CMS Manual SystemDepartment of Health &Human Services (DHHS)Pub 100-04 Medicare Claims ProcessingCenters for Medicare &Medicaid Services (CMS)Transmittal 1231Date: APRIL 27, 2007Change Request 5474Transmittal 1231, CR 5474, originally sent via RO-4906 and CI-4668, is being recommunicated tochange the Effective Date in the Business Requirements and in the manual instruction to correspondwith the Effective Date on the transmittal page. Originally, the date was October 1, 2007 and thecorrect date is December 3, 2007. All other information remains the same.Subject: The Use of Benefit's Exhaust (BE) Day as the Day of Discharge for Payment Purposes forthe Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) and Clarification ofDischarge for Long Term Care Hospitals (LTCH) and the Allowance of No-Pay Benefits Exhaust Bills(TOB 110)I. SUMMARY OF CHANGES: Under TEFRA, the Provider Statistical and Reimbursement (PS&R)Report used the benefits exhaust date as the discharge date. This changed when the Inpatient PsychiatricFacility Prospective Payment System (IPF PPS) became effective in 2005, and the 'actual' discharge datewas used to define discharge. This Change Request (CR) redefines the policy to use the benefits exhaustdate as the discharge date, and is consistent with the previous methodology. This CR also clarifies that thebenefits exhaust date has always been considered the discharge date for payment purposes under LTCHPPS. It also allows IPFs and LTCHs to bill no-pay bills once benefits exhaust.New / Revised MaterialEffective Date: For discharges/benefits exhaust date on or after December 3, 2007 for IPF andOctober 1, 2002 for LTCHImplementation Date: December 3, 2007Disclaimer for manual changes only: The revision date and transmittal number apply only to reditalicized material. Any other material was previously published and remains unchanged. However, if thisrevision contains a table of contents, you will receive the new/revised information only, and not the entiretable of contents.II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated)R REVISED, N NEW, D 2/Frequency of Billing for ProvidersR1/50.2.1/Inpatient Billing from Hospitals and SNFsR3/Table of ContentsR3/40.2/Determining Covered/Noncovered Days and ChargesR3/188.8.131.52/Interrupted StaysR3/150.13/Billing Requirements Under LTCH PPS
R3/150.17/Benefits ExhaustedR3/150.19/Interim BillingR3/150.23.1/Inputs/Outputs to PricerR3/190.10.1/General RulesR3/190.10.2/Billing PeriodN3/190.12.1/Benefits ExhaustR3/190.17.1/Inputs/Outputs to PRICERIII. FUNDING:No additional funding will be provided by CMS; contractor activities are to be carried out within their FY2007 operating budgets.IV. ATTACHMENTS:Business RequirementsManual Instruction*Unless otherwise specified, the effective date is the date of service.
Attachment - Business RequirementsPub. 100-04Transmittal: 1231Date: April 27, 2007Change Request: 5474Transmittal 1231, CR 5474, originally sent via RO-4906 and CI-4668, is being recommunicated tochange the Effective Date in the Business Requirements and in the manual instruction tocorrespond with the Effective Date on the transmittal page. Originally, the date was October 1,2007 and the correct date is December 3, 2007. All other information remains the same.SUBJECT: The Use of Benefit's Exhaust (BE) Day as the Day of Discharge for Payment Purposesfor the Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) and Clarification ofDischarge for Long Term Care Hospitals (LTCH) and the Allowance of No-Pay Benefits ExhaustBills (TOB 110)Effective Date: For discharges/benefits exhaust date on or after December 3, 2007 for IPF andOctober 1, 2002 for LTCH.Implementation Date: December 3, 2007I.GENERAL INFORMATIONA. Background: In the IPF PPS, claims are currently paid based on the date the beneficiary isphysically discharged rather than on the date benefits are exhausted. In accordance with §1812 of theAct, benefits exhaust occurs when no benefit days remain in the beneficiary’s applicable benefit periodor when the beneficiary has exhausted the 190-day lifetime limit in a psychiatric hospital. Somepsychiatric patients may have longer lengths of stays than the median length of stay of 9 days and theirassociated claims may cross a rate year change and would be paid at the higher rate (i.e., higher ECTrate or outlier). Currently, final bills are not submitted until the patient is officially discharged (i.e.,patient physically leaves the hospital or dies), and when benefits exhaust, type of bills (TOB) 117 aresubmitted with a patient status code of 30 (still an inpatient), also known as continuation bills. Inaddition, psychiatric patients with a long length of stay may not be captured on the applicable ProviderStatistical and Reimbursement (PS&R) report because they have not yet been discharged.In the LTCH PPS, discharge is defined as (1) when the patient is formally released, (2) the patient stopsreceiving Medicare covered long term care services, or (3) the patient dies. Much like IPF PPS,Medicare has been paying claims on the actual discharge date, not the benefits exhaust date if present.B. Policy: Effective for discharges/benefits exhaust date on or after December 3, 2007, for paymentpurposes, an IPF discharge occurs when benefits exhaust. The claim is