11-99 FORM HCFA (Cont.)

Transcription

1 05-08 FORM CMS WORKSHEET C - COMPUTATION OF RATIO OF COST TO CHARGES AND OUTPATIENT CAPITAL REDUCTION This wrksheet cnsists f five parts: Part I - Cmputatin f Rati f Cst t Charges Part II - Cmputatin f Outpatient Services Cst t Charge Ratis Net f Reductins Part III - Cmputatin f Ttal Inpatient Ancillary Csts - Rural Primary Care Hspitals Part IV - Cmputatin f Inpatient Operating Csts - Rural Primary Care Hspitals Part V - Cmputatin f Outpatient Cst Per Visit - Rural Primary Care Hspitals NOTE: Rural primary care designatin is replaced with critical access hspital beginning Octber 1, Fr cst reprting perids beginning after Octber 1, 1997, Parts III thrugh V are nt applicable Part I - Cmputatin f Rati f Cst t Charges.--This wrksheet cmputes the rati f cst t charges fr inpatient services and, fr prviders nt subject t the utpatient capital reductin, the utpatient rati f cst t charges. All charges entered n this wrksheet must cmply with PRM-I, sectins and This rati is used n Wrksheet D, Part V, fr titles V and XIX and fr title XVIII csts nt subject t the utpatient capital reductin; Wrksheet D-4; Wrksheet D-6; Wrksheet H-4, Part II; and Wrksheet J-2, Part II, t determine the prgram's share f ancillary service csts in accrdance with 42 CFR This wrksheet is als needed t determine the adjusted ttal csts used n Wrksheet D-1 because f yur status as PPS, TEFRA, r ther. 42 CFR (f)(4) prvides that the csts f therapy services furnished under arrangements t a hspital inpatient are exempt frm the guidelines fr physical therapy and respiratry therapy if such csts are subject t the prvisins f 42 CFR (rate f increase ceiling) r 42 CFR Part 412 (prspective payment). 42 CFR (a)(2) prvides that RCE limits d nt apply t the csts f physician cmpensatin attributable t furnishing inpatient hspital services (prvider cmpnent) paid fr under 42 CFR Part 412ff. T facilitate the cst finding methdlgy, apply the therapy limits and RCE limits t ttal departmental csts. This wrksheet prvides the mechanism fr adjusting the csts after cst finding t cmply with 42 CFR (f)(4) and 42 CFR (a)(2). This is dne by cmputing a series f ratis in clumns 9 thrugh 11. In clumn 9, a rati referred t as the "cst r ther rati" is cmputed based n the rati f ttal reasnable cst t ttal charges. This rati is used by yu r yur cmpnents nt subject t PPS r TEFRA (e.g., hspital-based SNFs). Als use this rati fr Part B services still subject t cst reimbursement but nt subject t utpatient capital reductin. In clumn 10, cmpute a TEFRA inpatient rati. This rati reflects the add-back f RT/PT limitatins t ttal cst since TEFRA inpatient csts are nt subject t these limits. (TEFRA inpatient services are subject t RCE limits.) In clumn 11, cmpute a PPS inpatient rati. This rati reflects the addback f RT/PT and RCE limitatins t ttal cst since inpatient hspital services cvered by PPS are nt subject t any f these limitatins. Clumn Descriptins The fllwing prvider cmpnents may be subject t 42 CFR r 42 CFR 412.1(a)ff: Hspital Part A inpatient services fr title XVIII, Hspital subprvider Part A inpatient services fr title XVIII, Hspital inpatient services fr titles V and XIX, and Hspital subprvider services fr titles V and XIX. Rev

2 (Cnt.) FORM CMS All cmpnents r prtins f cmpnents nt subject t PPS r TEFRA, e.g., utpatient services csts nt subject t utpatient capital reductin, are classified as "Cst r Other." The fllwing matrix summarizes the clumns cmpleted fr Cst r Other, TEFRA Inpatient, and PPS Inpatient: Clumns Cst r TEFRA PPS Type f Service Other Inpatient Inpatient Inpatient rutine service cst centers (lines 25-36) Inpatient ancillary (lines 37-68) 1, 8, 9 1-3, , 11 Outpatient ancillary and utpatient cst centers (fr csts nt subject t capital reductin) 1, 8, 9 1-3, , 11 Clumn 1--Enter n each line the