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Enable PPS Billing - Registry Setting

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This registry setting controls the application of PPS Billing rules.

PPS Billing applies to Medicare Part A and Inpatient Psychiatric Hospitals. It only applies to Room And Board services, not ancillaries that may be billed separately. These rules have only been implemented in Avatar for the 837I electronic claim.

Enable these rules if Avatar should systematically apply positive or negative contractual allowances based on formulas that use the information in the PPS Rate/Adjustment Factors form. The adjustments will be posted to the client's ledger either upon liability distribution or by batch depending on how  the contract guarantor is configured.

 For the following rules, the date specified in the Last Date of Service to Include field on the Electronic Billing form is referred to as the Through Date.

  1. A PPS guarantor will always be billed under the program a client is in as of the Through Date.
  2. If a client is not discharged and does not have any previous claims for the PPS guarantor (this is the first claim), then the client will only be included on the bill if there are at least 60 unbilled days from the client's admission date through the Through Date. The Claim Frequency Code (the last digit of the bill code) will be set to 2 (first claim).
  3. If a client is not discharged and has previous claims for the PPS guarantor, then the client will only be included on the bill if there are at least 60 unbilled days from the latest claim's Through Date for the PPS guarantor through the Through Date specified on the Electronic Billing form. Furthermore, the bill will include all days from the admission date through the Through Date specified and the Claim Frequency Code will be set to 7 (replacement claim).
  4. If a client is discharged on or before the Through Date and does not have any previous claims to the PPS guarantor (this is the first claim), the client will be included on the bill regardless of the number of unbilled days from the client's admission date through the Through Date specified. The Claim Frequency Code will be set to 1 (admit through discharge claim).
  5. If a client is discharged on or before the Through Date and has previous claims to the PPS guarantor, then the client will be included on the bill regardless of the number of unbilled days from the latest claim's Through Date for the PPS guarantor through the Through Date specified on the Electronic Billing form. Furthermore, the bill will include all days from the admission date through the Discharge Date and the Claim Frequency Code will be set to 7 (replacement claim).
  6. If a client's coverage/benefit is expired for a particular PPS guarantor, then a No-Pay (Claim Frequency Code = 0) claim will be generated provided that the 'Generate No-Pay ##0 claims' field for that guarantor is set to Yes in the Guarantors/Payors form.
  7. A Condition Code of 'Second or subsequent interim PPS bill' (D3) will be submitted in the Condition Information (HI) segment for all claims with Claim Frequency Code set to 7 or 0.

'Y' enables PPS Billing rules and adds the following functionality:

  • The PPS Rate/Adjustment Factors form is added. - Use this form to define calculations that will be applied to the federal per-diem base rate.

  • The following fields are added to the Guarantors/Payors form (Contractual Guarantor Information section):

    • Does This Guarantor Get Billed Under PPS Rules - Determines if PPS billing rules should be followed for the guarantor being billed during contractual adjustment processing and paper UB-92/837I bill generation.
      If a guarantor is being billed under PPS rules, services, which would normally be included on a Late Charge Bill (Bill Type xx5) on the 837 Institutional, will display on the error report. This will inform the user that they should attach the service to a previously generated claim by using the Attach Unbilled Service To A Claim form and then send a replacement claim using the re-billing functionality.
       Electronic UB-92 versions will not be modified to support PPS Billing rules.

    • Charge Override For Room And Board Charges (UB92/UB04 Claims) - Determines if Per-Diem Rate, Gross Charge or Fee from the Fee Table should appear on the paper UB-92 bill Form Locator 44. If no selection has been made in this field, the UB-92 bills will continue to display the Per-Diem Rate.

    • Override 837 Institutional PPS Claim Statement Dates and Claim Frequency Code For Expired Coverage

  • The 'Is This An ECT Code' field on the Service Codes form. - This field determines which services should receive an ECT adjustment during the contractual allowance process. This indication will also impact the 837 Institutional and Paper UB-92 bill generations by including this service in the procedure codes section of the bill with an ICD-9 indicator of 94.27.
     This field becomes enabled when the Is This Service A Procedure field is set to Yes.

  • The 'First Day Of Stay To Be Considered For Variable Per-Diem Adjustment' field on the 'UB-92/UB-04/ 37I Billing Maintenance Screen' form. - This field, if filed, will be used to apply the Variable Per-Diem Adjustments table. If the user has not entered the number of days, the adjustments will be applied from the ‘Day 1’ of the Variable Per-Diem Adjustments table. If a client’s previous admission was discharged less than three days prior to the admission of this episode, and the client’s last Room and Board date of the previous episode was billed to a PPS guarantor, the system will automatically calculate the ‘First Day Of Stay To Be Considered For Variable Per-Diem Adjustment’. This field is only necessary for clients whose previous stay occurred at a different facility.

  • The DRG Code dictionary on the Diagnosis form. - Upon entry of the Principle Diagnosis, the system will identify an associated DRG to the associated ICD code of the entered Principal Diagnosis. Should the Principal Diagnosis not have an associated DRG, the system will follow 'Code First' rules by reviewing each Axis I entry, then each Axis II entry, then each Axis III entry for an associated DRG. The first DRG found will default.

If the Principal Diagnosis does not have an associated DRG code, 'Code First' rules will be used for Axis I, Axis II, and Axis III entries.

'N' disables PPS Billing rules and the above functionality.