(Medicare Claims Processing Manual)

17. Limited Coverage   For certain procedures whose medical complexity and serious nature incur extraordinary associated costs, Medicare limits coverage to a portion of the cost.   18. Wrong Procedure Performed   Certain external causes of morbidity codes indicate that the wrong procedure was performed.   19. Procedure inconsistent with length of stay (LOS)   The following procedure code should only be coded on claims when the respiratory ventilation is provided for greater than four consecutive days during the length of stay.  Effective with discharges on and after October 1, 2015, ICD -10-PCS code, 5A1955Z -  Respiratory Ventilation, Greater than 96 Consecutive Hours   Prior to this date, discharges on and after October 1, 2012, ICD -9-CM procedure code, 96.72, Continuous invasive mechanical ventilation for 96 consecutive hours or more   20. Unspecified Code   Unspecified codes exist for circumstances when documentation in the medical record does not provide the level of detail needed to support reporting a more specific code. However, in the inpatient setting, there should generally be very limited and rare circumstances for whi ch the laterality (right, left, bilateral) of a condition is unable to be documented and reported.   Effective April 1, 2022, the Unspecified Code edit will be triggered for certain unspecified diagnoses codes currently designated as either a Complication or Comorbidity (CC) or Major Complication or Comorbidity (MCC), that include other codes available in  that code subcategory that further specify the anatomic site, when entered on the claim. This edit message indicates that a more specific code is available to report. It is the providers responsibility to determine if a more specific code from that subcategory is available in the medical record documentation by a clinical provider.   If, upon review, additional information to identify the laterality from the available EHR or paper medical record, or documentation by any other clinical provider is unable to be obtained or there is documentation in the record that the physician is clinic ally unable to determine the laterality because of the nature of the disease/condition, then the provider must enter that information into the remarks section.    The provider should submit the billing note/remarks that best identifies the primary reason why specificity could not be determined:    Billing Note/Remarks  Definition  UNABLE TO DET LAT 1  Provider is unable to obtain additional information to specify laterality.  UNABLE TO DET LAT 2  Physician is clinically unable to determine laterality.   20.2.1.1 - Paying Claims Outside of the MCE  (Rev. 1649; Issued:  12- 18-08; Effective/Implementation Date:  11 -25-08)  All institutional inpatient claims are routed through the MCE before they are processed to payment.  There may be special circumstances, however, when it is necessary to pay claims bypassing MCE edits. The CMS will notify the contractor of these instances.  They include:    New coverage policies are enacted by Congress with effective dates that preclude making the necessary changes timely; and    Errors are discovered that cannot be corrected timely.  A/B MACs (A) are responsible for reporting problems timely.  20.2.1.1.1 - Requesting to Pay Claims Without MCE Approval  (Rev. 1649; Issued:  12- 18-08; Effective/Implementation Date:  11 -25-08)  The contractor may also request approval from the RO in specific situations to pay claims without first sending them through the MCE. Examples of such situations are:    A systems error cannot be corrected timely, and the provider's cash flow will be substantially impacted; and/or    Administrative Law Judge (ALJ) decisions, court decisions, and CMS instructions in particular cases may necessitate that payment be made outside the normal process.   20.2.1.1.2 - Procedures for Paying Claims Without Passing through the MCE  (Rev. 2117, Issued: 12- 10-10, Effective: 01 -12-11, Implementation: 01- 12-11)  Before an inpatient claim may be paid without first going through the MCE, the contractor shall obtain approval from CMS Central Office or the RO.   Note:  In certain situations, contractors bypass the MCE through an established, CMS -instructed claim processing procedure (e.g., to verify a facility is certified to perform a specified service after a MCE limited coverage edit is applied).  Such scenario s do not require approval from the RO as the approval for such a bypass was inherently implied when the established procedure was first implemented.   In all instances involving payment outside the normal inpatient editing process, the contractor applies the following procedures:    Contractors shall submit the claim overriding the MCE using the appropriate field in FISS.    Pay interest accrued through the date payment is made on clean claims. Do not pay any additional interest.    Maintain a record of payment and implement controls to be sure that incorrect payment is not made, i.e., when the claim is paid without being subject to normal editing.   Monitor MCE software to determine when the impediment to processing is removed.    Consider the claim processed for workload and expenditure reports when it is paid.   Submit to the RO Consortium Contractor Manager (CCM) by the 20th of each month a report of all inpatient claims paid without processing through the MCE with the exception of override situations explained in the Note above (e.g., for limited coverage edits) .  The list of claims paid outside of the MCE is to include the following information:   o HIC o DCN o TOB  o DOS (From/Through)  o Provider Number  o MCE/OCE OVR (Claim/Line)  o Reimbursement Amount  o Receipt Date  o Process Date  o Paid Date   Also, include summary data for each edit code showing claim volume and payment.  Any override approvals received and/or relevant JSM references should be annotated on the reports.  20.2.2 - DRG GROUPER Program  (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)   The A/B MAC (A) pays for inpatient hospital services on the basis of a rate per discharge that varies according to the MS -DRG to which a beneficiary's stay is assigned.  