Definition: A cycle claim is a claim which bills the payer for 30 days’ worth of tests, treatments, rehab, etc.
Application and why is this type of claim asked for by either the client or the payer: The # 1 application for a cycle bill is for reoccurring treatment and/or testing, such as 3x a week chemo, physical rehab, 1x a week testing, etc. It is easier for the provider to create and for the payer to process numerous, potentially separate encounters in one claim and one encounter. Example: One cycle claim for 12 chemo treatments provided in a 30 day period, instead of 12 encounters and 12 separate claims. Obviously, these chemo treatments, rehab treatments, etc. are usually ordered through the same diagnosis, e.g., chemo 3x per week for Stage 4 cancer. Usually, cycle billing is used for reoccurring OP treatments.
The # 2 application for cycle billing is when there is a very long IP stay AND the adjudication/payment system implemented by the payer for the encounter IS NOT DRG BASED; the adjudication/payment system used by payer must be either % based or per diem based for a cycle claim to work. In the instance of a long IP stay, the payer may ask for each 30 day portion of the stay to be billed separately in a cycle bill.