(Medicare Benefit Policy Manual)

 To see a complete list of the CB exclusions (along with the ambulatory surgery and Part B therapy inclusions ), scroll down the Part A MAC Update page to the Downloads section.  Then, click on the link to the zipped file entitled Annual SNF Consolidated Billing HCPCS Updates for the current year.  Once this file is unzipped, the complete exclusion list can be selected in either Microsoft Excel or Text formats, and can then be searched for individual codes.     For a general explanation of the types of services encompassed by each of the Major Categories, scroll down the Part A MAC Update page to the Downloads section, and click on the link to the General Explanation of the Major Categories.  (For example, Major Category III.A lists the excluded chemotherapy codes, and Major Category III.B lists the excluded chemotherapy administration codes.)    For further information on the SNF CB provision, see Pub. 100-04, Medicare Claims Processing Manual, chapter 6, sections 10 through 20.6.   10.3 - Hospital Providers of Extended Care Services  (Rev. 228, Issued: 10-13-16, Effective: 10-18-16, Implementation: 10-18-16)  In order to  address the shortage of rural SNF beds for Medicare patients, rural hospitals with fewer than 100 beds may be reimbursed under Medicare for furnishing post-hospital extended care services to Medicare beneficiaries.  Such a hospital, known as a swing bed facility, can swing its beds between the hospital and SNF levels of care, on an as -needed basis, if it has obtained a swing bed approval from the Department of Health and Human Services.  See Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, Section 30.3 (Hospital Providers of Extended Care Services) for a description of general rules applicable to SNF -level services furnished in hospital swing beds; also, see Pub. 100-04, Medicare Claims Processing Manual, chapte r 6, sections 100ff regarding SNF PPS billing procedures for SNF- level services furnished in rural (non- CAH) swing -bed hospitals.  When a hospital is providing extended care services, it will be treated as a SNF for purposes of applying coverage rules.  This means that services provided in the swing bed are subject to the same Part A coverage, deductible, coinsurance and physician certification/recertification provisions that are applicable to SNF extended care services.  The SNF coverage provisions are set forth in 42 CFR 409 Subpart D and are more fully explained in this chapter.  A patient in a swing bed cannot simultaneously receive coverage for both SNF-level services under Part A and inpatient hospital ancillary services under Part B.   Swing bed patients who no longer qualify for Part A coverage of SNF- level services under the Medicare program (due to exhaustion of Part A SNF benefits, dropping below a SNF level of care, etc.) revert to receipt of a hospital level of care in the swing bed (see the Medicare Benefit Policy Manual, Chapter 6, Hospital Services Covered Under Part B, 10).  Thus, any further Medicare coverage in the swing bed would be for inpatient hospital ancillary services under Part B, notwithstanding a patients eligibi lity for Medicaid NF coverage.   A dually-eligible patient who continues to receive a SNF level of care or who has dropped below the SNF level may nonetheless still qualify for Medicaid coverage of nursing facility (NF) services, if the hospital has a Medicaid swing bed agreement that has been approved by the State in which the facility is located.  Such agreements permit Medicaid -participating rural hospitals to use their beds interchangeably to furnish both acute hospital care and NF care to Medicaid recipients, when no beds are availabl e in area nursing facilities (see Pub. 45, State Medicaid Manual, chapter 4, section 4560).    20 - Prior Hospitalization and Transfer Requirements  (Rev. 1, 10-01-03)  A3-3131, SNF-212  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.  In addition, effective December 5, 1980, the individual must have been transferred to a participating SNF within 30 days after discharge from the hospital, unless the exception in 20.2 applies.   20.1 - Three -Day Prior Hospitalization  (Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21)  In accordance with section 226(c)(1)(B) of the Social Security Act and the implementing regulations at 42 CFR 409.30(a)(2) , the hospital discharge must have occurred on or after the first day of the month in which the individual attained age 65 or, effective July 1, 1973, became entitled to health insurance benefits under the disability or chronic renal disease provisions of the law.  The 3 consecutive calendar day stay requirement can be met by stays totaling 3 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.   Time spent in observation or in the emergency room prior to (or in lieu of) an inpatient admission to the hospital does not count toward the 3-day qualifying inpatient hospital stay, as a person who appears at a hospitals emergency room seeking examination or treatment or is placed on observation has not been admitted to the hospital as an inpatient; instead, the person receives outpatient services.  For purposes of the SNF benefits qualifying hospital stay requirement, inpatient status commences with the  calendar day of hospital admission.  See 31 Fed. Reg. 10116, 10118-19 (July 27, 1966).  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 which arose while in the SNF for trea tment of a condition for which the beneficiary was previously hospitalized.  In this context, the applicable hospital condition need not have been the principal diagnosis that actually precipitated the beneficiarys admission to the hospital, but could be any one of the conditions present during the qualifying hospital stay.  In addition, the qualifying hospital stay must have been medically necessary.  Medical necessity will generally be presumed to exist.  When the facts that come to the A/B MACs (A) attention during the course of its normal claims review process indicate tha t the hospitalization may not have been medically necessary, it will fully develop the case, checking with the attending physician and the hospital, as appropriate.  