(Medicare Claims Processing Manual)

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)  124 of the Medicare, Medicaid, and SCHIP, Balance Budget Refinement Act of 1999 (BBRA) (Pub.L.106- 113), mandated the development of a per diem prospective payment system for inpatient psychiatric services furnished in hospitals and psychiatric distinct pa rt units of acute care hospitals. 405 (g)(2) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003(MMA) (Pub. L. 108- 173) extended the IPF PPS to distinct part psychiatric units of critical access hospitals (CAHs). 124 of the BBRA  provides the Secretary discretion in establishing the payment methodology including payments for cases incurring extraordinarily high costs. This additional payment known as an outlier is designed to protect IPFs from large financial losses due to unusually expensive cases.  If the estimated cost of the case is greater than the adjusted fixed dollar loss threshold amount (the fixed dollar loss threshold amount multiplied by area wage index, rural location, teaching and COLA adjustment factors), an additi onal payment is added to the IPF PPS payment amount.  The fixed dollar loss threshold amount is computed so that projected outlier payments equal 2 percent of total IPF PPS payments to ensure that IPFs treating unusually costly cases do not incur substantial losses and promote access to IPFs for patients who require expensive care.  The fixed dollar loss threshold amount is published in the annual IPF PPS update notice or final rule.  The specific regulations governing payments for outlier cases are located at 42 CFR 412.424(d) (3) (i).  Under 42 CFR 412.424 (d)(3)(i), for discharges in cost reporting periods beginning on or after January 1, 2005, high cost outlier payments may be reconciled at cost report settlement to account for differences between the cost -to-charge ratio (CCR) used to pay the claim at its original submission by the provider, and the CCR determined a t final settlement of the cost reporting period during which the discharge occurred. Medicare contractors will use either the most recent settled IPF cost report or the mos t recent tentatively settled IPF cost report, whichever is later, to obtain the applicable IPF CCR.   In addition, under 42 CFR  412.424 (d)(3)(i),effective for discharges in cost reporting periods beginning on or after January 1, 2005, at the time of reconciliation, outlier payments may be adjusted to account for the time value of any underpayments or overpayments based on the regulations in 42 CFR 412.84 (m), except that CMS calculates a single overall (com bined operating and capital ) CCR for IPFs and national average IPF CCRs are used instead of statewide average CCRs.   Once the threshold amount is met, CMS will share a declining percentage of the losses for a high cost case.  The risk -sharing percentages would be 80 percent of the difference between the cost for the case minus payment and the adjusted threshold amount for days 1 through 9 of the stay and 60 percent of the difference after the 9th day.  Medicare contractors will determine the total outlier amount and divide by the number of days, then pay 80 percent for days 1-9 and 60 percent for days beyond that.  Outlier payments are not paid on interim bills, but they are calculated on a final discharge bill, a benefits exhaust bill, or if the patient falls below a covered level of care. For a more detailed explanation on the calculation of outlier payments, visit our Web site at http://www.cms.gov/Medicare/Medicare- Fee-for-Service-Payment/InpatientPsychFacilPPS/index.html?redirect=/inpatientpsychfacilpps    Medicare contractors may choose to review outliers if data analysis deems it a priority.   The Pricer program makes all outlier determinations except for the medical review determinations.   190.7.2.1 - How to Calculate Outlier Payments  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  1 - Calculate the Adjusted Fixed Dollar Loss Threshold Amount   Multiply the threshold amount by the labor share and the area wage index;  Multiply the threshold amount by the non- labor share and any applicable COLA (Alaska or Hawaii);    Add these two products and then multiply by any applicable facility- level adjustments (teaching, rural); and    Add this amount to the sum of the Federal per diem payment and ECT payment to obtain the adjusted threshold amount.  2 - Calculate Eligible Outlier Costs    Multiply reported hospital charges by the cost -to-charge ratio to calculate cost.    Subtract the adjusted threshold amount from the cost.  This is the amount subject to outlier payments.   Divide this amount by the length of stay to calculate the per diem outlier amount.   For days 1 through 9, multiply this per diem outlier amount by 0.80.  For day 10 and thereafter, multiply the per diem outlier amount by 0.60.  The sum of these amounts is the total outlier payment.   190.7.2.2 - Determining the Cost -to-Charge Ratio (Rev. 4406, Issued: 10- 01-19, Effective: 10 -01-19, Implementation: 10- 07-19)  For discharges in cost reporting periods beginning on or after January 1, 2005, Medicare contractors are to use a CCR from the latest settled cost report or from the latest tentative settled cost report (whichever is from the later period) to determine the  IPFs CCR. Cost -to-charge ratios are updated each time a subsequent cost report is settled or tentatively settled. Total Medicare charges consist of the sum of inpatient routine charges and the sum of inpatient ancillary charges including capital. Total M edicare costs consist of the sum of inpatient routine costs (net of private room differential and swing bed cost) plus the sum of ancillary costs plus capital -related pass -through costs only. Based on current Medicare cost reports and worksheets, specific instructions are described below.   