Resolution Tips for Overlapping Claims

A/B & HHH MAC Collaborative Job Aid for Overlapping Claims

Introduction

This article is intended to assist providers that experience claim rejections for overlapping dates of service. The information contained in this article is designed to give providers tips that can be used to resolve an overlapping billing situation and avoid future overlapping situations.

Overlapping situations can occur for any number of reasons. This article contains information on the most common reasons for which an overlapping situation can occur.

Type of Bills (TOBs) Impacted

The overlapping situations may apply to TOBs:
11X                   72X              81X
13X                   74X              82X
21X                   75X              85X
32X                                                                            

Overlapping Situations

An overlapping situation may occur between hospitals for inpatient stays, which include [Inpatient Psychiatric Hospitals (IPH), Long Term Care Hospitals (LTCH), Inpatient Rehab Facilities (IRF), Critical Access 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 Disease (ESRD) Facilities, or a combination of one provider type and another. Overlapping situations may also occur due to SNF or Home Health consolidated billing, or the Place of Service (POS) submitted on physician claims where the SNF or Home Health has failed to properly discharge the beneficiary where the SNF or Home Health has failed to properly discharge the beneficiary.

Note: If the patient is in a Home Health or SNF, payment arrangements must be agreed upon by both the provider and the supplier.

Resolution Tips for All Provider Types

Medicare providers are expected to verify a beneficiary’s 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 beneficiary’s eligibility records also ensures that the facility/agency verifies whether or not the patient is receiving services from another entity that would cause an overlapping situation.

Medicare providers are expected to 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 Palmetto GBA as soon as it is evident that a resolution cannot be reached. Requests received for claims that are past the timely filing limit will not be processed without good cause as defined in the Medicare Claims Processing Manual. Reference: CMS IOM, Pub. 100-04. Chapter 1, Section 70.7 (PDF, 1.70 MB).

To request assistance with resolving a billing dispute, go to the Billing Disputes Resolution Requests Job Aid and the Billing Dispute Resolution Form (PDF, 295 KB). Ensure that all information is completed as incomplete requests will not be processed. Your request will be processed within 45 business days of the date it was received and we will notify you of the outcome by telephone or letter.

Your MAC may request additional documentation including call logs, letters, or bill attempts, and supporting medical records including transfer agreements, admission orders or discharge summaries.

Please select one of the topics below to view specific facility information.

Inpatient Hospitals
Outpatient Hospitals
Skilled Nursing Facilities (SNFs)
End Stage Renal Disease (ESRD) Facilities
Home Health Agencies
Outpatient Rehab Facilities & Comprehensive Outpatient Rehab Facilities
All Provider Type Overlapping A Hospice
Hospices

Resolution Tips for Inpatient Hospitals

Hospital transfer situation: Hospitals should ensure that the transfer requirements have been met before the transfer takes place. The transferring hospital cannot be paid for the actual date of transfer. The receiving hospital can be paid for the date of the transfer, but not the date of discharge. Hospitals should also ensure that they are submitting their discharge claims with the appropriate discharge status code reflecting the same day admission to the subsequent facility. Reference: CMS IOM,  Pub. 100-04, Chapter 3, Section 20.1.2.4 (PDF, 2.00 MB)

Hospital Discharge Coding: Hospitals should ensure that the patient status is billed accurately for proper payment. If the hospital learns that post-acute care was provided (i.e. left against medical advice, discharged but later readmitted the same day to another IPPS hospital, transferred), the hospital should submit an adjustment bill to correct the discharge status code. Reference: MLN Matters® Article SE1411 (PDF, 786 KB)

Hospital 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 within a 60-day episode of care, the home health agency is required to omit those dates from their final (end of episode) claim. However, both the hospital and the home health agency can be paid for the date of admission to the hospital stay. The home health agency can also receive payment for services rendered to a patient on the date of discharge from an inpatient hospital stay. Reference: CMS IOM, Pub. 100-04, Chapter 10, Section 30.9 (PDF, 1.97 MB)

Hospital overlapping with a Long Term Care Hospital (LTCH): When a patient is admitted to an inpatient acute care hospital, upon discharge from an LTCH and is readmitted to the same LTCH within 3 days, payment is made to the LTCH. The hospital may not bill Medicare, but must look to the LTCH for payment of services. The only exception to this rule is when treatment at an inpatient acute care hospital would be grouped to a surgical DRG. Reference: CMS IOM, Pub. 100-04, Chapter 3, Section 150.9.1.2 (PDF, 2.00 MB)

