evekhm/cms_iom_500 huggingface dataset:
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190.7.4 - Stop Loss Provision (Transition Period Only)  (Rev. 1543; Issued:  06- 27-08; Effective Date:  07 -01-08; Implementation Date:  07-07-08)  The IPF PPS includes a stop- loss provision during the 3- year transition.  The purpose is to ensure each facility receives an average payment per case under the IPF PPS that is no less than 70 percent of its average payment under the TEFRA.  It is calculated at cost report settlement.  New providers are not eligible for stop -loss payments.  See 190.9.1.  Example of stop- loss calculation in year 3 of the transition:   1.  Enter Total (100%) TEFRA payments for cases during cost reporting period  2.  Enter Total (100%) PPS payments for cases during cost reporting period   3.  Multiply Step 1 by 0.70.  4.  If Step 3 is greater than Step 2, subtract Step 2 from Step 3.  Otherwise, enter 0.   5.  Add Steps 2 and 4 to calculate total PPS payments.  6.  Multiply Step 1 by 0.25 to calculate the TEFRA portion.  7.  Multiply Step 5 by 0.75 to calculate the PPS portion.  8.  Add Steps 6 and 7 to calculate the IPFs aggregate payments in the third year of the IPF PPS.  Determine if this amount is at least 70 percent of what would have been paid under TEFRA, then pay the difference.   NOTE: Since the transition will be completed for RY 2009, for cost reporting periods beginning on or after January 1, 2008, IPFs will be paid 100 percent PPS and, therefore, the stop loss provision will no longer be applicable.  The CMS has previously stat ed that we would remove this 0.39 percent adjustment to the Federal per diem base rate after the transition.  Therefore, for RY 2009, the Federal per diem base rate and ECT rates will be increased by 0.39 percent.  190.8 - Transition (Phase -In Implementation)  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  190.8.1 - Implementation Date for Provider  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)
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190.8.1 - Implementation Date for Provider  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  The IPF PPS is phased -in over 3 years from the cost based reimbursement to the Federal prospective payment.  All IPF providers must transition over the 3-year transition period. There is no election of 100 percent PPS in the first year.  During the transition period, payment is based on an increasing percentage of the IPF prospective payment and a decreasing percentage of each IPFs TEFRA -based reimbursement rate for each case as follows:    Transition Year  Cost Reporting Periods   Beginning on or After  TEFRA Rate Percentage  IPF PPS Federal Rate  Percentage  1 January 1, 2005  75 25 2 January 1, 2006  50 50 3 January 1, 2007  25 75  January 1, 2008  0 100  The 3 -year transition period is separate from the annual update cycle of the IPF PPS.  The transition is effective according to cost reporting periods, but the updates to the rates take effect July 1 of each year.  For more detailed information regarding the annual update cycle, refer to 190.4.3-Annual Update.  Although the IPF PPS is effective January 1, 2005, an individual IPF's PPS transition year start date is the first day of the first cost reporting period that begins on or after that date.  An IPF may begin the IPF PPS as early as January 1, 2005, or as la te as December 31, 2005, should a cost reporting period begin on that date.  The IPF PPS applies to claims for discharges occurring in the IPF's first cost reporting period beginning on or after January 1, 2005.  Where the IPF has already billed interim claims for an inpatient that has benefit days remaining after the PPS implementation date, the provider must submit a cancel bill and re-bill under the IPF PPS so that payment for the entire stay is made under the IPF PPS.   If the provider ever had a TEFRA limit, the IPF is not a new provider and therefore will receive the blended payment.  This includes those providers that previously closed their psychiatric units and then re-opened the psychiatric units. If the provider ha d a TEFRA limit established, that TEFRA limit is updated using the rate of increase percentages in  42 CFR 413.40.
