Submitting Bills In Sequence for a Continuous Inpatient Stay or Course of Treatment
When a patient remains an inpatient of a SNF, TEFRA hospital or unit, swing-bed, or hospice beyond the end of a calendar month, providers must submit a bill for each calendar month. (See §50.2.1 for frequency of billing for inpatient services.) Claims for the beneficiary are to be submitted in service date sequence. The shared system must edit to prevent acceptance of a continuing stay claim or course of treatment claim until the prior bill has been processed. If the prior bill is not in history, the incoming bill will be returned to the provider with the appropriate error message.
When an out-of-sequence claim for a continuous stay or outpatient course of treatment is received, FIs will search the claims history for the prior bill. They do not suspend the out-of-sequence bill for manual review, but perform a history search for an adjudicated claim. For bills other than hospice bills, if the prior bill is not in the finalized claims history, they return to the provider the incoming bill with an error message requesting the prior bill be submitted first, if not already submitted. The returned bill may only be resubmitted after the provider receives notice of the adjudication of the prior bill. A typical error message would be as follows:
Bills for a continuous stay or admission or for a continuous course of treatment must be submitted in the same sequence in which the services are furnished. If you have not already done so, please submit the prior bill. Then, resubmit this bill after you receive the remittance advice for the prior bill.
For a partial hospitalization program claim to determine out-of-sequence claim submission for the outpatient course of treatment, providers must utilize the correct frequency digit in the type of bill as follows:
If the “from” and “through” (FL6) dates on the claim being submitted include the dates for all services of the course of treatment, then the frequency digit in the type of bill will be a “1” [Admit through Discharge Claim] (i.e., 131, 761, or 851). The final Patient Discharge Status code (FL 17) will be entered.
If the “from” and “through” dates (FL6) on the claim being submitted include the dates for services at the start of the course of treatment (first of a series of bills) and additional services are expected to be submitted on a subsequent bill, then the frequency digit in the type of bill will be a “2” [Interim – First Claim] (i.e., 132, 762, or 852). The Patient Discharge Status code (FL 17) will be a “30”.
If the “from” and “through” dates (FL6) on the claim being submitted include the dates for services at the neither at the start or at the completion of the course of treatment and additional services are expected to be submitted on a subsequent bill, then the frequency digit in the type of bill will be a “3” [Interim – Continuing Claim] (i.e., 133, 763, or 853). The Patient Discharge Status code (FL 17) will be a “30”
.
If the “from” and “through” dates (FL6) on the claim being submitted include the dates for services at the completion of the course of treatment (last of a series of bills) and no additional services are expected to be submitted on a subsequent bill, then the frequency digit in the type of bill will be a “4” [Interim – Last Claim] (i.e., 134, 764, or 854). The final Patient Discharge Status code (FL 17) will be entered.
Providers may submit Interim Bills daily, weekly, or monthly as long as the claims are submitted with the correct frequency code in the type of bill and sequentially.
For a hospice claim that is out of sequence, the FI searches their claims history. If the FI finds the prior claim has been received but has not been finalized (for instance, it has been suspended for additional development), they do not cause the out of sequence claim to be returned to the provider. Instead, they hold the out of sequence claim until the prior claim has been finalized and then process the out of sequence claim. If the prior hospice claim has not been received, the out of sequence hospice claim is returned to the provider with an error message as described above. FIs shall perform editing to ensure hospice claims are processed in sequence after any necessary medical review of the claims has been completed.
Since hospice claims received out of sequence do not pass all required edits, they do not meet the definition of “clean” claims defined in §80.2 below. As a result, they are not subject to the mandated claims processing timeliness standard and are not subject to interest payments. FIs will enter condition code 64 on the out of sequence claims they are holding when awaiting the processing of the prior claims to indicate that they are not “clean” claims.
Submitting Bills In Sequence for a Continuous Inpatient Stay or Course of Treatment
When a patient remains an inpatient of a SNF, TEFRA hospital or unit, swing-bed, or hospice beyond the end of a calendar month, providers must submit a bill for each calendar month. (See §50.2.1 for frequency of billing for inpatient services.) Claims for the beneficiary are to be submitted in service date sequence. The shared system must edit to prevent acceptance of a continuing stay claim or course of treatment claim until the prior bill has been processed. If the prior bill is not in history, the incoming bill will be returned to the provider with the appropriate error message.
When an out-of-sequence claim for a continuous stay or outpatient course of treatment is received, FIs will search the claims history for the prior bill. They do not suspend the out-of-sequence bill for manual review, but perform a history search for an adjudicated claim. For bills other than hospice bills, if the prior bill is not in the finalized claims history, they return to the provider the incoming bill with an error message requesting the prior bill be submitted first, if not already submitted. The returned bill may only be resubmitted after the provider receives notice of the adjudication of the prior bill. A typical error message would be as follows:
Bills for a continuous stay or admission or for a continuous course of treatment must be submitted in the same sequence in which the services are furnished. If you have not already done so, please submit the prior bill. Then, resubmit this bill after you receive the remittance advice for the prior bill.
For a partial hospitalization program claim to determine out-of-sequence claim submission for the outpatient course of treatment, providers must utilize the correct frequency digit in the type of bill as follows:
If the “from” and “through” (FL6) dates on the claim being submitted include the dates for all services of the course of treatment, then the frequency digit in the type of bill will be a “1” [Admit through Discharge Claim] (i.e., 131, 761, or 851). The final Patient Discharge Status code (FL 17) will be entered.
If the “from” and “through” dates (FL6) on the claim being submitted include the dates for services at the start of the course of treatment (first of a series of bills) and additional services are expected to be submitted on a subsequent bill, then the frequency digit in the type of bill will be a “2” [Interim – First Claim] (i.e., 132, 762, or 852). The Patient Discharge Status code (FL 17) will be a “30”.
