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Last Modified: 10/25/2022 Location: FL, PR, USVI Business: Part A

Occurrence code 47 for cost outlier claims FAQ

Q: When is it appropriate to use occurrence code 47 when submitting an inpatient cost outlier claim?
A: Reference the Outlier Flowchart pdf file after asking this question: Does the cost for an inpatient stay exceed the cost outlier threshold amount?
If no -- submit claim as regular inpatient claim.
If yes -- are there enough benefit days (regular or lifetime reserve) to cover the medically necessary days?
If yes -- submit claims as regular inpatient claim. Do not indicate occurrence code 47.
If no -- indicate occurrence code 47 and date of the first full day of cost outlier status (the day after the day that covered charges reach the cost outlier threshold).
For Medicare purposes, cost outlier payments are paid for each day during the outlier period that the beneficiary has an available benefit day (regular, coinsurance, and/or lifetime reserve).
Diagnosis related group (DRG) claims without cost outlier payments can never have regular benefit days combined with lifetime reserve benefit days. When regular benefit and lifetime reserve days are billed on the same claim, lifetime reserve usage begins on the cost outlier date (should be equal to occurrence code 47 date).
Occurrence code 47 -- 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. Occurrence code 47 cannot be equal to or during the dates of occurrence span code 74 or 76.
Occurrence span code 74 -- the from/through dates for a period at a non-covered level of care in an otherwise covered stay, excluding any period reported with occurrence span codes 76, 77, or 79. Codes 76 and 77 apply to most non-covered care. Used for leave of absence or for repetitive part B services to show a period of inpatient hospital care or outpatient surgery during the billing period. Also used for home health association (HHA) or hospice services billed under part A, but not valid for HHA under prospective payment system (PPS).
Occurrence span code 76 -- the from/through dates for a period of non-covered care for which the provider is permitted to charge the beneficiary. Codes should be used only where the MAC or fiscal intermediary (FI) of the quality improvement organization (QIO) has approved such charges in advance and the patient has been notified in writing three days prior to the ‘from’ date of this period.
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