For discharges on or after October 1, 2015, there are two separate payment categories for long term care hospital (LTCH) patients:
Standard (discharges meeting specific clinical criteria)
Site neutral (discharges that do not meet the specified clinical criteria)
To be paid at the standard LTCH prospective payment system (PPS) amount, an LTCH patient must either:
Be admitted directly from an inpatient prospective payment system (IPPS) hospital during which at least 3 days were spent in the intensive care unit or coronary care unit, but the discharge must not be assigned to a psychiatric or rehabilitation LTCH diagnosis related group (DRG).
Be admitted directly from an IPPS hospital and the LTCH discharge includes International Classification of Diseases, 10th Revision, Procedure Coding System code, 5A1955Z, for ventilator services of at least 96 hours, but must not be assigned to a psychiatric or rehabilitation LTCH DRG.
Note: Non-subsection (d) hospitals cannot fulfill the IPPS admission qualification, and therefore site neutral payment would be warranted. These hospitals include, but are not limited to, cancer hospitals and critical access hospitals.
Existing LTCH PPS policies, such as short stay outlier (SSO) and interrupted stay, continue to apply in determining the standard LTCH PPS payment for discharges meeting specific clinical criteria.
For cost reporting periods beginning on or after October 1, 2015, LTCH discharges that do not meet specific criteria will be paid at a site neutral payment rate.
The site neutral payment rate is generally the lower of:
The IPPS comparable per diem amount (as calculated under SSO policy)
The estimated costs of the case (calculated by multiplying the allowable charges by the LTCH’s cost-to-charge ration)
For discharges occurring during cost reporting periods beginning on or after October 1, 2015 and on or before September 30, 2017, a transition payment will be made for site neutral cases on a 50-50 blend of the standard payment rate and the site neutral payment rate.
Medicare's claims processing system was programmed correctly to identify subsection (d) hospitals, however, the patient may have had an immediately preceding inpatient stay at a subsection (d) hospital that is not present in the Medicare claims processing system. For example, the patient may have used their Veteran Affairs benefits or received inpatient care at a military treatment facility that qualifies as an “immediately preceding” stay (prior to admission to the LTCH).
In other scenarios, the immediately preceding subsection (d) hospital may submit claims to Medicare; however, billing errors made by the hospital may cause the LTCH claim to inappropriately receive the site neutral payment. The LTCH should contact the immediately preceding hospital when errors are identified and encourage them to adjust their claim to correct any billing error.
In either occurrence, when the LTCH disagrees with the site neutral payment, the LTCH shall collect the appropriate records from the immediately preceding hospital. The LTCH shall use the Long Term Care Hospital (LTCH) Site Neutral Dispute Form to submit the immediately preceding hospital records and their own records to demonstrate that the applicable criteria for exclusion from the site neutral payment rate have been met. If the documentation received reflects the standard payment criteria as met, we will adjust the applicable LTCH claim to make any appropriate adjustments to payment.
The preferred method for submission of the LTCH site neutral dispute form and supporting documentation is via fax at: 877-439-5479.
However, if size limits are exceeded, you may mail the dispute form and supporting documentation to:
Novitas Solutions, Inc.
Attention: Part A Claims - Site Neutral Dispute
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050