MLN6922507 - Medicare Payment Systems - CMS

04 Aug.,2025

 

MLN - Medicare Payment Systems - CMS

Direct Graduate Medical Education

We make direct graduate medical education (DGME) payments to teaching hospitals or hospitals that train residents in approved medical allopathic, osteopathic, dental, or podiatry residency programs. These payments are for the approved residency training programs’ direct operating costs.

If you want to learn more, please visit our website KAIRUIJIEDE.

We pay these separately from the IPPS per discharge payment and generally base DGME payments on the:

  • Hospital-specific costs per resident in a historical base year, updated for inflation
  • Number of residents a hospital trains
  • Hospital’s Medicare patient load (the proportion of Medicare inpatient days to total inpatient days)

Indirect Medical Education

Teaching hospitals or hospitals that train residents in approved medical allopathic, osteopathic, dental, or podiatry residency programs also get an IME adjustment, which reflects the higher indirect patient care costs of teaching hospitals compared to non-teaching hospitals. We calculate the IME adjustment factor using a hospital’s intern- and resident-to-bed ratio.

Medicare Disproportionate Share Hospitals

We make additional payments for inpatient operating and capital costs to hospitals that serve a disproportionate share of low-income patients.

Hospitals get 25% of the amount they previously got under the traditional Medicare disproportionate share hospital (DSH) statutory formula. The remainder, equal to 75% of what we otherwise would pay as Medicare DSH operating payments, goes toward an uncompensated care payment after reducing the amount for the uninsured individuals’ percentage change.

Each Medicare DSH gets an uncompensated care payment based on its share of uncompensated care costs compared to all Medicare DSHs. We annually update the factor estimates that determine each eligible DSH’s uncompensated care payment.

For most Medicare DSHs, we calculate uncompensated care payments from the most recent years of audited Worksheet S-10 data to determine each Medicare DSH’s share of uncompensated care payments. For FY and subsequent years, we use an average of the uncompensated care data from the 3 most recent FYs for which audited data is available.

Note: For Indian Health Service hospitals, tribal hospitals, and hospitals in Puerto Rico, we use the same multi-year average of Worksheet S-10 data to determine Factor 3 for FY and subsequent FYs. We also established a new supplemental payment for these hospitals under 42 CFR 412.106(h).

Sole Community Hospitals

A Medicare IPPS hospital is eligible for sole community hospital (SCH) classification if it meets 1 of the criteria in 42 CFR 412.92.

If a nearby hospital’s inpatient days attributable to acute care services (those payable under the acute care hospital IPPS) are less than or equal to 8% of the hospital seeking SCH status’s similar inpatient days, the nearby hospital isn’t considered a “like hospital.”

We base SCH operating payments on the higher of their hospital-specific payment rate or the federal rate and base capital payments on the capital base rate (like all other IPPS hospitals).

SCHs may qualify for a payment adjustment if they experience a significant volume decrease.

For IPPS purposes, we treat certain hospitals formerly designated as essential access community hospitals as SCHs.

Medicare-Dependent Hospitals

A Medicare IPPS hospital is eligible for Medicare-dependent hospital (MDH) classification if it meets the criteria in 42 CFR 412.108.

We base MDH operating payments on the higher of the federal rate payment or the federal rate payment plus 75% of the difference between the federal rate payment and its hospital-specific rate payment.

Section of the American Relief Act, (ARA, ), extended the MDH Program for FY discharges occurring before April 1, . Before the enactment of the ARA, , the MDH program was set to expire January 1, . We implemented the 3-month extension in Change Request (CR) .

Rural Referral Centers

The Rural Referral Center (RRC) Program supports high-volume rural hospitals. We generally classify a Medicare-participating acute care hospital as an RRC if it’s in a rural area for IPPS payment purposes and meets the criteria in 42 CFR 412.96.

Current RRCs or hospitals that previously had RRC status get certain advantages:

  • Proximity for MGCRB Reclassification: A hospital currently or previously designated as an RRC doesn’t need to demonstrate proximity to the area it gets reclassified. A hospital can apply for reclassification to the closest urban or rural area.
  • AHW Data Comparison for MGCRB Reclassification: We exempt hospitals currently or previously designated as the requirement that a hospital’s AHW must exceed, by a certain percentage, the AHW of the labor market area where the hospital is located.
  • Medicare DSH Cap: We exempt hospitals designated as an RRC from the 12% cap on Medicare operating DSH payments applicable to other rural hospitals.

Low-Volume Hospitals

Section of the American Relief Act, (ARA, ), extended the temporary changes (modified definition of low-volume hospital and the methodology for calculating the payment adjustment) for low-volume hospitals under section (d)(12) of the Social Security Act through March 31, . Before the enactment of the ARA, , the temporary changes were set to expire January 1, . The 3-month extension was implemented in CR .

Starting April 1, , the low-volume hospital qualifying criteria and payment adjustment will revert to the statutory requirements that were in effect before FY , and the preexisting low-volume hospital payment adjustment methodology and qualifying criteria will resume.

For FYs through , and the portion of FY occurring before April 1, , we make add-on payments to qualifying low-volume hospitals more than 15 road miles from the nearest subsection (d) hospital if it discharges less than 3,800 total patients during the FY based on its most recently submitted cost report. For each Medicare patient discharge:

  • For qualifying low-volume hospitals with 500 or fewer total discharges, the payment adjustment is 0.25
  • For qualifying low-volume hospitals with more than 500 total discharges but less than 3,800 total discharges, we calculate a low-volume hospital payment adjustment as 0.25 – [0.25/] × (number of total discharges – 500) = (95/330) – (number of total discharges/13,200)

For the portion of FY occurring on or after April 1, , we make add-on payments to qualifying low-volume hospitals more than 25 road miles from the nearest subsection (d) hospital if it discharges less than 200 total patients during the FY based on its most recently submitted cost report. For qualifying low-volume hospitals, the payment adjustment is 0.25 for each Medicare patient discharge.

Outlier Payments

We make additional payments for extremely costly outlier cases to promote seriously ill patients’ access to high quality inpatient care. We identify these cases by comparing their estimated operating and capital costs to a fixed-loss threshold.

We annually set the fixed-loss threshold and adjust it to reflect local labor market costs.

We pay outliers by offsetting reductions in the operating and capital base rates (reducing the payment rates to all cases so outlier payments don’t increase or decrease estimated aggregate Medicare spending).

We set the national fixed-loss threshold at 5.1% of total FY payments. Our methodology incorporates a projection of operating outlier payment reconciliations for the outlier threshold calculation.

CR provides additional instructions to MACs that expand the criteria for identifying cost reports. MACs are to refer to CMS for approval of outlier reconciliation starting with cost reports that started on or after October 1, . We use these new criteria to estimate outlier reconciliation dollars when calculating the FY outlier threshold.

Transfer Policy

We reduce MS-DRG payments when the patient’s LOS is at least 1 day less than the geometric mean MS-DRG LOS and the hospital transfers the patient to 1 of these:

  • Another IPPS-covered acute care hospital or, for certain MS-DRGs, a post-acute care setting
  • A hospital not participating in Medicare
  • A CAH

Our transfer policy includes these post-acute care settings:

  • Cancer hospitals
  • Children’s hospitals
  • Home health care, when the patient gets clinically related care that starts within 3 days after a hospital stay
  • Hospice care
  • LTCHs
  • Psychiatric distinct part units located in an acute care hospital or a CAH
  • Psychiatric facilities
  • Rehabilitation distinct part units located in an acute care hospital or a CAH
  • Rehabilitation facilities
  • SNFs

New Technology Add-On Payments

We make an additional payment for new medical services and technologies that meet the criteria in 42 CFR 412.87(b).

Certain new transformative devices and antimicrobial products may qualify under an alternative inpatient new technology add-on payment pathway discussed in 42 CFR 412.87(c) and (d).