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For cost reporting periods beginning in FY 1999 through FY 2002, the applicable rate-of-increase percentage is the market basket increase percentage minus a factor based on the percentage by which the hospitals operating costs exceed the hospitals ceiling for the most recently available cost reporting period.  To update the TEFRA limit for IPFs that were closed during FY 1999 through FY 2002 and then re-opened (including CAHs that were statutorily precluded from having a distinct part unit), the rate-of- increase for these years would be the full market basket up  to the cap on the target amounts.  190.9 - Definition of New IPF Providers Versus TEFRA Providers  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  190.9.1 - New Providers Defined  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  A new IPF provider is one that meets the definition of an IPF in 42 CFR 412.402, and under present or previous ownership or both, has not received payment under TEFRA for delivery of IPF services prior to the effective date of the IPF PPS, January 1, 2005.  To be a new provider, the first cost reporting period as a psychiatric hospit al, a distinct part unit in an acute care hospital or a CAH must have begun no earlier than January 1, 2005, coinciding with the effective date of the IPF PPS.  Change of ownership has no impact on whether an IPF is considered a new IPF provider.  190.10 - Claims Processing Requirements Under IPF PPS  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  190.10.1 - General Rules  (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)  Effective with cost reporting periods beginning on or after January 1, 2005, the following claim preparation requirements apply to IPFs:   Type of Bill (TOB) is 11X;
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 Medicare provider number ranges for IPFs are from xx -4000 - xx-4499, xx-Sxxx, and xx-Mxxx; ( NOTE :  Implementation of NPI will change this.)    The IPF must correctly code diagnoses for the principal diagnosis, and up to twenty four additional diagnoses, if applicable;   The IPF must correctly code one principal procedure and up to twenty four additional procedures performed during the stay;   The IPF must also code age, sex, and patient (discharge) status of the patient on the claim, using standard inpatient coding rules; and   An IPF distinct part must code source of admission code "D" on incoming transfers from the acute care area of the same hospital to avoid overpayment of the emergency department adjustment when the acute area has billed or will be billing for covered servic es for the same inpatient admission.  Other general requirements for processing Medicare Part A inpatient claims described in Chapter 25 of this manual apply.  CMS' hospital inpatient GROUPER applicable to the discharge date (or effective December 3, 2007, benefits exhaust date, if present) on the claim will determine the DRG/MS -DRG assignment.  190.10.2 - Billing Period  (Rev. 1231; Issued:  04- 27-07; Effective:  12 -03-07; Implementation:  12 -03-07) When the patient has Medicare benefits, IPF providers will submit one admit through discharge claim for the stay upon discharge.  IPFs may interim bill in 60- day intervals following the instructions in chapter 1, 50.2 of this manual should the patients stay be exceptionally long.  Final PPS payment is based upon the date of physical discharge or death, or the date benefits exhausted (effective December 3, 2007).   IPFs can submit adjustment claims, but late charge claims will not be allowed, e.g., the adjustment claim must include all charges and services and must replace the earlier claim(s) instead of including only the additional charges and services.
