(Medicare Claims Processing Manual)

40.6.3 - Reporting Accommodations on the Claim  (Rev. 3220, Issued: 03- 16-15, Effective: ICD -10: Upon Implementation of ICD-10, ASC-X12: 01-01-12, Implementation: 10-01-14, ICD-10: Upon Implementation of ICD-10 ASC X12: 09 -16-14)  See the Medicare Benefit Policy Manual, Chapter 1, Inpatient Hospital Services, for an explanation of the rules when other than semi -private accommodations are furnished that apply to SNFs as well as hospitals.  The type of accommodation furnished at the time of the SNF census -taking hour determines the applicable revenue code.  Where a patient is admitted with the expectation that he will remain overnight, but on the same day is discharged, dies, or is transferred prior to the census, the revenue code is determined by the type of accommodation furnished at the time of the patients discharge, death, or transfer.   Payment is based on the PPS rate, not on accommodation levels.  See 40.6.1 where the patient requests more expensive accommodations or patient convenience items.  The determination of charges does not affect the determination of inpatient utilization days or when a patient may be considered an inpatient for Medicare purposes as outlined in the Medicare Benefit Policy Manual, Chapter 8, Coverage of Extended Care (SN F) Services Under Hospital Insurance, 50 and 60.2.  Refer to the Medicare Claims Processing Manual, Chapter 25 for further information about billing.  SNFs show total charges for accommodation for the entire billing period and charges for any noncovered days in noncovered charges.)  The accommodation days do not include the day of death or discharge, even where the discharge was late.  However, where the SNF customarily makes an extra charge for a late discharge, they include this amount in total charges with the appropriate accommodation revenue code.  The day of discharge is not included in Covered Days even though an extra charge is included.  Where the late discharge was for the patients convenience and not for any medical necessity, SNFs enter the charge for late discharge as a noncovered charge.  Where the late discharge is for a medical reason, the charge is covered.  (See the Medicare Benefit Policy Manual, Chapter 8, Coverage of Extended Care (SNF) Services Under Hospital Insurance, 60.3.)  The charges for accommodations reflect only the total charges for general routine services as defined in 2202.6 and 2203.1 of the Medicare Provider Reimbursement Manual.  All charges, which are charged to every patient for every patient day, are included in the routine accommodation charge.  SNFs bill ancillary charges for day of discharge, death or the day on which a leave of absence begins, under the proper revenue code.  Where the patient is discharged on his first day of entitlement or the first day of the SNF participation in the Medicare program, they submit a bill with no accommodation charge, but with ancillary charges.  Where some of the days cannot be paid under Part A because benefits were exhausted before discharge, death, or the day on which a leave of absence began, SNFs show the charges for days after benefits where exhausted under noncovered charges, and enter the appropriate occurrence code, e.g., A3, and the date benefits are exhausted.  See the Medicare Claims Processing Manual, Chapter 7, SNF Part B Billing, 10, for billing under Part B in such circumstances.   40.6.4 - Bills with Covered and Noncovered Days (Rev. 3220, Issued: 03- 16-15, Effective: ICD -10: Upon Implementation of ICD -10, ASC- X12: 01- 01-12, Implementation: 10- 01-14, ICD -10: Upon Implementation of ICD- 10 ASC X12: 09 -16-14)  Any combination of covered and noncovered days may be billed on the same bill.  It is important to record a day or charge as covered or noncovered because of the following:    Beneficiary utilization is recorded based upon days during which the patient received hospital or SNF accommodations, including days paid by Medicare and days for which the provider was held liable for reasons other than medical necessity or custodial care.   The provider may claim credit on its cost report only for covered accommodations, days and charges for which actual payment is made.  Provider liable days and charges are not included on the cost report.  Data from the bill payment process are used in preparing the cost report.  SNFs show noncovered charges for denied or noncovered days, which will not be paid.  The SNF submits the bill with occurrence span code 76 and completes the from/through dates to report periods where the beneficiary is liable.  Occurrence span code 77 is used to report periods  of noncovered care where the SNF is liable.  If applicable, the FISS system will automatically assign occurrence code A3 indicating the last date for which benefits are available or the date benefits were exhausted.   The A/B MAC (A) will use Occurrence Span Code 79 (a payer only code sent to CWF) to report periods of noncovered care due to lack of medical necessity or custodial care for which the provider is held liable.  Periods of beneficiary liability and provider l iability may be reported on one bill.  Report all noncovered days.  See Chapter 25, Completing and Processing the CMS -1450 Data Set, for a complete description of billing data elements.  See the Medicare Claims Processing Manual, Chapter 30, Limitation on Liability, for determining SNF liability.   The provider is always liable unless the appropriate notice is issued.  If the SNF issues the appropriate notice, and the beneficiary agrees to make payment either personally or through a private insurer, the days will not be charged towards the 100 -day be nefit period.  Notice requirements for periods of noncoverage are found in Chapter 30, 70.   40.6.5 - Notification of Limitation on Liability Decision  (Rev. 133, 04- 02-04) SNF -517.8  Detailed instructions and application of limitation on liability is found in The Medicare Claims Processing Manual, Chapter 30, Limitation on Liability.  The limitation on liability decision is made by the A/B MAC (A) when the medical evidence and admiss ion notice, or the bill is submitted.  When coverage is denied, notification will be by telephone, if possible, so written notice can be provided to the patient immediately.  