evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
In the regulations at 42 CFR 412.521(e) we provide a payment methodology for such cases in which Medicare will consider all the days of the patient stay in the facility (both prior to and following the date of LTCH designation) to be a single episode of LTCH care. Payment for this single episode of care will include the day and cost data for that patient at both the acute care hospital and the LTCH in determining the payment to the LTCH under the LTCH PPS.  Furthermore, the days of the patients stay both prior to and following designation as a LTCH are counted in determining the patients total length of stay at the LTCH both for payment purposes as well as for the LTCHs avera ge length of stay (ALOS) calculation under 42 CFR 412.23(e)(2) and (3).   Bills paid to the facility for crossover patients when the facility was paid under IPPS must be canceled, so that the entire stay can be billed under the LTCH provider number and paid for under LTCH PPS.  150.15 - System Edits  (Rev. 1472, Issued: 03- 06-08, Effective: 05 -23-07, Implementation: 04- 07-08)  The Shared systems and/or Common Working File (CWF) must ensure:    That revenue code total charges line 0001 must equal the sum of the individual total charges lines;    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;    That Occurrence Span Code 74 is present on the claim when there is an interrupted stay (the beneficiary has returned to the LTCH in a specified amount of time).  See section 150.9.1.2.
(Medicare Claims Processing Manual)
 That Occurrence Span Code 74 is present on the claim when there is an interrupted stay (the beneficiary has returned to the LTCH in a specified amount of time).  See section 150.9.1.2.  If the interruption is greater than the specified number of days applicable to the specific provider, the bill is considered a discharge and two bills would exist if the beneficiary returns to the same LTCH, otherwise it is considered an interruption with one DRG payment associated.  CWF will edit for both of these situations.  Payments under the onsite discharge and readmittance policy are to be reconciled at cost report settlement, at which time it is possible to determine the total number of such cases that have occurred during that cost reporting period.  The accommodation revenue code 018X, (leave of absence) continues to be used in the current manner in terms of Occurrence Span code 74 and date range.   150.16 - Billing Ancillary Services Under LTCH PPS  (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)   When coding PPS bills for ancillary services associated with a Part A inpatient stay, the traditional revenue codes are shown, in conjunction with the appropriate entries in Service Units and Total Charges.    LTCHs are required to report the number of units based on the procedure or service.    LTCHs are required to report the actual charge for each line item, in Total Charges.    In general the current policy applies for billing ancillary services and nothing changes with the implementation of this PPS.   150.17 - Benefits Exhausted  (Rev. 1472, Issued: 03- 06-08, Effective: 05 -23-07, Implementation: 04- 07-08)  The day benefits exhaust is considered a discharge for payment purposes under LTCH PPS.   If a beneficiary's Part A benefits exhaust during the stay, providers code an Occurrence Code A3- C3.  If benefits are exhausted prior to the stay, hospitals submit a no- pay claim that is to be coded by the A/B MAC (A) with no pay code B.
