Medicare providers are expected to work together to resolve overlap situations. When a billing dispute arises between Medicare providers for dates of services or patient discharge status and neither party is able to reach a resolution, the Medicare contractor is tasked with assisting the providers with resolving the matter.
Full Answer
Can ESRD be overlapping with an inpatient hospital?
· ESRD Overlapping with an Inpatient Hospital: When a patient is in the hospital a separate payment cannot be made for dialysis services unless the services are excluded from SNF consolidated billing. The ESRD facility can be paid for the date of admission to or the date of discharge from an inpatient hospital; however, the hospitals are responsible for providing …
Who is responsible for paying for ESRD?
· The ESRD facility can be paid for the date of admission to or the date of discharge from an inpatient hospital. However, the hospitals are responsible for providing dialysis services to a patient while he/she is under inpatient care. Reference: CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 8, Section 10.5
What is consolidated billing under ESRD?
· Consolidated Billing Requirement. Medicare provides payment under the ESRD Prospective Payment System (PPS) for all renal dialysis services furnished to ESRD beneficiaries for outpatient maintenance dialysis. Therefore, ESRD facilities are responsible and paid for furnishing all renal dialysis services under the ESRD PPS directly or under arrangement.
What is the Ay modifier for ESRD?
· End stage renal disease (ESRD) facility Overlapping situations may also occur due to SNF or home health consolidated billing, or the place of service (POS) submitted on …
What is an overlapping claim?
Overlapping claims can happen when a beneficiary is an inpatient of one hospital and then sent to another hospital to obtain outpatient services that are not available at the originating hospital.
How do you bill for inpatient dialysis?
CPT code 90935 is used to report inpatient dialysis and includes one E/M evaluation provided to that patient on the day of dialysis. Inpatient dialysis requiring repeated evaluations on the same day is reported with code 90937.
What is Revenue Code 851?
Revenue codes 821, 831, 841, and 851 are all covered dialysis types and include all dialysis-related services rendered to the End Stage Renal Disease (ESRD) recipient, with the exception of the following codes: Revenue code 634 and 635 for Epogen, 1 unit equals 1000 units.
What does condition code 51 mean?
attestation of unrelated outpatient non-diagnostic servicesCondition code 51 (attestation of unrelated outpatient non-diagnostic services”) is not included on the outpatient claim. The line item date of service falls on the day of admission or any of the 3-days/1-day prior to an inpatient hospital admission.
What is the Medicare reimbursement rate for dialysis?
If the home patient deals with a dialysis facility, Medicare pays the facility 80 percent of the composite rate, or the same as for an in-center treatment. The payment covers all necessary dialysis supplies and equipment and related support services.
Does Medicare pay for CPT 90999?
– Considerations: Medicare requires that 90999 be used exclusively to bill for dialysis treatment. – A common industry practice is to use 90999 for the facility dialysis treatment and 90935, 90945, and 90947 for physician evaluation services.
What is revenue Code 761 used for?
Revenue code 761 is for a treatment room and should not be used in place of an observation room. There are no limits or parameters around the number of hours of observation or a requirement to roll into an inpatient claim if the patient is admitted and BCBSNE is the primary payer.
What is revenue Code 450 used for?
Commonly Billed ServicesRevenue CodeDescriptionPayment Status450Emergency room: general classificationER All-Inclusive Payment0250PharmacyIncluded in ER All-Inclusive Payment030xLaboratoryNot included in ER All-Inclusive Payment0730EKG/ECGNot included in ER All-Inclusive Payment1 more row•Apr 15, 2021
What is revenue Code 636?
We know that for Medicare claims, Revenue Code 636 is used for: 1) Inpatient – exclusively billing hemophilia clotting factors. 2) Outpatient – billing for "Drugs that require detail coding" (i.e., pharmacy with HCPCS).
What does condition code 77 mean?
