A/B Crossover Edits

110.2.2 - A/B Crossover Edits (Rev. 1757, Issued: 06-19-09, Effective: 07-20-09, Implementation: 07-20-09) Effective April 1, 2002, CWF implemented the following crossover edits for A/B MAC (B) submitted claims. Automated processes were implemented for the resolution of these edits based on the codes returned in the trailers from CWF. A. Edits 7258 and 7259 - Part B Physical Therapy Claim Against an Inpatient SNF 21x and Inpatient Part B 22x Claim Reject if an A/B MAC (B) claim is received containing physical therapy (type of service of W), occupational therapy, or speech-language pathology and From/Thru Dates overlap or are within the From/Thru Dates on an SNF inpatient claim (21x) or an inpatient Part B claim (22x). Use separate error codes where (1) dates are within (A/B MAC (B) will reject claim) or (2) where dates overlap (A/B MAC (B) will automate a separate denial message to provider). Bypass the edit in the following situations: • The 21x or 22x type of bill contains a cancel date. • The incoming claim from date equals the SNF 21x or 22x history claim discharge date or incoming through date equals the SNF 21x or 22x history claim admission date. Effective for claims with dates of service on or after April 1, 2001, CWF implemented revisions on January 2, 2008 to bypass the edits 7258 and 7259 when a therapy claim with a date of service on or after April 1, 2001 is submitted and the date of service is within the From/Thru dates of an occurrence Span code date of 74 reported on a SNF inpatient claim 21x in history. This will allow for services to be separately payable outside of SNF consolidated billing during non-covered periods in the SNF. Effective for claims with dates of service on or after April 1, 2001, CWF implemented revisions on April 7, 2008 to modify the existing therapy edit for Part B claims processing for non-covered SNF stays to read claims history to look for a 21x (SNF Inpatient) bill type that contains an Occurrence Code 22 (Date Active Care Ended) and a Patient Status Code 30 (Still patient or expected to return for outpatient services) where there is no subsequent 21x (SNF inpatient) bill type discharge claim from the same provider. As therapy services provided in a SNF must be consolidated when a beneficiary is in either a covered or non-covered stay, CWF will reject claims with dates of service after the posted SNF claim containing Occurrence Code 22 (Date Active Care Ended) and Patient Status 30 (Still patient or expected to return for outpatient services) until a 21x (SNF inpatient) bill type discharge claim is processed. The entity furnishing the therapy services must look to the SNF for reimbursement rather than the A/B MAC (A) or (B). For claims processed on or after January 5, 2009, this edit shall no longer be functional. A/B MACs (A) and (B) shall re-open and-re-process claims previously denied due to this edit when brought to their attention should they determine that the beneficiary was not in a SNF stay during the period the therapy service was rendered. B. Edits 7260 and 7261 - Part B Claim Without Therapy Against an Inpatient SNF Reject if a Part B claim is received with From/Thru Dates overlapping or are within the From/Thru Dates on an SNF Inpatient claim (21x). If the SNF 21x claim on history has patient status 30 and occurrence code 22 (Date Active Care Ended), use occurrence 22 date instead of the through date. Use separate error codes where (1) dates are within (A/B MAC (B) will reject claim); or (2) where dates overlap (A/B MAC (B) will automate a separate denial message to provider). Bypass the edit in the following situations: • The 21x history claim contains a cancel date. • The incoming A/B MAC (B) claim from date equals the SNF 21x history claim discharge date. The incoming A/B MAC (B) claim through date equals the SNF 21x history claim admission date. • A diagnosis code in any position on the incoming claim is for renal disease. • The A/B MAC (B) claim contains ambulance codes per the files supplied to CWF in the annual and quarterly updates with modifiers other than N (SNF) in both the origin and destination on the same claim. • The A/B MAC (B) claim is a CANCEL ONLY (Action Code 4) claim. • The A/B MAC (B) claim is denied. • The A/B MAC (B) service has a Payment Process Indicator other than A (allowed). • The A/B MAC (B) claim contains only separately payable services per the files supplied to CWF in the annual and quarterly updates. Effective for claims with dates of service on or after April 1, 2001, CWF implemented revisions on January 2, 2008 to bypass the edits 7260 and 7261 when a claim with a date of service on or after April 1, 2001 is submitted and the date of service is within the From/Thru dates with an occurrence Span code date of 74, 76, 77, 79, or M1 reported on a SNF inpatient claim 21x in history or the date of service is greater than the occurrence date on a SNF inpatient claim 21x in history with an occurrence code date of A3, B3, or C3. This will allow for services to be separately payable outside of SNF consolidated billing during non-covered periods in the SNF.