evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Specific Circumstances (applicable to all of the above scenarios)   NOTE:   MMSEA changes described above, as amended by the ARRA and further amended by the ACA, are  applicable for cost reporting periods beginning on or after October 1, 2007, and before October 1, 2012, or on or after July 1 2007, and before July 1, 2012..   For LTCHs and LTCH satellites located in rural areas, instead of the 25 percent threshold, we provide for a 50 percent threshold for patients from any individual referral hospital.  In addition, in determining the percentage of patients admitted from that referring hospital, any patient that had been Medicare outliers at the host and then transferred to the HwH would be considered as if they were admitted from a non- host hospital.  Under MMSEA, the 25 percentage threshold is increased to 50 percent for applicable LTCH HwHs, satellites, and grandfathered satellites.    For urban single or MSA dominant referring hospitals, we would allow the LTCH or LTCH satellite to admit from the host up to the referring hospitals percentage of total Medicare discharges in the MSA. A floor of 25 percent and a ceiling of 51 percent appl ied to this variation.  Under MMSEA, the 50 percentage threshold is increased to 75 percent.   Transition Periods   For Medicare discharges from referring hospitals:    Admitted to co -located LTCHs and LTCH satellites from their host hospitals   o This policy was finalized for FY 2005.   This payment adjustment will be phased- in over 4 years for existing LTCH HwHs and also for LTCHs -under -formation that satisfy the following two -prong requirement:   o On or before October 1, 2004 they have certification as acute care hospitals, under Part 489; and   o Before October 1, 2005 designation as a LTCH.   For purposes of full payment under the LTCH PPS during the transition period, the percentage of discharges from the LTCH HwH originating from the host hospital for each applicable cost reporting period, may not exceed the percentage of discharges during the hospitals cost reporting period during FY 2004 that were admitted from the host hospital.   Year 1 --  (cost reporting periods beginning on or after October 1, 2004 through September 30, 2005) a hold harmless
(Medicare Claims Processing Manual)
Year 1 --  (cost reporting periods beginning on or after October 1, 2004 through September 30, 2005) a hold harmless   o Payments will be made under the LTCH PPS but the percentage of LTCH HwH discharges originating from the host may not exceed the percentage for such patients established for cost reporting periods during FY 2004.   Year 2 --  (cost reporting periods beginning on or after October 1, 2005 through September 30, 2006)   o LTCH HwHs will be paid under the otherwise unadjusted LTCH PPS for the percentage of discharges originating from their host hospital that do not exceed the lesser of the percentage of those patients for their FY 2004 cost reporting period or 75 percent.   o For discharges in excess of that threshold, the payments will be determined under the basic payment formula specified above.   Year 3 --  (cost reporting periods beginning on or after October 1, 2006 through September 30, 2007)   o LTCH HwHs will be paid under the otherwise unadjusted LTCH PPS for the percentage of discharges originating from their host hospital that do not exceed the lesser of the percentage of those patients for their FY 2004 cost reporting period or 50 percent.   o For discharges in excess of that threshold, the payments will be determined under the basic payment formula specified above.   Year 4 --  (cost reporting periods beginning on or after October 1, 2007 through September 30, 2008)   o LTCH HwHs  will be paid under the otherwise unadjusted LTCH PPS for the percentage of discharges originating from their host hospital that do not exceed the 25 percent or the applicable percentage described for specific circumstances above.   o For discharges in excess of that threshold, the payments will be determined under the basic payment formula specified above.   Transition Period for all LTCHs affected by the Above Described Regulations for cost reporting periods beginning on or after July 1, 2008.  NOTE:   MMSEA as amended by the ARRA and further amended by the ACA changes described above applicable for cost reporting periods beginning on or after July 1, 2007, and before July 1, 2012 for grandfathered LTCH HwHs and freestanding LTCHs.   The full payment threshold adjustment will be phased in over 3- years as follows:   Year 1 -  (for cost reporting periods beginning on or after July 1, 2007 through June 30, 2008)
(Medicare Claims Processing Manual)
