(Medicare Claims Processing Manual)

Effective December 3, 2007, once the patients Medicare benefits exhaust, the IPF is allowed to submit no- pay bills (TOB 110), with a Patient Status Code of 30 every 60 days, until the patient is physically discharged or dies.  The last bill shall contain a discharge patient status code.  IPFs no longer need to continually adjust claims once benefits exhaust.  190.10.3 - Patient Status Coding  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  All patient status (i.e., discharge disposition) codes for 11X TOB are valid, but there are no special payment policies related to transfer codes; for example, discounted or per diem payments in transfer situations.  The same patient status codes applicabl e under inpatient PPS for same day transfers (with Condition Code 40) are applicable under IPF PPS.   190.10.4 - Reporting ECT Treatments  (Rev. 4104, Issued: 08- 03-18, Effective: 10 -01-18, Implementation: 10- 01-18)  IPFs must report on their claims under Revenue Code 0901: the total number of ECT treatments provided to the patient during their IPF stay listed under Service Units.  Providers will code ICD -9-CM procedure code 94.27 if ICD -9-CM is applicable, or, effec tive with the implementation of ICD -10, providers will code the ICD -10-PCS codes listed below in the procedure code field, and for the procedure date will use the date of the last ECT treatment the patient received during their IPF stay.   ICD- 10-PCS Code and Description  GZB0ZZZ -  Electroconvulsive Therapy, Unilateral -Single Seizure  GZB2ZZZ -  Electroconvulsive Therapy, Bilateral -Single Seizure  GZB4ZZZ -  Other Electroconvulsive Therapy   190.10.5 - Outpatient Services Treated as Inpatient Services  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  IPFs are subject to the 1 -day payment window for outpatient bundling rules.  Refer to chapter 3, 40.3 of this manual for more information on bundling rules.  190.10.6 - Patient is a Member of a Medicare Advantage Organization for Only a Portion of a Billing Period  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  The payer at the time of the patients admission to an IPF is responsible for the cost of the entire stay.  This could occur for patients who move from traditional Medicare to a Medicare Advantage plan or vice versa.   190.10.7 - Billing for Interrupted Stays  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  IPFs shall bill for the interrupted stay using Occurrence Span Code 74.  The Occurrence Span Code FROM date equals the day of discharge for the IPF and the THROUGH date is the last day the patient was not present in the IPF at midnight.  For example, the patient leaves the IPF on 1/1 and returns to the IPF on 1/3.  This is considered an interrupted stay and the Occurrence Span Code 74 will show 1/1 -  1/2.  Should the patient return to the IPF on 1/4, two bills will be allowed.  The accommodation Revenue Code 018X (RT 50, field 5), (SV 201), (leave of absence) will continue to be used in the current manner in terms of Occurrence Span Code 74 (RT 40, field 22 -  27) and date range.   190.10.8 - Grace Days  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  There are no grace days allowed under IPF PPS, therefore the date the beneficiary is notified of the provider's intent to bill (Occurrence Code 31) is the last covered day for that patient.   190.10.9 - Billing Stays Prior to and Discharge After PPS Implementation Date  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  If the patients stay begins prior to and ends on or after the providers first fiscal year begin date under IPF PPS, payment to the facility is based on IPF PPS rates and rules. There is no split billing.  If the facility submitted an interim bill, a debit/credit adjustment must be made prior to PPS payment (see chapter 1, 50.2 of this manual).  If the facility submitted multiple interim bills, the facility will need to submit cancels for all bills and then re -bill once the cancels are accepted.   Exceptions:   If the beneficiarys benefits were exhausted or the beneficiary is in a non -covered level of care prior to implementation of IPF PPS, then IPF PPS is not applicable and the IPF will continue to submit no- pay bills (TOB 110) to Medicare.   190.10.10 - Billing Ancillary Services Under IPF PPS  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  There are no special rules for billing IPF inpatient ancillary services.   190.10.11 - Covered Costs Not Included in IPF PPS Amount  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  The following covered services are not included in the IPF PPS discharge payment amount:   o Nursing and allied health education costs are pass -through costs paid outside the IPF PPS.   o DGME and bad debts.  190.10.12 - Same Day Transfer Claims (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)  A same day transfer occurs when a patient is admitted to an IPF and is subsequently transferred for acute care (or another type of inpatient facility care) on the same day.  If the patient is admitted to an IPF with the expectation that the patient will re main overnight, but is discharged before midnight, the day is counted as a full day for the cost report, but is not counted as a Medicare covered day for purposes of charging the beneficiary utilization.   IPFs should show the same day for admission and discharge, and report Condition Code 40 (Same Day Transfer).   