(Medicare Claims Processing Manual)

The IRF PPS  also in cludes a payment adjustm ent for certain cas es, such as short-stay cases (for cases that do n ot meet the  definition of  a transfer case).  A s eparate CMG payment (5001)  will be  made for cases with a  length of stay of 3 da ys or less, without consideration of  the clinical characteristics of the patient.  Cases  that expire with a le ngth of stay of 3 da ys or less, will also be  classified to CMG 5001.  Separate  CMGs will a lso be made for cases that expire with a  length of stay greater than 3 days.  To impr ove the explanatory power of the groups, f our additiona l CMGs w ere creat ed to a ccount f or cases that expire.  CMG 5101 is us ed for shor t-stay, orthope dic, expired cas es.  This C MG in cludes those  cases that would other wise be groupe d to R ICs 07, 08, a nd 09 a nd the  length of the stay is greater than 3 da ys, but l ess than or equal to 13 da ys.  CMG 5102 will be  used for orthope dic expired cas es where the length of stay is greater than or equal to 14 da ys.  CMG 5103 will  be used for short-stay, non-orthope dic, expired cas es.  This C MG in cludes those  cases that would not be  groupe d to the orthope dic RICs and the  length of the stay is greater than 3 da ys, but l ess than or equal to 15 da ys.  CMG 5104 will  be used for non-orthope dic expired cas es where the length of stay is greater than or equal to16 da ys.  140.2.5 - Facility-Level Adjustments  (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)  Facility-level adjustm ents apply to all cases and are based on the  individua l IRF characteristics.  The  facility-level adjustm ents in clude an area wage adjustm ent, an adjustm ent for facilities  located in r ural areas, a n adjustm ent for treatin g low-income patients and an adjustm ent for teachi ng facilitie s.  Outli er payments will a lso be  discussed in this s ection.  Althoug h outli er payments ar e considered to be  a case-level adjustm ent, a case can be determined to qua lify for these additiona l payments onl y after all oth er facilit y-level adjustme nts are comput ed.  Thus, f or ease of understanding, the discussion of  these facility-level and outlier adjustm ents ar e presented in the  same order that is us ed to assess their applicabil ity.  140.2.5.1 - Area Wage Adjustments (Rev. 11504, Issued 08- 05-22; Effective:10 -01-22; Implementation: 10 -03-22)  To adjust payments for area wage differences, CMS first identifies the labor -related portion of the prospective payment rates which is published annually in the Federal Register. The labor -related unadjusted Federal payment is multiplied by a wage index value to account for area wage differences. CMS uses the inpatient acute care hospital wage data to compute the wage indices on the basis of the labor market area in which the acute care hospital is located, but without taking into account geographic reclass ification under 1886(d)(8) or (d)(10) of the Act and without applying the rural floor under 4410 of the BBA. The wage data excludes the wages for services provided by teaching physicians, interns and residents, and nonphysician anesthetists under Medi care part B, because these services are not covered under the IRF PPS. For IRF PPS discharges occurring before October 1, 2005, IRFs are divided into labor market areas where urban areas are defined as a Metropolitan Statistical Area (MSA) or New England C ounty Metropolitan Area, as defined by the Executive Office of Management and Budget. For IRF PPS discharges occurring on or after October 1, 2005, the IRF PPS adopts new labor market area definitions based upon the new statistical area definitions issued by the Office of Management and Budget (OMB) in OMB Bulletin No. 03- 04, June 6, 2003. OMB Bulletin No. 03- 04 includes new definitions of Metropolitan Statistical Areas, Micropolitan Statistical Areas, and Combined Statistical Areas, more commonly referred to as Core -Based Statistical Areas (CBSAs). CBSA -based designations reflect the most recent available geographic classifications and more accurately reflect current labor markets. The OMB also established New England City and Town Areas, which are similar to the previous New England MSAs. CMS uses the county- based areas for all MSAs in the Nation, including those in New England. Adopting county- based labor market areas for the entire country creates consistency and stability in the Medicare payment program because all of the labor market areas, including New England, are defined using the same system (that is, counties), rather than different systems in different areas of the country, and minimizes program complexity. CMS uses the Metropolitan Divisions where applicable under the new CBSA-based labor market area definitions to determine urban areas. Micropolitan Areas are treated as rural labor market areas under t he IRF PPS. To calculate the statewide rural wage index for each State, CMS combines all of the counties in a State outside of designated urban areas along with all Micropolitan Areas.   