The Medicare Electronic Application Request Information System™ (MEARIS™) allows users to submit new technology add-on payment applications, requests for ICD-10-PCS procedure codes, or MS-DRG classification change requests. Starting with FY , we only accept MS-DRG classification change requests submitted through MEARIS™; we don’t accept requests.

Hospital Readmissions Reduction Program

The HRRP is a Medicare value-based purchasing program that encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions. The program supports the national goal of improving health care for Americans by linking payment to the quality of hospital care.

We include readmission measures for specific conditions or procedures that significantly affect the lives of many Medicare patients. Under HRRP, we reduce payments to hospitals with higher-than-expected rates of readmission following treatment for select conditions and procedures, encouraging hospitals to provide high-quality care to reduce avoidable returns to the hospital.

Hospital Value-Based Purchasing Program

The Hospital VBP Program delivers upward, downward, or neutral adjustments to participating hospitals’ base operating MS-DRG payments based on their quality measure performance. We fund value-based incentive payments by reducing hospitals’ base operating MS-DRG payment amounts. The Hospital VBP Program generally applies to all acute IPPS hospitals, with certain exceptions.

The applicable reduction to hospitals’ base operating MS-DRG payment amount is 2%. Each hospital then may earn back a value-based incentive payment that’s more than, equal to, or less than the 2% reduction depending on their measure performance.

Hospital-Acquired Condition Reduction Program

A HAC is a condition a patient gets during hospitalization (the condition wasn’t present on admission). The HAC Reduction Program is a value-based purchasing program that links Medicare payments to health care quality in the inpatient hospital setting.

We reduce overall Medicare IPPS payments by 1% for hospitals that rank in the worst-performing quartile of all hospitals on measures of HACs. Under the HAC Reduction Program, hospitals are ranked on their total of preventable conditions, like falls, surgical site infections, and catheter-associated urinary tract infections.

PDGM & Home Health Resource Groups

The PDGM case-mix methodology bases 30-day period payment rates on the patient’s clinical characteristics and resource needs. It assigns each 30-day period into 1 of 432 case-mix groups called home health resource groups.

We base case-mix payment on these groups, and each group’s case-mix weight reflects predicted mean group cost relative to the overall average across all groups.

We apply changes to the PDGM case-mix weights in a budget-neutral manner by multiplying the CY national standardized 30-day period payment rate by a case-mix budget neutrality factor. The final CY case-mix budget neutrality factor is 1..

We base the national, standardized 30-day period payment for case-mix on the patient’s condition, care needs, and area wage differences.

Adjustments to the 30-Day Period Payment Rate

Case-Mix Adjustments

We use a case-mix methodology that adjusts the 30-day payment rate based on the patient’s characteristics and their corresponding resource needs.

We put the 30-day periods into different subgroups for each of these categories:

  • Admission Source
    • Community
    • Institutional (acute hospital, inpatient rehabilitation facility, skilled nursing facility, long-term care hospital, inpatient psychiatric facility)
  • 30-Day Period Timing
    • Early (first 30-day care period)
    • Late (all subsequent 30-day care periods, unless there’s a gap of more than 60 days between the end of one care period and the start of another)
  • Clinical Grouping
    • Musculoskeletal Rehabilitation
    • Neuro/Stroke Rehabilitation
    • Wounds: Post-Op Wound Aftercare and Skin/Non-Surgical Wound Care
    • Behavioral Health
    • Complex Nursing Interventions
    • Medication Management, Teaching, and Assessment (MMTA):
      • MMTA — Surgical Aftercare
      • MMTA — Cardiac/Circulatory
      • MMTA — Endocrine
      • MMTA — Gastrointestinal Tract/Genitourinary System
      • MMTA — Infectious Disease/Neoplasms/Blood-forming Diseases
      • MMTA — Respiratory
      • MMTA — Other
  • Comorbidity Adjustment Based on Reported Secondary Diagnoses
    • None
    • Low
    • High

Case-Mix Variable Information from OASIS Assessment

  • Functional Impairment Level (based on 30-day care period)
    • Low
    • Medium
    • High

Labor Adjustments

The labor portion bases each 30-day period payment adjustment on wage levels and wage-related costs of providing patient home health care in different geographic areas.

We cap decreases to the home health wage index in a geographic area so the wage index isn’t less than 95% of the wage index in that area in the prior CY. We apply this 5% cap on negative wage index changes in a budget-neutral manner using wage index budget neutrality factors.

Continuous 60-Day Recertifications

The Home Health Prospective Payment System (PPS) allows continuous 60-day patient recertification when the patient remains eligible.

Medicare conditions of participation require recertification assessment during the last 5 days of the previous certification period (for example, during the initial 60-day certification period, you must complete the recertification visit on days 56–60).

Notice of Admission

HHAs must submit a one-time Notice of Admission (NOA) to establish that the patient is under a home health POC that covers all 30-day periods until the patient discharges.

We may waive the consequences of not submitting an NOA on time if we determine the HHA encountered a circumstance that’s exceptional and qualifies for the waiver.

HHAs may submit the NOA under these conditions:

  • The certifying physician’s or allowed practitioner’s written or verbal order meets the requirements in 42 CFR 409.43(d) and 42 CFR 484.60(b)
  • The initial visit happened within the 60-day certification period and the patient was admitted to home health care

Plan of Care

The certifying physician or allowed practitioner must periodically review the POC, and it must include:

  • The services for meeting the patient-specific needs identified in the comprehensive assessment.
  • The responsible disciplines and the frequency and duration of all visits as well as those listed in 42 CFR 484.60(a) that establish the need for services.
  • Remote patient monitoring or other services provided through a telecommunications system. Such services must be tied to patient-specific needs as identified in the comprehensive assessment. These services can’t substitute for a home visit the provider orders as part of the POC, and we won’t consider a home visit for patient eligibility or payment.

If the signed POC isn’t available at the time of NOA submission, the HHA must base the submission on 1 of these:

  • A physician’s or allowed practitioner’s verbal order that:
    • Is recorded in the POC
    • Has a patient-condition description and services the HHA provides
    • Has a responsible registered nurse’s or qualified therapist’s signed and dated attestation for providing or supervising ordered services in the POC defined in 42 CFR 484.115(a)
    • Is copied into the POC, which is immediately submitted to the physician or allowed practitioner
  • A referral with a required detailed services order signed and dated by the physician or allowed practitioner
  • A physician or allowed practitioner, who meets the certification and recertification requirements in 42 CFR 424.22, must sign and date the POC or any changes in the POC before submitting the claim for each 30-day period
  • If any services are based on a physician’s or allowed practitioner’s oral orders, the registered nurse or qualified therapist (defined in 42 CFR 484.115) responsible for providing or supervising the ordered services must document, sign, and date the receipt
  • The physician or allowed practitioner must review the POC at least every 60 days or more frequently if these apply:
    • The patient wants a transfer
    • There’s a change in the patient’s condition
    • The patient discharged with goals met or there’s no expectation they’ll need home health care and the patient returns to home health care within 60 days
  • The POC is terminated if the patient doesn’t get at least 1 covered SN, PT, SLP, or OT visit in a 60-day period unless the physician or allowed practitioner documents that the interval without this care is appropriate to treating the patient’s illness or injury

Low Utilization Payment Adjustment

We make Low Utilization Payment Adjustment (LUPA) payments for 30-day periods with a low number of visits below the 432 case-mix group’s threshold per-visit rather than paying the case-mix adjusted 30-day payment amount. We updated the LUPA thresholds using CY data.

Submit appropriate claims and supporting documentation for us to apply the LUPA threshold. Documentation must show the patient’s condition and care needs or the case-mix assignment.

Note: We may adjust a home health claim based on other claims a provider may or may not bill. Those claims could affect the Common Working File and PPS code already billed or paid.