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IPFs can submit adjustment claims, but late charge claims will not be allowed, e.g., the adjustment claim must include all charges and services and must replace the earlier claim(s) instead of including only the additional charges and services.   In situations when a patient falls below a skilled level of care, IPFs should submit a 112 TOB with both an Occurrence Code 22 (Date active care ended) and patient status code 30 (Still a patient).  IPFs should then continue to submit subsequent interim 117 TOBs, as appropriat e, with the patient status code 30 and the correct Occurrence Span Codes that identify payment liability (codes 76 or 77).   Effective December 3, 2007, once the patients Medicare benefits exhaust, the IPF is allowed to submit no- pay bills (TOB 110), with a Patient Status Code of 30 every 60 days, until the patient is physically discharged or dies.  The last bill shall contain a discharge patient status code.  IPFs no longer need to continually adjust claims once benefits exhaust.  190.10.3 - Patient Status Coding  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  All patient status (i.e., discharge disposition) codes for 11X TOB are valid, but there are no special payment policies related to transfer codes; for example, discounted or per diem payments in transfer situations.  The same patient status codes applicabl e under inpatient PPS for same day transfers (with Condition Code 40) are applicable under IPF PPS.   190.10.4 - Reporting ECT Treatments  (Rev. 4104, Issued: 08- 03-18, Effective: 10 -01-18, Implementation: 10- 01-18)  IPFs must report on their claims under Revenue Code 0901: the total number of ECT treatments provided to the patient during their IPF stay listed under Service Units.  Providers will code ICD -9-CM procedure code 94.27 if ICD -9-CM is applicable, or, effec tive with the implementation of ICD -10, providers will code the ICD -10-PCS codes listed below in the procedure code field, and for the procedure date will use the date of the last ECT treatment the patient received during their IPF stay.   ICD- 10-PCS Code and Description
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ICD- 10-PCS Code and Description  GZB0ZZZ -  Electroconvulsive Therapy, Unilateral -Single Seizure  GZB2ZZZ -  Electroconvulsive Therapy, Bilateral -Single Seizure  GZB4ZZZ -  Other Electroconvulsive Therapy   190.10.5 - Outpatient Services Treated as Inpatient Services  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  IPFs are subject to the 1 -day payment window for outpatient bundling rules.  Refer to chapter 3, 40.3 of this manual for more information on bundling rules.  190.10.6 - Patient is a Member of a Medicare Advantage Organization for Only a Portion of a Billing Period  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  The payer at the time of the patients admission to an IPF is responsible for the cost of the entire stay.  This could occur for patients who move from traditional Medicare to a Medicare Advantage plan or vice versa.   190.10.7 - Billing for Interrupted Stays  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  IPFs shall bill for the interrupted stay using Occurrence Span Code 74.  The Occurrence Span Code FROM date equals the day of discharge for the IPF and the THROUGH date is the last day the patient was not present in the IPF at midnight.  For example, the patient leaves the IPF on 1/1 and returns to the IPF on 1/3.  This is considered an interrupted stay and the Occurrence Span Code 74 will show 1/1 -  1/2.  Should the patient return to the IPF on 1/4, two bills will be allowed.  The accommodation Revenue Code 018X (RT 50, field 5), (SV 201), (leave of absence) will continue to be used in the current manner in terms of Occurrence Span Code 74 (RT 40, field 22 -  27) and date range.
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190.10.8 - Grace Days  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  There are no grace days allowed under IPF PPS, therefore the date the beneficiary is notified of the provider's intent to bill (Occurrence Code 31) is the last covered day for that patient.   190.10.9 - Billing Stays Prior to and Discharge After PPS Implementation Date  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  If the patients stay begins prior to and ends on or after the providers first fiscal year begin date under IPF PPS, payment to the facility is based on IPF 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 (see chapter 1, 50.2 of this manual).  If the facility submitted multiple interim bills, the facility will need to submit cancels for all bills and then re -bill once the cancels are accepted.   Exceptions:   If the beneficiarys benefits were exhausted or the beneficiary is in a non -covered level of care prior to implementation of IPF PPS, then IPF PPS is not applicable and the IPF will continue to submit no- pay bills (TOB 110) to Medicare.   190.10.10 - Billing Ancillary Services Under IPF PPS  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  There are no special rules for billing IPF inpatient ancillary services.   190.10.11 - Covered Costs Not Included in IPF PPS Amount  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  The following covered services are not included in the IPF PPS discharge payment amount:   o Nursing and allied health education costs are pass -through costs paid outside the IPF PPS.   o DGME and bad debts.
