Did You Know? – Skilled Nursing Facility
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- Where can SNFs find current data concerning RUG weights and supporting data, the County/MSA/CBSA crosswalk file, and files for the Fiscal Year Software Releases?
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Go to the CMS Skilled Nursing Facilities (SNF) PC Pricer page to locate RUG rates. Select the SNF Main Frame Pricing Programs for the current fiscal year located under Downloads
Reviewed 12/02/2022
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- A patient has utilized 150 days of the Part A inpatient benefit and has also utilized 100 days of the skilled nursing facility (SNF) benefit of that benefit period. What does this mean?
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This means that the patient's inpatient benefits are exhausted. Per the CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 3, section 20:
"A patient having hospital insurance coverage is entitled to have payment made on his/her behalf for up to 90 days of covered inpatient hospital services in each benefit period. Also, the patient has a lifetime reserve of 60 additional days.' In addition, 'a patient having hospital insurance coverage is entitled to have payment made on his/her behalf for up to 100 days of covered inpatient extended care services (i.e. Skilled Nursing Facility (SNF) services) in each benefit period."
Reviewed 12/02/2022
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- Are skilled nursing facilities required to bill Medicare for patients who have exhausted their Part A benefit?
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A skilled nursing facility (SNF) is required to submit a bill for a Medicare patient who has started a spell of illness under the SNF Part A benefit for every month of the related stay even though no benefits may be payable. The Centers for Medicare & Medicaid Services (CMS) maintains a record of all inpatient services for each beneficiary, whether covered or not. A SNF must submit a benefits exhaust bill monthly for those patients that continue to receive skilled care and also when there is a change in the level of care, regardless of whether the benefits exhaust bill will be paid by Medicaid, a supplemental insurer or private payer.
A benefits exhaust claim that indicates a drop in level of care and the patient remains in the Medicare-certified area of the facility after the drop in level of care, would be submitted on a 212 or 213 bill type. The claim must include an Occurrence Code 22, with the date covered SNF level of care ended, and covered days and charges as if the Medicare patient had days available up until the date active care ended. The Patient Status Code is 30 - still patient. A 210 bill type should not be used for benefits exhaust claims submission.
You may refer to the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 6, section 40.8
Reviewed 12/02/2022
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- Can a provider bill a skilled nursing facility (SNF) or swing bed (SB) claim if the patient does not have a qualifying hospital stay?
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SNF and swing bed SB providers must submit a qualifying hospital stay or an appropriate condition code for bypassing the qualifying stay, if applicable, on all claims including initial and subsequent claims that are submitted as covered. This is applicable for submitted bill types 21x (SNF inpatient) and 18x (SB inpatient). This also includes all covered claims (e.g., claims submitted for benefits exhaust denials). Covered claims submitted on 21x and 18x bill types that do not contain a qualifying hospital stay (using occurrence span code 70 with the qualifying hospital stay dates) or an appropriate condition code indicating why a qualifying hospital stay is not applicable will be denied.
Reference:
Reviewed 12/02/2022
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- If a patient is admitted into inpatient or skilled nursing facility care within 60 days of the benefits, does Medicare adjust claims to assign benefits sequentially for dates of service?
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No. Medicare does not adjust claims to be sequential by dates of service to the providers. Benefit utilization is calculated as claims are received.
Reviewed 12/02/2022
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- Where can I find the SNF consolidated billing list? I have researched this on the CMS website and went to the SNF consolidated billing section, but I was never able to locate an actual list that shows any codes.
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The SNF consolidated billing list is located on the CMS website. Access the individually excluded codes by completing the following steps:
- Go to the SNF Consolidated Billing | CMS.
- Select the appropriate year for the claim date of service (e.g., if the dates of service on your claim are for 020116 through 022816, you would select the 2016 Part A MAC Update on the left tab.)
- Scroll to the bottom of the page and select Annual SNF Consolidated Billing HCPCS Updates.
Reviewed 12/02/2022
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- How can we avoid getting a denial that results in our claim being down coded?
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To prevent denials which result in down coding, be sure to:
- Submit all documentation to support the Resource Utilization Group (RUG) code(s) billed.
- The Minimum Data Set (MDS) assessment that established the RUG code billed must be supported by the clinical documentation.
If any portion of documentation to support the RUG code billed is missing from the records submitted, CGS may down code the RUG code.
Reviewed 12/02/2022
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- What type of clinical documentation should we send to support medical necessity?