(Medicare Claims Processing Manual)
LTCH PPS uses Occurrence Code 47 to indicate the first full day of cost outlier status and also uses Occurrence Span Code 70 for covered non- utilization periods beyond the short -stay outlier threshold.  There is an exception if there are not enough regular  days to reach the short -stay outlier threshold point.  For the beneficiary to continue coverage, LTR days must be utilized for the remainder of the entire stay, as available.  Similarly, for the beneficiary to continue coverage, if only LTR days are avail able, they must be used on a continuous basis throughout the entire stay, as available.  150.17.1 - Assumptions for Use in Examples Below  (Rev. 1, 10- 01-03)  1.  Cost outlier threshold amount is $50,000  2.  Threshold amount is reached on the 25th day  3.  The DRG ALOS equals 12 days, therefore, the Short Stay Threshold equals 10 days  4.  Billed charges are $3,000 per day for the first 12 days, $2,000 on the 13 th day and $1,000 each day thereafter   5.  Beneficiary elects to use any available LTR days   150.17.1.1 - Example 1: Coinsurance Days < Short Stay Outlier Threshold (30 Day Stay)  (Rev. 1, 10- 01-03)  1a. Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $55,000  Benefits available: 9 coinsurance and 60 LTR   Covered days: 30   Noncovered days: 0   Coinsurance days used: 9  LTR days used: 21  Cost report days: 30  Reimbursement: Full DRG payment plus cost outlier based on $55,000 covered charges   1b.  Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $27,000  Benefits available: 9 coinsurance and 0 LTR   Covered days: 9   Noncovered days: 21   Coinsurance days used: 9   LTR days used: 0  Cost report days: 9  OC A3: 1/09/03  Reimbursement: Short stay outlier   1c.  Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $50,000  Benefits available: 9 coinsurance and 10 LTR   Covered days: 19
(Medicare Claims Processing Manual)
1c.  Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $50,000  Benefits available: 9 coinsurance and 10 LTR   Covered days: 19   Noncovered days: 11   Coinsurance days used: 9  LTR days used: 10  Cost report days: 25  OC 47: 1/26/03   OC A3: 1/25/03  OSC 70: 1/20/03 -  1/25/03  Reimbursement: Full DRG payment   150.17.1.2 - Example 2: Coinsurance Days Greater Than or Equal to Short Stay Outlier Threshold (30 day stay)  (Rev. 1, 10- 01-03)  2a.  Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $55,000  Benefits available: 15 coinsurance and 60 LTR   Covered days: 20   Noncovered days: 10   Coinsurance days used: 15  LTR days used: 5  Cost report days: 30  OC 47: 1/26/03   OSC 70: 1/16/03 -  1/25/03  Reimbursement: Full DRG payment plus cost outlier based on $55,000 covered charges   2b.  Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $53,000  Benefits available: 15 coinsurance and 3 LTR   Covered days: 18   Noncovered days: 12   Coinsurance days used: 15  LTR days used: 3  Cost report days: 28  OC 47: 1/26/03   OC A3: 1/28/03  OSC 70: 1/16/03 -  1/25/03  Reimbursement: Full DRG payment plus cost outlier based on $53,000 covered charges   2c.  Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $50,000  Benefits available: 15 coinsurance and 0 LTR   Covered days: 15   Noncovered days: 15   Coinsurance days used: 15  LTR days used:0  Cost report days: 25  OC 47: 1/26/03   OC A3: 1/25/03  OSC 70: 1/16/03 -  1/25/03  Reimbursement: Full DRG payment
(Medicare Claims Processing Manual)
OC A3: 1/25/03  OSC 70: 1/16/03 -  1/25/03  Reimbursement: Full DRG payment   150.17.1.3 - Example 3: Coinsurance Days Greater Than or Equal to Short Stay Outlier Threshold (20 day stay)  (Rev. 1, 10- 01-03)  Date of service: 1/1/03 -  1/21/03  Medically necessary days: 20   Covered charges: $45,000  Benefits available: 15 coinsurance and 0 LTR   Covered days: 15   Noncovered days: 5   Coinsurance days used: 15  LTR days used: 0  Cost report days: 20  OSC 70: 1/16/03 -  1/20/03  Reimbursement: Full DRG payment   150.17.1.4 - Example 4: Only LTR Days < Short Stay Outlier Threshold (30 day stay)  (Rev. 1, 10- 01-03)  Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $27,000  Benefits available: 9 LTR   Covered days: 9   Noncovered days: 21   Coinsurance days used: 0  LTR days used: 9  Cost report days: 9  OC A3: 1/09/03 Reimbursement: Short stay outlier payment   150.17.1.4 - Example 4: Only LTR Days < Short Stay Outlier Threshold (30 day stay)  (Rev. 1, 10- 01-03)  Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $27,000  Benefits available: 9 LTR   Covered days: 9   Noncovered days: 21   Coinsurance days used: 0  LTR days used: 9  Cost report days: 9  OC A3: 1/09/03 Reimbursement: Short stay outlier payment   150.17.1.5 - Example 5: Only LTR Greater Than or Equal to Short Stay Outlier Threshold (30 day stay)   5a.  Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $50,000  Benefits available: 12 LTR   Covered days: 12   Noncovered days: 18
