evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
When reprocessing claims due to outlier reconciliation, Medicare contractors shall maintain an accurate history of certain fields in the provider specific file (PSF). This history is necessary to ensure that claims already processed (from prior cost reporting periods that have already been settled) will not be subject to a duplicate systems adjustment in the event that claims need to be reprocessed. As a result, the following fields in the PSF can only be altered on a prospective basis: - 23 -Intern to Bed Ratio - 24 --Bed Size - 25 -Operating Cost to Charge Ratio and 21 - Case Mix Adjusted Cost Per Discharge. A separate history outside of the PSF is not necessary. The only insta nces a Medicare contractor retroactively changes a field in the PSF is to update the CCR when using the FISS Lump Sum Utility for outlier reconciliation or otherwise specified by the CMS Regional Office or Central Office.   190.7.2.3 - Outlier Reconciliation  (Rev. 2242, Issued: 06- 17-11, Effective: 07 -01-11, Implementation: 07- 01-11)  A. - General   Under 412.424 (d) (3) (i ), for IPF services furnished during cost reporting periods beginning on or after January 1, 2005, IPF outlier payments may be reconciled upon cost report settlement to account for differences between the overall ancillary CCR used to pay the claim at its original submission by the provider, and the CCR determined at final settlement of the cost reporting period during which the service was furnished. IPF PPS outlier payments are reconciled if the CMS Central Office and Regional Office confirm that reconcil iation is appropriate.   Effective for cost reporting periods beginning on or after April 1, 2011, subject to the approval of the CMS Central Office and Regional Office, the Medicare contractor shall reconcile an IPFs outlier claims at the time of cost report final settlement if they meet the following criteria:   1. The actual CCR is found to be plus or minus 10 percentage points from the CCR used during that time period to make outlier payments, and   2. Total IPF outlier payments in that cost reporting period exceed $500,000.
(Medicare Claims Processing Manual)
To determine if an IPF meets the criteria above, the Medicare contractor shall incorporate all the adjustments from the cost report, run the cost report, calculate the revised CCR, and compute the actual overall ancillary CCR prior to issuing a Notice of Program Reimbursement (NPR). If the criteria for IPF outlier reconciliation are not met, the cost report shall be finalized. If the criteria for reconciliation are met, Medicare contractors shall follow the instructions below i n 190.7.2.5 of this chapter. The NPR cannot be issued nor can the cost report be finalized until IPF outlier reconciliation is complete. These IPF cost reports will remain open until their claims have been processed for IPF PPS outlier reconciliation.   As stated above, if a cost report is reopened after final settlement and as a result of this reopening there is a change to the CCR (which could trigger or affect IPF PPS outlier reconciliation and outlier payments), Medicare contractors shall notify the C MS Central and Regional Offices for further instructions. Notification to the CMS Central Office shall be sent to the address and email address provided in 190.7.2.2(B) above.   Medicare contractors shall notify the CMS Central Office and Regional Office if a cost report was final settled and meets the qualifications for IPF PPS outlier reconciliation. Notification to the CMS Central Office shall be sent to the address and email address provided in 190.7.2.2 (B).  B. - Reconciling Outlier Payments IPFs   Beginning with the first cost reporting period starting on or after January 1, 2005, IPF 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 su bmission by the provider, and the CCR determined at final settlement of the cost reporting period during which the discharge occurred.  Effective for cost reporting periods beginning on or after April 1, 2011, if an IPF meets the criteria in part A of this  section, the Medicare contractor shall follow the instructions below in 190.7.2.5. The following examples demonstrate how to apply the criteria for reconciliation (as discussed in part A above):   EXAMPLE A:   Cost Reporting Period:  01/01/2010- 12/31/2010
(Medicare Claims Processing Manual)
