(Medicare Claims Processing Manual)

190.6.3.2 - Reconciliation of Teaching Adjustment on Cost Report  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  The teaching status adjustment is made on a claim basis as an interim payment and the final payment in full for the claim is made during the final settlement of the cost report.  The difference between those interim payments and the actual teaching adjustm ent amount based on information from the cost report are adjusted through lump sum payments/recoupments when the cost report is settled.  The teaching adjustment is calculated as follows:   1.  Determine the product of the wage -adjusted Federal per diem base rate and the applicable teaching, rural, DRG, comorbidity, and age adjustments.   2.  Determine the product of the wage adjusted base rate and the applicable rural, DRG, comorbidity, and age adjustments.  3.  Determine the difference of these two products (Step 1 minus Step 2).  4.  Calculate and sum the variable per diem amounts for the product in Step 2 to calculate the Federal payment net of the teaching adjustment amount.  5.  Calculate and sum the variable per diem amounts for the difference in Step 3 to calculate the portion of the Federal payment attributable to the teaching adjustment.   6.  To obtain the total Federal payment necessary for outlier calculations, etc., add Steps 4 and 5 together.  Step 5 alone is the teaching adjustment portion of the Federal payment, and can be separately identified and reconciled on the cost report.   190.6.4 - Emergency Department (ED) Adjustment  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  An adjustment is provided for IPFs that maintain a qualifying ED.  This is a facility -level adjustment that applies to all IPF admissions (with the one exception described below), regardless of whether a particular patient receives preadmission services in  the hospitals ED.  The ED adjustment is incorporated into the variable per diem adjustment for the first day of each stay for IPFs with a qualifying ED.  That is, IPFs with a qualifying ED receive a 31 percent adjustment as the variable per diem adjustment for day 1 of each stay.  If an IPF does not have a qualifying ED, it receives a 19 percent adjustment as the variable per diem adjustment for day 1 of each patient stay.  A qualifying ED means an ED of psychiatric units located in a hospital or CAH with EDs that are staffed and equipped to furnish a comprehensive array (medical as well as psychiatric) of emergency services and meets the definition of provider- based status (42 CFR 413.65 ) and meets the definition of a dedicated emergency department ( 42 CFR 489.24).   o Provider-based status means the relationship between a main provider and a provider-based entity or a department of a provider, remote location of a hospital, or satellite facility that complies with the provisions of this section. 42 CFR 413.65  o Dedicated emergency department means any department or facility of the hospital, regardless of whether it is located on or off the main hospital campus, that meets at least one of the following requirements:  (1) It is licensed by the State in which it is located under applicable State law as an emergency room or emergency department;   (2) It is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or  (3) During the calendar year immediately preceding the calendar year in which a determination under this section is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of al l its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment. See 42 CFR 489.24.  As specified in 42 CFR 412.424(d)(1)(v)(B), the ED adjustment is not made where a patient is discharged from an acute care hospital or CAH and admitted to the same hospitals or CAHs psychiatric unit.  An ED adjustment is not made in these cases because the costs associated with ED services are r eflected in the DRG payment to the acute care hospital or through the reasonable cost payment made to the CAH.  Therefore, when patients are discharged from an acute care hospital or CAH and admitted to the same hospitals or CAHs psychiatric unit, the IPF receives the 1.19 adjustment factor as the variable per diem adjustment for the first day of the patients stay in the IPF.  IPFs should notify their Medicare contractors 30 days before the beginning of their cost reporting period regarding if they have a qualifying ED.  Medicare contractors have the discretion to determine how they wish to be notified and the documentation they require.  Once the Medicare contractor is satisfied that the IPF has a qualifying ED, the Medicare contractor should enter the information in the provider- specific file within a reasonable timeframe so that the IPF can begin to receive the ED adjustment.  Application of the ED adjustment is prospective.  Medicare contractors may also use the date the documentation was received from the IPF to implement the ED adjustment.  The provider- specific file can be updated from the date of the attestation and claims processed from that date will receive the ED adjustment.  CMS does not intend that IPFs would have to wait until the beginning of their next cost report period to receive the ED adjustment.  