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The following covered services are not included in the IPF PPS discharge payment amount:   o Nursing and allied health education costs are pass -through costs paid outside the IPF PPS.   o DGME and bad debts.  190.10.12 - Same Day Transfer Claims (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  A same day transfer occurs when a patient is admitted to an IPF and is subsequently transferred for acute care (or another type of inpatient facility care) on the same day.  If the patient is admitted to an IPF with the expectation that the patient will re main overnight, but is discharged before midnight, the day is counted as a full day for the cost report, but is not counted as a Medicare covered day for purposes of charging the beneficiary utilization.   IPFs should show the same day for admission and discharge, and report Condition Code 40 (Same Day Transfer).   If the patient is admitted to an IPF and discharged (not transferred to another inpatient setting) the same day before midnight, the day is counted as a full day for the cost report, and is counted as a Medicare covered day for purposes of charging the ben eficiary utilization.  IPFs do not report Condition Code 40 on this case.  The purpose for the variance in coding is to charge the beneficiary only 1 day utilization where two facilities are billing.  Payment will be made for 1 day.   190.10.13 - Remittance Advice - Reserved  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  Not yet available.   190.10.14 - Medicare Summary Notices and Explanation of Medicare Benefits (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  Existing notices for inpatient hospital PPS are used.  190.11  - Benefit Application and Limits- 190 Days  (Rev. 4104, Issued: 08- 03-18, Effective: 10-01-18, Implementation: 10-01-18)
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The psychiatric benefit lifetime maximum of 190 days of inpatient care applies to Medicare participating psychiatric hospitals per 42 CFR 409.62.  The 190- day lifetime limitation does not apply to inpatient psychiatric care provided in certified psychiatric units of an acute care hospital or critical access hospital. Section 409.62 states, There is a lifetime maximum of 190 days on inpatient psyc hiatric hospital services available to any beneficiary.  Therefore, once an individual receives benefits for 190 days of care in a psychiatric hospital, no further benefits of that type are available to that individual.  Payment may not be made for more than a total of 190 days of inpatient psychiatric hospital services during the patient's lifetime.  This limitation does not apply to inpatient psychiatric   services furnished in a non- psychiatric hospital.  This limitatio n does not apply to inpatient psychiatric services furnished in a hospital, a CAH or distinct part psychiatric unit.  The period spent in a psychiatric hospital prior to entitlement does not count against the patient's lifetime limitation, even though pre -entitlement days may have been counted against the 150 days of eligibility in the first benefit period.  The Benefit Period provisions described in Medicare Publication 100-01, Medicare General Information, Eligibility, and Entitlement, chapter 3, 10.4-10.4.4  are applicable to inpatients in either a Medicare participating psychiatric hospital or a certified psychiatric unit of an acute care hospital or critical access hospital.    The CWF keeps track of days paid for inpatient psychiatric services and informs the Medicare contractor on claims where the 190- day limit is reached.   For a more detailed description see Pub. 100-02, Medicare Benefit Policy Manual, chapter 3, 30.C. and chapter 4, 50 for the 190- day lifetime limitation on payment for inpatient psychiatric hospital services.  For details concerning the pre- entitlement inpatient psychiatric benefit reduction provision see Pub. 100-02, Medicare Benefit Policy Manual, chapter 4, 10 - 50.  190.12 - Beneficiary Liability  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)
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Beneficiary liability will operate the same as under the former TEFRA cost- based payment system.  An IPF may not charge a beneficiary for any services for which payment is made by Medicare, even if the facilitys cost of furnishing services to that beneficiary are greater than the amount the facility is paid under the prospective payment system.   An IPF receiving payment under this subpart for a covered hospital stay (that is, a stay that included at least 1 covered day) may charge the Medicare beneficiary or other person only the applicable deductible and coinsurance amounts under 42 CFR 409.82, 42 CFR 409.83, and 42 CFR 409.87 and for items or services as specified under 42 CFR 489.30 .  