Inpatient PPS Billing for Cost Outlier

Inpatient Prospective Payment System (IPPS) claims with facility type inpatient hospital or inpatient rehabilitation may end up receiving cost outlier reimbursement if the claim has exceeded cost outlier threshold. For claims that exceed the cost outlier threshold providers are required to supply that information on the claim.

A beneficiary does not exhaust benefits until they have used all their full, co-insurance and Lifetime Reserve (LTR/LRD) days. After all of these have been used, providers may reflect the A3 occurrence code on the claim to show benefits exhaust.

The below IPPS Outlier tool was developed based on scenarios encountered by the Noridian Provider Contact Center and are subject to change.

Choose the scenario that applies to the beneficiary upon the admission date.

      

Does the beneficiary have enough full and/or coinsurance days to cover the entire stay?

   

Do bill:

  • Fully covered claim using the correct number of full and/or coinsurance days to cover the entire stay
  • Value Code 80 for covered days
  • Value Code 82 for coinsurance days
    • Value Code 09 and/or 11 for coinsurance amounts

Do not bill:

  • Occurrence Code 47

See the CMS example, "Full And Coinsurance Days Cover Cost Outlier," found in SE1310, Example 6.

Is a cost outlier met for the claim?

   
 
How to determine the cost Outlier amount.

The first and preferred method is to use the cost outlier threshold amount returned with the remittance advice, other notice of claims returned to the provider or Direct Data Entry (DDE) claims correction screen for bills submitted after systems changes have been made to provide this amount.

The second way is to use the instructions provided at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PCPricer/Downloads/Updated-PCPricer-Download-Instructions.pdf to download PC Pricer and calculate the amount based on data from the claim.

Include only your covered charges in the calculation. Calculate the outlier, then select Yes or No.

Does the beneficiary exhaust all of their full and/or coinsurance days before the cost outlier threshold is met?

   

Do bill:

  • Covered claim using the correct number of full and/or coinsurance days
  • Occurrence Span Code 70 for remainder of stay (non-utilization/inlier days)
    • Occurrence Span Code 70 begins the day after the last full and/or coinsurance day through the day before discharge
    • Associated days are non-covered (Value Code 81)
    • Associated units and charges on room and board revenue codes are covered
  • Value Code 80 for covered days
  • Value Code 82 for coinsurance days
    • Value Code 09 and/or 11 for coinsurance amounts

See the CMS example, "No Cost Outlier, Coinsurance Days available and Exhaust prior to discharge," found in the Medicare Claims Processing Manual, Chapter 3, Section 40, Example 2.

Does the beneficiary have LTR days available and do they elect to use them?

   

Does the beneficiary have LTR days available and do they elect to use them?

   

Does the beneficiary exhaust all their LTR days before they are discharged?

   

Do bill:

  • Covered claim using the correct number of full and/or coinsurance days
  • Condition Code 67 if beneficiary does not elect to use available LTR days
    • Not needed if there are no LTR days available
  • Occurrence Code A3 with the date of the last non-utilization/inlier day
    • After the A3 date, bill remainder of days, units and charges as non-covered for exhaust
  • Occurrence Code 47 with the date the claim began the outlier payment (the day after the outlier threshold is met)
  • Occurrence Span Code 70 (non-utilization/inlier day)
    • Occurrence Span Code 70 begins the day after the last coinsurance day through the day before the outlier payment would have begun
    • Associated days are added to any other non-covered days (Value code 81)
    • Associated units and charges on room and board revenue codes are covered
      • Covered charges must match the outlier threshold amount
  • Value Code 80 for covered days
  • Value Code 82 for coinsurance days
    • Value Code 09 and/or 11 for coinsurance amounts

Note: providers may not submit a 12X Type of Bill (TOB) claim for Medicare-covered ancillary services after the benefits exhaust.

See the CMS example, "Coinsurance Days Exhaust Prior to Cost Outlier and No LTR Days Are Available," found in the Medicare Claims Processing Manual, Chapter 3, Section 20.7.4, Example 4.

Do bill:

  • Covered claim using the correct number of full and/or coinsurance days and LTR days
  • Condition Code 68 for beneficiary's election to use LTR days
  • Occurrence Code A3 with the date of the last LTR day (benefits exhaust date)
    • After A3 date, bill remainder of days, units and charges as non-covered
  • Occurrence Code 47 with the date the claim began the outlier payment (the day after the outlier threshold is met)
  • Occurrence Span Code 70 (non-utilization/inlier days)
    • Occurrence Span Code 70 begins the day after the last coinsurance day through day before outlier began
    • Associated days are non-covered (Value Code 81)
    • Associated units and charges on room and board revenue codes are covered
  • Value Code 80 for covered days
    • Including available full and/or coinsurance days and utilized LTR days
  • Value Code 81 for non-covered days
    • Includes non-utilization/inlier days and exhaust days
  • Value Code 82 for coinsurance days
    • Value Code 09 and/or 11 for coinsurance amounts
  • Value Code 83 for LTR days
    • Value Code 08 and/or 10 for LTR amounts
  • All units and charges on room and board revenue codes, associated with exhaust days are in non-covered

Note: providers may submit a 12X Type of Bill (TOB) claim for Medicare-covered ancillary services after the benefits exhaust.

