evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
140.3 - Billing Requirements Under IRF PPS  (Rev. 11140, Issued:12- 02-21, Effective:01 -04-22, Implementation: 01- 04-22)  IRF PPS payment is contingent on the requirement that IRFs complete a patient assessment upon admission and discharge for Medicare patients.  The August 7, 2001, Final Rule, and subsequent final rules contain detailed information regarding the assessment schedule for the patient assessment instrument (PAI) with respect to transmission requirements, encoding dates, and other pertinent information.  Further, there is an item- by-item guide, which specifies detailed instructions regarding the manner in which ea ch item on the assessment instrument needs to be completed.   Effective with cost reporting periods beginning on or after January 1, 2002, IRFs are required to report billing data with a new revenue code and a Health Insurance PPS (HIPPS) Rate Code on the ASC X12 837 institutional claim or, in rare cases, on the Form  CMS -1450 for all Part A inpatient claims (Type of Bill 11X) to their A/B MACs (A).  The new revenue code, 0024, is used in conjunction with the HIPPS Rate Code to identify the CMG payment classification for the beneficiary.  In addition to all entries pre viously required on a Part A claim, the following additional instructions must be followed to accurately price and pay a claim under the IRF PPS.  These claims must be submitted on Type of Bill 11X.  The last four digits of the provider number for rehabili tation hospitals is from 3025 to 3099, and for rehabilitation distinct part units the third digit will be a T if the unit is located in an acute care hospital or an R if the unit is located in a CAH.   The Revenue code must contain revenue code 0024.  This code indicates that this claim is being paid under the PPS.  This revenue code can appear on a claim only once.    The following Patient Discharge Status codes are applicable under the transfer policy for IRF PPS: 02, 03, 61, 62, 63, and 64.
(Medicare Claims Processing Manual)
 The following Patient Discharge Status codes are applicable under the transfer policy for IRF PPS: 02, 03, 61, 62, 63, and 64.  NOTE :  IRFs that transfer a beneficiary to a nursing home that accepts payment under Medicare and/or Medicaid should use PS 03, discharged/transferred to a SNF.  IRFs that transfer a beneficiary to a nursing facility that does not accept Medicare or Medicaid, should code PS 04, discharged/transferred to an ICF, until such time that a new PS code is established to differentiate between nursing facilities that do not accept Medicare and/or Medicaid and those that do.  PS 04 does not constitute a transfer unde r the IRF PPS policy.
(Medicare Claims Processing Manual)
 For typical cases, the HCPCS/Rates must contain a five digit HIPPS Rate/CMG Code (AXXYY- DXXYY).  The first position of the code is an A, B, C, or D.  The HIPPS rate code beginning with A in front of the CMG is defined as without comorbidity.  The HIPPS rat e code containing a B in front of the CMG is defined as with comorbidity for Tier 1.  The HIPPS rate code containing a C in front of the CMG is defined as with comorbidity for Tier 2.  The HIPPS rate code containing a D in front of the CMG is defined as wi th comorbidity for Tier 3.  The (XX) in the HIPPS rate code is the Rehabilitation Impairment Category (RIC).  The (YY) in the HIPPS rate code is the sequential numbering system within the RIC.   For atypical cases effective January 1, 2010, the HCPCS/Rates must contain a five digit HIPPS Rate/CMG Code A5001.  An atypical case occurs under the new IRF coverage requirements that became effective January 1, 2010, where an IRF is eligible to receive t he IRF short stay payment for 3 days or less (HIPPS Rate/CMG A5001) if a patients thorough preadmission screening shows that the patient is an appropriate candidate for IRF care but then something unexpected happens between the preadmission screening and the IRF admission such that the patient is no longer an appropriate candidate for IRF care on admission and the day count is greater than 3.  In this scenario only, if the patient is discharged/transferred on or after day 4, we are instructing IRFs to bill  HIPPS Rate/CMG A5001.  Thus, whether or not the IRF is able to discharge the patient to another setting of care within 3 days, the IRF will only be eligible for and receive the IRF short stay payment for 3 days or less (HIPPS Rate/CMG A5001).