The full payment threshold adjustment will be phased in over 3- years as follows:   Year 1 -  (for cost reporting periods beginning on or after July 1, 2007 through June 30, 2008)   o LTCHs and LTCH satellites will be paid under the otherwise unadjusted LTCH PPS for the percentage of discharges originating from a referring hospital that do not exceed the lesser of the percentage of those patients for their RY 2005 cost reporting period or 75 percent.   o For discharges in excess of that threshold, the payments will be determined under the basic payment formula specified above.   Year 2 -  (for cost reporting periods on or after July 1, 2008 through June 30, 2009),  o LTCHs and LTCH satellites will be paid under the otherwise unadjusted LTCH PPS for the percentage of discharges originating from a referring hospital that do not exceed the lesser of the percentage of those patients for their RY 2005 cost reporting period or 50 percent.   o For discharges in excess of that threshold, the payments will be determined under the basic payment formula specified above.   Year 3 -  (for cost reporting periods on or after July 1, 2009)   o All LTCHs and LTCH satellites subject to the payment threshold policy effective for RY 2008, will be subject to the 25 percent (or applicable percentage) threshold.   o For discharges in excess of that threshold, the payments will be determined under the basic payment formula specified above.   Implementation:    The payment threshold policy for discharges from co- located LTCH HwHs and LTCH satellites admitted from their hosts (including grandfathered LTCH HwHs and satellites) is determined based on a location -specific basis.    The payment threshold policy for discharges from LTCHs and LTCH satellites admitted from referring hospitals with which they are not co-located is determined based upon provider numbers for both the LTCH and the referring hospital.   For LTCHs and LTCH satellites subject to both the FY 2005 and the RY 2008 threshold payment adjustment policies
(Medicare Claims Processing Manual)
For LTCHs and LTCH satellites subject to both the FY 2005 and the RY 2008 threshold payment adjustment policies    If a co -located LTCH or a co -located referring hospital (host) shares a provider number with a hospital or satellite at another location, threshold determinations will continue to be location -specific for the co -located LTCH and host.  The threshold percentage determinations will be applied to all other location or campus of either a LTCH or referring hospital in the aggregate.  For example, when the policy finalized for RY 2008 is fully phased in, a co-located LTCH (LTCH A) and host (referring hospital A) will have a 25 percent threshold under the policy finalized for FY 2005.  If referring hospital A shares a provider number with a remote location (RH A), then another 25 percent threshold will be applied to patients discharged from LTCH A that were admitted RH A.    We note that for cost reporting periods beginning on or after October 1, 2007, non- grandfathered co -located LTCHs, are fully phased -in to the full 25 percent (or applicable percentage threshold) for discharges admitted from their co -located hosts (under the initial 25 percent payment threshold established for FY 2005)s.   However, for discharges admitted from non- co-located referring hospitals, these LTCH HwHs and satellites are governed by the policy finalized for RY 2008.  Therefore, for cost reporting periods beginning on or after July 1, 2007 through June 30, 2008, the 75 percent threshold will apply, and the 50 percent threshold will apply for cost reporting periods beginning on or after July 1, 2008 through June 30, 2009 as described above in this response.)   Furthermore, under our finalized policy for RY 2008, grandfathered LTCH HwHs and satellites will be subject to the 3 -year transition that we are finalizing under this new policy for all  their discharges, both admitted from their co -located host and from other non- co-located referring hospitals.  When both policies apply:
(Medicare Claims Processing Manual)
When both policies apply:   If a patient discharged from a LTCH HwH or satellite was originally admitted from the host hospital and immediately prior to that admission to the host, the patient was being treated at the same LTCH HwH or LTCH satellite, both of the policies described in  this section, the 5 percent on- site policy as well as the 25 percent policy are applicable. In such a case, the following procedures should be followed keeping in mind that the 5 percent rule affects number of discharges and the 25 percent rule affects payment.   The on- site 5 percent computation is first in order to determine the real number of discharges.    Focusing on the relationship between an acute host and a LTCH HwH/satellite, if the number of revolving door discharges between these two facilities exceeds 5 percent during a CR period, this policy will collapse the number of discharges within that CR period, halving the # of revolving door LTCH stays where the intervening stay exceeded the threshold and eliminating from consideration those host stays that were bracketed by two LTCH stays. All such stays for the entire cost reporting period will be paid as  one LTCH PPS stay.   The next issue is to determine which of these stays will be paid an unadjusted LTCH PPS rate and which will be paid an amount equivalent to what would otherwise be paid under the IPPS. Cases prior to tripping the 25 percent threshold will be paid the other wise unadjusted LTCH PPS rate and those after the threshold that had not achieved outlier status at the host it will be paid based on the adjustment.   Because of the 5 percent policy that collapsed the discharges from the LTCH, for purposes of the 25 percent policy, we are focusing on fewer discharges in total from the LTCH and we need to determine what percent of these discharges originated in the host so that we can apply the payment adjustment.  BUT, in the event that  the 5 percent is not tripped during that cost reporting period, each acute-- >LTCH -->acute--> LTCH cycle, which will count as two LTCH discharges originating in the host for purposes of the 25 percent policy, since both the first and second LTCH admission were from the host.
