Last Modified: 10/25/2022
Location: FL, PR, USVI
Business: Part A
Q: Should a claim be submitted as a cost outlier?
Yes, we encourage you to code the claim appropriately when submitting it the first time. You have access to CMS PRICER software
which helps you determine the prospective payment system (PPS) threshold. Once you determine the PPS threshold and confirm the claim can be submitted as a cost outlier, you should code the claim appropriately and forward to the Fiscal Intermediary Standard System (FISS).
To determine if the inpatient hospital claim meets criteria for cost outlier reimbursement, you need two pieces of information:
• Total covered charges, and
• PPS threshold amount
If the total covered charges exceed the PPS threshold amount by CMS’ published standards for the current year, then you should follow the coding rules for inpatient cost outlier claims.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.