See the CMS example, "Coinsurance Days Exhaust Prior to Cost Outlier. LTR Days Exhausts," found in the Medicare Claims Processing Manual, Chapter 3, Section 20.7.4, Example 5.

Do bill:

  • Covered claim using the correct number of full and/or coinsurance days
  • Condition Code 68 for beneficiary's election to use LTR days
  • Occurrence Code 47 with the date the claim began the outlier payment (the day after the outlier threshold is met)
  • Occurrence Span Code 70 (non-utilization/inlier day)
    • Occurrence Span Code 70 begins the day after the last coinsurance day is used through the day before the outlier payment starts
    • Associated days are non-covered (Value Code 81)
    • Associated units and charges on room and board revenue codes are covered
  • Value Code 80 for covered days
  • Value Code 82 for coinsurance days
    • Value Code 09 and/or 11 for coinsurance amounts
  • Value Code 83 for LTR days
    • Value Code 08 and/or 10 for LTR amounts
  • Remainder of stay is billed with covered days, units and charges, using LTR days

Does the beneficiary have enough LTR days for the remainder of the stay?

   

Do bill:

  • Covered claim using the correct number of full and/or coinsurance days
  • Condition Code 67 if beneficiary does not elect to use available LTR days
    • Not needed if there are no LTR days available
  • Occurrence Code A3 with the date of the last coinsurance day
    • Bill remainder of days, units and charges as non-covered for exhaust
  • Occurrence Code 47 with the date the claim began the outlier payment (the day after the outlier threshold is met)
  • Value Code 80 for covered days
  • Value Code 81 for non-covered days
  • Value Code 82 for coinsurance days
    • Value Code 09 and/or 11 for coinsurance amounts

Do bill:

  • Fully covered claim using the correct number of full, coinsurance and LTR days available
  • Condition Code 68 for beneficiary's election to use LTR days
  • Occurrence Code 47 with the date the claim began the outlier payment (the day after the outlier threshold is met)
  • Value Code 80 for covered days
  • Value Code 82 for coinsurance
    • Value Code 09 and/or 11 for coinsurance amounts
  • Value Code 83 for LTR days
    • Value Code 08 and/or 10 for LTR amounts

Do bill:

  • Covered claim using the correct number of full, coinsurance and LTR days available
    • Occurrence Code 47 with the date the claim began the outlier payment (the day after the outlier threshold is met)
  • Condition Code 68 for beneficiary's election to use LTR days
  • Occurrence Code A3 with the date of the last LTR day
    • After A3 date, bill remainder of days, units and charges as non-covered
  • Value Code 80 for covered days
    • Full, coinsurance and LTR days
  • Value Code 81 for non-covered days
  • Value Code 82 for coinsurance days
    • Value Code 09 and/or 11 for coinsurance amounts
  • Value Code 83 for LTR days
    • Value Code 08 and/or 10 for LTR amounts

Note: providers may submit a 12X Type of Bill (TOB) claim for Medicare covered ancillary services after the benefits exhaust.

See the CMS example, "Coinsurance Days and LTR Days Exhaust in the Cost Outlier," found in the Medicare Claims Processing Manual, Chapter 3, Section 20.7.4, Example 7.

Do bill:

  • Fully non-covered claim for benefits exhaust
  • Type of Bill 110
  • Value Code 81 with all days as non-covered
  • All units and charges on all revenue codes as non-covered
  • Enter remarks stating, "Billing for benefits exhaust."

Do not bill:

  • Condition Code 21
  • Occurrence Span Code, such as 74 or 76
  • Occurrence Span Code M1, unless self-audited

This is an example of full benefits exhaust.

Note: you may submit a 12X Type of Bill (TOB) claim for Medicare covered ancillary services after the benefits exhaust.

Does the beneficiary elect to use LTR days?

   

Does the beneficiary have enough LTR days to cover the entire stay?

   

Do bill:

  • Fully non-covered claim for benefits exhaust
  • Type of Bill 110
  • Condition Code 67 for beneficiary not electing to use LTR days
  • Value Code 81 with all days as non-covered
  • All units and charges on all revenue codes as non-covered
  • Enter remarks stating, "Billing for benefits exhaust. Beneficiary elects not to use LTR days."

