(Medicare Claims Processing Manual)

Medicare no payment bills submitted by an SNF result in Medicare program payment determinations (i.e., denials).  Therefore, such no payment bills trigger the appropriate presumptions.  This also applies in any State where the Medicaid program utilizes no payment bills which lead to Medicaid program payment determinations.  If an SNF erroneously fails to submit a Medicare claim (albeit a no -pay claim) when Medicare rules require such submission, request compliance.  Once the no- pay bill is submitted and denied, the applicable presumption (other than presumption 7) is triggered.  If a patient is moving from a SNF level of care to a non -SNF level of care in a facility certified to provide SNF care, occurrence code 22 (date active care ended) is used to signify the beginning of the no- pay period on the bill and trigger the appropriate presumptions.  Some of the presumptions require knowledge of Medicaid's claims processing involvement with the prior claim.  The A/B MAC (A) uses current bill data, accompanying documentation, bill history files, and telephone contacts with the prior stay facility and/or  the Medicaid agency to develop the Medicaid aspects.  It does not continue Medicaid development beyond a telephone contact.  It concludes its consideration of the presumption at this point based upon the Medicaid information available.   10.4 - Payment of Nonphysician Services for Inpatients  (Rev. 3030, Issued: 08- 22-14, Effective: ASC X12: January 1, 2012, ICD -10: Upon Implementation of ICD- 10, Implementation: ICD -10: Upon Implementation of ICD -10, ASC X12: September, 23 2014)   All items and nonphysician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.  This provision applies to all hospitals, regardless of whether they are subject to PPS.   A. - Other Medical Items, Supplies, and Services   The following medical items, supplies, and services furnished to inpatients are covered under Part A.  Consequently, they are covered by the prospective payment rate or reimbursed as reasonable costs under Part A to hospitals excluded from PPS.    Laboratory services (excluding anatomic pathology services and certain clinical pathology services);    Pacemakers and other prosthetic devices including lenses, and artificial limbs, knees, and hips;    Radiology services including computed tomography (CT) scans furnished to inpatients by a physician's office, other hospital, or radiology clinic;    Total parenteral nutrition (TPN) services; and    Transportation, including transportation by ambulance, to and from another hospital or freestanding facility to receive specialized diagnostic or therapeutic services not available at the facility where the patient is an inpatient.   The hospital must include the cost of these services in the appropriate ancillary service cost center, i.e., in the cost of the diagnostic or therapeutic service.  It must not show them separately under revenue code 0540.  EXCEPTIONS:    Pneumococcal Vaccine - is payable under Part B only and is billed by the hospital using the ASC X12 837 institutional claim format or on the Form CMS -1450.   Ambulance Service -  For purposes of this section "hospital inpatient" means a beneficiary who has been formally admitted it does not include a beneficiary who is in the process of being transferred from one hospital to another.  Where the patient is transferred from one hospital to another, and is admitted as an inpatient to the second, the ambulance service is payable under only Part B.  If transportation is by a hospital owned and operated ambulance, the hospital bills separately using the ASC X12 837 ins titutional claim format or on Form CMS -1450 as appropriate.  Similarly, if the hospital arranges for the ambulance transportation with an ambulance operator, including paying the ambulance operator, it bills separately.  However, if the hospital does not a ssume any financial responsibility, the billing is to the A/B MAC (B) by the ambulance operator or beneficiary, as appropriate, if an ambulance is used for the transportation of a hospital inpatient to another facility for diagnostic tests or special treatment the ambulance trip is considered part of the DRG, and not separately billable, if the resident hospital is under PPS.    Part B Inpatient Services  - Where Part A benefits are not payable, payment may be made to the hospital under Part B for certain medical and other health services.  See Chapter 4 for a description of Part B inpatient services.    Anesthetist Services "Incident to" Physician Services  - If a physician's practice was to employ anesthetists and to bill on a reasonable charge basis for these services and that practice was in effect as of the last day of the hospital's most recent 12- month cost reporting period ending before September 30, 1983, the physician may continue that practice through cost reporting periods beginning October 1, 1984.  However, if the physician chooses to continue this practice, the hospital may not add costs of the anesthetists service to its base period costs for purposes of its transition payment rates.  If it is the existing or new practice of the physician to employ certified registered nurse anesthetists (CRNAs) and other qualified anesthetists and include charges for their services in the physician bills for anesthesiology services for the hospital's cost report periods beginning on or after October 1, 1984, and before October 1, 1987, the physician may continue to do so.  B. - Exceptions/Waivers   These provisions were waived before cost reporting periods beginning on or after October 1, 1986, under certain circumstances.  The basic criteria for waiver was that services furnished by outside suppliers are so extensive that a sudden change in billing practices would threaten the stability of patient care.  Specific criteria for waiver and processing procedures are in 2804 of the Provider Reimbursement Manual (CMS Pub. 15- 1).  10.5 - Hospital Inpatient Bundling  (Rev. 668, Issued:  09- 02-05; Effective:  Ambulance claims received on or after January 3, 2006, and 4 years after initial determination for adjustments; Implementation:  01 -03-06)  Hospital bundling rules exclude payment to independent suppliers of ambulance services for beneficiaries in a hospital inpatient stay. The Common Working File (CWF) performs reject edits to incoming claims from independent suppliers of ambulance services. The CWF searches paid claim history and compares the line item service date on an ambulance claim to the admission and discharge dates on a hospital inpatient stay. The CWF rejects the line item when the ambulance line item service date falls within the ad mission and discharge dates on a hospital inpatient claim. Based on CWF rejects, the A/B MAC (B)  must deny line items for ambulance services billed by independent suppliers that should be bundled to the hospital.  