How Would You Bill Overlapping Types Of Service To Insurance

This A/B & HHH MAC Collaborative Task Aid is intended to assistance providers with merits rejections for overlapping dates of service. Overlapping situations can occur for any number of reasons. This article contains information on the most mutual reasons for which an overlapping situation tin can occur.

Overlapping Situations

An overlapping situation may occur betwixt hospitals for inpatient stays, which include the post-obit provider types or a combination of the following provider types

Inpatient Psychiatric Hospitals (IPH)
Long Term Care Hospitals (LTCH)
Inpatient Rehab Facilities (IRF)
Critical Admission Hospital (CAH)
Hospitals for outpatient services
Skilled Nursing Facilities (SNFs)
Home Health Agencies (HHAs)
Hospice agencies
Outpatient Rehab Facilities (ORF)
Comprehensive Outpatient Rehab Facilities (CORF)
End Stage Renal Affliction (ESRD) Facilities

Overlapping situations may also occur due to SNF or Home Wellness consolidated billing, or the Place of Service (POS) submitted on physician claims where the SNF or HHA has failed to belch the beneficiary properly.

Annotation: If the patient is in a Home Health or SNF, both the provider and the supplier must concur upon payment arrangements.

Overlapping situations may apply to Types of Bills (TOBs):

Overlapping Claims Resolution Tips – All Provider Types

Medicare providers should verify a beneficiary'southward Medicare eligibility at the time of or prior to admission to ensure that the patient is eligible to receive the services covered by Medicare. Checking the casher'due south eligibility records likewise ensures that the facility/agency verifies whether or not the patient is receiving services from some other entity that would cause an overlapping situation.

Medicare providers should work together to resolve overlap situations. When a billing dispute arises between Medicare providers for dates of services or patient discharge status and neither party is able to reach a resolution, the Medicare contractor is tasked with assisting the providers with resolving the matter. Providers are encouraged to seek assistance from WPS GHA equally soon as it is evident that a resolution cannot be reached. Requests received for claims that are past the timely filing limit will not exist processed without proficient cause equally defined in the CMS Internet-Simply Manual (IOM) Publication 100-04, Chapter 1 , Department 70.vii.

To request assist with resolving a billing dispute, ship documentation proving your dates of service to the Full general Correspondence mailing address. Documentation to send would include documented attempts to contact other provider to correct their claim, nursing notes, doctor's order to admit/discharge (not admission/discharge form), and any other information you experience helps support the dates of service on your merits. Nosotros will process your request within 45 agenda days of the date information technology was received.

Click on the link that applies to your provider type to review the resolution tips.

Inpatient Hospitals
Outpatient Hospitals
Skilled Nursing Facilities (SNF)
Abode Wellness Agencies (HHAs)
Outpatient Rehab Facilities & Comprehensive Outpatient Rehab Facilities
All Provider Types Overlapping A Hospice
Hospices

Overlapping Claims Resolution Tips – Inpatient Hospitals

Hospital transfer state of affairs: Hospitals should ensure that the transfer requirements have been met before the transfer takes place. The transferring hospital cannot be paid for the bodily engagement of transfer. The receiving hospital can be paid for the appointment of the transfer, but not the date of discharge. Hospitals should also ensure that they are submitting their belch claims with the advisable discharge condition lawmaking reflecting the same day admission to the subsequent facility. Reference: CMS IOM Publication 100-04, Chapter 3 , Department twenty.ane.2.four.

Hospital Discharge Coding

Hospitals should ensure that the patient status is billed accurately for proper payment. If the hospital learns that post-astute care was provided (e.yard. left against medical advice, discharged merely afterwards readmitted the aforementioned day to another IPPS hospital, transferred), the hospital should submit an adjustment beak to correct the discharge status code. Reference: MLN Matters® Article SE1411 .