(Medicare Claims Processing Manual)
Covered Charges should contain zero covered charges when the revenue code is 0024.  For accommodation revenue codes (010x -021x), covered charges must equal the rate times the units.  The IRF Pricer will calculate and return the payment amount for the line item with revenue code 0024.  Non-outlier payments will not be made based on the total charges shown in Revenue Code 0001.   IRF providers will submit one admit through discharge claim for the stay.  Final PPS payment is based upon the discharge bill.   Should the patient's stay overlap the time in which the PPS applies to the facility, PPS payment will still be based on discharge.  If the facility submitted an interim bill, a debit/credit adjustment must be made prior to PPS payment.  If the facility submits multiple  interim bills, the provider will need to submit cancels and then rebill once the cancels are accepted.    IRFs can submit adjustment bills (even to correct the CMG), but late charge bills will not be allowed (Type of bill 115).   If a beneficiary has 1 day of Medicare coverage during their IRF stay, an entire CMG payment will be made.    IRFs will be paid under the IRF PPS beginning on the first day of their cost reporting period that begins on or after January 1, 2002.  Units established in a CAH will be paid under the IRF PPS beginning with CAH cost reporting periods on or after October 1, 2004.  For interim bills, if the stay is greater than 60 days, the interim bill should include the lowest level of the HIPPS code from the admission assessment.  The final claim will be adjusted to reflect data from the discharge assessment.   When coding PPS bills for ancillary services associated with a Part A inpatient stay, the traditional revenue codes will continue to be shown, e.g., 0250 - Pharmacy, 042x - Physical Therapy, in conjunction with the appropriate entries in Service Units and Total Charges.    IRFs are required to report the number of units based on the procedure or service.   IRFs are required to report the actual charge for each line item, in Total Charges.
(Medicare Claims Processing Manual)
 IRFs are required to report the number of units based on the procedure or service.   IRFs are required to report the actual charge for each line item, in Total Charges.   If a beneficiary's Part A benefits exhaust during the stay, code an occurrence code A3 -C3.  If benefits are exhausted prior to the stay, submit a no pay claim, which will be coded by the A/B MAC (A) with no pay code B.  Report any services that can be billed under the Part B benefit using 12X TOB.  NOTE :  For more information on outlier payments when benefits are exhausted, please see 20.7.4.  Although this references an expired instruction specific to inpatient hospital PPS billing, the information presented provides important general information.     140.3.1 - Shared Systems and CWF Edits  (Rev. 11075; Issued: 10- 28-21; Effective: 12 -01-21; Implementation: 12 -01-21)             To ensure that revenue code 0024 is not reported more than once on bill type 11X;    To ensure the claim can be matched to the corresponding Inpatient Rehabilitation Facility  Patient Assessment Instrument (IRF -PAI) assessment in the internet Quality Improvement Evaluation System (iQIES)    To compare applicable inpatient claims with post- acute claims that will allow erroneous claims to be reviewed and appropriate adjustments to be made on an ongoing basis to the discharging hospitals inpatient claim.   To check the incoming claims admission date to the history discharge date for the same provider except when patient status code is 30 (CWF);    To check the incoming claims discharge date to the history admission date for the same provider (CWF);    To reject subsequent claims with the same PPS provider on the same day (CWF);    Ensure accurate coding of patient status codes by checking the incoming claims admission date to the history discharge date;   o CWF accepts the incoming claim and sends an informational unsolicited response to the A/B MAC (A) on the history claim if the patient status code does not match the incoming provider number   o The A/B MAC (A) cancels the history claim to the provider    To check incoming claims discharge date to the history admission date to ensure the appropriate use of the patient status code on the incoming claim;
