PROGRAM MEMORANDUM
INTERMEDIARIES
Department of Health and Human Services
Health Care Financing Administration
Transmittal No. A-98-26 Date JULY 1998
CHANGE REQUEST #593
SUBJECT: Prospective Payment System (PPS) PRICER Changes for Fiscal Year (FY) 1999, Including Changes for Discharges to Post-Acute Care Providers and a Millennium Compliant Provider Specific File
These instructions include items requiring major systems changes by intermediaries, standard system maintainers, and providers. Intermediaries should promptly notify providers of these new discharge billing requirements. Additional information related to FY 1999 inpatient hospital PPS discharges will be distributed via a Program Memorandum after publication in the Federal Register on or about August 1, 1998.
Discharges to Post-Acute Care Providers
Section 1886(d)(5)(J) of the Act, which was added by §4407 of Public Law 105-33, requires the Secretary of the Department of Health and Human Services (HHS) to identify 10 Diagnosis Related Groups (DRGs) for which discharges from any one of these DRGs to a post-acute care provider will be treated as a transfer beginning with discharges on or after October 1, 1998, and paid accordingly under PPS (operating and capital) for inpatient hospital services. The 10 DRGs included under the expanded transfer definition are: 014, 113, 209, 210, 211, 236, 263, 264, 429, and 483.
Any discharge from a prospective payment hospital from one of these 10 DRGS that is admitted to one of the following post-acute providers on the date of discharge from the acute hospital would be considered a transfer: a hospital or unit excluded from the inpatient prospective payment system under §1886(d)(1)(B) of the Act (psychiatric, rehabilitation, children’s, long-term care, and cancer hospitals and psychiatric and rehabilitation distinct part units of a hospital); or a skilled nursing facility (SNF).
In addition, any discharge from one of these 10 DRGs for home health services provided by a home health agency, if the services are related to the condition or diagnosis for which the individual received inpatient hospital services, and if the home health services are provided within an appropriate period (as determined by the Secretary, HHS), would be considered a transfer under this section. With regard to home health services related to the condition or diagnosis for which the individual received inpatient hospital services, we are including as a related discharge any patient discharged from an acute hospital with a written plan of care for the provision of home health care services from a home health agency. With regard to the appropriate period of time, we have determined that all discharges from one of these 10 DRGs receiving related home health care within 3 days after the date of discharge will be considered a transfer under this section.
Payment Methodology
In a transfer situation, full payment is made to the final discharging hospital and each transferring hospital is paid a per diem rate for each day of the stay, not to exceed the full DRG payment that would have been made if the patient had been discharged without being transferred.
HCFA-Pub. 60A
Currently, the per diem rate paid to a transferring hospital is determined by dividing the full DRG payment that would have been paid in a nontransfer situation by the geometric mean length of stay for the DRG into which the case falls. Hospitals receive twice the per diem for the first day of the stay and the per diem for every following day up to the full DRG amount. Transferring hospitals are also eligible for outlier payments for cases that meet the cost outlier criteria established for all other cases (nontransfer and transfer cases alike) classified to the DRG. An exception to the transfer payment policy is a transfer case classified into DRG 385 (Neonates, Died or Transferred to Another Acute Care Facility) which is not paid on a per diem basis but instead receives the full DRG payment.
The statute does not dictate the payment methodology we are to use for the 10 DRGs. However, §1886(d)(5)(J)(I) of the Act limits payment to no more than half the DRG payment amount for the first day of the stay, and half of the current per diem payment for the stay. For post-acute transfers under this section in DRGs 209, 210, and 211, we will pay using this alternative methodology. That is, post-acute transfers from one of these DRGs will be paid 50 percent of the DRG payment for the first day of the stay, plus 50 percent of the per diem amount for the stay. The other seven DRGs would be paid under the current transfer per diem payment methodology described above.
We will check inpatient bills against home health service bills for care provided within 3 days after discharge similar to our current edit for hospital to hospital transfers. If we find that home health services were provided within the postdischarge window, the intermediary will be advised to notify the hospital, and the hospital payment will be adjusted unless the hospital can submit documentation verifying the discharge status of the patient. This will alert hospitals if there are problems with their discharge/transfer billing and allow them to adjust their discharge planning and billing practices so that their bills are complete and correct. If we find a continued hospital billing pattern for cases from the 10 DRGs as discharges and our records indicate that the patients are receiving post-acute care services either from an excluded hospital, a SNF or within the 3-day home health service window, the hospitals may be subject to an intense prepayment bill review or possible action under the False Claims Act.
