(Medicare Claims Processing Manual)

10 - General Inpatient Requirements  10.1 - Claim Formats  10.2 - Focused Medical Review (FMR)  10.3 - Spell of Illness  10.4 - Payment of Nonphysician Services for Inpatients  10.5 - Hospital Inpatient Bundling  20 - Payment Under Prospective Payment System (PPS) Diagnosis Related Groups (DRGs)  20.1 - Hospital Operating Payments Under PPS  20.1.1 - Hospital Wage Index  20.1.2 - Outliers  20.1.2.1 - Cost to Charge Ratios  20.1.2.2 - Statewide Average Cost to Charge Ratios  20.1.2.3 - Threshold and Marginal Cost  20.1.2.4 - Transfers  20.1.2.5 - Reconciliation  20.1.2.6 - Time Value of Money  20.1.2.7 - Procedure for Medicare contractors to Perform and Record Outlier Reconciliation Adjustments  20.1.2.8 - Specific Outlier Payments for Burn Cases  20.1.2.9 - Medical Review and Adjustments 20.1.2.10 - Return Codes for Price r 20.2 - Computer Programs Used to Support Prospective Payment System  20.2.1 - Medicare Code Editor (MCE)  20.2.1.1 - Paying Claims Outside of the MCE  20.2.1.1.1 - Requesting to Pay Claims Without MCE Approval  20.2.1.1.2 - Procedures for Paying Claims Without Passing through the MCE  20.2.2 -  DRG GROUPER Program  20.2.3 -  PPS Pricer Program  20.2.3.1 -  Provider -Specific Fil e 20.3 -  Additional Payment Amounts for Hospitals with Disproportionate Share of Low -Income Patients  20.3.1 -  Clarification of Allowable Medicaid Days in the Medicare Disproportionate Share Hospital (DSH) Adjustment Calculation  20.3.1.1 -  Clarification for Cost Reporting Periods Beginning On or After January 1, 2000 20.3.1.2 -  Hold Harmless for Cost Reporting Periods Beginning Before January 1, 2000  20.3.1.3 -  Disproportionate Share Hospital (DSH) Policy Changes Effective for Cost Reporting Periods beginning on or after October 1, 2009 20.3.1.4 -  Disproportionate Share Hospital (DSH) Policy Changes Effective for Cost Reporting Periods beginning on or after October 1, 2012 20.3.2 -  Updates to the Federal Fiscal Year (FY) 2001  20.3.2.1 -  Inpatient Hospital Payments and Disproportionate Share Hospital (DSH) Thresholds and Adjustments  20.3.3 -  Prospective Payment Changes for Fiscal Year (FY) 2003  20.3.4 -  Prospective Payment Changes for Fiscal Year (FY) 2004 and Beyond 20.4 -  Hospital Capital Payments Under PPS  20.4.1 -  Federal Rat e 20.4.2 -  Hold Harmless Payments  20.4.3 -  Blended Payments  20.4.4 -  Capital Payments in Puerto Rico  20.4.5 -  Old and New Capital  20.4.6 -  New Hospitals  20.4.7 -  Capital PPS Exception Payments  20.4.8 -  Capital Outliers  20.4.9 -  Admission Prior to and Discharge After Capital PPS Implementation Date  20.4.10 -  Market Basket Update  20.5 -  Rural Referral Centers (RRCs) 20.6 -  Criteria and Payment for Sole Community Hospitals and for Medicare Dependent Hospitals  20.7 -  Billing Applicable to PPS  20.7.1-  Stays Prior to and Discharge After IPPS Implementation Date  20.7.2 -  Split Bills  20.7.3 -  Payment for Blood Clotting Factor Administered to Hemophilia Inpatients  20.7.4 -  Cost Outlier Bills With Benefits Exhausted  20.8 -  Payment to Hospitals and Units Excluded from IPPS for Direct Graduate Medical Education (DGME) and Nursing and Allied Health (N&AH) Education for Medicare Advantage (MA) Enrollees  30 - Medicare Rural Hospital Flexibility Program and Critical Access Hospitals (CAHs)  30.1 -  Requirements for CAH Services, CAH Skilled Nursing Care Services and Distinct Part Units  30.1.1 -  Payment for Inpatient Services Furnished by a CAH  30.1.1.1 -  Payment for Inpatient Services Furnished by an Indian Health Service (IHS) or tribal CAH  30.1.2 -  Payment for Post -Hospital SNF Care Furnished by a CAH  30.1.3 -  Costs of Emergency Room On- Call Providers  30.1.4 -  Costs of Ambulance Service s 40 - Billing Coverage and Utilization Rules for PPS and Non- PPS Hospitals  40.1 -  "Day Count" Rules for All Providers  40.2 -  Determining Covered/Noncovered Days and Charges  40.2.1 -  Noncovered Admission Followed by Covered Level of Care  40.2.2 -  Charges to Beneficiaries for Part A Services  40.2.3 -  Determining Covered and Noncovered Charges -  Pricer and PS&R  40.2.4 -  IPPS Transfers Between Hospitals  40.2.5 -  Repeat Admissions  40.2.6 -  Leave of Absence 40.3 -  Outpatient Services Treated as Inpatient Services  40.3.1 -  Billing Procedures to Avoid Duplicate Payments  50 - Adjustment Bills  50.1 -  Tolerance Guidelines for Submitting Adjustment Requests  50.2 -  Claim Change Reasons  50.3 -  Late Charges  60 - Swing -Bed Services  70 - All-Inclusive Rate Providers  70.1 -  Providers Using All -Inclusive Rates for Inpatient Part A Charges  80 - Hospitals That Do Not Charge  80.1 -  Medicare Summary Notice (MSN) for Services in Hospitals That Do Not Charge  90 - Billing Transplant Services  90.1 -  Kidney Transplant -  General  