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MIR-2006-9AB, September 2006
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Modification to CWF Editing of the Existing Interrupted Stay Policy Under Long Term Care Hospital Prospective Payment System (LTCH PPS) (MM5073)
Provider Types Affected
Providers submitting claims to Medicare fiscal intermediaries (FIs) for services to Medicare beneficiaries in long term care hospitals (LTCHs)
Impact on Providers
Impact to You
This article is based on Change Request (CR) 5073 which modifies Medicare’s Common Working File (CWF) editing of the existing interrupted stay policy under the Long Term Care Hospital (LTCH) Prospective Payment System (PPS).
What You Need to Know
Currently, CWF is editing some LTCH claims incorrectly as an interrupted stay when a patient returns to the LTCH after the fixed-day threshold. CR5073 modifies CWF edits to correctly count the number of days applicable to interrupted stays to allow for two separate payments when the patient returns to the same LTCH after the applicable fixed-day threshold.
This is not a change in Medicare policy, but a correction of Medicare’s claims processing system to conform to existing policy.
What You Need to Do
See the Background and Additional Information sections of this article for further details regarding these changes.
Background
The Centers for Medicare & Medicaid Services (CMS) defines “interruption of a stay” as a stay at a Long Term Care Hospital (LTCH) during which a Medicare inpatient is:
- Discharged from the LTCH; and
- Readmitted to the same LTCH within a specified period of time.
Note: For payment purposes, all interrupted stays are treated as one discharge from the LTCH. |
Originally (at the start of the LTCH PPS for FY 2003), the CMS interrupted stay policy addressed the situation where an LTCH patient returns to the same LTCH for additional care after he/she had been admitted to:
- An acute care hospital (ACH);
- An inpatient rehabilitation facility (IRF);
- A skilled nursing facility (SNF); or
- A swing bed.
This original interrupted stay policy is now defined as “greater than three-day interruption of stay.”
LTCH Interrupted Stay Timeframes at the Start of the LTCH PPS
| Provider Type |
Fixed-Day Period |
ACH |
1-9 days if surgical DRG is present on acute care hospital claim |
ACH |
4-9 days if no surgical DRG present on acute care hospital claim |
IRF |
4-27 days |
SNF |
4-45 days |
The day-count of the applicable fixed-day period of an interrupted stay begins on the day of discharge from the LTCH.
Example
For example:
- If a patient was discharged from the LTCH on January 1, 2006, to an ACH, and returns to the same LTCH on January 9, 2006, this would be considered an interrupted stay; but
- If a patient was discharged from the LTCH on January 1, 2006, to an ACH, and returns to the same LTCH on January 10, 2006 (ten-day period), this would not be considered an interrupted stay. In this instance, the LTCH would receive two separate Medicare payments.
In the May 7, 2004 Final Rule (42CFR412) for the LTCH PPS, CMS revised the interrupted stay policy to include a discharge and readmission to the same LTCH within three days, regardless of where the patient goes upon discharge.
You can find the May 7, 2004 Final Rule at the following GPO Web site: http://a257.g.akamaitech.net/7/257/2422/14mar20010800/edocket.access.gpo.gov/
2004/pdf/04-10039.pdf.
Medicare payment for any tests, procedure, or care provided would be the responsibility of the LTCH “under arrangements” with one exception: if treatment in an ACH would be grouped to a surgical DRG, a separate payment would be made to the ACH.
Currently, CWF is editing some LTCH claims incorrectly when the patient is discharged to an acute care hospital and returns to the same LTCH after the fixed-day threshold of nine days.
CR5073 modifies CWF edits applicable to acute care discharges to correctly count the number of days applicable to interrupted stays to allow for two separate payments when the patient returns to the same LTCH from an ACH after the applicable fixed-day threshold of nine days.
CR 5073 also instructs intermediaries to:
- Allow providers to adjust previously processed LTCH interrupted stay claims to allow for two separate payments if they were determined to have been processed incorrectly due to the incorrect counting of the days; and
- Override timely filing for adjusted claims when reprocessing to correct the interrupted stay when received within six months of the implementation date of CR 5073 (January 2, 2007).
Implementation
The implementation date for CR5073 is January 2, 2007.
Additional Information
For complete details, please see the official instruction issued to your intermediary regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1001CP.pdf on the CMS Web site.
If you have any questions, please contact your intermediary at their toll-free number, which may be found at
http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip
 on the CMS Web site.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
MLN Matters Number: MM5073
Related Change Request (CR) #: 5073
Related CR Release Date: July 21, 2006
Effective Date: October 1, 2002
Related CR Transmittal #: R1001CP
Implementation Date: January 2, 2007
Do you have your NPI? National Provider Identifiers (NPIs) will be required on claims sent on or after May 23, 2007. Every health care provider needs to get an NPI. Learn more about the NPI and how to apply for an NPI by visiting
http://www.cms.hhs.gov/NationalProvIdentStand/  on the CMS Web site.
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