Enhancements to PDPM Claim Edits to Improve Claim Processing

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

CMS posted Transmittal 11932 on March 29, 2023 – same title as this blog.


A. Background: This Change Request (CR) implements changes to correct claims processing edits. This CR is applicable to the Fiscal Intermediary Shared System (FISS) and the Common Working File (CWF). Skilled Nursing Facilities (SNFs) billing on Type of Bill (TOB) 21X (subject to SNF Prospective Payment System (PPS)) will be subject to these requirements. The changes will also correct hospital overlap edits when billing during an interrupted stay where the hospital claim was processed as provider liable. This CR will modify claims processing to adhere to current policy.

B. Policy: No new policy changes exist with this CR.

The Business Requirements Table begins on page 2 of this Transmittal and continues through the last page of this 4-page notification.