Claims Processing Requirements
Transfers to psychiatric, rehabilitation, children’s, long-term care, and cancer hospitals and psychiatric and rehabilitation distinct part units of a hospital must have a Patient Status code of 05. Transfers to a SNF must have a Patient Status code of 03. Transfers to a home health agency must have a Patient Status code of 06. If the continuing care plan is not related to the purpose of the inpatient hospital admission, a Condition Code 42 must be entered on the claim. If the continuing care plan is related to the purpose of the inpatient hospital admission, but care did not start within the prescribed window of time (3 days after the date of discharge), a Condition Code 43 must be entered on the claim. The presence of either of these Condition Codes in conjunction with Patient Status code 06 will cause the PRICER software to calculate the full payment amount rather than the transfer payment amount.
All transfers for all DRGs must be coded accurately. The PRICER software will determine the correct payment amount based on the DRG and Review Code input by the intermediary/standard system.
A new Review Code of 09 must be sent to PRICER for claims that have a Patient Status code of 03 or 05. A new Review Code of 09 must also be sent to PRICER for claims that have a Patient Status code of 06 unless they also have a Condition Code of 42 or 43 in which case their Review Code would be 00 or 07 as appropriate.
A new Return Code of 14 will indicate that the length of stay for this claim is greater than the average length of stay for this DRG and a reduction in payment is not applicable. A normal DRG payment was made on this claim.
A new Return Code of 16 will indicate that the length of stay for this claim is greater than the average length of stay for this DRG and a reduction in payment is not applicable. A normal DRG payment and a cost outlier payment were made on this claim.
A new Return Code of 12 will indicate that the claim was paid as a transfer to a post-acute care setting under one of the seven DRGs paid at the per diem transfer payment methodology (42 CFR 412.4(f)(1)).
A new Return Code of 10 will indicate that the claim was paid as a transfer to a post-acute care setting under one of the three DRGs paid at the alternative transfer payment methodology (42 CFR 412.4(f)(2)).
The existing Return Codes of 03, 05 and 06 will continue to be returned when a Patient Status code of 02 is submitted on the claim and the claim is sent to PRICER with a Review Code of 03 or 06.
Provider Specific File (PSF)
The PSF has been updated to be millennium compliant in FY 1999. The FY 1999 release of PRICER software, which will price bills for FY 1999 back to FY 1995, requires that your entire PSF be changed to the new format. The new format which will be manualized in §3656.3 follows in Attachment 1, and the new format which will be manualized in §3850 follows in Attachment 2. Both are effective October 1, 1998, You must keep a copy of the pre FY 1999 PSF in the old format to use when running any older PRICER software for prior years.
PRICER Bill Data File
The new format for the Bill Data File follows:
Field Name Location Size Picture
NPI 1-10 10 X(10)
Oscar Prov. No. 11-16 6 X(06)
Bill Review Code 17-18 2 9(02)
DRG Number 19-21 3 9(03)
Length of Stay 22-24 3 9(03)
Covered Days 25-27 3 9(03)
LTR Days Used 28-29 2 9(02)
Discharge Date 30-37
Dis. Century 2 9(02)
Dis. Year 2 9(02)
Dis. Month 2 9(02)
Dis. Day 2 9(02)
Charges Claimed 38-46 9 9(07)V9(02)
PRICER Test Bill Data File
The new format for the Test Bill Data File follows:
Field Name Location Size Picture
NPI 1-10 10 X(10)
Oscar Prov. No. 11-16 6 X(06)
Hlth Ins Clm No. 17-28 12 X(12)
Bill Review Code 29-30 2 9(02)
DRG Number 31-33 3 9(03)
Length of Stay 34-36 3 9(03)
Covered Days 37-39 3 9(03)
LTR Days Used 40-41 2 9(02)
Discharge Date 42-49
Dis. Century 2 9(02)
Dis. Year 2 9(02)
Dis. Month 2 9(02)
Dis. Day 2 9(02)
Charges Claimed 50-58 9 9(07)V9(02)
Filler 59-70 12 X(12)
MSAX File
The MSAX file has been updated to be millennium compliant in FY 1999. The new format follows:
Field Name Location Size Picture
MSA or Rural Code 1-4 4 X(04)
Size Ind. L,O or R 5 1 X(01)
Effective Date 6-13 8 X(08)
(CCYYMMDD format)
Filler 14 1 X(01)
Wage Index 15-20 6 9(02)V9999
Puerto Rico W. I. 21-26 6 9(02)V9999
These instructions should be implemented within your current operating budget.
This Program Memorandum may be discarded after September 30, 1999.
Contact Person: Stuart Barranco on (410) 786-6152.
Attachments
ATTACHMENT 1
Provider Specific File.--The PROV file contains needed information about each provider to enable the pricing software to calculate the payment amount. Maintain the accuracy of the data in accordance with the following criteria.
