(Medicare Claims Processing Manual)

Medicare Claims Processing Manual  Chapter 6 - SNF Inpatient Part A Billing and SNF Consolidated Billing   Table of Contents  (Rev. 12283; Issued: 10-05-23)   Transmittals for Chapter 6   10 - Skilled Nursing Facility (SNF) Prospective Payment System (PPS) and Consolidated Billing Overview  10.1 - Consolidated Billing Requirement for SNFs 10.2 - Types of Facilities Subject to the Consolidated Billing Requirement for SNFs  10.3 - Types of Services Subject to the Consolidated Billing Requirement for SNFs  10.4 - Furnishing Services that are Subject to SNF Consolidated Billing Under an Arrangement with an Outside Entity  10.4.1 - Under Arrangements Relationships 10.4.2 - SNF and Supplier Responsibilities 20 - Services Included in Part A PPS Payment Not Billable Separately by the SNF  20.1 - Services Beyond the Scope of the Part A SNF Benefit 20.1.1 - Physicians Services and Other Professional Services Excluded From Part A PPS Payment and the Consolidated Billing Requirement 20.1.1.1 - Correct Place of Service (POS) Code for SNF Claims  20.1.1.2 - Hospitals Facility Charge in Connection with Clinic Services of a Physician  20.1.2 - Other Excluded Services Beyond the Scope of a SNF Part A Benefit  20.1.2.1 - Outpatient Surgery and Related Procedures- Inclusion 20.1.2.2 - Emergency Services  20.2 - Services Excluded from Part A PPS Payment and the Consolidated Billing Requirement on the Basis of Beneficiary Characteristics and Election  20.2.1 - Dialysis and Dialysis Related Services to a Beneficiary With ESRD  20.2.1.1 - ESRD Services  20.2.1.2 - Coding Applicable to Dialysis Services Provided in a Renal Dialysis Facility (RDF) or Home ) 20.2.2 - Hospice Care for a Beneficiarys Terminal Illness  20.3 -  Other Services Excluded from SNF PPS and Consolidated Billing  20.3.1 -  Ambulance Services  20.4 -  Screening and Preventive Services  20.5 -  Therapy Services  20.6 -  SNF CB Annual Update Proces for  A/B MACs (A)  30 - Billing SNF PPS Services  30.1 -  Health Insurance Prospective Payment System (HIPPS) Rate Code  30.2 -  Coding PPS Bills for Ancillary Services  30.3 -  Adjustment Request  30.4 -  SNF PPS Pricer Software  30.4.1 -  Input/Output Record Layout  30.4.2 -  SNF PPS Rate Components  30.4.3 -  Decision Logic Used by the Pricer on Claims  30.5 -  Annual Updates to the SNF Pricer  40 - Special Inpatient Billing Instructions  40.1 -  Submit Bills in Sequence  40.2 -  Reprocessing Inpatient Bills in Sequence  40.3 -  Determining Part A Admission Date, Discharge Date, and Utilization Days  40.3.1 -  Date of Admission  40.3.2 -  Patient Readmitted Within 30 Days After Discharge  40.3.3 -  Same Day Transfer  40.3.4 -  Situations that Require a Discharge or Leave of Absence  40.3.5 -  Determine Utilization on Day of Discharge, Death, or Day Beginning a Leave of Absence  40.3.5.1 -  Day of Discharge or Death Is the Day Following the Close of the Accounting Year  40.3.5.2 -  Leave of Absence  40.4 -  Accommodation Charges Incurred in Different Accounting Years  40.5 -  Billing Procedures for Periodic Interim Payment (PIP) Method of Payment  40.6 -  Total and Noncovered Charges  40.6.1 -  Services in Excess of Covered Services  40.6.2 -  Showing Discounted Charges  40.6.3 -  Reporting Accommodations on the Claim  40.6.4 -  Bills with Covered and Noncovered Days  40.6.5 -  Notification of Limitation on Liability Decision  40.7 Ending a Benefit Period 40.8 -  Billing in Benefits Exhaust and No- Payment Situations  40.8.1 -  SNF Spell of Illness Quick Reference Chart  40.8.2 -  Billing When Qualifying Stay or Transfer Criteria are Not Met  40.9-  Other Billing Situations  50 - SNF Payment Bans, or Denial of Payment for New Admissions (DPNA)  50.1 -  Effect on Utilization Days and Benefit Period  50.2 -  Billing When Ban on Payment Is In Effect  50.2.1 -  Effect of an Appeal to a DPNA on Billing Requirements During the Period a SNF is Subject to a DPNA  50.2.2 -  Provider Liability Billing Instructions  50.2.3 -  Beneficiary Liability Billing Instructions  50.2.4 -  Part B Billing  50.3 -  Sanctions Lifted: Procedures for Beneficiaries Admitted During the Sanction Period 50.3.1 -  Tracking the Benefit Period 50.3.2 -  Determining Whether Transfer Requirements Have Been Met  50.4 -  Conducting Resident Assessments  50.5 -  Physician Certification  50.6 -  A/B MAC (A)  Responsibilities  50.7 -  Retroactive Removal of Sanctions  60 - Billing Procedures for a Composite SNF or a  Change in Provider Number  70 - Billing for Services After Termination of Provider Agreement, or After Payment is Denied for New Admissions  70.1 -  General Rules  70.2 -  Billing for Covered Services  70.3 -  Part B Billing  80 - Billing Related to Physicians Services  80.1 -  Reassignment Limitations  80.2 -  Payment to Employer of Physician  80.3 -  Information Necessary to Permit Payment to a Facility  80.4 -  Services Furnished Within the SNF  80.5 -  Billing Under Arrangements  80.6 -  Indirect Contractual Arrangement  80.7 -  Establishing That a SNF Qualifies to Receive Part B Payment on the Basis of Reassignment  90 - Medicare Advantage (MA) Beneficiaries  90.1 -  Beneficiary Disenrolled from MA Plans  90.2 -  Medicare Billing Requirements for Beneficiaries Enrolled in MA Plans  100 -  Part A SNF PPS for Hospital Swing Bed Facilities  100.1 -  Swing Bed Services Not Included in the Part A PPS Rate  110 -  A/B MAC (B)/DME MAC  Claims Processing for Consolidated Billing for Physician and Non- Physician Practitioner Services Rendered to