31608

FISS Narrative
For discharges for non-teaching Inpatient Prospective Payment System (IPPS) hospitals, inpatient rehabilitation facilities (IRFs) and long term care hospitals (LTCHs) are required to submit informational only bills to Palmetto GBA for MA beneficiaries. In order for these days to be captured by CMS in the disproportionate share hospital (DSH) (or low income patient (LIP) payments for IRF) calculations, non-teaching hospitals are required to submit covered claims with condition code 04. IPPS teaching hospitals have always been required to submit MA claims with condition codes 04 and 69 in order to be reimbursed for the indirect medical education payment. IPPS teaching hospitals must continue to bill inpatient claims with condition codes 04 and 69. This reason code signifies that the claim was submitted with condition code 04 only and the discharge date has been submitted by an IPPS teaching hospital, and condition code 69 is missing.

Explanation and Suggestions:

  • This reason code occurs when a claim contains condition code 04 but the claim is not an inpatient claim from a non-teaching acute care provider, an IRF or an LTCH
  • If the provider is a teaching acute care provider, condition code 04 must be accompanied by condition code 69
  • For outpatient claims or claims from any other provider types other than those mentioned, condition code 04 does not apply and should be removed from the claim
  • Please make the appropriate corrections and resubmit the claim

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