Whenever the status of any element changes, prepare an additional record showing the effective date. For example, when a hospital's FY beginning date changes as a result of a change in ownership or other "good cause," make an additional record showing the effective date of the change.
The format and data shown below are required by the PRICER program and by the provider-specific file you submit to HCFA every 3 months. (See §3850.)
File Position Format Title Description
1-8X(8)National Provider Alpha-numeric 8 character Identifier (NPI)provider number.
9-10 X(2) NPI Filler Blank.
11-16 X(6) Provider Oscar No.Alpha-numeric 6 character provider number.
17-249(8)Effective DateNumeric CCYYMMDD. This is the effective date of the provider's first PPS period, or for subsequent PPS periods, the effective date of a change to the PROV file.
25-32 9(8) Fiscal Year Numeric (CCYYMMDD)
Beginning Date Month: 01-12
Day: 01-31
Year: Greater than 1981, but not greater than current year. Must be updated annually beginning October 1, 1991, to show the current year for PPS pricing purposes.
33-40 9(8) Report DateDate file created/run date of the PROV report for submittal to HCFA CO. Must be CCYYMMDD.
41-48 9(8) Termination DateTermination date in this context is the date on which the reporting intermediary ceased servicing the provider in question. Must be zeros or contain a termination date. Must be CCYYMMDD.
49 X Waiver Indicator "N" means not waived (under
PPS) and "Y" means waived (not
under PPS).
50-54 9(5) Intermediary Intermediary #
Number
55-56X(2)Provider TypeThis identifies providers that require special handling. Enter the appropriate code:
Must be blank or 00, 02-08, 13-18, 21-23, or 32-38.
00or blanks = Short Term Facility
02 Long Term
03 Psychiatric
04 Rehabilitation Facility
05 Pediatric
06 Hospital Distinct Parts
07 Rural Referral Center
08 Indian Health Service
13Cancer Facility
14Medicare Dependent Hospital (During cost reporting periods that began on or after 4-1-90.)
15Medicare Dependent Hospital /Referral Center (During cost reporting periods that began on or after 4-1-90. Invalid 10-1-94 through 9-30-97.) (See §3610.17B.)
16Rebased Sole Community Hospital
17Rebased Sole Community Hospital/Referral Center
18Medical Assistance Facility
21Essential Access Community Hospital
22Essential Access Community Hospital/Referral Center
23Rural Primary Care Hospital
32Nursing Home Case Mix Quality Demonstration Project - Phase II
33Nursing Home Case Mix Quality Demonstration Project - Phase III - Step 1
34 Reserved
35 Hospice
36 Home Health Agency
37 Critical Access Hospital
38Skilled Nursing Facility (SNF) -For non demo PPS SNFs- eff. for cost reporting periods beginning on or after 7/1/98.
57 9 Current CensusEnter the appropriate code for
Divisionthe current census division (based on the standard amount location MSA):
1 New England
2 Middle Atlantic
3 South Atlantic
4 East North Central
5 East South Central
6 West North Central
7 West South Central
8 Mountain
9 Pacific
NOTE: When a facility is reclassified for purposes of the standard amount, change the census division to reflect the new standardized amount location.
58 X Change Code for Enter "Y" if the hospital's wage index
Wage Index location has been reclassified for the
Reclassificationyear. Enter "N" if it has not been reclassified for the year. Adjust annually.
59-62 X(4) Actual Geographic Enter the appropriate code for MSA,
Location--MSA 0040-9953, or the rural area, (blank)
(blank) 2-digit numeric State code, such as 3 6 for Ohio, where the facility is physically located.
63-66 X(4) Wage Index The appropriate code for the MSA,
Location--MSA0040-9953, or the rural area, (blank) (blank) (2 digit numeric State code) such as _ _ 3 6 for Ohio, to which a hospital has been reclassified due to its prevailing wage rates. Leave blank or enter the actual location MSA if not reclassified. PRICER will automatically default to the actual location MSA if this field is left blank.
67-70 X(4) Standardized Amount The appropriate code for the MSA, Location--MSA0040-9953, or the rural area, (blank) (blank) (2-digit numeric State code) such as _ _ 3 6 for Ohio, to which a hospital has been reclassified. Leave blank or enter the actual location MSA if not reclassified. PRICER will automatically default to the actual location MSA if this is left blank.
71-72 X(2) Sole Community Leave blank if not a sole community
or Medicare Dependent hospital (SCH) or a Medicare dependent Hospitalhospital (MDH) effective with cost reporting periods that begin on or after April 1, 1990. If an SCH or an MDH, show the base year for the operating hospital specific rate, the higher of either 82 or 87. (See §3610.17.) Must be completed for any SCH or MDH that operated in 82 or 87, even if the hospital will be paid at the Federal rate.