Partial Period Payments

We adjust payments if a patient transfers from one HHA to another or discharges and readmits to the same agency within 30 days of the original 30-day period start date. We prorate case-mix adjusted payments for 30-day periods of that type based on the length of the 30-day period ending in a transfer or discharge and readmission, resulting in partial-period payment.

We recognize discharge and return to the same HHA during the 30-day period only when a patient reaches treatment goals in the original home health POC.

Terminate the original home health POC if you anticipate the patient won’t need home health services for the rest of the 30-day period.

We adjust partial period payments by proportionally adjusting the original 30-day period payment to reflect the number of days the patient was under HHA care before an intervening event. We calculate partial period payment adjustments using a span of days (the first billable service date through and including the last billable service date) under the original POC as a proportion of the 30-day period. We then multiply the proportion by the original case-mix and wage index to produce the 30-day payment.

Partial period payment adjustments don’t apply for transfers among HHAs of common ownership. We consider those situations as services provided under arrangement on behalf of the originating HHA by the receiving HHA with ownership interest until the end of the 30-day period.

Outlier Payments

We allow outlier payments when a 30-day period has unusually large, costly patient home health care needs. We add these outlier payments to the regular 30-day case-mix and wage-adjusted period payments when estimated costs exceed a threshold amount for each home health resource group.

You can calculate the amount of the outlier payment using steps 1–6 in Section 10.8 of the Medicare Benefit Policy Manual, Chapter 7.

Note: In CY , the fixed dollar loss ratio is 0.35 to ensure aggregate outlier payments don’t exceed 2.5% of total aggregate payments.

Consolidated Billing Requirements

We include all HHA patient services and supplies in the Home Health PPS 30-day period payment rate under a home health POC except:

  • Certain covered injectable osteoporosis drugs when patients meet specific criteria
  • DME, including home infusion drugs and related services
  • Negative pressure wound therapy (NPWT) disposable devices

Provide all other covered home health services directly or under arrangement (an outside supplier provides services under arrangement and looks to the HHA for payment). Bill the HHA for covered home health services.

Home Health Services & Medical Supplies Subject to Consolidated Billing Requirements

We subject these home health services to the consolidated billing Home Health PPS requirements. These services and supplies must meet consolidated billing requirements and get billed with the 30-day period payment:

  • Certain covered injectable osteoporosis drugs (get more billing instructions in Section 90.1 of the Medicare Claims Processing Manual, Chapter 10)
  • NPWT using a disposable device (get more billing instructions in Section 90.3 of the Medicare Claims Processing Manual, Chapter 10)

The hospice’s medical director (or designee), or the physician member of the hospice interdisciplinary group, and the patient’s attending physician (if they have an attending physician) must certify the patient is terminally ill no later than 2 calendar days after starting hospice care for their initial 90-day coverage period.

At the time of hospice election, the patient may designate an attending physician. The attending physician is identified by the patient, at the time they elect to get hospice care, as having the most significant role in the determination and delivery of the patient’s medical care, and can include a:

  • Doctor of medicine (MD)
  • Doctor of osteopathy (DO)
  • NP
  • PA

Only an MD or a DO can certify or recertify the patient is terminally ill. If a patient’s attending physician is an NP or a PA, the hospice medical director or the hospice interdisciplinary group physician member certifies the patient as terminally ill. If a patient wants to change attending physicians, they must file a signed statement with the hospice indicating the change.

When a patient chooses hospice care, the hospice must identify an interdisciplinary group to manage their care. The interdisciplinary group must include, but isn’t limited to, people who are qualified and competent to practice in these professional roles:

  • MD or a DO (who’s an employee or under contract with the hospice)
  • Registered nurse (RN)
  • Social worker, marriage and family therapist, or a mental health counselor
  • Pastoral or other counselor

The initial election period certification lasts 90 days. After the initial period, the patient gets another 90-day period and unlimited 60-day election periods. An MD or a DO must certify or recertify each election period.

Document the certification in the patient’s clinical record before submitting a claim to your Medicare Administrative Contractor (MAC), and include these items in the certification:

  • A statement certifying the patient is terminally ill with 6 months or less to live if the terminal illness runs its normal course
  • Specific clinical findings and documentation supporting life expectancy of 6 months or less
  • A certified physician’s brief narrative explaining clinical findings supporting life expectancy of 6 months or less
  • The certifying physician signature (or signatures, as appropriate), a certification signature date, and benefit period dates
  • A physician or an NP face-to-face visit with the hospice patient no more than 30 days before:
    • The third benefit period recertification
    • Each recertification afterwards to decide continued hospice benefits eligibility

When you newly admit a patient in their third or later benefit period, exceptional circumstances may prevent a face-to-face encounter before the benefit period starts.

The hospice physician or NP must document they had a face-to-face patient encounter. The attestation must:

  • Include the face-to-face visit date
  • State the certifying physician got clinical face-to-face findings to determine continued hospice care eligibility

Hospice Certifying Enrollment

Starting June 3, , under Section of the Affordable Care Act, these 2 categories of physicians must be enrolled in Medicare or must opt out of Medicare to get paid for hospice services:

  1. Hospice medical director or the physician member of the hospice interdisciplinary group who certifies the patient’s terminal condition
  2. Patient-designated attending physician (if they have one) who certifies their terminal condition

This gives unenrolled and non-opted-out physicians time to enroll or opt out of the Medicare Program and allows us to screen the physician to make sure they’re licensed to certify the terminal condition.

Under 42 CFR 418.22(c), either of the 2 categories of physicians listed above must certify the patient’s terminal condition. For subsequent coverage periods, only the hospice physician may certify the patient’s terminal condition.

For detailed information on this requirement, see the Hospice Certifying Enrollment Questions and Answers (Q&A).

Patients meeting eligibility requirements must file an election statement, which must:

  • Identify the hospice and attending physician providing care. The patient or representative must acknowledge they chose the attending physician, if applicable.
    • If a patient wants to change attending physicians, they must file a signed statement with the hospice indicating the change.
  • Show the patient or representative understands hospice is for palliative care rather than curative care.
  • Show the patient or representative understands they waive certain Medicare services by electing hospice benefits.
    • You must inform the patient that services unrelated to the terminal illness and related conditions are exceptional and unusual and the hospice should provide nearly all care the patient needs.
  • Show the effective election date; this means the first day of hospice care or a later date, but no earlier than the election date statement.
  • Provide individual hospice cost-sharing information.
  • If you find conditions, items, services, and drugs unrelated to the patient’s terminal illness and related conditions the hospice won’t cover, notify the patient (or representative) of their right to get an election statement addendum.
  • Provide Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) information, including the right to immediate advocacy and BFCC-QIO contact information.
  • Include the patient’s or representative’s signature.

Note: We require a complete election statement containing all required elements as a condition for payment.

Notice of Election

Hospice providers must file a Notice of Election (NOE) with their MAC within 5 calendar days after the hospice election date. You may submit the NOE through electronic data interchange. If you file the NOE after the 5-day period, you’re liable for services between the hospice election date and the NOE filing date and you may not bill the patient for this period.

Note: We allow exceptions when it’s beyond the hospice’s control to file the NOE within 5 calendar days.

Perform an eligibility check immediately before admission so you can reduce the number of potential errors for exception request-related changes to the patient identifier. This confirms the MBI is active and accurate since the eligibility inquiry system has an MBI End Date field. If there’s a date in that field, the MBI isn’t valid after that date. Contact the patient or use an MBI lookup tool to determine the current MBI to use on the NOE.

When you admit patients, you must inform them in writing that their care is subject to QIO review and discuss potential review results.

Revoking Hospice Election

A patient or representative may revoke hospice election at any time. Revoking a hospice election is the patient’s or representative’s choice made without undue influence from the hospice provider. To revoke the election, the patient must file a written document with the hospice that includes:

  • A signed statement saying they revoke hospice care for the remainder of that election period
  • The revocation effective date

The patient gives up their remaining days in that election period, and their previously waived Medicare coverage restarts. A patient may, at any time, elect to get hospice coverage for any other hospice election periods that they’re eligible to get.

