Mental Health

Inpatient Psychiatric Facilities Billing When Benefits Exhaust Job Aid

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Inpatient Psychiatric Facilities Billing When Benefits Exhaust Job Aid

IPFs must bill Medicare for inpatient services rendered to Medicare patients per the requirements in the CMS' CR 5474 Revised. With the implementation of CR 5474, IPFs submit claims to Medicare as follows:

  • Submit a claim through the patient’s benefits exhaust date and
  • Submit subsequent 60-day no-payment claims through the patient’s final discharge date or date of death

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Benefits Exhaust Date

A patient’s benefit days exhaust when the patient has used all of his/her inpatient hospital benefit days under Medicare in the applicable benefit period. Code this date on the claim with OC A3 and the date on which the last benefit day is available. Note: Patients may not use more than 190 benefit days in a freestanding IPF (due to the 190-day lifetime maximum).

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Submitting Claims Through the Benefits Exhaust Date

To submit claims through the benefits exhaust date, IPFs submit claims as follows:

  • If you did not submit a prior interim claim, submit one claim from admission through the benefits exhaust date:
    • TOB = 112
    • Admission Date = Original admission date
    • Statement from date = Original admission ate
    • Statement through date = Benefits exhaust date
    • PSC = 30
    • OC = A3 with benefits exhaust date
  • If you submitted one or more prior interim claim(s), adjust the most recent claim and add dates/services through the benefits exhaust date:
    • TOB = 117
    • Admission Date = Original admission date
    • Statement from date = Original admission ate
    • Statement through date = Benefits exhaust date
    • PSC = 30
    • OC = A3 with benefits exhaust date

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Incorrect Benefits Exhaust Date and Statement Through Date

We will RTP the claim if you submitted the claim with an incorrect benefits exhaust date and/or statement through date. The statement through date must be equal to the benefits exhaust date and the benefits exhaust date must be correct. When we RTP the claim, we ask you to correct the statement through date, the benefits exhaust date or both dates if you coded them incorrectly. We provide the correct benefits exhaust date if you had coded it incorrectly so you can ensure your claim’s statement through date is equal to this date. If we place the correct benefits exhaust date in the claim’s Remarks field, you may enter it in the claim’s occurrence code field with OC A3.

Make all of the required changes, return the claim to us and watch for it to finalize.

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Submitting No-Payment Claims Following Benefits Exhaust Claim

You may submit no-payment claims once the benefits exhaust claim has finalized. Submit no-payment claims through the patient’s final discharge date or date of death as follows:

  • Submit the first no-payment claim after benefits exhaust:
    • TOB = 110
    • Admission Date = Original admission date
    • Statement from date = Day after benefits exhaust date
    • Statement through date = 60th day or date of discharge or death if final claim
    • PSC = 30 or appropriate PSC if final claim
    • Days/services = All noncovered
  • Submit subsequent no-payment claims after the first no-payment claim finalizes:
    • TOB = 110
    • Admission Date = Original admission date
    • Statement from date = Day after statement through date on prior TOB 110
    • Statement through date = 60th day or date of discharge or death if final claim
    • PSC = 30 or appropriate PSC if final claim
    • Days/services = All noncovered

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Posted 9/24/2021