Enter condition code 77 to report provider accepts the amount paid by primary as payment in full. No Medicare reimbursement will be made. Enter Medicare on the second Payer line. Enter beneficiary and primary payer information exactly as reported on the Common Working File (CWF)
What does condition code 69 mean?
teaching hospitals onlyCondition code 69 (teaching hospitals only - code indicates a request for a supplemental payment for Indirect Medical Education/Graduate Medical Education/Nursing and Allied Health)
What is a condition code 44?
A Condition Code 44 is a billing code used when it is determined that a traditional Medicare patient does not meet medical necessity for an inpatient admission. An order to change the patient status from Inpatient to Observation (bill type 13x or 85x) MUST occur PRIOR TO DISCHARGE.
How does Medicare work with providers?
Medicare providers are expected to work together to resolve overlap situations. When a billing dispute arises between Medicare providers for dates of services or patient discharge status and neither party is able to reach a resolution, the Medicare contractor is tasked with assisting the providers with resolving the matter. Providers are encouraged to seek assistance from First Coast as soon as it is evident that a resolution cannot be reached. Requests received for claims that are past the timely filing limit will not be processed without good cause as defined in the Medicare claims processing manual. Reference: CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 1, Section 70.7
What is overlapping with IRF?
Hospital overlapping with IRF: When the stay is for three days or less, ver ify the IRF has added OSC 74 with the associated dates of service and the hospital bills Medicare. When the patient is discharged and returns to the same IRF on the same day, the other facility will need to look to the IRF for payment of services. Reference: CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 3, Section 140.2.4
Can you have hospital overlapping with outpatient?
Hospital overlapping with outpatient services: A patient cannot receive inpatient and outpatient services at the same time. In situations where the patient is in outpatient status and later admitted to the same facility as an inpatient without a break in service, all charges are billed on the inpatient claim. Exception: Outpatient diagnostic services furnished provided more than three days preceding the date of the admission are not part of the payment window. Reference: CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 3, Section 40.3
What is the OSC code for hospital overlapping with IPF?
Hospital overlapping with IPF: When the stay is for three days or less, verify the IPF has added occurrence span code (OSC) 74 with the associated dates of service. Reference: CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 3, Section 190.7.1
Can a hospital bill Medicare for LTCH?
The hospital may not bill Medicare, but must look to the LTCH for payment of services. The only exception to this rule is when treatment at an inpatient acute care hospital would be grouped to a surgical DRG. Reference: CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 3, Section 150.9.1.2
What is discharge coding?
Hospital discharge coding: Hospitals should ensure that the patient status is billed accurately for proper payment. If the hospital learns that post-acute care was provided (e.g., left against medical advice, discharged but later readmitted the same day to another IPPS hospital, transferred), the hospital should submit an adjustment bill to correct the discharge status code. Reference: MLN Matters® Article SE1411
Can a hospital be paid for discharge?
The receiving hospital can be paid for the date of the transfer, but not the date of discharge. Hospitals should also ensure that they are submitting their discharge claims with the appropriate discharge status code reflecting the same day admission to the subsequent facility.
When a renal dialysis service is provided to an ESRD beneficiary by other providers, should that provider look
When a renal dialysis service is provided to an ESRD beneficiary by other providers, that provider should look to the ESRD facility for payment, as opposed to submitting a claim to their Medicare Administrative Contractor (MAC).
What is consolidated billing in ESRD?
The ESRD PPS implemented consolidated billing requirements for limited Part B items and services included in the ESRD facility’s bundled payment. Certain laboratory services, drugs and biologicals, equipment, and supplies are subject to consolidated billing and are no longer separately payable when provided to ESRD beneficiaries by providers other than the ESRD facility. Under consolidated billing, ESRD facilities are expected to furnish services, either directly, or under an arrangement with an outside supplier.
Does Medicare pay for renal dialysis?
Medicare provides payment under the ESRD Prospective Payment System (PPS) for all renal dialysis services furnished to ESRD beneficiaries for outpatient maintenance dialysis. Therefore, ESRD facilities are responsible and paid for furnishing all renal dialysis services under the ESRD PPS directly or under arrangement.