Infirmary Overlapping with Home Health Care

A patient cannot receive home health care while he/she is in an inpatient hospital stay. When the patient is in the hospital that falls inside a lx-twenty-four hours episode of intendance, the dwelling house health agency is required to omit those dates from their final (finish of episode) claim. However, both the infirmary and the dwelling house health agency can exist paid for the engagement of admission to the infirmary stay. The home health agency can also receive payment for services rendered to a patient on the date of belch from an inpatient infirmary stay. Reference: CMS IOM Publication 100-04, Chapter x , Department 30.9.

Infirmary Overlapping with a Long Term Care Infirmary (LTCH)

When a patient is admitted to an inpatient astute care hospital, upon discharge from an LTCH and is readmitted to the same LTCH inside 3 days, payment is fabricated to the LTCH. The infirmary may non bill Medicare but must expect to the LTCH for payment of services. The just exception to this rule is when treatment at an inpatient acute intendance infirmary would be grouped to a surgical DRG. Reference: CMS IOM Publication 100-04, Chapter three , Section 150.9.1.two.

Hospital Overlapping with an Inpatient Psychiatric Facility (IPF)

When the stay is for 3 days or less, verify the IPF has added Occurrence Span Code (OSC) 74 with the associated dates of service. Reference: CMS IOM Publication 100-04, Chapter iii , Section 190.7.one.

Infirmary Overlapping with an Inpatient Rehabilitation Facility (IRF)

When the stay is for 3 days or less, verify the IRF has added Occurrence Span Code 74 with the associated dates of service and the hospital bills Medicare. When the patient is discharged and returns to the same IRF on the same day, the other facility will need to await to the IRF for payment of services. Reference: CMS IOM Publication 100-04, Chapter 3 , Section 140.ii.4.

Hospital Overlapping with Outpatient Services

A patient cannot receive inpatient and outpatient services at the same time. All outpatient diagnostic services and non-diagnostic services related to the inpatient stay that fall within the 3-twenty-four hours (or 1-day) payment window must exist added to the inpatient merits. Reference: CMS IOM Publication 100-04, Chapter 3 , Department 40.3.

In situations where the inpatient hospital does non have the technology to perform a procedure and transfers the patient for completion of the procedure, and the patient returns equally inpatient, the outpatient infirmary must look to the inpatient facility for payment under arrangement. Reference: CMS IOM Publication 100-02, Affiliate 6 , Department ten.

Hospital Overlapping with A SNF

The hospital should ensure that they take submitted the correct admit and discharge dates on their claim. In addition, the correct discharge patient status code must be billed on the merits. If the patient was transferred from a SNF and returned to the SNF prior to midnight, the infirmary would need to bill a Same Day Transfer. Reference: CMS IOM Publication 100-04, Chapter 3 , Section xl.1.

Repeat Admissions/Leave of Absence: Hospitals may place a patient on a exit of absence when readmission is expected and the patient does not require a hospital level of care during the acting menstruum. Institutional providers must non use the leave of absence billing procedure when the second access is unexpected. Reference: CMS IOM Publication 100-04, Chapter 3 , Section 40.2.5.

Same-24-hour interval, Same-Provider Acute Care Readmissions:
- If the patient is readmitted on the aforementioned twenty-four hours for symptoms related to prior admission then the facility needs to combine the bills to create i continuous stay. The other facility must bill the infirmary under arrangement.
- If the patient is readmitted on the same day for symptoms NOT related to the prior admission then two separate claims are required with the second claim having condition code B4. The other facility would bill same day transfer.

Overlapping Claims Resolution Tips – Outpatient Hospitals

Hospital outpatient overlapping hospital inpatient including Astute, IRF, IPF, and LTCH: A patient cannot receive outpatient services simultaneously while admitted to an inpatient facility. Situations arise when an inpatient facility transfers a patient for an outpatient procedure during an inpatient admission. The outpatient facility should look to the inpatient facility for payment nether arrangements. Reference: CMS IOM Publication 100-04, Chapter four , Section 10.2.

Infirmary outpatient overlapping a SNF Office A stay: A patient may receive outpatient infirmary care during a covered Part A SNF stay. Certain services possibly part of SNF consolidated billing, and therefore payment received for those services, should exist fabricated by the SNF to the outpatient facility. Reference: CMS SNF Consolidated Billing.