amunt frm the crrespnding line f Wrksheet B, Part I, clumn 27. Transfer the amunt n line 62 frm Wrksheet D-1, Part IV, line 85, if yu d nt have a distinct bservatin bed area. If yu have a distinct bservatin bed area, subscript line 62 int line 62.01, and transfer the apprpriate amunt frm Wrksheet B, Part I, clumn 27. In a cmplex cmprised f an acute care hspital with an excluded unit, the acute care hspital reprts the bservatin bed csts. Subprviders (hspital nly, i.e. psychiatric, rehabilitatin, r lng term care facility) with separate prvider numbers frm the main hspital may reprt bservatin bed csts if a separate utpatient department is maintained within the subprvider unit. If the subprvider is reprting bservatin bed days (Wrksheet S-3, line 26.01), add the amunt reprted by bth the hspital and the subprvider frm Wrksheet D-1, line 85, and enter the sum n line 62. The RHC/FQHC csts n lines thrugh 63.99, fr cst reprting perids which verlap the January 1, 1998, effective date will be transferred t this wrksheet frm Wrksheet B, clumn 27. Fr cst reprting perids beginning n r after January 1, 1998, n cst r charges are reprted n this wrksheet fr the RHC/FQHC. Hwever, any services prvided by the RHC/FQHC utside the benefits package fr thse clinics are reprted by the hspital in its apprpriate ancillary cst center, but nt in the RHC/FQHC cst center lines thrugh (1/98). D nt bring frward any cst center with a credit balance frm Wrksheet B, Part I, clumn 27. Hwever, reprt the charges applicable t such cst centers with a credit balance in clumn 6 f the apprpriate line n Wrksheet C, Part I. Clumn 2--Enter the amunt f therapy limits applied t the cst center n lines 49 t 52. Obtain these amunts frm Wrksheet A-8, lines 25, 26, 35 and 36 respectively. NOTE: Cmplete this clumn nly when the hspital r subprvider is subject t PPS (see 42 CFR 412.1(a) thrugh ) r the TEFRA rate f increase ceiling. (See 42 CFR ) If the hspital and all subprviders have crrectly indicated that their payment system is in the "ther" categry n Wrksheet S-2, d nt cmplete clumns 2 thrugh 5, 10, and 11. Clumn 3--Enter n each cst center line the sum f clumns 1 and 2. Clumn 4--Only cmplete this sectin if yu r yur subprviders are subject t PPS. Enter n each line the amunt f the RCE disallwance. Obtain these amunts frm the sum f the amunts fr the crrespnding line n Wrksheet A-8-2, clumn Rev. 18

3 11-99 FORM HCFA (Cnt.) Clumn 5--Cmplete this sectin nly if yu r yur subprviders are subject t PPS. Enter n each cst center line the sum f the amunts entered in clumns 3 and 4. Clumns 6 and 7--Enter n each cst center line the ttal inpatient and utpatient grss patient charges including charity care fr that cst center. Include in the apprpriate cst centers items reimbursed n a fee schedule (e.g., DME, xygen, prsthetics, and rthtics). DME, xygen, and rthtic and prsthetic devices (except fr enteral and parental nutrients and intracular lenses furnished by prviders) are paid by the Part B carrier r the reginal hme health intermediary n the basis f the lwer f the supplier s actual charge r a fee schedule. Therefre, d nt include Medicare charges applicable t these items in the Medicare charges reprted n Wrksheet D-4 and Wrksheet D, Part V. Hwever, include yur standard custmary charges fr these items in ttal charges reprted n Wrksheet C, Part I. This is necessary t avid the need t split yur rganizatinal cst centers such as medical supplies between thse items paid n a fee basis and thse items subject t cst reimbursement. NOTE: Fr line 60, any ancillary service billed as clinic services must be reclassified t the apprpriate ancillary cst center, e.g., radilgy-diagnstic, PBP clinical lab services - prgram nly. A similar adjustment must be made t prgram charges. Enter n line 62 all bservatin bed charges fr bservatin beds nt set up as a