evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
190.4.4 - Calculating the Federal Payment Rate  (Rev. 11140, Issued:12-02-21, Effective: 01-04-22, Implementation: 01-04-22)   To calculate an IPF PPS payment, follow the steps below:  1 - Multiply the Federal per diem base rate by the labor share.  2 - Multiply the resulting amount by the appropriate wage index factor.  3 - Multiply the Federal per diem base rate by the non- labor share.   4 - Multiply the resulting amount from this by any applicable cost- of-living adjustment (COLA) (Alaska or Hawaii).   5 - Add the adjusted labor portion of the Rate to the adjusted non-labor portion of the Rate (Add the results of steps 2 and 4).  This is the Federal rate.  You must multiply this sum (step 5) by the all applicable facility and patient level adjustment factors described in 190.5 and 190.6, to calculate the final payment.  190.5 - Patient -Level Adjustments  (Rev. 1543; Issued:  06-27- 08; Effective Date:  07 -01-08; Implementation Date:  07-07-08)  Patient -level adjustments include a DRG, or MS-DRG, adjustment, comorbidity adjustment, an age adjustment, and a variable per diem adjustment.  190.5.1 - Diagnosis - Related Groups (DRGs) Adjustments   (Rev. 4104, Issued: 08- 03-18, Effective: 10 -01-18, Implementation: 10- 01-18)
(Medicare Claims Processing Manual)
(Rev. 4104, Issued: 08- 03-18, Effective: 10 -01-18, Implementation: 10- 01-18)  On claims with discharges before October 1, 2007, the IPF PPS provides adjustments for 15 designated DRGs.  On claims with discharges on or after October 1, 2007, the IPF PPS provides adjustments for 17 designated MS -DRGs.  Payment is made under the IPF PP S for claims with a principal diagnosis included in Chapter Five of the International Classification of Diseases (ICD -9- or ICD -10 as applicable) or the Diagnostic and Statistical Manual of Mental Disorders -Fourth Edition, Text Revision (DSM -IV-TR).  The language about the source of the principal diagnosis code is from our regulations at 42 CFR 412.27, and has been in place since 2006, but there have since been updates to the versions of these code sets.    In a final rule published on September 5, 2012 (77 FR 54664), the Secretary of HHS adopted the ICD 10CM and ICD 10PCS, in place of the ICD 9CM, as the standard medical data code sets for HIPAA covered entities.  Because we are required to use the HIPAA standards, effective October 1, 2015, IPF claims for eligible patients must have a psychiatric principal diagnosis that is listed in the ICD 10CM. It should be noted that the DSM codes map to ICD -10 codes , but the mapping is not exclusive to chapter 5 of the ICD10CM, as it was with ICD 9CM.    Nevertheless, only those claims with diagnoses that group to a psychiatric DRG/MS -DRG will receive the DRG adjustment in addition to all other applicable adjustments.  Although the IPF will not receive a DRG adjustment for a principal diagnosis not found i n one of the following psychiatric DRGs/MS -DRGs, the IPF will receive the Federal per diem base rate and all other applicable adjustments.   IPFs must submit claims providing the principal diagnosis.  To classify the case to the appropriate DRG/MS -DRG, the GROUPER software for the hospital IPPS is used and the IPF PRICER applies the appropriate adjustment factor to the Federal per diem base rat e.