90.1.1 -  The Standard Kidney Acquisition Charge  90.1.2 -  Billing for Kidney Transplant and Acquisition Services  90.1.3 -  Billing for Donor Post -Kidney Transplant Complication Services  90.2 -  Heart Transplants  90.3 -  Stem Cell Transplantation  90.3.1 -  Allogeneic  for Stem Cell Transplantation  90.3.2 -  Autologous Stem Cell Transplantation (AuSCT)  90.4 -  Liver Transplants  90.4.1 -  Standard Liver Acquisition Charge  90.4.2 -  Billing for Liver Transplant and Acquisition Services  90.5 -  Pancreas Transplants With Kidney Transplants  90.5.1 -  Pancreas Transplants Alone (PA)  90.6 -  Intestinal and Multi- Visceral Transplants  100 -  Billing Instructions for Specific Situations  100.1 -  Billing for Abortion Services  100.2 -  Payment for CRNA or AA Services  100.3 -  Resident and Interns Not Under Approved Teaching Programs  100.4 -  Billing for Services After Termination of Provider Agreement  100.4.1 -  Billing Procedures for a Provider Assigned Multiple Provider Numbers or a Change in Provider Number  100.5 -  Review of Hospital Admissions of Patients Who Have Elected Hospice Care  100.6 -  Inpatient Renal Services  100.7 -  Lung Volume Reduction Surgery  100.8 -  Replaced Devices Offered Without Cost or With a Credit  100.9  Requirements for Processing Non Veterans Administration (VA) Authorized Inpatient Claims  100.10  Requirements  for Processing  Programs of All -Inclusive Care for the Elderly (PACE) Disenrollments during an  Inpatient  Stays 130 -  Coordination With the Quality Improvement Organization (QIO)  140 -  Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS)  140.1 -  Medicare IRF Classification Requirements  140.1.1 -  Crite ria That Must B e Met By Inpatient Rehabilitation Facilities  140.1.2 -  Additional Criteria That Must Be Met By Inpatient Rehabilitation Units  140.1.3 -  Verification Process Used to Determine if the Inpatient Rehabilitation Facility Met the Classification Criteria  140.1.4 -  New IRFs  140.1.5 -  Changes in the Status of an IRF Unit  140.1.6 -  New IRF Beds  140.1.7 -  Change of Ownership or Leasing 140.1.8 -  Mergers  140.1.9 -  Retroactive Adjustments For Provisionally Excluded IRFs or IRF Beds  140.2 -  Payment Provisions Under IRF PPS  140.2.1 -  Phase- In Implementation  140.2.2 -  Payment Adjustment Factors and Rates  140.2.3 -  Case- Mix Groups  140.2.4 -  Case- Level Adjustments  140.2.5 -  Facility -Level Adjustments  140.2.5.1 -  Area Wage Adjustments  140.2.5.2 -  Rural Adjust ment 140.2.5.3 -  Low-Income Patient (LIP) Adjustment: The S upplem ental S ecurity Income (SSI)/Medicare Beneficiary Data for Inpatient Rehabilitation Fac ilities (IRFs) Paid Under the P rospective Payment System ( PPS)  140.2.5.4 -  Teaching Status Adjus tment  140.2.5.4.1 -  FTE Resid ent Cap 140.2.5.5 -  Outl iers 140.2.6 -  Cost -to-Charge Ratios  140.2.7-  Use of a National Average Cost -to-Charge Ratio  140.2.8-  Reconciling Outlier Payments for IRF  140.2.9- Time Value of Money  140.2.10 -  Procedure for Medicare Contractors to Perform and Record Outlier Reconciliation Adjustments for IRFs  140.2.11-  Quality Reporting Program  140.3 -  Billing Requirements Under IRF PPS  140.3.1 -  Shared Systems and CWF Edits  140.3.1.1 -  Actions When a Claim Does Not Match the Inpatient Rehabilitation Facility -   Patient Assessment Instrument (IRF -PAI)  140.3.2 -  IRF PPS Pricer Software  140.3.3 -  Remittance Advices  150 -  Long Term Care Hospitals (LTCHs) PPS  150.1 -  Background  150.2 -  Statutory Requirements  150.3 -  Affected Medicare Providers  150.4 -  Revision of the Qualification Criterion for LTCHs  150.5 -  Payment Provisions Under LTCH PPS  150.5.1 -  Budget Neutrality 150.5.2 -  Budget Neutrality Offset  150.6 -  Beneficiary Liability  150.7 -  Patient Classification System  150.8 -  Relative Weights  150.9 -  Payment Rate  150.9.1 -  Case- Level Adjustments  150.9.1.1 -  Short -Stay Outliers  150.9.1.2 -  Interrupted Stays  150.9.1.3 -  Payments for Special Cases  150.9.1.4 -  Payment Policy for Co- Located Providers  150.9.1.5 -  High Cost Outlier Cases  150.10 -  Facility -Level Adjustments  150.10.1 -  Phase- in Implementation  150.11 -  Requirements for Provider Education and Training 150.12 -  Claims Processing and Billing  150.12.1 -  Processing Bills Between October 1, 2002, and the Implementation Date  150.13 -  Billing Requirements Under LTCH PPS  150.14 -  Stays Prior to and Discharge After PPS Implementation Date  150.14.1- Crossover Patients in New LTCHs  150.15 -  System Edits  150.16 -  Billing Ancillary Services Under LTCH PPS  150.17 -  Benefits Exhausted  150.17.1 -  Assumptions for Use in Examples Below  150.17.1.1 -  Example 1: Coinsurance Days < Short Stay Outlier Threshold (30 Day Stay)  150.17.1.2 -  Example 2: Coinsurance Days Greater Than or Equal to