August 8, 2014

A/B Rebilling: Timeline and Claim Submission Instructions

When an inpatient admission is determined to be not medically reasonable and necessary, the A/B rebilling process allows hospitals to bill for all Part B services that would have been payable if a beneficiary had been treated as a hospital outpatient rather than admitted as an inpatient, except when those services specifically require an outpatient status (e.g., outpatient visits, emergency department visits, and observation services). A/B rebilling began as a demonstration project and several subsequent instructions and rules were issued. This article outlines instructions applicable on various dates and explains the circumstances in which certain Part A services may be "rebilled" under Part B.

Timeline

Details and Claim Submission Instructions

• Prior to March 13, 2013:
  • A limited set of Part B inpatient services may be paid in the following circumstances:
    • The patient is not entitled to Medicare Part A
    • No Part A payment is made for the hospital stay because the patient exhausted benefits before admission
    • The day(s) of the otherwise covered stay during which the services were provided was not reasonable and necessary (and no payment was made under waiver of liability)
    • The admission was disapproved as not reasonable and necessary (and waiver of liability payment was not made)
  • Claim submission instructions:
    • Submit a 12X Type of Bill (TOB) claim within the Medicare timely filing limit (i.e., one calendar year from the "through" date of service on the claim).
    • When there is no Part A coverage for an inpatient hospital stay, there is no inpatient service into which outpatient hospital services (provided within the three-day/one-day payment window) must be bundled. Therefore, outpatient hospital services provided to the patient prior to the point of admission (i.e., the admission order) may be separately billed on a 13X TOB claim.
    • This policy remains in effect for the first three circumstances listed above. A list of revenue codes that are NOT billable on a 12X TOB claim in those circumstances is available in the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 4, section 240.2.
• March 13, 2013:
  • CMS issued Administrator Ruling CMS-1455-R, which revised the policy and billing instructions related to the fourth circumstance listed above.
  • An interim process was established for hospitals to bill Medicare Part B for most services provided during the inpatient stay when a Medicare review contractor (e.g., MAC, CERT, RAC, ZPIC) denied an inpatient claim because it was determined to be not medically reasonable and necessary.
  • The effective date is March 13, 2013, and applies as long as the denial was made:
    • While the Ruling is in effect (March 13, 2013, until a final policy is established by CMS)
    • Prior to March 13, 2013, but for which the timeframe to file an appeal has not expired
    • Prior to March 13, 2013, but for which an appeal is pending
  • Claim submission instructions:
    • Temporary billing instructions are outlined in MLN Matters article MM8277 and on the CMS website at: http://cms.gov/Center/Provider-Type/Hospital/Other-Content-Types/Quick-Reference-CMS-1455-R.pdf
    • TOB:
      • 12X – Part B inpatient services = Any Part B services that would have been payable to the hospital if the patient had originally been treated as an outpatient rather than admitted as an inpatient, except when those services specifically require an outpatient status (e.g., outpatient visits, emergency department visits, and observation services)
      • 13X – Part B outpatient services = Any outpatient services that were bundled into the inpatient claim because they were furnished during the three-day/one-day payment window prior to the inpatient admission
    • Treatment Authorization Code = SPN65
      • Electronic claim submitters: Enter REF*G1*SPN65~ in Loop 2300 REF02 (REF01=G1)
      • DDE or paper submitters: Enter SPN65 on page 5 (MAP 1715) in DDE or in Form Locator 63 on the UB-04 claim form
    • Remarks = The DCN of the denied inpatient claim, last adjudication date, and CMS1455R

      NOTE: The last adjudication date means: the date of denial on the remittance advice for a Part A claim that has not been appealed, the date of a final or binding appeal decision, or the date of a dismissal notice in response to a request for a withdrawal of an appeal.

