subject to OPPS, or ESRD services included in the composite rate. These are
rejected back to the hospital with the message, “This change requires an xx7
debit-only or xx8 cancel-only request from you. Late charges are not acceptable
for inpatient PPS ancillaries, inpatient accommodations in any facility, services on
the same day as outpatient surgery subject to the ASC payment limitation,
services on the same day as services subject to OPPS, or ESRD services included
in the composite rate.”
• When an xx5 suspends as a duplicate, (dates of service equal or overlapping,
provider ID equal, Medicare beneficiary identifier equal, and patient surname
equal), the FI must determine the status of the original paid bill. If it is denied,
the FI must deny the late charge bill.
• If an xx5 does not suspend as a potential duplicate, the FI rejects it back to the
provider with the message, “No original bill paid. Please combine and submit a
single original bill (xx1).”
• If the original bill was approved and paid, the FI compares the revenue codes on
the original paid bill with the associated late charge bill:
° For all providers (any bill type), if any are the same, and are revenue codes
41x, 42x, 43x, 44x, 63x, 76x, or 91x, the FI rejects the bill back to the
provider with the message, “You must submit an adjustment (xx7) to the
original paid bill. Revenue codes subject to utilization review are
duplicated on the late charge bill.”
° For HHA services not under a plan of care (bill type 34x), the FI must
apply the same logic for the following additional revenue codes. If any
are the same and are revenue codes 27x, 29x, 55x, 56x, 57x, 58x, 59x,
60x, or 63x, the FI rejects the bill back to the provider with the message,
“You must submit an adjustment (xx7) to the original paid bill. Revenue
codes subject to utilization review are duplicated on the late charge bill.”
° For hospital outpatient services (bill type 13x only), the FI must apply the
same logic for the following additional revenue codes. If any are the same
and are revenue codes 255, 32x, 33x, 34x, 35x, 40x, 62x, 73x, 74x, 92x, or
943, the FI rejects the bill back to the hospital with the message, “You
must submit an adjustment (xx7) to the original paid bill. Revenue codes
subject to utilization review are duplicated on the late charge bill.”
° For RDFs (bill type 72x or 73x), the FI must apply the same logic for the
following additional revenue codes; if any are the same and are revenue
codes 634, 635, 82x, 83x, 84x, 85x, or 88x, the FI rejects the bill back to
the provider with the message, “You must submit an adjustment (xx7) to
the original paid bill. Revenue codes subject to utilization review are
duplicated on the late charge bill.”
• If the late charges bill relates to two or more “original” paid bills, and one of these
is denied, the FI must suspend and investigate the late charge bill.
• The FI must compare total charges on the original paid bill with those on the
associated late charge bill, and suspend and investigate any xx5 bill type with
total charges in excess of those on the original paid bill. This edit suggests the
provider may have rebilled the already paid services.
The FI may decide to perform additional edits on late charge bills.