(Medicare Claims Processing Manual)
5a.  Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $50,000  Benefits available: 12 LTR   Covered days: 12   Noncovered days: 18   Coinsurance days used: 0  LTR days used: 12  Cost report days: 25  OC 47: 1/26/03   OC A3: 1/25/03  OSC 70: 1/13/03 -  1/25/03  Reimbursement: Full DRG payment   5b.  Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $55,000  Benefits available: 60 LTR   Covered days: 30   Noncovered days: 0   Coinsurance days used: 0  LTR days used: 30  Cost report days: 30  Reimbursement: Full DRG payment plus cost outlier based on $55,000 covered charges   5c.  Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $53,000  Benefits available: 28 LTR   Covered days: 28   Noncovered days: 2   Coinsurance days used: 0  LTR days used: 28  Cost report days: 28  OC 47: 1/26/03   OC A3: 1/28/03  Reimbursement: Full DRG payment plus cost outlier based on $53,000 covered charges   150.18 - Provider Interim Payment (PIP)  (Rev. 1, 10- 01-03)  PIP applies to LTCH PPS.  Outlier payments in regards to PIP are handled the way they currently are under other inpatient PPS systems.  150.19 - Interim Billing  (Rev. 1231; Issued:  04- 27-07; Effective:  12 -03-07; Implementation:  12 -03-07)  Interim bills are allowed every 60 days.  Refer to Chapter 1, section 50.2 for specifics on interim billing under PPS.   Effective December 3, 2007, LTCHs are allowed to submit no- pay bills (TOB 110) once benefits exhaust, every 60 days.  They do not have to continually adjust bills until physical discharge or death once benefits exhaust.  The last bill shall contain a dis charge patient status code.   150.20  Intermediary Benefit Payment Report (IBPR)  (Rev. 1, 10- 01-03)
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150.20  Intermediary Benefit Payment Report (IBPR)  (Rev. 1, 10- 01-03)  The IBPR report changes to reflect the payments for LTCHs going to PPS free -standing hospitals.  150.21 - Remittance Advices (RAs)  (Rev. 1, 10- 01-03)  Reason and remark codes already in existence for inpatient hospital PPS apply under this PPS.   150.22 - Medicare Summary Notices (MSNs)  (Rev. 1, 10- 01-03)  Use existing notices for inpatient hospital PPS for LTCH PPS.   150.23 - LTCH Pricer Software  (Rev. 1, 10- 01-03)  The CMS developed a LTCH Pricer program that calculates the Medicare payment rate.   Pricer software is electronically supplied to the Shared systems.  Pricer pays a short -stay outlier if the stay is between 1 day and up to and including 5/6 of the average length of stay for the LTC -DRG.    Pricer incorporates the five- year phase -in period for those providers that choose to be paid on the blended rate.   150.23.1 - Inputs/Outputs to Pricer  (Rev. 1231; Issued:  04- 27-07; Effective:  12- 03-07; Implementation:  12 -03-07)  Inputs    Provider Specific File Data; Fields -1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14, 18, 19, 21, 22, and 25 (although this field refers to the operating cost/charge ratio, for LTCH, entered here will be a combined operating and capital cost/charge ratio).  Effec tive July 1, 2005, A/B MACs (A) shall no longer populate fields 12, 13, or 14.  Field 35 must be populated for all LTCHs.  Fields 33 and 38 shall be populated if applicable.  Effective July 1, 2006, data elements 23, 24, 27, 28, and 49 are required.  See t he section "Determining the Cost -to-Charge Ratio" below for determining the cost/charge ratio.   The facility -specific rate (Field 21) will be determined using the same methodology that would be used to determine the interim payment per discharge under the TEFRA system if the LTCH PPS were not being implemented.    Bill Data
(Medicare Claims Processing Manual)