Beneficiaries in a SNF Part A Stay  110.1 -  Correct Place of Service (POS) Code for SNF Claims  110.2 -  CWF Edits  110.2.1 -  Reject and Unsolicited Response Edits  110.2.2 -  A/B Crossover Edit s 110.2.3 -  Duplicate Edits  110.2.4 -  Edit for Ambulance Services  110.2.5 -  Edit for Clinical Social Workers ( CSWs ) 110.2.6 -  Edit for Therapy Services Separately Payable When Furnished by a Physician 110.2.7 -  Edit to Prevent Payment of Facility Fees for Services Billed by an Ambulatory Surgical Center (ASC) when Rendered to a Beneficiary in a Part A Stay  110.3 -  CWF Override Codes  110.4 -  Coding Files and Updates  110.4.1 -  Annual Update Process   120-  Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)   120.1 -  HIPPS Updates and Structure Changes   120.2 -  Interrupted Stay Policy   120.3 -  Variable Per Diem (VPD) Adjustment   120.4 -  AIDS Adjustments   120.5 -  Transition Claims   120.6 -  Default Billing   10 - Skilled Nursing Facility (SNF) Prospective Payment System (PPS) and Consolidated Billing Overview  (Rev.4163, Issued: 11- 02-18, Effective: 12-04-18, Implementation: 12-04-18)   All SNF Part A inpatient services are paid under a prospective payment system (PPS).  Under SNF PPS, beneficiaries must meet the regular eligibility requirements for a SNF stay.  That is, the beneficiary must have been an inpatient of a hospital for a medically necessary stay of at least three consecutive calendar days.  In addition, the be neficiary must have been transferred to a participating SNF within 30 days after discharge from the hospital, unless the patients condition makes it medically inappropriate to begin an active course of treatment in an SNF within 30 days after hospital discharge, and it is medically predictable at the time of the hospital discharge that the beneficiary will require covered care within a predetermined time period.  (See the Medicare Benefit Policy Manual, Chapter 8, Coverage of Extended Care Services Under Hospital Insurance, 20.2, for further information on the 30-day transfer requirement and exception.)  To be covered, the extended care services must be needed for a condition which was treated during the patients qualifying hospital stay, or for a condition which arose while in the SNF for treatment of a condition for which the beneficiary was previously treated in a hospital. Also under SNF PPS all Medicare covered Part A services that are considered within the scope or capability of SNFs are considered paid in the PPS rate.  In some cases this means that the SNF must obtain some services that it does not provide directly.  Nei ther the SNF nor another provider or practitioner may bill the program for the services under Part B, except for services specifically excluded from PPS payment and associated consolidated billing requirements. Any DME or oxygen furnished to inpatients in a covered Part A stay is included in the SNF PPS rate.  The definition of DME in 1861(n) of the Social Security Act (the Act) provides that DME is covered by Part B only when intended for use in the home, which explicitly does not include a SNF.  This definition applies to oxygen also.  (See the Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Service, 110.) Most prosthetics and all orthotic devices are included in the Part A PPS rate.  An exception involves certain designated customized prosthetic devices that are specifically identified as being outside the rate (see the regulations at 42 CFR 411.15(p)(2)(xvi) and Major Category III.D of the SNF consolidated billing editing).  Those customized prosthetic devices that are considered outside the PPS rate are billed by the qualified outside entity that furnished the service.  That entity bills its normal MAC.  Services that are not considered to be furnished within SNF PPS are identified in sections 20.1 - 20.4.  These may be billed separately under Part B.  Some services must be billed by the SNF.  (This is referred to as consolidated billing.)  Some services must be billed by the rendering provider (SNF or otherwise).  These are discussed further in 20.1 - 20.4.  10.1 - Consolidated Billing Requirement for SNFs  (Rev.4163, Issued: 11- 02-18, Effective: 12-04-18, Implementation: 12-04-18)   Section 4432 (b) of the Balanced Budget Act (BBA) requires consolidated billing (CB) for SNFs.  Under the CB requirement, the SNF must submit ALL Medicare claims for ALL the services that its residents receive under Part A, except  for certain excluded services described in 20.1 - 20.3, and  for all physical, occupational and speech-language pathology services received by residents under Part B (see 20.5).  A SNF resident is defined as a beneficiary who is admitted to a Medicare participating SNF or the participating, Medicare- certified, distinct part unit (DPU) of a larger institution.  Under the regulations at 42 CFR 411.15(p)(3)(i)- (iv), if  such a beneficiary leaves the facility (or the DPU), the beneficiarys status as a SNF resident for CB purposes (along with the SNFs responsibility  to furnish or make arrangements for needed services) ends when any one of the following events occurs:   The beneficiary is admitted as an inpatient to a Medicare-participating hospital or critical access hospital (CAH), or as a resident to another SNF;   The beneficiary receives services from a Medicare -participating home health agency under a plan of care;   The beneficiary receives one of the types of outpatient hospital services that CMS has designated as being exceptionally intensive (see 20.1.2); or