Overlapping Claims Resolution Tips – Skilled Nursing Facilities (SNF)

SNF Transfer Situations

SNFs should ensure that the transfer requirements are met before the transfer takes place. The transferring SNF cannot be paid for the bodily appointment of transfer. The receiving SNF can be paid for the engagement of the transfer, merely not the engagement of discharge. SNFs should also ensure that they are submitting their discharge claims with the appropriate discharge status code. Reference: CMS IOM Publication 100-04, Chapter six , Section twoscore.three.iv.

If the patient was admitted to the hospital and returned to the SNF prior to midnight, the SNF would demand to submit a belch claim and then submit a new claim with a new Admit Date (this would be considered a readmission and the 57 condition lawmaking may need applied). As a reminder, inpatient admission to a hospital or admission to another SNF forces a discharge from a SNF.
Reference: CMS IOM Publication 100-04, Affiliate 6 , Section 40.3.two.

SNF Overlapping with Home Wellness Care

A patient cannot receive home wellness care while in a SNF regardless of whether the patient is under a Medicare Function A stay. The dwelling house health agency is required to omit dates of service from their merits while the patient is under the care of the SNF between the admit and discharge dates. Reference: CMS IOM Publication 100-04, Chapter half dozen , Department 40.3.4.

SNF Overlapping with An Inpatient Hospital

SNFs tin can exist paid for the date of admission from a infirmary, but not the engagement of discharge should the patient render to the hospital from the SNF. SNFs must also ensure that they are submitting their claims with the correct discharge status code when a patient is returned to the hospital. Reference: CMS IOM Publication 100-04, Chapter six , Section 40.iii.3.

SNF Overlapping with ORF Or CORF

Therapy falls under the consolidated billing requirements, and therefore cannot be paid separately when a patient is under a SNF stay in a Medicare certified bed. If therapy services are needed from an ORF, the SNF and the ORF must enter into an understanding where services will exist paid to the SNF and the SNF volition reimburse the ORF. Arrangement examples can exist found on the CMS' Best Practices Guidelines website. Reference: CMS IOM Publication 100-04, Chapter six , Section 10.1.

SNF Overlapping with LTCH

When a patient is admitted to a SNF upon discharge from an LTCH and is readmitted to the aforementioned LTCH within three days, payment is made to the LTCH. The SNF must look to the LTCH for payment. Reference: CMS IOM Publication 100-04, Chapter 3 , Section 150.9.1.2.

SNF Consolidated Billing

The consolidated billing requirement confers on the SNF the billing responsibility for the entire parcel of intendance that residents receive during a Part SNF stay and concrete, occupational, and speech therapy services received during a not-covered stay. There are a express number of services specifically excluded from consolidated billing, and therefore, separately payable. Reference: CMS SNF Consolidated Billing.

Overlapping Claims Resolution Tips – Home Health Agencies (HHAs)

Home Wellness Transfer Situations

Only the patient can elect to transfer from one HHA to another. Reference: CMS IOM Publication 100-02, Affiliate 7 , Section 10.8 E.

When a patient has elected to transfer from ane HHA to some other, the receiving HHA is required to:

Access the patient'due south eligibility records in the Direct Data Entry (DDE) organization and impress and save a copy of the folio that validates whether or not the patient is under an established abode health program of care
Contact the transferring agency to arrange for a transfer date
Document the proper noun of the individual with whom they communicate, the date and time of the contact and the appointment of transfer
Inform the patient that the initial HHA volition no longer receive Medicare payment or provide services later the date of the elected transfer
Document in the patient'southward file that he/she was notified of the transfer criteria and possible payment implications
Ship a re-create of the transfer agreement to the transferring agency

The transferring agency is required to certificate the following:

Date and time that the receiving HHA contacted them to inform them of the transfer
Proper name of the individual from the receiving agency
The date agreed upon for the transfer
Retain a copy of the transfer understanding

Dwelling house Health Overlapping Inpatient Infirmary or SNF Part A Stay

HHAs tin can be paid for the date of access to an inpatient facility or the engagement of discharge from an inpatient facility. The HHA cannot provide services to the patient while he/she is in an inpatient facility. The HHA omits any dates of service from their claim that fall on the days betwixt the admission and discharge dates for an inpatient facility. Reference: CMS IOM Publication 100-04, Chapter 10 , Section 30.9.