Hospitals   For IPFs that are psychiatric hospitals:   1) Identify total Medicare costs from worksheet D -1, Part II, line 49, minus (Worksheet D, Part III, column 8, lines 25 through 30, plus Worksheet D, Part IV, column 7, line 101).   2) Identify total Medicare charges (the sum of routine and ancillary charges) from Worksheet D -4, column 2, the sum of lines 25 through 30 and line 103 from the cost report; where possible, these charges should be confirmed with the PS&R data.   3) Divide the Medicare costs by the Medicare charges to compute the CCR.   Distinct Part Units   For IPFs that are distinct part psychiatric units:   1) Identify total Medicare costs from Worksheet D -1, Part II, line 49 minus (Worksheet D, Part III, column 8, line 31 plus Worksheet D, Part IV, column 7, line 101).    2) Identify total Medicare charges (the sum of routine and ancillary charges) from Worksheet D -4, Column 2, line 31 plus line 103 from the cost report; where possible, these charges should be confirmed with the PS&R data.   3) Divide the Medicare costs by the Medicare charges to compute the CCR.   All references to Worksheets and specific line numbers shall correspond with the sub-provider identified as the IPF unit that has the letter "S" or M in the third position of the Medicare provider number.   A. - Use of Alternative Data in Determining CCRs For IPFs Subject to the IPF PPS   Under 42 CFR 412.424( d)(3)(i,), for discharges in cost reporting periods beginning on or after January 1, 2005, CMS may direct Medicare contractors to use an alternative CCR to the CCRs from the latest settled cost report or latest tentatively settled cos t report, if CMS believes this will result in a more accurate CCR. In addition, if the Medicare contractor finds evidence that indicates that using data from the latest settled or tentatively settled cost report would not result in the most accurate CCR, t hen the Medicare contractor shall contact the CMS Central Office to seek approval to use a CCR based on alternative data.   B. - Request by the IPF for use of a Different CCR   For discharges in cost reporting periods beginning on or after January 1, 2005, an IPF may request that an alternative CCR be applied in the event it believes the CCR being applied is inaccurate. The IPF is required to present substantial evidence supporti ng its request. Such evidence should include documentation regarding its costs and charges that demonstrate its claim that an alternative ratio is more accurate. The CMS Regional Office, in conjunction with the CMS Central Office, will approve or deny any request after evaluation by the Medicare contractor of the evidence presented by the IPF. Revised CCRs are applied prospectively to all IPF claims. Medicare contractors shall send notification to the CMS Central Office via the following address and e -mail address:   CMS  C/O Division of Chronic Care Management- IPF Outlier Team  7500 Security Blvd.  Mail Stop C5 -05-27  Baltimore, MD. 21244  outliersipf@cms.hhs.gov    C. - Application of National Median CCRs for IPFs   For discharges in cost reporting periods occurring on or after January 1, 2005, the Medicare contractor may use the national CCRs for an IPF in one of the following circumstances:  1. New IPFs that have not yet submitted their first Medicare cost report.  2. IPFs whose CCR is in excess of 3 standard deviations above the corresponding national geometric mean (that is, above the ceiling). 3. Other IPFs for whom the Medicare contractor obtains inaccurate or incomplete data with which to calculate a CCR.   For new IPFs, we are using the national median CCRs until the facilitys actual CCR can be computed using the first tentatively settled or final settled cost report, which will then be used for the subsequent cost report period.   NOTE : IPF PPS provides two national ceilings, one for IPFs located in rural areas and one for IPFs located in urban areas. We computed the ceilings by calculating the national average and the standard deviation of the CCR for both urban and rural IPFs.   The policies in section E below can be applied as an alternative to the national median CCR.  For those IPFs assigned the national median CCR, the CCR must be updated every October 1st based on the latest national median CCRs published in each years IPF PPS notice or final rule until the hospital is assigned a CCR based on the latest tentative or final settled cost report or a CCR based on the policies of part E and F of this section.   D. - Notification to IPFs Under the IPF PPS of a Change in the CCR   The Medicare contractor shall notify an IPF whenever it makes a change to its CCR. When a CCR is changed as a result of a tentative settlement or a final settlement, the change to the CCR can be included in the notice that is issued to each provider after a tentative or final settlement is completed. Medicare contractors can also issue separate notification to an IPF about a change to their CCR(s).   E. - Ongoing CCR Updates Using CCRs From Tentative Settlements For Entities Subject to the IPF PPS   For discharges beginning on or after January 1, 2005, Medicare contractors are to use a CCR from the latest settled cost report or from the latest tentatively settled cost report (whichever is from the later period) to determine the IPFs CCR. Under the IP F PPS, Medicare contractors must update the IPFs CCR on the Provider Specific File to reflect the IPFs CCR from the most recent tentative settlements or final settled cost reports, (whichever is the later period). Revised CCRs shall be entered into the Provider Specific File not later than 30 days after the date of the latest settlement used in calculating the CCR.   Subject to the approval of CMS, an IPFs CCR may be revised more often if a change in a hospitals operations occurs which materially affects a hospitals costs or charges. A revised CCR will be applied prospectively to all IPF PPS claims processed after t he update.