Content Section
|
Medicare Information Resource
|
Note: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material which is copyrighted by the American Medical Association (AMA). You are forbidden to download the files unless you read, agree to and abide by the provisions of the copyright statement. Read the copyright statement now (you will be linked back to here).
|
MIR-2007-3A, March 2007
Quick Tip: Submitting Continuing Stay Claims Appropriately
to Avoid Reason Codes 38118, 38119, and U5607
The Medicare regulations state that, Skilled Nursing Facility (SNF) inpatient claims have to be processed in sequence by Medicare. That means that when the beneficiary is going to be in the SNF for several months in a row, the claims for the months the beneficiary is in the SNF must be submitted one at a time, in sequential order. The subsequent claims in the stay should not be submitted until the prior month’s claim has been processed and finalized.
| Example : If the beneficiary is in the SNF from January 1, 2006 through May 31, 2006, this is considered a continuing stay. Providers should submit the January claim, and allow that claim to finalize. After the January claim has finalized, submit the claim for February services. Allow the February to finalize before submitting the claim for March, etc. |
Avoiding Reason Codes 38118, 38119, and U5607
To avoid reason code 38118, providers should ensure that the prior month’s claim in a continuing stay has been finalized prior to submitting the next month claim for this stay. The most common scenario to cause this reason code is one where the provider has submitted the next month’s claim before the prior month’s claim has finalized. Do not submit the next month’s claim for a continuing stay unless the prior month’s claim is in the status location of a D B9997, P B9997 or R B9997. Claim location can be verified by going into the OMNIPRO SM claim inquiry menu.
To avoid reason code 38119, providers should ensure that the prior month’s claim in a continuing stay has been submitted. The most common scenario to cause this reason code is when the claim for the prior month in a continuing stay has not been submitted. Submit the prior month claim and allow that claim to process.
Reason code U5607 will be applied to claim when the admit date on the incoming claim does not match the admit date listed for the prior months’ claims that have been processed. This code can be avoided by making sure that the admit date for the prior month’s claim matches what is being submitted on the subsequent month’s claim for a continuing stay.
| Example : Beneficiary was in the facility from 01/01-06/01/2006, the January claim was submitted with an admit date of 01/01/2006. On all subsequent claims that are going to be submitted within that continuing stay, the admit date should be 01/01/2006. |
When you submit each continuing stay claim one month at a time and allow that claim to process before submitting the next month’s claim, the claims will be in compliance with Medicare regulations.
© All current procedural terminology (CPT) codes and descriptors copyrighted by the American Medical Association.
|