EXAMPLE A:   Cost Reporting Period:  01/01/2010- 12/31/2010  Operating CCR used to pay original claims submitted during cost reporting period:  0.40  (In this example, this CCR is from the tentatively or final settled 2007 cost report)   Final settled operating CCR from 01/01/2010- 12/31/2010 cost report:  0.50  Total IPF PPS outlier payout in 01/01/2010- 12/31/2010 cost reporting period:  $600,000  Because the CCR of 0.40 used at the time the claim was originally paid changed to 0.50 at the time of final settlement, and the provider received greater than $500,000 in IPF PPS outlier payments during that cost reporting period, the criteria are met for reconciliation, and therefore, the Medicare contractor notifies the Central Office and the Regional Office. The providers IPF PPS outlier payments for this cost reporting period are reconciled using the correct CCR of 0.50.  In the event that multiple CCRs are used in a given cost reporting period to calculate outlier payments, Medicare contractors should calculate a weighted average of the CCRs in that cost reporting period. Example B below shows how to weight the CCRs. The Medicare contractor shall then compare the weighted CCR to the CCR determined at the time of final settlement of the cost reporting period to determine if IPF PPS outlier reconciliation is required. Total IPF PPS outlier payments for the entire cost reporting period must exceed $500,000 in order to trigger reconciliation.  EXAMPLE B:   Cost reporting period:  01/01/2010- 12/31/2010   Overall CCR used to pay original claims submitted during cost reporting period:     0.40 from 01/01/2010 to 03/31/2010 (This CCR could be from the tentatively settled 2006 cost report.)    0.50 from 04/01/2010 to 12/31/2010 (This CCR could be from the tentatively settled 2007 cost report.)   Final settled operating CCR from 01/01/2010 -  12/31/2010 cost report:  0.35   Total IPF outlier payout in 01/01/2010 - 12/31/2010 cost reporting period:  $600,000  Weighted average CCR:  0.476
(Medicare Claims Processing Manual)
Total IPF outlier payout in 01/01/2010 - 12/31/2010 cost reporting period:  $600,000  Weighted average CCR:  0.476   CCR  DAYS  Weight  Weighted CCR  0.40 90 0.247 (90 Days / 365 Days)  (a) 0.099 = (0.40 * 0.247)  0.50 275 0.753 (275 Days / 365 Days)  (b) 0.377 = (0.50 * 0.753)  TOTAL  365 365 (a)+(b) = 0.476   The IPF meets the criteria for IPF PPS outlier reconciliation in this cost reporting period because the variance from the weighted average CCR at the time the claim was originally paid compared to the CCR from the cost report at the time of settlement is g reater than 10 percentage points (from 0.476 to 0.35) and the provider received total IPF outlier payments greater than $500,000 for the entire cost reporting period.   Even if the IPF does not meet the criteria for reconciliation in 190.7.2.3, subject to approval of the CMS Central and Regional Offices, the Medicare contractor has the discretion to request that IPF PPS outlier payments in a cost reporting period be reconciled if the IPFs most recent cost and charge data indicate that the IPF PP S outlier payments to the IPF were significantly inaccurate. The Medicare contractor sends notification to the CMS Regional Office and Central Office via the address and email address provided in 190.7.2.2 (B).  Upon approval of the CMS Central and Regional Office that IPFs outlier claims need to be reconciled, Medicare contractors should follow the instructions in 190.7.2.3.  190.7.2.4 - Time Value of Money (Rev. 2242, Issued: 06- 17-11, Effective: 07 -01-11, Implementation: 07- 01-11)
(Medicare Claims Processing Manual)
Effective for discharges occurring on or after January 1, 2005, at the time of any reconciliation under 190.7.2, IPF outlier payment may be adjusted to account for the time value of money of any adjustments to IPF outlier payments as a result of reconciliation.  The time value of money is applied from the midpoint of the IPFs cost reporting period being settled to the date on which the CMS Central Office receives notificatio n from the Medicare contractor that reconciliation should be performed.  If an IPFs outlier payments have met the criteria for reconciliation, Medicare contractors will calculate the aggregate adjustment using the instructions below concerning reprocessing claims and determine the additional amount attributable to the time value of money of that adjustment.  The index that will be used to calculate the time value of money is the monthly rate of return that the Medicare trust fund earns.  This index can be found at http://www.ssa.gov/OACT/ProgData/newIssueRates.html.  The following formula shall be used to calculate the rate of the time value of money.  (Rate from Web site as of the midpoint of the cost report being settled / 365) * # of days from that midpoint until date of reconciliation. NOTE : The time value of money can be a positive or negative amount depending if the provider is owed money by CMS or if the provider owes money to CMS.  For purposes of calculating the time value of money, the date of reconciliation is the day on which the CMS Central Office receives notification.  This date is either the postmark from the written notification sent to the CMS Central Office via mail by the Medicare contractor, or the date an email was received from the Medicare contractor by the CMS Central Office, whichever is first.
