evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
140.2.2 - Payment Adjustment Factors and Rates (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)  Section 1886(j) of the Act s ets forth the  methodolo gy for establishing the payment rates as well as the data on whi ch the y are based.  In addition, this s ection pre scribes adjustm ents to suc h rates based on geographic variation a nd cas e-mix and othe r factors the Secretary deems n ecessary to ensure that payment most accur ately reflects cost.  For the initia l period of  the IRF  PPS, be ginning on or after January 1, 2002, a ll payment rates and associated rules were publish ed in the  "Federal Register" on August 7, 20 01.  For each succeedi ng fiscal year, the rates will be  publishe d in the  "Federal Register" on or  before Au gust 1 of  the year preceding the affected fiscal year.  140.2.3 - Case-Mix Groups (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)
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140.2.3 - Case-Mix Groups (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)  In general, a case will be  grouped into a  Case-Mix Group ( CMG)  based on the  clinical characteristics of the Medicare beneficiary.  Rehabilita tion I mpairment Categories (RICs), functional measu rements, age, and comor biditie s were used to de velop the  CMGs. Specifically, RICs are used to g roup cas es that are simila r in clinical c haracteristics and resource use.  The  RICs are codes that indi cate the primary cause of the rehabilita tion hospit alization a nd ar e clinically homogeneous.  In addition to the  first two dig its of  the CMG indi cating  the RIC, the CMGs a re further partition ed usi ng functional measures of motor  and cognitive  scores.  Age improves the explanatory power of the C MGs if  some  groups  are split b ased on this var iable.  Lastly, comorbidites were found to subst antially increase the average cost of  a case in  specific CMGs.  The  comor biditie s are arrayed in three categories (or tiers) based on w hether the costs ar e considered hi gh, medium, or low.  If a case has more than one  comor bidity, the CMG p ayment rate will be based on the comor bidity that results in the  highest payment.  140.2.4 - Case-Level Adjustments (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)
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Payment is b ased on t he CMGs d escribed above, as well as possible  adjustm ents sp ecific to the  case  and the facility characteristics.  For case level adjustm ents, mor e than one  case level adjustm ent may apply to the  same case.  For ease of understanding, the case  level discussion is pre sented below in the  same order that is us ed to a ssess wh ether or not the y apply.  For example, a case may be classified as a transfer, but m ay also receive additional pa yments becaus e it me ets the  definition of  an outli er case.  Interrupt ed stays are defined as those  cases in wh ich a Medicare beneficiary is discharged from the  inpa tient rehabilita tion facili ty and returns to the  same inpatient rehabilita tion facilit y within 3 c onsecutive calendar days.  The 3 consecutive  calendar days begin with the  day of the discharge from the  IRF and ends on midni ght of the third day.  The  length of stay for these cases will be determined by the total length of the IRF stay including the d ays prior to the  interruption a nd the  days after the interruption.  One  CMG payment will be  made for interrupted stay cases and the  payment will be  based on the initia l assessment. For example, if a Medicare beneficiary is dis charged on February 1, 2001, and is readmitt ed on F ebruary 3, the case  would b e considered a n interrupt ed stay and onl y one CMG p ayment will be  made based on t he initia l assessment.  Howe ver, if the Medicare beneficiary was readmitt ed on Fe bruary 4, then it would not be  considered an interrupted stay.  A s eparate DRG payment will not be  made to the  acute  care hospit al when the be neficiary is dis charged and re turns to the  same IRF on the  same day.  However, a DRG payment can b e made if the beneficiary does not r eturn to the  same IRF on the same day as they were discharged.  If a case is determined to be  an interrupted stay, other a djustme nts m ay apply to this pa yment amount.  For example, the case still ma y meet
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same IRF on the same day as they were discharged.  If a case is determined to be  an interrupted stay, other a djustme nts m ay apply to this pa yment amount.  For example, the case still ma y meet the d efinition of  a transfer case  described below.
