Billing OP/oObs for Denied IP Claims
This may be old news but since this has been a subject line in the past, thought I would forward.
******************************************************************************
Jurisdiction 1 Part A
Administrative Law Judge (ALJ) Decisions: Impact on Some Inpatient Medicare Claims
The Centers of Medicare & Medicaid Services (CMS) addressed recent Administrative Law Judge (ALJ) decisions that affect the final payment for certain denied inpatient Medicare claims.
CMS has issued instructions for Medicare contractors to permit the processing of inpatient claims that were denied as not reasonable and necessary to process on an outpatient basis or at an observation level of care. CMS understands that the ALJ order conflicts with Chapter 6, sections 10 and 20.6 of the Medicare Benefit Policy Manual (Publication 100-02) and Chapter 1, section 50.3 of the Medicare Claims Processing Manual (Publication 100-04). Please note: This action is being taken only to effectuate these specific ALJ orders.
Background:
If at least $130 remains in controversy following the Qualified Independent Contractor’s (QIC) decision, a party to the reconsideration may request an ALJ hearing within 60 days of receipt of the reconsideration decision. (Refer to the reconsideration decision letter from the QIC for details regarding the procedures for requesting an ALJ hearing.)
Providers Type Affected:
Medicare hospitals as defined by Social Security ACT §1886(d) and paid under the Medicare Inpatient Prospective Payment System.
What You Need to Know:
•Palmetto GBA will notify the provider by letter within 30 days of receiving the ALJ decision to secure a new replacement claim with the appropriate outpatient HCPCS code
•The inpatient claim will be canceled in the FISS system by the Claims Department at Palmetto GBA. A line item charge for observation may only be included if there was an order for observation.
•In the absence of an order for observation, the observation charges should not be included if the ALJ only specified payment for outpatient care or services
•However, if the ALJ specified 'observation level of care' or 'including observation care,' line item charges for observation may be added if otherwise appropriate, as the ALJ is specifically substituting the order to admit for the order for observation.
•Provider must include in the remarks section of the claim the inpatient DCN, the ALJ rebilling code and the observation (OB575) code if applicable upon rebilling.
•If Palmetto GBA does not receive a replacement claim from the provider within 180 days, the case will be closed and effectuation complete.
•The beneficiary must be refunded the difference between any Part A deductible and/or coinsurance and Part B deductible/coinsurance.
•Palmetto will bypass or override timely filing requirements and any other edits (including medical review), if necessary, to issue payment.
Additional information:
These instructions should not be construed or interpreted as a change in the policy outlined in these manual sections. Providers should continue to follow existing policy and practices in all situations where there is not a conflicting ALJ order.
Sharon
******************************************************************************
Jurisdiction 1 Part A
Administrative Law Judge (ALJ) Decisions: Impact on Some Inpatient Medicare Claims
The Centers of Medicare & Medicaid Services (CMS) addressed recent Administrative Law Judge (ALJ) decisions that affect the final payment for certain denied inpatient Medicare claims.
CMS has issued instructions for Medicare contractors to permit the processing of inpatient claims that were denied as not reasonable and necessary to process on an outpatient basis or at an observation level of care. CMS understands that the ALJ order conflicts with Chapter 6, sections 10 and 20.6 of the Medicare Benefit Policy Manual (Publication 100-02) and Chapter 1, section 50.3 of the Medicare Claims Processing Manual (Publication 100-04). Please note: This action is being taken only to effectuate these specific ALJ orders.
Background:
If at least $130 remains in controversy following the Qualified Independent Contractor’s (QIC) decision, a party to the reconsideration may request an ALJ hearing within 60 days of receipt of the reconsideration decision. (Refer to the reconsideration decision letter from the QIC for details regarding the procedures for requesting an ALJ hearing.)
Providers Type Affected:
Medicare hospitals as defined by Social Security ACT §1886(d) and paid under the Medicare Inpatient Prospective Payment System.
What You Need to Know:
•Palmetto GBA will notify the provider by letter within 30 days of receiving the ALJ decision to secure a new replacement claim with the appropriate outpatient HCPCS code
•The inpatient claim will be canceled in the FISS system by the Claims Department at Palmetto GBA. A line item charge for observation may only be included if there was an order for observation.
•In the absence of an order for observation, the observation charges should not be included if the ALJ only specified payment for outpatient care or services
•However, if the ALJ specified 'observation level of care' or 'including observation care,' line item charges for observation may be added if otherwise appropriate, as the ALJ is specifically substituting the order to admit for the order for observation.
•Provider must include in the remarks section of the claim the inpatient DCN, the ALJ rebilling code and the observation (OB575) code if applicable upon rebilling.
•If Palmetto GBA does not receive a replacement claim from the provider within 180 days, the case will be closed and effectuation complete.
•The beneficiary must be refunded the difference between any Part A deductible and/or coinsurance and Part B deductible/coinsurance.
•Palmetto will bypass or override timely filing requirements and any other edits (including medical review), if necessary, to issue payment.
Additional information:
These instructions should not be construed or interpreted as a change in the policy outlined in these manual sections. Providers should continue to follow existing policy and practices in all situations where there is not a conflicting ALJ order.
Sharon