(Medicare Claims Processing Manual)

Applicable Fiscal Year  Budget Neutrality Adjustment Factors  1993  0.999851  1994  0.999003  1995  0.998050  1996  0.999306  1997  0.998703  1998  0.997731  1999  0.998978  2000  0.997808  2001  0.997174  Applicable Fiscal Year  Budget Neutrality Adjustment Factors  2002  0.995821  2003  0.993111  2004  1.002608  2005  0.999876  2006  0.998993  2007  0.997395  2008  0.995743  2009  0.998795  2010  0.997941   D. - Claims Processing   The Qualifying DSH Percent uses the following provider type codes to enable Pricer to calculate the appropriate rates for these facilities:    14 for a MDH that is not an RRC;    15 for a MDH that is also an RRC;    16 for a rebased SCH that is not an RRC; and    17 for a rebased SCH that is also an RRC.   The A/B MAC (A) calculates the HSP rate and determines the greatest HSP rate (for SCHs, FY 1982, 1987, 1996 or 2006; for MDHs, FY 1982, 1987 or 2002).  Then the A/B MAC (A) updates the HSP rate to the applicable FY and enters that amount in the PPS Facility Specific Rate of the Provider -Specific File (PSF), for the applicable effective date.  The HSP rate is to be entered even if the Federal rate is expected to result in higher payments than the applicable HSP rate.  Preloading the applicable HSP rate befor e the effective date is acceptable as long as the correct effective date is used for the PSF record.  The A/B MAC (A) leaves the field blank if the hospital was not in operation during any of the applicable HSP base years.   Pricer will calculate the payment based on the higher of the Federal rate or the HSP rate.  Where the HSP rate is higher, Pricer reports the amount of the difference in the hospital -specific field.  The A/B MAC (A) carries this amount forward in the hospit al-specific payment field to its PS&R record for use at cost settlement.   20.7 - Billing Applicable to PPS  (Rev. 1, 10- 01-03)  20.7.1- Stays Prior to and Discharge After IPPS Implementation Date  (Rev. 1, 10- 01-03)  A3-3610.4, HO -415.7  When the admission is before the hospital's PPS effective date and the discharge is later than that date (transition claims), the Medicare payment for the period before PPS is on a reasonable cost basis and the payment for the period after PPS is on a DRG basis.  The hospital must submit two bills.  The first bill is for the period before the PPS effective date and is processed and paid in accordance with requirements in effect before the hospital's PPS effective date.  The second bill is processed under PPS but the amount of payment on the first bill is subtracted from it.  A/B MACs (A) make the adjustment by subtracting the interim payment from the prospective payment (before any deduction for deductible or coinsurance) for  the inpatient operating costs applicable to the days in the prior period.  The interim payment applicable to the prior period is adjusted to exclude estimated costs related to capital and direct medical education, kidney acquisition costs, and for bad debts for uncollectible deductible and coinsurance.  A/B MACs (A) will make an estimate if necessary.   For hospitals previously receiving interim payment on the basis of an average cost per diem or under PIP, the A/B MAC (A) determines and removes a per diem amount for the excluded costs for that period from the interim payments before reducing the prospect ive payment amount applicable to the discharge in the subsequent period under PPS.  Similarly, for hospitals that received a percentage of billed charges, the portion of the percentage applicable to the excluded cost items is removed.  The net percentage t o the charges billed in the prior period (cut -off bill) is applied.  The resulting amount is subtracted from the PPS payment applicable to the discharge in the subsequent period.   For transition claims, payment must not exceed the higher of what would have been paid under PPS including the outlier adjustment or  any earlier cost payment.  The final amount is not reduced to less than zero.  No further adjustments are appropriate.   The interim payments used to reduce the prospective payment amounts are considered to represent fairly the inpatient operating costs incurred and fair payment for the portion of the stay occurring in the prior period.  Therefore, the adjustment is final an d not subject to further modification.  On bills covering two cost reporting periods:    Each bill includes charges and covered days that apply to the period covered.  The cut -off bill for the cost period is completed per Chapter 25.    The PPS bill contains principal diagnosis and surgical procedures for the entire stay.    The PPS bill shows the admission date, but the period covered begins with the first day of the new accounting year.    Where discharge is on the first day of the new accounting year, a PPS bill is still due.  Some payment may be due the provider, and the open admission must be closed on CMS' records.  There are no accommodation charges on the day of discharge; the hospital  will report ancillary charges for the day of discharge on the prior bill.    Coinsurance days and related amounts are applied separately to each bill, i.e., the proper deduction for coinsurance days reported on the second bill is taken from that bill.  20.7.2 - Split Bills (Rev. 1, 10- 01-03)  A3-3610.6, HO -415.9  Under PPS, split billing is not needed for cost reporting purposes; however, it is necessary to show on the bill the coinsurance days in each calendar year for proper application of the coinsurance amount.  For admissions prior to the cost reporting year under IPPS with a discharge after the beginning of the prospective payment year, the DRG payment for the discharge is reduced by the cost of services furnished in the prior period.   