(Rev. 1, 10-01-03)
A3-3615.3, A3-3656.3
The CMS provides a Pricer program to determine the price upon which to base payment
under prospective payment. A separate Pricer installation guide is provided. The A/B
MAC (A) uses the Pricer appropriate for the date of discharge.
After GROUPER determines the DRG, the A/B MAC (A) 's system calls the Pricer
program. Pricer determines the price to pay and prepares a report.
Four data files are included. CMS maintains three:
• DRGX file - contains DRG weights, average length of stay and outlier cutoff
points.
• MSAX file - contains urban and rural wage indexes used in calculating payment.
CMS may request that the A/B MAC (A) make interim changes to this file when
index changes are issued for individual hospitals after issuance of Pricer for the
period.
• RATE file - contains census division values and updating amounts used in
calculating payment.
The A/B MAC (A) maintains the provider-specific file, (PROV file). This contains
information about the facts specific to the provider that affect computations, e.g., effective
dates for PPS, type of provider (for application of special computation rules), census
division, MSA, adjusted cost per discharge, disproportionate share adjustment percentage,
and capital data.
Pricer also calculates the disproportionate share adjustment and adds it to the DRG
payment. Correct calculation depends upon the accuracy of related information the A/B
MAC (A) includes in the PRICER PROV file.
The Pricer program applies the DRG relative weights, hospital urban or rural and census
division location, provider-specific data, and beneficiary hospital data from the bill to
determine the amount payable for each PPS discharge bill.
Pricer uses the Intern-to-Bed ratio in calculating the indirect teaching adjustment for
operating costs for the A/B MAC (A) to accumulate and use in related payments. Pricer
uses the intern-to-average daily census ratio to calculate the indirect teaching adjustment
for capital costs. The A/B MAC (A) ensures that these ratios are available for Pricer to
compute payment for teaching hospitals. It includes the ratios in its PROV file to ensure
that cost outliers are not overpaid to its teaching hospitals.
Pricer does not calculate utilization days required for the PS&R, CWF, or cost report. It
does not determine the amount to pay after deduction for deductible, coinsurance, or the
primary payment where Medicare is secondary. The A/B MAC (A) must calculate the
price and make adjustments to the price furnished before making payment
The A/B MACs (A) use the Pricer implementation guide for information concerning
Pricer processing reports, input parameters and data requirements.
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