If a Medicare Advantage (MA) enrollee revokes their hospice election, they can continue services through their MA Plan or Medicare Fee-for-Service (FFS) providers (subject to the FFS deductible) until the start of the next month when they get services only through their MA Plan.

Unless submitting a final claim, you must file a MAC Notice of Termination/Revocation within 5 calendar days after a patient or representative revokes a hospice election, or the patient discharges.

Hospice Patient Discharge

You may only discharge a hospice patient if:

  • The patient moves out of the hospice service area or transfers to another hospice.
  • You find the patient is no longer terminally ill.
  • There are extraordinary circumstances where the hospice can’t continue providing care. These situations include cases where the safety of the patient or hospice staff is at risk. The hospice must tell the patient that discharge for cause is under consideration, make a serious effort to resolve the issues, and make sure the discharge isn’t related to the patient’s use of hospice services. You must document the problem and efforts to resolve the issues in the patient’s medical record. Additionally, you must notify the Medicare contractor and State Survey Agency and make referrals if necessary.

Discharging a patient only to avoid exceeding the cap limit violates these regulations and may cause undue distress and potential harm to terminally ill patients who must find care outside the hospice benefit.

Change of Designated Hospice

A patient can change their hospice election designation once each election period with a transfer, which isn’t considered a revocation. To change the designated hospice, the patient must file a signed statement with the hospice where they got care and the newly designated hospice. The statement must include the:

  • Previous hospice provider name
  • New hospice provider name
  • Effective date of change

We require home health agencies, skilled nursing facilities, hospices, and comprehensive outpatient rehabilitation facilities to provide a Notice of Medicare Non-Coverage (NOMNC) to patients ending their Medicare-covered services. The NOMNC tells patients how to request a BFCC-QIO determination and lets them request an expedited determination. A patient gets a Detailed Explanation of Non-Coverage, which explains specific reasons for ending covered services, only if they ask for an expedited determination.

Hospice Level of Care Payment

Even if you don’t provide a service on a given day, we pay for hospice care each day a patient is under hospice election. Payments cover service costs in the patient’s POC, including services directly from, or arranged by, the hospice. We make payments on 4 levels of care to meet the patient’s and family’s needs:

  1. Routine home care at:
    • Higher payment rate for days 1–60
    • Lower payment rate for days 61 and beyond
  2. Continuous home care (to manage a short-term symptom crisis in the home, involving 8 or more hours of care per day, mostly nursing)
    • When fewer than 8 hours of care are required, the services are covered as routine home care rather than continuous home care
  3. Inpatient respite care (facility care for up to 5 days at a time to give an informal caregiver a break)
  4. General inpatient care (provided in a facility on a short-term basis to manage symptoms that can’t be managed in another setting)

We also pay a service intensity add-on with the routine home care rate during the patient’s last 7 days of life if their care meets these criteria:

  • The day is a routine level-of-health care
  • The day happens during the patient’s last 7 days of life, and the patient is discharged as deceased
  • An RN or social worker provides direct patient care each day

The service intensity add-on payment is the continuous home care hourly payment rate multiplied by the amount of direct patient care an RN or social worker provides during the 7-day period for a minimum of 15 minutes and up to 4 total hours per day.

Under the IRF PPS, IRFs get a predetermined payment for goods and services they provide during each patient’s IRF stay. Federal rates reflect all IRF patient care costs, including routine, ancillary, and capital costs. Federal rates don’t include operating-approved educational activities costs described in 42 CFR 413.75(a)(1) and 42 CFR 413.85(c), bad debts, or hemophilia blood product costs.

To determine the federal payment amount for each IRF patient, we group patients by clinical condition and expected resource use:

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  • Rehabilitation impairment categories according to the primary IRF admitting condition
  • Case-mix groups (CMGs) according to their functional status (motor and cognitive scores) and age
    • An unweighted motor score determines a patient’s CMG placement. The 18 items scored have an equal weight of 1.
    • Within each CMG, we categorize cases into 1 of 4 tiers based on the patient’s comorbidities (conditions secondary to the principal admitting diagnosis). We make 1 tier payment for the case based on the patient’s highest-paying tier comorbidity.

We adjust for interrupted stays, short stays less than 3 days, short-stay transfers (transfers to another institutional setting with an IRF length of stay less than the average CMG length of stay), deaths, and high-cost outlier cases.

We apply a permanent 5% cap on any decrease to a provider’s wage index from its wage index in the previous year, and we apply this cap in a budget-neutral manner.

Facility Characteristics

We adjust the hospital wage index to reflect geographic wage rate differences.

We apply an adjustment to the base rate for IRFs that treat a higher proportion of low-income patients.

IRFs with residency training programs get higher payment rates based on the number of interns and residents trained compared to their average daily census. We cap this adjustment.

We annually update rates to reflect:

  • Inflation costs for IRF goods and services using a market basket index calculated for free-standing and hospital-based IRFs
  • Changes in local wage rates

The FY IRF market basket increase factor is 3.0%, which is a 3.5% market basket update reduced by a 0.5 percentage point productivity adjustment.

Compliance Threshold

A facility must meet IRF classification requirements to get IRF PPS payment. At least 60% of the facility’s total inpatient population must need intensive IRF treatment for 1 or more of 13 medical conditions. We include comorbidities in the compliance threshold if they meet certain criteria.

Medicare Administrative Contractor Compliance Percentage

An IRF’s compliance percentage is the percentage of the total inpatient population requiring intensive IRF treatment for 1 or more of 13 medical conditions. Medicare Administrative Contractors (MACs) use compliance review period data to calculate the compliance percentage.

Each compliance review period, except for new IRFs, is 1 continuous 12-month period, starting 4 months before starting a cost reporting period and ending 4 months before the next cost reporting period.

MACs calculate the compliance percentage using:

  • Presumptive Methodology: MACs use CMS software to analyze IRF PPS impairment group codes and etiologic diagnosis and comorbidity codes. The etiologic diagnosis and comorbidity codes are ICD-10-CM codes on the IRF-PAIs sent to us through the iQIES system.
    • If at least 60% of the IRF’s inpatient population requires IRF treatment for 1 or more of the 13 medical conditions, then the IRF meets the 60% rule.
    • If the IRF doesn’t meet the 60% rule requirements based on the first part of the process, MACs must review IRF Arthritis Verification Report cases to ensure they meet regulatory requirements in the IRF’s presumptive methodology compliance percentage, explained in Section 140.1.3 of the Medicare Claims Processing Manual, Chapter 3.
    • If at least 50% of your inpatient population is Medicare FFS or MA patients, then your MAC may use the presumptive methodology to determine if you meet the 60% compliance threshold. Your MAC can review a random medical records sample if it believes that’s a more accurate way of calculating your compliance percentage. Your MAC must conduct a manual medical review if the IRF doesn’t meet the 60% compliance threshold using the presumptive methodology.
    • A MAC-calculated, random medical record sample always replaces the presumptive compliance percentage review.
  • Medical Records Review: MACs analyze a random medical records sample representing IRF inpatients during the compliance review period.

MACs must use the random sample medical record method to calculate the compliance percentage when:

  • The facility’s presumptive compliance percentage is less than the required 60% compliance threshold
  • The facility’s Medicare population (Medicare FFS + MA patients) is less than half its total patient population

MACs must send results to the appropriate CMS Survey & Operations Group (CMS Location), which determines an IRF’s classification before the next cost reporting period starts and is effective for the entire cost reporting period.

If the CMS Location doesn’t classify a Medicare provider as an IRF, they aren’t eligible for payment under the IRF PPS. We pay them under the Inpatient PPS.