(Medicare Claims Processing Manual)
For the IRF PPS, t ransfer cases are defined as thos e in whi ch a Medicare beneficiary is transferred to e ither another rehabilita tion facili ty, a long term care hospit al, an inpa tient hospit al, or a nursing home  that accepts pa yment unde r either the Medicare program and/or  the Medicaid program AND the  length of stay of the case is less than the average length of stay for a given CMG.  The  transfer policy consists of  a per diem payment amount cal culated by dividing the per discharge CMG p ayment rate by the average length of stay for the CMG.  M edicare will p ay transfer cases a per diem amount a nd include an additiona l half day payment for the first day.  Transfer payments will be  calculated by first adding  the length of stay of the case to 0.5 ( to account f or the addition of the half day payment for the first day) and the n multip lying the result b y the CMG p er diem amount.   The IRF PPS  also in cludes a payment adjustm ent for certain cas es, such as short-stay cases (for cases that do n ot meet the  definition of  a transfer case).  A s eparate CMG payment (5001)  will be  made for cases with a  length of stay of 3 da ys or less, without consideration of  the clinical characteristics of the patient.  Cases  that expire with a le ngth of stay of 3 da ys or less, will also be  classified to CMG 5001.
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Separate  CMGs will a lso be made for cases that expire with a  length of stay greater than 3 days.  To impr ove the explanatory power of the groups, f our additiona l CMGs w ere creat ed to a ccount f or cases that expire.  CMG 5101 is us ed for shor t-stay, orthope dic, expired cas es.  This C MG in cludes those  cases that would other wise be groupe d to R ICs 07, 08, a nd 09 a nd the  length of the stay is greater than 3 da ys, but l ess than or equal to 13 da ys.  CMG 5102 will be  used for orthope dic expired cas es where the length of stay is greater than or equal to 14 da ys.  CMG 5103 will  be used for short-stay, non-orthope dic, expired cas es.  This C MG in cludes those  cases that would not be  groupe d to the orthope dic RICs and the  length of the stay is greater than 3 da ys, but l ess than or equal to 15 da ys.  CMG 5104 will  be used for non-orthope dic expired cas es where the length of stay is greater than or equal to16 da ys.  140.2.5 - Facility-Level Adjustments  (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)
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140.2.5 - Facility-Level Adjustments  (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)  Facility-level adjustm ents apply to all cases and are based on the  individua l IRF characteristics.  The  facility-level adjustm ents in clude an area wage adjustm ent, an adjustm ent for facilities  located in r ural areas, a n adjustm ent for treatin g low-income patients and an adjustm ent for teachi ng facilitie s.  Outli er payments will a lso be  discussed in this s ection.  Althoug h outli er payments ar e considered to be  a case-level adjustm ent, a case can be determined to qua lify for these additiona l payments onl y after all oth er facilit y-level adjustme nts are comput ed.  Thus, f or ease of understanding, the discussion of  these facility-level and outlier adjustm ents ar e presented in the  same order that is us ed to assess their applicabil ity.  140.2.5.1 - Area Wage Adjustments (Rev. 11504, Issued 08- 05-22; Effective:10 -01-22; Implementation: 10 -03-22)
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To adjust payments for area wage differences, CMS first identifies the labor -related portion of the prospective payment rates which is published annually in the Federal Register. The labor -related unadjusted Federal payment is multiplied by a wage index value to account for area wage differences. CMS uses the inpatient acute care hospital wage data to compute the wage indices on the basis of the labor market area in which the acute care hospital is located, but without taking into account geographic reclass ification under 1886(d)(8) or (d)(10) of the Act and without applying the rural floor under 4410 of the BBA. The wage data excludes the wages for services provided by teaching physicians, interns and residents, and nonphysician anesthetists under Medi care part B, because these services are not covered under the IRF PPS. For IRF PPS discharges occurring before October 1, 2005, IRFs are divided into labor market areas where urban areas are defined as a Metropolitan Statistical Area (MSA) or New England C ounty Metropolitan Area, as defined by the Executive Office of Management and Budget. For IRF PPS discharges occurring on or after October 1, 2005, the IRF PPS adopts new labor market area definitions based upon the new statistical area definitions issued by the Office of Management and Budget (OMB) in OMB Bulletin No. 03- 04, June 6, 2003. OMB Bulletin No. 03- 04 includes new definitions of Metropolitan Statistical Areas, Micropolitan Statistical Areas, and Combined Statistical Areas, more commonly referred to as Core -Based Statistical Areas (CBSAs). CBSA -based designations reflect the most recent available geographic classifications and more accurately reflect current labor markets. The OMB also established New England City and Town Areas, which are similar to the previous New England MSAs. CMS uses the county- based areas for all MSAs in the Nation, including those in New England. Adopting county- based labor market areas for the entire country creates consistency and stability in the Medicare payment program because all of the labor market areas, including New England, are defined using the same system (that is, counties), rather than different systems in different areas of the country, and minimizes program complexity. CMS uses the Metropolitan Divisions where applicable under the new CBSA-based labor market area definitions to determine urban areas. Micropolitan Areas are treated
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counties), rather than different systems in different areas of the country, and minimizes program complexity. CMS uses the Metropolitan Divisions where applicable under the new CBSA-based labor market area definitions to determine urban areas. Micropolitan Areas are treated as rural labor market areas under t he IRF PPS. To calculate the statewide rural wage index for each State, CMS combines all of the counties in a State outside of designated urban areas along with all Micropolitan Areas.
