(Medicare Claims Processing Manual)

a. For cost reporting periods beginning on or after May 1, 2010, under cost report 2552- 10, the Medicare contractor shall record the original outlier amount from Worksheet E -3, Part III, line 4, the outlier reconciliation adjustment amount ( the difference between the original outlier amount (value code 17)  and the revised outlier amount (value code 17) calculated by the Lump Sum Utility), the total time value of money and the rate used to calculate the time value of money on lines 50-53, of Worksheet E-3, Part III of the cost report ( NOTE : the amounts recorded on lines 50, 51 and 53 can be positive or negative amounts per the instructions above). The total outlier reconciliation amount ( the difference between the original outlier amount (value code 17) and the revised outlier amount (value code 17) calculated by the Lump Sum Utility plus the time value of money ) shall be recorded on line 30 of Worksheet E-3, Part 3.   16) The Medicare contractor shall finalize the cost report, issue a NPR and make the necessary adjustment from or to the provider.  17) After determining the total outlier reconciliation amount and issuing a NPR, Medicare contractors shall restore the CCR(s) to their original values (that is, the CCR(s) used to pay the claims) in the applicable provider records in the PSF to ensure an accu rate history is maintained. Specifically, for hospitals paid under the IRF PPS, Medicare contractors shall enter the original CCR(s) in PSF field 25 -Operating Cost to Charge Ratio.  Medicare contractors shall contact the CMS Central Office via the mailing address or email address provided in 140.2.6 (F) with any questions regarding this process.  Table 1:  Data Elements for FISS Extract   List of Data Elements for FISS Extract  Provider #  Health Insurance Claim (HIC) Number  Document Control Number (DCN)  Type of Bill  Original Paid Date  Statement From Date  Statement To Date  Original Reimbursement Amount (claims page 10)  Revised Reimbursement Amount (claim page 10)  Difference between these amounts  Original Deductible Amount, Payer A, B, C (Value Code A1, B1, C1)  Revised Deductible Amount, Payer A, B, C (Value Code A1, B1, C1)  Difference between these amounts  Original Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2)  Revised Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2)  Difference between these amounts  Original Outlier Amount (Value Code 17)  Revised Outlier Amount (Value Code 17)  Difference between these amounts  Original DSH Amount (Value Code 18)  List of Data Elements for FISS Extract  Revised DSH Amount (Value Code 18)  Difference between these amounts  Original IME Amount (Value Code 19)  Revised IME Amount (Value Code 19)  Difference between these amounts  Original New Tech Add -on (Value Code 77)  Revised New Tech Add -on (Value Code 77)  Difference between these amounts  Original Device Reductions (Value Code D4)  Revised Device Reductions (Value Code D4)  Difference between these amounts  Original Hospital Portion (claim page 14)  Revised Hospital Portion (claim page 14)  Difference between these amounts  Original Federal Portion  (claim page 14)  Revised Federal Portion  (claim page 14)  Difference between these amounts  Original C TOT PAY (claim page 14)  Revised C TOT PAY (claim page 14)  Difference between these amounts  Original C FSP (claim page 14)  Revised C FSP (claim page 14)  Difference between these amounts  Original C OUTLIER (claim page 14)  Revised C OUTLIER (claim page 14)  Difference between these amounts  Original C DSH ADJ (claim page 14)  Revised C DSH ADJ (claim page 14)  Difference between these amounts  Original C IME ADJ (claim page 14)  Revised C IME ADJ (claim page 14)  Difference between these amounts  Original Pricer Amount  Revised Pricer Amount  Difference between these amounts  Original PPS Payment (claim page 14)  Revised PPS Payment (claim page 14)  Difference between these amounts  Original PPS Return Code (claim page 14)  Revised PPS Return Code (claim page 14)  DRG  MSP Indicator (Value Codes 12 -16 & 41 -43 - indicator indicating the claim is MSP; Y = MSP, blank = no MSP  Reason Code  List of Data Elements for FISS Extract  HMO -IME Indicator  Filler   140.2.11 - Quality Reporting Program  (Rev. 3039, Issued: 08- 22-14, Effective: 10-01-14, Implementation: 10-06-14)  Section 1886 (j)(7)(A)(i) of the Act requires application of a 2% reduction of the applicable market basket increase factor for IRFs that fail to comply with the quality data submission requirements.  FY 2014 is to be the first year that the mandated reduction will be applied for IRFs that failed to comply with the data submission requirements during the data collection period October 1, 2012 through December 31, 2012.  Thus, in compliance with 1886(j)(7)(A)(i) of the Act, we will apply a 2 percentage point reduction to the applicable FY 2014 market basket increase factor in calculating an adjusted FY 2014 standard payment conversion factor to apply to payments for only those IRFs that failed to comply with the data submission requirements.  Application of the 2% reduction may result in an update that is less than 0.0 for a fiscal year and in payment rates for a fiscal year being less than such payment rates for the preceding fiscal year.  Also, reporting-based reductions to the market basket increase factor will not be cumulative; they will only apply for the FY involved.   