separate unit. These charges relate t all payer classes and include thse bservatin bed charges fr patients released as utpatients and thse patients admitted as inpatients. If yu have a distinct bservatin unit, reprt yur grss charges n line (which was subscripted n Wrksheet A). If bservatin bed csts are als prvided by a subprvider (n alpha character in the prvider number), cmbine the charges fr purpses f calculating the cst t charge rati. If the ttal charges fr all patients fr a department include a charge fr the prvider-based physician s prfessinal cmpnent, then ttal and prgram charges used n Wrksheets D, D-2, D- 4, and D-6 must als include the PBP s prfessinal cmpnent charge in rder t crrectly apprtin csts t the prgram. Similarly, when ttal charges n Wrksheet C, Part I, fr a department are fr prvider services nly, charges n Wrksheets D, D-2, D-4, and D-6 must als include prvider services nly. When reprting charges fr a cmplex, e.g., hspital, subprvider, SNF, charges fr like services must be unifrm. (See HCFA Pub. 15-I, 2203 and 2314 fr the exceptin dealing with grssing up f charges.) When certain services are furnished under arrangements and an adjustment is made n Wrksheet A- 8 t grss up csts, grss up the related charges entered n Wrksheet C, Part I, in accrdance with HCFA Pub. 15-I, If n adjustment is made n Wrksheet A-8, shw nly the charges yu actually billed n Wrksheet C, Part I. NOTE: Any cst center that includes CRNA charges must exclude these charges unless the hspital qualifies fr the rural exceptin as utlined in All cst centers fr which CRNA csts are excluded n Wrksheet A-8 must als exclude the charges assciated with these csts. Clumn 8--Enter the ttal f clumns 6 and 7. Clumn 9--Always cmplete this clumn. Divide the cst fr each cst center in clumn 1 by the ttal charges fr the cst center in clumn 8 t determine the rati f ttal cst t ttal charges (referred t as the "Cst r Other" rati) fr that cst center. Enter the resultant departmental ratis in this clumn. Rund ratis t 6 decimal places. Clumn 10--Cmplete this sectin nly when the hspital r its subprvider is subject t the Rev

4 (Cnt.) FORM HCFA TEFRA rate f increase ceiling. (See 42 CFR ) Divide the amunt reprted in clumn 3 (which represents the ttal cst adjusted fr the add-back f amunts excluded n Wrksheet A-8 fr the RT/PT limits) fr each cst center by the ttal charges fr the cst center in clumn 8. This cmputatin determines the RT/PT adjusted rati f cst t charges (referred t as the TEFRA inpatient rati) fr each cst center. Enter the resultant departmental rati. Rund ratis t 6 decimal places. Clumn 11--Cmplete this sectin nly when the hspital r its subprvider is subject t PPS. (See 42 CFR 412.1(a) thrugh ) Divide the amunt reprted in clumn 5 (which represents the ttal cst adjusted fr the add-back f amunts excluded n Wrksheet A-8 fr the RT/PT and the RCE limits) fr each cst center by the ttal charges fr the cst center in clumn 8. This cmputatin determines the RCE/RT/PT adjusted rati f cst t charges (referred t as the PPS inpatient rati) fr each cst center. Enter the resultant departmental rati. Rund ratis t 6 decimal places. Line Descriptins Lines 25 thrugh 68--These cst centers have the same line numbers as the respective cst centers n Wrksheets A, B, and B-1. This design facilitates referencing thrughut the cst reprt. Therefre, if yu have subscripted any lines n thse wrksheets, yu must subscript the same lines n this wrksheet. NOTE: The wrksheet line numbers start at line 25 because f this referencing feature. Line 102--Enter the amunts frm line 62. Calculate the bservatin bed cst n line 62 using the rutine cst per diem frm Wrksheet D-1 because it is part f rutine csts and as such has been included in the amunts reprted n line 25 fr the hspital r line 31 in the case f a subprvider. Therefre, in rder t arrive