CMS Pub. 100-04, ch. 3, § 140.3.2

The CMS has developed an IRF Pricer Program that calculates the Medicare payment rate.

Pricer will use a variety of inputs listed below to calculate the payment rate.

A. Inputs to Pricer

• Provider Specific File data (see section 20.2.3.1 and Addendum of this chapter for

required elements)

• Bill Data includes:

° Patient Status:

° Payment Modification Flag (if condition code is 66, set flag "Y" otherwise use

"N.");

° Covered Charges;

° Discharge Date;

° HIPPS/CMG Rate Code;

° Length of Stay (LOS);

° Covered Days;

° Lifetime Reserve Days (LTR)

B. Data Returned From Pricer

Pricer returns the following information:

• PPS Return Code

• MSA /CBSA (effective October 1, 2005)

• Wage Index

• Average LOS

• Relative Weight

• Total Payment Amount

• PPS Federal Payment Amount

• Facility Specific Payment Amount

• Outlier Payment Amount

• Low-Income Payment (LIP) Amount

• Teaching Amount (effective October 1, 2005)

• LOS

• Regular Days Used

• LTR Days Used

• Transfer Percentage

• Facility Specific Rate pre-blend

• Standard Payment Amount

• PPS federal amount pre-blend

• Facility costs

• Outlier threshold

• Submitted HIPPS/CMG code

• PPS Pricer CMG code

• Calculation version code

The Pricer is available electronically to the Shared Systems.