Outlier Reconciliation and other Outlier Manual Updates for the Inpatient Prospective Payment System (IPPS), Outpatient Prospective Payment System (OPPS), Inpatient Rehabilitation Facility (IRF) PPS, Inpatient Psychiatric Facility (IPF) PPS and Long Term Care Hospital (LTCH) PPS
The purpose of this transmittal is to instruct FISS to update the Lump Sum Utility (created in the confidential CR 6267) for the IPPS, LTCH PPS, IRF PPS, IPF PPS and OPPS with additional output fields and to use the appropriate versions of Pricer. The updated utility will then be used by Medicare contractors to re-price outlier claims offline without affecting Co-Pays, Lifetime Reserve Days or the Medicare Summary Notice (MSN). Within this transmittal, we are also establishing criteria for outlier reconciliation for the IPF PPS. Additionally, we are manualizing the instructions from transmittal A-03-058 for the LTCH PPS. We also provide guidance to Medicare contractors how to use the Lump Sum Utility for each of the PPSs mentioned above. Finally, we are also issuing formal manual instructions on cost-to charge ratios, alternative cost-to-charge ratios, statewide and national average CCRs for the respective PPS and mergers and acquisitions that mirror the instructions for the IPPS.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: December 03, 2010
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