Inpatient Psychiatric Facilities
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1 Payment Integrity Compass Inpatient Psychiatric Facilities Understanding IPF Calculations Updated 12/05/12
2 2 Questions from the Group Please use GoToMeeting to Ask a Question Use the Raise Hand function to ask a question
3 3 Road Map 1 Background on IPF 2 Understanding the IPF Calculation 3 Where IPF is Loaded in PIC 4 Validation and Troubleshooting
4 4 Goals of IPF Medicare Basics Training Payment Integrity Compass Upkeeps Information in the System, but a Member Must Understand What Goes into a Calculation The Goal of IPF Medicare Basics Is to Ensure Members Can Troubleshoot IPF Claims Effectively 1. Understand the basic calculation methods used to determine payment 2. Understand where the information making up IPF payments is loaded in the system 3. Understand how to click into an account to figure out what went into a IPF payment
5 5 Inpatient Psychiatric Facility Patients Patients are Admitted When They are a Risk to Themselves or Others Criteria of an IPF Patient Patients considered a risk to themselves or others. Ex. Drug rehab or eating disorders Psychiatric conditions covered for 90 days of care per illness Lifetime limit of 190 days of treatment
6 6 Road Map 1 Background on IPF 2 Understanding the IPF Calculation 3 Where IPF is Loaded in PIC 4 Validation and Troubleshooting
7 7 How Is IPF Reimbursed? IPF Pays Add-ons and Outliers in Addition to the Per Diem Psych DRG Per Diem Per Diem + Add-Ons + Outliers = Total Payment Multipliers Age Comorbidities DRG * Code 1 st adjustments are not loaded in the admin profile, they are loaded behind the scenes Electroconvulsive Therapy (ECT)
8 8 Multiple Codes Will Calculate On An IPF Account Psych DRGs Or A Code 1 st DRGs Will Trigger An IPF Calculation Regular Psych DRG Service Description Code 1 st Service Description
9 An Age Multiplier Is Applied To The Per Diem Payment 9 Adjustment Rates Rise As The Patient s Age Increases 55-60= = = =1.0! The age adjustment factor is determined on the patient s age at time of admission, not at time of discharge
10 A Comorbidity Adjustment Is Applied To The Per Diem Payment Patients Can Qualify for One Adjustment Per Group 10 Example Account: Charge Lines Adjustment 1.03 Adjustment 1.05 Adjustment No Additional adjustment No Additional adjustment No Additional adjustment Comorbidity Adjustment Table Adjustment Category Code Adjustment Factor Drug/Alcohol Induced Mental Disorders Developmental Disabilities Uncontrolled Type I Diabetes Mellitus
11 A DRG Adjustment Is Applied To The Per Diem Payment DRG Adjustments and Payment Rates Increase Concurrently 11 DRG 876= 1.22 DRG 887=.92 DRG 056= 1.05 Adjustment Rate DRG 896=.88 DRG 881=.99 DRG 080= 1.07 Average Cost of DRG Medicare assigns a weight to each of the DRGs reflecting the average costliness of cases in that group. The more costly the DRG, the higher the Adjustment Rate.