73 X Change Code Enter an "L" if the MSA has for Lugar been reclassified for wage Reclassificationindex purposes under §1886(d)(8)(B) of the Act. These are also known as Lugar reclassifications, and apply to ASC-approved services provided on an outpatient basis when a hospital qualifies for payment under an alternate wage index MSA.
Leave blank if there has not been a Lugar reclassification.
For hospice providers only, enter a "6", "7", "8" or "9" if the hospice is located in one of the four special hospice MSAs.
74 X Temporary Relief Enter a "Y" if this provider qualifies for Indicator a payment update under the temporary relief provision. Blank if not "Y".
75 X Federal PPS Blend Enter the appropriate code for the blend
Indicatorratio between Federal and facility rates. For PPS SNFs eff. for cost reporting period beginning on or after 7/1/98.
Federal % Facility %
1 25 75
2 50 50
3 75 25
4 100 00
76-80 X(5) FillerBlank.
81-87 9(5)V9(2) Case Mix AdjustedFor PPS hospitals and waiver State
Cost per Discharge/ nonexcluded hospitals, enter the PPS Facility Specific Rate base year cost per discharge divided by the case mix index. Enter zero for new providers. See §3610.17 for sole community and Medicare-dependent hospitals on or after 4/1/90. Must be updated effective October 1, 1994. For PPS SNF’s that qualify for the transition period eff. with cost reporting periods beginning on or after 7/1/98, enter the facility specific payment rate.
88-91 9V9(3) Cost of Living Enter the appropriate cost of Adjustmentliving adjustment for the current fiscal year as published in the Federal Register.
92-96 9V9(4) Intern/Beds Enter the provider's intern/resident to
Ratiobed ratio. Calculate this by dividing the provider's full-time equivalent residents by the number of available beds (as calculated in positions 50-54). Do not include residents in anesthe-siology who are employed to replace anesthetists or those assigned to excluded units. Base the count upon the average number of full-time equivalent residents assigned to the hospital during the fiscal year. Correct cases where there is reason to believe
that the count is substantially in error for a particular facility. You are responsible for reviewing hospital records and making any necessary changes in the count at the end of the cost reporting period. Enter zero for nonteaching hospitals.
97-101 9(5) Bed SizeIndicate the number of adult hospital beds and pediatric beds available for lodging inpatients. (See Provider Reimbursement Manual, §2405.3G.)
If there is a change during the year, make an adjustment if it would make a significant difference in the amount of payments.
102-105 9V9(3)Operating Cost to Derived from the latest settled cost Charge Ratioreport and corresponding charge data from the billing file. Compute this amount by dividing the Medicare operating costs by the Medicare covered charges. Obtain Medicare operating costs from the Medicare cost report Form HCFA-2552-96, Supplemental Worksheet D-1, Part II, Line 53. Obtain Medicare covered charges from your billing file, i.e., PS&R record. For hospitals for which you are unable to compute a reasonable cost-to-charge ratio, use the appropriate urban or rural statewide average cost-to-charge ratio calculated annually by HCFA and published in the Federal Register. These average ratios are used to calculate cost outlier payments for those hospitals where you compute cost-to-charge ratios that are not within the limits published in the Federal Register.
106-110 9V9(4)Case Mix IndexThe case mix index used to complete positions 81-87. In most cases, this is the case mix index that has been calculated and published by HCFA for each hospital (based on 1981 cost and billing data) reflecting the relative cost of that hospital's mix of cases compared to the national average mix.
111-114V9(4)Supplemental SSI ratio used to determine if the
Security Income hospital qualifies for a disproportionate Ratioshare adjustment and to determine the size of the capital and operating DSH adjustments.
115-118 V9(4) Medicaid RatioMedicaid ratio used to determine if the hospital qualifies for a disproportionate share adjustment and to determine the size of the capital and operating DSH adjustments.
119-160 X(42) Filler Blank.
161-166 9(4)V99 Pass Through Per diem amount based on the Amount for Capitalinterim payments to the hospital. (See Provider Reimbursement Manual §2405.2.) Used for PPS hospitals prior to their cost reporting period beginning in FY 92, new hospitals during their first 2 years of operation FY 92 or later, and non-PPS hospitals or units. Zero fill if this does not apply.
167-172 9(4)V99 Pass Through Per diem amount based on the Amount for Direct interim payments to the hospital. Medical Education(See Provider Reimbursement Manual §2405.2.) Zero fill if this does not apply.
173-178 9(4)V99 Pass Through Per diem amount based on the Amount for Organ interim payments to the hospital. AcquisitionInclude standard acquisition amounts for kidney, heart and liver transplants. Do not include acquisition costs for bone marrow transplants. (See Provider Reimbursement Manual §2405.2.) Zero fill if this does not apply.
