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Printed Date: 9/22/2015
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).
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:
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:
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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Last Updated: 07/23/2020