The hospital uses the day or charge statistics on the bill representing the portion of the stay in the prior period to determine the cost of the services furnished.  Split bills are not needed at the end of the government's fiscal year or the calendar year  as changes in DRG prices are determined by the date of discharge.  This is shown in value codes 09 (first year coinsurance) and 11 (second year coinsurance).  (See Chapter 25.)   PPS days on the cost report are allocated to the year of the discharge.  Hospitals not on IPPS, LTCHPPS, or IRFPPS continue to submit split bills at the end of their fiscal years and allocate the days to the hospital year in which they occurred.   When split billing applies, DRG payments are made only on bills that show a discharge date and status.  No DRG payment is made on PPS bills that show "still patient" status.   The hospital may not split a bill for the periods before and after the onset of capital PPS that fall into the same billing period.  Capital payment issued for an inpatient hospital stay that begins prior to and ends after the onset of capital PPS is the amount determined by Pricer for that DRG.  No reasonable cost capital pass through payment is payable for the portion of the stay that pre -dates capital PPS.   20.7.3 - Payment for Blood Clotting Factor Administered to Hemophilia Inpatients  (Rev. 3481, Issued: 03- 18-16. Effective: 06 -20-16, Implementation: 06- 20-16)  Section 6011 of Public Law (P.L.) 101- 239 amended 1886(a)(4)  of the Social Security Act (the Act) to provide that prospective payment system (PPS) hospitals receive an additional payment for the costs of administering blood clotting factor to Medicare hemophiliacs who are hospital inpatients.  Section 6011(b) of P.L. 101.239 specified that the payment be based on a predetermined price per unit of clotting factor multiplied by the number of units provided.  This add- on payment originally was effective for blood clotting factors furnished on or after June 19, 1990, and before December 19, 1991.  Section 13505 of P. L. 103- 66 amended 6011 (d) of P.L. 101- 239 to extend the period covered by the add- on payment for blood clotting factors administered to Medicare inpatients with hemophilia through September 30, 1994.  Sect ion 4452 of P.L. 105- 33 amended 6011(d) of P.L. 101- 239 to reinstate the add -on payment for the costs of administering blood- clotting factor to Medicare beneficiaries who have hemophilia and who are hospital inpatients for discharges occurring on or after  October 1, 1998.   A/B MACs (B) shall process non- institutional blood clotting factor claims.   The A/B MACs (A) shall process institutional blood clotting factor claims payable under either Part A or Part B.  A. - Inpatient Bills   Under the Inpatient Prospective Payment System (IPPS), hospitals receive a special add -on payment for the costs of furnishing blood clotting factors to Medicare beneficiaries with hemophilia, admitted as inpatients of PPS hospitals. The clotting factor add- on payment is calculated using the number of units (as defined in the HCPCS code long des criptor) billed by the provider under special instructions for units of service.   The PPS Pricer software does not calculate the payment amount. The Fiscal Intermediary Shared System (FISS) calculates the payment amount and subtracts the charges from those submitted to Pricer so that the clotting factor charges are not included in cost outlier computations.  Blood clotting factors not paid on a cost or PPS basis are priced as a drug/biological under the Medicare Part B Drug Pricing File effective for the specific date of service.  As of January 1, 2005, the average sales price (ASP) plus 6 percent shall be use d.  If a beneficiary is in a covered Part A stay in a PPS hospital, the clotting factors are paid in addition to the DRG/HIPPS payment (For FY 2004, this payment is based on 95 percent of average wholesale price.) For a SNF subject to SNF/PPS, the payment is bundled into the SNF/PPS rate.  For SNF inpatient Part A, there is no add- on payment for blood clotting factors.  The codes for blood- clotting factors are found on the Medicare Part B Drug Pricing File.  This file is distributed on a quarterly basis.  For discharges occurring on or after October 1, 2000, and before December 31, 2005, report HCPCS Q0187 based on 1 billing unit per 1.2 mg.  Effective January 1, 2006, HCPCS code J7189 replaces Q0187 and is defined as 1 billing unit per 1 microgram (mcg).   The examples below include the HCPCS code and indicate the dosage amount specified in the descriptor of that code. Facilities use the units field as a multiplier to arrive at the dosage amount.   EXAMPLE 1   HCPCS  Drug  Dosage  J7189  Factor VIIa  1 mcg   Actual dosage: 13,365 mcg  On the bill, the facility shows J7189 and 13,365 in the units field (13,365 mcg divided by 1 mcg = 13,365 units).  NOTE:   The process for dealing with one international unit (IU) is the same as the process of dealing with one microgram.   EXAMPLE 2   HCPCS  Drug  Dosage  J9355  Trastuzumab  10 mg   Actual dosage: 140 mg   On the bill, the facility shows J9355 and 14 in the units field (140 mg divided by 10mg = 14 units).  When the dosage amount is greater than the amount indicated for the HCPCS code, the facility rounds up to determine units. When the dosage amount is less than the amount indicated for the HCPCS code, use 1 as the unit of measure.   EXAMPLE 3   HCPCS  Drug  Dosage  J3100  Tenecteplase  50 mg   Actual Dosage: 40 mg  The provider would bill for 1 unit, even though less than 1 full unit was furnished.