Last Modified: 5/7/2020
Location: FL, PR, USVI
Business: Part A
Q: Is there a timetable available to help determine if a claim meets the criteria as cost outlier?
Yes, the Cost Outlier timetable example
is designed to assist providers in determining if a claim qualifies as cost outlier. Prior to coding an inpatient cost outlier claim, first determine the diagnosis related group (DRG) cutoff date, by using the example timetable.
• Cost outlier -- an inpatient hospital discharge that is extraordinarily costly. Hospitals may be eligible to receive additional payment for the discharge. Section 1886(d)(5)(A) of the social security act provides for Medicare payments to Medicare-participating hospitals in addition to the basic prospective payments for cases incurring extraordinarily high costs.
• To qualify for outlier payment, a case must have costs above a fixed-loss cost threshold amount (a dollar amount by which the costs of a case must exceed payments to qualify for outliers).
• Total covered charges for an inpatient admission are $100,000 (hospital costs)
• The prospective payment system (PPS) threshold amount for the DRG is $65,000 (fixed-loss threshold amount)
• The Centers for Medicare & Medicaid Services (CMS) publishes the outlier threshold amounts in the annual inpatient prospective payments system (IPPS) final rule. Providers may access CMS' website to download the IPPS pricer.
• Inlier -- a case where the cost of treatment falls within the established cost boundaries of the DRG payment. To determine if the inpatient hospital claim meets the criteria for cost outlier reimbursement, two pieces of information are needed: 1) total covered charges and 2) PPS threshold amount. If the total covered charges exceed the PPS threshold amount, follow the coding rules for inpatient cost outlier claims.
• DRG cutoff day -- the "To" date or "End" date of the inlier period. Once the PPS threshold amount is known add the daily covered charges incurred by the patient until determining the day that covered charges reach the cost outlier threshold amount. Exclude days and charges during noncovered spans (e.g., occurrence span code 74 [noncovered level of care], 76 [patient liability], 79 [payer code] dates).
• Occurrence code (OC) 47
-- a code that indicates the first day the inpatient cost outlier threshold is reached or the date after the DRG cutoff date. For Medicare purposes, a beneficiary must have regular coinsurance and/or lifetime reserve days available beginning on this date to allow coverage of additional daily charges for the purpose of making cost outlier payments. OC47 date cannot
be equal to or during dates coded for occurrence span code 74, 76, or 79. Click here
for an example.
• Occurrence code A3 -- (Benefits Exhausted) the last date for which benefits are available and after which no payment can be made.
• Occurrence span code 70
-- a code and span of time that indicates the from and through dates during the PPS inlier stay for which the beneficiary has exhausted all regular days and/or coinsurance days, but which is covered on the cost report. Click here
for an example.
• Condition code 61
-- a code that indicates this bill is a cost outlier. Click here
for an example.
• Condition code 67 -- a code that indicates the beneficiary has elected not to use lifetime reserve (LTR) days.
• Condition code 68 -- a code that indicates the beneficiary has elected to use lifetime reserve (LTR) days.
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