(Medicare Claims Processing Manual)

Publication 100- 10, The Quality Improvement Organization Manual, Chapter 7, provides detailed instructions regarding QIO responsibilities and procedures related to HINNs.   The FI is responsible for making liability determinations in other cases (e.g., eligibility and reductions of payment).  However, the FI adjudicates claims, makes payment and sends beneficiaries Medicare Summary Notices in all cases, reflecting both QIO an d FI determinations on liability.  This joint responsibility requires that the QIO notify the FI of its denial determinations, all preadmission determinations, and diagnostic or procedural coding changes.  The FI does not issue a denial notice to the benef iciary or the hospital for cases that have been reviewed by the QIO.  The QIO notifies the beneficiary and hospital.  NOTE:   QIO determinations are binding and cannot be reversed by the FI.   150.2.3 - Billing and Claims Processing Requirements Related to HINNs  (Rev. 1472, Issued: 03- 06-08, Effective: 05 -23-07, Implementation: 04- 07-08)  Where QIO review is done prior to billing (preadmission or admission HINN), the hospital reports the results of the QIO's review on the claim using special indicators.  A set of condition codes were created to reflect these reviews.  These codes, C1 - C7, a re known as the QIO approval indicator codes. Information regarding the form locator numbers that correspond to condition codes and a table to crosswalk UB -04 form locators to the 837 transaction is found in Chapter 25.  The FI reviews these codes and makes determinations as follows:    Code C1, C3, or C6 -  Pay as billed.   Code C4 -  Do not pay, but process a no- payment bill.   Blank or Code C5 -  Return the claim to the provider for QIO review, unless the FIs agreement with the QIO requires sending it directly to the QIO.   Where the QIO review occurs after FI processing (postpayment review), the QIO reports adjustments to the FI.  Currently there is no approved electronic format for this report.  150.3 - Skilled Nursing Facility (SNF), Home Health Agency (HHA), Hospice and Comprehensive Outpatient Rehabilitation Facility (CORF) Claims Subject to Expedited Determinations  (Rev. 632, Issued: 07- 29-05, Effective: 01 -03-06, Implementation: 01- 03-06)  In short, SNFs, HHAs, hospices and CORFs must give notice to Medicare beneficiaries of their right to expedited determinations when their period of covered care ends.  Expedited determinations allow beneficiaries to challenge/appeal their providers decisi ons to discharge, whereas the standard appeal process available after a claim is adjudicated allows beneficiaries to dispute payment denials.  Detailed instructions regarding expedited determination notices are found in CMS Transmittal 594.  150.3.1 - Scope of Issuance of Expedited Determination Notices  (Rev. 632, Issued: 07- 29-05, Effective: 01 -03-06, Implementation: 01- 03-06) Expedited determination notices are required prior to discharge when Medicare covered care has been occurring for some type of duration, such as a stay in an inpatient facility, or a period of services delivered under a plan of care supported by a physicia n order.  Generally, intermittent items or services covered under Part B do not trigger the right to expedited determinations, since there is no continuous care to end.  Expedited determinations are available to beneficiaries for each of the specified prov ider types as follows:  HHAs:  Provider initiated discharges for coverage reasons from HH services under a home health plan of care (types of bill 32x and 33x) are subject to expedited determination notices.  Home health services billed on a 34x type of bill are included if there is a therapy plan of care, but not when the HHA is acting as a durable medical equipment supplier in one -time or sporadic delivery of equipment.  SNFs:  Provider initiated discharges for coverage reasons associated with SNF and swing bed inpatient claims (types of bill 18x, 21x and 22x) are subject to expedited determination notices.  Hospices:  Provider initiated discharges for coverage reasons from hospice services (types of bill 81x and 82x), whether in inpatient or home care settings, are subject to expedited determination notices.  Even though revocation represents an end of covere d hospice care, it cannot trigger an expedited determination since it is the beneficiarys, not the providers, choice to revoke.  Hospice discharges related to qualification/coverage specific to the benefit would be rare cases where a beneficiary previously certified as terminally ill is judged no longer to be terminal.  CORFs:  Provider initiated terminations of all covered CORFs services (type of bill 75x) provided under a therapy plan of care are subject to expedited determination notices.  CORF services not provided under a plan of care, such as injections, are not inc luded.  Therapy services provided by outpatient rehabilitation facilities (type of bill 74x) or therapy services in hospital outpatient departments are not included.  Expedited determinations notices are not required when discharge is unrelated to coverage. 150.3.2 - General Responsibilities of QIOs and FIs Related to Expedited Determinations  (Rev. 632, Issued: 07- 29-05, Effective: 01 -03-06, Implementation: 01- 03-06) A.  QIO Role  QIOs review expedited determination notices providers give beneficiaries, both as part of making decisions relative to coverage and to assure providers have given valid notice.  The QIO is responsible for establishing contact with the provider, so that the  beneficiarys medical records can used in making a determination, although QIOs can still make such decisions even if records are not available.  The QIO makes a decision on coverage in answer to the beneficiarys request for review, relaying this decision back to the involved parties.  If the beneficiary does not accept the QIO determination, they may request a reconsideration from a Qualified Independent Contractor (QIC).  B.  Intermediary Role Intermediaries support beneficiaries and providers through an awareness of the expedited determination process and by performing routine duties potentially affected by this process --liability notice oversight, claims processing and medical review.  In the initial implementation of expedited determinations, FIs need to coordinate with QIOs regarding the outcome of QIO r eviews.  As providers begin reporting the outcomes of QIO reviews on claims, the need for this coordination will diminish. Intermediary medical review should never repeat or contradict the results of QIO review regarding coverage, since this would be duplicative and QIO decisions are binding, and QIOs are bound by the same coverage policy in making their determinations --even l ocal policy.  