CMS Pub. 100-04, ch. 3, § 190.6.4

An adjustment is provided for IPFs that maintain a qualifying ED. This is a facility-level

adjustment that applies to all IPF admissions (with the one exception described below),

regardless of whether a particular patient receives preadmission services in the hospital’s

ED.

The ED adjustment is incorporated into the variable per diem adjustment for the first day

of each stay for IPFs with a qualifying ED. That is, IPFs with a qualifying ED receive a

54 percent adjustment as the variable per diem adjustment for day 1 of each stay. If an

IPF does not have a qualifying ED, it receives a 28 percent adjustment as the variable per

diem adjustment for day 1 of each patient stay.

A qualifying ED means an ED of psychiatric units located in a hospital or CAH with EDs

that are staffed and equipped to furnish a comprehensive array (medical as well as

psychiatric) of emergency services and meets the definition of “provider-based status” (42

CFR 413.65) and meets the definition of a “dedicated emergency department” (42 CFR

489.24).

o “Provider-based status means the relationship between a main provider and a

provider-based entity or a department of a provider, remote location of a hospital,

or satellite facility that complies with the provisions of this section.” 42 CFR

413.65

o “Dedicated emergency department means any department or facility of the

hospital, regardless of whether it is located on or off the main hospital campus, that

meets at least one of the following requirements:

(1) It is licensed by the State in which it is located under applicable

State law as an emergency room or emergency department;

(2) It is held out to the public (by name, posted signs, advertising, or

other means) as a place that provides care for emergency medical

conditions on an urgent basis without requiring a previously scheduled

appointment; or

(3) During the calendar year immediately preceding the calendar year in

which a determination under this section is being made, based on a

representative sample of patient visits that occurred during that calendar

year, it provides at least one-third of all its outpatient visits for the

treatment of emergency medical conditions on an urgent basis without

requiring a previously scheduled appointment.” See 42 CFR 489.24.

As specified in 42 CFR 412.424(d)(1)(v)(B), the ED adjustment is not made where a

patient is discharged from an acute care hospital or CAH and admitted to the same

hospital’s or CAH’s psychiatric unit. An ED adjustment is not made in these cases

because the costs associated with ED services are reflected in the DRG payment to the

acute care hospital or through the reasonable cost payment made to the CAH.

Therefore, when patients are discharged from an acute care hospital or CAH and admitted

to the same hospital’s or CAH’s psychiatric unit, the IPF receives the 1.28 adjustment

factor as the variable per diem adjustment for the first day of the patient’s stay in the IPF.

IPFs should notify their Medicare contractors 30 days before the beginning of their cost

reporting period regarding if they have a qualifying ED. Medicare contractors have the

discretion to determine how they wish to be notified and the documentation they require.

Once the Medicare contractor is satisfied that the IPF has a qualifying ED, the Medicare

contractor should enter the information in the provider-specific file within a reasonable

timeframe so that the IPF can begin to receive the ED adjustment. Application of the ED

adjustment is prospective.

Medicare contractors may also use the date the documentation was received from the IPF

to implement the ED adjustment. The provider specific file can be updated from the date

of the attestation and claims processed from that date will receive the ED adjustment.

CMS does not intend that IPFs would have to wait until the beginning of their next cost

report period to receive the ED adjustment.

However, if an IPF no longer meets the definition of a qualified ED, the IPF must

promptly notify their Medicare contractor. The Medicare contractor would immediately

remove the flag from the provider-specific file and the provider will not receive the ED

adjustment. If the provider should once again meet the definition of a qualified ED, they

should contact their Medicare contractor immediately in order to update their file.