New IRF Units

We allow a hospital to open a new IRF unit anytime within the cost reporting year if the hospital notifies the Office of Program Operations and Local Engagement and their MAC in writing of the change at least 30 days before opening the new IRF unit. If a hospital opens a new IRF unit during a cost reporting year, this change remains in effect for the rest of the cost reporting year.

Documentation Requirements

MACs must consider these items in a patient’s IRF medical record when determining if an IRF admission was reasonable and necessary:

  • Preadmission screening.
  • Individual overall plan of care completed within 4 days of IRF admission.
  • Physician visit notes.
  • Patient’s in-house medical record IRF-PAI forms (electronic or paper format). Submit IRF-PAI admission and discharge assessments together after a patient’s discharge. We won’t accept and process a Medicare Part A FFS IRF claim for payment until we get and accept a corresponding IRF-PAI.

Reasonable & Necessary Criteria

For Medicare to pay an IRF claim, the patient’s IRF stay must be reasonable and necessary according to the requirements at 42 CFR 412.622(a)(3)(4)(5) and Section 110 of the Medicare Benefit Policy Manual, Chapter 1.

Note: We removed the physician post-admission evaluation verifying the patient’s preadmission screening requirement, but you still need to complete a history and physical under the conditions of participation.

Licensed or certified clinicians must complete a preadmission patient screening within the 48 hours before IRF admission and get this information:

  • A detailed, comprehensive review of each patient’s condition and medical history, including:
    • Prior function level
    • Expected improvement level and time expected to reach it
    • Clinical complications risk
    • Conditions causing rehabilitation
    • Required treatments (for example, physical therapy, occupational therapy, speech-language pathology, prosthetics, or orthotics)
    • Anticipated discharge destination
  • A preadmission screening that includes all the required elements but is conducted more than 48 hours immediately before the IRF admission is acceptable if an IRF conducts an update in person or by to document the patient’s medical and functional status in the patient’s medical record at the IRF within the 48 hours immediately before the IRF admission.
  • The rehabilitation physician must document their review and agreement with the preadmission screening findings before the IRF admission, or we deny the claim.

Interdisciplinary team meetings must be held at least once each week throughout the IRF stay. A rehabilitation physician may lead the weekly interdisciplinary team meetings either in person, by video, or by .

Team meetings must involve a registered nurse with rehabilitation training or experience, a social worker or case manager (or both), and a licensed or certified therapist from each treating therapy discipline involved in treating the patient. Keep the results and findings of the meetings, and the concurrence by the rehabilitation physician with those results and findings, in the patient’s medical record.

Interdisciplinary team meetings should include participant names and professional titles. You don’t need signatures from interdisciplinary team meeting participants other than the rehabilitation physician’s agreement in the form of a signature.

The patient must:

  • Need active and ongoing therapeutic intervention from multiple therapy disciplines (physical therapy, occupational therapy, speech-language pathology, or prosthetics or orthotics therapy), 1 of which must be physical or occupational therapy.
  • Generally, need and get at least 3 hours of therapy per day at least 5 days per week and show measurable improvement in functional capacity or adapting to impairments. The facility staff must deliver the first session within 36 hours from midnight on the day of admission. In certain well-documented cases, this intensive rehabilitation therapy program might instead be at least 15 hours per week within a 7 consecutive calendar day period, starting with the IRF admission date.
  • Be stable enough to benefit from intensive IRF services at admission. Patients who are unable to actively participate in, and benefit from, the intensive rehabilitation therapy services because they’re still completing their treatment course in the referring hospital should stay in the referring hospital until they can participate.
  • Have the rehabilitation physician document an individualized plan of care by day 4.
  • Have at least 3 face-to-face meetings with the rehabilitation physician to assess the patient’s medical and functional status within the first week of admission. Starting the second week after admission, a non-physician practitioner with specialized training and experience may conduct 1 of the 3 required face-to-face visits per week.

IRF Rules and Related Files has more information.

SSO, HCO, fixed-loss amounts, and interrupted stay payment policy adjustments all apply to site neutral and standard federal payment rate discharges except where noted.

Short-Stay Outlier

The SSO policy helps prevent inappropriately paying for cases without a full episode of care. SSO payment adjustments apply only to the standard federal payment rate discharges and may happen when a patient:

  • Experiences an acute condition that needs urgent treatment or more intensive rehabilitation and discharges to another facility
  • Doesn’t need an LTCH care level and discharges to another facility
  • Discharges to home
  • Dies within the first several days of LTCH admission
  • Exhausts LTCH benefits during the stay

We apply an adjustment when the LOS ranges from 1 day through 5/6 of the ALOS for the MS-LTC-DRG where we group that case. We subject the MS-LTC-DRG payment to the SSO adjustment.

We don’t apply an adjustment when the LOS is more than 5/6 of the ALOS for the MS-LTC-DRG where we group that case. In this situation, the LTCH gets the full MS-LTC-DRG payment.

Note: When calculating the SSO adjustment, we cap the SSO threshold (5/6 of the ALOS for the MS-LTC-DRG) at 25 days. We never subject stays of 25 days or more to the SSO policy.

This policy doesn’t apply to site neutral discharges.

We blend the MS-LTC-DRG per diem amount with what we would pay under the IPPS, calculated as a per diem and capped at the full IPPS comparable amount.

SSO Payments When Patient Benefits Exhaust During an LTCH Stay

We base LTCH payments on the patient’s covered benefit days until the LOS triggers a full MS-LTC-DRG payment. This means a patient’s remaining benefit days and length of hospital stay affects LTCH payments and may result in an SSO payment adjustment.

Table 3. Benefits Exhaust & LOS is Below MS-LTC-DRG Threshold If Then Example The patient uses regular episode benefit days during an LOS below the SSO MS-LTC-DRG threshold
  • The patient pays for non-covered days
  • The LTCH gets SSO payment for the patient’s covered hospital stay
  • The MS-LTC-DRG SSO threshold is 25 days, and the patient’s LOS is 20 days; the LTCH gets SSO payment
  • The patient’s benefit days end on day 15
  • We pay for 15 covered days under the LTCH SSO policy
  • The patient pays for days 16–20
Table 4. Benefits Exhaust & LOS Exceeds MS-LTC-DRG Threshold If Then Example The patient uses all episode benefit days during an LOS exceeding the SSO MS-LTC-DRG threshold
  • The patient doesn’t pay for non-covered days (until they reach HCO threshold)
  • The LTCH gets full MS-LTC-DRG payment
  • The MS-LTC-DRG SSO threshold is 25 days, and the patient’s benefit days end on day 30; the patient’s LOS is 35 days
  • The patient doesn’t pay for days 31–35 (SSO policy doesn’t apply)
  • The LTCH gets full MS-LTC-DRG payment; the patient pays for first day stay, and the LOS qualifies as an HCO

Note: We allow 90 covered episode benefit days of care under the inpatient hospital benefit. Each patient has 60 lifetime reserve days, which the patient may use to cover non-covered episode days of care exceeding 90 days.

High-Cost Outlier

The HCO policy adjusts the applicable LTCH PPS payment rate (site neutral rate or standard federal rate) for LTCH stays with costs exceeding typical cases of similar case-mix cost. To qualify for an HCO payment, an LTCH’s estimated treatment costs must exceed the outlier threshold. We calculate the applicable outlier threshold as the case’s applicable LTCH PPS payment plus the applicable fixed-loss amount.

The HCO payment equals 80% of the difference between the estimated case cost and the outlier threshold.

For SSO cases, we calculate the outlier threshold by adding the applicable fixed-loss amount to the adjusted SSO MS-LTC-DRG payment. If the estimated SSO case cost exceeds the outlier threshold, it qualifies for an HCO payment.