Does an ESRD beneficiary have to submit a claim with an AY modifier?
For example, if an ESRD beneficiary also has cancer and has a laboratory test done related to cancer treatment, the laboratory should submit the claim with an AY modifier in order to receive separate payment.
What is the OSC code for hospital overlapping with IPF?
Hospital overlapping with an IPF: When the stay is for 3 days or less, verify the IPF has added Occurrence Span Code (OSC) 74 with the associated dates of service.
Who agrees to pay for home health?
Note: If the patient is in a Home Health or SNF, payment arrangements must be agreed upon by both the provider and the supplier.
What happens if you return to the SNF prior to midnight?
If the patient was admitted to the hospital and returned to the SNF prior to midnight, the SNF would need to submit a discharge claim and then submit a new claim with a new Admit Date (this would be considered a readmission and the 57 condition code may need applied). As a reminder, inpatient admission to a hospital or admission to another SNF forces a discharge from a SNF.
Can SNF be paid for discharge?
The transferring SNF cannot be paid for the actual date of transfer. The receiving SNF can be paid for the date of the transfer, but not the date of discharge. SNFs should also ensure that they are submitting their discharge claims with the appropriate discharge status code.
Can a hospital outpatient overlap a SNF?
Hospital outpatient overlapping a SNF Part A stay: A patient may receive outpatient hospital care during a covered Part A SNF stay. Certain services maybe part of SNF consolidated billing, and therefore payment received for those services, should be made by the SNF to the outpatient facility.
Can an inpatient hospital receive outpatient services?
Hospital outpatient overlapping hospital inpatient including Acute, IRF, IPF, and LTCH: A patient cannot receive outpatient services simultaneously while admitted to an in patient facility. Situations arise when an inpatient facility transfers a patient for an outpatient procedure during an inpatient admission. The outpatient facility should look to the inpatient facility for payment under arrangements.
What happens if a patient is readmitted on the same day for symptoms related to prior admission?
If the patient is readmitted on the same day for symptoms related to prior admission then the facility needs to combine the bills to create one continuous stay. The other facility must bill the hospital under arrangement.
Why is Medicare overpayment?
The payments associated with these claims are considered overpayments because Medicare does not allow separate payment for DMEPOS when a beneficiary is in a covered inpatient stay (Medicare Claims Processing Manual, Ch. 20 01).
What is overlapping claims?
Overlapping claims can happen when a beneficiary is an inpatient of one hospital and then sent to another hospital to obtain outpatient services that are not available at the originating hospital. Certain items, supplies, and services furnished to inpatients are covered under Medicare Part A and should not be billed separately to Medicare Part B ...
Is DMEPOS billed to Medicare?
Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) claims for beneficiaries who received DMEPOS items while in an inpatient stay in a hospital should not be billed to Medicare separately. The payments associated with these claims are considered overpayments because Medicare does not allow separate payment for DMEPOS ...
What happens when an outpatient hospital does not have the technology to perform a procedure?
In situations where the inpatient hospital does not have the technology to perform a procedure and transfers the patient for completion of the procedure, and the patient returns as inpatient, the outpatient hospital must look to the inpatient facility for payment under arrangement. Hospital Overlapping with a SNF.
How long does it take for a hospital to pay for LTCH?
When a patient is admitted to an inpatient acute care hospital, upon discharge from an LTCH and is readmitted to the same LTCH within three (3) days, payment is made to the LTCH. The hospital may not bill Medicare, but must look to the LTCH for payment of services.
What is hospice transfer?
