CMS Pub. 100-04, ch. 1, § 50.2.1

Non PPS Hospitals and SNFs

Inpatient services in TEFRA hospitals (i.e., hospitals excluded from inpatient prospective

payment system (PPS), cancer and children’s hospitals) and SNFs are billed:

• Upon discharge of the beneficiary;

• When the beneficiary’ benefits are exhausted;

• When the beneficiary’s need for care changes; or

• On a monthly basis.

Hospitals in Maryland that are under the jurisdiction of the Health Services Cost Review

Commission are subject to monthly billing cycles.

Providers shall submit a bill to the FI when a beneficiary in one of these hospitals ceases

to need a hospital level of care (occurrence code 22). FIs shall not separate the

occurrence code 31 and occurrence span code 76 on two different bills. Each bill must

include all applicable diagnoses and procedures. However, interim bills are not to include

charges billed on an earlier claim since the “From” date on the bill must be the day after

the “Thru” date on the earlier bill.

SNF providers shall follow the billing instructions provided in Chapter 6 (SNF Inpatient

Part A Billing), Section 40.8 (Billing in Benefits Exhaust and No-Payment Situations) for

proper billing in benefits exhaust and no-payment situations.

PPS Hospitals

Inpatient acute-care PPS hospitals, inpatient rehabilitation facilities (IRFs), long term

care hospitals (LTCHs) and inpatient psychiatric facilities (IPFs) may interim bill in at

least 60-day intervals. Subsequent bills must be in the adjustment bill format. Each bill

must include all applicable diagnoses and procedures.

All inpatient providers will also submit a bill when the beneficiary’s benefits exhaust.

This permits them to bill a secondary insurer when Medicare ceases to make payment.

Initial inpatient acute care PPS hospital, IRF, IPF and a LTCH interim claims must have

a patient status code of 30 (still patient). When processing interim PPS hospital bills,

providers use the bill designation of 112 (interim bill - first claim). Upon receipt of a

subsequent bill, the FI must cancel the prior bill and replace it with one of the following

bill designations:

• For subsequent interim bills, bill type 117 with a patient status of 30 (still patient);

or

• For subsequent discharge bills, bill type 117 with a patient status other than 30.

(See Chapter 25 for a list of valid patient discharge status codes)

All inpatient providers must submit bills when any of the following occur, regardless of

the date of the prior bill (if any):

• Benefits are exhausted;

• The beneficiary ceases to need a hospital level of care (all hospitals);

• The beneficiary falls below a skilled level of care (SNFs and hospital swing

beds); or

• The beneficiary is discharged.

Effective December 3, 2007, when a beneficiary’s Medicare benefits exhaust in an IPF or

an LTCH, the hospital is allowed to submit a no pay bill (TOB 110) with a patient status

code 30 in 60 day increments until discharge. They no longer have to continually adjust

bills until physical discharge or death. The last bill shall contain a discharge patient

status code.

These instructions for hospitals and SNFs apply to all providers, including those

receiving Periodic Interim Payments (PIP). Providers should continue to submit no-pay

bills until discharge.

NOTE: For stays that necessitate the reporting of more than ten OSCs (i.e., more OSCs

than the claim formats allow), Long Term Care Hospitals, Inpatient Psychiatric Facilities,

and Inpatient Rehabilitation Facilities shall refer to instructions provided in Chapter 32,

section 74.3 of this manual.