(Medicare Claims Processing Manual)

 If the claim change reason code is equal to D5 or D6, type of bill must be equal to XX8 on the provider's request.  If type of bill is not equal to XX8, the A/B MAC (A) rejects the request back to the provider with the message, "Type of bill must be equal to XX8 for claim change reason codes D5 or D6."    If the claim change reason code is equal to D7, an MSP value code (12 -16, 41- 43, or 47) must be present, if a value code, 12 -16, 41- 43, or 47, is not present, the A/B MAC (A) rejects the request back to the provider with the message, "An MSP value code (12- 16, 41 -43, or 47) must be present for claim change reason code D7."    If the claim change reason code is equal to D7, and one or more of value codes 12- 16, 41- 43, and/or 47 is present but each value amount is equal to 0 (zero) or spaces, the A/B MAC (A) rejects the request back to the provider with the message, "invalid value amount for claim change reason code D7."    If the claim change reason code is equal to D8, and a value code 12 -16, 41- 43, or 47 is present, the A/B MAC (A) rejects the claim back to the provider with the message, "Invalid value code for claim change reason D8."    If the claim change reason code is equal to E0, the A/B MAC (A) compares patient status on the provider's request to that on the claim to be adjusted.  If patient status is the same, the A/B MAC (A) rejects the request back to the provider with the message, "Patient status must change for claim change reason E0."   If an adjustment the provider initiates results in a change to a higher weighted DRG, the A/B MAC (A) edits the adjustment request to insure it was submitted within 60 days of the date of the remittance for the claim to be adjusted.  If it is, the A/B MAC (A) processes the claim for payment.  If the remittance date is more than 60 days prior to the receipt date of the adjustment request and results in a change to a lower weighted DRG, the A/B MAC (A) processes the claim for payment and forwards it to CWF.   The A/B MAC (A) must suspend for investigation all adjustment requests with claim change reason codes D4, D8, and D9.  Providers that consistently use D9 will be investigated and, if a pattern of abuse is evident, may be reported to the OIG.   C. - Additional edits   The A/B MAC (A) must perform the following additional edits and investigate adjustment requests the provider submits:    A full denial once the bill is paid, except to accomplish retraction of a duplicate payment;    A change in DRG based on a change in age or sex;    A change in deductible;    An adjustment request that changes a previously submitted QIO adjustment request;    An adjustment of a bill due to a change in utilization or spell data on another bill;    A reopening to change a no- payment bill to a payment bill;    A reopening to pay a previously denied line item;    An adjustment request the provider initiates with a claim change reason code equal to D7, with the Medicare payment amount equal to or greater that the previously paid amount; or    An adjustment request with a claim change reason code equal to E0, and the claim is for a PPS provider.  The A/B MAC (A) must investigate if the change is from patient status 02, transferred to another acute care facility.   50.3 - Late Charges  (Rev. 1, 10- 01-03)  HO- 411.3, HO -IM411.3  Providers billing under Inpatient Hospital PPS, Outpatient PPS, SNF PPS, or HHA PPS may not bill late charges, nor will the contractor accept such bills, for any type of PPS service, inpatient or outpatient.  Charges omitted from the original bill must be submitted on an adjustment bill that contains all pertinent charges including those billed earlier.  When the provider submits late charges on bills to the A/B MAC (A) as bill type XX5, these bills contain only additional charges.  Adjustment requests and not late charge bills should be submitted for    Services on the same day as outpatient surgery subject to the ASC limit,    ESRD services paid under the composite rate,    All inpatient accommodation charges, and    All inpatient PPS ancillaries as adjustment requests.  The provider may submit the following charges omitted from the original paid bill to the A/B MAC (A) as late charges:    Any outpatient services other than the exceptions stated in this paragraph.  This includes late charges for HHA services under either Part A or Part B, hospice services, hospital outpatient services except those on the day of ambulatory surgery subject to the ASC payment limitation, RHC services, OPT services, SNF outpatient services, CORF services, FQHC services, CHMC services, and ESRD services not included in the composite rate; and    Any inpatient SNF ancillaries or inpatient hospital ancillaries other than from PPS hospitals.  The hospital may not  submit late charges (XX5) for inpatient accommodations.  The hospital must submit these as adjustments (bill type XX7).   The A/B MAC (A) has the capability to accept XX5 bill types electronically and process them as initial bills except as described in the following paragraph.   The A/B MAC (A) also performs the following edit routines on any XX5 type bills received:    Pass all initial bill edits, including duplicate checks.    Must not be for any of: Inpatient PPS ancillaries, inpatient accommodations in any facility, services on the same day as outpatient surgery subject to the ASC payment limitation, or ESRD services included in the composite rate.  These are rejected back to the hospital with the message, This change requires an XX7 debit -only or XX8 cancel -only request from you.  Late charges are not acceptable for inpatient PPS ancillaries, inpatient accommodations in any facility, services on the same day as outpatient surgery subject to the ASC payment limitation, or ESRD services included in the composite rate.    