MLN
Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare &
Medicaid Services) |
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Part A Information
MLN Matters Number: MM6086
Related Change Request (CR) #: 6086
Related CR Release Date: June 13, 2008
Effective Date: October 1, 2008
Related CR Transmittal #: R354OTN
Implementation Date: October 6, 2008
Hospitals Exempt
from Present on Admission (POA) Reporting (i.e. non-Inpatient
Prospective Payment System (IPPS) Hospitals) and the Grouper
Provider Types Affected
IPPS exempt hospitals submitting claims to Medicare
contractors (fiscal intermediaries (FI), and/or Part A/B Medicare
Administrative Contractors (A/B MAC)) for services provided
to Medicare beneficiaries
Provider Action Needed
Impact to You
This article is based on Change Request (CR) 6086, which provides
updated information to hospitals that are exempt from Present
on Admission (POA) reporting, but still report the POA.
What You Need to Know
Although POA reporting is not required for IPPS exempt hospitals,
their claims still process through Grouper. Some exempt hospitals
report the POA, however, due to other payer requirements or
business needs. When exempt hospitals report the POA, they
must include an “X” to indicate the end of POA reporting in
the K3 segment of the claim. The “X” indicator will prevent
Grouper from applying Hospital Acquired Condition (HAC) logic
to the claim.
What You Need to Do
See the Background and Additional Information sections
of this article for further details regarding these changes.
Background
The Deficit Reduction Act (DRA) of 2005 (Section 5001(c);
see http://www.cms.hhs.gov/LegislativeUpdate/downloads/DRA0307.pdf
on the CMS Web site) requires the Centers for Medicare
& Medicaid Services (CMS) to identify (by October 1, 2007)
at least two conditions that:
- Are high cost or high volume or both,
- Result in the assignment of a case to
a diagnosis related group (DRG) that has a higher payment
when present as a secondary diagnosis, and
- Could reasonably have been prevented
through the application of evidence based guidelines.
For discharges occurring on or after October
1, 2008, hospitals will not receive additional payment for
cases in which one of the selected conditions was not present
on admission. That is, the case would be paid as though the
secondary diagnosis were not present.
The DRA (Section 5001(c)):
- Provides that CMS can revise the list
of conditions from time to time, as long as it contains
at least two conditions; and
- Requires hospitals to report “present
on admission (POA)” information for both primary and secondary
diagnoses when submitting claims for discharges on or after
October 1, 2007.
CR 5679 (Transmittal R289OTN, dated July 20, 2007) provided
information on the requirements for completing a Present On
Admission (POA) Indicator for every diagnosis on an inpatient
acute care hospital claim beginning with discharges on or
after October 1, 2007, and provides your Medicare contractor
with the coding and editing requirements, and software modifications
needed to successfully implement this indicator. You can review
CR5679 at http://www.cms.hhs.gov/Transmittals/downloads/R289OTN.pdf
on the CMS Web site.
Exempt providers that report POA information
(due to other payer requirements or any other business need)
must include an “X” to indicate the end of POA reporting in
the K3 segment. The “X” is necessary so that IPPS grouper
software will not apply Hospital-Acquired Condition (HAC)
Diagnosis Related Group (DRG) logic to these claims.
| Note: Effective October
1, 2008, the Fiscal Intermediary Standard System (FISS)
will auto-matically replace any reported “Z” indicator
with an “X” for providers exempt from reporting POA. However,
exempt providers should begin to report an “X” to indicate
the end of POA reporting as soon as possible. |
Additional Information
The official instruction, CR 6086, issued to your FI and A/B
MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R354OTN.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 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.
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