(Medicare Claims Processing Manual)
150.9.1.5 - High Cost Outlier Cases (Rev. 1547, Issued:  07- 03-08; Effective:  07 -01-08; Implementation:  07 -07-08)  Additional payments are made for those cases that are considered high cost outliers.  A case falls into this category if the estimated cost of the case exceeds the outlier threshold (the LTC -DRG payment plus a fixed loss amount).  (Short -stay outliers, des cribed above, are also eligible for outlier payments if their costs exceed the outlier threshold.  The applicable short -stay outlier payment is used to determine the outlier threshold for short -stay outlier cases.)   The fixed loss amount is determined annually on July 1 such that projected outlier payments are equal to 8 percent of total LTCH PPS payments.  July 1, 2008, is the final rate year; LTCH PPS is moving back to a Federal Fiscal Year effective October 1, 2009 .  If the estimated cost of the case is greater than the outlier threshold an additional payment is added to the LTC -DRG payment amount.   The outlier payment is 80 percent of the difference between the estimated cost of the case and the outlier threshold (the LTC -DRG payment plus a fixed loss amount).  The estimated cost of the case is calculated by multiplying the Medicare allowable charge on the claim by the LTCH's overall cost -to-charge ratio obtained from the latest settled cost report.   For discharges occurring on or after August 8, 2003, (high cost  outlier payments may be reconciled upon cost report settlement to account for differences between the estimated cost-to-charge -ratio and the actual cost -to-charge ratio for the period during which the discharge occurs.  For further information, refer to t he June  9, 2003 High Cost Outlier final rule (68 FR 34506 -  34513).  150.10 - Facility-Level Adjustments  (Rev. 1547, Issued:  07-03- 08; Effective:  07 -01-08; Implementation:  07 -07-08)
(Medicare Claims Processing Manual)
150.10 - Facility-Level Adjustments  (Rev. 1547, Issued:  07-03- 08; Effective:  07 -01-08; Implementation:  07 -07-08)  Facility -level adjustments are based on individual LTCH characteristics.  The BIPA confers broad authority on the Secretary to include "appropriate adjustments to the long-term hospital payment system."  Variables examined include an area wage adjustment, adjustment for geographic reclassification, disproportionate share patient (DSH) percentage, and an adjustment for indirect medical education (IME).    The system includes an area wage adjustment that is being phased in over 5 years.  The wage adjustment is made by multiplying the labor- related share of the standard Federal rate by the applicable wage index value.    A LTCH's wage index is based on the Metropolitan Statistical Area (MSA) or rural area in which the hospital is physically located, without regard to geographic reclassification under http://www.ssa.gov/OP_Home/ssact/title18/1886.htm 1886(d)(8) - (10)  of the Act.  Effective July 1, 2005, an LTCH wage index is based on the Core- Based Statistical Area (CBSA).    The phase-in of the wage index adjustment is as follows:  Cost Reporting Periods Beginning During  Applicable Wage Index Value  FY 2003  1/5th of the value of the applicable pre- reclassification, no floor hospital inpatient wage index  FY 2004  2/5ths of the value of the applicable pre- reclassification, no floor hospital inpatient wage index  FY 2005  3/5ths of the value of the applicable pre- reclassification, no floor hospital inpatient wage index  FY 2006  4/5ths of the value of the applicable pre- reclassification, no floor hospital inpatient wage index  FY 2007  Full value (5/5ths) of the value of the applicable pre -reclassification, no floor hospital inpatient wage index   Based on analyses of patient charge data from FYs 2000 and 2001 MedPAR data and cost report data from FY 1998 and 1999 HCRIS data, there is no empirical evidence to support other adjustments.  Therefore, for the present, there are no adjustments for DSH, I ME, or geographic reclassification.
