Inpatient Hospital Billing Guide - JE Part A
Inpatient Hospital Billing Guide
| Description & Regulation | Inpatient Hospital PPS |
|---|---|
| Implementation Date | Social Security Administration (SSA) Amendment of 1983 |
| Unique Identifying Provider Number Ranges | 3rd digit = 001-0999 |
| Bill Type |
|
| Special Revenue Codes | NA |
| Payment Type | 489 Diagnosis Relation Group (DRG) at time of discharge |
| Payment Calculators | PC Pricer |
| Frequency of Billing | Bill upon discharge or interim billing after 60 days from admission and every 60 days thereafter as adjustment claim. No need to split claims for provider/Medicare FYE or Calendar years |
| Diagnosis Related Grouper (DRG) Adjustments | Changes or adjustments to inpatient hospital claims resulting in a higher-weighted DRG are required within 60 days of remittance date. Once 60 day time limit has expired, claim cannot be corrected either by an adjustment or cancellation and rebilling Changes or adjustments to inpatient hospital claims resulting in a lower-weighted DRG are allowed to be submitted after 60 days of remittance date to repay Medicare overpayment |
| Billing Pre-Entitlement Days | Provider may only bill for days after entitlement if claim exceeds cost outlier if they were not entitled to Medicare upon admission date |
| Benefit Period CMS IOM, Publication 100-02, Benefit Policy Manual, Chapter 3, Section 10 | A period of consecutive days during which medical benefits for covered services, with certain specified maximum limitations, are available to beneficiary. 60 full days of hospitalization plus 30 coinsurance days represent maximum benefit period. When beneficiary has not been in a hospital or SNF for 60 days, period is renewed |
| Benefits Exhaust CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 40.2 | Benefits do not exhaust until all 90 days are used in benefit period and lifetime reserve (LTR) days is at zero Use A3 Occurrence code for last covered day on claim that exhausts benefits |
| Same Day Transfers CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 40.1 | First hospital bills day in non-covered, charges in covered with 40 condition code. Receiving hospital bills claim as usual. Shared DRG would apply |
| 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 |
| Services Provided at Other Facilities During Inpatient Stay | Services provided at other facilities are billed by originating hospital on their claim, charges for any ambulance transports are rolled into cost for service provided since 0540 revenue code isn't allowed on 11x Type of Bill (TOB) |
| 72-hour/24 hour preadmission bundling rule CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 40.3 | All diagnostic services within 72 hours of inpatient admission always have to be bundled into 11x TOB for same provider numbers, Non-diagnostic services are bundled into inpatient admission if exact diagnosis match on admitting diagnosis as outpatient principle diagnosis |
| Same Day Discharge and Readmission CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 40.2.5 | If original discharge and return readmission is related diagnosis then it must be billed on one continuous claim. If return readmission is unrelated diagnosis then both claims can be billed with B4 condition code on second claim |
| Leave of Absence (LOA) 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 |
| Interrupted Stays/LOA CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 150.9.1.2 | NA - Follow LOA policy |
| Outpatient Charges During Interrupted Stay CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 150.9.1.2 | NA - Follow LOA policy |
| Inpatient care no longer needed CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 40.2.2 | Use 31 occurrence code for date beneficiary notified through limitation of liability along with 76 span code and 31 value code |
| Cost Outlier CMS IOM, Publication 100-04, Medicare Claims Processing Manual Chapter 3, Sections 20.1.2, 20.7.4 | Cost outlier day is shown on a claim with a 47 occurrence code.
|
| Lung Volume Reduction Surgery CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 100.7 | Only covered when provided at these approved facilities |
| Ancillary Part B Claims | When beneficiary doesn't qualify under Part A due to entitlement or benefits exhaust, bill on 12x TOB |