179-184 9(4)V99 Total Pass Through Per diem amount based on the Amount, Including interim payments to the hospital. Miscellaneous (See Provider Reimbursement Manual §2405.2.) Must be at least equal to the three pass through amounts listed above. The following are included intotal pass through amount in addition to the above pass through amounts: Certified Registered Nurse Anesthetists (CRNAs) are paid as part of Miscellaneous Pass Through for rural hospitals that perform fewer than 500 surgeries per year; and Nursing and Allied Health Professional Education when conducted by a provider in an approved program. Do not include amounts paid for Indirect Medical Education, Hemophilia Clotting Factors, or DSH adjustments. Zero fill if this does not apply.
185 X Capital PPS Type of capital payment
Payment Codemethodology:
A=Hold harmless-cost payment for old capital.
B=Hold harmless-100% Federal rate.
C=Fully prospective blended rate.
Blank if a "Y" is entered in position 207.
186-191 9(4)V99 Hospital-Specific Numeric. Hospital's allowable
Capital Rateadjusted base year inpatient capital costs per discharge.
192-197 9(4)V99 Old Capital Hold Numeric. Hospital's allowable
Harmless Rateinpatient "old" capital costs per discharge incurred for assets acquired before December 31, 1990 for capital PPS. Update annually.
198-202 9V9(4) New Capital-Hold Numeric. Ratio of hospital's allow-
Harmless Ratioable inpatient costs for new capital to the hospital's total allowable inpatient capital costs. Update annually.
203-206 9V999 Capital Cost- Derived from the latest cost report
to-Charge Ratioand corresponding charge data from the billing file. For hospitals for which you are unable to compute a reasonable cost-to-charge ratio, use the appropriate Statewide average cost-to-charge ratio calculated annually by HCFA and published in the Federal Register. These average ratios are used to calculate cost outlier payments for those hospitals where you compute cost-to-charge ratios that are not within the limits published in the Federal Register. A provider may submit evidence to justify a capital cost-to-charge ratio that lies outside a 3 standard deviation band. Use thehospital's ratio rather than the statewide average if you agree the hospital’s ratio is justified.
207 X New HospitalEnter "Y" for the first 2 years that a new hospital is in operation.
Leave blank if hospital is not within first 2 years of operation.
208-212 9V9(4) Capital Indirect The ratio of residents/interns to the
Medical Educationhospital's average daily census.
Ratio Calculate by dividing the hospital's full-time equivalent total of residents during the fiscal year by the hospital's total inpatient days. (See §3611.1.) Zero fill for a non-teaching hospital.
213-218 9(4)V99 Capital Exception The per discharge exception payment
Payment Rateto which a hospital is entitled. (See §3611.7.)
219-240 X(22) Filler Blank.
ATTACHMENT 2
Provider-Specific Payment Data.--Submit a file of provider-specific payment data to Central Office (CO) every 3 months for PPS and non-PPS hospitals, hospices and HHAs, including those in Maryland. Create a new record any time a change occurs for a provider. Report data for the following periods: October 2-January 1, January 2-April 1, April 2-July 1, and July 2-October 1. This file must be received in CO within 7 calendar days after the end of the period being reported.
NOTE:Submit your latest available provider-specific data for the entire reporting period to CO by the 7 calendar day deadline. If CO fails to issue applicable instructions concerning changes or additions to the file fields by 10 calendar days before the end of the reporting period, you may delay reporting of data related to the CO instructions until the next file due date. For example, if CO instructions changing a file field are issued on or after September 21 with an effective date of October 1, you may exclude the October 1 CO-required changes from the file you submit by October 16. Include the October 1 CO-required changes, and all subsequent changes through January 1 in the file submitted in January.
A. PPS Hospitals.--Submit all records (past and current) for all PPS providers every 3 months. Duplicate the provider file used in the "PRICER" module of your claims processing system.
B. Non-PPS Hospitals and Exempt Units.--Create a provider specific history file using the listed data elements for each non-PPS hospital and exempt hospital unit. Submit the current and the preceding fiscal years every 3 months. Code Y in position 13 (waiver code) if you want to maintain the record in your PRICER PROV file.
C. Hospice and HHA.--Create a provider specific history file using the following data elements for each hospice or HHA. Submit the current and the preceding fiscal years every 3 months. Code Y in position 13 (waiver code) if you want to maintain the record in your PRICER PROV file. Data elements 1, 2, 4, 7, 18, 20, 21 and 33 are required. All other data elements are optional for these provider types.