(Medicare Claims Processing Manual)
Changes to the ICD coding system are addressed annually in the IPPS proposed and final rules published each year.  The updated codes are effective October 1 of each year and must be used to report diagnostic or procedure information.  Since the IPF PPS uses the same GROUPER as the IPPS, including the same diagnostic code set and DRG classification system, the IPF PPS is adopting IPPS new MS -DRG coding system in order to maintain that consistency. The updated codes are effective October  1 of each year. Although the code set is being updated, note that these are the same adjustment factors in place since implementation.   Based on changes to the IPPS, the following changes are being made to the principal diagnosis DRGs under the IPF PPS. Below is the crosswalk of current DRGs to the new MS-DRGs which were effective October 1, 2007:    (v24) DRG  Prior to 10/01/07  (v25) MS -DRG From 10/01/07  MS-DRG Descriptions  Adjustment Factor 12 056   057 Degenerative nervous system disorders w MCC   Degenerative nervous system disorders w/o MCC  1.05 023 080  081 Nontraumatic stupor & coma w MCC   Nontraumatic stupor & coma w/o MCC  1.07 424 876 O.R. procedure w principal diagnoses of mental illness  1.22 425 880 Acute adjustment reaction & psychosocial dysfunction  1.05 426 881 Depressive neuroses  0.99 427 882 Neuroses except depressive  1.02 428 883 Disorders of personality & impulse control  1.02 429 884 Organic disturbances & mental retardation  1.03 430 885 Psychoses  1.00 431 886 Behavioral & developmental disorders  0.99 432 887 Other mental disorder diagnoses  0.92 433 894 Alcohol/drug abuse or dependence, left AMA  0.97 521-522 895 Alcohol/drug abuse or dependence w rehabilitation therapy  1.02 523 896   897 Alcohol/drug abuse or dependence w/o rehabilitation therapy w MCC  Alcohol/drug abuse or dependence w/o rehabilitation therapy w/o MCC  0.88
(Medicare Claims Processing Manual)
897 Alcohol/drug abuse or dependence w/o rehabilitation therapy w MCC  Alcohol/drug abuse or dependence w/o rehabilitation therapy w/o MCC  0.88  190.5.2 - Application of Code First  (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)  According to the ICD Official Guidelines for Coding and Reporting, when a principal diagnosis code has a Code First notation, the provider follows the applicable coding convention, which requires the underlying condition (etiology) to be sequenced first, followed by the manifestation due to the underlying condition.  Therefore, CMS considers Code First diagnoses to be the principal diagnosis.  The submitted claim goes through the IPF PPS claims processing system that identifies the principal diagnosis code as non-psychiatric and searches only the first secondary code for a psychiatric code to assign the DRG/MS -DRG in order to pay Code First claims properly.  For more coding guidance, refer to the ICD-9-CM Official Guidelines for Coding and Reporting which can be located on the CDC Web site at:   http://www.cdc.gov/nchs/icd/icd9cm.htm  The ICD -10-CM Official Guidelines are posted on the CDCs website at:   http://www.cdc.gov/nchs/icd/icd10cm.htm   The most current Code First list is posted on the IPF PPS Web site at:   www.cms.gov/InpatientPsychFacilPPS.  Select Tools and Worksheets from the column at the left.   Code First Example - ICD-9- CM  Diagnosis code 294.11 Dementia in Conditions Classified Elsewhere with Behavioral Disturbances is designated as NOT ALLOWED AS PRINCIPAL DX code.   Four digit code 294.1 Dementia in Conditions Classified Elsewhere, is designated as a Code First diagnosis indicating that all 5 digit diagnosis codes that fall under the 294.1 category (codes 294.10 and 294.11) must follow the Code First rule.  The 3 digit code 294 Persistent Mental Disorders Due to Conditions Classified Elsewhere appears in the ICD -9-CM as follows:
(Medicare Claims Processing Manual)
294 - PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE  294.1 - Dementia in Conditions Classified Elsewhere   Code First any underlying physical condition, as:  Dementia in:  Alzheimers disease (331.0) Cerebral lipidosis (330.1) Dementia with Lewy bodies (331.82) Dementia with Parkinsonism (331.81) Epilepsy (345.0 - 345.9) Frontal dementia (331.19) Frontotemporal dementia (331.19) General paresis [syphilis] (094.1)  Hepatolenticular degeneration (275.1)  Huntingtons chorea (333.4)  Jacob -Creutzfeldt disease (046.1)  Multiple sclerosis (340)  Pick's disease of the brain (331.11)  Polyarteritis nodosa (446.0)  Syphilis (094.1)   294.10  Dementia in Conditions Classified Elsewhere Without Behavioral Disturbances   NOT ALLOWED AS PRINCIPAL DX   294.11  Dementia in Conditions Classified Elsewhere With Behavioral Disturbances   NOT ALLOWED AS PRINCIPAL DX   According to Code First requirements, the provider would code the appropriate physical condition first, for example, 333.4 Huntingtons Chorea as the principal diagnosis code and 294.11 Dementia In Conditions Classified Elsewhere With Behavioral Disturbances as a secondary diagnosis or comorbidity code on the patient claim.   The purpose of this example is to demonstrate proper coding for a Code First situation.  However, in this case, the principal diagnosis groups to one of the 15 DRGs, or 17 MS -DRGs, for which CMS pays an adjustment.  Had the diagnosis code grouped to a non-psychiatric DRG/MS -DRG, the PRICER would search the first of the other diagnosis codes for a psychiatric code listed in the Code First list in order to assign a DRG adjustment.   Code First Example -  ICD- 10-CM  Diagnosis code F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance is designated as NOT ALLOWED AS PRINCIPAL DX code.
