CMS Announces PDPM Claim Edit Enhancements

CMS; Medicare; PDPM

Recently, the Centers for Medicare and Medicaid Services (CMS) posted MLN Matters article MM12896 (Revised) that explains provider actions needed related to recent instructions to Medicare Administrative Contractors (MACs) Enhancements to Patient Driven Payment Model (PDPM) Claim Edits to Improve Claim Processing. 
CMS encourages skilled nursing facility (SNF) provider billers to review this updated guidance due to: 

  • Corrections to edits of SNF Type of Bill (TOB) 21X claims 
  • Changes to certain hospital overlap edits 

The effective date of the policy remains October 1, 2019. The implementation date of the claims system edits to correctly apply the policy for SNF claim payments impacted is April 3, 2023. 
The updated instructions implement changes to correct claims processing edits. SNFs billing on TOB 21X (subject to SNF Prospective Payment System) are subject to these requirements. There aren’t any policy changes. Instead, this corrects Medicare systems to agree with existing policy. 
Specifically, effective October 2019, Medicare systems won’t set the Fiscal Year End edit when providers submit a no-pay TOB 210 or 180. 
Also, effective October 2019, MACs will process and pay an inpatient claim (TOB 11X) and process and pay the inpatient SNF claim (TOB 21X) when the 11X contains a condition code 40, indicating a same day transfer.