(Medicare Claims Processing Manual)
EXAMPLE C:  Cost reporting period:  01/01/2010 - 12/31/2010  Midpoint of cost reporting period:  07/01/2010  Date of reconciliation:  12/31/2010  Number of days from midpoint until date of reconciliation:  547  Rate from Social Security Web site:  4.625%   Overall ancillary CCR used to pay actual original claims in cost reporting period:  0.40 (This CCR could be from the tentatively settled 2006 or 2007 cost report.)  Final settled operating CCR from 01/01/2009 - 12/31/2009 cost report:  0.50  Total IPF outlier payout in 01/01/2009 - 12/31/2009 cost reporting period:  $600,000  Because the CCR fluctuated from 0.40 at the time the claims were originally paid to 0.50 at the time of final settlement and the provider has an IPF outlier payout greater than $500,000, the criteria have been met to trigger reconciliation. The Medicare contractor follows the procedures in 190.7.2.4.  The reprocessing of claims indicates the revised IPF hospital outlier payments are $700,000.  Using the values above, the rate that is used for the time value of money is determined:  (4.625 / 365) * 548 = 6.9438%   Based on the claims reconciled, the provider is owed $100,000 ($700,000 -  $600,000) for the reconciled amount and $6,943.80 for the time value of money.   190.7.2.5 - Procedures for Medicare Contractors to Perform and Record Outlier Reconciliation Adjustments  (Rev.  2111, Issued: 12- 03-10, Effective: 04 -01-11, Implementation: 04- 04-11)   The following is a step- by-step explanation of the procedures that Medicare contractors are to follow if an IPF is eligible for outlier reconciliation:
(Medicare Claims Processing Manual)
The following is a step- by-step explanation of the procedures that Medicare contractors are to follow if an IPF is eligible for outlier reconciliation:   1) The Medicare contractor shall send notification to the CMS Central Office (not the hospital), via the street address and email address provided in 190.7.2.2 (B), and CMS Regional Office that a hospital has met the criteria for reconciliation. Medicare contractors shall include in their notification the provider number, provider name, cost reporting begin date, cost reporting end date, total outlier payments in the cost reporting period, the CCR or weighted average CCR from the time the claims were paid dur ing the cost reporting period eligible for reconciliation and the final settled CCR.   2) If the Medicare contractor receives approval from the CMS Central Office that reconciliation is appropriate, the Medicare contractor shall follow steps 3- 14 below. NOTE : Hospital cost reports will remain open until their claims have been processed for outlier reconciliation.  3) The Medicare contractor shall notify the hospital and copy the CMS Regional Office and Central Office in writing and via email (through the addresses provided in 190.7.2.2 (B) ) that the hospitals outlier claims are to be reconciled.   4) Prior to running claims in the *Lump Sum Utility, Medicare contractors shall update the applicable provider record in the Provider Specific File (PSF) by entering the final settled CCR from the cost report in the - 25 -Operating Cost to Charge Ratio field. No other elements in the PSF shall be updated for the applicable provider records in the PSF that span the cost reporting period being reconciled aside from the CCR.   *NOTE : The FISS Lump Sum Utility is a Medicare contractor tool that, depending on the elements that are input, will produce an extract that will calculate the difference between the original PPS payment amounts and revised PPS payment amounts into a Microsoft A ccess generated report. The Lump Sum Utility calculates the original and revised payments offline and will not affect the original claim payment amounts as displayed in various CMS systems (such as NCH).   5) Medicare contractors shall ensure that, prior to running claims through the FISS Lump Sum Utility, all pending claims (e.g., appeal adjustments) are finalized for the applicable provider.   6) Medicare contractors shall only run claims in the Lump Sum Utility that meet the following criteria:
(Medicare Claims Processing Manual)
6) Medicare contractors shall only run claims in the Lump Sum Utility that meet the following criteria:    Type of Bill (TOB) equals 11X   Previous claim is in a paid status (P location) within FISS   Cancel date is blank   7) The Medicare contractor reconciles the claims through the IPF Pricer software and not through any editing or grouping software.   8) Upon completing steps 3 through 7 above, the Medicare contractor shall run the claims through the Lump Sum Utility. The Lump Sum Utility will produce an extract, according to the elements in Table 1 below. NOTE :  The extract must be importable by Microsoft Access or a similar software program (Microsoft Excel).   9) Medicare contractors shall upload the extract into Microsoft Access or a similar software program to generate a report that contains elements in Table 1. Medicare contractors shall ensure this report is retained with the cost report settlement work papers.   10) For hospitals paid under the IPF PPS, the Lump Sum Utility will calculate the difference between the original outlier amount (value code 17) and the revised outlier amount (value code 17). If the difference between the original and revised outlier amount (calculated by the Lump Sum Utility) is positive, then a credit amount (addition) shall be issued to the provider. If the difference between the original and revised outlier amount (calculated by the Lump Sum Utility)  is negative , then a debit amount (deduc tion) shall be issued to the provider.
(Medicare Claims Processing Manual)
11) Medicare contractors shall determine the applicable time value of money amount by using the calculation methodology in 190.7.2.4. If the difference between the original and revised outlier amount (calculated by the Lump Sum Utility) is a negative amount then the time value of money is also a negative amount. If the difference between the original and revised outlier amount (calculated by the Lump Sum Utility) is a positive amount then the time value of money is also a positive amount.  Similar to step 10, i f the time value of money is positive, then a credit amount (addition) shall be issued to the provider. If the time value of money is negative, then a debit amount (deduction) shall be issued to the provider. NOTE : The time value of money is applied to the difference between the original outlier amount (value code 17) and the revised outlier amount (value code 17).  12) For cost reporting periods beginning before May 1, 2010, under cost report 2552-96, the Medicare contractor shall record the original outlier amount from Worksheet E -3, Part 1 line 1.09, the outlier reconciliation adjustment amount ( the difference between the original outlier amount (value code 17) and the revised outlier amount (value code 17) calculated by Lump Sum Utility) , the total time value of money and the rate used to calculate the time value of money on lines 50-53, of Worksheet E-3, Part 1 of the cost report ( NOTE : the amounts recorded on lines 50, 51 and 53 can be positive or negative amounts per the instructions above). The total outlier reconciliation amount ( the difference between the original outlier amount (value code 17) and the revised outlier amount (value code 17) calculated by the Lump Sum Utility plus the time value of money ) shall be recorded on line 15.99 of Worksheet E-3, Part 1. For complete instructions on how to fill out these lines please see  3633.1 of the Provider Reimbursement Manual, Part II.