12 A Length of Stay Adjustment Is Applied To The Per Diem Payment The Longer a Patient Stays, the Lower the Daily Adjustment 12 Adjustments per day Example of Daily Adjustments Per Day Day of patient s stay Per diem adjustment With ED W/o ED
13 13 Codes That Make Up The IPF Add-on Service Electroconvulsive Therapy Codes Are Found On The Details Tab * Reimbursement is conditional upon both the revenue and ICD-9 codes being present on an account. If the add-on is not calculating correctly, check for this error.. Revenue Code 901 and ICD must be present to receive payment for an ECT add-on*
14 14 Outlier Payments Are Calculated At A Per Diem Rate Costs Are Determined By Multiplying The Per Diem By The Cost-to- Charge Ratio Outlier payments are provided when the estimated cost of the patient s entire stay exceeds the outlier threshold amount: Per Diem Rates $A X Cost-to-Charge Ratio $A $B $C + = $B X Cost-to-Charge Ratio $C X Cost-to-Charge Ratio Total Outlier Payments
15 15 Road Map 1 Background on IPF 2 Understanding The IPF Calculation 3 Where IPF is Loaded in PIC 4 Validation and Troubleshooting
16 Changes Made Within The Institutional Terms Screen IPF Details Must Be Entered In Add-on, Override, And Service Rates 16 Service Rule Calculation Method Where Rates are Added Psychiatric/Mental Health (override) Psychiatric Services MSDRG DRG 056,057,080,081, 876, , IPF Schedule IPF Profile, Factors, and Rates make up the reimbursement Non-Psych DRG w/code 1 st (override) Non Psych DRG w/code 1st IPF Schedule IPF Profile, Factors, and Rates make up the reimbursement Electroconvulsive Therapy (ECT) (add-on) Fee Schedule Fee Schedule Fee Schedule
17 17 Facility Rates Updated In Institutional Terms Facility Factors Impact Expected Reimbursement Facility Factors are updated regularly in IPF Rates
18 18 Add IPF Profiles Through Admin Information Loaded Is Found On CMS Website
19 19 Age Adjustment Factors Are Loaded In IPF Profile Age Factors Must be Entered Manually From Age: is equal to and greater. To Age: is less than or up to but not including.
20 20 DRG Factors Are Loaded In IPF Profile DRGs and Corresponding Adjustments Can Be Entered Manually or With a Fast Load Adjustment Factor Reflects average costliness
21 21 Comorbidity Factors Are Loaded In IPF Profile Patients with Comorbidity Conditions are More Costly and Receive a Higher Adjustment Each group has a set of codes associate with it
22 22 Road Map 1 Background on IPF 2 Understanding The IPF Calculation 3 Where IPF is Loaded in PIC 4 Validation and Troubleshooting
23 23 Common Errors Found in Validation Troubleshooting IPF Accounts Common Issues when troubleshooting Correct understanding of PIC age limits Factors entered correctly (ie. Most current wage index in use, comorbidity factors and codes entered correctly) Code 1 st Diagnosis Rank (these only get paid at rank 1 and 2) Psychiatric/Mental Health and Non-Psych DRG code 1 st are set in override Is prerequisite code needed? box checked for Oncology in the Comorbidity Adjustments
24 24 Appendix IPF Factor Calculations IPF Base Factor Calculations IPF Outlier Factor Calculations
25 25 IPF Base Factor Calculations The Following Equations Are Obtained From CMS and Are Used to Calculate Each Factor Factor/Component Description Labor Share Amount Non-Labor Share Amount PPS Adjustment Factor PPS Adjusted Per Diem PPS Wage Adjusted Per Diem Pre-Los Adjusted Per Diem Labor Rate x Wage Index Labor Rate x (100% - Labor Share Percent) Teaching Adjustment x Rural Adjustment x DRG Adjustment x Age Adjustment x Comorbidity Adjustment (Labor Share Amount + Non-Labor Share Amount) x PPS Adjustment Factor Labor Rate + Adjusted Labor Portion + Adjusted Non Labor Portion PPS Adjustment Factor x PPS Wage Adjusted Per Diem
26 26 IPF Outlier Factor Calculations The Following Equations Are Obtained From CMS and Are Used to Calculate Each Factor Factor/Component PPS Outlier Per Diem PPS Outlier Per Diem AddOn PPS Outlier Per Diem Adjusted Factor PPS Transaction Adjusted Outlier Payment Description (Estimated Costs Adjusted Outlier Threshold) / Total Covered Days PPS Outlier Per Diem x PPS Outlier Per Diem Adjusted Factor A variable percentage applied to the PPS Outlier Per Diem. NOTE: Days 1 through 9 80%, Days 10 and thereafter 60% PPS Outlier Per Diem x PPS Outlier Per Diem Adjusted Factor
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