D. Skilled Nursing Facility (SNF).--Create a provider specific history file using the following data elements for each SNF beginning with their first cost reporting period that starts on or after July 1, 1998. Submit the current and the preceding fiscal years every 3 months. Code Y in position 13 (waiver code) if you want to maintain the record in your PRICER PROV file. Data elements 1, 2, 4, 6, 7, 9, 18, 20, and 21 are required. All other data elements are optional for this provider type.
Send a paper listing copy to your RO. If you service providers outside of your area, submit a hardcopy of the file to the RO in which the facility is located. (For example, Mutual of Omaha submits a hardcopy of the file to the Denver, San Francisco, Atlanta, and Dallas ROs.)
NOTE:The intermediary servicing Indian Health Facilities needs to submit a hardcopy of the file only to the Dallas RO.
The provider specific file (PSF) should be transferred to CO using the Network Data Mover (NDM) system, COPY TO and RUN JOB statements, which will notify CO of PSF file transfer. You must setup an NDM transfer from your system for which you are responsible. It is critical that the Provider Specific data is copied to the HCFA Data Center using the following input dataset names. 99999 should be changed to your five digit intermediary number.
Dataset Name ---COPY TO: --MU00.@FPA2175.FI99999
DCB=(HCFA1.MODEL,BLKSIZE=2400,LRECL=2400,RECFM=FB)
Dataset Name ---RUN JOB: --MU00.@FPA2175.CLIST(FI99999)
Provider-Specific Data Record Layout and Description.--Complete all fields for PPS hospitals, PPS-exempt hospitals, distinct part units, HHAs, hospices, and SNFs as indicated below. Use the space bar to indicate a (blank). Do not enter zeroes, nines or nulls in these fields.
Field Format Location Coding and Edits
1. National Provider X(8) 1-8 NA
Identifier (NPI)
2. NPI - Filler X(2) 9-10 NA
3.Provider Oscar No.X(6)11-16Alpha/Numeric - Cross check to Item 10 provider type. Positions 3 and 4 of:
Provider # Type (see field 4)
00-08Blanks, 00, 07-11, 13-17, 21-22
12 18
13 23, 37
20-22 02
30 04
33 05
40-44 03
50-64 32-34, 38
15-17 35
70-84, 90-99 36
Codes for special units S, T, U, W and Y are in the third position of the provider number and should be type 06 (hospital distinct parts).
4. Effective Date9(8) 17-24Month 01-12, day 01-31, year greater than 1982 but not greater than current year. This is the effective date of the provider's first PPS period, or for subsequent PPS periods, the effective date of a change to the PROV file. This must be equal to or greater than the Fiscal Year Begin Date for this record. Must be numeric (CCYYMMDD).
5. Fiscal Year 9(8) 25-32 Must be numeric (CCYYMMDD).
Beginning Date Month: 01-12
Day: 01-31
Year: Greater than 1981 but not greater than the current year. Must be updated annually to show the current year. Must be equal to or less than the effective date.
6. Report Date 9(8) 33-40Must be numeric (CCYYMMDD). Date file created/run date of the PROV report for submittal to HCFA CO.
7. Termination Date 9(8) 41-48Termination in this context is the date on which the reporting intermediary ceased servicing the provider. Must be zeros or contain a termination date. Must be numeric (CCYYMMDD).
If you terminate or transfer the provider to another intermediary, place a termination date in the file to reflect the last date you serviced the provider. Likewise, if the provider identification number changes, you must place a termination date in the PROV file you transmit to HCFA for the old provider identification number.
8. Waiver Indicator X 49Provider waived from PPS? Must be Y (yes) or N (no).
Y = Hospital is not under PPS
N = Hospital is under PPS
9.Intermediary 9(5) 50-54 Assigned intermediary number
Number
10. Provider Type X(2) 55-56Must be blank or 00, 02-08, 13-18, 21-23 or 32-38.
Blanks or 00 Short Term Facility
02 Long Term
03 Psychiatric
04 Rehabilitation Facility
05 Pediatric
06 Hospital Distinct Parts
07 Rural Referral Center
08 Indian Health Center
13 Cancer Facility
14Medicare Dependent Hospital (for cost reporting periods that began on or after 4/1/90, except FY 95-97.) See §3610.17B.
15Medicare Dependent Hospital/Referral Center (for cost reporting periods that began on or after 4/1/90, except FY 95-97.) See §3610.17B.