      • Electronic submitters: Enter NTE*ADD*12345678901234-99999999-CMS1455R~ in the Billing Notes Loop 2300/NTE (NTE01=ADD)
      • DDE or paper submitters: Enter 12345678901234-99999999-CMS1455R in the Remarks field on page 4 (MAP 1714) in DDE or Form Locator 80 on the UB-04 claim form
  • The timely filing limit is within 180 days of the inpatient claim denial, final appeal decision, or dismissal notice.
• July 1, 2013:
  • MLN Matters article MM8185 was implemented, which revised the billing instructions and allowed for the automatic processing of A/B rebilling claims.
  • Effective date is March 13, 2013, and applies as long as the denial was made:
    • While the Ruling is in effect (March 13, 2013, until a final policy is established by CMS)
    • Prior to March 13, 2013, but for which the timeframe to file an appeal has not expired
    • Prior to March 13, 2013, but for which an appeal is pending
  • Claim submission instructions for claims submitted on and after July 1, 2013:
    • TOB:
      • 12X – Part B inpatient services = Any Part B services that would have been payable to the hospital if the patient had originally been treated as an outpatient rather than admitted as an inpatient, except when those services specifically require an outpatient status (e.g., outpatient visits, emergency department visits, and observation services)
      • 13X – Part B outpatient services = Any outpatient services that were bundled into the inpatient claim because they were furnished during the three-day/one-day payment window prior to the inpatient admission
    • Condition Code W2 (attesting that this is a rebilling and no appeal is in process)
    • Treatment Authorization Code = A/B REBILLING
      • Electronic claim submitters: Enter REF*G1*A/B REBILLING~ in Loop 2300 REF02 (REF01=G1)
      • DDE or paper submitters: Enter A/B REBILLING in the field on page 5 (MAP 1715) in DDE or in Form Locator 63 on the UB-04 claim form
    • Remarks = ABREBILL, the DCN of the denied inpatient claim, and the last adjudication date

      NOTE: The last adjudication date means: the date of denial on the remittance advice for a Part A claim that has not been appealed, the date of a final or binding appeal decision, or the date of a dismissal notice in response to a request for a withdrawal of an appeal.

      • Electronic submitters: Enter NTE*ADD*ABREBILL12345678901234-99999999~ in the Billing Notes Loop 2300/NTE (NTE01=ADD)
      • DDE or paper submitters: Enter ABREBILL12345678901234-99999999 in the Remarks field on page 4 (MAP 1714) in DDE or in Form Locator 80 on the UB-04 claim form
  • The timely filing limit is within 180 days of the inpatient claim denial, final appeal decision, or dismissal notice.
• August 2, 2013:
  • CMS published the Inpatient Final Rule, CMS-1599-F, which revised some of the policies and billing instructions above as described below.
• October 1, 2013:
  • MLN Matters article SE1333 was published, which allows hospitals to submit A/B rebilling claims when they conduct a self-audit and determine that an inpatient stay was not medically reasonable and necessary after the patient was discharged.
  • Claim submission instructions effective for admissions on and after October 1, 2013:
    • If the hospital submitted a Part A 11X TOB claim, the hospital must cancel the claim.
    • Once the canceled claim processes (if applicable), the hospital must submit a provider liable claim:
      • TOB 110
      • Occurrence Span Code M1 and dates of service
      • Non-covered days and charges for all services rendered
    • Once the provider liable claim processes, the hospital may submit a 12X and/or 13X A/B rebilling claim as described below.
    • CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 4, section 240.1includes a list of revenue codes NOT billable on a 12X TOB claim in this situation.
  • MLN Matters article MM8445was published, which revised the timely filing limit for A/B rebilling claims.
  • Claim submission instructions, effective for admissions on and after October 1, 2013:
    • FISS must reflect either an inpatient claim that was denied by a Medicare review contractor, or a no-pay provider liable claim submitted by the provider (as described above).
    • The 12X and/or 13X A/B rebilling claim must include:
      • Condition Code W2 (attesting that this is a rebilling and no appeal is in process)
      • Treatment Authorization Code = A/B REBILLING
        • Electronic claim submitters: Enter REF*G1*A/B REBILLING~ in Loop 2300 REF02 (REF01=G1)
        • DDE or paper submitters: Enter A/B REBILLING in the field on page 5 (MAP 1715) in DDE or in Form Locator 63 on the UB-04 claim form
      • Remarks = ABREBILL and the DCN of the denied inpatient claim
        • Electronic submitters: Enter NTE*ADD*ABREBILL12345678901234~ in the Billing Notes Loop 2300/NTE (NTE01=ADD)
        • DDE or paper submitters: Enter ABREBILL12345678901234 in the Remarks field on page 4 (MAP 1714) in DDE or in Form Locator 80 on the UB-04 claim form
    • The timely filing limit is one calendar year from the "through" date of service on the claim.

You may also reference the A/B Rebilling FAQs on our website.