Last Modified: 5/7/2020
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 the Centers for Medicare & Medicaid Services’ (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.
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