Hospice Transfer Situations#N#Hospices are expected to ensure that they are verifying a beneficiary’s status in the hospice program. When the patient has chosen to change hospices during an election period, the transferring and receiving hospice are expected to agree upon a transfer date before the transfer takes place. The beneficiary or authorized representative is required to ensure that a transfer notice is on file with both hospices at the time of the transfer. Given that hospice beneficiaries are terminally ill and may not be in a position to complete the necessary transfer notification, hospice agencies are encouraged to assist the patient or representative with completing the transfer agreement and notifying the other hospice. Reference: CMS IOM, Pub. 100-02, Chapter 9, Section 20.1 (PDF, 639 KB).#N#Hospice Overlapping with Other Provider Types#N#Hospices should not encounter overlapping situations with other provider types as hospice care can be provided in any location that the beneficiary/patient resides whether temporarily or permanently. Once enrolled in the Hospice Medicare Benefit, the hospice is responsible for managing the patient’s care that is related to the terminal illness. All services related to the terminal illness are to be billed to Medicare by the hospice agency. The hospice should also coordinate with other providers for services that are not related to the terminal illness to ensure accurate billing of non-related services.
Can SNFs be paid for discharge?
SNFs can be paid for the date of admission from a hospital, but not the date of discharge should the patient return to the hospital from the S NF. SNFs must also ensure that they are submitting their claims with the correct discharge status code when a patient is returned to the hospital.
Can a patient receive home health care while in a SNF?
A patient cannot receive home health care while in a SNF regardless of whether the patient is under a Medicare Part A stay. The home health agency is required to omit dates of service from their claim while the patient is under the care of the SNF between the admit and discharge dates.
Can an inpatient patient receive outpatient services?
A patient cannot receive outpatient services simultaneously while admitted to an inpatient facility. Situations arise when an inpatient facility transfers a patient for an outpatient procedure during an inpatient admission. The outpatient facility should look to the inpatient facility for payment under arrangements.
Can a hospital overlap an outpatient?
Hospital Overlapping with Outpatient Services. A patient cannot receive inpatient and outpatient services at the same time. In situations where the patient is in outpatient status and later admitted to the same facility as an inpatient without a break in service, all charges are billed on the inpatient claim.
How does Medicare work with providers?
Medicare providers should work together to resolve overlap situations. When a billing dispute arises between Medicare providers for dates of services or patient discharge status and neither party is able to reach a resolution, the Medicare contractor is tasked with assisting the providers with resolving the matter. Providers are encouraged to seek assistance from WPS GHA as soon as it is evident that a resolution cannot be reached. Requests received for claims that are past the timely filing limit will not be processed without good cause as defined in the CMS Internet-Only Manual (IOM) Publication 100-04, Chapter 1 , Section 70.7.
When should Medicare providers verify a beneficiary's eligibility?
Medicare providers should verify a beneficiary’s Medicare eligibility at the time of or prior to admission to ensure that the patient is eligible to receive the services covered by Medicare. Checking the beneficiary’s eligibility records also ensures that the facility/agency verifies whether or not the patient is receiving services from another entity that would cause an overlapping situation.
Can an inpatient hospital receive outpatient services?
Hospital outpatient overlapping hospital inpatient including Acute, IRF, IPF, and LTCH: A patient cannot receive outpatient services simultaneously while admitted to an inpatient facility. Situations arise when an inpatient facility transfers a patient for an outpatient procedure during an inpatient admission. The outpatient facility should look to the inpatient facility for payment under arrangements. Reference: CMS IOM Publication 100-04, Chapter 4 , Section 10.2.
What happens if a patient is readmitted on the same day for symptoms related to prior admission?
If the patient is readmitted on the same day for symptoms related to prior admission then the facility needs to combine the bills to create one continuous stay. The other facility must bill the hospital under arrangement.
Do hospitals have to bill for discharge?
The hospital should ensure that they have submitted the correct admit and discharge dates on their claim. In addition, the correct discharge patient status code must be billed on the claim. If the patient was transferred from a SNF and returned to the SNF prior to midnight, the hospital would need to bill a Same Day Transfer. Reference: CMS IOM Publication 100-04, Chapter 3 , Section 40.1.
What is the OSC code for a 3 day stay?
When the stay is for 3 days or less, verify the IPF has added Occurrence Span Code (OSC) 74 with the associated dates of service. Reference: CMS IOM Publication 100-04, Chapter 3 , Section 190.7.1.
