(Medicare Claims Processing Manual)

190.7.3 - Electroconvulsive Therapy (ECT) Payment  (Rev. 3575, Issued: 08- 01-16, Effective: 10-01- 16; Implementation: 10 -03-16)  IPFs receive an additional payment for each ECT treatment furnished during the IPF stay.  The ECT base rate is based on the median hospital cost used to calculate the calendar year 2005 Outpatient Prospective Payment System amount for ECT and is updated annually by the market basket and wage budget neutrality factor.  The ECT base rate is adjusted by the wage index and any applicable COLA factor.  In order to  receive the payment, an IPF must report revenue code 0901 along with the number of units of ECT on the claim. The units should reflect the number of ECT treatments provided to the patient during the IPF stay.  In addition, IPFs must include the ICD-9-CM p rocedure code for ECT (94.27) in the procedure code field and use the date of the last ECT treatment the patient received during their IPF stay.   Effective with the implementation of ICD -10 the following ICD-10-PCS codes apply:  ICD-10- PCS Code and Description  GZB0ZZZ - Electroconvulsive Therapy, Unilateral- Single Seizure  GZB2ZZZ - Electroconvulsive Therapy, Bilateral -Single Seizure  GZB4ZZZ  Other Electroconvulsive Therapy  It is important to note that since ECT treatment is a specialized procedure, not all providers are equipped to provide the treatment.  Therefore, many patients who need ECT treatment during their IPF stay must be referred to other providers to receive the ECT treatments, and then return to the IPF.  In accordance with 42 CFR 412.404(d)(3), in these cases where the IPF is not able to furnish necessary treatment directly, the IPF would furnish ECT under arrangements with another provider.  While a patient is an i npatient of the IPF, the IPF is responsible for all services furnished, including those furnished under arrangements by another provider.  As a result, the IPF claim for these cases should reflect the services furnished under arrangements by other provider s.  190.7.4 - Stop Loss Provision (Transition Period Only)  (Rev. 1543; Issued:  06- 27-08; Effective Date:  07 -01-08; Implementation Date:  07-07-08)  The IPF PPS includes a stop- loss provision during the 3- year transition.  The purpose is to ensure each facility receives an average payment per case under the IPF PPS that is no less than 70 percent of its average payment under the TEFRA.  It is calculated at cost report settlement.  New providers are not eligible for stop -loss payments.  See 190.9.1.  Example of stop- loss calculation in year 3 of the transition:   1.  Enter Total (100%) TEFRA payments for cases during cost reporting period  2.  Enter Total (100%) PPS payments for cases during cost reporting period   3.  Multiply Step 1 by 0.70.  4.  If Step 3 is greater than Step 2, subtract Step 2 from Step 3.  Otherwise, enter 0.   5.  Add Steps 2 and 4 to calculate total PPS payments.  6.  Multiply Step 1 by 0.25 to calculate the TEFRA portion.  7.  Multiply Step 5 by 0.75 to calculate the PPS portion.  8.  Add Steps 6 and 7 to calculate the IPFs aggregate payments in the third year of the IPF PPS.  Determine if this amount is at least 70 percent of what would have been paid under TEFRA, then pay the difference.   NOTE: Since the transition will be completed for RY 2009, for cost reporting periods beginning on or after January 1, 2008, IPFs will be paid 100 percent PPS and, therefore, the stop loss provision will no longer be applicable.  The CMS has previously stat ed that we would remove this 0.39 percent adjustment to the Federal per diem base rate after the transition.  Therefore, for RY 2009, the Federal per diem base rate and ECT rates will be increased by 0.39 percent.  190.8 - Transition (Phase -In Implementation)  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  190.8.1 - Implementation Date for Provider  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  The IPF PPS is phased -in over 3 years from the cost based reimbursement to the Federal prospective payment.  All IPF providers must transition over the 3-year transition period. There is no election of 100 percent PPS in the first year.  During the transition period, payment is based on an increasing percentage of the IPF prospective payment and a decreasing percentage of each IPFs TEFRA -based reimbursement rate for each case as follows:    Transition Year  Cost Reporting Periods   Beginning on or After  TEFRA Rate Percentage  IPF PPS Federal Rate  Percentage  1 January 1, 2005  75 25 2 January 1, 2006  50 50 3 January 1, 2007  25 75  January 1, 2008  0 100  The 3 -year transition period is separate from the annual update cycle of the IPF PPS.  The transition is effective according to cost reporting periods, but the updates to the rates take effect July 1 of each year.  For more detailed information regarding the annual update cycle, refer to 190.4.3-Annual Update.  Although the IPF PPS is effective January 1, 2005, an individual IPF's PPS transition year start date is the first day of the first cost reporting period that begins on or after that date.  An IPF may begin the IPF PPS as early as January 1, 2005, or as la te as December 31, 2005, should a cost reporting period begin on that date.  The IPF PPS applies to claims for discharges occurring in the IPF's first cost reporting period beginning on or after January 1, 2005.  