The CMS must record a day or charge as either covered or noncovered because of the
following:
Beneficiary utilization is recorded based upon days during which the patient received
hospital or SNF accommodations, including days paid by Medicare and days for which the
provider was held liable for reasons other than medical necessity or custodial care. Days
denied as not medically necessary or as custodial care are not charged against a
beneficiary's utilization record when the provider is determined to be liable.
The provider may claim credit on its cost report only for covered accommodations, days
and charges for which actual payment is made, i.e., provider liable days and charges are
not included. Data from the bill payment process are used in preparing the cost report.
The number of days and charges provided to the Pricer program affects the day and cost
outlier determinations and the DRG payment amount. Non-PPS provider days are
excluded from Pricer consideration.
It is possible to use a different number of days on a single bill for each of the above
purposes, although the same number of days will generally apply in actual practice. For
example, if the beneficiary had at least 1 day of eligibility remaining at admission, days
that occur after benefits are exhausted up through the day outlier threshold for the
applicable DRG are counted for cost reporting purposes under IPPS
A. - General Rule on Counting of Days
These following are general rules for counting days. However, these rules are also subject
to special rules for determining day of admission, discharge, death, beginning a leave of
absence, same day transfer, guarantee of payment days, provider liability issues and
outlier days for PPS outliers. See §40.1 and §40.1.G for an explanation of these special
rules.
The provider calculates and enters on the bill the number of claimable Medicare patient
days on the cost report. (Medicare patient days always refer to cost report days.) For PPS
facilities the A/B MAC (A) counts, for the cost report, utilization and Pricer purposes, all
days for which Part A payment may be made to the hospital. This includes days for which
the provider is not liable under the limitation of liability provision. It does not count days
for which no Part A payment may be made for cost report, utilization or Pricer purposes.
For non-PPS providers, the A/B MAC (A) does not count the days for Pricer purposes,
because DRG payment or outlier calculations are not made.
B. - Medically Unnecessary Days for Which the Provider May Charge the
Beneficiary
Days on which the hospital furnished no covered Part A services are not charged to
utilization and are not counted as Medicare patient days.
If the hospital or SNF stay includes any medically unnecessary days for which the
provider has met the requirements of §§40.2.2 C or D for charging the beneficiary, the
A/B MAC (A) counts those days as noncovered under Part A for cost report, utilization
and Pricer purposes.
Since the provider may not be aware of the date benefits are exhausted or when the outlier
threshold is reached, the A/B MAC (A) verifies the provider's counts. If, for any reason,
the A/B MAC (A) or the QIO determines fewer days are claimable (e.g., if the A/B MAC
(A) or the QIO indicates that benefits are exhausted), the A/B MAC (A) will adjust cost
report days for its PS&R system. If the A/B MAC (A) or the QIO determines fewer days
are claimable for the cost report, it determines the proper number of days of utilization to
charge the beneficiary and the proper number of days for the length of stay used by Pricer.
It uses the factors in §40.1 and §40.1G to make these calculations.
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