paid either based on the benefitsexhaust date (if present), rather than the physical discharge date. This is current policy under LTCHPPS, however it was never implemented. This CR allows the following: Benefits exhaust date to substitute for the discharge date (if present) for payment purposes; The PRICER version used will be the one in effect at the time the services were provided; No pay/110 TOBs are allowed once benefits have exhausted, instead of continually adjusting theclaims (117 TOB) until actual physical discharge occurs (new for both IPFs and LTCHs).Under the Tax Equity and Fiscal Responsibility Act (TEFRA), the PS&R report used the benefitsexhaust date as the discharge date. This changed when both the IPF PPS and LTCH PPS wereimplemented, and the 'actual' discharge date was used. This CR redefines the policy and is consistentwith the previous methodology. This will make it easier for contractors to use the PS&R (especially
during the blend period) to settle the cost report as the days stay with the year they occurred. Thischange in policy means:1. Claims will now be settled on the appropriate cost report;2. The appropriate PPS-TEFRA blend percentage will be paid;3. Patients with long lengths of stay will be counted on the correct PS&R report;4. The PRICER version used will be the one in effect at the time the services were provided(i.e., when the Medicare beneficiary had Medicare benefits).II.BUSINESS REQUIREMENTS TABLEUse “Shall" to denote a mandatory requirementNumberRequirement5474.1The Shared System Maintainer (SSM) shall usethe benefits exhaust (Occurrence Code A3, B3,or C3) date to substitute for the ‘actual’discharge date on both IPF (provider numberrange: XX-4XXX- XX-4499, XX-SXXX, andXX-MXXX) and LTCH PPS (provider numberrange XX-2000 – XX-2299) claims whenpresent.The Shared System Maintainer (SSM) shallpass to the Medicare Code Editor, Grouper, andPricer, the benefits exhaust date (if present)instead of the ‘actual’ discharge date so that thecorrect MCE/Grouper/Pricer software programis pulled.The Shared System Maintainer (SSM) shall usethe IPF or LTCH PPS Pricer version in effect atthe time the services occurred (i.e., ‘actual’discharge date or benefits exhaust date ifpresent) to price claims.The Shared System Maintainer (SSM) shallaccept and process no pay claims (110 TOB)for IPF PPS and LTCH PPS, once benefitsexhaust instead of requiring the adjustment ofclaims (117 TOB) until actual discharge occurs.(Note that 117 adjustments are still requiredwhen the beneficiary has benefits and when thepatient is in a noncovered level of care.)Contractors shall return to provider (RTP)Xclaims that meet the benefits exhaust claim5474.25474.2.15474.35474.4Responsibility (place an “X” in eachapplicable column)A D F C D R SharedOTHER/ M I A M H SystemB ER E H MaintainersR R I F M V CICM WM MI CSSSFSA AEC CRXXXXX
Number5474.55474.5.1III.Requirementcriteria to have the provider split the claim.Providers shall add the appropriate diagnosisand/or procedure codes on the applicable claimsbased on the date of service (DOS).The Shared System Maintainer (SSM) shallpass the benefits exhaust date (if present)instead of the ‘actual’ discharge date to the paidclaim file.The PS&R report shall use the benefits exhaustdate (if present) as the discharge date for costreporting purposes for IPF PPS and LTCH PPS.Responsibility (place an “X” in eachapplicable column)A D F C D R SharedOTHER/ M I A M H SystemB ER E H MaintainersR R I F M V CICM WM MI CSSSFSA AEC CRXPS&RPROVIDER EDUCATION TABLENumberRequirement5474.5A provider education article related to thisinstruction will be available y after the CR is released. You willreceive notification of the article release via theestablished "MLN Matters" listserv.Contractors shall post this article, or a directlink to this article, on their Web site and includeinformation about it in a listserv message within1 week of the availability of the providereducation article. In addition, the providereducation article shall be included in your nextregularly scheduled bulletin. Contractors arefree to supplement MLN Matters articles withlocalized information that would benefit theirprovider community in billing andadministering the Medicare program correctly.Responsibility (place an “X” in eachapplicable column)A D F C D R SharedOTHER/ M I A M H SystemB ER E H MaintainersR R I F M V CM MI CI C M WA AES S S FC CRSXX
IV.SUPPORTING INFORMATIONA. For any recommendations and supporting information associated with listed requirements, usethe box below:Use "Should" to denote a ecommendations or other supporting information:Example: A provider submits a claim with dates of service 09/25/07-10/05/07. In goodfaith the provider did not know that benefits would exhaust on the claim and used theappropriate diagnosis and procedure codes valid on and after 10/01/07 (the MCE effectivedate for this claim). The claim goes to CWF and benefits are exhausted on 09/28/07. Adiagnosis code that is valid for that claim on 10/01/07 is not valid for the prior MCE,which in this case was 10/01/06. FISS will edit the claim and suspend with an MCE error.The FI’s should RTP to have the provider split bill. The first claim should be a 112 withDOS 9/25/07 through 9/28/07 with a patient status 30. The next and final