When an XX5 suspends as a duplicate, (dates of service equal or overlapping, provider ID equal, HICNs equal, and patient surname equal), the A/B MAC (A) must determine the status of the original paid bill.  If it is denied, the A/B MAC (A) must deny the la te charge bill.    If an xx5 does not suspend as a potential duplicate, the A/B MAC (A) rejects it back to the provider with the message, No original bill paid.  Please combine and submit a single original bill (XX1).    If the original bill was approved and paid, the A/B MAC (A) compares the revenue codes on the original paid bill with the associated late charge bill:    For all providers (any bill type), if any are the same, and are revenue codes 041x, 042x, 043x, 044x, 063x, 076x, or 091x, the A/B MAC (A) or (HHH) rejects the bill back to the provider with the message,  You must submit an adjustment (7) to the original paid bill.  Revenue codes subject to utilization review are duplicated on the late charge bill.    For HHAs (bill type 32X, 33X, or 34X), the A/B MAC (HHH) must apply the same logic for the following additional revenue codes.  If any are the same and are revenue codes 0291, 0293, 055x, 056x, 057x, 058x, 059x, 060x, 066x, the A/B MAC (HHH) rejects the bi ll back to the provider with the message,  "You must submit an adjustment (xx7) to the original paid bill.  Revenue codes subject to utilization review are duplicated on the late charge bill."    For hospital outpatient services (bill type 13X only), the A/B MAC (A) must apply the same logic for the following additional revenue codes.  If any are the same and are revenue codes 0255, 032x, 033x, 034x, 035x, 040x, 062x, 073x, 074x, 092x, or 0943, the  A/B MAC (A) rejects the bill back to the hospital with the message,  "You must submit an adjustment (xx7) to the original paid bill.  Revenue codes subject to utilization review are duplicated on the late charge bill."    For RDFs (bill type 72X or 73X), the A/B MAC (A) must apply the same logic for the following additional revenue codes; if any are the same and are revenue codes 0634, 0635, 082x, 083x, 084x, 085x, or 088x, the A/B MAC (A) rejects the bill back to the provi der with the message, You must submit an adjustment (XX7) to the original paid bill.  Revenue codes subject to utilization review are duplicated on the late charge bill.    If the late charges bill relates to two or more "original" paid bills, and one of these is denied, the A/B MAC (A) must suspend and investigate the late charge bill.   The A/B MAC (A) must compare total charges on the original paid bill with those on the associated late charge bill, and suspend and investigate any XX5 bill type with total charges in excess of those on the original paid bill.  This edit suggests the provi der may have rebilled the already paid services.   The A/B MAC (A) may decide to perform additional edits on late charge bills.   60 - Swing -Bed Services  (Rev. 11396, Issued:05- 04-22, Effective:10 -01-22, Implementation:10- 03-22)  Swing -bed services must be billed separately from inpatient hospital services. Swing- bed hospitals use one provider number when billing for hospital services to identify hospital swing- bed SNF bills. The following alpha letters identify hospital swing -bed SNF bills (for CMS use only, effective May 23, 2007, providers are required to submit only their NPI. NOTE: The swing- bed NPI will be mapped to the 6- digit alpha -numeric CMS Certification Number (CCN.)   "U" = short -term/acute care hospital swing -bed; "W" = long -term hospital swing -bed;  "Y" = rehabilitation hospital swing -bed; and  Z=CAH swing -bed.  Note that CAHs are exempt from the SNF PPS and instead are paid based on 101 percent of reasonable cost for swing -bed services. CAHs are subject to the hospital bundling requirements at section 1862(a)(14) of the Social Security Act and 42 CFR  411.15(m), and therefore, all services provided to a CAH swing-bed patient must be included on the  CAH swing -bed bill (subject to the exceptions at 42 CFR  411.15(m)(3)).  Certified registered nurse anesthetist services paid on a pass -through basis are also to be included on the CAH swing-bed bill.  A. - Inpatient Hospital Services in a Swing -Bed  The patient status code of 03 is inserted on the claim when the beneficiary swings from acute to SNF level of care.  (This constitutes a discharge for purposes of Medicare payment for inpatient hospital services under PPS.) The A/B MAC (A) indicates in the  Statement Covers Through Date  the last day of care at the hospital level.   If the beneficiary is discharged from a Medicare swing -bed and remains in the hospital, there is no need for a no-pay bill.  However, if a beneficiary continues to receive care after completing their stay in a SNF swing-bed, in a NF swing- bed, the hospital  must submit covered claims to Medicare.   B. - SNF Services in a Swing -Bed  Services are billed, in accordance with Chapter 25 with the following exceptions:    The date of admission on the swing- bed SNF bill is the date the patient began to receive SNF level of care services;    State level agreements may call for varying types of bill coding Type of Bill.  The CMS does not perform edits on type of bill coding on bills with 8 in the 2nd digit (bill classification), in FL 18 of the CWF inpatient record if the record is identified  in FL 1 as hospital or SNF. Therefore, the A/B MAC (A) accepts, with subsequent conversion, any bill type agreed to at the State level to identify swing-bed billing, i.e., 18X or 21X. It must be sure the record identification of CWF FL 1 is consistent wit h the provider number shown.    70 - All-Inclusive Rate Providers (Rev. 1, 10- 01-03) A3-3660.4