Module 6 Questions & Answers
LONG-TERM CARE HOSPITAL (LTCH) CERTIFICATION - ANSWERSLTCHs are
certified under Medicare as short-term acute care hospitals and generally treat
medically complex patients who require
long-stay hospital-level care. For Medicare payment purposes, LTCHs are generally
defined as having an average inpatient Length of
Stay (LOS) greater than 25 days.
MEDICARE SEVERITY LONG-TERM CARE DIAGNOSIS-RELATED GROUPS (MS-
LTC-DRGs) - ANSWERSThe LTCH PPS uses MS-LTC-DRGs as a patient classification
system. The MS-LTC-DRGs are the same Medicare Severity DiagnosisRelated Groups
(MS-DRGs) the Centers for Medicare & Medicaid Services (CMS) uses under the
Inpatient Prospective Payment System
(IPPS), weighted to reflect the different resources used by LTCHs
MS LTC DRG groupings - ANSWERSdx, procedures performed, age, gender, D/C
status
SITE NEUTRAL PAYMENT RATE - ANSWERSLTCH discharges that do not meet
specific criteria will be paid at a
new site neutral payment rate. The site neutral payment rate is generally the lower of:
● The IPPS comparable per diem amount (as calculated under our SSO policy) or
● The estimated costs of the case (calculated by multiplying the allowable charges by
the LTCH's Cost-to-Charge Ratio [CCR])
CCR - ANSWERSCost-to-Charge Ratio
Twenty-Five Percent Threshold Rule - ANSWERSPayments were adjusted for certain
discharges for cost reporting periods in which more than 25 percent of the LTCH HwH's
or
LTCH satellite's discharges were admitted from its co-located host hospital. Specifically,
after the 25 percent payment threshold was
crossed, the net payment amount for the discharges occurring beyond the threshold
was based on the lesser of a payment based
on the MS-LTC-DRGs or an amount equivalent to what Medicare would have otherwise
paid under the IPPS. In special situations
(such as admissions from rural and urban single or Metropolitan Statistical Area [MSA]-
dominant hospitals), the payment threshold
was between 25 percent and 50 percent, set as the host's percentage of total Medicare
discharges in the MSA for like hospitals.
, Short-Stay Outlier (SSO) - ANSWERSThe SSO, which assists in preventing
inappropriate payment for cases that do not have a full episode of care, is an
adjustment to the
Federal payment rate for LTCH stays that are generally much shorter than the ALOS for
an MS-LTC-DRG. An SSO payment adjustment
to the standard Federal payment rate may occur when a patient
High Cost Outlier (HCO) - ANSWERSThe HCO is an adjustment to the applicable LTCH
PPS payment rate (either the site neutral rate or the standard Federal rate) for LTCH
stays with unusually high costs that exceed the typical cost for cases with a similar
case-mix. It equals 80 percent of the difference
between the estimated cost of the case and the outlier threshold, and it is made in
addition to the applicable LTCH PPS payment rate.
Fixed-Loss Amounts - ANSWERSBeginning October 1, 2015, under the new dual-rate
LTCH PPS payment structure, CMS sets two fixed-loss amounts: one for standard
Federal rate payments and one for site neutral rate payments. The fixed-loss amount for
cases paid based on the Federal rate is set at
an amount that allows the projected total HCO payments in a given year to equal 8
percent of the total LTCH PPS standard Federal rate
payments estimated for that year (the full MS-LTC-DRG payments or the adjusted SSO
amount plus HCO payments). For FY 2017, the
fixed-loss amount for site neutral cases is set at the same value as the IPPS fixed-loss
amount.
Interrupted Stay - ANSWERSAn interrupted stay occurs when a patient discharges from
an LTCH and, after a specific number of days, readmits to the same LTCH
for further medical treatment. For example, an LTCH patient may be discharged for
treatment and services that are not available in the
LTCH. Each stay is evaluated separately to make certain that it meets the interrupted
stay criteria. A case may have multiple interrupted
stays. A case with interrupted stays may be eligible for other case-level adjustments
(such as the HCO payment).
The two types of interrupted stays are 3-day or less interruption of stay and greater than
3-day interruption of stay.
Three-Day or Less Interruption of Stay - ANSWERSFor discharges and readmissions to
the same LTCH within 3 days, the patient may:
● Receive outpatient or inpatient tests, treatment, or care at an inpatient acute care
hospital, Inpatient Rehabilitation Facility (IRF), or
Skilled Nursing Facility (SNF)/Swing Bed or
● Have an intervening patient stay at home for up to 3 days without the delivery of
additional tests, treatment, or care
LONG-TERM CARE HOSPITAL (LTCH) CERTIFICATION - ANSWERSLTCHs are
certified under Medicare as short-term acute care hospitals and generally treat
medically complex patients who require
long-stay hospital-level care. For Medicare payment purposes, LTCHs are generally
defined as having an average inpatient Length of
Stay (LOS) greater than 25 days.
