CMS Pub. 100-04, ch. 3, § 150.23.1

Inputs

• Provider Specific File Data; Fields-1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14, 18,

19, 21, 22, and 25 (although this field refers to the operating cost/charge ratio,

for LTCH, entered here will be a combined operating and capital cost/charge

ratio). Effective July 1, 2005, A/B MACs (A) shall no longer populate fields

12, 13, or 14. Field 35 must be populated for all LTCHs. Fields 33 and 38

shall be populated if applicable. Effective July 1, 2006, data elements 23, 24,

27, 28, and 49 are required. See the section "Determining the Cost-to-Charge

Ratio" below for determining the cost/charge ratio.

• The facility-specific rate (Field 21) will be determined using the same

methodology that would be used to determine the interim payment per

discharge under the TEFRA system if the LTCH PPS were not being

implemented.

• Bill Data

o Provider #

o Patient Status

o Covered Charges

o Discharge Date (or benefit’s exhaust date if present (Occurrence Code

A3, B3, or C3))

o Length of Stay (LOS)

o Covered Days

o Lifetime Reserve Days (LTR)

o DRG (from Grouper)

Outputs

• PPS Return Code

• MSA/CBSA (CBSAs will be returned for discharges on or after July 1, 2005).

• Wage Index

• Average LOS

• Relative Weight

• Final Payment Amount

• DRG Adjusted Payment Amount

• Federal Payment Amount

• Outlier Payment Amount

• Payment Amount

• Facility Costs

• LOS

• Regular Days Used

• LTR Days Used

• Blend Year, 1-5

• Outlier Threshold

• DRG

• COLA

• Calculation Version Code

• National Labor Percent

• National Non-Labor Percent

• Standard Federal Rate

• Budget Neutral Rate

• New Facility-specific Rate