at the ttal allwable csts, subtract this cst t avid reprting these csts twice. Line 103--Fr each clumn, subtract line 102 frm line 101, and enter the result. NOTE: Since the charges n line 45 are als included n line 44, labratry, the ttal charges n line 101 are verstated by the amunt n line 45. Transfer Referencing Csts--The csts f the inpatient rutine service cst centers are transferred: Frm Wrksheet C, Part I (Clumns 1, 3, r 5) Line 25 Wkst. D-1, Part I, Line 21 Lines Wkst. D-1, Part II, Lines Line 31 and subscripts Separate Wkst. D-1, Part I, Line 21 Line 33 (titles V and XIX nly) Wkst. D-1, Part II, Line 42 Line 34 (title XVIII nly) Separate Wkst. D-1, Part I, Line 21 Line 35 and subscripts (titles V and Separate Wkst. D-1, Part I, Line 21 XIX nly) T Charges--Transfer the ttal charges fr each f lines 37 thrugh 68, clumn 8, t Wrksheet C, Part II, clumn 7, and Wrksheet D, Part IV, clumn 6, lines as apprpriate Rev. 4

5 04-05 FORM CMS Ratis Cst r Other Ratis--The "Cst r Other" rati is transferred frm clumn 9: Fr Hspital, subprvider, SNF, NF, swing bed-snf, and swing bed-nf: 1. Inpatient ancillary services fr Wkst. D-4, clumn 1, titles V, XVIII, Part A, and XIX fr each cst center Ancillary services furnished by the hspital-based HHA Hspital-based CORF, CMHC, r OPT/OOT/OSP shared ancillary services fr titles V, XVIII, Part B, and XIX T Wkst. H-6, Part II, clumn 1, line as apprpriate Wkst. J-2, Part II, clumn 3, line as apprpriate TEFRA Inpatient Rati--Transfer the TEFRA inpatient rati n lines 37 thrugh 64 and 66 thrugh 68 frm clumn 10 fr hspital r subprvider cmpnents fr titles V, XVIII, Part A, and XIX inpatient services subject t the TEFRA rate f increase ceiling (see 42 CFR ) t Wrksheet D-4, clumn 1 fr each cst center. PPS Inpatient Rati--Transfer the PPS inpatient rati n lines 37 thrugh 64 and 66 thrugh 68 frm clumn 11 fr hspital r subprvider cmpnents fr titles V, XVIII, Part A, and XIX inpatient services subject t PPS (see 42 CFR 412.1(a) thrugh ) t Wrksheet D-4, clumn 1 fr each cst center Part II - Calculatin f Outpatient Services Cst t Charge Ratis Net f Reductins.-- This wrksheet cmputes the utpatient cst t charge ratis reflecting the fllwing: (D nt cmplete this sectin fr cst reprting perids beginning n r after August 1, 2000.) The reductin in hspital utpatient capital payments attributable t prtins f cst reprting perids ccurring frm Octber 1, 1989 thrugh September 30, 1998, as required by 1861(v)(1)(S)(ii) f the Act. The amunt f capital reductin is 10 percent fr payments fr services rendered frm Octber 1, 1991 thrugh July 31, The reductin in reasnable csts f hspital utpatient services (ther than the capital-related csts f such services) attributable t prtins f cst reprting perids ccurring frm Octber 1, 1990 thrugh September 30, 1998, as required by 1861(v)(1)(S)(ii) f the Act and enacted by 4151(b) f OBRA The amunt f the reductin is 5.8 percent fr payments fr services rendered n r after Octber 1, 1990 thrugh July 31, The reductin des nt apply t inpatient services paid under Part B f the prgram (10/90). The reductins d nt apply t sle cmmunity hspitals (SCH), rural primary care hspitals (RPCH)/Critical Access Hspitals (CAH). Hwever, if yu have been granted SCH status r have ended SCH status during this cst reprting perid, calculate the reductins fr the perids during which time yur hspital was nt granted SCH status during yur cst reprting year (i.e., cmpute the reductin percentage by dividing the number f days in yur cst reprting perid t which the reductins applied (and during which yu were nt a SCH) by the ttal number f days in the cst reprting perid. Multiply that rati by the applicable percentage. The result is the applicable utpatient reductin percentage). Titles V and XIX fllw their state plan in determining the applicable utpatient cst t charge ratis. Rev