Claims Reference · Long-Term Care
LTCH Claim Reference
How an LTCH stay is billed to Medicare — the type of bill, how the MS-LTC-DRG and the standard-versus-site-neutral determination are reflected, and the case-level adjustments. Background for institutional LTCH billing.
No PHIReferenceInformational reference — paraphrased from CMS rules and manuals, not billing or legal advice; verify against the Medicare Claims Processing Manual (Pub. 100-04, Ch. 3) and your MAC.
The LTCH claim at a glance
TOB 11x| Type of bill | 11x (inpatient hospital) — one admit-through-discharge claim per stay |
| Classification | an MS-LTC-DRG assigned by the grouper from the diagnoses and procedures — there is no HIPPS code |
| Rate path | the standard federal rate only if the case meets the clinical criteria; otherwise the site-neutral rate |
| Preceding stay | standard-rate cases must be admitted within one day of discharge from a subsection (d) IPPS hospital |
Standard-rate criteria on the claim
Excludes site-neutral| ICU/CCU | at least 3 days in an intensive or coronary care unit during the immediately preceding acute stay, or |
| Ventilator | at least 96 hours of ventilator services in the LTCH (ICD-10-PCS 5A1955Z) |
| Exclusion | the discharge must not group to one of the 15 psychiatric or rehabilitation MS-LTC-DRGs |
When the MAC applies the site-neutral rate but the LTCH believes the standard criteria are met, records from the preceding hospital are submitted through the LTCH Site-Neutral payment dispute process.
Adjustments that ride on the claim
Case-level| High-cost outlier | added when estimated cost exceeds the payment plus the outlier threshold |
| Short-stay outlier | reduces payment when the covered stay is short relative to the MS-LTC-DRG average |
| Interrupted stay | a single payment when the patient leaves and returns to the same LTCH within the policy window |