16Rebased Sole Community Hospital
17Rebased Sole Community Hospital/Referral Center
18Medical Assistance Facility
21Essential Access Community Hospital(EACH)
22EACH/Referral Center
23 Rural Primary Care Hospital
32 NHCMQ-II (SNF only)
33 NHCMQ-III (SNF only)
34 Reserved
35 Hospice
36 Home Health Agency
37 Critical Access Hospital
38Skilled Nursing Facility (SNF) -For non-demo PPS SNFs- eff. for cost reporting periods beginning on or after 7/1/98
11. Current Census9 57Must be numeric (1-9). The
Division census division to which the facility belongs for payment purposes. When a facility is reclassified for the standardized amount, change the census division to reflect the new standardized amount location. Used to select the payment rates. (See §3656.3B for valid codes.)
12. Change Code for X 58 Enter "Y" if the hospital's wage Wage Index index location has been reclassified Reclassificationfor this year. Enter "N" if not reclassified for this year. Adjust annually.
13. Actual Geographic X(4) 59-62Must be (blank)(blank) 2-digit
Location-MSA code if rural or MSA # 0040 -9953.
14. Wage Index X(4) 63-66 The appropriate code for the MSA Location--MSA 0040-9953, or the rural area, (blank) (blank) (2-digit numeric State code) such as _ _ 3 6 for Ohio, to which a hospital has been reclassified due to its prevailing wage rates. Leave blank or enter the actual location MSA (field 7), if not reclassified. PRICER automatically defaults to the actual location MSA if this is left blank.
15. Standardized Amount X(4) 67-70 The appropriate code for the MSA Location--MSA0040-9953, or the rural area, (blank) (blank) (2-digit numeric State code) such as _ _ 3 6 for Ohio, to which a hospital has been reclassified. Leave blank or enter the actual location MSA (field 7) if not reclassified. PRICER automatically defaults to the actual location MSA if this is left blank.
16. Sole Community X(2) 71-72 Leave blank if not an SCH or Medicare effective with cost Dependent Hospital reporting periods that --Base Yearbegan on or after 4/1/90, except FY95-97. If an SCH or an MDH, must show the base year for the operating hospital specific rate, either 82 or 87. Must be left blank if an SCH or a MDH did not operate in 82 or 87.
17. Change Code for X 73 "L" must be entered if the Lugar Reclassification wage index was reclassified under the Lugar Amendment for ASC-approved services provided on an outpatient basis. Blank if not reclassified under the Lugar Amendment.
For hospice providers only, enter a "6", "7", "8" or "9" if the hospice is located in one of the four special hospice MSAs.
18. Temporary Relief X 74 Enter a "Y" if this provider Indicator qualifies for a payment update under the temporary relief provision. Blank if not "Y".
19. Federal PPS Blend X 75 The appropriate code for the Indicatorblend ratio between Federal and facility rates. For PPS SNF’s eff. for cost reporting period beginning on or after 7/1/98. If present, must be 1, 2, 3 or 4.
20. Filler X(5) 76-80 Blank.
21. Case Mix Adjusted 9(5)V9(2) 81-87For PPS hospitals and waiver State
Cost Per Discharge/ nonexcluded hospitals, enter the Facility Specific RatePPS base year cost per discharge divided by the case mix index. Enter zero for new providers. See §3610.17 for sole community and Medicare-dependent hospitals on or after 4/1/90. For PPS SNFs that qualify for the transition period eff. with cost reporting periods beginning on or after 7/1/98, enter the facility specific payment rate. For all others, see §3610.B. Verify if figure is less than $400 or greater than $10,000.
22. Cost of Living 9V9(3) 88-91For PPS hospitals report the
Adjustmentadjustment in these positions of your PROV file. All hospitals except Alaska and Hawaii use 1.000.
23. Intern-Bed Ratio9V9(4) 92-96See §3656.3B for the calculation of the provider's intern-to-bed ratio. Does not include residents in anesthesiology employed to replace anesthetists or those assigned to PPS excluded units. Enter zeros for non-teaching hospitals.
24. Bed Size 9(5) 97-101Enter the number of hospital beds available. See §3656.3B for definition. Must be greater than zero.
25. Operating Cost-to-9V9(3)102-105Derived from latest settled cost
Charge Ratio report and corresponding charge data from the billing file. Compute this amount by dividing the Medicare Operating Cost (from the cost report) by the Medicare Covered Charge (from the billing
file, i.e., the PS&R record). For hospitals for which you are unable to compute a reasonable cost-to-charge ratio, use the appropriate urban or rural statewide average cost-to-charge ratio calculated annually by HCFA. Use these average ratios to calculate cost outlier payments for hospitals where you compute cost-to-charge ratios that are not within the limits published in the Federal Register.
26. Case Mix Index 9V9(4) 106-110For PPS hospitals, enter the case mix index used to compute field 21. Zero fill for all others.
27. Supplemental V9(4) 111-114 SSI ratio used to determine if the
Security Income hospital qualifies for the dispropor-
Ratio tionate share adjustment, and to determine the size of the capital and operating DSH adjustments.
