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INPATIENT REHABILITATION FACILITY-PPS SYSTEM
Effective for services with cost reporting periods beginning on or after January 1, 2002.
IRF-PPS = Inpatient Rehabilitation Facility (rehab hospitals or units) Prospective Payment System.
CMG = Case Mix Groups (100 total groups; 95 normal and 5 atypical) = basis for payment.
Effects PA ACT 6 (Auto Insurance) claims only.
Payment = Federal PPS Rates = adjusted for area wage differences and rural locations.
If Applicable, payments can be further adjusted for DSH (low income patients) and cost outliers.
Effective for Home Health Agency Services on or after October 1, 2000.
HH PPS = Home Health Prospective Payment System.
HHRG Groups = Home Health Resource Groups = basis for payment.
Effects PA ACT 6 (Auto Insurance) claims only.
Durable Medical Equipment (DME) services are excluded from new HH PPS system.
Unit of Payment = 60-day episode period.
Physician assigns the HHRG group and number of visits for care.
Payment = National Payments rates adjusted for area wage differences and intensity of care (HHRG groups).
Payments
can be further adjusted for the following reasons:
- Low Utilization Payment Adjustment (LUPA) = 4 or fewer visits assigned for
care.
- Partial Episode Payment (PEP) Adjustment = Patient does not require entire
care
assigned to the 60-day episode period.
- Significant Change in Condition (SCIC) Adjustment = Patient is assigned a
new HHRG
group during the 60-day episode period due to a significant change in
their original
condition.
- Outlier Cases = High cost of care above national thresholds.
Medical Supplies are included in the HH PPS Payment.
No transitional period.
HHA's cannot submit a claim with Date of Services straddling both September and October 2000.
Effective for Hospital Inpatient DRG Services on or after October 1, 2009.
Final Regulations published in the Federal Register on August 27, 2009.
Changes are as follows:
- DRG Weights, ALOS, and GLOS.
- Wage Index.
- Geographic
Adjustment Factor.
- National Labor
and Nonlabor Amounts.
- National Fixed
Loss Cost Outlier Threshold factor.
- IME factor.
- DSH payment
reduction has been eliminated.
- Capital Federal
Rate.
- ICD9 code
additions/deletions.
HOSPITAL OUTPATIENT APC SYSTEM
Effective for Hospital Outpatient Services on or after August 1, 2000.
APC=Ambulatory Payment Classifications.
APC Groups = Basis for payment.
Effects PA ACT 6 (Auto Insurance) claims only.
Free-Standing ASC's are excluded from new APC system.
Hospital Services Included in APC system:
-
Surgical Procedures
- Radiology Services
- Diagnostic Services
- Other Diagnostic Tests
- Emergency Room
- Clinic Visits
- Radiation Therapy
- Chemotherapy
Hospital Services Excluded from APC system
- Clinical
Lab = Medicare Fee Schedule
- ESRD = Composite Rate
- Ambulance Services = Medicare Fee Schedule
- Inpatient Services = DRG
- DME/Orthotics = Medicare Fee Schedule
- All therapy (PT, OT, ST) Services = Medicare Fee Schedule
Payment = National rates adjusted for wage differences
Payments
can be further adjusted for the following reasons:
- Outlier Cases = For high costs of care exceeding national
thresholds.
- Transitional Corridors - Adjustment to limit the decline in
payments. Provider must
meet national thresholds, adjustment will be not be effective
on or after January 1,
2004
Hospital
cannot submit a claim with Date of Services straddling both July and August
2000.
Note: Medicare makes payment rates changes in every quarter of the year January 1st, April 1st, and July 1st, October 1st
HOT & COLD PACKS (CPT CODE 97010)
There has been confusion on how to handle CPT code 97010 on both Act 6 and Act 44 claims. The following is a guide to help you with this process:
For ACT 6 (PA. Auto Insurance)
Effective for dates of service on or after January 1, 1997, all claims items that are billed with CPT code 97010 should be denied as this was a Medicare regulatory change. HCFA is now saying that these services are included in the primary care reimbursement.
For ACT 44 (PA Workers' Compensation)
The Pennsylvania Bureau of Workers' Compensation position on this issue is that for all Part A Outpatient providers, CPT code 97010 remains reimbursable, however for Part B providers CPT code 97010 can be denied.
APC
Ambulatory Payment Classification - New Hospital Outpatient
Prospective
System effective for services on or after 08/01/00.
ASC
Ambulatory Surgical Centers
- Free-standing facilities providing
surgical procedures as an outpatient service.
AWP
Average Wholesale Prices - Used for PA Act 44 Pharmacy
reimbursement.
BBA
Balance Budget Act of 1997 - Medicare Regulation that changed how many
provider services are paid. This law was passed on August 7, 1997.
BBRA
Balance Budget Refinement Act of 1999 - Medicare regulation that amended
some of the BBA of 1997 issues. This law was passed on November 29, 1999.
BIPA
Benefits Improvement and Protection Act of 2000 - Medicare regulation that
made
provisions to increase various Inpatient DRG Medicare rates.
This law was passed on December 21, 2000.
CAH
Critical Access Hospital - A Specially licensed hospital designed
to provide
care to under-served areas. They are cost reimbursed for both inpatient and
outpatient processing.
CBSA Core-Based
Statistical Area - A new statistic used to determine the
labor
portion of a PPS payment for differences in wages nationally replacing the MSA
Area.
CCI Correct Coding Initiative
CMS
Centers for Medicare and Medicaid Services - Federal Agency that
administers the Medicare and Medicaid
programs formerly known as
HCFA.
CORF
Comprehensive Outpatient Rehabilitation Facility.
CPT
Current Procedural Terminology.
DME
Durable Medical Equipment - Reimbursed by the Medicare Fee
Schedule.
DRG
Diagnostic Related Groups - Basis of payment for Inpatient
Acute Care
Hospitals.
ESRD
End Stage Renal Dialysis
FI
Fiscal Intermediary - Agent of HCFA to process Medicare Part A
claims.
FY
Fiscal Year - Government fiscal year that runs from Oct 1st to
September 30th.
Grouper Medicare Grouper - Process of
determining the DRG number needed
to
re-price Hospital Acute-care Inpatient claims.
HCFA Health Care
Financing Administration - Federal Agency that administers the Medicare
and Medicaid programs now called the "Centers for Medicare and Medicaid
Services"
HCPCS HCFA Common Procedural
Coding System
HGSA HGSAdministrators - Regional Federal Carrier that administers the
Medicare
program for Physicians and Suppliers (formerly XACT).
HH PPS Home Health Prospective Payment
System - New payment system
for
Home Health Agencies effective for services on or after 10-01-00
HHA Home Health Agency
IME
Indirect
Medical Education - Additional payment within the DRG
PPS
that a hospital receives if they have an approved Medical
Education program.
IRF
Inpatient Rehabilitation Facility
MSA
Metropolitan
Statistical Wage - A statistical used to determine the
labor
portion of a PPS payment for differences in wages nationally.
NCC National Correct Coding
OPT Outpatient
Physical Therapy
PPS Prospective
Payment System
Pricer
Medicare Pricer
System - A system used to re-price Medicare claims.
RUGs Resource Utilization
Groups - Basis of payment for the Skilled
Nursing
Facilities Medicare PPS system since July 1, 1998.
SCH
Sole
Community Hospitals
SNF
Skilled
Nursing Facilities - Nursing Homes