(Medicare Claims Processing Manual)
There is a cost -of-living adjustment (COLA) for LTCHs located in Alaska and Hawaii.   The adjustment is made by multiplying the nonlabor-related portion of the unadjusted standard Federal rate by the applicable COLA factor from OPM based on the county that the LTCH is located (similar to the COLA under the acute care hospital inpatient PPS) .   Annual updates for the LTCH PPS appear in Federal Register publications:  for payment rates and associated adjustments, see the LTCH PPS final rule with an effective date of July 1.  Annual updates of the LTC-DRGs are published in the IPPS final rule with an effective date of October 1.    The COLA factors effective July 1, 2004 are the same as under the acute care hospital inpatient PPS and are as follows:  Area  COLA Alaska:      All Areas  1.25 Hawaii:       Honolulu 1.25     Hawaii County 1.165     Kauai County 1.2325     Maui County 1.2375     Kalawao County 1.2375  Cost -of-Living Adjustment Factors: Alaska and Hawaii Hospitals Area Cost of Living Adjustment Factor effective for discharges on and after October 1, 2008.  Alaska: City of Anchorage and 80- kilometer (50 -mile) radius by road 1.24 City of Fairbanks and 80- kilometer (50 -mile) radius by road 1.24 City of Juneau and 80-kilometer (50-mile) radius by road 1.24 Rest of Alaska 1.25  Hawaii:  City and County of Honolulu 1.25 County of Hawaii 1.17  County of Kauai 1.25  County of Maui and County of Kalawao 1.25   150.10.1 - Phase -in Implementation  (Rev. 1, 10- 01-03)  The PPS for LTCHs is to be phased- in over a five- year period from cost -based reimbursement to Federal prospective payment.  During this transition period, payment is based on an increasing percentage of the LTCH prospective payment and a decreasing percentage of each LTCH's cost -based reimbursement rate for each dis charge as follows:
(Medicare Claims Processing Manual)
Cost Reporting Periods Beginning  On or After  LTCH PPS Federal Rate Percentage  TEFRA Rate Percentage  October 1, 2002, through September 30, 2003  20 80 October 1, 2003, through September 30, 2004  40 60 October 1, 2004, through September 30, 2005  60 40 October 1, 2005, through September 30, 2006  80 20 October 1, 2006  100 0  The LTCHs can exercise a one- time irrevocable option to elect payment based on 100 percent of the Federal rate rather than transition from cost -based reimbursement to prospective payment.  To exercise this option, for cost reporting periods beginning on or after October 1, 2002, and before December 1, 2002, the LTCH was to notify its A/B MAC (A) of this election in writing, and it was to be received by the A/B MAC (A) no later than November 1, 2002.  To exercise this option, for cost reporting periods beginning on or after December 1, 2002, the LTCH must notify its A/B MAC (A) in writing 30 days prior to the start of the LTCH's next cost reporting period.  Payments to new LTCHs, i.e., a hospital that has its first cost reporting period as a LTCH beginning on or after October 1, 2002, are made based on 100 percent of the standard Federal rate.   NOTE:  under the BIPA, during cost reporting periods beginning during FY 2001, target amounts under TEFRA were increased by 25 percent.  This increase will continue to be in effect for the TEFRA portion of transitions payments.  150.11  - Requirements for Provider Education and Training  (Rev. 1, 10- 01-03)
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Training resources are available for A/B MAC (A) staff to use in training providers about the Long Term Care Hospital Prospective Payment System (LTCH PPS).  The train -the-trainer process for LTCH PPS does not include in-  person instruction for A/B MACs (A ).  Instead, CMS provides various educational resources for A/B MACs (A) to learn about LTCH PPS.   The CMS provides the following LTCH PPS education resources for A/B MACs (A):   A training guide is available on; http://www.cms.gov/Medicare/Medicare- Fee-for-Service- Payment/LongTermCareHospitalPPS/ltch_train.html, the actual Training Guide can then be downloaded;    A training video was mailed to A/B MACs (A);   A PowerPoint presentation for training providers is available on http://www.cms.gov/Medicare/Medicare- Fee-for-Service-Payment/LongTermCareHospitalPPS/ltch_train.html, the actual Power Point presentation can then be downloaded; and   An e -mail mailbox was established to address questions.  Send questions to: LTCHPPS@cms.gov .  150.12 - Claims Processing and Billing (Rev. 1, 10-01-03)
