Monday, 14 August 2017

Hospitals That Do Not Charge

Participating hospitals that do not charge individuals and also meet the exceptions to the law that normally exclude payment for expenses paid for directly or indirectly by a governmental entity, may be reimbursed the reasonable cost of furnishing covered services to Medicare beneficiaries. The following special procedures apply to their bills. 

Computing Medicare Billing Rate 

The Medicare billing rate per day is determined by the following equation:

Total allowable inpatient cost = cost per day per patient

Total inpatient days

Thus, the billing rate that appears is the average inpatient cost per day per inpatient as calculated from entries on the latest cost settlement report approved by Medicare. Where this is the provider's first year in the program, the A/B MAC (A) determines this rate based on the provider's books and records the appropriate billing rate for services rendered to Medicare beneficiaries.

Computing Medicare Billing Rate (Inpatient) 

The Medicare billing rate is determined in the following manner:

Total available inpatient cost = Cost per day per patient

Total inpatient days 

The A/B MAC (A) multiplies the cost per day per patient by 93 percent for short-term hospitals and by 98 percent for long-term hospitals.  Then it applies the following fixed percentages. The result is the Medicare billing rate.  

Saturday, 5 August 2017


Revenue Codes - Codes that identify the accommodations furnished, ancillary services provided or billing calculation are entered in this field. The code indicates whether the rate includes charges for ancillary services or only room and board.

If the patient was furnished more than one type of accommodation, the loops or lines for each type of accommodation are completed. This is necessary whether or not the provider charges an all-inclusive rate according to accommodations.

Where the all-inclusive rate varies with the type of accommodation, the Remarks field is annotated for a five-or-more bed accommodation showing the reason for the accommodation.

Unit of Service - A quantitative measure for services furnished, by revenue category, to or for the patient which includes items such as the number of accommodation days, pints of blood, or renal dialysis treatments, is entered.

Total Charges - The total charges pertaining to the related revenue code for the current billing period is entered.

Noncovered Charges - The total non-covered charges pertaining to the related revenue code for the current billing period is entered.

Ancillary Services
One All-Inclusive Charge Rate - Hospitals with one all-inclusive charge rate, including ancillary services, are reflected in the revenue code. The total charge reflects the charge for both accommodations and ancillary services.

Separate Ancillary All-Inclusive Rate - Some providers segregate charges for ancillary services for billing purposes. Where a separate flat rate charge for ancillary services is incurred either on a daily or total stay basis, the provider enters separate codes for the services. These codes indicate whether the total charge includes only ancillary cost or includes other costs (i.e., blood).
If applicable, the following additional billing instructions are applied:
• Blood
Whenever whole blood is furnished the patient, value codes and amounts are completed. If the all-inclusive rate does not include the charge for whole blood or packed cells, revenue codes, rates, service dates, units, and total charges are completed in the same way a provider not using all-inclusive rates would complete them. When the provider discounts its customary charges for unreplaced blood to which the deductible is applicable, it shows the charges before the discount.

Monday, 31 July 2017

Swing-Bed Services

Swing-bed services must be billed separately from inpatient hospital services. Swing-bed hospitals use one provider number when billing for hospital services to identify hospital swing-bed SNF bills. The following alpha letters identify hospital swing-bed SNF bills (for CMS use only, effective May 23, 2007, providers are required to submit only their NPI. NOTE: The swing-bed NPI will be mapped to the 6-digit alpha-numeric legacy (OSCAR) number.):

"U" = short-term/acute care hospital swing-bed;
 "W" = long-term hospital swing-bed;
 "Y" = rehabilitation hospital swing-bed; and
 ”Z”=CAH swing-bed.

A. - Inpatient Hospital Services in a Swing-Bed
The patient status code of 03 is inserted on the claim when the beneficiary swings from acute to SNF level of care. (This constitutes a discharge for purposes of Medicare payment for inpatient hospital services under PPS.) The A/B MAC (A) indicates in the Statement Covers Through Date the last day of care at the hospital level.

If the beneficiary is discharged from a Medicare swing bed and remains in the hospital, there is no need for a no-pay bill. However, if a beneficiary continues to receive care after completing their stay in a SNF swing bed, in a NF swing bed, the hospital must submit covered claims to Medicare.

B. - SNF Services in a Swing-Bed
• The date of admission on the swing-bed SNF bill is the date the patient began to receive SNF level of care services;
• State level agreements may call for varying types of bill coding Type of Bill. The CMS does not perform edits on type of bill coding on bills with 8 in the 2nd digit (bill classification), in FL 18 of the CWF inpatient record if the record is identified in FL 1 as hospital or SNF. Therefore, the A/B MAC (A) accepts, with subsequent conversion, any bill type agreed to at the State level to identify swing-bed billing, i.e., 18X or 21X. It must be sure the record identification of CWF FL 1 is consistent with the provider number shown.

