Revenue Cycle

Peeling away the confusion: Split billing guidance

Medicare Update for CAHs, January 25, 2012

 The concept of split billing in both the inpatient and outpatient setting is a hot topic amongst providers as of late, according to Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc.

The guidance for billing in these two settings can both be found within the Medicare Claims Processing Manual, first of which comes in chapter 1, section 70.8.1.

Outpatient split billing

There are a number of prescribed situations where a claim is received for certain services that require the splitting of the single claim into one or more additional claims, according to CMS. Splitting claims is necessary for the following reasons: Proper recording of deductibles, separating expenses payable on a cost basis from those paid on a charge basis, or for accounting and statistical purposes.

According to the manual, expenses incurred in different calendar years cannot be processed as a single claim, so a separate claim is required for the expenses incurred in each calendar year. In addition, Palmetto GBA, a Medicare administrative contractor (MAC), elaborates by stating: “All outpatient claims, SNF claims and non-PPS inpatient claims (e.g. critical access hospitals), which can be billed on an interim basis, should be split at the provider’s fiscal year end and at the calendar year end. It should not be split at Medicare’s fiscal year end unless it corresponds with the provider’s fiscal year.”

Inpatient split billing

For inpatient split billing requirements for the inpatient setting, Trailblazer Health Enterprises, LLC, another MAC, offers a sound summary: Non-PPS providers and providers who are reimbursement through periodic interim payments (PIPs) split-bill their claims at the fiscal year end (FYE), and the days are allocated to the provider year in which they occurred. When services span a non-PPS provider’s FYE for inpatient bills, a provider must submit two claims, the first of which reflects the admission date to the FYE using TOB 112 and status code 30 (still patient). The second claim reflects the first day of the new FY to the discharge date using TOB 115 and the appropriate discharge status code.

Guidance on split billing for inpatient and outpatient services is important to providers since it can prevent delays in payment because they will have to rebill their claims if their outpatient, rural health clinic and swing bed claims cross over calendar years, says Mackaman.

“If providers keep in mind that every calendar year, the patient’s deductibles and coinsurance amounts change for both Part A and Part B services, they can put the split billing process on their radar as part of their annual procedures.”

She continued, “CAHs also need to remember this at the end of their fiscal years for these services as well as their inpatient claims.”

For more information on when to split Part A bills, click here:

http://www.trailblazerhealth.com/Publications/Job%20Aid/WhentoSplitPartABills.pdf

For information on split billing for IPPS hospitals that are paid under the DRG, see section 20.7.2 of the Medicare Claims Processing Manual:

http://www.cms.gov/manuals/downloads/clm104c03.pdf

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