But the scope of these QIO decisions is limited to discharge, and medical review examines a much broader range of potential issues and periods of care.  For example, a monthly SNF claim could include a discharge reviewed by a QIO, but it also contains other days of billing not related to discharge the non- discharge period is not considered by the QIO, and would still be subject to medical review.   150.3.3 - Billing and Claims Processing Requirements Related to Expedited Determinations  (Rev. 1472, Issued: 03- 06-08, Effective: 05 -23-07, Implementation: 04- 07-08)  As noted above, the outcome of expedited determinations and reconsiderations will be reported on Medicare claims to assure intermediary adjudication of claims is consistent with QIO/QIC decisions.  Note that the expedited review process is always completed  prior to billing, and therefore does not directly affect established billing procedures, even demand billing, other than the use of indicators described below.   Special indicators are used on claims to reflect the outcome of QIO expedited determinations and QIC reconsiderations.  Before the creation of the expedited review process, QIO related determinations were reflected only on hospital claims.  A set of condit ion codes were used to reflect these determinations. These codes, C1 - C7, are known as the QIO approval indicator codes.   With the advent of the expedited determination process, these QIO approval indicators are relevant to types of bill other than inpatient hospital claims.  The QIO approval indicator codes described below are valid for Medicare billing on the following type s of bill: 18x, 21x, 22x, 23x, 32x, 33x, 34x, 75x, 81x, 82x.  Since QIO expedited decisions and QIC reconsideration decisions have the same effect on providers and beneficiaries, the same QIO approval indicator codes will be used to report a decision by either entity.  Providers should note that no indicators are required on discharge claims in the case where a generic notice is provided and the beneficiary does not request an expedited determination.  A  Reporting of QIO/QIC Decisions Upholding a Discharge   Providers must also report indicators on claims when they receive notification of decisions which uphold the providers decision to discharge the beneficiary from Medicare covered care.  In these cases, providers submit a discharge claim for the billing period that precedes the determination according to all applicable claims instructions plus one additional data element. Providers must annotate these claims with condition code C4, defined as Services Denied.   Beneficiaries are protected from liability for the period from the delivery of the expedited notice, usually two days before the end of coverage, to the end of the covered period written on the notice if the beneficiary requests an expedited determination timely.  If the beneficiary does not request the determination timely, or if the determination process at the QIO is delayed, the beneficiary may be liable for services provided from the day after the end of the covered period until the date of the actual discharge.   In cases where the beneficiary may be liable, in addition to reporting condition code C4 providers must also report occurrence span code 76, defined as patient liability period, along with the days of liability that have been incurred.  Line items with dates of service falling within this patient liability period are reported with noncovered charges and, if they require HCPCS coding, with modifier TS.  Intermediaries will deny these lines and hold the beneficiary liable.  In certain cases, an Advance Beneficiary Notice (ABN) may be issued simultaneously or immediately following the issuance of an expedited determination notice.  These ABNs would pertain to continued services that the beneficiary wishes to receive despite the providers intent to discharge the beneficiary.  Any required physician orders continue to be needed for the services to continue.  If these ABN situations result in a beneficiarys request for a demand bill to Medicare regarding continuing services after the QIO/QIC has upheld the discharge, providers must report condition code C4 on the demand bill.  The demand bill must otherwise be prepared according to all other applicable instructions.  B  Reporting of QIO/QIC Decisions Not Upholding a Discharge   When providers are notified of QIO/QIC decisions that authorize continued Medicare coverage and do not specify a coverage ending date, they must submit a continuing claim for the current billing or certification period according to all claims instructions for the applicable type of bill, plus a single additional data element.  Providers must annotate these claims with condition code C7, which is defined QIO extended authorization. This indicator will alert FIs/RHHIs that coverage of the services on the claim has already been subject to review.   In the circumstance, expected to be rare, when providers are notified of QIO/QIC decisions which authorize continued Medicare coverage only for a limited period of time, they must submit claims as follows:   If the time period of coverage specified by the QIO/QIC extends beyond the end of the normal billing or certification period for the applicable type of bill, providers submit a continuing claim for that period according to all applicable claims instructions plus two additional data elements.  Providers must annotate these claims with condition code C3, which is defined QIO partial approval and with occurrence span code M0, which is defined QIO approved stay dates, along with the following dates the be ginning date of the coverage period provided by the QIO/QIC, and the statement through date of the claim.    If the time period of coverage specified by the QIO/QIC does not extend to the end of the normal billing or certification period for the applicable type of bill, providers submit a discharge claim according to all applicable claims instructions plus two additional data elements.  Providers must annotate these claims with condition code C3, which is defined QIO partial approval and with occurrence span code M0, which is defined QIO approved stay dates and the dates provided by the QIO/QIC.   NOTE:   Regarding any decision that does not uphold a discharge, QIO/QIC decisions authorizing extended coverage cannot authorize delivery of services if there are not also the required physician orders needed to authorize the care.   C  Billing Beneficiaries in Cases Subject to Expedited Determinations