How Medicare pays post-acute and other facility claims
Five payment systems sit outside the acute-hospital IPPS. A long-term care hospital (LTCH) is paid per discharge at the LTCH standard federal rate, $52,126.94 for FY2027, with its labor share adjusted by the wage index, times the relative weight of the stay’s MS-LTC-DRG. A stay at or below five-sixths of the DRG’s geometric average length of stay is a short-stay outlier and is paid less. Cases that do not meet the LTCH patient criteria (3+ ICU days in the prior acute stay, or 96+ hours of ventilation) are paid the site-neutral rate: the lower of the IPPS-comparable amount and 100% of estimated cost. This pricer shows the standard rate and lists the site-neutral rate as not modeled. An inpatient rehabilitation facility (IRF) is paid per discharge on its case-mix group (CMG) and comorbidity tier, named by the HIPPS code on the claim’s 0024 line: the FY2027 conversion factor, $19,868, times the CMG’s weight, wage adjusted, then the facility’s rural adjustment (14.9% for a facility in a rural area), low-income (LIP) and teaching adjustments, plus a high-cost outlier payment when the stay’s estimated cost is above the payment plus a fixed-loss amount. An inpatient psychiatric facility (IPF) is paid per day: the per diem base rate, wage adjusted, times the MS-DRG, age, comorbidity, rural and teaching adjustments, times a factor for each day of the stay that starts highest on day 1 and declines.
Hospice is paid per day by level of care: routine home care (a higher rate for the first 60 days of the election), continuous home care (by the hour, at least 8 hours a day), inpatient respite and general inpatient care, each with its labor share adjusted by the wage index, plus an hourly service-intensity add-on for nurse and social worker visits in the last seven days of life. Dialysis facilities are paid per treatment under the ESRD PPS: the CY2026 base rate, $281.71, wage adjusted.
All of the inpatient ones bill type 11x, like an acute hospital. The provider’s CMS certification number (CCN) tells them apart: the last four digits 2000-2299 are an LTCH, 3025-3099 a rehabilitation hospital and 4000-4499 a psychiatric hospital; a T or R in the third place is a rehabilitation unit and an S or M a psychiatric unit. The claim import and batch tools on this site read the CCN and send each claim to its own pricer.
Questions
Where does the IRF CMG come from?
From the patient assessment (the IRF-PAI), reported on the claim as a HIPPS code on revenue line 0024: a tier letter (A no comorbidity tier, B tier 1, C tier 2, D tier 3) and the 4-digit CMG. Enter that code; this pricer does not assign it.
Why does an IRF or IPF price need the CCN and discharge date?
The facility’s wage area, low-income percentage, teaching ratio and cost-to-charge ratio come from its CMS provider record in force on the discharge date. Without a CCN, enter the wage index; the facility adjustments are then left out.
Is the hospice cap applied?
No. The aggregate and inpatient caps are settled per hospice after the cap year ends, not on a claim. The figure is what the claim’s days pay.
What is left out of the ESRD figure?
The patient-level case-mix adjustments, the low-volume and rural facility adjustments, outliers and the training and drug add-ons. The figure is the wage-adjusted base rate per treatment.