(Medicare Claims Processing Manual)
Code First Example -  ICD- 10-CM  Diagnosis code F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance is designated as NOT ALLOWED AS PRINCIPAL DX code.   The three digit code F02 Dementia in other diseases classified elsewhere, is designated as a Code First diagnosis indicating that all diagnosis codes that fall under the F02 category (codes F02.80 and F02.81) must follow the Code First rule.  The 3 digit  code F02 Dementia in other diseases classified elsewhere appears in the ICD -10-CM as follows:   F02 Dementia in other diseases classified elsewhere   Code first the underlying physiological condition, such as:  Alzheimer's (G30.0 -  G30.9)  cerebral lipidosis (E75.4)  Creutzfeldt -Jakob disease (A81.0 -  A81.09)  dementia with Lewy bodies (G31.83)  epilepsy and recurrent seizures (G40 - G40.919)  frontotemporal dementia (G31.09)  hepatolenticular degeneration (E83.0)  human immunodeficiency virus [HIV] disease (B20)  hypercalcemia (E83.52)  hypothyroidism, acquired (E00 -  E03.9)  intoxications (T36 -  T65)  Jakob- Creutzfeldt disease (A81.00 -  A81.09)  multiple sclerosis (G35)  neurosyphilis (A52.17)  niacin deficiency [pellagra] (E52)  Parkinson's disease (G20)  Pick's disease (G31.01)  polyarteritis nodosa (M30.0)  systemic lupus erythematosus (M32 -  M32.9)  trypanosomiasis (B56 -  B57.39)  vitamin B deficiency (E53.8)   F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance   NOT ALLOWED AS PRINCIPAL DX   F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance   NOT ALLOWED AS PRINCIPAL DX
(Medicare Claims Processing Manual)
F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance   NOT ALLOWED AS PRINCIPAL DX   F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance   NOT ALLOWED AS PRINCIPAL DX   According to Code First requirements, the provider would code the appropriate physical condition first, for example, G20 Parkinsons disease as the principal diagnosis code and F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance as a secondary diagnosis or comorbidity code on the patient claim.   190.5.3 - Comorbidity Adjustments   (Rev. 4104, Issued: 08- 03-18, Effective: 10 -01-18, Implementation: 10- 01-18)  Comorbidities are specific patient conditions that are secondary to the patient's principal diagnosis and that require treatment during the stay.  Diagnoses that relate to an earlier episode of care and have no bearing on the current hospital stay are excl uded and not reported on IPF claims.  Comorbid conditions must co- exist at the time of admission, develop subsequently, affect the treatment received, affect the length of stay or affect both treatment and the length of stay.  IPFs enter the full codes for  up to twenty four additional diagnoses if they co- exist at the time of admission or develop subsequently.  The IPF PPS has 17 comorbidity categories, each containing codes of comorbid conditions.  Each comorbidity grouping will receive a grouping- specific adjustment.  Facilities can receive only one comorbidity adjustment per comorbidity category, but can recei ve an adjustment for more than one comorbidity category on the claim.  The IPF PRICER then applies the appropriate adjustment factors to the Federal per diem base rate.   A list of the ICD -10-CM/PCS codes that are associated with each category is on the IPF PPS Web site at http://www.cms.gov/Medicare/Medicare- Fee-for-Service -Payment/InpatientPsychFacilPPS/index.html?redirect=/inpatientpsychfacilpps .  Select Tools and Worksheets from the column at the left.
