administration Hospitals, hospitals that are reimbursed under state cost control systems approved under 42 CFR Part 403, and hospitals that are reimbursed in accordance with demonstration projects authorized under 402(a) of Public Law 90- 248 (42 U.S.C.  1395b- 1) or 222(a) of Public Law 92- 603 (42 U.S.C. 1395b- 1) are not included in the LTCH PPS.  (See 42 CFR 412.22(c).)   Payment to foreign hospitals will be made in accordance with the provisions set forth in 42 CFR 413.74.  Currently, two of the four Maryland LTCHs included on CMS Certification Number (CCN) database are presently paid in accordance with demonstration projects (i.e., the Maryland "Waiver") and therefore not subject to payments under the LTCH PPS:  Levindal e Hebrew Geriatric Center and Deaton Hospital and Medical Center (now known as University Specialty Hospital).   150.4 - Revision of the Qualification Criterion for LTCHs  (Rev. 208, 06- 18-04)  Under the LTCH PPS, the greater than 25- day average length of stay (ALOS) calculation is based only on a hospital's Medicare inpatients, counting total medically necessary days, not only covered days.  For cost reporting periods beginning on or after October 1, 2002, LTCHs are required to meet this revised criteria in order to qualify as LTCHs for Medicare payment purposes.   The average Medicare length of stay is calculated by dividing the total number of covered and noncovered days of care provided to Medicare patients, by the Medicare discharges occurring during that period.  If the days of a stay involve days of care furnis hed during two or more separate cost reporting periods, that is, an admission during one cost reporting period and a discharge during a future cost reporting period, the total number of days of the stay are considered to have occurred during the cost repor ting period during which the patient was discharged.  For cost reporting periods beginning on or after July 1, 2004, if a hospital fails to meet the ALOS requirement under this provision, the A/B MAC (A) will determine the ALOS for cost reporting periods beginning on or after July 1, 2004 but before July 1, 2005 by dividing the applicable total days for Medicare inpatients during the cost reporting period when they occur, by the number of discharges occurring during the same cost reporting period.  If the A/B MAC (A) determines that the LTCH does not qualify, A/B MACs (A) are to follow the procedures already established in the Medicare General Information, Eligibility, and Entitlement Manual (CMS Pub. 100-01).  The new manual can be found at http://www.cms.gov/Regulations- and-Guidance/Guidance/Manuals/index.html?redirect=/manuals/cmsindex.asp .  Select Internet-Only Manuals (IOM) from the left side of the page, then select 100-01.  The CMS requires on-going monitoring of LTCH compliance with the above requirements as well as notification by A/B MACs (A) regarding this compliance.  150.5 - Payment Provisions Under LTCH PPS  (Rev. 1, 10-01-03)  Section 123 of Public Law 106-113(BBRA), as amended by 307 of Public Law 106-554(BIPA), authorizes the establishment of Federal payment rates under PPS for LTCHs.  The BIPA confers broad authority on the Secretary to determine what payment system adjustme nts should be included in the LTCH PPS, both on a facility level and on a case-level, to ensure that payment most accurately reflects cost.   The CMS has established a transition to full payments under the LTCH PPS:  a 5- year phase-in during which a decreasing percentage of payments will based upon what payments would have been under the reasonable cost-based system.  LTCHs may also elect to receiv e payment based on 100 percent of the "Federal payment rate."  New LTCHs are to be paid based fully on 100 percent of the Federal rate (i.e. hospitals for which the first cost reporting period as an LTCH began on or after October 1, 2002). (See 150.10.1.)  150.5.1 - Budget Neutrality  (Rev. 1, 10-01-03)  The BBRA requires that total payments under the PPS must equal the amount that would have been paid if the PPS had not been implemented.  150.5.2 - Budget Neutrality Offset  (Rev. 3445, Issued: 01- 29-16, Effective: 01-01-16, Implementation: 04-04-16)  A reduction factor to all Medicare payments during the transition to account for the monetary effect of the 5 -year transition from the present cost-based payment system and the LTCH PPS, and the policy to permit LTCHs to elect payment solely under the PPS rather than based on the blend during the transition.  (See 150.10.1.)  If a LTCH is paid under the transition blend methodology, the budget neutrality offset will be applied to both the TEFRA Rate Percentage and the Federal Rate percentage.   The budget neutrality offset equals 1 minus the ratio of the estimated TEFRA reasonable cost-based payments that would have been made had the LTCH PPS not been implemented to the projected total Medicare program payments that would be made under the transi tion methodology and the option to elect payment based on the 100 percent of the Federal rate.   The per discharge Federal rates under the PPS are based on average LTCH costs in a base year updated for inflation to the first effective period of the system.  Fiscal year changes to the LTCH PPS system occur annually in October.  Specific instructions will be published shortly after the publication of the LTCH Final Rule each year.  In addition, other changes to the inpatient prospective payment system may occur  in January, April or July as necessary.   150.6 - Beneficiary Liability  (Rev. 1, 10- 01-03)  Beneficiary liability will operate the same as under the former TEFRA cost- based payment system, i.e., if Medicare payments are below the cost of care for a patient under prospective payment, the patient cannot be billed for the difference.   As under the former TEFRA cost -based payment system, beneficiaries (or their Medigap insurers or other private insurers, such as an employer -sponsored plan, as applicable) are responsible for all noncovered days, where Medicare has not made a full LTC -DRG payment.  For more detailed information regarding lifetime reserve days, refer to the Medicare Benefit Policy Manual, chapter 5.   150.7 - Patient Classification System  (Rev. 3030, Issued: 08- 22-14, Effective: ASC X12: January 1, 2012, ICD -10: Upon Implementation of ICD -10, Implementation: ICD -10: Upon Implementation of ICD -10, ASC X12: September, 23 2014)