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National
Government Services, Inc.
Medicare Monthly Review Part A and B |
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A
Combined Part A and Part B Newsletter |
MMR-2007 08A, August 2007
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Clarification of Skilled Nursing Facility (SNF) No-Payment Billing
(MM5583-R)
Note: This article was revised on July 11,
2007, to delete a reference to “Part A exhausted” in
the “No Pay Billings” discussion at the top of page
2. All other information remains the same.
Provider Types Affected
Skilled Nursing Facilities (SNF) submitting claims to Medicare Fiscal Intermediaries
(FI) or Part A/B Medicare Administrative Contractors (A/B MAC) for SNF services
provided to Medicare beneficiaries
Provider Action Needed
Impact to You
This article is based on Change Request (CR) 5583, which clarifies Skilled Nursing
Facility (SNF) No-Payment Billing when the no-pay services overlap periods covered
by a previously paid SNF type of bill 22X.
What You Need to Know
Providers must include occurrence span code 74 with the “statement covers
period” of the 210 bill being submitted in order to bypass Medicare edits
that do not allow SNF TOB 210 (SNF noncovered level of care) to process when
overlapping with previously paid 22X bill types (SNF inpatient stay, Part B
only services (Part A exhausted)). CR 5583 also clarifies provider billing
requirements for beneficiaries who have disenrolled from Medicare Advantage
(MA) plans, and it updates various sections of Chapter 6 (SNF Inpatient Part
A Billing) of the Medicare Claims Processing Manual (Publication 100-04). However,
there are no policy changes made by CR5583.
What You Need to Do
See the Background and Additional Information sections of
this article for further details regarding these clarifications.
Background
No-Pay Billings
Change Request (CR) 5583 clarifies No-Pay billing instructions for Skilled
Nursing Facility (SNF) Type of Bill (TOB) 210 (SNF noncovered level of care)
that overlap previously paid SNF TOB 22X (SNF inpatient stay, Part B only services).
In order to bypass Medicare edits that do not allow SNF TOB 210 to process
when overlapping with previously paid 22X bill types, providers must include
occurrence span code 74 with the “statement covers period” of the
210 bill being submitted.
Beneficiaries Disenrolled from Medicare Advantage (MA) Plans
Medicare covers SNF inpatient services for beneficiaries disenrolling from
risk MA Plans when the beneficiary has not met the three-day prior
hospital stay requirement. (Where a beneficiary disenrolls from
a risk MA, is discharged from the SNF, and then is readmitted to the SNF
under the 30-day rule, all requirements of original Medicare will apply,
including the three-day prior hospital stay.)
Your FI or A/B MAC will begin counting 100 days of SNF care with the SNF
admission date regardless of whether the beneficiary met the skilled level
of care requirements on that date. All other Medicare rules apply, including:
- The requirement that beneficiaries meet the skilled level of care requirement
(for the period for which the original Medicare fee-for-service program is
billed), and
- The rules regarding cost sharing apply to these cases.
In other words, providers may only charge beneficiaries for SNF coinsurance
amounts.
SNFs submit the first fee-for-service inpatient claim with condition
code “58” to indicate:
- A patient was disenrolled from an MA Plan, and
- The three-day prior stay requirement was not met.
Claims with condition code “58” will not require the three-day
prior inpatient hospital stay.
CR5583 updates various sections of Chapter 6 of the Medicare Claims Processing
Manual and these updates are provided as enclosures to CR5583 including the
following SNF Spell of Illness Quick Reference chart:
Level of Care |
Patient's Medicare SNF Part A Benefits
Are Exhausted |
Patient Is In Medicare Certified
Area of the Facility * |
If in non-Medicare Area, the Facility
Meets the Definition of a SNF ** |
Is the Inpatient Spell of Illness
Continued? |
Billing Action |
Medicare Skilled |
YES |
YES |
N/A |
YES |
Submit Monthly Covered Claim |
NO |
YES |
N/A |
YES |
Submit Monthly Covered Claim |
YES |
NO |
YES |
YES |
Submit Monthly Covered Claim |
NO |
NO |
YES |
Patient should be returned to certified
area for Medicare to be billed |
N/A |
NO |
NO |
NO |
Patient should be returned to certified
area for Medicare to be billed |
N/A |
Level of Care |
Patient's Medicare SNF Part A Benefits
Are Exhausted |
Patient Is In Medicare Certified
Area of the Facility * |
If in non-Medicare Area, the Facility
Meets the Definition of a SNF ** |
Is the Inpatient Spell of Illness
Continued? |
Billing Action |
Not Medicare Skilled |
YES |
NO |
NO |
NO |
Do not submit claim if patient (pt) came
in non-skilled. Otherwise, submit no-pay claim w/ discharge status code
when patient leaves the certified area. |
YES |
YES |
N/A |
NO |
Do not submit claim if pt came in non-skilled.
Otherwise, submit no-pay claim w/ discharge status code when patient
leaves the certified area. |
NO |
YES |
N/A |
NO |
Do not submit claim if pt came in non-skilled.
Otherwise, submit no-pay claim w/ discharge status code when patient
leaves the certified area. |
NO |
NO |
YES |
NO |
Do not submit claim if pt came in non-skilled.
Otherwise, submit no-pay claim w/ discharge status code when patient
leaves the certified area. |
YES |
NO |
YES |
NO |
Do not submit claim if pt came in non-skilled.
Otherwise, submit no-pay claim w/ discharge status code when patient
leaves the certified area. |
* Whether the facility considers a patient's bed in the certified area to
be a Medicare bed or not has no effect on whether the spell of illness continues.
** In some states, licensing laws for all nursing homes have incorporated
requirements of the basic SNF definition (Social Security Act §1819(a)(1)).
When this is the case, any nursing home in such a state would be considered
to meet this definition (see CMS Internet-Only Manual, Pub. 100-7,
Chapter 2, §2164 at www.cms.hhs.gov/manuals/  on
the CMS Web site).
Additional
Information
The official instruction, CR 5583 , issued to your FI and A/B MAC regarding
this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1252CP.pdf  on
the CMS Web site.
If you have any questions, please contact your FI or A/B MAC at their toll-free
number, which may be found on the CMS Web site at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip  .
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: MM5583 Revised
Related Change Request (CR) #: 5583
Related CR Release Date: May 25, 2007
Effective Date: October 1, 2006
Related CR Transmittal #: R1252CP
Implementation Date: August 27, 2007
Medicare Guide to Rural Health Services
The Medicare Guide to Rural Health Services: Information for
Providers, Suppliers, and Physicians (Second Edition), which
provides rural information pertaining to rural health facility types, coverage
and payment policies, and rural provisions under the 2003 MMA and the Deficit
Reduction Act of 2005 is now available in downloadable format at http://www.cms.hhs.gov/MLNProducts/downloads/MedicareRuralHealthGuide.pdf .
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