When it is determined during the course of a beneficiarys stay in an SNF that the care is not covered but both the beneficiary and the SNF are entitled to limitation on liability, the Medicare program may make payment for the noncovered services for a grace period of one day (24 hours) after the date of notice to the SNF or to the beneficiary, whichever is earlier.  If it is determined that more time is required in order to arrange post- discharge care, up to 1 additional grace period day may be paid for.   Limitation of liability may apply to Part A and Part B services furnished by the provider.   40.7 - Ending a Benefit Period  (Rev. 930, Issued: 04- 28-06, Effective: 10 -01-06, Implementation: 10- 02-06)  A benefit period ends 60 days after the beneficiary has ceased to be an inpatient of a hospital and has not received inpatient skilled care in a SNF during the same 60- day period.  When the SNF resident's health has improved to the point where he or she no longer needs or receives the level of skilled care required for Part A coverage, the SNF must bill one of the two following scenarios:   1. For the resident that leaves the Medicare- certified SNF or DPU:   a. Submit a final discharge bill, and   b. Any services rendered after the discharge and billed by the SNF should be submitted on a 23x.  2. For the resident that remains in the Medicare- certified SNF or DPU after the skilled level of care has ended:   a. Submit the last skilled care claim with an occurrence code 22 to indicate the date active care ended. i.e.,  date covered SNF level of care ended,  and patient status code 30 to indicate the patient is still a resident in the Medicare -certified SNF or DPU;   b. Any Part B covered services rendered and billed by the SNF after the skilled care ended should be submitted on a 22x; and  c. All therapies must be billed by the SNF on the 22x.  For additional instructions on ending a benefit period go to the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, 10.4.2.  40.8 - Billing in Benefits Exhaust and No- Payment Situations  (Rev. 4491, Issued: 01- 09- 20, Effective: 04-01-20, Implementation: 04-06-20)  An SNF is required to submit a bill for a beneficiary that 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.   CMS maintains a record of all inpatient services for each beneficiary, whether covered or n ot.  The related information is used for national healthcare planning and also enables CMS to keep track of the beneficiarys benefit period.  These bills have been required in two situations:  1) when the beneficiary has exhausted his/her 100 covered days  under the Medicare SNF benefit (referred to below as benefits exhaust bills) and 2) when the beneficiary no longer needs a Medicare covered level of care (referred to below as no-payment bills).  For benefits exhaust bills, an SNF must submit monthly a benefits exhaust bill 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 insure, or private payer.  There are two types of benefits exhaust claims:  1) Full benefits exhaust claims: no benefit days remain in the beneficiarys applicable benefit period for the submitted statement covers from/through date of the claim and 2) Partial benefits exhaust claims: only one or some benefit days, in the beneficiarys applicable benefit period, remain for the submitted statement covers from/through date of the claim.   Monthly claim submission of both types of benefits exhaust bills are required in order to extend the beneficiarys applicable benefit period posted in the Common Working File (CWF).  Furthermore, when a change in level of care occurs after exhaustion of a beneficiarys covered days of care, the provider must submit the benefits exhaust bill in the next billing cycle indicating that active care has ended for the beneficiary.   NOTE :  Part B 22x bill types must be submitted after the benefits exhaust claim has been submitted and processed.  In addition, SNF providers must submit no- payment bills for beneficiaries that have previously received Medicare-covered skilled care and subsequently dropped to a non-covered level of care but continue to reside in a Medicare- certified area of the facility.  Consolidated Billing (CB) legislation indicates that physical therapy, occupational therapy, and speech language pathology services furnished to SNF residents are always subject to SNF CB.   This applies even when a resident receives the therapy during a non-covered stay in which the beneficiary who is not eligible for Part A extended care benefit still resides in an institution (or part thereof) that is Medicare -certified as a SNF.   SNF CB edits require the SNF to bill for these services on a 22x (inpat ient part B) bill type.   NOTE : Unlike with benefits exhaust claims, Part B 22x bill types may  be submitted prior to the submission of bill type 210 no payment claims.   If a facility has a separate, distinct non -skilled area or wing then beneficiaries may be discharged to this area using the appropriate patient discharge status code and no-  payment bills would not be required.  In addition, SNF CB legislation for therapy services would not apply for these beneficiaries.   No-payment bills are not required for non- skilled beneficiary admissions.  As indicated above, they are only required for beneficiaries that have previously received covered care and subsequently dropped to non- covered care and continue to reside in the certified area of the facility.   NOTE:   Providers may bill benefits exhaust and no payment claims using the default HIPPS code AAA00 prior to October 1, 2019 and ZZZZZ October 1, 2019 and after, in addition to an appropriate room & board revenue code only.  No further ancillary services need b e billed on these claims.   SNF providers and A/B MACs (A) shall follow the billing guidance provided below for the proper billing of benefits exhaust bills and no- payment bills.   1) SNF providers shall submit benefits exhaust claims for those beneficiaries that continue to receive skilled services as follows:   a)   Full or partial benefits exhaust claim. (Submitted monthly)   i) Bill Type = Use appropriate covered bill type (i.e., 211, 212, 213 or 214 for SNF and 181, 182, 183 or 184 for Swing Bed (SB).  NOTE:   Bill types 210 or 180 should not be used for benefits exhaust claims submission).   ii) Occurrence Span Code 70 with the qualifying hospital stay dates.  iii) Covered Days and Charges = Submit all covered days and charges as if beneficiary had days available.