Provider Types Affected
Inpatient Rehabilitation Facilities (IRFs) submitting claims to Medicare Fiscal Intermediaries (FIs) or Part A/B Medicare Administrative Contractors (A/B MACs) for services provided to Medicare beneficiaries

Provider Action Needed
This article is based on Change Request (CR) 5354 which informs your FI that edits will be implemented within Medicare’s Common Working File (CWF) that will be used when reviewing claims and will match 1) beneficiary discharge dates with 2) admission dates to others providers to identify possible miscoded claims. Claims coded incorrectly will be cancelled and returned to the IRF for correction.

Background
In response to a recommendation by the Office of the Inspector General (OIG), the Centers for Medicare & Medicaid Services (CMS) will implement edits, effective April 1, 2007, to match beneficiary discharge dates with admission dates to other providers in order to identify potentially miscoded claims. Claims identified as transfers will be canceled back to the provider for correction and thus ensure proper payment. For the Inpatient Rehabilitation Facility-Prospective Payment System (IRF-PPS), transfer cases are defined as those in which:

• A Medicare beneficiary is transferred to either:
• Another rehabilitation facility (patient status code 62),
• A long-term care hospital (patient status code 63),
• An inpatient hospital (patient status code 02),

or

• A nursing home that accepts payment under either the Medicare program and/or the Medicaid program (patient status codes 03, 61, or 64); AND
• The length of stay (LOS) of the case is less than the average length of stay (ALS) for a given Case-Mix Group (CMG).

The transfer policy consists of a per diem payment amount which is calculated by dividing 1) the per discharge CMG payment rate, by 2) the average LOS for the CMG. Medicare will pay transfer cases a per diem amount, and an additional half day payment for the first day. Transfer payments will be calculated by:

• First adding the LOS of the case to 0.5 (to account for the addition of the half day payment for the first day), and
• Then multiplying the result by the CMG per diem amount.

IRFs should note that timely filing rules will apply to resubmitted claims.

Additional Information
For complete details, please see the official instruction (CR5354) issued to your FI or A/B MAC regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1099CP.pdf on the CMS Web site.

If you have any questions, please contact your FI or A/B MAC at their toll-free number, which may be found on the CMS Web site at: http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip .
 
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: MM5354
Pub. 100-4, Transmittal# R1099CP, CR# 5354
Related CR Release Date: November 2, 2006
Effective Date: April 1, 2007
Implementation Date: April 2, 2007

Flu Shot Reminder
Flu season is here! Medicare patients give many reasons for not getting their flu shot, including -- “It causes the flu; I don’t need it; it has side effects; it’s not effective; I didn’t think about it; I don’t like needles!” The fact is that out of the average 36,000 people in the U.S. who die each year from influenza and complications of the virus, greater than 90 percent of deaths occur in persons 65 years of age and older. You can help your Medicare patients overcome these odds and their personal barriers through patient education. Talk to your Medicare patients about the importance of getting their annual flu shot -- and don’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot. Remember, influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’s Web site: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf .
 

Posted: 11/10/2006

CPT codes, descriptions, and other data only are copyright 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.