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Long-Term Acute Care Hospital (LTACH) Billing Services Billing & RCM Services
Qualigenix bills LTACH stays so each discharge is paid at the rate it qualifies for. Under the LTCH prospective payment system, a case earns the standard federal rate only when it follows an acute hospital stay with at least 3 ICU days, or when the LTACH stay includes at least 96 hours of mechanical ventilation. Cases that miss both are paid the site-neutral rate, the lower of an IPPS-comparable amount or the cost of the stay. Our CPC- and CCS-certified coders check those criteria, the MS-LTC-DRG and the outlier status on every discharge they code.
What It Takes to Bill an LTACH Correctly
LTACH billing runs on the LTCH PPS: each discharge is grouped to an MS-LTC-DRG, then paid at the standard rate if it meets the ICU or ventilator criteria, or at the site-neutral rate if it doesn't. Stays at or under five-sixths of the DRG's geometric average length of stay are paid as short-stay outliers, very costly stays can earn high-cost outlier payments, and the hospital must keep a Medicare average length of stay over 25 days. Qualigenix handles the coding, the criteria checks and the denial work, with 79% of the denials it works overturned. Call 786-259-0231 to review your hospital's claims.
01
MS-LTC-DRG Assignment
The principal diagnosis, secondary diagnoses and procedures, including ventilation hours, set the MS-LTC-DRG and its relative weight. A missed ventilation hour count or an unsupported secondary diagnosis moves the case to a different DRG.
02
Admission Authorizations
Medicare Advantage and commercial plans that require authorization for LTACH admission also run concurrent reviews during the stay. Days past the last approved review can go unpaid.
03
Site-Neutral Criteria
A case qualifies for the standard rate only when it's admitted directly from an acute care hospital and meets the ICU or ventilator criterion. ICU days are counted from the referring hospital's ICU and CCU revenue codes, so missing records from that hospital can push a qualifying case to site-neutral payment.
04
Short-Stay Outliers
A stay at or under five-sixths of the geometric average length of stay for its MS-LTC-DRG is paid an adjusted, lower amount. Discharge dates and transfers have to be exact, because one day can change the payment method.
05
Lifetime Reserve Days
LTACH stays draw on Medicare's inpatient hospital limits: 90 days per benefit period, plus 60 lifetime reserve days. Lifetime reserve days carry a daily coinsurance of $868 in 2026, which has to be billed to the patient or a secondary payer.
06
ICU & Ventilator Records
The standard rate depends on records the LTACH doesn't always hold: ICU days from the referring hospital, and ventilation start and stop times inside its own stay. Without both, a reviewer can't confirm the criterion was met.
07
LTACH Denial Triggers
LTACH denials come from medical necessity findings, DRG changes on review, authorization and concurrent-review lapses, site-neutral reclassification, benefit-day errors and missing documentation.
08
25-Day ALOS Compliance
An LTACH must keep its Medicare average length of stay over 25 days. Site-neutral cases and Medicare Advantage cases are left out of that calculation, so coding each case to the right payment type affects the hospital's status.
PRECISION: WHAT QUALIGENIX DOES
How Qualigenix Secures LTACH Reimbursement
Qualigenix codes each LTACH discharge, confirms its payment tier and checks its outlier status before the claim is filed.
DRG Validation
We check the principal diagnosis, ventilation hours and secondary diagnoses against the record before assigning the MS-LTC-DRG.
Auth & Concurrent Review
We obtain admission authorizations, track each concurrent review date and send clinical updates before approved days run out.
Site-Neutral Screening
At admission we collect the referring hospital's ICU and CCU days and track ventilation hours, so each case is billed at the rate it qualifies for.
Outlier Claim Review
We compare each stay's length with its DRG's short-stay threshold and its costs with the high-cost outlier threshold, and bill accordingly.
Benefit-Day Verification
At admission we check the patient's remaining Part A days and lifetime reserve days, and set up secondary billing for any coinsurance.
CDI Support
Our coders send documentation queries to your physicians when the record doesn't support a diagnosis, ventilation time or acuity level that the stay appears to have.
Denials & Appeals
We appeal LTACH denials with the full record, the referring hospital's ICU documentation and the payer's own criteria attached. Qualigenix overturns 79% of the denials it works, across 50,000 denials worked each month.
ALOS Monitoring
We report the hospital's Medicare average length of stay from coded cases, excluding site-neutral and Medicare Advantage cases as the rule requires.
CASE STUDY 01
How a 3-provider podiatry group cleared $214K in aged A/R
THE SITUATION
A 3-provider podiatry group with roughly 60% Medicare payer mix carried $412,000 in A/R, 38% of it past 120 days. Routine foot care claims (11720, 11721, 11055–11057) had stalled on inconsistent Q7/Q8/Q9 modifiers and class-finding documentation, so payers held or partially paid and nobody worked the remainder. Medicare crossover to secondaries was not being posted, and small patient balances were written off.