Upon receipt of a hospital inpatient claim, CWF searches paid claim history and compares the period between the hospital inpatient admission and discharge dates to the line item service date on an ambulance claim billed by an independent supplier. The CWF shall generate an unsolicited response when the line item service date falls within the admission and discharge dates of the hospital inpatient claim.   Upon receipt of the unsolicited response, the A/B MAC (B)  shall adjust the ambulance claim and recoup the payment.  Ambulance services with a date of service that is the same as the admission or discharge date on an inpatient claim are separately payable and not subject to the bundling rules.  The CWF performs an additional edit before determining if the ambulance line item should be rejected w hen the beneficiary is an inpatient of a long term  care facility (LTCH), inpatient psychiatric facility (IPF) or inpatient rehabilitation facility (IRF) and is transported via ambulance to an acute care hospital to receive specialized services. The CWF edits the claim for the presence of occurrence span code 74 (non- covered level of care) and the associated occurrence span code from and through dates. The CWF bypasses the reject edit when the ambulance line item service date falls within the occurrence span code 74 from and through dates plus one day. In this case, the ambulance line item is separately payable.  The CWF rejects the ambulance line item when the service date falls outside the occurrence span code 74 from and through dates plus one day.   20 - Payment Under Prospective Payment System (PPS) Diagnosis Related Groups (DRGs)  (Rev. 10210, Issued: 07- 10-2020, Effective: 08 -10-2020 , Implementation: 08- 10-2020)   A. - General   The Social Security Amendments of 1983 (P.L. 98- 21) provided for establishment of a prospective payment system (PPS) for Medicare payment of inpatient hospital services.  (See 20.4  for corresponding information for PPS capital payments and computation of capital and operating outliers for FY 1992.)  Under PPS, hospitals are paid a predetermined rate per discharge for inpatient hospital services furnished to Medicare beneficiaries.  Each type of Medicare discharge is classified according to a list of DRGs.  These amounts are, with certain exceptions, payment in full to the hospital for inpatient operating costs.  Beneficiary cost-sharing is limited to statutory deductibles, coinsurance, and payment for noncovered items and services.  Section 4003 of OBRA of 1990 (P.L. 101-508) expands the definition of inpatient operating costs to include certain preadmission services.  (See 40.3. )  The statute excludes children's hospitals and cancer hospitals, hospitals located outside the 50 States.  In addition to these categorical exclusions, the statute provides other special exclusions, such as hospitals that are covered under State reimbursement control systems.  These excluded hospitals and units are paid on the basis of reasonable costs subject to the target rate of increase limits.   In accordance with Section 1814 (b) (3) of the Act, services provided by hospitals in Maryland subject to the Health Services Cost Review Commission (provider numbers 21000- 21099) are paid at a lower percentage rate (plus adjustments for sequestration when applicable) instead of determining the payment amount of the claim through the Inpatient Prospective Payment System (IPPS) or the Outpatient Prospective Payment System (OPPS).   For discharges occurring on or after April 1, 1988, separate standardized payment amounts are established for large urban areas and rural areas.  Large urban areas are urban areas with populations of more than 1,000,000 as determined by the Secretary of HHS on the basis of the most recent census population data.  In addition, any New England County Metropolitan Area (NECMA) with a population of more than 970,000 is a large urban area.   The OBRA 1987 required payment of capital costs under PPS effective with cost reporting periods that began October 1, 1991, or later.  A 10-year transition period was provided to protect hospitals that had incurred capital obligations in excess of the standardized national rate from major disruption.  High capital cost hospitals are known as "hold harmless" hospitals.  The transition period also provides for phase-in of the national Federal capital payment rate for hospitals with capital obligations that ar e less than the national rate.  New hospitals that open during the transition period are exempt from capital PPS payment for their first 2 years of operation.  Hospitals and hospital distinct part units that are excluded from PPS for operating costs are al so excluded from PPS for capital costs.  Capital payments are based on the same DRG designations and weights, outlier guidelines, geographic classifications, wage indexes, and disproportionate share percentages that apply to operating payments under PPS.  The indirect teaching adjustment is based on the ratio of residents to average daily census.  The hospital split bill, adjustment bill, waiver of liability and remaining guidelines that have historically been applied to operating payments also apply to capital payments under PPS.  B. - Hospitals and Units Excluded   The following hospitals and distinct part hospital units (DPU) are excluded from PPS and are paid on a reasonable cost or other basis:   Pediatric hospitals whose inpatients are predominately under the age of 18.  Hospitals located outside the 50 States.   Hospitals participating in a CMS -approved demonstration project or State payment control system.   Nonparticipating hospitals furnishing emergency services have not been affected by the PPS statute (P.L. 97- 21).  They are paid under their existing basis.    C. - Situations Requiring Special Handling   1. Sole community hospitals are paid in accordance with the methods used to establish the operating prospective rates for the first year of the PPS transition for operating costs.  The appropriate percentage of hospital -specific rate and the Federal region al rate is applied by the Pricer program in accordance with the current values for the appropriate fiscal year.   2. Hospitals have the option to continue to be reimbursed on a reasonable cost basis subject to the target ceiling rate or to be reimbursed under PPS if the following are met:    Recognized as of April 20, 1983, by the National Cancer Institute as comprehensive cancer centers or clinical research centers;    Demonstrating that the entire facility is organized primarily for treatment of, and research on, cancer; and    Having a patient population that is at least 50 percent of the hospital's total discharges with a principal diagnosis of neoplastic disease.