When a patient is admitted to an inpatient acute care hospital, upon discharge from an LTCH and is read
When a patient is admitted to an inpatient acute care hospital, upon discharge from an LTCH and is readmitted to the same LTCH within 3 days, payment is made to the LTCH. The hospital may not bill Medicare but must look to the LTCH for payment of services. The only exception to this rule is when treatment at an inpatient acute care hospital would be grouped to a surgical DRG. Reference: CMS IOM Publication 100-04, Chapter 3 , Section 150.9.1.2.
What is an overlapping hospital?
An overlapping situation may occur between hospitals for inpatient stays, which include Inpatient Psychiatric Hospitals (IPH), Long Term Care Hospitals (LTCH), Inpatient Rehab Facilities (IRF), Critical Access Hospital (CAH)], hospitals for outpatient services, Skilled Nursing Facilities (SNFs ), Home Health Agencies (HHAs), Hospice agencies, Outpatient Rehab Facilities (ORF), Comprehensive Outpatient Rehab Facilities (CORF), End Stage Renal Disease (ESRD) Facilities, or a combination of one provider type and another.#N#Overlapping situations may also occur due to SNF or Home Health consolidated billing, or the Place of Service (POS) submitted on physician claims where the SNF or Home Health has failed to properly discharge the beneficiary.#N#Note: If the patient is in a Home Health or SNF, payment arrangements must be agreed upon by both the provider and the supplier.
How to access eligibility records?
Access the patient’s eligibility records in the Direct Data Entry (DDE) system and print and save a copy of the page that validates whether or not the patient is under an established home health plan of care
What is hospice transfer?
Hospice Transfer Situations#N#Hospices are expected to ensure that they are verifying a beneficiary’s status in the hospice program. When the patient has chosen to change hospices during an election period, the transferring and receiving hospice are expected to agree upon a transfer date before the transfer takes place. The beneficiary or authorized representative is required to ensure that a transfer notice is on file with both hospices at the time of the transfer. Given that hospice beneficiaries are terminally ill and may not be in a position to complete the necessary transfer notification, hospice agencies are encouraged to assist the patient or representative with completing the transfer agreement and notifying the other hospice. Reference: CMS IOM, Pub. 100-02, Chapter 9, Section 20.1 (PDF, 261 KB).#N#Hospice Overlapping with Other Provider Types#N#Hospices should not encounter overlapping situations with other provider types as hospice care can be provided in any location that the beneficiary/patient resides whether temporarily or permanently. Once enrolled in the Hospice Medicare Benefit, the hospice is responsible for managing the patient’s care that is related to the terminal illness. All services related to the terminal illness are to be billed to Medicare by the hospice agency. The hospice should also coordinate with other providers for services that are not related to the terminal illness to ensure accurate billing of non-related services.
Can a patient receive home health care while in a SNF?
A patient cannot receive home health care while in a SNF regardless of whether the patient is under a Medicare Part A stay. The home health agency is required to omit dates of service from their claim while the patient is under the care of the SNF between the admit and discharge dates.
Can SNF be paid for discharge?
The transferring SNF cannot be paid for the actual date of transfer. The receiving SNF can be paid for the date of the transfer, but not the date of discharge. SNFs should also ensure that they are submitting their discharge claims with the appropriate discharge status code.
Can an inpatient patient receive outpatient services?
A patient cannot receive outpatient services simultaneously while admitted to an inpatient facility. Situations arise when an inpatient facility transfers a patient for an outpatient procedure during an inpatient admission. The outpatient facility should look to the inpatient facility for payment under arrangements.
What happens when an outpatient hospital does not have the technology to perform a procedure?
In situations where the inpatient hospital does not have the technology to perform a procedure and transfers the patient for completion of the procedure, and the patient returns as inpatient, the outpatient hospital must look to the inpatient facility for payment under arrangement. Hospital Overlapping with a SNF.