Beginning in FY 2023 a five percent cap will be applied on any decrease to a providers wage index from that providers final wage index in the prior fiscal year. For subsequent years, a provider's wage index would not be less than 95 percent of its wage index calculated in the prior FY. A new IRF will be paid the wage index for the area in which it is geographic ally located for its first full or partial FY with no cap applied, because a new IRF will not have a wage index in the prior FY.  140.2.5.2 - Rural A djustment (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)  Payments are adjusted for facilitie s located in rura l areas.  A facility is cons idered to be a rura l IRF if th ey are lo cated in a non-urban ar ea.  For FY 2006 and F Y 20 07, a hold har mless policy applie s to IRFs that meet the definition of rura l in FY 2005 in 412.602 and become urban under the FY 2006 CBS A-based de signations.  The IRF s that meet the  criteria descr ibed in the pre vious sentence will qu alify for an adjustme nt to th eir payme nts in FY 2006 and FY 2007 equal to some portion of the 19.14 per cent rura l adjustme nt effective in FY 2005.  This adjustme nt is in addition to the one-y ear blended wage index des cribed above for discharge s occurring on or after October 1, 2005 and on or bef ore September 30, 2006.  140.2.5.3 - Low-Incom e Patient ( LIP) A djustment: The Su pplem ental Secur ity Incom e (SS I)/Medica re Beneficiary Data for Inpatie nt Rehabilitatio n Facilities (I RFs) Paid Under the Pros pective Payment System (PPS)  (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)  The LIP adjustment accounts for di fferences in costs among IRFs a ssociated with differences in the proportion of low- income pa tients t reated.  The LIP adjustme nt is calculated a s (1 + dispropor tionate share hospital (DS H) patient pe rcentage) ra ised to a power sp ecified in the most recent IRF PPS f inal rule published in the Fe deral Register. To compute the DS H patient percentage the follo wing  formula  is us ed:  DSH = Medicare SSI Days + Medicaid, Non -Medicare Days   Total Medicare Days  Total Days  This instruction pr ovides the data for det ermining additiona l payment amounts for IRF s with low -income pa tients. An SSI da ta file below shows the late st ava ilable IRF- specific data to compute an IRF's SSI ratio for the a ssociated specified f iscal year (FY) . An IRF may use this r atio as part of the formula  to estima te their LIP adjustm ent for a cost reporting period tha t begins subs equent to the  FY specified by the data file. As appropriate, a f ile will be  upda ted annually (usually each October/Nov ember).  Patients who ar e enrolled in M edicare Adv antage (administered thr ough Medicare Part C) should a lso be  included in the  Medicare fraction.  These days will be  included in the Medicare/SSI fraction, b ut in or der for them to be  counted, the  hospit al must submit a n informational only bill ( TOB  111), which inc ludes both C ondition C ode 04 and the  CMG code from the  IRF P AI, to the ir Medicare contractor.  This will e nsure that these days are included in the  IRFs SSI ratio for Fiscal Y ear 2007 a nd be yond.  T eaching IRFs do not have to submit a n additiona l bill with C ondition Code 04.  The y already submit bills w ith Condition C odes 04 a nd 69 f or Indirect Medical E ducation pa yments and C MS will use the information fr om th ese bills f or the SSI ratio.  IRFs that received LIP payments dur ing F Y 2006 are also required to subm it informational only bills f or their Medicare Advantage patients.  Informational Only Claim El ements:   Covered 111 T OB  Condition C ode 04  Medicare Fee-for-Service is the  primary payer  There is no M SP  Beneficiarys Me dicare HICN  For claims p rior to O ctober 1, 2011, re port the Revenue Code 0024 line  containing C MG A9999 a nd, inst ead of inputting the transmission da te of the IRF-PAI in the s ervice date field (as is r equired for FFS claims), input the  discharge date as a default f or these informational only claims. The  discharge date is required on informational only claims to re duce reporting burden for IRFs who may be submitting  old informational only claims.  NOTE: E ffective January 1, 2011, do not r eport the service date for the revenue code 0024 line.  Instead, use  occurrence code 50 in pl ace of the service date to report the d efault discharge date for informational only claims.   Effective October 1, 201 1, report the Revenue Code 0024 line  containing the CMG from the  IRF-PAI and the transmission da te of the IRF-PAI in the  occurrence code 50 and da te field (as is r equired for FFS claims).   All oth er required claim elements