CMS Pub. 100-04, ch. 1, § 150.4.1

Expedited Determinations Following Appeal of Status Change s

(Rev.13026, Issued: 12-27-24, Effective: 10-11-24, Implementation: 02-15- 25)

The outcome of expedited determinations and reconsiderations based on appeals of

hospital status changes are reported on Medicare claims to assure A/B MAC (A)

adjudication of claims is consistent with QIO decisions. Note that the expedited review

process for timely submitted appeals is completed prior to billing, and therefore does not

directly affect established billing procedures, even demand billing, other than the use of

indicators described below.

Special indicators are used on claims to reflect the outcome of QIO expedited

determinations and reconsiderations. A set of condition codes are used to reflect these

determinations. These condition codes, C1- C7, are known as the QIO approval indicator

codes.

With the advent of the expedited determination process based on appeals of hospital

status changes, these QIO approval indicators are used in new ways on inpatient hospital

claims and skilled nursing facility. The QIO approval indicator code uses described

below are valid for Original Medicare billing on the following Types of Bill: 11x, 18x,

and 21x.

Providers should note that no indicators are required on claims subject to a change in

status where the beneficiary does not request an expedited determination.

A. QIO Decisions Upholding a Change in Status

Providers do not report indicators on claims when they receive notification of decisions

which uphold the provider’s change of the beneficiary’s status from inpatient to

outpatient. Providers do not annotate these claims with condition code C4 to reflect the

QIO denial of the appeal, since the code is defined as “Services Denied” and hospital

services are not denied but will be billed on outpatient Types of Bill. In these cases, SNF

services will not be billed to Original Medicare because there is no qualifying hospital

stay.

B. Reporting of QIO Decisions Reversing a Change of Status

When providers are notified of QIO decisions to reverse a change of status from inpatient

to outpatient, hospitals must bill the beneficiary’s stay using Type of Bill 011x. Hospitals

must annotate these claims with condition code C6, which is defined “Admission

preauthorization” and indicates the QIO has authorized the admission but has not

reviewed the services provided. Hospital shall also add Remarks stating “MCSN” to

specify the circumstance of the review. These indicators will alert A/B MAC (A) that the

beneficiary’s inpatient status has already been subject to review and upheld by the QIO.

When billing for a SNF stay where the 3-day qualifying hospital stay was subject to a

change of status review, SNFs and swing bed providers must also add condition code C6

and Remarks “MCSN” to their Type of Bill 021x or 018x admission claims. These

indicators will alert the A/B MAC (A) that the beneficiary’s inpatient status has already

been subject to review and upheld by the QIO for the qualifying hospital stay dates

reported in occurrence span code 70.

C. Billing Beneficiaries in Cases Subject to Expedited Determinations Related to

Expedited Determinations Following Appeal of Status Change

If an eligible beneficiary requests an appeal timely, they would not be billed during the

QIO appeals process. However, if the appeal is untimely, the hospital may bill a

beneficiary before this QIO process is complete. An eligible beneficiary may file a

request for review by the QIO regarding the change in status after the timely filing

deadline established in regulation (that is, the beneficiary may file the request after

release from the hospital) but the QIO’s determination will be provided on a different

timeframe and the eligible beneficiary will not be entitled to protection from billing

during this time.