If the “from” and “through” dates (FL6) on the claim being submitted include the dates for services at the neither at the start or at the completion of the course of treatment and additional services are expected to be submitted on a subsequent bill, then the frequency digit in the type of bill will be a “3” [Interim – Continuing Claim] (i.e., 133, 763, or 853). The Patient Discharge Status code (FL 17) will be a “30”
.
If the “from” and “through” dates (FL6) on the claim being submitted include the dates for services at the completion of the course of treatment (last of a series of bills) and no additional services are expected to be submitted on a subsequent bill, then the frequency digit in the type of bill will be a “4” [Interim – Last Claim] (i.e., 134, 764, or 854). The final Patient Discharge Status code (FL 17) will be entered.
Providers may submit Interim Bills daily, weekly, or monthly as long as the claims are submitted with the correct frequency code in the type of bill and sequentially.
For a hospice claim that is out of sequence, the FI searches their claims history. If the FI finds the prior claim has been received but has not been finalized (for instance, it has been suspended for additional development), they do not cause the out of sequence claim to be returned to the provider. Instead, they hold the out of sequence claim until the prior claim has been finalized and then process the out of sequence claim. If the prior hospice claim has not been received, the out of sequence hospice claim is returned to the provider with an error message as described above. FIs shall perform editing to ensure hospice claims are processed in sequence after any necessary medical review of the claims has been completed.
Since hospice claims received out of sequence do not pass all required edits, they do not meet the definition of “clean” claims defined in §80.2 below. As a result, they are not subject to the mandated claims processing timeliness standard and are not subject to interest payments. FIs will enter condition code 64 on the out of sequence claims they are holding when awaiting the processing of the prior claims to indicate that they are not “clean” claims.
When a patient remains an inpatient of a SNF, TEFRA hospital or unit, swing-bed, or hospice beyond the end of a calendar month, providers must submit a bill for each calendar month. (See §50.2.1 for frequency of billing for inpatient services.) Claims for the beneficiary are to be submitted in service date sequence. The shared system must edit to prevent acceptance of a continuing stay claim or course of treatment claim until the prior bill has been processed. If the prior bill is not in history, the incoming bill will be returned to the provider with the appropriate error message.
When an out-of-sequence claim for a continuous stay or outpatient course of treatment is received, FIs will search the claims history for the prior bill. They do not suspend the out-of-sequence bill for manual review, but perform a history search for an adjudicated claim. For bills other than hospice bills, if the prior bill is not in the finalized claims history, they return to the provider the incoming bill with an error message requesting the prior bill be submitted first, if not already submitted. The returned bill may only be resubmitted after the provider receives notice of the adjudication of the prior bill. A typical error message would be as follows:
Bills for a continuous stay or admission or for a continuous course of treatment must be submitted in the same sequence in which the services are furnished. If you have not already done so, please submit the prior bill. Then, resubmit this bill after you receive the remittance advice for the prior bill.
For a partial hospitalization program claim to determine out-of-sequence claim submission for the outpatient course of treatment, providers must utilize the correct frequency digit in the type of bill as follows:
If the “from” and “through” (FL6) dates on the claim being submitted include the dates for all services of the course of treatment, then the frequency digit in the type of bill will be a “1” [Admit through Discharge Claim] (i.e., 131, 761, or 851). The final Patient Discharge Status code (FL 17) will be entered.
If the “from” and “through” dates (FL6) on the claim being submitted include the dates for services at the start of the course of treatment (first of a series of bills) and additional services are expected to be submitted on a subsequent bill, then the frequency digit in the type of bill will be a “2” [Interim – First Claim] (i.e., 132, 762, or 852). The Patient Discharge Status code (FL 17) will be a “30”.
If the “from” and “through” dates (FL6) on the claim being submitted include the dates for services at the neither at the start or at the completion of the course of treatment and additional services are expected to be submitted on a subsequent bill, then the frequency digit in the type of bill will be a “3” [Interim – Continuing Claim] (i.e., 133, 763, or 853). The Patient Discharge Status code (FL 17) will be a “30”
.
If the “from” and “through” dates (FL6) on the claim being submitted include the dates for services at the completion of the course of treatment (last of a series of bills) and no additional services are expected to be submitted on a subsequent bill, then the frequency digit in the type of bill will be a “4” [Interim – Last Claim] (i.e., 134, 764, or 854). The final Patient Discharge Status code (FL 17) will be entered.
Providers may submit Interim Bills daily, weekly, or monthly as long as the claims are submitted with the correct frequency code in the type of bill and sequentially.
For a hospice claim that is out of sequence, the FI searches their claims history. If the FI finds the prior claim has been received but has not been finalized (for instance, it has been suspended for additional development), they do not cause the out of sequence claim to be returned to the provider. Instead, they hold the out of sequence claim until the prior claim has been finalized and then process the out of sequence claim. If the prior hospice claim has not been received, the out of sequence hospice claim is returned to the provider with an error message as described above. FIs shall perform editing to ensure hospice claims are processed in sequence after any necessary medical review of the claims has been completed.
Since hospice claims received out of sequence do not pass all required edits, they do not meet the definition of “clean” claims defined in §80.2 below. As a result, they are not subject to the mandated claims processing timeliness standard and are not subject to interest payments. FIs will enter condition code 64 on the out of sequence claims they are holding when awaiting the processing of the prior claims to indicate that they are not “clean” claims.
https://www.cms1500claimbilling.com/2016/06/billing-continuous-visit-on-ub-04-form.html