US · guidance
CMS Pub. 100-04, ch. 3, § 150.17
Benefits Exhausted
The day benefits exhaust is considered a “discharge” for payment purposes under LTCH
PPS.
If a beneficiary's Part A benefits exhaust during the stay, providers code an Occurrence
Code A3-C3. If benefits are exhausted prior to the stay, hospitals submit a no-pay claim
that is to be coded by the A/B MAC (A) with no pay code B.
LTCH PPS uses Occurrence Code 47 to indicate the first full day of cost outlier status and
also uses Occurrence Span Code 70 for covered non-utilization periods beyond the short-stay outlier threshold. There is an exception if there are not enough regular days to reach
the short-stay outlier threshold point. For the beneficiary to continue coverage, LTR days
must be utilized for the remainder of the entire stay, as available. Similarly, for the
beneficiary to continue coverage, if only LTR days are available, they must be used on a
continuous basis throughout the entire stay, as available.
History
(Rev. 1472, Issued: 03-06-08, Effective: 05-23-07, Implementation: 04-07-08)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
6456ec51d4f2c1f40a7e0ad3570f65a0644421958262b2668fb49e6be1e13815
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