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