We set 2 fixed-loss amounts:

  • Site neutral payment rate
  • Standard federal rate

The HCO adjustment:

  • Improves LTCH PPS hospital- and patient-resource cost accuracy
  • Cuts LTCH financial losses from treating patients needing more costly care
  • Limits LTCH loss to fixed-loss amount and cost percentages above the marginal cost factor
  • Discourages underserving high-cost patients

Medicare Administrative Contractors (MACs) use PRICER software to determine if enough medically necessary benefit days are in the outlier period. If a patient has enough benefit days, the MAC processes the claim as usual and the LTCH takes no other action. If a patient’s benefit days exhaust, the MAC returns the claim to the LTCH for correction, indicating the correct HCO threshold amount.

HCO Payments When Patient Benefits Exhaust During an LTCH Stay

We make HCO payments for:

  • Days the patient has Medicare coverage (regular, coinsurance, or lifetime reserve days) for part of the stay beyond the HCO threshold
  • Medically necessary covered cost days when the patient has a benefit day available
Table 5. Patient Benefits Exhaust Before Qualifying for Full LTCH PPS Standard Federal Rate Payment If Then Example
  • The patient’s benefits exhaust before qualifying for the full MS-LTC-DRG payment
  • Covered care costs exceed the standard federal rate HCO threshold for an SSO-adjusted payment
The LTCH gets HCO payment with SSO-adjusted payment for covered medically necessary benefit days
  • The LTCH admits a standard federal rate patient with 5 remaining benefit days grouped to an MS-LTC-DRG with a 30-day ALOS
  • The patient doesn’t have enough regular benefit days to trigger a full MS-LTC-DRG standard federal rate payment (5/6 of MS-LTC-DRG ALOS) qualifying case for an SSO-adjusted payment
  • The LTCH-covered services’ cost during 5 benefit days exceeds the standard federal rate HCO threshold qualifying case HCO payment for all costs above the HCO threshold days 1–5
  • The patient pays for days 6–discharge
Table 6. Patient Benefits Exhaust After Qualifying for Full Applicable LTCH PPS Payment If Then Example
  • The patient’s benefits exhaust after qualifying for the full applicable LTCH PPS payment
  • Covered care costs exceed the applicable HCO threshold
The LTCH gets HCO payment with the full LTCH PPS payment for covered medically necessary benefit days
  • The LTCH admits a standard federal rate patient with 36 remaining benefit days grouped to an MS-LTC-DRG with a 30-day ALOS
  • On day 33, the patient’s care cost exceeds the standard federal rate HCO threshold qualifying the case for the full MS-LTC-DRG standard federal rate payment and the HCO payment for all covered costs (available benefit days) above the HCO threshold
  • The patient pays for days 37–discharge

Full applicable LTCH PPS payment means the standard federal rate (including SSO adjustment) or the site neutral payment rate, based on the LTCH case. Applicable HCO threshold means the HCO threshold determined from the standard federal rate fixed-loss amount or site neutral fixed-loss amount based on the LTCH case.

Table 7. Patient Benefits Exhaust Before Exceeding Applicable HCO Threshold If Then Example
  • The patient qualifies for the full applicable LTCH PPS payment
  • The patient uses all regular benefit days for the stay before exceeding the applicable HCO threshold
  • The LTCH gets the full LTCH PPS payment (and doesn’t get the HCO payment)
  • The patient pays costs incurred the day after the case exceeds the applicable HCO threshold
  • The LTCH admits a standard federal rate patient with 36 remaining benefit days grouped to an MS-LTC-DRG with a 30-day ALOS
  • The patient care cost exceeds the standard federal HCO threshold on day 45
  • The patient exhausted all benefit days before reaching the HCO threshold; the case isn’t eligible for HCO payment
  • The patient doesn’t pay covered costs for days 37–45
  • The patient pays for days 46–discharge

If the patient’s benefits exhaust during the LTCH stay, determine the:

  • Day when the case cost reaches the applicable HCO threshold (use charges per day and CCR)
  • Number of benefit days the patient has left

To calculate the HCO, use the costs for the days after the patient’s case cost reaches the HCO threshold of available benefit days. If the patient remains under care after benefits exhaust, they pay the costs of those remaining days.

Under Medigap or Medicaid, changes to HCO payments under the LTCH PPS outlier reconciliation policy won’t retroactively affect a patient’s lifetime reserve days or coverage status, benefits, and payments.

HCO Fixed-Loss Amounts

The fixed-loss amount for standard federal payment rate cases is the amount allowing yearly projected total HCO payments to equal 7.975% of the total LTCH PPS standard federal payment rate payments estimated for that year (full MS-LTC-DRG payments or adjusted SSO amount plus HCO payments).

We include estimated uncompensated care payments in the outlier fixed-loss cost threshold calculation. Specifically, we use the estimated per-discharge uncompensated care payments to hospitals eligible for the uncompensated care payment for all cases in the outlier fixed-loss cost threshold calculation.

The applicable HCO threshold for site neutral payment rate cases is the sum of the case’s site neutral payment rate and the IPPS fixed-loss amount. We set the site neutral case fixed-loss amount to the same as the IPPS fixed-loss amount.

We estimate each case’s cost using provider-specific file CCRs:

  • Use the applicable statewide average CCR when the LTCHs’ provider-specific file CCRs aren’t available
  • MACs estimate a case’s cost by multiplying the Medicare-covered charges by the LTCH’s overall CCR, based on the most recently settled or tentatively settled cost report

These CCR revisions or determinations may also apply:

  • We may ask MACs to use an alternate CCR showing recent substantial increases or decreases in a hospital’s charges
  • LTCHs may ask their MAC to use a higher or lower CCR based on substantial evidence when their CMS Regional Office approves it
  • MACs annually assign the statewide average CCR to LTCHs with CCRs above the maximum ceiling
  • MACs use an LTCH’s actual CCR rather than the statewide average LTCH CCR with CCRs below the minimum floor
  • MACs may use the statewide average CCR when the LTCH CCR isn’t determined (for example, before a new LTCH submits its first Medicare cost report or when data isn’t available to calculate the CCR because it’s missing or incorrect)

LTCH PPS outlier policy allows for reconciling HCO payments at cost report settlement and looks for differences between the estimated and actual CCR.

Interrupted Stay

An interrupted stay happens when an LTCH discharges a patient to an acute care hospital, inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), swing bed, or home, and the patient readmits to the same LTCH for more medical treatment within a specified period. For example, when an LTCH patient discharges for treatment, and the services are unavailable in the LTCH.

The 2 types of interrupted stays are:

  • 3 days or less
  • Greater than 3 days

Interruption day count starts the day of discharge (the first day the patient is away from the LTCH at midnight).

3-Day or Less Interruption Example

  • If an LTCH discharges a patient on September 2, the 3-day or less interrupted stay policy determines payment if the LTCH readmits the patient to the same LTCH on September 2, 3, or 4
  • If an LTCH discharges a patient and readmits them to the same LTCH within 3 days, the patient may:
    • Get outpatient or inpatient tests, treatment, or care at an inpatient acute care hospital, IRF, SNF, or swing bed:
      • Outpatient or inpatient care during interruption is part of a single LTCH care episode and bundled into the LTCH payment
      • If a patient gets tests or procedures during a 3-day interruption and the LTCH pays the provider under arrangements, the total patient day count includes all interrupted days
    • Have an intervening patient stay at home for up to 3 days with no tests, treatment, or care:
      • If the patient doesn’t get care during the 3-day interruption, the LTCH can’t use days away in the total LOS
      • If the patient gets care during an interruption the LTCH pays for under arrangements, the LTCH uses all interruption days in that patient’s LOS

Greater Than 3-Day Interruption Example

If a patient discharges from an LTCH on September 2, the greater than 3-day interrupted stay policy determines payment if the patient is readmitted to the same LTCH between September 5 and the applicable provider’s fixed-period threshold.