The adjusted FY 2014 standard payment conversion factor that will be used to compute IRF PPS payment rates for any IRF that failed to meet the quality reporting requirements for the period from October 1, 2012 through December 2012 will be $14,555.  After the reconsideration process has occurred and prior to October 1 of each FY, CMS will provide the Medicare contractors with a final list of IRFs that failed to comply with the data submission requirements.  The Medicare contractors will then be responsible for notifying each IRF that failed to comply with the quality data submission requirements that it will receive a 2% reduction in payment.  Additionally, the Medicare contractors shall include information regarding the IRFs right to further appeal the 2% reduction via the Provider Reimbursement Review Board (PRRB) appeals process.  Contractors shall send this second letter only to IRFs that requested a reconsideration.  Medicare contractors shall include the model language at the end of this section i n their notification letter to the IRFs.   The Medicare contractor shall update (or not update) the IRFs provider file based on the appropriate scenario listed below:   If the IRF was notified that it was potentially subject to the 2% reduction, and did not request a reconsideration, then the Medicare contractor shall set a quality reporting indicator in the provider file that triggers Medicare systems to calculate the 2% reduction on all of the IRFs claims for the upcoming fiscal year.   If the IRF was notified that it was potentially subject to the 2% reduction, and requested a reconsideration, but on reconsideration CMS upheld the decision to apply the 2% reduction, then the Medicare contractor shall set a quality reporting indicator in the provider file that triggers Medicare systems to calculate the 2% reduction on all of the IRFs claims for the upcoming fiscal year.    If the IRF was notified that it was potentially subject to the 2% reduction, and requested a reconsideration, and on reconsideration CMS determined that the IRF should not be subject to the 2% reduction (i.e., reversed its decision), then the Medicare cont ractor shall not update the quality reporting indicator in the IRFs provider file and shall notify the IRF that they will receive their full IRF PPS payment update for the upcoming fiscal year.    If the IRF submitted the necessary IRF Quality Reporting data and was never notified that it might potentially be subject to the 2% reduction, then the Medicare contractor shall take no action regarding the quality reporting indicator in the IRFs provider  file.  Below are the Quality Annual Rate Updates for the applicable Fiscal Years (FYs):   FY data collection from  data collection through  adjusted standard payment conversion factor  FY 2014  10/01/2012  12/31/2012  $14,555  FY 2015  01/01/2013  12/31/2013  $14,901   140.3 - Billing Requirements Under IRF PPS  (Rev. 11140, Issued:12- 02-21, Effective:01 -04-22, Implementation: 01- 04-22)  IRF PPS payment is contingent on the requirement that IRFs complete a patient assessment upon admission and discharge for Medicare patients.  The August 7, 2001, Final Rule, and subsequent final rules contain detailed information regarding the assessment schedule for the patient assessment instrument (PAI) with respect to transmission requirements, encoding dates, and other pertinent information.  Further, there is an item- by-item guide, which specifies detailed instructions regarding the manner in which ea ch item on the assessment instrument needs to be completed.   Effective with cost reporting periods beginning on or after January 1, 2002, IRFs are required to report billing data with a new revenue code and a Health Insurance PPS (HIPPS) Rate Code on the ASC X12 837 institutional claim or, in rare cases, on the Form  CMS -1450 for all Part A inpatient claims (Type of Bill 11X) to their A/B MACs (A).  The new revenue code, 0024, is used in conjunction with the HIPPS Rate Code to identify the CMG payment classification for the beneficiary.  In addition to all entries pre viously required on a Part A claim, the following additional instructions must be followed to accurately price and pay a claim under the IRF PPS.  These claims must be submitted on Type of Bill 11X.  The last four digits of the provider number for rehabili tation hospitals is from 3025 to 3099, and for rehabilitation distinct part units the third digit will be a T if the unit is located in an acute care hospital or an R if the unit is located in a CAH.   The Revenue code must contain revenue code 0024.  This code indicates that this claim is being paid under the PPS.  This revenue code can appear on a claim only once.    The following Patient Discharge Status codes are applicable under the transfer policy for IRF PPS: 02, 03, 61, 62, 63, and 64.  NOTE :  IRFs that transfer a beneficiary to a nursing home that accepts payment under Medicare and/or Medicaid should use PS 03, discharged/transferred to a SNF.  IRFs that transfer a beneficiary to a nursing facility that does not accept Medicare or Medicaid, should code PS 04, discharged/transferred to an ICF, until such time that a new PS code is established to differentiate between nursing facilities that do not accept Medicare and/or Medicaid and those that do.  PS 04 does not constitute a transfer unde r the IRF PPS policy.