However, if an IPF no longer meets the definition of a qualified ED, the IPF must promptly notify their Medicare contractor.  The Medicare contractor would immediately remove the flag from the provider- specific file and the provider will not receive the ED  adjustment.  If the provider should once again meet the definition of a qualified ED, they should contact their Medicare contractor immediately in order to update their file.   190.6.4.1 - Source of Admission for IPF PPS Claims for Payment of ED Adjustment  (Rev. 3030, Issued: 08- 22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of ICD -10, Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: September, 23 2014)  Source of admission code D is reported by IPFs to identify IPF patients who have been transferred to the IPF from the same hospital or CAH.  Claims with source of admission code "D" do not receive the ED adjustment.  See Pub. 100-04, Medicare Claims Processing Manual chapter 25, 60.1, for additional instructions for completing the CMS claim data set.   190.6.5 - Cost -of-Living Adjustment (COLA) for Alaska and Hawaii  (Rev. 11039; Issued: 10-05-21; Effective: 10 -01-21; Implementation:  10-04-21)  The IPF PPS includes a payment adjustment for IPFs located in Alaska and Hawaii based upon the area in which the IPF is located.  An adjustment for IPFs located in Alaska and Hawaii is made by multiplying the non- labor related share of the Federal per diem  base rate and ECT rate by the applicable COLA factor.  The CMS notes that the COLA areas for Alaska are not defined by county as are the COLA areas for Hawaii.  In 5 CFR 591.207, the OPM established the following COLA areas:  (a) City of Anchorage, and 80- kilometer (50 -mile) radius by road, as measured from the Federal courthouse;  (b) City of Fairbanks, and 80 -kilometer (50 -mile) radius by road, as measured from the Federal courthouse;  (c) City of Juneau, and 80- kilometer (50- mile) radius by road, as measured from the Federal courthouse;  (d) Rest of the State of Alaska.   In FY 2018, CMS updated the IPF COLA amounts; these updated amounts will remain in effect for FY 2018 through FY 2021.    In FY 2022, CMS updated the IPF COLA amounts; these updated amounts will remain in effect for FY 2022 through FY 2025.  For comparison purposes, CMS is showing the COLA factors effective for FY 2018 through FY 2021 in the first column and in the second col umn COLA factors effective for FY22 through FY25.   Comparison of IPF PPS Cost -of-Living Adjustment Factors: IPFs Located in Alaska and Hawaii   Area  FY 2018 through FY 2021  FY 2022 through FY 2025  Alaska:       City of Anchorage and 80 -kilometer (50 -mile) radius by road 1.25 1.22    City of Fairbanks and 80 -kilometer (50 -mile) radius by road 1.25 1.22    City of Juneau and 80 -kilometer (50 -mile) radius by road  1.25 1.22    Rest of Alaska  1.25 1.24 Hawaii:       City and County of Honolulu  1.25 1.25    County of Hawaii  1.21 1.22    County of Kauai  1.25 1.25    County of Maui and County of Kalawao  1.25 1.25  190.7 - Other Payment Policies  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  190.7.1 - Interrupted Stays  (Rev. 2083, Issued: 10- 29-10, Effective: 01 -01-11, Implementation: 01 -03-11)  An interrupted stay is a case in which a patient is discharged from an IPF and is readmitted to the same or another IPF before midnight on the third consecutive day following discharge from the original IPF stay.    For a patient who is discharged and readmitted to the same IPF, interrupted stays are considered to be continuous for the purposes of applying the variable per diem adjustment and determining if the case qualifies for an outlier payment.  In other words, a n interrupted stay is treated as one stay and one discharge for the purpose of payment.  Thus, the IPF should hold the claim for 3 days to ensure there is not a readmission that soon.  In this way, the readmission is included on the original claim.  For example, if a patient leaves the IPF on 1/1 and returns to the same IPF on 1/3, this is considered an interrupted stay and the Occurrence Span Code 74 will show 1/1  1/2.  Should the patient return to the IPF on 1/4, two bills are allowed.   For a patient who is discharged and readmitted to another IPF, interrupted stays are considered to be continuous for the purposes of applying the variable per diem adjustment.  For example, if a patient is discharged from IPF A and within 3 days is readmitted to IPF B, this is considered an interrupted stay under IPF PPS.  There will be no provider action.  FISS will process the claim from IPF B with information received fr om CWF on covered days from the claim received from IPF A(this information will be displayed in FISS with a value code 75 on claim that is processed for IPF B).   Medicare contractors should monitor trends to ensure IPFs are not consistently admitting, discharging, and readmitting patients in order to receive the larger variable per diem payments associated with the first days of a patients stay.   190.7.2 - Outlier Policy (Rev.  2111, Issued: 12- 03-10, Effective: 04 -01-11, Implementation: 04- 04-11)