The A/B MAC will rule the stay unnecessary only when hospitalization for 3 days represents  a substantial departure from normal medical practice.  However, in accordance with Pub. 100-04, Medicare Claims Processing Manual, Chapter 30, 130.2.A, when a beneficiary qualifies for limitation on liability in connection with the hospital stay (or a po rtion thereof), this conclusively establishes that the hospital stay (or portion thereof) was not medically necessary.   Even if a beneficiarys care during a qualifying hospital stay becomes less intensive during the latter part of the stay, the date of hospital discharge in this context is still considered to be the day that the beneficiary physically leaves the hospital , and the level of care being furnished at that particular point is not a determining factor as long as some portion of the stay included at least 3 consecutive days of medically necessary inpatient hospital services.  In addition, when a hospital inpatients care needs drop from acute - to SNF-level but no SNF bed is available, the regulations at 42 CFR 424.13(c) permit a physician to certify that the beneficiarys continued inpatient stay in the hospital is, in fact, medically necessary under this particul ar set of circumstances (see also Pub. 100- 01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, 10.6).  Accordingly, such additional, alternate placement days spent in the hospital can be included in the 3- day count toward m eeting the SNF benefits qualifying hospital stay requirement.   The 3 -day hospital stay need not be in a hospital with which the SNF has a transfer agreement (see Pub. 100- 01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, 30.2 for a discussion of the SNFs required transfer agreement with a hospital) .  However, the hospital must be either a Medicare- participating hospital or an institution that meets at least the conditions of participation for an emergency services hospital (see Pub. 100- 01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, 20.2 , for the definition of an emergency services hospital).  A nonparticipating psychiatric hospital need not meet the special requirements applicable to psychiatric hospitals (see Pub. 100- 01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, 20.3) .  Stays in Religious Nonmedical Health Care Institutions (see Pub. 100 -01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, 40, for definition of RNHCIs) are excluded for the purpose of satisfying the 3- day period of hospitalization.  See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 9, 40.1.5, regarding a qualifying stay that consists of general inpatient care furnished in a hospital under the hospice benefit.  NOTE:  While a 3 -day stay in a psychiatric hospital satisfies the prior hospital stay requirement, institutions that primarily provide psychiatric treatment cannot participate in the program as SNFs.  Therefore, a patient with only a psychiatric condition who is  transferred from a psychiatric hospital to a participating SNF is likely to receive only non-covered care.  In the SNF setting, the term non- covered care refers to any level of care less intensive than the SNF level of care that is covered under th e program.  (See 30ff.).   20.1.1 - Three -Day Prior Hospitalization - Foreign Hospital  (Rev. 261, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19)  Regardless of whether a foreign hospital stay is itself coverable under the heading of foreign hospital services (see Pub. 100- 04, Medicare Claims Processing Manual, chapter 32, 350ff. for a description of the foreign hospital services that are payable by Medicare), an inpatient stay of 3 or more days in a hospital outside the United States may nevertheless satisfy the prior inpatient stay requirement for post -hospital extended care services within the United States as long as the foreign hospital can qualify as an emergency hospital (see Pub. 100- 01, Medicare General Information, Eligibility, and Entitlement Manual, c hapter 5, 20.2, for the definition of an emergency services hospital).  If a stay of 3 or more days in a hospital outside the United States is being considered to satisfy the prior inpatient stay requirement, the SNF will submit documentation to the A/B M AC (A).  This evidence will be either:   A.  An itemized bill or hospital form prepared by the foreign hospital showing dates of admission and discharge and a description of the illness or injury treated (obtained from the beneficiary); or   B.  A medical report prepared by the foreign hospital and sent to the patients U.S. physician showing dates of admission and discharge and a description of the illness or injury treated (obtained from the physician).  If neither type of evidence can be obtained, the SNF will secure whatever information is available for submission to the A/B MAC (A).  When the A/B MAC (A) receives a bill involving a prior inpatient stay in a foreign hospital, it contacts the regional off ice for a determination as to whether the prior stay requirement is met.  If the regional office states the hospital does not qualify as an emergency hospital, the A/B MAC (A) advises the provider that the prior inpatient stay requirement is not met.  If the regional office states the hospital qualifies as an emergency hospital and documentation is submitted as outlined in either 20.2.1 or 20.2.2 which otherwise meets the prior -stay requirement, the A/B MAC (A) processes the SNF claim.   20.2 - Thirty -Day Transfer  (Rev. 1, 10- 01-03)  A3-3131.3, SNF -212.3   20.2.1 - General  (Rev. 161, Issued: 10-26-12, Effective: 04-01-13, Implementation: 04-01-13)  A3-3131.3.A, SNF-212.3.A  Post-hospital extended care services represent an extension of care for a condition for which the individual received inpatient hospital services.  Extended care services are post-hospital if initiated within 30 days after discharge from a hospital stay that included at least three consecutive days of medically necessary inpatient hospital services.  In certain circumstances the 30 -day period may be extended, as described in 20.2.2