(Medicare Claims Processing Manual)

In the regulations at 42 CFR 412.521(e) we provide a payment methodology for such cases in which Medicare will consider all the days of the patient stay in the facility (both prior to and following the date of LTCH designation) to be a single episode of LTCH care. Payment for this single episode of care will include the day and cost data for that patient at both the acute care hospital and the LTCH in determining the payment to the LTCH under the LTCH PPS.  Furthermore, the days of the patients stay both prior to and following designation as a LTCH are counted in determining the patients total length of stay at the LTCH both for payment purposes as well as for the LTCHs avera ge length of stay (ALOS) calculation under 42 CFR 412.23(e)(2) and (3).   Bills paid to the facility for crossover patients when the facility was paid under IPPS must be canceled, so that the entire stay can be billed under the LTCH provider number and paid for under LTCH PPS.  150.15 - System Edits  (Rev. 1472, Issued: 03- 06-08, Effective: 05 -23-07, Implementation: 04- 07-08)  The Shared systems and/or Common Working File (CWF) must ensure:    That revenue code total charges line 0001 must equal the sum of the individual total charges lines;    That the length of stay in the statement covers period, from and through dates equals the total days for accommodations revenue codes 010x- 021x, including revenue code 018x (leave of absence)/interrupted stay;    That Occurrence Span Code 74 is present on the claim when there is an interrupted stay (the beneficiary has returned to the LTCH in a specified amount of time).  See section 150.9.1.2.  If the interruption is greater than the specified number of days applicable to the specific provider, the bill is considered a discharge and two bills would exist if the beneficiary returns to the same LTCH, otherwise it is considered an interruption with one DRG payment associated.  CWF will edit for both of these situations.  Payments under the onsite discharge and readmittance policy are to be reconciled at cost report settlement, at which time it is possible to determine the total number of such cases that have occurred during that cost reporting period.  The accommodation revenue code 018X, (leave of absence) continues to be used in the current manner in terms of Occurrence Span code 74 and date range.   150.16 - Billing Ancillary Services Under LTCH PPS  (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)   When coding PPS bills for ancillary services associated with a Part A inpatient stay, the traditional revenue codes are shown, in conjunction with the appropriate entries in Service Units and Total Charges.    LTCHs are required to report the number of units based on the procedure or service.    LTCHs are required to report the actual charge for each line item, in Total Charges.    In general the current policy applies for billing ancillary services and nothing changes with the implementation of this PPS.   150.17 - Benefits Exhausted  (Rev. 1472, Issued: 03- 06-08, Effective: 05 -23-07, Implementation: 04- 07-08)  The day benefits exhaust is considered a discharge for payment purposes under LTCH PPS.   If a beneficiary's Part A benefits exhaust during the stay, providers code an Occurrence Code A3- C3.  If benefits are exhausted prior to the stay, hospitals submit a no- pay claim that is to be coded by the A/B MAC (A) with no pay code B.   LTCH PPS uses Occurrence Code 47 to indicate the first full day of cost outlier status and also uses Occurrence Span Code 70 for covered non- utilization periods beyond the short -stay outlier threshold.  There is an exception if there are not enough regular  days to reach the short -stay outlier threshold point.  For the beneficiary to continue coverage, LTR days must be utilized for the remainder of the entire stay, as available.  Similarly, for the beneficiary to continue coverage, if only LTR days are avail able, they must be used on a continuous basis throughout the entire stay, as available.  150.17.1 - Assumptions for Use in Examples Below  (Rev. 1, 10- 01-03)  1.  Cost outlier threshold amount is $50,000  2.  Threshold amount is reached on the 25th day  3.  The DRG ALOS equals 12 days, therefore, the Short Stay Threshold equals 10 days  4.  Billed charges are $3,000 per day for the first 12 days, $2,000 on the 13 th day and $1,000 each day thereafter   5.  