(Medicare Claims Processing Manual)
o The A/B MAC (A) cancels the history claim to the provider    To check incoming claims discharge date to the history admission date to ensure the appropriate use of the patient status code on the incoming claim;    CWF rejects the incoming claim if the patient status code does not match the provider number;    A/B MAC (A) returns the incoming claim to the provider for correction of the patient status code.    To insure that revenue code 0024 is only on claims submitted by IRF providers.  Bills submitted incorrectly will be returned to the provider.    To insure that a valid HIPPS/CMG rate code is always present with revenue code 0024;    Units entered on the 0024 must be accepted, but are not required.    To insure that revenue code total charges line 0001 must equal the sum of the individual total charges lines;   To insure that the length of stay in the statement covers period, from and through dates equals the total days for accommodations revenue codes 010x-021x, including revenue code 018x (leave of absence)/interrupted stay,   To insure that Occurrence Span Code 74 is present on the claim if there is an interrupted stay < 3 days.  If the interruption is greater than 3 days, the bill should be considered a discharge.  If the patient returns to the IRF by midnight of the 3rd day, the bill continues under the same CMG.  CWF will need to edit to ensure that if another IRF bill comes in during the interrupted stay, it is rejected, as it should be associated with the original CMG; and   If HIPPS rate code is 5101, 5102, 5103, or 5104 patient status must be 20 (Expired)/    The accommodation revenue code 018x (leave of absence) will continue to be used in the current manner including the appropriate occurrence span code 74 and date range.   140.3.1.1 - Actions When a Claim Does Not Match the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF- PAI)   (Rev.  12306; Issued: 10-19- 23; Effective:01 -24-24; Implementation:01 -24-24)   The following outcomes are possible when the HIPPS code on a claim does not match the HIPPS code calculated on the IRF-PAI found in the internet Quality Improvement Evaluation System (iQIES):
(Medicare Claims Processing Manual)
The following outcomes are possible when the HIPPS code on a claim does not match the HIPPS code calculated on the IRF-PAI found in the internet Quality Improvement Evaluation System (iQIES):   o A matching assessment is found. The claim HIPPS code does not match the IRF-PAI HIPPS code, but the transmission date matches causing the claims processing system to use the assessment HIPPS code documented in iQIES for claims processing purposes;  o A matching assessment is found. The claim HIPPS code does not match IRF-PAI HIPPS code, and the transmission date is different causing the claims processing system to use the assessment HIPPS code and date documented in iQIES for claims processing purposes;  o A matching assessment is not found. This causes the claim to Return to Provider (RTP) with Reason Code 37096.   IRFs should be sure to have an IRF-PAI that has completed processing at iQIES before submitting an IRF claim to the Medicare Administrative Contractor. The IRF can verify this by reviewing their IRF-PAI validation report.  If an IRF has inadvertently submitted their claim prior to the corresponding IRF-PAI being accepted in iQIES and the claim has RTPd with Reason Code 37096, simply resubmit the claim once the IRF -PAI has completed processing. This will require communicatio n between the providers billing office and their clinical staff that submits their IRF -PAI.   If a claim is returned because Medicare systems do not find the matching assessment, there is no need to call the QIES Technical Support Office (QTSO) help desk for such billing issues.  If a provider has submitted an IRF- PAI prior to submission of the claim with information that is different from the claim submission for any of the following information:  o Medicare Beneficiary Identifier (IRF -PAI item 2);   o Beneficiary date of birth (IRF -PAI item 6);   o Provider CCN (IRF- PAI item 1B);  o Claim statement covers through dates (IRF-PAI item 40); and  o Claim admission date (IRF -PAI item 12).
