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.

Definitions

View this article to see how the error rate is determined.

Reference the Outlier Flowchart after asking this question: Does the cost for an inpatient stay exceed the cost outlier threshold amount?

No. The services provided by physical therapist assistants (PTAs) cannot be billed incident to a physician/non-physician practitioner’s (NPP), because PTAs do not meet the qualifications of a therapist. Only the services of a licensed/registered physical therapist can be billed “incident to” a physician service. PTAs may not provide evaluation services, make clinical judgments or decisions, or take responsibility for the service. PTAs act at the direction and under the supervision of the treating physical therapist and in accordance with state laws.

Providers are responsible to collect patient data, asking questions related to employment and liability insurance, to identify payers other than Medicare. This action minimizes incorrect billing and Medicare overpayments. Providers must determine if Medicare is the primary or secondary payer by obtaining MSP information such as group health coverage through employment or non-group health coverage resulting from an injury or illness. Patients should be questioned at each visit to determine if there have been changes in insurance coverage or if there may be other insurer liability.

OSC70 should be coded on the cost outlier claim when the beneficiary’s benefit days have exhausted and there are extra days within the inlier portion of the claim. The claim may be paid up to the diagnosis related group (DRG), as long as there are benefit days remaining for the claim.

Answering this question will assist in submitting the claim correctly. Did the beneficiary’s regular, coinsurance or lifetime reserve days exhaust during the inlier portion of the stay?

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).

The MSP Contractor consolidates the activities that support the collection, management, and reporting of other insurance coverage for Medicare beneficiaries. The purpose of the COB program is to identify the health benefits available to a Medicare beneficiary and to coordinate the payment process to prevent mistaken Medicare payment. The MSP Contractor does not process claims or claim-specific inquiries. The MACs are responsible for processing claims submitted for primary or secondary payment and resolving situations where a provider receives a mistaken payment of Medicare benefits.

Under certain circumstances, yes. The beneficiary may complete an appointment of representative form (CMS-1696). This form is used to authorize an individual to act as a beneficiary’s representative in connection with a Medicare appeal.