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, Pub. 100-04, Chapter 3, Section 190.7.1 (PDF, 2.00 MB)

Hospital 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 look to the IRF for payment of services. Reference: CMS IOM, Pub. 100-04, Chapter 3, Section 140.2.4 (PDF, 2.00 MB)

Hospital overlapping with outpatient services: A patient cannot receive inpatient and outpatient services at the same time. In situations where the patient is in outpatient status and later admitted to the same facility as an inpatient without a break in service, all charges are billed on the inpatient claim. Exception: Outpatient diagnostic services furnished provided more than 3 days preceding the date of the admission are not part of the payment window. Reference: CMS IOM, Pub. 100-04, Chapter 3, Section 40.3 (PDF, 2.00 MB)

In situations where the inpatient hospital does not have the technology to perform a procedure and transfers the patient for completion of the procedure, and the patient returns as inpatient, the outpatient hospital must look to the inpatient facility for payment under arrangement.

Hospital overlapping with a SNF: The hospital should ensure that they have submitted the correct admit and discharge dates on their claim. In addition, the correct discharge patient status code must be billed on the claim. If the patient was transferred from a SNF and returned to the SNF prior to midnight, the hospital would need to bill a Same Day Transfer. Reference: CMS IOM. Pub. 100-04, Chapter 3, Section 40.1 (PDF, 2.00 MB)

Repeat Admissions/Leave of Absence: Hospitals may place a patient on a leave of absence when readmission is expected and the patient does not require a hospital level of care during the interim period. Institutional providers must not use the leave of absence billing procedure when the second admission is unexpected. Reference: CMS IOM, Pub. 100-04, Chapter 3, Section 40.2.5 (PDF, 2.00 MB)

  • Same-day, Same-Provider Acute Care Readmissions:
    • If the patient is readmitted on the same day for symptoms related to prior admission then the facility needs to combine the bills to create one continuous stay. The other facility must bill the hospital 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.

Resolution Tips for Outpatient Hospitals

Hospital outpatient overlapping hospital inpatient including Acute, 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 under arrangements. Reference: CMS IOM, Pub. 100-04, Chapter 4, Section 10.2 (PDF, 1.20 MB)

Hospital outpatient overlapping a SNF Part A stay: A patient may receive outpatient hospital care during a covered Part A SNF stay. Certain services maybe part of SNF consolidated billing, and therefore payment received for those services, should be made by the SNF to the outpatient facility. Reference: CMS SNF Consolidated Billing website

Resolution Tips for SNFs

SNF transfer situations: SNFss should ensure that the transfer requirements are met before the transfer takes place. The transferring SNF cannot be paid for the actual date of transfer. The receiving SNF can be paid for the date of the transfer, but not the date of discharge. SNFs should also ensure that they are submitting their discharge claims with the appropriate discharge status code. Reference: CMS IOM, Pub. 100-04, Chapter 6, Section 40.3.4 (PDF, 442 KB)

If the patient was admitted to the hospital and returned to the SNF prior to midnight, the SNF would need to submit a discharge claim and then submit a new claim with a new Admit Date (this would be considered a readmission and the 57 condition code 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, Pub. 100-04, Chapter 6, Section 40.3.2 (PDF, 442 KB)

SNF overlapping with home health care: A patient cannot receive home health care while in a SNF regardless of whether the patient is under a Medicare Part A stay. The home health agency is required to omit dates of service from their claim while the patient is under the care of the SNF between the admit and discharge dates. Reference: CMS IOM. Pub. 100-04, Chapter 6, Section 40.3.4 (PDF, 442 KB)

SNF overlapping with an inpatient hospital: SNF’s can be paid for the date of admission from a hospital, but not the date of discharge should the patient return 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, Pub. 100-04, Chapter 6, Section 40.3.3 (PDF, 442 KB)

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 Part A Stay in a Medicare certified bed. If therapy services are needed from an ORF, the SNF and the ORF must enter into an agreement where services will be paid to the SNF and the SNF will reimburse the ORF. Arrangement examples can be found on the CMS website Reference: CMS IOM, Pub. 100-04, Chapter 6, Section 10.1 (PDF, 442 KB)

SNF overlapping with LTCH: When a patient is admitted to a SNF upon discharge from an LTCH and is readmitted to the same LTCH within 3 days, payment is made to the LTCH. The SNF must look to the LTCH for payment. Reference: CMS IOM 100-04, Chapter 3, Section 150.9.1.2 (PDF, 2.00 MB)

