Innovative Resources for Payors
Medicare FAQs for Claims Management

Questions

  1. Does your system handle all bill types, including interim bills and replacement bills?
  2. How do you handle lab chemistry ad hoc bundling, as practiced by the FIs?
  3. How often do you update your system?
  4. Do you use the Medicare Pricer Code or write your own?
  5. If you write your own, do you confirm it against the Medicare Pricer code?
  6. How do you handle multiple outpatient psychiatric services provided on the same day?
  7. Do OT and PT have any bearing on your psychiatric pricing?
  8. Does your system allow for the payment variations typical of Sole Community Hospitals, Medicare Dependent Hospitals, and Critical Access Hospitals?
  9. On the APC side, how do you price drugs and biologicals?
  10. Can your system reprice any outpatient claim back to the beginning of APCs?
  11. What happens if we drop an inpatient claim (Type of Bill 111), and then drop a TOB 121 on the same patient, with the same account number?
  12. How do you handle TOB 135?
  13. How do you handle TOB 115 for inpatient acute?
  14. Does your OPPS system calculate patient co-payment amounts?
  15. What about annual deductibles?
  16. Does your system consider lengths of stay when calculating inpatient outliers?

Medicare Answers

1. Does your system handle all bill types, including interim bills and replacement bills?

Yes.

2. How do you handle lab chemistry ad hoc bundling, as practiced by the FIs?

We bundle those procedures using exactly the same logic and the same prices.

3. How often do you update your system?

Every time there is a change, we update our system. We read the program memoranda, Federal Register, and transmittals. We scan every Fiscal Intermediary site at regular intervals and download updates to the manuals every quarter.

4. Do you use the Medicare Pricer Code or write your own?

We write our own, because we have found errors in the Medicare OPPS code.

5. If you write your own, do you confirm it against the Medicare Pricer code?

Yes, but if we believe they are wrong–as was the case with the April 2002 Pricer–we follow our own.

6. How do you handle multiple outpatient psychiatric services provided on the same day?

Two or more on the same calendar day result in all being bundled into APC 34, which pays the same as APC 33 (Partial Hospitalization).

7. Do OT and PT have any bearing on your psychiatric pricing?

Sometimes. There are specified circumstances in which one psychiatric service and one therapy are combined into APC 34, as if they both were psychiatric.

8. Does your system allow for the payment variations typical of Sole Community Hospitals, Medicare Dependent Hospitals, and Critical Access Hospitals?

Yes.

9. On the APC side, how do you price drugs and biologicals?

Using the CMS "95 percent of AWP." There are no regional variations for drugs and biologicals. We handle device pass-throughs by using hospital-specific cost-to-charge ratios, and then reducing that amount by the portion of the device that is included in the procedural APC--in other words, exactly as the FIs do it. We do not "estimate."

10. Can your system reprice any outpatient claim back to the beginning of APCs?

Yes, provided you give us the CTC ratios, IMEs (if applicable) and DSHs (if applicable) throughout the period.

11. What happens if we drop an inpatient claim (Type of Bill 111), and then drop a TOB 121 on the same patient, with the same account number?

We price the 111 under DRGs, and the 121 under APCs, exactly as specified by CMS.

12. How do you handle TOB 135?

TOB 135 is "outpatient late charge," which is prohibited under the APC system. Therefore, we ignore those claims.

13. How do you handle TOB 115 for inpatient acute?

Inpatient acute late charges are added to the initial 111 bill and priced anew, except for rehab for which late charges are prohibited.

14. Does your OPPS system calculate patient co-payment amounts?

Yes.

15. What about annual deductibles?

No. Calculating deductibles requires access to the "Common Working File," which we cannot obtain because we are neither a provider nor an FI.

16. Does your system consider lengths of stay when calculating inpatient outliers?

Yes. If there are "non-covered days," the charges associated with those days are excluded from the outlier calculation.