Inpatient CAH Billing Guide - JE Part A
Inpatient CAH Billing Guide
Unique Identifying Provider Number Ranges
3rd and 4th digits = 13
Bill Type
CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 1
- 111 - Admit to discharge
- 112 - 1st sequential
- 117 - Adjustment or Interim
- 118 - Cancel
- 110 - No payment
See Bill Types
Professional Services
All professional fees for inpatient services are billed on the CMS-1500 Claim Form to Part B.
See below requirements for Certified Registered Nurse Anesthetist (CRNA) pass-through exemption.
CRNA Services
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 100.2
CAHs qualifying for Rural Hospital Certified Registered Nurse Anesthetist (CRNA) Pass-through Exemption may include CRNA professional fees on inpatient facility claims only if the CRNA is not included in Method II outpatient reimbursement. CRNA charges are reported with revenue code 0964, separate from anesthesia and supplies.
Pre-admission Bundling
CMS IOM, Publication 100-4, Medicare Claims Processing Manual, Chapter 3, Section 40.3B
Applies only when a patient receives outpatient services at a CAH that is wholly owned or operated by an IPPS hospital and is admitted as an inpatient to that IPPS hospital, either on the same day or within 3 days immediately following the day of those outpatient services.
All outpatient charges not related to the above paragraph are billed on 85x or 14x TOB separate from inpatient claim.
Emergency room, observation services, and all ancillary services rendered prior to admission cannot be included on the inpatient claim. Report each item or service on the line item on the outpatient UB-04 claim form.
Services Provided at Other Facilities During Inpatient Stay
Services provided at other facilities are billed by the originating hospital on their claim, the charges for any ambulance transports are rolled into the cost for the service provided since the 0540 revenue code isn't allowed on the 11x type of bill (TOB).
Reimbursement
- Interim payment =
- Charges × interim rate
- Subtract applicable deductible and coinsurance
Fully cost reimbursed upon cost report settlement
Payment Type
101% of Reasonable cost for facility charges
Frequency of Billing
Upon discharge
Exempt Units
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 30.1
10 bed maximum per unit
Paid under Prospective Payment System (PPS):
- Inpatient Psychiatric Facility (IPF)
- Inpatient Rehabilitation Facility (IRF)
Length of Stay
Maximum 96 hours - annual average
Physician must certify patient is reasonably expected to be discharged or transferred within 96 hours after admission to CAH
Benefit Period
Benefits Exhaust
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 40.2.2
Benefits do not exhaust until all 90 days are used in the benefit period and LTR days is at zero.
Use the A3 occurrence code for the last covered day on the claim that exhausts benefits.
Leave of Absence Days
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 40.2.6
Show days in non-covered, 74 occurrence span code and 180 revenue code.
Provider Liable Days
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 40.1
If provider liable days are for other than medical necessity or custodial care use 77 occurrence span code.
Same Day Transfers
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 40.1
Bill day as non-covered, charges in covered, patient status of transfer and 40 condition code.
Same Day Discharge & Readmission
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 40.2.5
If the original discharge and return readmission is for a related diagnosis then it needs to be billed on 1 continuous claim. If the return readmission has an unrelated diagnosis then both claims can be billed and the 2nd claim will need the B4 condition code listed.
Inpatient Care No Longer Needed
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 40.2.2
Use the 31 occurrence code for date beneficiary notified through limitation of liability waiver along with 76 span code and 31 value code.
Ancillary Part B Claims
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 240
Billed on 12x TOB when beneficiary doesn't qualify under Part A due to lack of entitlement, benefits exhausted or inpatient stay not medically necessary. Room and board are not allowed to be billed on the 12x TOB.
