Provider Contact Center (PCC) Frequently Asked Questions (FAQs): July 2019 - September 2019

Palmetto GBA is publishing the following Frequently Asked Questions (FAQs) based upon data analytics identifying topics generating a high volume of telephone inquiries between July 1, 2019, through September 30, 2019. We hope the answers to the questions below help you maximize your time by reducing your need to contact the Provider Contact Center (PCC).

RTP/Status

7,556

Financial

888

Denial/Reject Explained

7,235

Appeals

966

General

4,723

Billing

1,049

Highest Inquiry Categories for JJA for period July 1, 2019 through September 30, 2019.

RTP/Status

9,682

Financial

1,137

Denial/Reject Explained

7,974

Appeals 1,215
General

2,901

Billing

888

 FAQs Related to Highest Inquiry Categories

Question: Where can I find information regarding billing services rendered prior to Medicare Part A entitlement (pre-entitlement)?

Answer:
If the patient was inpatient and then received Medicare entitlement, you would bill the claim with the original admission date, with the “From” and “Through” dates on the claim being the dates of Medicare entitlement. You may reference MLN Matters Article SE1117 (PDF, 57 KB)and the CMS Internet-Only Manual 100-4, Chapter 3, Section 40 (PDF, 2.05 MB).

Question:
Does Medicare require procedures excluded by statute to be billed on institutional claims?

Answer:
Medicare will not pay for services excluded by statute, which are often services not recognized as part of a covered Medicare benefit. Medicare does not require procedures excluded by statute to be billed on institutional claims submitted to Medicare unless:

  • Established policy requires that either:
    • All services in a certain period, covered or non-covered, to be billed together so that all such services can be bundled for payment consideration or billing is required for reasons other than payment (e.g., utilization chargeable in inpatient settings); or
    • A beneficiary requests Medicare be billed in a manner that the service in question will be reviewed by Medicare

For access to the payment status indicator providers may review the Federal Register for OPPS that usually is updated each November and available on the CMS OPPS website in Addendum B of the Federal Register. Please refer to the article on our website entitled Services Excluded By Statute.

Question:
When do you use the patient discharge status code 04?

Answer:
Discharge status 04 indicates a patient is discharged or transferred to an Intermediate Care Facility (ICF). Patient discharge status code 04 is typically defined at the state level for specifically designated intermediate care facilities. It is also used to designate patients that are discharged or transferred to a nursing facility with neither Medicare nor Medicaid certification, or for discharges/transfers to state-designated assisted living facilities.

Question:
What patient discharge status would be used to discharge a patient to home health care?

Answer:
Discharge status 06 indicates that a patient is discharged/transferred to Home under Care of Organized Home Health Service Organization in Anticipation of Covered Skilled Care. This code should be reported when a patient is:

  • Discharged/transferred to home with a written plan of care for home care services (tailored to the patient’s medical needs), whether home attendants, nursing aides, certified attendants, etc.;
  • Discharged/transferred to a foster care facility with home care; and
  • Discharged to home under a home health agency with durable medical equipment (DME)
    • This code should not be used for home health services provided by a DME supplier or Home IV provider for home IV services

Further information is available on the CMS website (PDF, 154 KB) and on the Palmetto GBA website:

Question: What is the new Skilled Nursing Facility (SNF) default code under Patient Driven Payment Model (PDPM)?

Answer:
The default code under PDPM, which may be used in cases where an assessment is late, is ZZZZZ. The default code under PDPM represents the sum of the lowest per diem rate under each PDPM component, plus the non-case-mix component. In cases where the default code is used, the variable per diem schedule must still be followed.

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