(Medicare Claims Processing Manual)
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 IRF will be paid the wage index for the area in which it is geographic ally located for its first full or partial FY with no cap applied, because a new IRF will not have a wage index in the prior FY.  140.2.5.2 - Rural A djustment (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)  Payments are adjusted for facilitie s located in rura l areas.  A facility is cons idered to be a rura l IRF if th ey are lo cated in a non-urban ar ea.  For FY 2006 and F Y 20 07, a hold har mless policy applie s to IRFs that meet the definition of rura l in FY 2005 in 412.602 and become urban under the FY 2006 CBS A-based de signations.  The IRF s that meet the  criteria descr ibed in the pre vious sentence will qu alify for an adjustme nt to th eir payme nts in FY 2006 and FY 2007 equal to some portion of the 19.14 per cent rura l adjustme nt effective in FY 2005.  This adjustme nt is in addition to the one-y ear blended wage index des cribed above for discharge s occurring on or after October 1, 2005 and on or bef ore September 30, 2006.  140.2.5.3 - Low-Incom e Patient ( LIP) A djustment: The Su pplem ental Secur ity Incom e (SS I)/Medica re Beneficiary Data for Inpatie nt Rehabilitatio n Facilities (I RFs) Paid Under the Pros pective Payment System (PPS)  (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)
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The LIP adjustment accounts for di fferences in costs among IRFs a ssociated with differences in the proportion of low- income pa tients t reated.  The LIP adjustme nt is calculated a s (1 + dispropor tionate share hospital (DS H) patient pe rcentage) ra ised to a power sp ecified in the most recent IRF PPS f inal rule published in the Fe deral Register. To compute the DS H patient percentage the follo wing  formula  is us ed:  DSH = Medicare SSI Days + Medicaid, Non -Medicare Days   Total Medicare Days  Total Days  This instruction pr ovides the data for det ermining additiona l payment amounts for IRF s with low -income pa tients. An SSI da ta file below shows the late st ava ilable IRF- specific data to compute an IRF's SSI ratio for the a ssociated specified f iscal year (FY) . An IRF may use this r atio as part of the formula  to estima te their LIP adjustm ent for a cost reporting period tha t begins subs equent to the  FY specified by the data file. As appropriate, a f ile will be  upda ted annually (usually each October/Nov ember).  Patients who ar e enrolled in M edicare Adv antage (administered thr ough Medicare Part C) should a lso be  included in the  Medicare fraction.  These days will be  included in the Medicare/SSI fraction, b ut in or der for them to be  counted, the  hospit al must submit a n informational only bill ( TOB  111), which inc ludes both C ondition C ode 04 and the  CMG code from the  IRF P AI, to the ir Medicare contractor.  This will e nsure that these days are included in the  IRFs SSI ratio for Fiscal Y ear 2007 a nd be yond.  T eaching IRFs do not have to submit a n additiona l bill with C ondition Code 04.  The y already submit bills w ith Condition C odes 04 a nd 69 f or Indirect Medical E ducation pa yments and C MS will use the information fr om th ese bills f or the SSI ratio.