Do not bill:

  • Occurrence Span Code, such as 74 or 76
  • Occurrence Span Code M1, unless self-audited

Note: providers may submit a 12X Type of Bill (TOB) claim for Medicare-covered ancillary services after the benefits exhaust.

Because the beneficiary elects not to use LTR days, this is an example of full benefits exhaust.

Do bill:

  • Fully covered claim using LTR days for entire claim
  • Condition Code 68 for beneficiary's election to use LTR days
  • Value Code 80 for covered days
  • Value Code 83 for LTR days
    • Value Codes 08 and/or 10 for LTR amounts

Do not bill:

  • Occurrence Code 47

See the CMS example, "LTR Days Cover Cost Outlier," found in the Medicare Claims Processing Manual, Chapter 3, Section 20.7.4. Example 1.

Is a cost outlier met for the claim?

   
 
How to determine the cost Outlier amount.

The first and preferred method is to use the cost outlier threshold amount returned with the remittance advice, other notice of claims returned to the provider or Direct Data Entry (DDE) claims correction screen for bills submitted after systems changes have been made to provide this amount.

The second way is to use the instructions provided at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PCPricer/Downloads/Updated-PCPricer-Download-Instructions.pdf to download PC Pricer and calculate the amount based on data from the claim.

Include only your covered charges in the calculation. Calculate the outlier, then select Yes or No.

Does the beneficiary exhaust all their LTR days before the cost outlier threshold is met?

   

Do bill:

  • Covered claim with LTR days
  • Condition Code 68 for LTR days
  • Occurrence Code A3 with the discharge date
  • Occurrence Span Code 70 for remainder of stay (non-utilization/inlier day)
    • Occurrence Span Code 70 begins the day after the last LTR day is used through discharge
    • Associated days are non-covered (Value Code 81)
    • Associated units and charges on room and board revenue codes are covered
  • Value Code 80 for covered days
  • Value Code 83 for LTR days
    • Value Codes 08 and/or 10 for LTR amounts

Do not bill:

  • Occurrence Code 47

See the CMS example, "LTR Days Cover Inlier and No Cost Outlier," found in SE1310, Example 11.

Do bill:

  • Covered claim with LTR days
  • Condition Code 68 for beneficiary's election to use LTR days
  • Occurrence Code A3 with the last non-utilization/inlier day's date
    • After A3 date, bill remainder of days, units and charges as non-covered
  • Occurrence Code 47 with the date the claim would have begun the outlier payment
  • Occurrence Span Code 70 for non-utilization/inlier day
    • Occurrence Span Code 70 begins the day after the last LTR day is used through the day before the outlier payment starts (Occurrence Code 47)
    • Associated days are non-covered (Value Code 81)
    • Associated units and charges on room and board revenue codes are covered
  • Value Code 80 for covered days
  • Value Code 81 for non-covered days
  • Value Code 83 for LTR days
    • Value Codes 08 and/or 10 for LTR coinsurance amounts

See the CMS example, "LTR Days Exhaust Prior to Cost Outlier," found in SE1310, Example 3.

For select DRGs with certain average length of stays, Noridian may ask you to bill as outlined in a Medicare workaround. In these cases:

Do bill:

  • Covered claim using all LTR days
  • Condition Code 66 for waiving outlier payment
  • Condition Code 68 for beneficiary's election to use LTR days
  • Occurrence Span Code 70 for non-utilization/inlier day
    • Occurrence Span Code 70 begins the day after the last LTR day is used through discharge
    • Associated days are non-covered (Value Code 81)
    • Associated units and charges on room and board revenue codes are covered
  • Value Code 80 for covered days
  • Value Code 81 for non-covered days
  • Value Code 83 for LTR days
    • Value Codes 08 and/or 10 for LTR amounts

Do not bill:

  • Occurrence Code A3
  • Occurrence Code 47

Note: in either scenario, providers may not submit a 12X Type of Bill (TOB) claim for Medicare-covered ancillary services after the benefits exhaust.

Do bill:

  • Covered claim using LTR days
  • Condition Code 68 for LTR days
  • Occurrence Code A3 with the last LTR date
    • Bill remainder of days, units and charges as non-covered
  • Occurrence Code 47 for the date the claim began the outlier payment
  • Value Code 80 for covered days
  • Value Code 81 for non-covered days
  • Value Code 83 for LTR days
    • Value Codes 08 and/or 10 for LTR amounts

Note: you may submit a 12X Type of Bill (TOB) claim for Medicare covered ancillary services after the benefits exhaust.

See the CMS example, "LTR Days Exhaust in the Cost Outlier," found in SE1310, Example 2.

 

Last Updated Wed, 29 Apr 2020 20:25:43 +0000