Home Wellness Overlapping with ORF or CORF

Therapy falls under the consolidated billing requirements, and therefore cannot be paid separately when a patient is under a abode health plan of care. If therapy services are needed from an ORF, the HHA and the ORF must enter into an agreement where services will exist paid to the HHA and the HHA will reimburse the ORF.

Habitation Health Consolidated Billing

For individuals under a dwelling house health plan of care, payment for all services and supplies, with the exception of osteoporosis drugs, Durable Medical Equipment (DME), and furnishing Negative Pressure Wound Therapy (NPWT) using a disposable device is included in the HH PPS base payment rates. HHAs must provide the covered home wellness services (except DME) either straight or under arrangement and must bill for such covered home health services. Reference: CMS IOM Publication 100-02, Affiliate vii , Department 10.11 and Home Health Consolidated Billing Chief Code List.

Overlapping Claims Resolution Tips – Outpatient Rehab Facilities & Comprehensive Outpatient Rehab Facilities

ORF or CORF Overlapping with SNF

Therapy falls nether the consolidated billing requirements, and therefore cannot exist paid separately when a patient is under a SNF stay in a Medicare certified bed. If therapy services are needed from an ORF or CORF, the SNF and the ORF or CORF must enter into an agreement where services will exist paid to the SNF and the SNF will reimburse the ORF or CORF. Reference: CMS IOM Publication 100-04, Affiliate half dozen , Section 10.i.

ORF or CORF Overlapping with Home Health Services

Therapy falls under the consolidated billing requirements, and therefore cannot exist paid separately when a patient is under a home wellness program of care. If therapy services are needed from an ORF or CORF, the HHA and the ORF or CORF must enter into an agreement where services will exist paid to the HHA and the HHA will reimburse the ORF or CORF. CMS IOM Publication 100-02, Chapter seven , Section 10.11.

All Provider Types Overlapping A Hospice

Providers of all types whose claims are overlapping a hospice ballot should contact the Hospice agency to decide if the services are related to the terminal illness. If related, payment arrangements should be made with the hospice provider. Services that are not related to the last illness should be billed with a 07 Status Code. Reference: CMS IOM Publication 100-04, Chapter xi , Section 30.3.

Providers who doubtable that the hospice may no longer be in business and are unable to verify if their services are related, or if the hospice has failed to update the revocation indicator should contact their MAC for assist.

Hospices

Hospice Transfer Situations

Hospices are expected to ensure that they are verifying a beneficiary's status in the hospice programme. When the patient has called to change hospices during an election period, the transferring and receiving hospice are expected to agree upon a transfer date before the transfer takes place. The beneficiary or authorized representative is required to ensure that a transfer notice is on file with both hospices at the time of the transfer. Given that hospice beneficiaries are terminally ill and may not exist in a position to complete the necessary transfer notification, hospice agencies are encouraged to assistance the patient or representative with completing the transfer understanding and notifying the other hospice. Reference: CMS IOM Publication 100-02, Affiliate 9 , Section twenty.i.

Hospice Overlapping with Other Provider Types

Hospices should non run into overlapping situations with other provider types as hospice intendance can exist provided in any location that the beneficiary/patient resides whether temporarily or permanently. Once enrolled in the Hospice Medicare Benefit, the hospice is responsible for managing the patient's care that is related to the terminal illness. All services related to the concluding illness are to be billed to Medicare by the hospice bureau. The hospice should likewise coordinate with other providers for services that are not related to the final affliction to ensure authentic billing of not-related services.