claim should bea 110 with dates of service 09/29/07 through 10/05/07, with the appropriate dischargepatient status. Providers should resubmit the split claims with the appropriate diagnosisand procedure codes based on dates of service.Note: This policy has been effective for LTCH since implementation of LTCH PPS,October 1, 2002.B. For all other recommendations and supporting information, use this space: N\AV. CONTACTSPre-Implementation Contact(s):Policy: IPF-Dorothy Colbert at (410) 786-9671, LTCH-Judy Richter at (410) 786-2590Claims Processing: Valeri Ritter at [email protected] or (410)786-8652Post-Implementation Contact(s): Regional OfficeVI. FUNDINGA. TITLE XVIII Contractors:No additional funding will be provided by CMS; contractor activities are to be carried out within theirFY 2007 operating budgets.B. Medicare Administrative Contractors:The contractor is hereby advised that this constitutes technical direction as defined in your contract.CMS does not construe this as a change to the Statement of Work (SOW). The contractor is notobligated to incur costs in excess of the amounts specified in your contract unless and until specificallyauthorized by the contracting officer. If the contractor considers anything provided, as described above,to be outside the current scope of work, the contractor shall withhold performance on the part(s) inquestion and immediately notify the contracting officer, in writing or by e-mail, and request formaldirections regarding continued performance requirements.
50.2 - Frequency of Billing for Providers(Rev. 1231; Issued: 04-27-07; Effective: 12-03-07; Implementation: 12-03-07)Different types of providers are paid based on different payment policies depending uponthe circumstance of the provider. These payment policies are described in detail in thechapters related to the provider type. The following billing requirements are to strike abalance between program administration efficiency and maintaining cash flow forproviders.Standard System Maintainer (SSM) shall ensure that providers adhere to theserequirements.50.2.1 – Inpatient Billing From Hospitals and SNFs(Rev. 1231; Issued: 04-27-07; Effective: 12-03-07; Implementation: 12-03-07)Non PPS Hospitals and SNFsInpatient services in TEFRA hospitals (i.e., hospitals excluded from inpatient prospectivepayment system (PPS), cancer and children’s hospitals) and SNFs are billed: Upon discharge of the beneficiary;When the beneficiary’ benefits are exhausted;When the beneficiary’s need for care changes; orOn a monthly basis.Hospitals in Maryland that are under the jurisdiction of the Health Services Cost ReviewCommission are subject to monthly billing cycles.Providers shall submit a bill to the FI when a beneficiary in a SNF ceases to need activecare (occurrence code 22), or a beneficiary in one of these hospitals ceases to needhospital level care (occurrence code 22). FIs shall not separate the occurrence code 31and occurrence span code 76 on two different bills. Each bill must include all applicablediagnoses and procedures. However, interim bills are not to include charges billed on anearlier claim since the “From” date on the bill must be the day after the “Thru” date onthe earlier bill.SNF providers shall follow the billing instructions provided in Chapter 6 (SNF InpatientPart A Billing), Section 40.8 (Billing in Benefits Exhaust and No-Payment Situations) forproper billing in benefits exhaust and no-payment situations.PPS HospitalsInpatient acute-care PPS hospitals, inpatient rehabilitation facilities (IRFs), long termcare hospitals (LTCHs) and inpatient psychiatric facilities (IPFs) may interim bill in at
least 60-day intervals. Subsequent bills must be in the adjustment bill format. Each billmust include all applicable diagnoses and procedures.Initial inpatient acute care PPS hospital, IRF, IPF and LTCH interim claims must have apatient status code of 30 (still patient). When processing interim PPS hospital bills,providers use the bill designation of 112 (interim bill - first claim). Upon receipt of asubsequent bill, the FI must cancel the prior bill and replace it with one of the followingbill designations: For subsequent interim bills, bill type 117 with a patient status of 30 (still patient);or For subsequent discharge bills, bill type 117 with a patient status of one of thefollowing:01 - Discharged to home or self care;02 - Discharged/transferred to another short-term general hospital;03 - Discharged/transferred to SNF;04 - Discharged/transferred to an ICF;05 - Discharged/transferred to a non-Medicare PPS children’s hospital or non-MedicarePPS cancer hospital for inpatient care;06 - Discharged/transferred to home under care of an organized home health serviceorganization;07 - Left against medical advice;08 - Discharged/transferred to home under care of a home IV drug therapy provider;09 - Admitted as an inpatient to this hospital;20 - Expired (or did not recover - Religious Non-Medical Healthcare Institution patient);43 - Discharged/transferred to a Federal hospital (effective for discharges on and afterOctober 1, 2003);50 - Discharged/transferred to Hospice - home51 - Discharged/transferred to Hospice - medical facility61 - Discharged/transferred within this institution to a hospital-based Medicare approvedswing bed.
