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MIR-2006-9AB, September 2006
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Correction to Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement if SNF Inpatient Claims Are Partially Noncovered (CR5220)
Provider Types Affected
Skilled nursing facilities (SNFs) that bill Medicare fiscal intermediaries (FIs) for SNF services
Provider Action Needed
Impact to You
If you submit 22X bill type claims to your FI that contain therapy services (Physical therapy, speech language pathology services, and occupational therapy) subject to SNF consolidated billing (CB), the claims may be rejected inappropriately by SNF CB when they fall within partially noncovered periods identified on inpatient SNF bill types (i.e., 21X bill types).
What You Need to Know
To address this issue, under certain conditions (outlined below) the Centers for Medicare & Medicaid Services (CMS) systems will bypass line item dates of service reported on 22X bill types from the SNF CB therapy edit.
What You Need to Do
Please refer to the Background section of this article for further information.
Background
When Part A program payment is not possible (e.g., the beneficiary’s benefits have been exhausted or the inpatient SNF stay is partially noncovered), some or all services provided in these noncovered periods may be medically necessary and may be covered as ancillary services under Part B.
Section 1888 of the Social Security Act requires SNF consolidated billing (CB). Under the SNF CB provision, therapy services are subject to SNF CB during noncovered SNF stays and are only billable on a 22X (SNF inpatient part B) bill type.
To ensure that 22X bill type claims containing therapy services subject to SNF CB will not be rejected as a result of the circumstance described above, the CMS systems will bypass line item dates of service reported on 22X bill types from the SNF CB therapy edit when the dates of service:
- Fall within reported noncovered periods on overlapping SNF 21X bill types (identified by occurrence span codes 74, 76, or 77, 79, and/or M1);
- Are greater than the benefit exhaust date or date active care ended reported on overlapping SNF 21X bill types (greater than the occurrence code A3, B3, C3, or 22 reported on the 21X SNF inpatient claim).
Please note that your FI will not search their files to retroactively pay claims that were incorrectly rejected. However, they will adjust claims that you bring to their attention.
Implementation
The implementation date for this instruction is January 2, 2007.
Additional Information
CR5220, containing the attached manual revision to Publication 100-04, Medicare Claims Processing Manual, Chapter 6 (SNF Inpatient Part A Billing), Section 20.5 (Therapy Services), is the official instruction issued to your Medicare FI regarding changes mentioned in this article. CR5220 may be found at http://www.cms.hhs.gov/Transmittals/downloads/R1009CP.pdf  on the CMS Web site.
If you have questions, please contact your local Medicare FI at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip  on the CMS Web site.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
MLN Matters Number: MM5220
Pub. 100-4, Transmittal# R1009CP, CR# 5220
Related CR Release Date: July 28, 2006
Effective Date: October 1, 2005
Implementation Date: January 2, 2007
Attention Skilled Nursing Facilities!
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