(Medicare Claims Processing Manual)
For cost reporting periods beginning on or after May 1, 2010, under cost report 2552-10, the Medicare contractor shall record the original outlier amount from Worksheet E -3, Part II line 2, the outlier reconciliation adjustment amount ( the difference between the original outlier amount (value code 17) and the revised outlier amount (value code 17) calculated by the Lump Sum Utility ), the total time value of money and the rate used to calculate the time value of money on lines 50-53, of Worksheet E- 3, Part II o f the cost report ( NOTE : the amounts recorded on lines 50, 51 and 53 can be positive or negative amounts per the instructions above). The total outlier reconciliation amount ( the difference between the original outlier amount (value code 17) and the revised outlier amount (value code 17) calculated by the Lump Sum Utility plus the time value of money ) shall be recorded on line 29 of Worksheet E-3, Part II.   13) The Medicare contractor shall finalize the cost report, issue a NPR and make the necessary adjustment from or to the provider.  14) After determining the total outlier reconciliation amount and issuing a NPR, Medicare contractors shall restore the CCR(s) to their original values (that is, the CCRs used to pay the claims) in the applicable provider records in the PSF to ensure an accurate history is maintained. Specifically, for hospitals paid under the IPF PPS, Medicare contractors shall enter the original CCR in PSF field 25 -Operating Cost to Charge Ratio.  Medicare contractors shall contact the CMS Central Office via the address and email address provided in 190.7.2.2 (B) with any questions regarding this process.  Table 1:  Data Elements for FISS Extract
(Medicare Claims Processing Manual)
List of Data Elements for FISS Extract  Provider #  Health Insurance Claim (HIC) Number  List of Data Elements for FISS Extract  Document Control Number (DCN)  Type of Bill  Original Paid Date  Statement From Date  Statement To Date  Original Reimbursement Amount (claims page 10)  Revised Reimbursement Amount (claim page 10)  Difference between these amounts  Original Deductible Amount, Payer A, B, C (Value Code A1, B1, C1)  Revised Deductible Amount, Payer A, B, C (Value Code A1, B1, C1)  Difference between these amounts  Original Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2)  Revised Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2)  Difference between these amounts  Original Outlier Amount (Value Code 17)  Revised Outlier Amount (Value Code 17)  Difference between these amounts  Original DSH Amount (Value Code 18)  Revised DSH Amount (Value Code 18)  Difference between these amounts  Original IME Amount (Value Code 19)  Revised IME Amount (Value Code 19)  Difference between these amounts  Original New Tech Add -on (Value Code 77)  Revised New Tech Add -on (Value Code 77)  Difference between these amounts  Original Device Reductions (Value Code D4)  Revised Device Reductions (Value Code D4)  Difference between these amounts  Original Hospital Portion (claim page 14)  Revised Hospital Portion (claim page 14)  Difference between these amounts  Original Federal Portion  (claim page 14)  Revised Federal Portion  (claim page 14)  Difference between these amounts  Original C TOT PAY (claim page 14) Revised C TOT PAY (claim page 14)  Difference between these amounts  Original C FSP (claim page 14)  Revised C FSP (claim page 14)  Difference between these amounts  Original C OUTLIER (claim page 14)  Revised C OUTLIER (claim page 14)  Difference between these amounts  Original C DSH ADJ (claim page 14)  Revised C DSH ADJ (claim page 14)  List of Data Elements for FISS Extract  Difference between these amounts  Original C IME ADJ (claim page 14)  Revised C IME ADJ (claim page 14)  Difference between these amounts  Original Pricer Amount  Revised Pricer Amount  Difference between these amounts  Original PPS Payment (claim page 14)  Revised PPS Payment (claim page 14)  Difference between these amounts  Original PPS Return Code (claim page 14)  Revised PPS Return Code
(Medicare Claims Processing Manual)
amounts  Original Pricer Amount  Revised Pricer Amount  Difference between these amounts  Original PPS Payment (claim page 14)  Revised PPS Payment (claim page 14)  Difference between these amounts  Original PPS Return Code (claim page 14)  Revised PPS Return Code (claim page 14)  DRG  MSP Indicator (Value Codes 12 -16 & 41 -43 - indicator indicating the claim is MSP; Y = MSP, blank = no MSP  Reason Code  HMO -IME Indicator  Filler
(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.