Wednesday, 26 July 2017

Additional edits

The A/B MAC (A) must perform the following additional edits and investigate adjustment requests the provider submits:
• A full denial once the bill is paid, except to accomplish retraction of a duplicate payment; 
• A change in DRG based on a change in age or sex; 
• A change in deductible; 
• An adjustment request that changes a previously submitted QIO adjustment request; 
• An adjustment of a bill due to a change in utilization or spell data on another bill; 
• A reopening to change a no-payment bill to a payment bill;
• A reopening to pay a previously denied line item; 
• An adjustment request the provider initiates with a claim change reason code equal to D7, with the Medicare payment amount equal to or greater that the previously paid amount; or 
• An adjustment request with a claim change reason code equal to E0, and the claim is for a PPS provider. The A/B MAC (A) must investigate if the change is from patient status 02, transferred to another acute care facility.

Late Charges
Providers billing under Inpatient Hospital PPS, Outpatient PPS, SNF PPS, or HHA PPS may not bill late charges, nor will the contractor accept such bills, for any type of PPS service, inpatient or outpatient. Charges omitted from the original bill must be submitted on an adjustment bill that contains all pertinent charges including those billed earlier. When the provider submits late charges on bills to the A/B MAC (A) as bill type XX5, these bills contain only additional charges. Adjustment requests and not late charge bills should be submitted for

• Services on the same day as outpatient surgery subject to the ASC limit, 
• ESRD services paid under the composite rate, 
• All inpatient accommodation charges, and 
• All inpatient PPS ancillaries as adjustment requests 

The provider may submit the following charges omitted from the original paid bill to the A/B MAC (A) as late charges:

• Any outpatient services other than the exceptions stated in this paragraph. This includes late charges for HHA services under either Part A or Part B, hospice services, hospital outpatient services except those on the day of ambulatory surgery subject to the ASC payment limitation, RHC services, OPT services, SNF outpatient services, CORF services, FQHC services, CHMC services, and ESRD services not included in the composite rate; and
• Any inpatient SNF ancillaries or inpatient hospital ancillaries other than from PPS hospitals. The hospital may not submit late charges (XX5) for inpatient accommodations. The hospital must submit these as adjustments (bill type XX7).

The A/B MAC (A) has the capability to accept XX5 bill types electronically and process them as initial bills except as described in the following paragraph. 
The A/B MAC (A) also performs the following edit routines on any XX5 type bills received:
• Pass all initial bill edits, including duplicate checks. 
• Must not be for any of: Inpatient PPS ancillaries, inpatient accommodations in any facility, services on the same day as outpatient surgery subject to the ASC payment limitation, or ESRD services included in the composite rate. These are rejected back to the hospital with the message, “This change requires an XX7 debit-only or XX8 cancel-only request from you. Late charges are not acceptable for inpatient PPS ancillaries, inpatient accommodations in any facility, services on the same day as outpatient surgery subject to the ASC payment limitation, or ESRD services included in the composite rate.” 
• When an XX5 suspends as a duplicate, (dates of service equal or overlapping, provider ID equal, HICNs equal, and patient surname equal), the A/B MAC (A) must determine the status of the original paid bill. If it is denied, the A/B MAC (A) must deny the late charge bill. 
• If an xx5 does not suspend as a potential duplicate, the A/B MAC (A) rejects it back to the provider with the message, “No original bill paid. Please combine and submit a single original bill (XX1).” 
• If the original bill was approved and paid, the A/B MAC (A) compares the revenue codes on the original paid bill with the associated late charge bill:
° For all providers (any bill type), if any are the same, and are revenue codes 041x, 042x, 043x, 044x, 063x, 076x, or 091x, the A/B MAC (A) or (HHH) rejects the bill back to the provider with the message, “You must submit an adjustment (7) to the original paid bill. Revenue codes subject to utilization review are duplicated on the late charge bill.” 
° For HHAs (bill type 32X, 33X, or 34X), the A/B MAC (HHH) must apply the same logic for the following additional revenue codes. If any are the same and are revenue codes 0291, 0293, 055x, 056x, 057x, 058x, 059x, 060x, 066x, the A/B MAC (HHH) rejects the bill back to the provider with the message, "You must submit an adjustment (xx7) to the original paid bill. Revenue codes subject to utilization review are duplicated on the late charge bill." 

Friday, 21 July 2017

Claim Change Reasons

Claim Change Reason Codes

The provider submits one of the following claim change reason codes to its A/B MAC (A) with each debit-only or cancel-only adjustment request:

Bill Type
Reason Code
D0 (zero)
Change to service dates
Change in charges
Change in revenue codes/HCPCS
Second or subsequent interim PPS bill - inpatient only
Change in GROUPER input (diagnoses or procedures) - inpatient only
Cancel-only to correct a HICN or provider identification number
Cancel-only to repay a duplicate payment or OIG overpayment (includes cancellation of an outpatient bill containing services required to be included on the inpatient bill.)
Change to make Medicare the secondary payer
Change to make Medicare the primary payer
Any other change
E0 (zero)
Change in patient status

The provider may not submit more than one claim change reason code per adjustment request. It must choose the single reason that best describes the adjustment it is requesting. It should use claim change reason code D1 only when the charges are the only change on the claim. Other claim change reasons frequently change charges, but the provider may not "add" reason code D1 when this occurs.

