Additional Outlier Payment Guidance – PGBA

CMS Pub 100-04, Medicare Claims Processing Manual, Chapter 10, Home Health Agency Billing (10.1.21 Adjustments of Episode Payment – Outlier Payments)

Effective January 1, 2010, for calendar year 2010, the outlier payments made to each home health agency (HHA) will be subject to an annual limitation. Medicare systems will ensure that outlier payments comprise no more than 10 percent of the HHAs total HH PPS payments for the year. Medicare systems will track both the total amount of HH PPS payments that each HHA has received and the total amount of outlier payments that each HHA has received. When each HH PPS claim is processed, Medicare systems will compare these two amounts and determine whether the 10 percent has currently been met.

If the limitation has not yet been met, any outlier amount will paid normally. (Partial outlier payments will not be made. Only if the entire outlier payment on the claim does not result in the limitation being met, will outlier payments be made for a particular claim.) If the limitation has been met or would be exceeded by the outlier amount calculated for the current claim, other HH PPS amounts for the episode will be paid but any outlier amount will not be paid. When the calculated outlier amount is not paid, HHAs will be alerted to this by the presence of claim adjustment reason code 45 on the accompanying remittance advice. This code is defined “Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.”

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