SNF Consolidated Billing: The consolidated billing requirement confers on the SNF the billing responsibility for the entire package of care that residents receive during a Part SNF stay and physical, occupational, and speech therapy services received during a non-covered stay. There are a limited number of services specifically excluded from consolidated billing, and therefore, separately payable. Reference: CMS SNF Consolidated Billing website

Resolution Tips for ESRD Facilities

ESRD overlapping with an inpatient hospital: When a patient is in the hospital a separate payment cannot be made for dialysis services unless the services are excluded from SNF consolidated billing. The ESRD facility can be paid for the date of admission to or the date of discharge from an inpatient hospital. However, the hospitals are responsible for providing dialysis services to a patient while he/she is under inpatient care. Reference: CMS IOM, Pub. 100-04, Chapter 8, Section 10.5 (PDF, 1.80 KB)

Resolution Tips for Home Health Agencies (HHAs)

Home health transfer situations: Only the patient can elect to transfer from one HHA to another. Reference: CMS IOM, Pub., 100-02, Chapter 7, Section 10.8 E (PDF, 464 KB)

When a patient has elected to transfer from one HHA to another, the receiving HHA is required to:

  1. Access the patient’s eligibility records in the Direct Data Entry (DDE) system and print and save a copy of the page that validates whether or not the patient is under an established home health plan of care
  2. Contact the transferring agency to arrange for a transfer date
  3. Document the name of the individual with whom they communicate, the date and time of the contact and the date of transfer
  4. Inform the patient that the initial HHA will no longer receive Medicare payment or provide services after the date of the elected transfer
  5. Document in the patient’s file that he/she was notified of the transfer criteria and possible payment implications
  6. Send a copy of the transfer agreement to the transferring agency
 The transferring agency is required to document the following:
  1. Date and time that the receiving HHA contacted them to inform them of the transfer
  2. Name of the individual from the receiving agency
  3. The date agreed upon for the transfer
  4. Retain a copy of the transfer agreement  

Home Health overlapping inpatient hospital or SNF Part A stay: HHA’s can be paid for the date of admission to an inpatient facility or the date 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 between the admission and discharge dates for an inpatient facility. Reference: CMS IOM, Pub. 100-04, Chapter 10, Section 30.9 (PDF, 1.97 MB)

Home Health overlapping with ORF or CORF: Therapy falls under the consolidated billing requirements, and therefore cannot be paid separately when a patient is under a home 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 be paid to the HHA and the HHA will reimburse the ORF.

Home Health Consolidated Billing: For individuals under a home health plan of care, payment for all services and supplies, with the exception of osteoporosis drugs, DME, and furnishing NPWT using a disposable device is included in the HH PPS base payment rates. HHAs must provide the covered home health services (except DME) either directly or under arrangement, and must bill for such covered home health services. Reference: CMS IOM, Pub. 100-02, Chapter 7, Section 10.11 (PDF, 464 KB) and Home Health Consolidated Billing Master Code List

Resolution Tips for Outpatient Rehab Facilities & Comprehensive Outpatient Rehab Facilities

ORF or CORF overlapping with SNF: Therapy falls under the consolidated billing requirements, and therefore cannot be paid separately when a patient is under a SNF Part A 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 be paid to the SNF and the SNF will reimburse the ORF or CORF.

ORF or CORF overlapping with home health services: Therapy falls under the consolidated billing requirements, and therefore cannot be paid separately when a patient is under a home health plan 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 be paid to the HHA and the HHA will reimburse the ORF or CORF. CMS IOM, Pub. 100-02, Chapter 7, Section 10.11 (PDF, 464 KB)

Resolution Tips for all Provider Type Overlapping a Hospice

Providers of all types whose claims are overlapping a hospice election should contact the Hospice agency to determine 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 terminal illness should be billed with a 07 Condition Code. Reference: CMS IOM Pub. 100-04, Chapter 11, Section 30.3 (PDF, 412 KB).

Providers who suspect 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 assistance.

Resolution Tips for Hospices

Hospice transfer situations: Hospices are expected to ensure that they are verifying a beneficiary’s status in the hospice program. When the patient has chosen 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 be in a position to complete the necessary transfer notification, hospice agencies are encouraged to assist the patient or representative with completing the transfer agreement and notifying the other hospice. Reference: CMS IOM, Pub. 100-02, Chapter 9, Section 20.1 (PDF, 619 KB)

Hospice overlapping with other provider types: Hospices should not encounter overlapping situations with other provider types as hospice care can be 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 terminal illness are to be billed to Medicare by the hospice agency. The hospice should also coordinate with other providers for services that are not related to the terminal illness to ensure accurate billing of non-related services.

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