(Medicare Claims Processing Manual)

The data is used for settlement purposes for hospitals.   Note that CMS issues a Recurring Update Notification prior to the Federal Fiscal Year beginning date to provide contractors with the updated SSI file information.  A. - Regular Calculation of DSH Percentage   The operating DSH percentage is the sum of:   The percentage of the hospital's total Medicare Part A patient days attributable to Medicare patients who are also SSI recipients (this percentage will be supplied to the A/B MAC (A) by CMS).  Since the SSI/Medicare percentages are determined by CMS on a fiscal year basis, hospitals will be afforded the option (for settlement purposes) of determining their SSI/Medicare percentage based upon data from their own cost reporting period.  I f a hospital avails itself of this option, it must furnish its FI, in a manner and format prescribed by CMS, data on its Medicare patients for the cost reporting period.  CMS will match these data to data supplied by SSA to determine the patients dually entitled to Medicare Part A and SSI for the hospital's cost reporting period.  The hospital bears the full cost of this process, including the cost of verification by SSA.  Consistent with the regulations at 42 CFR 412.106(b)(2)(i) and 412.106(b)(2)(iii), patients who are enrolled in Medicare Advantage (administered through Medicare Part C) should also be included in the Medicare fraction. These days will be included in the Medicare/SSI fraction, but in order for them to be counted, the hospital must submit an informational only bill (TOB 111) which includes Condition Code 04 to their Medicare contractor.  This will ensure that these days are included in the hospitals SSI rat io for Fiscal Year 2007 and beyond.  Acute Care hospitals that received DSH during FY 2006 are also required to submit informational only bills for their Medicare Advantage patients.   For MA patients, Long Term Care Hospitals are also required to submit informational only bills (TOB 111) with Condition Code 04.   For MA patients, Inpatient Rehabilitation Facilities are also required to submit informational only bills (TOB 111) with both Condition Code 04 and the Case Mix Group (CMG) from the IRF PAI. Refer to section 140.2.4.3 for the requirements for Inpatient Rehabilitation Facilities.   (Teaching hospitals do not need to submit additional claims with Condition Code 04 as they already submit claims for Indirect Medical Education for MA beneficiaries with Condition Codes 04 and 69.  We will capture SSI information from these claims.)    The percentage of total patient days attributable to patients entitled to Medicaid, but not to Medicare Part A.  (Medicaid days and total days are available on the cost report.)   For operating DSH payments:   For discharges between May 1, 1986, and March 31, 1990, a hospital qualifies for an operating cost DSH adjustment if it has a DSH percentage of:    At least 15 percent for an urban hospital with 100 or more beds;    At least 40 percent for an urban hospital with less than 100 beds; or    At least 45 percent for a rural hospital, with fewer than 500 beds.   For discharges on and after October 1, 1986, the hospital qualifies for an operating cost DSH adjustment if it has a DSH percentage of at least 15 percent, is located in a rural area, and has 500 or more beds.   For discharges between April 1, 1990 and December 31, 1995, a hospital qualifies for an operating DSH adjustment if it has a DSH percentage of:    At least 15 percent for an urban hospital with 100 or more beds, or a rural hospital with 500 or more beds;    At least 40 percent for an urban hospital with fewer than 100 beds;    At least 45 percent for a rural hospital with 100 beds or fewer, if it is not also classified as a sole community hospital; or    At least 30 percent for a rural hospital with more than 100 beds which is classified as a sole community hospital.   A hospital qualifies for a capital DSH adjustment if it is located in a large urban or other urban area, has at least 100 beds, and has a DSH percentage greater than 0.  For the DSH determination, the number of beds in a hospital is determined by counting the number of inpatient care bed days available during the cost reporting period, excluding beds assigned to newborns, custodial care, and PPS excluded distinct part hospital units, and dividing that number by the number of days in the cost reporting period.  Inpatient care bed days available should be the same as Indirect Medical Education (IME) bed days.  Available beds may not match the number of licensed beds.   B. - Determination of Operating DSH Adjustment Percentage   Hospitals that meet the DSH percentage criteria are entitled to adjustments to the Federal portion of their operating cost DRG payments (including the Federal portion of outlier payments) as follows.  For hospitals that qualify for DSH payment, Pricer calc ulates the DSH adjustment percentage.  (See 20.2.3.)  The following procedures are used to calculate the DSH adjustment.  For the period May 1, 1986 -  September 30, 1988:   Urban hospitals with 100 or more beds and rural hospitals with 500 or more beds  - The lesser of 15 percent or the percentage determined by using the following formula:   (DSH % -  15)(.5) + 2.5   EXAMPLES:   Hospital A is an urban hospital with 200 beds and has a DSH percentage of 21.  