For more detailed information regarding lifetime reserve days, refer to Pub. 100-02 Medicare Benefit Policy Manual, chapter 5.   190.12.1 - Benefits Exhaust  (Rev. 1231; Issued:  04-27- 07; Effective:  12 -03-07; Implementation:  12 -03-07)  Effective December 3, 2007, for payment purposes, an IPF discharge occurs when benefits exhaust and the date benefits exhaust (if present) will substitute for the actual discharge date.  The claim is paid based on the benefits exhaust date if present rat her than the discharge date.  The Pricer version used to price claims for the discharge is when the services actually were provided (i.e., when the Medicare beneficiary has Medicare benefits).  No pay/110 TOBs are allowed instead of continually adjusting the claims (117 TOB) until actual discharge occurs once benefits exhaust.   Under TEFRA, the PS&R report used the benefits exhaust date as the discharge date (if present).  This changed when the IPF PPS was implemented, and the 'actual' discharge date was used.  The days stay with the year they occurred, making it easier for the P S&R report (especially during the blend period) to settle the cost report.  This means that:  1. Claims will now be settled on the appropriate cost report;  2. The appropriate PPS -TEFRA blend percentage will be paid;   3. Patients with long lengths of stay will be counted on the correct PS&R report;
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3. Patients with long lengths of stay will be counted on the correct PS&R report;   4. The PRICER version used will be the one in effect at the time the services were provided (i.e., when the Medicare beneficiary actually has Medicare benefits).   190.13 - Periodic Interim Payments (PIP)  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  Medicare contractors shall pay PIP for providers who send a request to their Medicare contractor and qualify.  Outlier payments, teaching adjustment, and ECT add- on payments are not included in the PIP payment amount but are paid on the discharge claim for  ECT, and on a discharge, benefits exhaust, or last day of a Medicare covered level of care claim, for the teaching adjustment and outlier payment.   190.14 - Intermediary Benefit Payment Report (IBPR)  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  The IBPR report has been changed to reflect the payments for IPFs going to PPS psychiatric hospitals and units.   190.15  - Monitoring Implementation of IPF PPS Through Pulse  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  The FISS 620A and 620B reports will be modified to add an additional row for IPF monitoring.  The report will be modified to include a separate reporting line titled IPF PPS.  This entry will appear immediately below IPF PPS and report the total claim count and total reimbursement amount.  IPF PPS totals will include all providers with the last four digits of the provider numbers in range 4000 -  4499, xx- Sxxx, and xx- Mxxx.  190.16 - IPF PPS System Edits (Rev. 2157, Issued: 02- 11-11, Effective: 04 -01-11, Implementation: 04- 04-11)  FISS shall ensure that:    Revenue Code total charges line 0001 must equal the sum of the individual total charges lines.
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FISS shall ensure that:    Revenue Code total charges line 0001 must equal the sum of the individual total charges lines.    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.    Value Code 75 is allowed from contractor entry and not allowed from Provider entry. Also, Providers are not allowed to alter this information.   The ED adjustment is not made where a patient is discharged from an acute care hospital or CAH and admitted to the same hospitals or CAHs psychiatric unit with the application of the correct Point of Origin code D on the IPF PPS claim.  FISS and CWF shall ensure that multiple Occurrence Span Code 74s are allowed.  CWF shall ensure that:    Occurrence Span Code 74 is present on the claim when there is an interrupted stay (the beneficiary has returned to the same IPF within 3 days).   Value Code 75 is present on claims when there is an interrupted stay resulting from a discharge at another IPF (the beneficiary has returned to the different IPF within 3 days).  190.17 - IPF PPS PRICER Software  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  CMS has developed an IPF PRICER program that calculates the Medicare payment rate. PRICER software will be electronically supplied to the Standard Systems.  A Personal Computer (PC) version of this PRICER will be available on the CMS Web site in the future  at http://www.cms.hhs.gov/PCPricer.  PRICER will incorporate the 3 -year phase- in period for all current IPFs.  New IPFs will be paid completely under the new IPF PPS (i.e., there is no transition for new IPFs).  190.17.1 - Inputs/Outputs to PRICER  (Rev. 11396, Issued:05-04-22, Effective:10 -01-22, Implementation:10-03-22)  Provider Specific File Data