Did You Know? – Hospital
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- How do I determine the number of Lifetime Reserve (LTR) days available to a patient?
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The number of LTR days available to a patient can be accessed via the Interactive Voice Response (IVR), myCGS web portal, or Direct Data Entry (DDE).
In DDE, access the ELGA or HIQA inquiry. The number of LTR days a patient has remaining can be found on page 1 in the LRSV field. In the example below, this patient has all 60 of his LTR days available.
Example:
A-ENT 080107 A-TRM 000000 B-ENT 070108 B-TRM 000000 DOD 000000 LRSV 60 LPSY 190Reference:
- DDE User Manual, Chapter Two: Checking Beneficiary Eligibility
- IVR User Guide
- myCGS User Manual, Chapter 4: Eligibility Tab
Reviewed 12/02/2022
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- How do I report a leave of absence?
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To report a leave of absence during an inpatient hospital stay, submit one bill from admission to discharge as follows:
- Occurrence Span Code 74 and the dates the leave began and ended
- Non-covered days (Value Code 81 and the number of days the patient was absent)
- Revenue code 018X (Units equal the number of days reported with Occurrence Span Code 74 and non-covered charges for leave of absence days (holding a bed)
Reference:
To report an inpatient stay, outpatient surgery, or outpatient services subject to the Outpatient Prospective Payment System (OPPS), during a period of outpatient repetitive services, submit one monthly repetitive services bill. Report occurrence span code 74 with the dates that correspond to the inpatient stay, outpatient surgery, or outpatient services subject to the OPPS.
Reference:
Reviewed 12/02/2022
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- Our hospital receives Periodic Interim Payments (PIP). We received a demand letter requesting payment on a RAC DRG change that resulted in an overpayment. If we issue a check to CGS and the claim is also adjusted in the FISS system, will we be repaying the amount twice, both in the check issued and then upon cost report settlement?
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The Provider Statistical & Reimbursement System (PS&R) should segregate and exclude RAC-initiated adjustments to PIP claims. Therefore, you may send in payment for the demanded overpayment. You will not get "double charged" when the cost report is settled, since the payment will be excluded from the settlement calculation. If you do not want to send in a check, CGS will create an accounts receivable (AR) and send a demand letter for RAC adjustments. In this case, we would offset against the PIP payment to collect the debt. If the offset collection is not enough to fully collect the debt, interest may accrue.
You also have the option of requesting an immediate offset on all future ARs or specific ARs. If you select this option, you will still receive the demand letter to notify you that a debt has been incurred; CGS will then offset the debt from future PIP payments.
Reviewed 12/02/2022
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- A patient has utilized 150 days of the Part A inpatient benefit and has also utilized 100 days of the skilled nursing facility (SNF) benefit of that benefit period. What does this mean?
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This means that the patient's inpatient benefits are exhausted. Per the CMS Medicare Benefit Policy Manual (Pub. 100-02), Chapter 3, section 20:
"A patient having hospital insurance coverage is entitled to have payment made on his/her behalf for up to 90 days of covered inpatient hospital services in each benefit period. Also, the patient has a lifetime reserve of 60 additional days.' In addition, 'a patient having hospital insurance coverage is entitled to have payment made on his/her behalf for up to 100 days of covered inpatient extended care services (i.e. Skilled Nursing Facility (SNF) services) in each benefit period."
Reference:
Reviewed 12/02/2022
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- Can an acute care prospective payment system hospital bill two inpatient claims if a patient is discharged and then readmitted to the same hospital on the same day, but for a different diagnosis?
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An acute care Prospective Payment System (PPS) hospital may submit two inpatient claims in this case. Report condition code (CC) B4 on the readmitting claim when a patient is discharged or transferred from an acute care PPS hospital and is readmitted to the same acute care PPS hospital on the same day for symptoms unrelated to, and/or not for evaluation and management of, the prior stay's medical condition.
Reference:
Reviewed 12/02/2022
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- I am receiving reason code W7062, which means 'code not recognized by OPPS; alternative code for same service may be available', on several of our outpatient hospital claims. Where can I find coding guidance?
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Outpatient Prospective Payment System (OPPS) guidance concerning alternate codes is available on the CMS website at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html.
Coding guidance and resources are available on the HCPCS Coding Questions page on the CMS website.
Reviewed 12/02/2022
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- If a hospital elects to report charges for recurring, non-repetitive services on a single bill, what must they report on the bill?
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If hospitals elect to report charges for recurring, non-repetitive services (i.e., chemotherapy or radiation therapy) on a single bill, they must also report all charges for services and supplies associated with the recurring service on the same bill. The services may be billed either:
- On the same claim
- Separately (by date of service)
Reference:
Reviewed 12/02/2022
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- There is a field on the Remittance Advice entitled Hemophilia Add-On. What does this field report to Part A hospitals, and what generates this additional payment?
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This field reflects the additional payment amount an inpatient hospital provider receives for hemophilia blood clotting factor. An add-on payment is generated when a claim is billed with a HCPCS code for hemophilia blood clotting factor. The hemophilia blood clotting factor payment is based on the number of units billed.
Reviewed 12/02/2022
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- What is interim billing for prospective payment system hospitals?
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For long stay cases, prospective payment system (PPS) hospitals may submit interim bills to Medicare for every 60 days. The provider must submit an adjustment to cancel the original interim bill and re-bill the stay from the admission date through the discharge date.
For example, a beneficiary is inpatient for 130 days. The first claim is a 112 type of bill (TOB) for 60 days. An admission claim is for no less or no more than 60 days. The second claim is a 117 adjustment TOB for no more than 120 days. This adjustment cancels the admission 112 TOB and replaces it. The third claim submitted to report the discharge is also a 117 adjustment TOB for 130 days. A final discharge adjustment will be for no more than 180 days, if needed.
Reference:
Reviewed 12/02/2022
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- When a patient has preoperative diagnostic services two days before his/her inpatient surgery stay, am I able to bill a separate outpatient claim?
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Diagnostic services provided to a Medicare patient by the admitting hospital or by an entity wholly owned or operated by the hospital (or by another entity under arrangements with the hospital) within three days prior to the date of the patient's admission are deemed to be inpatient services and should be billed on the inpatient claim.
Reference:
Reviewed 12/02/2022
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