Inpatient psychiatric facility (IPF) benefits exhaust
Benefits exhaust occurs when no benefit days remain in the beneficiary's applicable benefit period or when the beneficiary has exhausted the 190-day lifetime limit in a psychiatric hospital. The 190-day lifetime limit applies only to care received in freestanding IPFs and does not apply to psychiatric units within acute care hospitals.
Occurrence code (OC) AC is used to report the benefits exhaust date, which is the beneficiary's last available covered benefit day.
When an IPF discharge occurs because benefits exhaust, the benefits exhaust date becomes the actual discharge date.
Billing guidelines
To submit claims through the benefits exhaust date, submit the claim as follows:
- If no prior interim claim submitted, submit one claim from admission through the benefits exhaust date:
- Type of Bill (TOB) - 112
- Admission Date - Date of original admission
- Statement From Date - Date of original admission
- Statement Through Date - Benefits exhaust date
- Patient Status Code - 30
- OC - A3 with benefits exhaust date
- If one or more prior interim claim(s) previously submitted, adjust the most recent claim to add dates/services through the benefits exhaust date:
- TOB - 117
- Admission Date - Date of original admission
- Statement From Date - Date of original admission
- Statement Through Date - Benefits exhaust date
- Patient Status Code - 30
- OC - A3 with benefits exhaust date
After the benefits exhaust claim has been processed and finalized, the facility may submit no-payment claims for the remaining stay with all days and charges reported as noncovered.
- First No-Payment Claim after Benefits Exhaust:
- TOB - 110
- Admission Date - Date of original admission
- Statement From Date - Day after date benefits exhausted
- Statement Through Date - 60th day or date of discharge or death if final claim
- Patient Status Code - 30 or appropriate patient status code if final claim
- Subsequent No-Payment Claims after Benefits Exhaust:
- TOB - 110
- Admission Date - Date of original admission
- Statement From Date - Day following the Statement Through Date reported on the previous TOB 110 claim
- Statement Through Date - 60th day or date of discharge or death if final claim
- Patient Status Code - 30 or appropriate patient status code if final claim
Claims submitted with an incorrect benefits exhaust date will be returned to the provider for correction of the Statement Through Date and/or OC A3 date. Once that benefits exhaust claim is finalized, the IPF can submit the appropriate 60-day no-payment bills.
References