Each MS -DRG represents the average resources required to care for a case in that parti cular MS -DRG relative to the national average of resources consumed per case.  The MS -DRG weights used to calculate payment are in the Pricer DRGX file.   The A/B MAC (A) uses the GROUPER program to assign the MS -DRG number.  GROUPER determines the MS-DRG from data elements reported by the hospital.  This applies to all inpatient discharge/transfer bills received from both PPS and non- PPS facilities, including those from waiver States, long- term care hospitals, and excluded units.   The Pricer (PPSMAIN) driver program calls the correct fiscal year GROUPER based upon the discharge date.  If the A/B MAC (A) or shared system writes its own driver program, it must access the GROUPER for the correct FY based on discharge date.  GROUPER doe s not determine the MS -DRG price.  GROUPER input/output are specified below.  The A/B MAC (A) determines the best place in its total system to place the GROUPER program.   Grouper requires the following items:   1. Principal and up to 24 other diagnoses   2. Principal and up to 24 additional procedures   3. Age at last birthday at admission   4. Sex (1=male and 2=female)   5. Discharge destination (patient status code from the claim)   The claim sex coding is M for male and F for female while GROUPER is l for male and 2 for female.  Discharge destination codes are similar to claim definitions for patient status except codes 20 -29 are summarized as 20.  The A/B MAC (A) calculates age at admission.  GROUPER needs age rather than date of birth.  Grouper responds with the following information:   1. Major diagnostic category   2. MS-DRG number   3. Grouper return code (a one position code indicating the action taken by the program)   4. Procedure code used in determining the MS -DRG  5. Diagnosis code used in determining the MS -DRG  6. Secondary diagnosis code used in determining the MS -DRG, if applicable   20.2.3 - PPS Pricer Program  (Rev. 1, 10- 01-03)  A3-3615.3, A3- 3656.3   The CMS provides a Pricer program to determine the price upon which to base payment under prospective payment.  A separate Pricer installation guide is provided.  The A/B MAC (A) uses the Pricer appropriate for the date of discharge.   After GROUPER determines the DRG, the A/B MAC (A) 's system calls the Pricer program.  Pricer determines the price to pay and prepares a report.   Four data files are included.  CMS maintains three:    DRGX file -  contains DRG weights, average length of stay and outlier cutoff points.   MSAX file -  contains urban and rural wage indexes used in calculating payment.  CMS may request that the A/B MAC (A) make interim changes to this file when index changes are issued for individual hospitals after issuance of Pricer for the period.   RATE file -  contains census division values and updating amounts used in calculating payment.   The A/B MAC (A) maintains the provider -specific file, (PROV file).  This contains information about the facts specific to the provider that affect computations, e.g., effective dates for PPS, type of provider (for application of special computation rules), census division, MSA, adjusted cost per discharge, disproportionate share adjustment percentage, and capital data.   Pricer also calculates the disproportionate share adjustment and adds it to the DRG payment.  Correct calculation depends upon the accuracy of related information the A/B MAC (A) includes in the PRICER PROV file.   The Pricer program applies the DRG relative weights, hospital urban or rural and census division location, provider -specific data, and beneficiary hospital data from the bill to determine the amount payable for each PPS discharge bill.   Pricer uses the Intern -to-Bed ratio in calculating the indirect teaching adjustment for operating costs for the A/B MAC (A) to accumulate and use in related payments.  Pricer uses the intern -to-average daily census ratio to calculate the indirect teaching adjustment for capital costs.  The A/B MAC (A) ensures that these ratios are available for Pricer to compute payment for teaching hospitals.  It includes the ratios in its PROV file to ensure that cost outliers are not overpaid to its teaching hospitals.   Pricer does not calculate utilization days required for the PS&R, CWF, or cost report.  It does not determine the amount to pay after deduction for deductible, coinsurance, or the primary payment where Medicare is secondary.  The A/B MAC (A) must calculate the price and make adjustments to the price furnished before making payment.  The A/B MACs (A) use the Pricer implementation guide for information concerning Pricer processing reports, input parameters and data requirements.   20.2.3.1 - Provider -Specific File  (Rev. 3836, Issued: 08 -18-17, Effective: 11-21-17, Implementation: 11-21-17)  The PROV file contains needed information about each provider to enable the pricing software to calculate the payment amount.  The FI maintains the accuracy of the data in accordance with the following criteria.   Whenever the status of any element changes, the FI prepares an additional record showing the effective date.  For example, when a hospital's FY beginning date changes as a result of a change in ownership or other "good cause," the FI makes an additional record showing the effective date of the change.   The format and data required by the PRICER program and by the provider-specific file is found in Addendum A.  The FIs submit a file of provider-specific payment data to CMS CO every three months for PPS and non- PPS hospitals, inpatient rehabilitation hospitals or units (referred to as IRFs), long term care hospitals (LTCHs), inpatient psychiatric facilities (IPFs), SNFs, and hospices, including those in Maryland.  Regional home health FIs (RHHIs) submit a file of provider specific data for all home health agencies.  FIs serving as the audit FI for hospital based HHAs do not submit a file of provider specific data f or HHAs.