(Medicare Claims Processing Manual)
o Provider CCN (IRF- PAI item 1B);  o Claim statement covers through dates (IRF-PAI item 40); and  o Claim admission date (IRF -PAI item 12).   The claim or the IRF -PAI should be corrected (depending on which item had the error) and then the claim resubmitted. If the claim is resubmitted without correcting the appropriate information, the claim will be returned to the provider again.   In most cases the claim is being submitted one (1) day prior to the finalization of the IRF -PAI. IRFs may want to add an additional claim hold day(s) on their claim submission to allow IRF-PAI completing processing and to avoid claims being RTPd with Reas on Code 37096.  When IRF -PAI Assessments Cannot Be Submitted Within 24 Months   A Medicare beneficiary's entitlement date may sometimes be approved or changed retroactively.  Frequently, these cases result in services becoming covered for dates of service that are beyond the Medicare timely filing limit.  Retroactive entitlement is an established exception to the timely filing pe riod, so these claims may be submitted for payment (see Pub. 100-04, chapter 1, section 70.7.2).  iQIES accepts assessments for up to 24 months from the assessment date.  In rare cases, a retroactive entitlement decision may extend back beyond this 24 month period.  Each assessment that cannot be submitted to iQIES because of the 24 month limit will correspond to a Medicare claim for that IRF discharge.    To process the claims for these older dates of service, IRFs should contact their MAC to alert them to the situation and request any special instructions for the timing and coding of the claims.  In addition to any other special instructions, the IRF shall  submit the claims with a note in the Remarks field saying "IRF -PAI over 24 months."   Upon receipt of the claims, the MAC shall take the following actions:
(Medicare Claims Processing Manual)
Upon receipt of the claims, the MAC shall take the following actions:    When the untimely claims are suspended to check for exception requests, confirm the dates of service are over 24 months from the occurrence code 50 date on the claim.   Temporarily turn off the edit that triggers the iQIES finder file, process the affected claims without sending them to iQIES, then turn the edit back on.   Process the IRF claim using the provider -submitted HIPPS code for payment calculations.    140.3.2 - IRF PPS Pricer Software  (Rev. 693, Issued: 09- 30-05, Effective: 10 -01-05, Implementation: 10- 31-05)  The CMS has developed an IRF Pricer Program that calculates the Medicare payment rate.  Pricer will use a variety of inputs listed below to calculate the payment rate.   A.  Inputs to Pricer    Provider Specific File data (see section 20.2.3.1 and Addendum of this chapter for required elements)    Bill Data includes:    Patient Status:    Payment Modification Flag (if condition code is 66, set flag "Y" otherwise use "N.");   Covered Charges;    Discharge Date;    HIPPS/CMG Rate Code;    Length of Stay (LOS);    Covered Days;    Lifetime Reserve Days (LTR)   B.  Data Returned From Pricer   Pricer returns the following information:    PPS Return Code    MSA /CBSA (effective October 1, 2005)    Wage Index    Average LOS    Relative Weight    Total Payment Amount    PPS Federal Payment Amount    Facility Specific Payment Amount   Outlier Payment Amount    Low-Income Payment (LIP) Amount    Teaching Amount (effective October 1, 2005)    LOS    Regular Days Used    LTR Days Used    Transfer Percentage    Facility Specific Rate pre -blend   Standard Payment Amount    PPS federal amount pre -blend   Facility costs    Outlier threshold    Submitted HIPPS/CMG code    PPS Pricer CMG code    Calculation version code   The Pricer is available electronically to the Shared Systems.   140.3.3 - Remittance Advices  (Rev. 3481, Issued: 03- 18-16. Effective: 06 -20-16, Implementation: 06- 20-16)   A remittance advice remark code is used to notify an IRF when the CMG code was changed.
(Medicare Claims Processing Manual)
A remittance advice remark code is used to notify an IRF when the CMG code was changed.   The following reflects the remittance advice messages and associated codes that will appear when communicating claims under this policy.  The CARC below is not included in the CAQH CORE Business Scenarios.   Group Code: N/A  CARC: N/A  RARC: Alert N69  MSN: N/A  150 - Long Term Care Hospitals (LTCHs) PPS  (Rev. 1, 10- 01-03) PM A -02-093  150.1 - Background  (Rev. 1, 10- 01-03)  LTCHs are certified under Medicare as short -term acutecare hospitals that have been excluded from the acute care hospital inpatient prospective payment system (PPS) under 1886(d)(1)(B)(iv)  of the Act and, for   Medicare payment purposes, are generally defined as having an average inpatient length of stay of greater than 25 days.  This PPS replaced the previous reasonable cost -based payment system for LTCHs.  150.2 - Statutory Requirements  (Rev. 1, 10- 01-03)  The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (BBRA), as amended by the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), required that a budget neutral, per discharge PPS for LTCHs based on diagnosis -related groups (DRGs) be implemented for cost reporting periods beginning on or after October 1, 2002.  The CMS satisfied the statutory implementation requirement by establishing October 1, 2002 as the effective date of the LTCH PPS with systems changes to follow.  Payments for LTCH services furnished for cost reporting periods beginning on or after October 1, 2002 are based on the policies set forth in the August 30, 2002 final rule (67 FR 55954).   150.3 - Affected Medicare Providers  (Rev. 11396, Issued:05- 04-22, Effective:10 -01-22, Implementation:10- 03-22)  LTCHs are certified under Medicare as short -term acute care hospitals and, for Medicare payment purposes, are generally defined as having an average inpatient length of stay of greater than 25 days.