If the patient is admitted to an IPF and discharged (not transferred to another inpatient setting) the same day before midnight, the day is counted as a full day for the cost report, and is counted as a Medicare covered day for purposes of charging the ben eficiary utilization.  IPFs do not report Condition Code 40 on this case.  The purpose for the variance in coding is to charge the beneficiary only 1 day utilization where two facilities are billing.  Payment will be made for 1 day.   190.10.13 - Remittance Advice - Reserved  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  Not yet available.   190.10.14 - Medicare Summary Notices and Explanation of Medicare Benefits (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  Existing notices for inpatient hospital PPS are used.  190.11  - Benefit Application and Limits- 190 Days  (Rev. 4104, Issued: 08- 03-18, Effective: 10-01-18, Implementation: 10-01-18)  The psychiatric benefit lifetime maximum of 190 days of inpatient care applies to Medicare participating psychiatric hospitals per 42 CFR 409.62.  The 190- day lifetime limitation does not apply to inpatient psychiatric care provided in certified psychiatric units of an acute care hospital or critical access hospital. Section 409.62 states, There is a lifetime maximum of 190 days on inpatient psyc hiatric hospital services available to any beneficiary.  Therefore, once an individual receives benefits for 190 days of care in a psychiatric hospital, no further benefits of that type are available to that individual.  Payment may not be made for more than a total of 190 days of inpatient psychiatric hospital services during the patient's lifetime.  This limitation does not apply to inpatient psychiatric   services furnished in a non- psychiatric hospital.  This limitatio n does not apply to inpatient psychiatric services furnished in a hospital, a CAH or distinct part psychiatric unit.  The period spent in a psychiatric hospital prior to entitlement does not count against the patient's lifetime limitation, even though pre -entitlement days may have been counted against the 150 days of eligibility in the first benefit period.  The Benefit Period provisions described in Medicare Publication 100-01, Medicare General Information, Eligibility, and Entitlement, chapter 3, 10.4-10.4.4  are applicable to inpatients in either a Medicare participating psychiatric hospital or a certified psychiatric unit of an acute care hospital or critical access hospital.    The CWF keeps track of days paid for inpatient psychiatric services and informs the Medicare contractor on claims where the 190- day limit is reached.   For a more detailed description see Pub. 100-02, Medicare Benefit Policy Manual, chapter 3, 30.C. and chapter 4, 50 for the 190- day lifetime limitation on payment for inpatient psychiatric hospital services.  For details concerning the pre- entitlement inpatient psychiatric benefit reduction provision see Pub. 100-02, Medicare Benefit Policy Manual, chapter 4, 10 - 50.  190.12 - Beneficiary Liability  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  Beneficiary liability will operate the same as under the former TEFRA cost- based payment system.  An IPF may not charge a beneficiary for any services for which payment is made by Medicare, even if the facilitys cost of furnishing services to that beneficiary are greater than the amount the facility is paid under the prospective payment system.   An IPF receiving payment under this subpart for a covered hospital stay (that is, a stay that included at least 1 covered day) may charge the Medicare beneficiary or other person only the applicable deductible and coinsurance amounts under 42 CFR 409.82, 42 CFR 409.83, and 42 CFR 409.87 and for items or services as specified under 42 CFR 489.30 .  For more detailed information regarding lifetime reserve days, refer to Pub. 100-02 Medicare Benefit Policy Manual, chapter 5.   190.12.1 - Benefits Exhaust  (Rev. 1231; Issued:  04-27- 07; Effective:  12 -03-07; Implementation:  12 -03-07)  Effective December 3, 2007, for payment purposes, an IPF discharge occurs when benefits exhaust and the date benefits exhaust (if present) will substitute for the actual discharge date.  The claim is paid based on the benefits exhaust date if present rat her than the discharge date.  The Pricer version used to price claims for the discharge is when the services actually were provided (i.e., when the Medicare beneficiary has Medicare benefits).  No pay/110 TOBs are allowed instead of continually adjusting the claims (117 TOB) until actual discharge occurs once benefits exhaust.   Under TEFRA, the PS&R report used the benefits exhaust date as the discharge date (if present).  This changed when the IPF PPS was implemented, and the 'actual' discharge date was used.  The days stay with the year they occurred, making it easier for the P S&R report (especially during the blend period) to settle the cost report.  This means that:  1. Claims will now be settled on the appropriate cost report;  2. The appropriate PPS -TEFRA blend percentage will be paid;   3. Patients with long lengths of stay will be counted on the correct PS&R report;   4. The PRICER version used will be the one in effect at the time the services were provided (i.e., when the Medicare beneficiary actually has Medicare benefits).   190.13 - Periodic Interim Payments (PIP)  (Rev. 1101, Issued: 11- 03-06, Effective: 01 -01-05, Implementation: 12- 04-06)