Its DSH payment factor is computed:   (21 -  15)(.5) + 2.5 = 5.5%   DSH adjustment factor = 5.5% (.0550)   Hospital B is an urban hospital with 250 beds and has a DSH percentage of 45.  Its DSH payment adjustment factor is computed:   (45 -  15)(.5) + 2.5 = 17.5%   DSH adjustment factor = 15% (.1500) (the maximum adjustment under the law)    Urban hospitals with fewer than 100 beds  - 5 percent.    Rural hospitals with fewer than 500 beds  - 4 percent.   For the period October 1, 1988 -  March 31, 1990:    Urban hospitals with 100 or more beds and rural hospitals with 500 or more beds  - the following formula is used:   (DSH % -  15) (.5) + 2.5   EXAMPLES:   Hospital A is an urban hospital with 200 beds and has a DSH percentage of 21 percent.  Its DSH payment factor is computed:   (21-15)(.5) + 2.5 = 5.5%   DSH adjustment factor = 5.5% (.0550)   Hospital B is an urban hospital with 250 beds and has a DSH percentage of 45 percent.  Its DSH payment adjustment factor is computed:   (45-15) (.5) + 2.5 = 17.5%   DSH adjustment factor = 17.5% (.1750, the limit was removed effective 10/1/88)    Urban hospitals with fewer than 100 beds  - 5 percent.    Rural hospitals with fewer than 500 beds  - 4 percent.   For the period April 1, 1990 -  December 31, 1995:    Urban hospitals with 100 or more beds and rural hospitals with 500 or more beds whose DSH percentage is greater than 20.2   - the following formula is used:   Through December 31, 1990 -  (DSH % -  20.2) (.65) + 5.62   January 1, 1991, and later -  (DSH % - 20.2) (.7) + 5.62  EXAMPLES:   Hospital A is an urban hospital with 200 beds and has a DSH percentage of 21 percent.  Its December 1990 DSH payment factor is computed:   (21 -  20.2) (.65) + 5.62 = 6.14%   DSH adjustment factor = 6.14% (.0614)   Hospital B is an urban hospital with 250 beds and has a DSH percentage of 45 percent.  Its December 1990 DSH payment adjustment factor is computed:   (45 -  20.2) (.65) + 5.62% = 21.74%   DSH adjustment factor = 21.74% (.2174)   Urban hospitals with 100 or more beds and rural hospitals with 500 or more beds whose DSH percentage is equal to or less than 20.2 -  the following formula is used:   (DSH % -  15) (.6) + 2.5    Urban hospitals with fewer than 100 beds  - 5 percent.    Rural hospitals that are RRCs and sole community hospitals  - the greater of 10 percent or the percentage determined using the following formula:   (DSH % -  30) (.6) + 4.0   EXAMPLES:   Hospital C is a rural hospital that is an RRC and a sole community hospital, and has a DSH percentage of 35 percent.  Its DSH payment factor is computed:   (35 -  30) (.6) + 4.0 = 7%   DSH adjustment factor = 10% (.1000)   Hospital D is a rural hospital which is a RRC and a sole community hospital.  It has a DSH percentage of 45 percent.  Its DSH payment factor is computed:   (45 -  30) (.6) + 4.0 = 13%   DSH adjustment factor is 13% (.1300)    Rural hospitals that are RRCs, but are not sole community hospitals -the following formula is used:   (DSH % -  30) (.6) + 4.0    Rural hospitals that are sole community hospitals, but are not RRCs -  10 percent.    Rural hospitals not described above with 100 beds or less  - 4 percent if DSH percentage is 45 percent or more.    Rural hospitals not described above with more than 100 beds but fewer than 500 beds  - 4 percent if DSH percentage is 30 percent or more.    Urban hospitals with 100 or more beds whose DSH percentage is less than or equal to 20.2 -  the following formula is used:   (DSH % -  15) (.6) + 2.5   For the period October 1, 1993, through September 30, 1994:    Urban hospitals with 100 or more beds whose DSH percentage is greater than 20.2- the following formula is used:   (DSH % -  20.2) (.8) + 5.88   Urban hospitals with 100 or more beds whose DSH percentage is less than or equal to 20.2 -  the following formula is used:   (DSH % -  15) (.6) + 2.5   Rural hospitals that are RRCs and sole community hospitals -  the greater of 10 percent or the percentage determined using the following formula:   (DSH % -  30) (.6) + 4.0    EXAMPLES:   Hospital C is a rural hospital that is a RRC and a sole community hospital.  It has a DSH percentage of 35 percent.  The DSH payment factor is computed:   (35 -  30) (.6) + 4.0 = 7%   DSH adjustment factor = 10% (.1000), the greater payment   Hospital D is a rural hospital that is a RRC and a sole community hospital.  It has a DSH percentage of 45 percent.  Its DSH payment factor is computed:   (45 -  30) (.6) + 4.0 = 13%   DSH adjustment factor = 13% (.1300)   Rural hospitals that are RRCs and are not sole community hospitals  - the percentage is determined using the following formula:   (DSH % -  30) (.6) + 4.0    Rural hospitals that are sole community hospitals and are not RRCs  - 10 percent.    Rural hospitals not described above  - 4 percent.   For discharges after September 30, 1994:    Urban hospitals with 100 or more beds and rural hospitals with 500 or more beds whose DSH percentage is greater than 20.2  - the percentage is determined using the following formula:   (DSH % -  20.2) (.825) + 5.88   Urban hospitals with 100 or more beds whose DSH percentage is less than or equal to 20.2 -  the following formula is used:   (DSH % -  15) (.65) + 2.5