The claim change reason code is entered as a condition code on the ASC X12 837 institutional claim format or on the hard copy Form CMS-1450 For reason codes D0-D4 and D7-D9, submit a debit-only adjustment request, bill type XX7. For reason codes D5 and D6, submit a cancel-only adjustment request, bill type XX8.

Edits on Claim Change Reason Codes
The following edits are based on the claim change reason code. The A/B MAC (A) must apply them to each incoming adjustment request.

• If the type of bill is equal to XX7 and the claim change reason code is not equal to D0-D4, D7-D9, or E0, the A/B MAC (A) rejects the request back to the provider with the following error message, "Claim change reason code must be present and equal to D0-D4, D7-D9, or E0 for a debit-only adjustment request."
• If the type of bill is equal to XX8 and the claim change reason code is not equal to D5-D6, the A/B MAC (A) rejects the request back to the provider with the following error message, "Claim change reason code must be present and equal to D5-D6 for a cancel-only adjustment request." 
• If the type of bill is equal to XX7 or XX8 and the ICN/DCN of the claim being adjusted is not present, the A/B MAC (A) rejects the request back to the provider with the following message, "ICN/DCN of the claim being adjusted is required for an adjustment request."

Sunday, 16 July 2017

Adjustment Bills Involving Time Limitation for Filing Claims

If a provider fails to include a particular item or service on its initial bill, an adjustment bill(s) to include such an item(s) or service(s) is not permitted after the expiration of the time limitation for filing a claim. However, to the extent that an adjustment bill otherwise corrects or supplements information previously submitted on a timely claim about specified services or items furnished to a specified individual, it is subject to the rules governing administrative finality, rather than the time limitation for filing.

Under prospective payment, adjustment requests are required from the hospital where errors occur in diagnoses and procedure coding that change the DRG, or where the deductible or utilization is affected. A hospital is allowed 60 days from the date of the A/B MAC (A) payment notice for adjustment bills where diagnostic or procedure coding was in error. Adjustments reported by the QIO have no corresponding time limit and are adjusted automatically by the A/B MAC (A) without requiring the hospital to submit an adjustment bill. However, if diagnostic and procedure coding errors have no effect on the DRG, adjustment bills are not required.

Under PPS, for long-stay cases, hospitals may bill 60 days after an admission and every 60 days thereafter if they choose. The A/B MAC (A) processes the initial bill through Grouper and Pricer. The provider must submit an adjustment to cancel the original interim bill(s) and rebill the stay from the admission date through the discharge date. When the adjustment bill is received, it processes it as an adjustment. In this case, the 60- day requirement for correction does not apply.

Where payment is handled through cost reporting and settlement processes, the provider accumulates a log for those items not requiring an adjustment bill. Maryland inpatient hospital providers also keep a log of late charges when the amount is under $500. They submit the log with their cost reports. After cost reports are filed, the A/B MAC (A) makes a lump sum payment to cover these charges as shown on the summary log. The provider uses the summary log for late charges only under cost settlement (outpatient hospital), except in Maryland.

Tuesday, 11 July 2017

General Rules for Submitting Adjustment Requests

Adjustment requests that only recoup or cancel a prior payment are "credits" and must match the original in the following fields:
• A/B MAC (A) control number (ICN/DCN); 
• Surname; 

When a definite match cannot be made on the 3 fields above, the provider's A/B MAC (A) will use the fields below as needed. Note that for older claims, ICN/DCN probably will not match.
• Date of birth; 
• Admission date (Start of Care Date for Home Health), unless changed by this adjustment requests; and 
• From/thru dates (Date of First Visit/Date of Last Visit for Home Health), unless changed by this adjustment request.

Cancel-only adjustment requests must be submitted only in cases of incorrect provider identification numbers and incorrect HICNs. After the cancel-only request for the incorrect bill is resolved, the provider must submit correct information as a new bill.

The provider must submit all other adjustment requests as debits only. It shows the ICN/DCN of the bill to be adjusted as described above, with the bill type shown as XX7. It submits adjustment requests to its A/B MAC (A) either electronically or on hard copy. Electronic submission is preferred.

The A/B MAC (A) prepares an adjustment if instructed by CO or RO to make a change. Typically, the A/B MAC (A) receives such direction from CMS when it decides to retroactively change payment for a class or other group of bills. Occasionally, CMS will discover an error in the processing of a single bill and direct the A/B MAC (A) to correct it.

If the A/B MAC (A) furnished the A/B MAC (B) a copy of the original bill which is being adjusted, it must furnish them a copy of the adjusted bill.

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