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The type of documentation that will help support medical necessity includes:
- Physician orders for care and treatments
- Medical diagnoses
- Rehabilitation diagnosis (as appropriate)
- Patient's past medical history
- Progress notes that describe the beneficiary' response to treatments and his physical/mental status
- Lab and other test results
- Other documentation supporting the beneficiary' need for the skilled services being provided in the SNF
Reviewed 12/02/2022
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- Can you provide clarification for the following? We provide outpatient services to SNF patients who are brought to our hospital and returned to the SNF via an ambulance. We send claims to Medicare for the patient's outpatient service and it was rejected stating that it overlapped the SNF services. When we billed the SNF, they responded that it is not part of SNF consolidated billing and they do not owe the hospital for the ambulance service.
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If a SNF resident is taken to the hospital for outpatient services other than for those excluded from consolidated billing and they are returned to the SNF, they retain their resident status. In that case the ambulance services remains subject to consolidated billing even if the purpose of the trip is to receive a service that is itself excluded from CB."
CMS Article SE0433 "Skilled Nursing Facility Consolidated Billing As It Relates to Ambulance Services" states: "Medicare regulations specify the receipt of certain exceptionally intensive or emergency services furnished during an outpatient visit to a hospital as one circumstance that ends a beneficiary's status as a SNF resident for consolidated billing purposes. Such outpatient hospital services are, themselves, excluded from the CB requirement on the basis that they are well beyond the typical scope of the SNF care plan. These services are the following:
- Cardiac catheterization
- Computerized axial tomography (CT) scans
- Magnet resonance imaging (MRIs)
- Ambulatory surgery involving the use of an operating room, including the insertion, removal or replacement of a percutaneous esophageal gastrostomy (PEG) tube in the hospital's gastrointestinal (GI) or endoscopy suite
- Emergency services
- Angiography
- Lymphatic and Venous Procedures
- Radiation therapy
In these cases, any associated ambulance trips will also be considered excluded from consolidated billing. Therefore, an ambulance trip from the SNF to the hospital for one of the above listed services should be billed separately under Part B. This also holds true for return trips from the hospital to the SNF as the patient will not be considered a SNF resident until they are returned to the SNF.
Reviewed 12/02/2022
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- If a SNF patient goes to the outpatient hospital to have Part B services such as therapy, does the facility have to provide it under consolidated billing even though the patient is not under a Part A stay?
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The CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 6, section 10.3 , states: "Physical therapy, occupational therapy, and/or speech-language pathology services (other than audiology services, which are considered diagnostic tests rather than therapy services) furnished to a SNF resident during a non-covered stay must still be billed by the SNF itself."
Reviewed 12/02/2022
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- What is a Swing Bed?
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In rural areas where a skilled nursing facility might not be readily available, rural hospitals and Critical Access Hospitals who have been approved by CMS can furnish swing bed services. They are able to use or "swing" their beds to furnish either acute hospital or skilled nursing facility level care.
For further information, read CMS MLN006951 - Swing Bed Services (cms.gov).
Reviewed 12/02/2022
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- Can the 3-day qualifying hospital stay requirement for skilled nursing facility (SNF) coverage be satisfied by a stay in an inpatient rehabilitation facility (IRF)?
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Yes, as long as the patient is an inpatient in the IRF for at least 3 days not including the day of discharge.
Reviewed 12/02/2022
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- A patient is in observation for 2 days, then is admitted to the hospital as an inpatient for 2 days. Have they met the technical requirement for a 3 day stay in the hospital for skilled nursing facility coverage?
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No, days in observation do not count toward the 3 day qualifying stay. Therefore, since this patient was only an inpatient for 2 days, the requirement was not met.
Reviewed 12/02/2022
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- Where can I find information on SNFABN?
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The SNF ABN form and instructions can be found on the CMS FFS SNF ABN and SNF Denial Letters website.
Reviewed 12/02/2022
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- Why is it important to have a written "arrangement" for services provided under SNF consolidated billing?
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For any Part A or Part B services that are subject to SNF consolidated billing, the SNF must either furnish the services directly with its own resources, or obtain the service from an outside entity under an "arrangement" as described in CMS Claims Processing Manual 100-04, chapter 6, section 80.5. Under this type of arrangement, the SNF must reimburse the outside entity for the services that are subject to consolidated billing.
When ordering or furnishing services "under arrangements" both parties need to reach a common understanding on the terms of payment (e.g., how to submit an invoice, how payment rates will be determined, and the turn-around time between billing and payment). Whenever possible, SNFs should document arrangements with suppliers in writing. The absence of a valid agreement does NOT remove the SNF's responsibility to reimburse providers for services.
It is important to note that SNFs who demonstrate a pattern on nonpayment are at risk of being found in violation of the terms of its provider agreement.
Reference:
Reviewed 12/02/2022
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- Where can I find information on Patient Driven Payment Model (PDPM)?
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It can be found on our Browse by Topic Patient Driven Payment Model page.
Reviewed 12/02/2022
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