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IRFs that received LIP payments dur ing F Y 2006 are also required to subm it informational only bills f or their Medicare Advantage patients.  Informational Only Claim El ements:   Covered 111 T OB  Condition C ode 04  Medicare Fee-for-Service is the  primary payer  There is no M SP  Beneficiarys Me dicare HICN  For claims p rior to O ctober 1, 2011, re port the Revenue Code 0024 line  containing C MG A9999 a nd, inst ead of inputting the transmission da te of the IRF-PAI in the s ervice date field (as is r equired for FFS claims), input the  discharge date as a default f or these informational only claims. The  discharge date is required on informational only claims to re duce reporting burden for IRFs who may be submitting  old informational only claims.  NOTE: E ffective January 1, 2011, do not r eport the service date for the revenue code 0024 line.  Instead, use  occurrence code 50 in pl ace of the service date to report the d efault discharge date for informational only claims.   Effective October 1, 201 1, report the Revenue Code 0024 line  containing the CMG from the  IRF-PAI and the transmission da te of the IRF-PAI in the  occurrence code 50 and da te field (as is r equired for FFS claims).   All oth er required claim elements
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 All oth er required claim elements  The SSI/Medicare beneficiary data for IRF PPS  is available to A/B MACs (A) electronically and contains the  name of the facilit y, provider number , SSI days, covered Medicare days, and the  ratio of  Medicare Part A pa tient da ys attributable to SSI recipients.  A/B MACs (A) will use  this in formation to upda te their provider specific file.  The files are located at the  following CMS Web site  address: http://www.cms.gov/Medicare/Medicare- Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/index.html .  Select Inpatient Rehabilitation Facility PPS, then select, from the list at the left, SSI Data.  A/B MACs (A) use  this d ata to deter mine  an initia l PPS payment amount, and if applicable, to det ermine  a final outlier payment amount for IRFs whose discharge s are during a sp ecific cost re porting per iod.  A/B MACs (A) m ake a det ermination of the amount of this p ercenta ge to compute the f inal LIP adjustment which a llows the  year-end settlement of a facilitys cost re port.  When the A/B MAC (A)  se ttles a cost re port for a specific fiscal ye ar, that settled cost re port will d etermine  the f inal SSI ra tio th at is associated with th at cost report.  The A/B MAC (A)  use s the most recently se ttled SSI ratio to s ettle the current cost re port.  Once the fina l SSI ratio is d etermined for the actua l fiscal year the cost repor t corre sponds to, a re trospective adjustment may be made to account for the di fference betw een the actu al lip adjustment amount a nd the  initia l PPS lip adjustment payment amount.  A - Cla rification of Allowab le Medicaid Days in Cal culating the Dis proport ionate Share Va riable  Background
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A - Cla rification of Allowab le Medicaid Days in Cal culating the Dis proport ionate Share Va riable  Background  Under the IRF PPS, facilitie s receive additiona l payment amounts to accou nt for the cost of furnishing care to low- income pa tients. This is done by making adjustme nts to  the prospective  payment ra te. Under 1886(d )(5)(F) of the Act, the Medi care DS H percenta ge is m ade up of two computations. The re sults of th ese two computations ar e added toge ther to d etermine  the DS H percentage. First, the pa tient d ays of pa tients who, during a given month, w ere entitled to b oth M edicare Part A and SSI (excluding those patients who received only Sta te supplementa tion) is divid ed by the number of cov ered patient day s utilized by pa tients under Medi care P art A for th at same period. S econd, a determination is made regarding the patient days a ssociate d with  benef iciaries who w ere eligible for medical assistance (Medi caid) under a Sta te plan approved under Title  XIX but who w ere not e ntitle d to M edicare Part A (See 42 CFR 412.106(b)(4)) is d etermined. This number is divid ed by the total number of pa tient days for tha t same period. The SSI data is updated on an a nnual basis and the se data are one of the components used to determine the DS H variable th at is p art of the appropria te LIP adjustment for each IRF.  Included Days  In