For a greater than 3-day interruption, the LTCH must discharge the patient; admit them directly to an inpatient acute care hospital, IRF, SNF, or swing bed; and readmit them to the original LTCH within a specified period.

Table 8. Greater Than 3-Day Interruption Facility Discharge to Interrupted Stay Fixed Period Inpatient acute care hospital Between 4 and 9 consecutive days IRF Between 4 and 27 consecutive days SNF or swing bed Between 4 and 45 consecutive days
  • We treat an interrupted stay episode as 1 discharge for payment and make 1 LTCH PPS payment
  • Interrupted stays are eligible for HCO payments
  • We pay separately for an intervening inpatient stay at the acute care hospital, IRF, SNF, or swing bed

Uninterrupted Stay Examples

  • The patient’s facility stay (acute care inpatient hospital, IRF, SNF, or swing bed) exceeds the fixed-day period
  • The patient discharges to a facility type other than an acute care inpatient hospital, IRF, SNF, or swing bed
  • The patient discharges to more than 1 facility or goes home between LTCH stays
  • If the stay disruption doesn’t meet the interrupted stay definition, the original discharge ends the patient’s first stay
  • If an LTCH readmits the patient, the second admission starts a new stay
  • The LTCH gets 2 LTCH PPS payments (full MS-DRG payment or adjusted SSO payment, as applicable) for 2 patient stays:
    • Payment for the first stay
    • Payment for the stay after an LTCH readmission

Interrupted Stay Billing Requirements

  • The from date is the original admission date
  • The through date is the final discharge date
  • Report payable days in the Covered Days field (value code 80)
  • Report interrupted days in the Non-Covered Days field (value code 81)
  • Occurrence span code (OSC) 74 with dates the patient is absent at midnight (interruptions of more than 1 day)
    • OSC from date is the initial LTCH discharge date
    • OSC through date is the last LTCH date the patient isn’t present at midnight
  • Don’t change the principal diagnosis when the patient readmits to an LTCH; if the patient has other medical conditions when they return, report the diagnosis codes on the claim
  • Use revenue code 018X to show the number of interruption days

Discharge Payment Percentage Adjustment

An LTCH’s discharge payment percentage is the ratio of the LTCH’s discharges that got the standard federal rate payment to its total Medicare discharges number under the LTCH PPS. If an LTCH’s discharge payment percentage for a cost reporting period isn’t at least 50%, this payment adjustment policy applies after we calculate the percentage and notify the LTCH. For cost reporting periods subject to this adjustment, the discharge payment percentage adjustment is:

  • An amount like the hospital IPPS payment
  • An added HCO-cases payment based on the fixed-loss amount for an IPPS hospital in effect at the time of the LTCH discharge

The payment adjustment ends when the calculated cost reporting period’s discharge payment percentage is at least 50%. We may subject the LTCH to this adjustment again if, after reinstatement, the discharge payment percentage falls below 50%.

LTCHs subject to a cost reporting period payment adjustment can get a special probationary reinstatement. They can do this by getting the payment adjustment delayed if, for at least 5 consecutive months of the 6 months before the cost reporting period, they calculate the discharge payment percentage to at least 50%.

For any cost reporting period the payment adjustment would apply without a delay, the payment adjustment applies for all discharges if the discharge payment percentage isn’t at least 50%.

PDPM classifies patients into 5 separate case-mix index (CMI)-adjusted components:

  1. Physical therapy (PT)
  2. Occupational therapy (OT)
  3. Speech-language pathology (SLP)
  4. Non-therapy ancillary (NTA)
  5. Nursing

Under the PDPM, only PT, OT, and NTA payments get variable per diem (VPD) resource-use adjustment rate changes over the stay.

Each patient classification component uses different measures:

  • PT: Clinical Category, Functional Score
  • OT: Clinical Category, Functional Score
  • SLP: Presence of Acute Neurologic Condition, SLP-related Comorbidity or Cognitive Impairment, Mechanically Altered Diet, Swallowing Disorder
  • NTA: NTA Comorbidity Score
  • Nursing: Functional Score

To calculate each payment component, multiply the CMI linked to the patient’s case-mix group (CMG) by the wage-adjusted component base rate, then by the VPD schedule-specific day, when applicable. Add each component payment to the non-case-mix component payment rate to create the patient’s PDPM per diem rate.

Figure 4. Calculating PDPM Classification


Clinical Category & Functional Status

PT and OT components use 2 classifications: clinical category and functional status.

Clinical Category

We base the clinical category on the primary SNF stay diagnosis code by mapping the ICD-10-CM codes on the Minimum Data Set (MDS) in Item IB to a PDPM clinical category.

A surgical procedure during the previous inpatient stay may adjust the clinical category and map to 1 of these primary diagnosis clinical categories:

  • Acute Infections
  • Acute Neurologic
  • Cancer
  • Cardiovascular and Coagulations
  • Major Joint Replacement or Spinal Surgery
  • Medical Management
  • Non-Orthopedic Surgery
  • Non-Surgical Orthopedic/Musculoskeletal
  • Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery)
  • Pulmonary

Mapping the ICD-10-CM diagnosis or surgical category classifies a SNF resident into each of the clinical categories. Each year we consider stakeholder ICD-10-CM mapping suggestions.

Given similar costs among certain PT and OT clinical categories, we grouped certain patient clinical classification categories together.

PDPM PT & OT Clinical Categories

  • Major Joint Replacement or Spinal Surgery
    • Major Joint Replacement
    • Spinal Surgery
  • Non-Orthopedic Surgery and Acute Neurologic
    • Non-Orthopedic Surgery
    • Acute Neurologic
  • Other Orthopedic
    • Non-Surgical Orthopedic/Musculoskeletal
    • Orthopedic: Surgical Extremities Not Major Joint
  • Medical Management
    • Acute Infections
    • Cancer
    • Cardiovascular & Coagulations
    • Medical Management
    • Pulmonary

Functional Status

We calculate the PDPM PT and OT functional score in Table 9 using MDS 3.0 data based on 10 Section GG items that proved highly predictive of PT and OT costs per day:

  • 2 bed mobility items
  • 3 transfer items
  • 1 eating item
  • 1 toileting item
  • 1 oral hygiene item
  • 2 walking items
Table 9. Section GG Items Included in PT & OT Functional Score Section GG Item Functional Score Range GGA1 — Self-care: Eating Admission Performance 0–4 GGB1 — Self-care: Oral Hygiene Admission Performance 0–4 GGC1 — Self-care: Toileting Hygiene Admission Performance 0–4 GGB1 — Mobility: Sit to Lying Admission Performance 0–4 (average of 2 items) GGC1 — Mobility: Lying to Sitting on Side of Bed Admission Performance 0–4 (average of 2 items) GGD1 — Mobility: Sit to Stand Admission Performance 0–4 (average of 3 items) GGE1 — Mobility: Chair- or Bed-to-Chair Transfer Admission Performance 0–4 (average of 3 items) GGF1 — Mobility: Toilet Transfer Admission Performance 0–4 (average of 3 items) GGJ1 — Mobility: Walk 50 Feet with 2 Turns 0–4 (average of 2 items) GGK1 — Mobility: Walk 150 Feet 0–4 (average of 2 items) Table 10. Section GG Items Included in Nursing Functional Score Section GG Item Functional Score Range GGA1 — Self-care: Eating 0–4 GGC1 — Self-care: Toileting Hygiene 0–4 GGB1 — Mobility: Sit to Lying 0–4 (average of 2 items) GGC1 — Mobility: Lying to Sitting on Side of Bed 0–4 (average of 2 items) GGD1 — Mobility: Sit to Stand 0–4 (average of 3 items) GGE1 — Mobility: Chair- or Bed-to-Chair Transfer 0–4 (average of 3 items) GGF1 — Mobility: Toilet Transfer 0–4 (average of 3 items)

Under the PDPM, we assess a patient’s cognitive status using the Brief Interview for Mental Status (BIMS). In cases where you can’t complete the BIMS, complete a Staff Assessment for Mental Status. We use the Cognitive Performance Scale (CPS) to score patients based on the staff assessment responses. We base the new PDPM cognitive score on the Cognitive Function Scale, which combines scores from the BIMS and CPS into 1 scale that compares cognitive function across all patients.