28. Medicaid RatioV9(4)115-118Medicaid ratio used to determine if the hospital qualifies for the disproportionate share adjustment and to determine the size of the capital and operating DSH adjustments.
29. Filler X(42) 119-160 Blank.
30. Pass Through 9(4)V99 161-166 Per diem amount based on
Amount for Capitalthe interim payments to the hospital. Must be zero if location 185 = A, B, or C.
31. Pass Through Amount 9(4)V99 167-172 Per diem amount based on the For Direct Graduate interim payments to the hospital. Medical Education Zero fill if this does not apply.
32. Pass Through 9(4)V99 173-178 Per diem amount based on the Amount for Organ interim payments to the hospital. AcquisitionInclude standard acquisition amounts for kidney, heart and liver transplants. Do not include acquisition costs for bone marrow transplants. (See Provider Reimbursement Manual §2405.2.) Zero fill if this does not apply.
33. Total Pass Through 9(4)V99 179-184 Per diem amount based on interim Amount, Including payments to the hospital. Must be Miscellaneous equal to or greater than the sum of the 3 pass through amounts listed above. The following are included in total pass through amount in addition to the above pass through amounts: Certified Registered Nurse Anesthetists (CRNAs) are paid as part of Miscellaneous Pass Through for rural hospitals that perform fewer than 500 surgeries per year; and Nursing and Allied Health Professional Education when conducted by a provider in an approved program. Do not include amounts paid for Indirect Medical Education, Hemophilia Clotting Factors, or DSH adjustments. Zero fill if this does not apply.
34. Capital PPS X 185 Type of capital payment method- Payment code ology:
A=Hold harmless-cost payment for old capital.
B=Hold harmless-100% Federal rate.
C=Fully prospective blended rate.
Must be present unless a "Y" is entered in location 49 or 207, or 08 is entered in location 55-56 or a termination date is present in location 41-48.
35. Hospital Specific 9(4)V99 186-191 The FY 93 hospital specific Capital Rate rate should be entered in this field. Do not update this field after FY 93, except to reflect the effects of a hospital specific rate redetermination.
PRICER applies the appropriate update factor automatically after 10/01/93. Numeric. Hospital's allowable adjusted base year inpatient capital costs per discharge.
36. Old Capital-Hold 9(4)V99 192-197 Numeric. Hospital's allowable Harmless Rate inpatient "old" capital costs per discharge incurred for assets acquired by December 31, 1990 (or incurred subsequent to December 31, 1990, but allowed as "obligated" capital) for capital PPS. Must be updated annually.
37. New Capital-Hold 9V9(4) 198-202 Numeric. Ratio of hospital's
Harmless Ratio allowable inpatient costs for new capital to the hospital's total allowable inpatient capital costs. Must be updated annually.
38. Capital Cost-to- 9V999 203-206 Computed by dividing the
Charge Ratio Medicare capital costs by the Medicare covered charges in the PS&R record. For hospitals for which you cannot calculate a capital cost-to-charge ratio, use the appropriate statewide average cost-to-charge ratio calculated annually by HCFA, or an alternate justified capital cost-to-charge ratio. (See §3656.3B.)
39. New Hospital X 207Enter "Y" if a hospital is in its first 2 years of operation under the capital regulation. Otherwise leave blank.
40. Capital Indirect 9V9(4) 208-212 Enter the ratio of residents to the Medical Education hospital's average daily census.
Ratio Zero fill for a non-teaching hospital.
41. Capital Exception 9(4)V99 213-218 Enter the per discharge Payment Rate exception payment to which a hospital is entitled.
42. Filler X(22) 219-240Blank.
Intermediary Responsibilities.--Create a new record when a change occurs for a provider. You may have multiple records for a single provider within a quarter.
Prior to submitting the file to HCFA, print and review the data. Edit all items for accuracy. Correct any errors before submitting the file. Some edit examples:
o Effective date other than CCYYMMDD;
o Facility has two or more records with different provider numbers for the same month;
o Non-PPS facility with incorrect provider type;
o Incorrect census division for a redesignated facility;
o MSA field with other than (blank) (blank) (2-digit State number) for a rural provider; and
o Questionable pattern of coding, e.g., all provider types in field 10 are identical, all case mix indexes in field 26 are identical.
Provider-specific payment data must be received in CO within 7 calendar days of the end of the reporting period. The data will be evaluated based on the following criteria:
o Files conform to tape specifications;
o Files reflect data from all required providers; and
o Files are submitted in the correct record format.
CO will forward an error listing to you for correction. Submit corrected data files to CO within 10 calendar days of notification.
Last Updated 7/31/98
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