(Medicare Claims Processing Manual)
LTCHs are certified under Medicare as short -term acute care hospitals and, for Medicare payment purposes, are generally defined as having an average inpatient length of stay of greater than 25 days.   Veterans Administration Hospitals, hospitals that are reimbursed under state cost control systems approved under 42 CFR Part 403, and hospitals that are reimbursed in accordance with demonstration projects authorized under 402(a) of Public Law 90- 248 (42 U.S.C.  1395b- 1) or 222(a) of Public Law 92- 603 (42 U.S.C. 1395b- 1) are not included in the LTCH PPS.  (See 42 CFR 412.22(c).)   Payment to foreign hospitals will be made in accordance with the provisions set forth in 42 CFR 413.74.  Currently, two of the four Maryland LTCHs included on CMS Certification Number (CCN) database are presently paid in accordance with demonstration projects (i.e., the Maryland "Waiver") and therefore not subject to payments under the LTCH PPS:  Levindal e Hebrew Geriatric Center and Deaton Hospital and Medical Center (now known as University Specialty Hospital).   150.4 - Revision of the Qualification Criterion for LTCHs  (Rev. 208, 06- 18-04)  Under the LTCH PPS, the greater than 25- day average length of stay (ALOS) calculation is based only on a hospital's Medicare inpatients, counting total medically necessary days, not only covered days.  For cost reporting periods beginning on or after October 1, 2002, LTCHs are required to meet this revised criteria in order to qualify as LTCHs for Medicare payment purposes.
(Medicare Claims Processing Manual)
The average Medicare length of stay is calculated by dividing the total number of covered and noncovered days of care provided to Medicare patients, by the Medicare discharges occurring during that period.  If the days of a stay involve days of care furnis hed during two or more separate cost reporting periods, that is, an admission during one cost reporting period and a discharge during a future cost reporting period, the total number of days of the stay are considered to have occurred during the cost repor ting period during which the patient was discharged.  For cost reporting periods beginning on or after July 1, 2004, if a hospital fails to meet the ALOS requirement under this provision, the A/B MAC (A) will determine the ALOS for cost reporting periods beginning on or after July 1, 2004 but before July 1, 2005 by dividing the applicable total days for Medicare inpatients during the cost reporting period when they occur, by the number of discharges occurring during the same cost reporting period.  If the A/B MAC (A) determines that the LTCH does not qualify, A/B MACs (A) are to follow the procedures already established in the Medicare General Information, Eligibility, and Entitlement Manual (CMS Pub. 100-01).  The new manual can be found at http://www.cms.gov/Regulations- and-Guidance/Guidance/Manuals/index.html?redirect=/manuals/cmsindex.asp .  Select Internet-Only Manuals (IOM) from the left side of the page, then select 100-01.  The CMS requires on-going monitoring of LTCH compliance with the above requirements as well as notification by A/B MACs (A) regarding this compliance.  150.5 - Payment Provisions Under LTCH PPS  (Rev. 1, 10-01-03)  Section 123 of Public Law 106-113(BBRA), as amended by 307 of Public Law 106-554(BIPA), authorizes the establishment of Federal payment rates under PPS for LTCHs.  The BIPA confers broad authority on the Secretary to determine what payment system adjustme nts should be included in the LTCH PPS, both on a facility level and on a case-level, to ensure that payment most accurately reflects cost.