 The facility -specific rate (Field 21) will be determined using the same methodology that would be used to determine the interim payment per discharge under the TEFRA system if the LTCH PPS were not being implemented.    Bill Data   o Provider #  o Patient Status   o Covered Charges   o Discharge Date (or benefits exhaust date if present (Occurrence Code A3, B3, or C3))   o Length of Stay (LOS)   o Covered Days   o Lifetime Reserve Days (LTR)   o DRG (from Grouper)   Outputs    PPS Return Code    MSA/CBSA (CBSAs will be returned for discharges on or after July 1, 2005).   Wage Index    Average LOS    Relative Weight    Final Payment Amount    DRG Adjusted Payment Amount    Federal Payment Amount    Outlier Payment Amount    Payment Amount    Facility Costs    LOS    Regular Days Used    LTR Days Used    Blend Year, 1 -5   Outlier Threshold    DRG   COLA   Calculation Version Code    National Labor Percent    National Non- Labor Percent    Standard Federal Rate    Budget Neutral Rate    New Facility -specific Rate  150.24 - Determining the Cost -to-Charge Ratio (Rev. 4390, Issued: 09- 06-19, Effective: 10 -01-19, Implementation: 10- 07-19)  For all LTCHs, effective October 1, 2003, Medicare contractors are to use a CCR from the latest final settled cost report or from the latest tentative settled cost report (whichever is from the later period) to determine a LTCHs CCR.   A. - Calculating an overall LTCH Medicare Cost -to-Charge Ratio
(Medicare Claims Processing Manual)
For the LTCH PPS outlier calculations (short stay and high cost), Medicares portion of hospital costs are determined by using a hospitals overall Medicare cost -to-charge ratio  (CCR).  At the end of the cost reporting period, the hospital prepares and submits a cost report to its Medicare contractor, which includes Medicare allowable costs and charges.  The Medicare contractor completes a preliminary review of the as -submitted co st report and issues a tentative settlement.  The cost report is later final s ettled, which may be based on a subsequent review, and a Notice of Program Reimbursement (NPR) is issued.  The Medicare contractor shall update the PSF using the CCR calculated from the final settled cost report or from the latest tentative settled cost report (whichever is from the later period).   Under the LTCH PPS, the following methodology shall be used to calculate a hospitals overall Medicare cost -to-charge ratio:   1) Identify total Medicare inpatient costs from Worksheet D -1, Part II, line 49 minus (Worksheet D, Part III, col. 8, lines 25 through 30 plus Worksheet D, Part IV, col. 7, line 101)   2) Identify total Medicare inpatient charges obtained from Worksheet D -4, Column 2, lines 25 through 30 plus line 103 from the cost report (where possible, these charges should be confirmed with the PS&R data).  3) Determine the LTCHs overall Medicare CCR by dividing the amount in step 1 by the amount in step 2.   B. - Use of Alternative Data in Determining  CCRs For LTCHs
(Medicare Claims Processing Manual)
3) Determine the LTCHs overall Medicare CCR by dividing the amount in step 1 by the amount in step 2.   B. - Use of Alternative Data in Determining  CCRs For LTCHs   Effective August 8, 2003, the CMS Central Office may direct Medicare contractors to use an alternative CCR if CMS believes this will result in a more accurate CCR.  Also, if the Medicare contractor finds evidence that indicates that using data from the lat est settled or tentatively settled cost report would not result in the most accurate CCR, then the Medicare contractor shall notify the CMS Regional Office and CMS Central Office to seek approval to use a CCR based on alternative data.  For example, a CCR may be revised more often if a change in a LTCHs operations occurs which materially affects a LTCHs costs and/or charges. The CMS Regional Office, in conjunction with the CMS Central Office, must approve the Medicare contractors request before the Medicare contractor may use a CCR based on alternative data.  Revised CCRs will be applied prospectively to all LTCH claims processed after the update.  Medicare contractors shall send notification to the CMS Central Office via email to outliersIPPS@cms.gov.  C. - Ongoing CCR Updates Using  CCRs From Tentative Settlements For Hospitals Subject to the LTCH PPS   Medicare contractors shall continue to update a LTCHs CCR (in the Provider Specific File) each time a more recent cost report is settled (either final or tentative). A revised CCR 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.   D. - Request for use of a Different CCR by CMS, the Medicare Contractor or the LTCH
(Medicare Claims Processing Manual)