WHAT QUALIGENIX DID
We ran a full A/R aging segmentation, worked claims by payer and denial reason rather than by date, rebilled the stalled routine-care claims with corrected modifiers, and reactivated secondary and crossover billing.
Key Outcomes & Turnaround
38% to 14%A/R past 120 days
$214,000recovered from aged A/R
90 daysto turn it around
~60%Medicare payer mix
Audited Practice Results
How a solo podiatrist lifted first-pass acceptance to 96%
THE SITUATION
A solo podiatrist coding 320 encounters a month was stuck at 82% first-pass acceptance. Routine foot care went out without the systemic-condition diagnosis pairing and class findings Medicare requires, so it read as non-covered. Wound debridement was coded to the wrong depth (11042 for skin and subcutaneous where the note supported 11043 for muscle and fascia). Same-day E/M with a procedure went out without modifier 25 and got bundled.
WHAT QUALIGENIX DID
We rebuilt the coding workflow: diagnosis-to-CPT pairing rules for at-risk foot care, correct Q-modifier logic, depth-based debridement coding tied to the operative note, and disciplined use of modifiers 25 and 59/XS.
Key Outcomes & Turnaround
82% to 96%first-pass acceptance
+11%per-encounter reimbursement
60 daysto turn it around
320/moencounters coded
Audited Practice Results
How a 2-location podiatry practice cut its denial rate by two-thirds
THE SITUATION
A 2-location podiatry practice sat at a 19% denial rate, mostly Medicare routine-foot-care and nail-debridement rejections. The denials clustered in three buckets: medical-necessity rejections on routine foot care (missing qualifying diagnosis and class findings), frequency-edit denials on nail debridement billed inside the 60-day window, and missing Q modifiers that flagged services as non-covered.
WHAT QUALIGENIX DID
We built a front-end denial-prevention layer, checking eligibility and coverage against payer LCDs before claims went out, plus a structured appeal workflow with documentation templates mapped to each denial reason.
Key Outcomes & Turnaround
19% to 6%denial rate
$68,000recovered on appealed claims
4 monthsto turn it around
2 locationspractice size
Audited Practice Results
LTACH Coding by Case Type
Qualigenix codes each LTACH discharge by the case type that sets its payment.
Prolonged Ventilation (96+ Hours)
Cases with at least 96 hours of mechanical ventilation in the LTACH stay qualify for the standard rate. The ventilation start and stop times have to be documented to the hour.
COMPLIANCE
How We Keep LTACH Billing Compliant
Qualigenix keeps LTACH billing compliant by billing each discharge at the payment tier its record supports and by applying the LTCH PPS rules as written: the ICU and ventilator criteria, the short-stay outlier threshold and the 25-day average length of stay. We review each claim for overcoding and undercoding. A ventilation hour left out can drop a case to site-neutral payment, and an unsupported secondary diagnosis invites a DRG change on review. Our coding holds a 98.6% compliance and audit pass rate, with an over- and undercoding rate under 2%. All patient data is handled in HIPAA-compliant workflows under strict security controls.
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Audit Pass Rate
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Variance Threshold
Why LTACHs Choose Qualigenix
Our LTACH coders track the payment-tier criteria, the DRG and the outlier thresholds on each discharge, and they collect the referring hospital's records the standard rate depends on. Medicare's error review reports long-term care hospitals separately from short-term acute hospitals.
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IMPROPER PAYMENT RATE
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FROM DOC GAPS
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FROM CODING ERRORS
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PAID IN ERROR
QUESTIONS BUYERS ASK
Frequently Asked Questions
Qualigenix charges a percentage of collections, so the fee tracks what your hospital is paid. The rate depends on discharge volume, payer mix and scope. Call 786-259-0231 to discuss your hospital.
We screen each admission for the 3-day ICU and 96-hour ventilation criteria, collect the referring hospital's ICU records, and bill cases that miss both at the site-neutral rate so the claim matches the record.
We report your Medicare average length of stay from coded cases, leaving out site-neutral and Medicare Advantage cases as the rule requires, so you can see where it stands.
Yes. We take over aged LTACH claims and work them by payer, denial reason and review status. Our A/R follow-up has reduced days in A/R from 54 to 36.
Medicare pays LTACHs per discharge under the LTCH prospective payment system, using the MS-LTC-DRG. Cases that meet the ICU or ventilator criteria get the standard rate, and the rest get the lower site-neutral rate, with adjustments for short-stay and high-cost outliers.
LTACH stays fall under Medicare's inpatient hospital limits: 90 days per benefit period, plus 60 lifetime reserve days. We check each patient's remaining days at admission.
Yes. Qualigenix is system-agnostic and works inside your current hospital EHR and patient accounting system, and our team has worked across 133 EMR/EHR platforms.