Beneficiary elects to use any available LTR days   150.17.1.1 - Example 1: Coinsurance Days < Short Stay Outlier Threshold (30 Day Stay)  (Rev. 1, 10- 01-03)  1a. Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $55,000  Benefits available: 9 coinsurance and 60 LTR   Covered days: 30   Noncovered days: 0   Coinsurance days used: 9  LTR days used: 21  Cost report days: 30  Reimbursement: Full DRG payment plus cost outlier based on $55,000 covered charges   1b.  Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $27,000  Benefits available: 9 coinsurance and 0 LTR   Covered days: 9   Noncovered days: 21   Coinsurance days used: 9   LTR days used: 0  Cost report days: 9  OC A3: 1/09/03  Reimbursement: Short stay outlier   1c.  Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $50,000  Benefits available: 9 coinsurance and 10 LTR   Covered days: 19   Noncovered days: 11   Coinsurance days used: 9  LTR days used: 10  Cost report days: 25  OC 47: 1/26/03   OC A3: 1/25/03  OSC 70: 1/20/03 -  1/25/03  Reimbursement: Full DRG payment   150.17.1.2 - Example 2: Coinsurance Days Greater Than or Equal to Short Stay Outlier Threshold (30 day stay)  (Rev. 1, 10- 01-03)  2a.  Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $55,000  Benefits available: 15 coinsurance and 60 LTR   Covered days: 20   Noncovered days: 10   Coinsurance days used: 15  LTR days used: 5  Cost report days: 30  OC 47: 1/26/03   OSC 70: 1/16/03 -  1/25/03  Reimbursement: Full DRG payment plus cost outlier based on $55,000 covered charges   2b.  Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $53,000  Benefits available: 15 coinsurance and 3 LTR   Covered days: 18   Noncovered days: 12   Coinsurance days used: 15  LTR days used: 3  Cost report days: 28  OC 47: 1/26/03   OC A3: 1/28/03  OSC 70: 1/16/03 -  1/25/03  Reimbursement: Full DRG payment plus cost outlier based on $53,000 covered charges   2c.  Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $50,000  Benefits available: 15 coinsurance and 0 LTR   Covered days: 15   Noncovered days: 15   Coinsurance days used: 15  LTR days used:0  Cost report days: 25  OC 47: 1/26/03   OC A3: 1/25/03  OSC 70: 1/16/03 -  1/25/03  Reimbursement: Full DRG payment   150.17.1.3 - Example 3: Coinsurance Days Greater Than or Equal to Short Stay Outlier Threshold (20 day stay)  (Rev. 1, 10- 01-03)  Date of service: 1/1/03 -  1/21/03  Medically necessary days: 20   Covered charges: $45,000  Benefits available: 15 coinsurance and 0 LTR   Covered days: 15   Noncovered days: 5   Coinsurance days used: 15  LTR days used: 0  Cost report days: 20  OSC 70: 1/16/03 -  1/20/03  Reimbursement: Full DRG payment   150.17.1.4 - Example 4: Only LTR Days < Short Stay Outlier Threshold (30 day stay)  (Rev. 1, 10- 01-03)  Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $27,000  Benefits available: 9 LTR   Covered days: 9   Noncovered days: 21   Coinsurance days used: 0  LTR days used: 9  Cost report days: 9  OC A3: 1/09/03 Reimbursement: Short stay outlier payment   150.17.1.4 - Example 4: Only LTR Days < Short Stay Outlier Threshold (30 day stay)  (Rev. 1, 10- 01-03)  Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $27,000  Benefits available: 9 LTR   Covered days: 9   Noncovered days: 21   Coinsurance days used: 0  LTR days used: 9  Cost report days: 9  OC A3: 1/09/03 Reimbursement: Short stay outlier payment   150.17.1.5 - Example 5: Only LTR Greater Than or Equal to Short Stay Outlier Threshold (30 day stay)   5a.  Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $50,000  Benefits available: 12 LTR   Covered days: 12   Noncovered days: 18   Coinsurance days used: 0  LTR days used: 12  Cost report days: 25  OC 47: 1/26/03   OC A3: 1/25/03  OSC 70: 1/13/03 -  1/25/03  Reimbursement: Full DRG payment   5b.  Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $55,000  Benefits available: 60 LTR   Covered days: 30   Noncovered days: 0   Coinsurance days used: 0  LTR days used: 30  Cost report days: 30  Reimbursement: Full DRG payment plus cost outlier based on $55,000 covered charges   5c.  Date of service: 1/1/03 -  1/31/03  Medically necessary days: 30   Covered charges: $53,000  Benefits available: 28 LTR   Covered days: 28   Noncovered days: 2   Coinsurance days used: 0  LTR days used: 28  Cost report days: 28  OC 47: 1/26/03   OC A3: 1/28/03  Reimbursement: Full DRG payment plus cost outlier based on $53,000 covered charges