D. - Request for use of a Different CCR by CMS, the Medicare Contractor or the LTCH   Effective August 8, 2003, CMS (or the Medicare contractor) may specify an alternative CCR if it believes that the CCR being applied is inaccurate.  In addition, a LTCH will have the opportunity to request that a different CCR be applied in the event it bel ieves the CCR being applied is inaccurate.  The LTCH is required to present substantial evidence supporting its request. Such evidence should include documentation regarding its costs and charges that demonstrate its claim that an alternative ratio is more  accurate.  After the Medicare contractor has evaluated the evidence presented by the LTCH, the Medicare contractor notifies the CMS Regional Office and CMS Central Office of any such request.  The CMS Regional Office, in conjunction with the CMS Central Office, will approve or deny any request by the LTCH or Medicare contractor for use of a different CCR. Medicare contractors shall send requests via email to the CMS Central at outliersIPPS@cms.hhs.gov.   E. - Notification to Hospitals Under the LTCH PPS of a Change in the CCR   The Medicare contractor shall notify a LTCH 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 a LTCH about a change to their CCR.  F. - Mergers, Conversions and Errors with CCRs
(Medicare Claims Processing Manual)
Effective April 1, 2011, for LTCHs that merge, Medicare contractors shall continue to use the CCR from the LTCH with the surviving provider number.  If a new provider number is issued, as explained in 150.25 below, Medicare contractors should use the Stat ewide average CCR because a new provider number indicates the creation of a new hospital (as stated in 42 CFR  412.525(a)(4)(iv)(C)(1) and 412.529(c)(3)(iv)(C)(1), a new hospital is defined as an entity that has not accepted assignment of an existing hospitals provider agreement).  However, the policy of 150.24 part B and C can be applied to determine an alternative to the Statewide average CCR.   For newly classified LTCHs, that is those hospitals (e.g., short term acute, psychiatric, or rehabilitation hospitals) that meet the requirements set forth in 42 CFR 412.23(e), or LTCHs that receive a new LTCH provider number, the Statewide average CCR sho uld be used until a CCR can be computed from the LTCHs cost report data, as described in part A of this section. However, as noted in part C above, the Medicare contractor or the LTCH may request use of a different CCR, such as a CCR based on the cost and charge data from the hospitals cost report immediately preceding its classification as a LTCH or receiving a new LTCH provider number. The Medicare contractor must verify the cost and charge data from that cost report. Use of the alternative CCR is subject to the approval of the CMS Central and Regional Offices. NOTE: A newly classified LTCH must request an alternative CCR and receive approval from the CMS Central Office prior to the effective date of the hospitals classification as a LTCH  in order for that alternative CCR to be effective beginning on the date of classification (as a LTCH).  If the request and approval for an alternative CCR occurs after the effective date of the LTCH classification, then the use of the alternative CCR will be effective prospectively beginning with the date of the approval of the alternative CCR request.
(Medicare Claims Processing Manual)
In instances where errors related to CCRs and/or outlier payments are discovered, Medicare contractors shall contact the CMS Central Office to seek further guidance.  Medicare contractors may contact the CMS Central Office via email at outliersIPPS@cms.hhs.gov.   If a cost report is reopened after final settlement and as a result of this reopening there is a change to the CCR, Medicare contractors shall contact the CMS regional and Central Office for further instructions. Medicare contractors may contact the CMS Central Office via email at outliersIPPS@cms.hhs.gov.  G. - Maintaining a History of CCRs and Other Fields in the Provider Specific File   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: 21 -Case Mix Adjusted Cost Per Discharge, 23 -Intern to Bed Ratio, 24 -Bed Size, 25 -Operating Cost to Charge Ratio, 27 -SSI Ratio and 28 -Medicaid Ratio. A separate history outside of the PSF is not necessary. ( NOTE : PSF elements 23, 24, 27, 28 and 49 are only required for LTCHs effective 7/11/06.). The only instances 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.    150.25 - Statewide Average Cost -to-Charge Ratios  (Rev.  2111, Issued: 12- 03-10, Effective: 04 -01-11, Implementation: 04- 04-11)  For discharges prior to August 8, 2003, the Statewide average CCR is used in those instances in which a LTCHs CCR falls above or below reasonable parameters.  CMS sets forth these parameters and the Statewide average CCRs in each years IPPS annual notice of prospective payment rates.