(Medicare Claims Processing Manual)

38 Skilled Nursing Facility (SNF)  For non-demo PPS SNFs  effective for cost reporting periods beginning on or after July 1, 1998   40 Hospital Based ESRD Facility   41 Independent ESRD Facility   42 Federally Qualified Health Centers   43 Religious Non-Medical Health Care Institutions   44 Rural Health Clinics-Free Standing   45 Rural Health Clinics-Provider Based   46 Comprehensive Outpatient Rehab Facilities   47 Community Mental Health Centers   48 Outpatient Physic al Therapy Services   49 Psychiatric Distinct Part   50 Rehabilitation Distinct Part   51 Short-Term Hospital  Swing Bed   52 Long -Term Care Hospital  Swing Bed   53 Rehabilitation Facility  Swing Bed   54 Critical Access Hospital  Swing Bed    57  X(1)  Special Locality Indicator  Indicates the type of special locality provision that applies.    For End Stage Renal Disease (ESRD) facilities value Y equals low volume adjustment applicable.    58  X(1)  Change Code For Wage Index  Reclassification  Enter Y if the hospitals wage index location has been reclassified for the year.  Enter N if it has not been reclassified for the year. Adjust annually. Does not apply to ESRD Facilities.    59-62  X(4)  Actual  Geographic  LocationMSA   Enter the appropriate code for MSA, 00409965, or the rural area, (blank) (blank)  2-digit numeric State code, such as _ _ 3 6  for Ohio, where the facility is physically located.    63-66  X(4)  Wage Index  LocationMSA   The appropriate code for the MSA, 0040-9965, or the rural area, (blank)(blank) (2 digit numeric State code) such as _ _ 3 6 for Ohio, to which a hospital has been reclassified for wage index. Leave blank or enter the actual location MSA if not reclassified. Does not apply to ESRD Facilitie s.    67-70  9V9(3)  Payment -to-Cost Ratio  Enter the providers payment -to-cost ratio. Does not apply to ESRD Facilities.     71-72  9(2)  State Code  Enter the 2-digit state where the provider is located. Enter only the first (lowest) code for a given state.  For example, effective October 1, 2005, Florida has the following State Codes: 10, 68 and 69. Contractors shall enter a 10 for Floridas State C ode.      List of valid State Codes is located in Pub. 10007, Chapter 2, Section 2779A1.  73  X(1)  TOPs Indicator  Enter the code to indicate whether TOPs applies or not.    Y = qualifies for TOPs   N = does not qualify for TOPs    74  X(1)  Quality Indicator Field  Hospital:  Enter the code to indicate whether the hospital meets data submission criteria per HOP QDRP requirements.   1 = Hospital quality reporting standards have been met or hospital is not required to submit quality data (e.g., hospitals that are specifically excluded from the IPPS or which are not paid under the OPPS, including psychiatric, rehabilitation, long -term care and childrens and cancer hospitals, Maryland hospitals, Indian Health Service hospitals, or hospital units;  or hospitals that are located in Puerto Rico or the U.S. territories). The reduction does not apply to hospices, CORFs, HHAs, CMHCs, critical access hospitals or to any other provider type that is not a hospital.      Blank = Hospital does not meet criteria.     Independent and Hospital -based End Stage Renal Disease (ESRD)Facilities:  Enter the code applicable to the ESRD Quality Incentive Program (QIP):    Blank = no reduction  1 =  percent payment reduction  2 = 1 percent payment reduction  3 = 1  percent payment reduction  4 = 2 percent payment reduction     * Please refer to file position 101 for ESRD Childrens Hospitals Quality Indicator.    75  X(1)  Filler  Blank.  76-79  9V9(3)  Outpatient Cost -to-Charge Ratio  Derived from the latest available cost report data.  See 10.11 of this chapter for instructions on how to calculate and report the Cost-to -Charge Ratio.      Does not apply to ESRD Facilities.    80-84  X(5)  Actual  Geographic  Location CBSA  00001-89999, or the rural area, (blank) (blank)  (blank) 2 digit numeric State code such as _ _ _ 3 6 for Ohio, where the facility is physically located.     85-89  X(5)  Wage Index  Location CBSA  Enter the appropriate code for the CBSA, 0000189999, or the rural area, (blank)(blank)(blank) (2 digit numeric State code) such as _ _ _ 3 6 for Ohio, to which a hospital has been reclassified due to its prevailing wage rates. Leave blank or enter the Actual Geographic Location CBSA, if not reclassified. Pricer will automatically default to the actual location CBSA if this field is left blank. Does not apply to ESRD Facilities.    90-95  9(2) V9(4)  Special Wage Index  Enter the special wage index that certain providers may be assigned. Enter zeroes unless the Special Payment Indicator equals a 1 or 2.    96  X(1)  Special Payment Indicator  The following codes indicate the type of special payment provision that applies.    Blank = not applicable  Y = reclassified  1 = special wage index indicator  2 = both special wage index indicator and reclassified  D = Dual Reclassified    97-100  9(4)  Reduced  Coinsurance  Trailer Count  Enter the number of APCs the provider has elected to reduce coinsurance for. The number cannot be greater than 999.  101  X(1)  Quality Indicator  ESRD Childrens  Hospitals  Childrens Hospitals for End Stage Renal Disease (ESRD) Facilities:  Enter the code applicable to the ESRD Quality Incentive Program (QIP):    Blank = no reduction  1 =  percent payment reduction  2 = 1 percent payment reduction  3 = 1  percent payment reduction  4 = 2 percent payment reduction    102-105  9V9(3)  Device departments Cost-to-Charge Ratio  Derived from the latest available cost report data.      