Overlapping Claim Tips for Resolution

Overlapping Claim Tips for Resolution
Type of Bills Impacted
Inpatient Hospital Overlap Tips
Hospital Discharge Coding
Hospital Overlapping with Home Health Care
Hospital Overlapping with an LTCH
Hospital Overlapping with an IPF
Hospital Overlapping with an IRF
Hospital Overlapping with Outpatient Services
Hospital Overlapping with a SNF
Repeat Admissions/Leave of Absence
Same-day, Same-Provider Acute Care Readmissions
Outpatient Hospitals Tips
Skilled Nursing Facility Tips
SNF Overlapping with Home Health Care
SNF Overlapping with an Inpatient Hospital
SNF Overlapping with ORF or CORF
SNF Overlapping with LTCH
SNF Consolidated Billing
Home Health Agencies Overlap Tips
Requirements for the receiving HHA
HHAs overlapping with an ORF or CORF
HHA and Consolidated Billing
Hospice Overlap Tips
Hospice overlapping other provider types

Overlapping Claim Tips for Resolution

Overlapping situations can occur for any number of reasons. An overlapping situation may occur between hospitals for inpatient stays, home health agencies, outpatient services and hospice agencies. Overlapping situations may also occur due to SNF or home health consolidated billing, or the POS submitted on physician claims where the SNF or home health has failed to properly discharge the beneficiary.

Medicare providers are expected to verify a beneficiary's Medicare eligibility at the time of or prior to admission to ensure that the patient is eligible to receive the services covered by Medicare. Checking the beneficiary's eligibility records also ensures that the facility/agency verifies if the patient is receiving services from another entity that would cause an overlapping situation.

Medicare providers are expected to work together to resolve overlap situations. Should a dispute arise and neither party can reach a resolution, the Medicare contractor is tasked with assisting to resolve the matter. Providers are encouraged to contact National Government Services as soon as it is discovered that a resolution cannot be reached.

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Type of Bills Impacted

11X, 13X, 21X, 32X, 72X, 74X, 75X, 81X, 82X, 85X

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Inpatient Hospital Overlap Tips

Hospital Transfer Situation: It is the responsibility of the hospitals to ensure that the transfer requirements have been met before the transfer takes place. The transferring hospital cannot be paid for the actual date of transfer. The receiving hospital can be paid for the date of the transfer, but not the date of discharge. Hospitals should also make sure that they are submitting their discharge claims with the appropriate discharge status code reflecting the same day admission to the subsequent facility.

Hospital Discharge Coding

Hospitals are responsible to ensure that the patient status is billed accurately based on the discharge plan for the patient. If the hospital learns that post-acute care was provided (i.e. transferred, left against medical advice, discharged but later readmitted the same day to another IPPS hospital), the hospital should submit an adjustment bill to correct the discharge status code.

Hospital Overlapping with Home Health Care

A patient cannot receive home health care while he/she is in an inpatient hospital stay. If a home health claim is received, and the CWF finds dates of service on that claim that fall within the dates of an inpatient, SNF or swing bed claim (not including the dates of admission, discharge, or dates for leave of absence), the Medicare systems will reject the home health claim.

Hospital Overlapping with an LTCH

When a patient is admitted to an inpatient acute care hospital, upon discharge from an LTCH and is readmitted to the same LTCH within three days, payment is made to the LTCH. The hospital may not bill Medicare, but must look to the LTCH for payment of services. See CMS IOM, Publication 100-04, Chapter 3, Section 150.9.1.2

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Hospital Overlapping with an IPF

When the stay is for three days or less, verify the IPF has added OSC 74 with the associated dates of service.

Hospital Overlapping with an IRF

When the stay is for three days or less, verify the IRF has added OSC 74 with the associated dates of service and the hospital bills Medicare. When the patient is discharged and returns to the same IRF on the same day, the other facility will need to look to the IRF for payment of services.

Hospital Overlapping with Outpatient Services

A patient cannot receive inpatient and outpatient services at the same time. In situations where the patient is in outpatient status and later admitted to the same facility as an inpatient without a break in service, all charges are billed on the inpatient claim.

Exception: Outpatient diagnostic services furnished provided more than 3 days preceding the date of the admission are not part of the payment window. See CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 40.3

In situations where the inpatient hospital does not have the ability to perform a procedure and transfers the patient to another facility to receive the services and the patient returns as inpatient, the other facility must look to the inpatient facility for payment under arrangement.

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Hospital Overlapping with a SNF

It is the responsibility of the hospital to ensure that they have submitted the correct admit and discharge dates on their claim. In addition, the correct discharge patient status code must be billed on the claim. If the patient was transferred from a SNF and returned to the SNF prior to midnight, the hospital must bill a Same Day Transfer.

Repeat Admissions/Leave of Absence

Hospitals may place a patient on a leave of absence when readmission is expected and the patient does not require a hospital level of care during the interim period. Institutional providers must not use the leave of absence billing procedure when the second admission is unexpected.