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 An e -mail mailbox was established to address questions.  Send questions to: LTCHPPS@cms.gov .  150.12 - Claims Processing and Billing (Rev. 1, 10-01-03)  150.12.1 - Processing Bills Between October 1, 2002, and the Implementation Date  (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)  Claims submitted prior to implementation were processed under the current methodology.  On or after January 1, 2003, submit mass adjust claims under the PPS payment methodology by April 30, 2003.  The shared systems is creating a mass adjustment program.  Beginning October 16, 2003, all LTCHs are required to comply with the HIPAA Administrative Simplification Standards, unless they have obtained an extension in compliance with the Administrative Compliance Act to submit claims in compliance with the standards at 42 CFR 162.1002 and 45 CFR 162.1192 using the ICD.  All ICD coding must be used for LTCH providers with cost reporting period beginning on or after October 1, 2002.  150.13 - Billing Requirements 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)   Billing LTCH PPS Services   Effective with cost reporting periods beginning on or after October 1, 2002, LTCHs are to incorporate the following so that A/B MACs (A) accurately price and pay a claim under the LTCH PPS.  These claims must be submitted on Type of Bill 11X.  This is a DRG - based payment system; therefore the LTCH DRG is determined by the grouping of diagnosis codes reported on the claim for the  principal diagnosis, up to twenty four additional diagnoses, and up to twenty five  procedures performed during the stay, as well as age, sex, and discharge status of the patient on the claim.  Grouper software will determine DRG assignment.
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Each bill from an LTCH must contain the complete diagnosis and procedure coding for purposes of the GROUPER software.  Normal adjustments will be allowed.  LTCH providers submit one admit through discharge claim for the stay.  Final PPS payment is based upon the discharge bill (note that the day in which benefits exhaust is considered a discharge for payment purposes).  Effective December 3, 2007, once a patients Medicare benefits exhaust, the LTCH is allowed to submit no-pay bills until physical discharge or death.  150.14 - Stays Prior to and Discharge After PPS Implementation Date  (Rev. 1, 10-01-03)  If the patient's stay begins prior to and ends on or after the provider's first fiscal year begin date under LTCH PPS, payment to the facility is based on LTCH PPS rates and rules.  There is no split billing.  If the facility submitted an interim bill, a debit/credit adjustment must be made prior to PPS payment.  If the facility submits multiple interim bills, the provider needs to submit cancels for all bills and then rebill once the cancels are accepted.  150.14.1 - Crossover Patients in New LTCHs  (Rev. 267, Issued 07-30- 04, Effective: 10 -01-04, Implementation: 01-03-05)  When a hospital undergoes a change in ownership or a change in classification from an acute care hospital to a LTCH, payment issues arise for cross -over patients who were admitted prior to the change in classification who are still hospitalized under the new provider number.  Since all LTCHs are required to be certified as hospitals and generally be paid under the IPPS, for 6 months prior to designation as a LTCH, in 42 CFR 412.23(e), there are cross-over patients, at the creation of every LTCH, who wer e admitted to the facility when it was an acute care hospital.  The policy was to discharge the patient under the acute provider number and readmit the patient under the new LTCH provider number (see section 100.4.1 of this chapter).  Medicare paid twice f or what was really one episode of care since separate payment would be made to both the acute hospital and the LTCH.  Effective October 1, 2004, Medicare will issue one discharge-based payment to the LTCH that discharges the patient, under the applicable payment system.