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Included Days  In calcula ting the number of Medi caid day s, the  hospit al must d etermine  whether the patient wa s elig ible for Medi caid under a Sta te plan approved under Title  XIX on the day of service.  If the pa tient was so e ligible, the day counts in the Medi care dispropor tionate share adjustment calculation.  The st atutory formula  for "Medi caid day s" refl ects seve ral key concepts.  First, the focus is on the pa tient's e ligibility for Medi caid benef its as determined by the State, not the hospital' s "eligibility " for some form of Medi caid payment.  S econd, the focus is on the pa tient's e ligibility for me dical assistance under an approve d Title  XIX Sta te plan, not the pa tient's e ligibility for gene ral assi stance under a State-only progra m.  Third, the focus is on e ligibility for medi cal assistance under an approve d Title  XIX Sta te plan, not medi cal assistance under a State-only program or othe r program.  Thus, f or a day to be  counted, the patient must be  eligible on that day for medical assistance benefits unde r the Federal-State coope rative program known as Medicaid ( unde r an approved Title  XIX State plan).  In othe r words, for purposes of the Medicare dispr oportionate share adjustm ent cal culation, the  term "Medicaid days" refers to da ys on whi ch the  patient is e ligible for medical assistance benefits unde r an approved Title  XIX State plan.  The term "Medicaid d ays" does not ref er to all days that have some relation to the  Medicaid program, th rough a matching payment or otherwise; if a patient is not e ligible for medical assistance benefits unde r an approved Title  XIX State plan, the patient da y cannot b ecome  a "Medicaid da y" simply by virtue of some  other association with the  Medicaid pr ogram.
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Medicaid da ys, for purposes of the Medicare dispr oportionate share adjustm ent calculation, inc lude all days during whi ch a patient is e ligible, unde r a State plan approved unde r Title  XIX, for Medicaid be nefits, e ven if Medicaid did not m ake payment for any services.  Thus, M edicaid days include, but a re not limite d to, da ys that are determined to be medically necessary but for which payment is denied by Medicaid b ecause the provide r did not bill t imely, days that are beyond the  num ber of days for which a State will p ay, days that are utiliz ed by a Medicaid be neficiary prior to an admission a pproval but f or which a valid enrollme nt is determined within the  prescribed period, a nd days for which payment is ma de by a third par ty.  In addition, CMS  reco gnizes the calculation da ys that are utiliz ed by a Medicaid beneficiary who is e ligible for Medicaid unde r a State plan approved und er Title  XIX through a managed care organization ( MCO) or health maintenance organization ( HMO) .  Ho wever, in accordance with 42 C FR 412.106( b)(4) , a day does not c ount in the  Medicare dispr oportionate share adjustm ent cal culation if  the patient was entitle d to both M edicare Part A a nd Medicaid on tha t day.  Theref ore, onc e the eligibilit y of the patient for Medicaid unde r a State plan approved und er Title  XIX has been ver ified, the  A/B MAC (A) mu st determine  whether any of the days are dual entitlement da ys and, to the  extent that they are, subt ract them from  the othe r days in the  calculation.  Excluded Days
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Excluded Days  Many States operate  programs th at include both S tate-only and Federal-State eligibilit y groups in a n integrated program.  F or example, some  States provide  medical assistance to beneficiaries of State-funde d inc ome suppor t programs.  Th ese beneficiaries, how ever, are not e ligible for Medicaid unde r a State plan approved unde r Title  XIX, and, therefore, days utiliz ed by these beneficiaries do not c ount in the  Medicare dispr oportionate share adjustm ent cal culation.  If a hospit al is un able to distin guish be tween M edicaid beneficiaries and othe r medical assistance beneficiaries, the n it must c ontact the State for assistance in doing so.  In addition, if  a given patient da y affects the  level of Medicaid D SH payments to the hospit al but the  patient is not e ligible for Medicaid unde r a State plan approved unde r Title X IX on tha t day, the day is not in cluded in the  Medicare DSH calculation.  It should be  noted that the types of days discussed above  are not ne cessarily the only types of excluded days.  See the chart below, whi ch summar izes som e, but not necessa rily all, of the  types of days to be  excluded from ( or included in) the Medicare DSH adjustme nt cal culation.  To provide  consist ency in both c ompone nts of  the calculation, a ny days that are added to the  Medicaid da y count must a lso be  added to the  total day count, to the  extent that they have not been p revious ly so added.