Where the IPF has already billed interim claims for an inpatient that has benefit days remaining after the PPS implementation date, the provider must submit a cancel bill and re-bill under the IPF PPS so that payment for the entire stay is made under the IPF PPS.   If the provider ever had a TEFRA limit, the IPF is not a new provider and therefore will receive the blended payment.  This includes those providers that previously closed their psychiatric units and then re-opened the psychiatric units. If the provider ha d a TEFRA limit established, that TEFRA limit is updated using the rate of increase percentages in  42 CFR 413.40.  For cost reporting periods beginning in FY 1999 through FY 2002, the applicable rate-of-increase percentage is the market basket increase percentage minus a factor based on the percentage by which the hospitals operating costs exceed the hospitals ceiling for the most recently available cost reporting period.  To update the TEFRA limit for IPFs that were closed during FY 1999 through FY 2002 and then re-opened (including CAHs that were statutorily precluded from having a distinct part unit), the rate-of- increase for these years would be the full market basket up  to the cap on the target amounts.  190.9 - Definition of New IPF Providers Versus TEFRA Providers  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  190.9.1 - New Providers Defined  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  A new IPF provider is one that meets the definition of an IPF in 42 CFR 412.402, and under present or previous ownership or both, has not received payment under TEFRA for delivery of IPF services prior to the effective date of the IPF PPS, January 1, 2005.  To be a new provider, the first cost reporting period as a psychiatric hospit al, a distinct part unit in an acute care hospital or a CAH must have begun no earlier than January 1, 2005, coinciding with the effective date of the IPF PPS.  Change of ownership has no impact on whether an IPF is considered a new IPF provider.  190.10 - Claims Processing Requirements Under IPF PPS  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  190.10.1 - General Rules  (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)  Effective with cost reporting periods beginning on or after January 1, 2005, the following claim preparation requirements apply to IPFs:   Type of Bill (TOB) is 11X;   Medicare provider number ranges for IPFs are from xx -4000 - xx-4499, xx-Sxxx, and xx-Mxxx; ( NOTE :  Implementation of NPI will change this.)    The IPF must correctly code diagnoses for the principal diagnosis, and up to twenty four additional diagnoses, if applicable;   The IPF must correctly code one principal procedure and up to twenty four additional procedures performed during the stay;   The IPF must also code age, sex, and patient (discharge) status of the patient on the claim, using standard inpatient coding rules; and   An IPF distinct part must code source of admission code "D" on incoming transfers from the acute care area of the same hospital to avoid overpayment of the emergency department adjustment when the acute area has billed or will be billing for covered servic es for the same inpatient admission.  Other general requirements for processing Medicare Part A inpatient claims described in Chapter 25 of this manual apply.  CMS' hospital inpatient GROUPER applicable to the discharge date (or effective December 3, 2007, benefits exhaust date, if present) on the claim will determine the DRG/MS -DRG assignment.  190.10.2 - Billing Period  (Rev. 1231; Issued:  04- 27-07; Effective:  12 -03-07; Implementation:  12 -03-07) When the patient has Medicare benefits, IPF providers will submit one admit through discharge claim for the stay upon discharge.  IPFs may interim bill in 60- day intervals following the instructions in chapter 1, 50.2 of this manual should the patients stay be exceptionally long.  Final PPS payment is based upon the date of physical discharge or death, or the date benefits exhausted (effective December 3, 2007).   IPFs can submit adjustment claims, but late charge claims will not be allowed, e.g., the adjustment claim must include all charges and services and must replace the earlier claim(s) instead of including only the additional charges and services.   In situations when a patient falls below a skilled level of care, IPFs should submit a 112 TOB with both an Occurrence Code 22 (Date active care ended) and patient status code 30 (Still a patient).  IPFs should then continue to submit subsequent interim 117 TOBs, as appropriat e, with the patient status code 30 and the correct Occurrence Span Codes that identify payment liability (codes 76 or 77).   Effective December 3, 2007, once the patients Medicare benefits exhaust, the IPF is allowed to submit no- pay bills (TOB 110), with a Patient Status Code of 30 every 60 days, until the patient is physically discharged or dies.  The last bill shall contain a discharge patient status code.  IPFs no longer need to continually adjust claims once benefits exhaust.  190.10.3 - Patient Status Coding  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  All patient status (i.e., discharge disposition) codes for 11X TOB are valid, but there are no special payment policies related to transfer codes; for example, discounted or per diem payments in transfer situations.  The same patient status codes applicabl e under inpatient PPS for same day transfers (with Condition Code 40) are applicable under IPF PPS.   190.10.4 - Reporting ECT Treatments  (Rev. 4104, Issued: 08- 03-18, Effective: 10 -01-18, Implementation: 10- 01-18)