MIR-2007-05A, May 2007

Quick Tip: Verifying Three-Day Qualifying Hospital Stay to Avoid Skilled Nursing Facility (SNF) Reason Code 19904

The initial claim in a Skilled Nursing Facility (SNF) inpatient stay will be rejected if there is no qualifying hospital stay (FISS reason code 19904). Once the initial claim has been rejected for this reason, any subsequent claim within the stay will also be rejected.

To show the qualifying hospital stay on the SNF claim, enter Occurrence Span Code 70 with the FROM and THROUGH dates of the qualifying hospital stay.

Correcting Reason Code 19904

• Verify that the beneficiary did have a qualifying hospital stay. If there was a qualifying hospital stay, enter Occurrence Span Code 70 with the dates of the qualifying hospital stay on your claim. Submit an adjustment if the claim rejected; resubmit if the claim was RTP.
• If the beneficiary did not have a qualifying hospital stay and you did not receive the correct denial, submit an adjustment if the claim processed incorrectly; resubmit if the claim was RTP. The claim will process as rejected with the correct ANSI and MSN coding.

Avoiding Reason Code 19904
To prevent reason code 19904 from occurring, set up your billing system for your SNF inpatient claims to include the Occurrence Span Code 70 with dates when there was a qualifying hospital stay. If the beneficiary did not have a qualifying stay and you are attempting to get a denial, submit the claim with no qualifying stay. The claim will process as rejected with the correct ANSI and MSN coding.

Qualifying Hospital Stay Defined
The qualifying hospital stay is defined in Medicare Benefit Policy Manual, Chapter 8 – “Coverage of Extended Care (SNF) Services Under Hospital Insurance.”

Section 20: In order to qualify for post-hospital extended care services, the individual must have been an inpatient of a hospital for a medically necessary stay of at least three consecutive calendar days.

Section 20.1: The hospital discharge must have occurred on or after the first day of the month in which the individual attained age 65 or became entitled to health insurance benefits under the disability or chronic renal disease provisions of the law. The three consecutive calendar day stay requirement can be met by stays totaling three consecutive days in one or more hospitals. In determining whether the requirement has been met, the day of admission, but not the day of discharge, is counted as a hospital inpatient day. To be covered, the extended care services must have been for the treatment of a condition for which the beneficiary was receiving inpatient hospital services (including services of an emergency hospital) or a condition that arose while in the SNF for treatment of a condition for which the beneficiary was previously hospitalized.