62 - Discharged/transferred to an inpatient rehabilitation facility including distinct partunits of a hospital63 - Discharged/transferred to long term care hospitals64 - Discharged/transferred to a nursing facility certified under Medicaid but not certifiedunder Medicare65 - Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of ahospital (effective April 1, 2004)66- Discharged/transferred to a critical access hospital (CAH)71 - Discharged/transferred/referred to another institution for outpatient services asspecified by the discharge plan of care (deleted October 1, 2003)72 - Discharged/transferred/referred to this institution for outpatient services as specifiedby the discharge plan of care (deleted October 1, 2003)All inpatient providers must submit bills when any of the following occur, regardless ofthe date of the prior bill (if any): Benefits are exhausted;The beneficiary ceases to need a hospital level of care (all hospitals);The beneficiary falls below a skilled level of care (SNFs and hospital swing beds;orThe beneficiary is discharged.Effective December 3, 2007, when a beneficiary’s Medicare benefits exhaust in an IPF oran LTCH, the hospital is allowed to submit a no pay bill (TOB 110) with a patient statuscode 30 in 60 day increments until discharge. They no longer have to continually adjustbills until physical discharge or death. The last bill shall contain a discharge patientstatus code.These instructions for hospitals and SNFs apply to all providers, including thosereceiving Periodic Interim Payments (PIP).
Medicare Claims Processing ManualChapter 3 - Inpatient Hospital BillingTable of Contents(Rev. 1231, 04-27-07)190.12.1 - Benefits Exhaust
40.2 - Determining Covered/Noncovered Days and Charges(Rev. 1231; Issued: 04-27-07; Effective: 12-03-07; Implementation: 12-03-07)The CMS must record a day or charge as either covered or noncovered because of thefollowing:Beneficiary utilization is recorded based upon days during which the patient receivedhospital or SNF accommodations, including days paid by Medicare and days for whichthe provider was held liable for reasons other than medical necessity or custodial care.Days denied as not medically necessary or as custodial care are not charged against abeneficiary's utilization record when the provider is determined to be liable.The provider may claim credit on its cost report only for covered accommodations, daysand charges for which actual payment is made, i.e., provider liable days and charges arenot included. Data from the bill payment process are used in preparing the cost report.The number of days and charges provided to the Pricer program affects the day and costoutlier determinations and the DRG payment amount. Non-PPS provider days areexcluded from Pricer consideration.It is possible to use a different number of days on a single bill for each of the abovepurposes, although the same number of days will generally apply in actual practice. Forexample, if the beneficiary had at least 1 day of eligibility remaining at admission, daysthat occur after benefits are exhausted up through the day outlier threshold for theapplicable DRG are counted for cost reporting purposes under IPPS (see section190.12.1for IPF and section 150.17 for LTCH benefits exhaust claims processing).A. General Rule on Counting of DaysThese following are general rules for counting days. However, these rules are alsosubject to special rules for determining day of admission, discharge, death, beginning aleave of absence, same day transfer, guarantee of payment days, provider liability issuesand outlier days for PPS outliers. See §40.1 and §40.1.G for an explanation of thesespecial rules.The provider calculates and enters on the bill the number of claimable Medicare patientdays on the cost report. (Medicare patient days always