"Day Count" Rules for All Providers

A. - Day of Admission 

For all hospitals, the A/B MAC (A) counts the day of admission for the cost report and for utilization. For PPS hospitals, it counts the day of admission for Pricer purposes unless the rules for same day transfer apply.

B. - Day of Discharge, Death, or Beginning a Leave of Absence 

The A/B MAC (A) does not count the day of discharge or death for cost report, utilization or Pricer purposes unless the admission and discharge day are the same day. Where admission and discharge occur on the same day, it counts one day for cost report, utilization and Pricer purposes. If the patient is admitted with the expectation that the patient will remain overnight, but is discharged or dies before midnight, it counts the day for the cost report, utilization and Pricer. It does not count any days in a leave of absence (occurrence span code 74), for cost report, utilization or Pricer purposes.

C. - Same Day Transfer From Participating Hospital to Nonparticipating Hospital or Nonparticipating Distinct Part of Hospital 

If the beneficiary is admitted to a PPS hospital with the expectation that the beneficiary will remain overnight, but is transferred to a nonparticipating provider or a nonparticipating distinct part of the same provider before midnight, the A/B MAC (A) counts the day for the cost report, utilization and Pricer. If the beneficiary is admitted to a non-PPS hospital with the expectation that the beneficiary will remain overnight, but is transferred to a nonparticipating hospital or a nonparticipating distinct part of a hospital before midnight, the A/B MAC (A) counts the day for cost report and utilization purposes.

D. - Same Day Transfer From Participating Hospital to Participating Hospital

 If the beneficiary is transferred to a participating hospital or distinct part of a participating hospital, the A/B MAC (A) counts the day, if it is determined to be covered, for the cost report and for Pricer at both hospitals. However, it charges utilization on the bill only for  the later admission to avoid charging the beneficiary twice for the same day. The earlier admission, for which the A/B MAC (A) does not charge utilization, can be recognized by condition code 40 (same day transfer), and the same date entered in the "From" and "Through" dates in CWF.

E. - Guarantee of Payment Days 

There can be up to fourteen guarantee of payment days (8 days plus weekends and Federal holidays) beginning with the date in occurrence code 20. The A/B MAC (A) does not charge utilization, as the beneficiary has no days remaining, but counts guarantee of payment days for the cost report and Pricer. 

F. - Provider Liability Issue 

When the A/B MAC (A) or the QIO finds the provider liable, the A/B MAC (A) or the QIO determines the cause for provider liability prior to making any decision regarding utilization. If the provider is technically liable, i.e., liable for reasons other than custodial care or medical necessity of the services, the A/B MAC (A) shows the dates of provider liability in occurrence span code 77, and counts the days for utilization, but not for cost report or Pricer purposes. If the provider is liable because services were not medically necessary or were custodial care, the A/B MAC (A) shows the dates of provider liability in occurrence span code 79 and does not count the days for cost report, utilization or Pricer purposes.

G. - Special Rules Which Differ for PPS and Other Providers

 If Part A payment may be made for a hospital stay under PPS (i.e., there is at least one Medicare patient day, guarantee of payment day, or day for which the program is liable to the hospital under the limitation of liability provision), the A/B MAC (A) treats all days as covered for cost report purposes, except as provided below. It applies this same rule when per diem payments are made to a transferring PPS hospital, whether for all or part of a stay, or when a PPS hospital requests outlier payment, whether or not such payment is made.

 For non-PPS hospitals, PPS exempt units and SNFs, it counts the number of days available to the beneficiary for all purposes.

 Where outlier status is involved and there are either pre-entitlement days or days after benefits were exhausted, the A/B MAC (A) reduces cost report days by the lesser of the number of pre-entitlement/post-benefits exhausted days or the number of days in the stay in excess of the outlier threshold.

1. Length of Stay Does Not Exceed the Day Outlier Threshold (Day outliers discontinued after FY 97)

The A/B MAC (A) counts all days (including day of admission, but not the day of discharge or death, unless it is also the day of admission) as covered for cost report and Pricer purposes. It does not count those medically unnecessary days for which the provider meets notice requirements and other conditions for charging the beneficiary.  It does not count those medically unnecessary days for cost report or Pricer purposes. It counts the actual number of days available to the beneficiary for utilization.

2. Length of Stay Exceeds the Day Outlier Threshold (Day outliers discontinued after FY 97) 

The A/B MAC (A) counts all days (including the day of admission, but not the day of discharge or death unless it is also the day of admission) in the stay for cost report and Pricer purposes except as follows:

a. Pre-entitlement Days 

The A/B MAC (A) does not count pre-entitlement days for the cost report or for utilization in non-PPS hospitals, exempt units or SNFs. For PPS hospitals, it does not count preentitlement days for utilization or for Pricer. The number of days counted as noncovered for the cost report is limited to the number of days in the stay in excess of the day outlier threshold. To determine which preentitlement days are counted as noncovered, the A/B MAC (A) begins at the end of the stay (the day before the day of discharge, death, etc.) and working backward, counts off days identified as pre-entitlement days until it has counted all preentitlement days or, until the number of days counted equals the total number of days in excess of the outlier threshold.

b. Post-Exhaustion of Benefit Days 

The A/B MAC (A) treats post-exhaustion of benefit days exactly like pre-entitlement days.