Occurrence Code 50: Reminders

Published 03/08/2019

Occurrence Codes identify a significant event relating to an institutional claim that may affect payer processing. These codes are claim-related occurrences that are related to a time period (span of dates).

Tips:

  • Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) will use occurrence code 50 to report the date on which assessment data was transmitted to the CMS National Assessment Collection Database
  • Occurrence code 50 must be reported on all IRF PPS (11x bill types)
  • Medicare will return such claims as unprocessed if the provider fails to include occurrence code 50
  • Providers must append an occurrence code 50 with the Assessment Reference Date for each Health Insurance Prospective Payment System Code (HIPPS) reported on the claim
  • HIPPS code AAAxx (where “xx” is varying digits) does not need an accompanying occurrence code 50
  • Skilled Nursing Facility (SNF) providers must ensure that each HIPPS code reported on the claim is billed in the order in which that level of care is received for the month
  • SNF and Swing Bed (SB) PPS providers must include occurrence code 50 for each revenue code 0022 on 21x and 18x bill types, except where the HIPPS code reported with the 0022 revenue code is AAAxx
  • Only one occurrence code 50 needs to be reported for 2 (two) HIPPS code lines that both end in the same two digits for the following HIPPS: xxx05, xxx06, xxx12, xxx13, xxx14, xxx15, xxx16, xxx17, xxx24, xxx25, xxx26, xxx34, xxx35, xxx36, xxx44, xxx45, xxx46, xxx54, xxx55 and xxx56, where “xxx” is varying digits

Reason Code: 31346
This reason code indicates that you entered a value code without the corresponding occurrence code or vice versa. For example, value code 50 is present but no occurrence code 35 is present; or an occurrence code 35 is present but no value code 50 was reported.

Resolution:

  • Verify billing and if appropriate, correct
  • When billing revenue code 42x, the occurrence code 35 (date treatment began), occurrence code 11 (onset of illness/injury) and the value code 50 (cumulative number of visits) must appear on the claim
  • Value code 50 is entered as a dollar amount, e.g.., 10 visits would appear as 10.00

Reason Code 37096
When providers submit claims to their MAC prior to the Inpatient Rehabilitation Facility (IRF) – Patient Assessment Instrument (PAI) completing processing at the CMS National Assessment Collection Database, Reason Code 37096 will return the claim to the provider. It is important to remember that prior to submission of your IRF claim to FISS, you must have an IRF-PAI that has completed processing at the CMS National Assessment Collection Database. The provider can verify this by reviewing their IRF-PAI validation report.

Resolution:

  • Do not submit your claim until the IRF-PAI has completed processing at the CMS National Assessment Collection Database
  • Providers may want to add an additional claim hold day(s) on their claim submission to allow IRF-PAI completing processing and to avoid claims being returned with Reason Code 37096
  • Use Occurrence Code 50 to indicate assessment date

References:

  • Claims Submission Error Help:
  • Systematic Validation of Payment Group Codes for Prospective Payment Systems (PPS) Based on Patient Assessments (SE1342) (PDF, 176 KB)
  • Inpatient Rehabilitation Facility (IRF) Coverage & Documentation Webcast Handout