CMS Issues Correction to Medicare PDPM Claim Edits

CMS; Medicare; PDPM

​​The Centers for Medicare and Medicaid Services (CMS) recently issued a change request transmittal (CR12896) to the Medicare Administrative Contractors (MACs) to address uncommon claim denial situations occurring since October 2019 with the onset of the Patient Driven Payment Model (PDPM).  Details are explained in MLN Matters article MM12896. Provider billing staff should review the CMS update to determine if it impacts previously denied claims.   

The effective date applies to services on or after October 1, 2019, however, the implementation date for the systems fix is April 3, 2023. 

In summary, CR 12896 implements changes to correct claims processing edits. SNFs billing on (TOB) 21X (subject to SNF Prospective Payment System (PPS)) 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 Type of Bill (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 either: 

  • Falls within Occurrence Span Code (OSC) 74, indicating an interrupted stay and the claim is billed as provider liable indicated with an M1 condition code; or 
  • Contains a condition code 40, indicating a same day transfer.