(Medicare Claims Processing Manual)
The 17 comorbidity categories and specific adjustments are as follows:  Description of Comorbidity  Adjustment Factor  Developmental Disabilities  1.04 Coagulation Factor Deficits  1.13 Tracheostomy  1.06 Renal Failure, Acute  1.11 Renal Failure, Chronic  1.11 Oncology Treatment  1.07 Uncontrolled Diabetes -Mellitus with or without complications  1.05 Severe Protein Calorie Malnutrition  1.13 Eating and Conduct Disorders  1.12 Infectious Disease  1.07 Drug and/or Alcohol Induced Mental Disorders  1.03 Cardiac Conditions  1.11 Gangrene  1.10 Chronic Obstructive Pulmonary Disease  1.12 Artificial Openings - Digestive and Urinary  1.08 Severe Musculoskeletal and Connective Tissue Diseases  1.09 Poisoning  1.11  190.5.4 - Age Adjustments  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  The IPF PPS has an age adjustment with 9 age categories; under 45, over 80, and categories in 5 year groupings in between.  IPFs receive this adjustment for each day of the stay.  The age adjustment is determined based on the age at admission and does not change regardless of the length of stay.  Age Adjustment Factor  Under 45  1.00 45 and under 50  1.01 50 and under 55  1.02 55 and under 60  1.04 60 and under 65  1.07 65 and under 70  1.10 70 and under 75  1.13 75 and under 80  1.15 80 and over  1.17  190.5.5 - Variable Per Diem Adjustments (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  The variable per diem adjustments account for the ancillary and certain administrative costs that occur disproportionately in the first days after admission to an IPF.  The variable per diem adjustments decline each day of the patients stay through day 21.  After day 21, the adjustments remain the same each day for the remainder of the stay.
(Medicare Claims Processing Manual)
Day-of-Stay  Variable Per Diem Payment Adjustment*  Day 1 - Facility Without a Qualifying Emergency Department  1.19 Day 1 - Facility With a Qualifying Emergency Department  1.31 Day 2  1.12 Day 3  1.08 Day 4  1.05 Day 5  1.04 Day 6  1.02 Day 7  1.01 Day 8  1.01 Day 9  1.00 Day 10  1.00 Day 11  0.99 Day 12  0.99 Day 13  0.99 Day-of-Stay  Variable Per Diem Payment Adjustment*  Day 14  0.99 Day 15  0.98 Day 16  0.97 Day 17  0.97 Day 18  0.96 Day 19  0.95 Day 20  0.95 Day 21  0.95 Over 21  0.92  *The adjustment for day 1 would be 1.31 or 1.19 depending on whether the IPF has a qualifying emergency department or is a psychiatric unit in an acute care hospital or CAH with a qualifying emergency department (see 190.6.4).  190.6 - Facility-Level Adjustments  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  Facility -level adjustments include the hospital wage index, a rural location adjustment, a teaching status adjustment, an emergency department adjustment for qualifying EDs, and a cost -of-living adjustment for IPFs located in Alaska and Hawaii.