MEDICARE SEVERITY LONG-TERM CARE DIAGNOSIS-RELATED GROUPS (MS-
LTC-DRGs) - ANSWERSThe LTCH PPS uses MS-LTC-DRGs as a patient classification
system. The MS-LTC-DRGs are the same Medicare Severity DiagnosisRelated Groups
(MS-DRGs) the Centers for Medicare & Medicaid Services (CMS) uses under the
Inpatient Prospective Payment System
(IPPS), weighted to reflect the different resources used by LTCHs
MS LTC DRG groupings - ANSWERSdx, procedures performed, age, gender, D/C
status
SITE NEUTRAL PAYMENT RATE - ANSWERSLTCH discharges that do not meet
specific criteria will be paid at a
new site neutral payment rate. The site neutral payment rate is generally the lower of:
● The IPPS comparable per diem amount (as calculated under our SSO policy) or
● The estimated costs of the case (calculated by multiplying the allowable charges by
the LTCH's Cost-to-Charge Ratio [CCR])
CCR - ANSWERSCost-to-Charge Ratio
Twenty-Five Percent Threshold Rule - ANSWERSPayments were adjusted for certain
discharges for cost reporting periods in which more than 25 percent of the LTCH HwH's
or
LTCH satellite's discharges were admitted from its co-located host hospital. Specifically,
after the 25 percent payment threshold was
crossed, the net payment amount for the discharges occurring beyond the threshold
was based on the lesser of a payment based
on the MS-LTC-DRGs or an amount equivalent to what Medicare would have otherwise
paid under the IPPS. In special situations
(such as admissions from rural and urban single or Metropolitan Statistical Area [MSA]-
dominant hospitals), the payment threshold
was between 25 percent and 50 percent, set as the host's percentage of total Medicare
discharges in the MSA for like hospitals.
, Short-Stay Outlier (SSO) - ANSWERSThe SSO, which assists in preventing
inappropriate payment for cases that do not have a full episode of care, is an
adjustment to the
Federal payment rate for LTCH stays that are generally much shorter than the ALOS for
an MS-LTC-DRG. An SSO payment adjustment
to the standard Federal payment rate may occur when a patient
High Cost Outlier (HCO) - ANSWERSThe HCO is an adjustment to the applicable LTCH
PPS payment rate (either the site neutral rate or the standard Federal rate) for LTCH
stays with unusually high costs that exceed the typical cost for cases with a similar
case-mix. It equals 80 percent of the difference
between the estimated cost of the case and the outlier threshold, and it is made in
addition to the applicable LTCH PPS payment rate.
Fixed-Loss Amounts - ANSWERSBeginning October 1, 2015, under the new dual-rate
LTCH PPS payment structure, CMS sets two fixed-loss amounts: one for standard
Federal rate payments and one for site neutral rate payments. The fixed-loss amount for
cases paid based on the Federal rate is set at
an amount that allows the projected total HCO payments in a given year to equal 8
percent of the total LTCH PPS standard Federal rate
payments estimated for that year (the full MS-LTC-DRG payments or the adjusted SSO
amount plus HCO payments). For FY 2017, the
fixed-loss amount for site neutral cases is set at the same value as the IPPS fixed-loss
amount.
Interrupted Stay - ANSWERSAn interrupted stay occurs when a patient discharges from
an LTCH and, after a specific number of days, readmits to the same LTCH
for further medical treatment. For example, an LTCH patient may be discharged for
treatment and services that are not available in the
LTCH. Each stay is evaluated separately to make certain that it meets the interrupted
stay criteria. A case may have multiple interrupted
stays. A case with interrupted stays may be eligible for other case-level adjustments
(such as the HCO payment).
The two types of interrupted stays are 3-day or less interruption of stay and greater than
3-day interruption of stay.
Three-Day or Less Interruption of Stay - ANSWERSFor discharges and readmissions to
the same LTCH within 3 days, the patient may:
● Receive outpatient or inpatient tests, treatment, or care at an inpatient acute care
hospital, Inpatient Rehabilitation Facility (IRF), or
Skilled Nursing Facility (SNF)/Swing Bed or
● Have an intervening patient stay at home for up to 3 days without the delivery of
additional tests, treatment, or care