These 12 SLP-related comorbidities predict higher SLP costs:

  • ALS
  • Aphasia
  • Apraxia
  • CVA, TIA, or Stroke
  • Dysphagia
  • Hemiplegia or Hemiparesis
  • Laryngeal Cancer
  • Oral Cancers
  • Speech & Language Deficits
  • Tracheostomy Care (while a resident)
  • Traumatic Brain Injury
  • Ventilator or Respirator (while a resident)

PDPM has more information about mapping between ICD-10-CM diagnoses and SLP comorbidities.

After completing the BIMS or CPS, use the cognitive measure classification methodology in Table 11 to determine the BIMS and CPS scores.

Table 11. Cognitive Measure Classification PDPM Cognitive Level BIMS Score CPS Score Cognitively Intact 13–15 0 Mildly Impaired 8–12 1–2 Moderately Impaired 0–7 3–4 Severely Impaired N/A 5–6

NTA Comorbidity Score

We found NTA costs increase with 50 conditions and extensive services:

  • Providers report these conditions and extensive services on the MDS 3.0 with the ICD-10-CM codes identified in Item MDS I
  • The PDPM NTA accounts for relative costliness between comorbidity scores and comes from a patient’s weighted comorbidities count, rather than a simple comorbidities count
  • To get this weighted count, we assign points between 1 and 8 to each of the 50 PDPM comorbidities to classify the patient’s NTA based on its relative costliness

To determine the patient’s NTA comorbidity score, determine all the patient’s qualifying comorbidities and add each comorbidity’s points. This sum is the patient’s NTA comorbidity score putting that patient into an NTA component classification group.

Streamlined Assessment Schedule

  • PDPM PPS assessments include:
    • Initial 5-day PPS assessment
    • Interim Payment Assessment (IPA), an optional assessment completed at any point during the patient’s stay when clinical change occurs
    • Discharge assessment
  • Providers bill the default Health Insurance Prospective Payment System (HIPPS) late assessments code for non-compliant days
  • Use the 5-day assessment HIPPS code for the rest of the stay unless the provider completes an IPA
  • Late assessments affect VPD (for example, if a 5-day assessment is 2 days late, we adjust VPD for days 1 and 2 and calculate it using the default HIPPS code)
  • 5-day assessment HIPPS code controls payment starting on day 3 of the VPD schedule

PDPM HIPPS Coding

The PDPM HIPPS algorithm:

  • Character 1: PT and OT Payment Group
  • Character 2: SLP Payment Group
  • Character 3: Nursing Payment Group
  • Character 4: NTA Payment Group
  • Character 5: Assessment Indicator

IPA Item Set

Providers may complete the IPA to report the patient’s PDPM classification change with no VPD schedule change. The IPA changes payment starting on the assessment review date, ending when the Part A stay stops, unless the provider completes another IPA.

State Assessments

States can choose PDPM item sets to calculate Medicaid payments. Each state determines if providers use PDPM comparisons and payment data for Medicaid. If so, states may require Omnibus Budget Reconciliation Act PDPM assessment data, like comprehensive and quarterly assessments. These item sets use Section GG, Item IB (primary medical condition) and J (recent surgery requiring active SNF care).

MDS 3.0 Technical Information has more information.

MDS Items

Section I: SNF Primary Diagnosis: IB lets providers use an ICD-10-CM code to report a patient’s primary diagnosis. This item asks, “What’s the main reason for admitting this person to the SNF?” Code Item IB when Item I is coded as any response 1–13. We retired Item IA; use only I and IB.

Section J: Patient Surgical History: J–J capture major surgical procedures during the hospital stay immediately before SNF admission. We use these items with the diagnosis captured in IB to classify patients into PT and OT case-mix categories.

Section O: Discharge Therapy Items: MDS, Section O uses Items OA1–OC5 for each therapy discipline mode (for example, individual, group, or concurrent therapy) and therapy amount (in minutes) the patient gets. Users get an error message if that discipline’s group and concurrent minutes total more than 25% of total therapy.

Section GG: Interim Performance: To get a patient’s interim performance, use MDS Section GG items for patient functional assessments. The new column look-back period is a 3-day window before the IPA’s Assessment Reference Date.

Swing Bed PPS PDPM Assessment uses several existing MDS items:

  • K: Swallowing Disorder
  • I: Inflammatory Bowel Disease
  • I: Active Diagnosis: Aphasia
  • OD2: Special Treatments & Programs: Suctioning Post-Admit Code

I: Inflammatory Bowel Disease is an existing MDS item added to the 5-day PPS Assessment and IPA.

Concurrent & Group Therapy Limit

The PDPM combined limit for both concurrent (1 therapist with 2 patients doing different activities) and group therapy (1 therapist with 2–6 patients doing the same or similar activities) can’t equal more than 25% of the therapy that SNF patients get for each therapy discipline.

The PPS Discharge Assessment checks therapy limit compliance and includes the number of minutes per mode, per discipline, for the entire PPS stay.

Interrupted SNF Stay Policy

An interrupted SNF stay happens when a patient leaves Part A-covered SNF care, then readmits to Part A-covered SNF care in the same SNF (not a different SNF) within the interruption window.

Note: If a resident drops to a non-skilled level of care or leaves Part A SNF care, we consider the patient discharged because of the interrupted stay policy, even if the patient remains in the facility.

The interruption window is a 3-day period starting on the first non-covered day after a Part A-covered SNF stay and ending at 11:59 pm on the third consecutive non-covered day.

The first non-covered day may be different if the patient leaves the facility or Part A coverage:

  • If the patient physically leaves the SNF, the first interruption window is the departure day
  • If the patient stops Part A coverage but stays in the SNF, the first interruption window is the day after the final Part A coverage day

If the patient meets both conditions, we consider the subsequent stay a continuation of the last interrupted stay because of VPD and assessment schedules:

  • The VPD schedule continues from the last discharge day. For example, if the SNF patient discharges from Part A on day 17 (in other words, day 17 was the last covered SNF day), payment rates start on day 18 upon readmission.
  • The assessment schedule continues from the Part A discharge day. We don’t require a new 5-day assessment when the patient readmits, but the provider may decide to complete the IPA.

If the patient readmits to the same SNF outside the interruption window or the patient readmits to a different SNF (regardless of length of time between stays), the interrupted stay policy doesn’t apply, and we consider the subsequent stay a new stay. In these cases, the VPD schedule resets to day 1 payment rates, and the assessment schedule also resets to day 1, requiring a new 5-day assessment.

Administrative Level of Care Presumption Under PDPM

SNF PPS administrative presumption automatically classifies a patient who’s correctly assigned 1 of the designated, more intensive case-mix classifiers on the 5-day PPS assessment to a SNF level of care through the assessment reference date.

Patients not assigned to a designated classifier get an individual determination using existing administrative criteria. This doesn’t automatically classify as meeting or not meeting the level of care definition.

PDPM classifiers designated under this administrative presumption include:

  • Nursing groups covered by Extensive Services, Special Care High, Special Care Low, and Clinically Complex nursing categories
  • PT and OT groups TA, TB, TC, TD, TE, TF, TG, TJ, TK, TN, and TO
  • SLP groups SC, SE, SF, SH, SI, SJ, SK, and SL
  • NTA component’s uppermost (12+) comorbidity group

PDPM Payment for AIDS Patients

PDPM focuses AIDS patient costs by assigning the highest classification point value (8 points) of any condition or service under its NTA component and adds 18% to the nursing component.

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