(Medicare Claims Processing Manual)
Facility -level adjustments include the hospital wage index, a rural location adjustment, a teaching status adjustment, an emergency department adjustment for qualifying EDs, and a cost -of-living adjustment for IPFs located in Alaska and Hawaii.  190.6.1 - Wage Index  (Rev. 11543, Issued: 08-04-22, Effective: 10-01-22, Implementation: 10-03-22)   The wage index accounts for the geographic differences in labor costs. Prior to Fiscal Year 2020, the IPF PPS used the unadjusted, pre- floor, pre -reclassified hospital wage index from the prior year as the basis for the IPF wage index. Beginning with Fiscal Year 2020, the IPF PPS uses the concurrent unadjusted, pre-floor, pre- reclassified hospital wage index as the basis for the IPF wage index. The wage index is applied to the labor- related share of the Federal per diem base rate.  Core -Based Statistical Area (CBSA) designations are used for assigning a wage index value for discharges occurring on or after October 1. Updates to the IPF PPS wage index are made in a budget neutral manner. CMS calculates a budget -neutral wage index adjustment factor by comparing estimated payments under the previous wage index to estimated payments under the updated wage index. This factor is applied in the update to the Federal per diem base rate.   Beginning in FY 2023 a five percent cap will be applied on any decrease to a providers wage index from that providers final wage index in the prior fiscal year. For subsequent years, a provider's wage index would not be less than 95 percent of its wage index calculated in the prior FY. A new IPF will be paid the wage index for the area in which it is geographically located for its first full or partial FY with no cap applied, because a new IPF will not have a wage index in the prior FY.  190.6.2 - Rural Location Adjustment  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  There is a 17 percent adjustment if a facility is located in  a rural area.  The IPF PPS defines urban and rural areas at 42 CFR 412.402.
(Medicare Claims Processing Manual)
There is a 17 percent adjustment if a facility is located in  a rural area.  The IPF PPS defines urban and rural areas at 42 CFR 412.402.  190.6.3 - Teaching Status Adjustment  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  IPFs that train interns and residents receive a facility -level adjustment to the Federal per diem base rate.  The cost of direct graduate medical education (DGME) and nursing and allied health education are not paid through the IPF PPS.  PRICER calculates the adjustment by adding 1 to the ratio of interns and residents to the average daily census (ADC), and then raising that sum to the 0.5150 power.  The number of interns and residents is capped at the level indicated on the latest cost report submitted by the IPF prior to November 15, 2004.  (See 190.6.3.1 for more detailed instructions for the FTE Resident Cap).  For beneficiaries enrolled in a Medicare Advantage plan, IPFs may bill for DGME and nursing and allied health education costs.  There is no authority to pay teaching status adjustment to IPFs for Medicare Advantage beneficiaries, as is done under the IPPS.   190.6.3.1 - Full-Time Equivalent (FTE) Resident Cap  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  There is a cap on the number of FTE residents that may be counted for purposes of calculating the teaching adjustment.  There is no limit to the number of residents teaching institutions can hire or train.  There is only a limit to the number of residents who may be counted in calculation of the IPF PPS teaching adjustment.  The cap is the number of FTE residents that trained in the IPF during a base year.
(Medicare Claims Processing Manual)
An IPFs FTE resident cap is determined based on the IPFs most recently filed cost report, filed prior to November 15, 2004.  IPFs that first began training residents after November 15, 2004, will initially receive an FTE cap of zero.  The FTE caps for ne w IPFs (as well as existing IPFs) that start training residents in a new DGME program (as defined in 42 CFR 413.79(1)) may be subsequently adjusted in accordance with the policies that are being applied in the IPF PPS (as described in 42 CFR 412.424(d)(1)(iii)(B)(2) ).  IPFs are not permitted to aggregate the FTE resident caps used to compute the IPF PPS teaching status adjustment through affiliation agreements.  Residents with less than full-time status and residents rotating through the psychiatric hospital or unit for less than a full year are counted in proportion to the time they spend in their assignment with the IPF (for example, a resident on a full -time, 3 -month rotation to the IPF would be counted as 0.25 FTEs for purposes of counting residents to calculate the ratio).  No F TE resident time counted for purposes of the IPPS Indirect Medical Education (IME) adjustment is allowed to be counted for purposes of the teaching status adjustment under the IPF PPS.   The denominator used to calculate the teaching status adjustment under the IPF PPS is the IPFs ADC from the current cost reporting period.  If IPFs have more FTE residents in a given year than in the base year (the base year being used to establish the ca p) payments are based on the lower number (the cap amount) in that year.  If an IPF were to have fewer FTE residents in a given year than in the base year (that is, fewer residents than its FTE resident cap) an adjustment in payments in that year is based on the lower number (the actual number of FTE residents the facility trains).   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)
(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.