Does not apply to ESRD Facilities.     106-112  X(7)  Carrier/Locality code  The carrier/locality code for the provider service facility.  The first five positions represent the carrier code and the last two positions represent the locality code.  113-117  9(5)  County Code  Enter the County Code.    Must be 5 numbers.    118-122  X(5)  Payment CBSA   Enter the appropriate code for the CBSA, 0000189999, or the rural area, (blank)(blank)(blank) (2 digit numeric State code) such as _ _ _ 3 6 for Ohio, to which a hospital has been reclassified due to its prevailing wage rates.  Leave blank or enter the Actual Geographic Location CBSA, if not reclassified. Pricer will automatically default to the actual location CBSA if this field is left blank. Does not apply to ESRD Facilities.   123-128  9V9(5)   Payment Model Adjustment (PMA)   Derived from payment model Technical Direction Letter.   129-133   9V9999   Medicare Performance Adjustment (MPA)   Enter the MPA percentage calculated and published by the Centers for Medicare & Medicaid Services (CMS).   134-139 9(2) V9(4)  Supplemental Wage Index  Enter the supplemental wage index that certain providers may be assigned.  Enter zeroes if it does not apply. 140-140 X(1)  Supplemental Wage Index Flag Enter the supplemental wage index flag:  1=Prior Year Wage Index 2=Future use 3=Future use  Enter blank if it does not apply.  141-162 X(22)  FILLER     The contractor enters the number of APCs for which the provider has elected to reduce coinsurance. Cannot be greater than 999. Reduced Coinsurance Trailer Record - Occurs 0-999 times depending on the  reduced Coinsurance Trailer Count in positions 97-100. Due to systems capacity limitations the maximum number of reduced coinsurance trailers allowable is 999 at this time.     1-4   9(4)   APC Classification - Enter the 4-digit APC classification for which the provider has elected to reduce coinsurance.   5-10   9(4)V9(2)   Reduced Coinsurance Amount - Enter the reduced coinsurance amount elected by the provider     The Shared system will verify that the last position of the record is equal to the number in file positions 97 through 100 multiplied by 10 plus 100 (last position of record = (# in file position 97-100)(10) + 100).     50.2 - Deductible Application  (Rev. 1, 10-03-03) A-03-066  Pricer determines the deductible for OPPS services on a claim, and the A/B MAC (A) determines the deductible for other services on the same claim.  Pricer will automatically apply the deductible to the APC line item with the largest national unadjusted coinsurance as a percent of the APC payment.  Pricer then goes to the next largest coinsurance as a percent of the APC payment and so on until the deductible is met or no other payments can be used to satisfy the deductible.  This method of applying the deductible is the most advantageous for the beneficiary.  If less than $100, or less than the beneficiarys remaining deductible amount is applied, an additional deductible amount from other services, if applicable, is applied to the clai m for other types of payments on the same claim before submitting to CWF.  The deductible does not apply to the influenza virus vaccines, pneumococcal pneumonia vaccine, clinical diagnostic laboratory services (which include screening pap smears), screening mammographies, screening pelvic examinations, and screening prostate examinations.  Only influenza virus vaccine, pneumococcal pneumonia vaccine, screening pelvic examinations and screening prostate examinations are subject to OPPS.  50.3 - Transitional Pass Through Payments for Designated Devices  (Rev. 3941; Issued: 12- 22-17; Effective: 01- 01- 18; Implementation: 01 -02-18)  Certain designated new devices are assigned to APCs and identified by the OCE as eligible for payment based on the reasonable cost of the new device reduced by the amount included in the APC for the procedure that reflects the packaged payment for devices used with the procedure. OCE will determine the proper payment amount for these APCs as well as the coinsurance and any applicable deductible.  All related payment calculations will be returned on the same APC line and identified as a designated new device.   Refer to https://www.cms.gov/Medicare/Medicare- Fee-for-Service-Payment/HospitalOutpatientPPS/passthrough_payment.html  for the most current OPPS APC Offset File.   50.4  Changes to Pricer Logic Effective April 1, 2002  (Rev. 3941; Issued: 12- 22-17; Effective: 01- 01- 18; Implementation: 01 -02-18)  The following list contains a description of all OPPS Pricer logic changes that are effective beginning April 1, 2002.   A. New OPPS wage indexes will be effective April 1, 2002.  These are the same wage indexes that were implemented on October 1, 2001, for inpatient hospitals.  Some corrections have been made since the publication of the inpatient rule, and CMS is using the corrected wage indexes where applicable.   B. Inpatient hospitals considered reclassified on October 1, 2001, will be considered reclassified for OPPS on April 1, 2002.  C. Section 401 designations and floor MSA designations will be considered effective for OPPS on April 1, 2002.  D. New payment rates and coinsurance amounts were effective for OPPS on April 1, 2002, except those 55 APCs with coinsurance amounts limited to 55 percent of the payment rate, which were effective January 1, 2002.  The coinsurance limit equal to the inpatient deductible of $812 remains effective January 1, 2002.  E. APC 339, for Observation, will be priced at 1 unit no matter how many units are submitted.