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PRICER Prospective Payment System (PPS)
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Introduction | System Requirements | Release Schedule | Downloads | PRICER Feedback
Calculate APC rates, coinsurance and deductibles

 

Inpatient, Skilled Nursing, Home Health, Inpatient Rehabilitation Facilities,
Long-Term Care Hospitals, and Outpatient

Introduction:

Inpatient PPS PC PRICER

The Social Security Amendments of 1983 (Public Law 98-21) established the Prospective Payment System (PPS) for hospital inpatient services provided to Medicare beneficiaries. Under this system, a hospital is paid a fixed amount for each patient discharged in a particular treatment category or Diagnosis Related Group (DRG). This fixed amount is intended to cover the cost of treating a typical patient for a particular DRG. The PPS Pricer software, which will be released on a quarterly basis, calculates discharges from October 1 through September 30 for a given fiscal year.

Skilled Nursing Facilities (SNF PPS) PC PRICER

The Balanced Budget Act (BBA) of 1997 (Public Law 105-33) mandated the implementation of a per diem prospective payment system (PPS) for skilled nursing facilities (SNFs), covering all costs (routine, ancillary, and capital) of covered SNF services furnished to beneficiaries under Part A of the Medicare program effective for cost reporting periods beginning on or after July 1, 1998.

Home Health Prospective Payment System (HH PPS) PC PRICER

The Balanced Budget Act (BBA) of 1997 (Public Law 105-33) required the creation of a prospective payment system for home health services. The Omnibus Consolidated and Emergency Supplemental Appropriations Act for 1999 (Public Law 105-277) established the effective date of the system, using dates of service on or after October 1, 2000. HH PPS applies to all home health services billed on type of bill 32x or 33x. The HH PPS Pricer makes all reimbursement calculations applicable under HH PPS, including percentage payments on requests for anticipated payments (RAPs), claim payments for full episodes of care, and all payment adjustments, including low utilization payment adjustments (LUPAs), partial episode payment (PEP) adjustments, significant change in condition(SCIC) adjustments and outlier payments.

Inpatient Rehabilitation Facility (IRF PPS ) PC PRICER

The Balanced Budget Act (BBA) of 1997 (Public Law 105-33) authorizes the implementation of per discharge prospective payment system (PPS) for inpatient rehabilitation hospitals and rehabilitation units. Each facility must show that during its most recent 12-month cost reporting period, it served an inpatient population of whom at least 75 percent required intensive rehabilitative services for the treatment of one or more of the following conditions: stroke, spinal cord injury, congenital deformity, amputation, major multiple trauma, fracture of femur (hip fracture), brain injury, polyarthritis (including rheumatoid arthritis), neurological disorders (including multiple sclerosis, motor neuron diseases, polyneuropathy, muscular dystrophy, and Parkinson's disease), and burns.

Long-Term Care Hospital (LTCH PPS) PC PRICER

The Balanced Budget Refinement Act (BBRA) of 1999 and the Benefits Improvement Act (BIPA) of 2000 established the Prospective Payment System (PPS) for operating and capital-related costs of hospital inpatient stays in long-term care hospitals (LTCHs) under Medicare Part A. Under this system, a hospital is paid a fixed amount for each patient discharged in a particular treatment category or Diagnosis Related Group (DRG). This fixed amount is intended to cover the cost of treating a typical patient for a particular DRG. This PC Pricer software will be released on a quarterly basis. The criteria for classification as a LTCH is outlined in section 1886(d)(1)(B)(iv) of the Social Security Act. The PPS for LTCHs is effective for cost reporting periods beginning on or after October 1, 2002.

System Requirements:

The PRICERs can be installed in a Windows environment. You will need an IBM PC or clone with a hard disk drive for Microsoft Windows Version 95 or greater with at least 8MB RAM. Both monochrome and color monitors are supported. A printer is essential to produce the report that displays the PRICER results. Finally, the PRICERS can run in a network environment.

Release Schedule:

For each new release of the PRICERS, the Provider Specific File will contain all quarterly updates. Each new release will replace any previous release.

For a given fiscal year, the PRICER release schedule is as follows:

  • Initial Release of PRICERS — October 1
  • First Quarterly Release — On or about October 15
  • Second Quarterly Release — On or about January 15
  • Third Quarterly Release — On or about April 15
  • Fourth Quarterly Release — On or about July 15

Outpatient PPS Pricer

Calculate Rates:

There is no PC Pricer application for Outpatient PPS at this time. The following files contain the logic, rates, wage index, and off-set amounts used by the OPPS PRICER program to calculate APC rates, coinsurance and deductibles:

File Name (All files contain the latest updates effective October 1, 2004)
Offset files remain unchanged

File Size
(in .pdf format)

File Size
(in .zip format)

oppscalv200440.pdf
oppscalv200440.zip

318Kb

32Kb

oppsapcsv200440.pdf
oppsapcsv200440.zip

604Mb

65Kb

oppswinxv200440.pdf
oppswinxv200440.zip

84Kb

13Kb

oppsof02v200310.pdf

20Kb

 

oppsof03v200310.pdf

20Kb

 

oppsof04v200410.pdf

35Kb

 

baseapcsv200440.pdf
baseapcsv200440.zip

359Kb

48Kb

basewinxv200440.pdf
basewinxv200440.zip

122Kb

14Kb


Downloads:

Download the Outpatient Provider Specific File

File Name Effective as of: File Size
psfall0704.zip July 2004 zip format 262Kb compressed / 3.31Mb decompressed
psfall0404.zip April 2004 zip format 253Kb compressed / 3.3Mb decompressed
psf0103hosp.zip January 2004 zip format 334Kb compressed / 4.9Mb decompressed
To view the data elements and formats of the Outpatient Provider Specific File, see section 50.1 at www.cms.hhs.gov/manuals/104_claims/clm104c04.pdf

Pricer Feedback:
If you have any comments or questions about PPS Pricer, please use the PRICER Feedback page.
Note: Some of the files on this page are available only in Adobe Acrobat - Portable Document Format (PDF). To view PDF files, you must have the Adobe Acrobat Reader (minimum version 5, version 6 suggested). You can check here to see if you have the Acrobat Reader installed on your computer. If you do not already have the Acrobat Reader installed, please go to Adobe's Acrobat download page now.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Last Modified on Thursday, September 16, 2004