CMS Pub. 100-04, ch. 3, § 140.3

IRF PPS payment is contingent on the requirement that IRFs complete a patient

assessment upon admission and discharge for Medicare patients. The August 7, 2001,

Final Rule, and subsequent final rules contain detailed information regarding the

assessment schedule for the patient assessment instrument (PAI) with respect to

transmission requirements, encoding dates, and other pertinent information. Further, there

is an item-by-item guide, which specifies detailed instructions regarding the manner in

which each item on the assessment instrument needs to be completed.

Effective with cost reporting periods beginning on or after January 1, 2002, IRFs are

required to report billing data with a new revenue code and a Health Insurance PPS

(HIPPS) Rate Code on the ASC X12 837 institutional claim or, in rare cases, on the Form

CMS-1450 for all Part A inpatient claims (Type of Bill 11X) to their A/B MACs (A). The

new revenue code, 0024, is used in conjunction with the HIPPS Rate Code to identify the

CMG payment classification for the beneficiary. In addition to all entries previously

required on a Part A claim, the following additional instructions must be followed to

accurately price and pay a claim under the IRF PPS. These claims must be submitted on

Type of Bill 11X. The last four digits of the provider number for rehabilitation hospitals

is from 3025 to 3099, and for rehabilitation distinct part units the third digit will be a T if

the unit is located in an acute care hospital or an R if the unit is located in a CAH.

• The Revenue code must contain revenue code 0024. This code indicates that this

claim is being paid under the PPS. This revenue code can appear on a claim only

once.

• The following Patient Discharge Status codes are applicable under the transfer

policy for IRF PPS: 02, 03, 61, 62, 63, and 64.

NOTE: IRFs that transfer a beneficiary to a nursing home that accepts payment under

Medicare and/or Medicaid should use PS 03, discharged/transferred to a SNF. IRFs that

transfer a beneficiary to a nursing facility that does not accept Medicare or Medicaid,

should code PS 04, discharged/transferred to an ICF, until such time that a new PS code is

established to differentiate between nursing facilities that do not accept Medicare and/or

Medicaid and those that do. PS 04 does not constitute a transfer under the IRF PPS

policy.

• For typical cases, the HCPCS/Rates must contain a five digit HIPPS Rate/CMG

Code (AXXYY-DXXYY). The first position of the code is an A, B, C, or D. The

HIPPS rate code beginning with A in front of the CMG is defined as without

comorbidity. The HIPPS rate code containing a B in front of the CMG is defined

as with comorbidity for Tier 1. The HIPPS rate code containing a C in front of the

CMG is defined as with comorbidity for Tier 2. The HIPPS rate code containing a

D in front of the CMG is defined as with comorbidity for Tier 3. The (XX) in the

HIPPS rate code is the Rehabilitation Impairment Category (RIC). The (YY) in

the HIPPS rate code is the sequential numbering system within the RIC.

• For atypical cases effective January 1, 2010, the HCPCS/Rates must contain a five

digit HIPPS Rate/CMG Code A5001. An atypical case occurs under the new IRF

coverage requirements that became effective January 1, 2010, where an IRF is

eligible to receive the IRF short stay payment for 3 days or less (HIPPS Rate/CMG

A5001) if a patient’s thorough preadmission screening shows that the patient is an

appropriate candidate for IRF care but then something unexpected happens

between the preadmission screening and the IRF admission such that the patient is

no longer an appropriate candidate for IRF care on admission and the day count is

greater than 3. In this scenario only, if the patient is discharged/transferred on or

after day 4, we are instructing IRFs to bill HIPPS Rate/CMG A5001. Thus,

whether or not the IRF is able to discharge the patient to another setting of care

within 3 days, the IRF will only be eligible for and receive the IRF short stay

payment for 3 days or less (HIPPS Rate/CMG A5001).

Covered Charges should contain zero covered charges when the revenue code is 0024.

For accommodation revenue codes (010x-021x), covered charges must equal the rate

times the units. The IRF Pricer will calculate and return the payment amount for the line

item with revenue code 0024. Non-outlier payments will not be made based on the total

charges shown in Revenue Code 0001.

• IRF providers will submit one admit through discharge claim for the stay. Final

PPS payment is based upon the discharge bill.

• Should the patient's stay overlap the time in which the PPS applies to the facility,

PPS payment will still be based on discharge. If the facility submitted an interim

bill, a debit/credit adjustment must be made prior to PPS payment. If the facility

submits multiple interim bills, the provider will need to submit cancels and then

rebill once the cancels are accepted.

• IRFs can submit adjustment bills (even to correct the CMG), but late charge bills

will not be allowed (Type of bill 115).

• If a beneficiary has 1 day of Medicare coverage during their IRF stay, an entire

CMG payment will be made.

• IRFs will be paid under the IRF PPS beginning on the first day of their cost

reporting period that begins on or after January 1, 2002. Units established in a

CAH will be paid under the IRF PPS beginning with CAH cost reporting periods

on or after October 1, 2004.

For interim bills, if the stay is greater than 60 days, the interim bill should include the

lowest level of the HIPPS code from the admission assessment. The final claim will be

adjusted to reflect data from the discharge assessment.

When coding PPS bills for ancillary services associated with a Part A inpatient stay, the

traditional revenue codes will continue to be shown, e.g., 0250 - Pharmacy, 042x -

Physical Therapy, in conjunction with the appropriate entries in Service Units and Total

Charges.

• IRFs are required to report the number of units based on the procedure or service.

• IRFs are required to report the actual charge for each line item, in Total Charges.

If a beneficiary's Part A benefits exhaust during the stay, code an occurrence code A3-C3.

If benefits are exhausted prior to the stay, submit a no pay claim, which will be coded by

the A/B MAC (A) with no pay code B. Report any services that can be billed under the

Part B benefit using 12X TOB.

NOTE: For more information on outlier payments when benefits are exhausted, please

see §20.7.4. Although this references an expired instruction specific to inpatient hospital

PPS billing, the information presented provides important general information.