CMS Pub. 100-04, ch. 3, § 150.13

Billing LTCH PPS Services

Effective with cost reporting periods beginning on or after October 1, 2002, LTCHs are to

incorporate the following so that A/B MACs (A) accurately price and pay a claim under

the LTCH PPS. These claims must be submitted on Type of Bill 11X.

This is a DRG- based payment system; therefore the LTCH DRG is determined by the

grouping of diagnosis codes reported on the claim for the principal diagnosis, up to

twenty four additional diagnoses, and up to twenty five procedures performed during the

stay, as well as age, sex, and discharge status of the patient on the claim. Grouper

software will determine DRG assignment.

Each bill from an LTCH must contain the complete diagnosis and procedure coding for

purposes of the GROUPER software. Normal adjustments will be allowed. LTCH

providers submit one admit through discharge claim for the stay. Final PPS payment is

based upon the discharge bill (note that the day in which benefits exhaust is considered a

“discharge” for payment purposes).

Effective December 3, 2007, once a patient’s Medicare benefit’s exhaust, the LTCH is

allowed to submit no-pay bills until physical discharge or death.