Same-day, Same-Provider Acute Care Readmissions

If the patient is readmitted on same day for symptoms related to prior admission, then the facility must combine bills to create one continuous stay and the other facility must bill the hospital under arrangements.
If the patient is readmitted on same day for symptoms not related to prior admission, then two separate claims are required with the second claim having condition code B4. The other facility will bill same day transfer.

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Outpatient Hospitals Tips

ORF or CORF Overlapping with SNF: Therapy falls under the consolidated billing requirements and therefore cannot be paid separately when a patient is in a SNF Part A Stay in a Medicare certified bed. If therapy services are needed from an ORF or CORF, the SNF and the ORF or CORF must enter into an agreement where services will be paid to the SNF and the SNF will reimburse the ORF or CORF.

ORF or CORF Overlapping with Home Health Services: Therapy falls under the consolidated billing requirements and therefore cannot be paid separately when a patient is under a home health plan of care. If therapy services are needed from an ORF or CORF, the HHA and the ORF or CORF must enter into an agreement where services will be paid to the HHA and the HHA will reimburse the ORF or CORF.

Skilled Nursing Facility Tips

SNF Transfer Situation: SNFs are responsible to ensure that the transfer requirements are met before the transfer takes place. The transferring SNF cannot be paid for the actual date of transfer. The receiving SNF can be paid for the date of the transfer, but not the date of discharge. SNFs should also ensure that they are submitting their discharge claims with the appropriate discharge status code.

SNF Overlapping with Home Health Care

A patient cannot receive home health care while in a SNF regardless of whether the patient is under a Medicare Part A stay. The home health agency is required to omit dates of service from their claim while the patient is under the care of the SNF between the admit and discharge dates.

SNF Overlapping with an Inpatient Hospital

SNFs can be paid for the date of admission from a hospital, but not the date of discharge should the patient return to the hospital from the SNF. SNFs must also ensure that they are submitting their claims with the correct discharge status code when a patient is returned to the hospital.

SNF Overlapping with ORF or CORF

Therapy falls under the consolidated billing requirements, and therefore cannot be paid separately when a patient is under a SNF Part A Stay in a Medicare certified bed. If therapy services are needed from an ORF, the SNF and the ORF must enter into an agreement where services will be paid to the SNF and the SNF will reimburse the ORF. Arrangement examples can be found in the CMS Best Practices Guidelines.

SNF Overlapping with LTCH

When a patient is admitted to a SNF upon discharge from an LTCH and is readmitted to the same LTCH within three days, payment is made to the LTCH. The SNF must look to the LTCH for payment.

SNF Consolidated Billing

The consolidated billing requirement confers on the SNF the billing responsibility for the entire package of care that residents receive during a Part SNF stay and physical, occupational and speech therapy services received during a non-covered stay. There are a limited number of services specifically excluded from consolidated billing, and therefore, separately payable.

Home Health Agencies Overlap Tips

Home Health Transfers: Only the patient can elect to transfer from one HHA to another.

Requirements for the receiving HHA

Verify the patient’s eligibility using the DDE system. Print and save a copy of the validation report for your records.
Contact the transferring agency to verify the transfer date.
Document the date, time and name of contact whom you spoke with to validate the transfer.
Inform the patient that the former HHA will no longer receive Medicare payments or provide services after the elective date of transfer.
Document in the patients file that he/she was notified of the transfer requirements and possible payment implications.
Send a copy of the transfer agreement either by certified mail, fax or email. Keep a copy of the certified tracking number, the fax transmittal of receipt and the email for record.

The transferring agency is required to document the following:

Date, time and name of person(s) of the receiving HHA whom contacted them to inform them of transfer.
Date agreed upon for transfer
Retain a copy of the agreement by certified mail, fax or mail.

HHAs overlapping inpatient hospital or SNF Part A stay: HHAs can be paid for the date of admission to an inpatient facility or the date of discharge. The HHA will not provide services to the patient while in the inpatient setting. The HHA will omit any days from their claim where the patient is within the care of the inpatient facility.

HHAs overlapping with an ORF or CORF

Therapy services fall under the consolidated billing requirements and therefore cannot be paid separately. If therapy services are needed for the ORF, the HHA and the ORF would need to enter in an agreement where services will be paid to the HHA for therapy and then the ORF would be reimbursed.

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HHA and Consolidated Billing

For patients under the home health plan of care, payments for all services and supplies, with the exception of osteoporosis drugs, DME, and furnishing NPWT sing a disposable device is included in the HHPPS base payment rates. HHAs must provide the services (except DME) either directly or under arrangement and would bill for covered home health services.

Hospice Overlap Tips

Hospice Transfer: Hospice agencies are required to verify patient eligibility in the hospice program. When the patient elects to transfer within the current hospice benefit period, both hospice agencies must:

Agree on a transfer date before the transfer takes place.
Document for patients file

Hospice overlapping other provider types

Other provider types should work with the hospice to determine if the services rendered are a part of the Hospice Plan of Care. If the services are related, the other facility will bill the services to the hospice and the other facility would then be reimbursed from the hospice. If the services are not related, the other facility would bill their claim to Medicare with Condition Code 07 present on the claim.

Overlapping Claim Tips for Resolution

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