(Medicare Claims Processing Manual)

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.   iv) Value Code 09 (First year coinsurance amount) 1.00 (If applicable, the FISS will assign the correct coinsurance amount based off the CWF response).   v) Patient Status Code = Use appropriate code.   b)   Benefits  exhaust claim with a drop in level of care within the month; Patient remains in the Medicare- certified area of the facility after the drop in level of care.   i) Bill Type = Use appropriate bill type (i.e., 212 or 213 for SNF and 182 or 183 for 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) Occurrence Code 22 (date active care ended, i.e., date covered SNF level of care ended) = include the date active care ended; this should match the statement covers through date on the claim.   iv) Covered Days and Charges = Submit all covered days and charges as if the beneficiary had days available up until the date active care ended.   v) Value Code 09 (First year coinsurance amount) 1.00 (If applicable, the FISS will assign the correct coinsurance amount based off the CWF response).   vi) Patient Status Code = 30 (still patient).   c)   Benefits exhaust claim with a patient discharge.   i) Bill Type = 211 or 214 for SNF and 181 or 184 for SB ( NOTE:  Bill types 210 or 180 should not be used for benefits exhaust claims submission).   ii) Covered Days and Charges = Submit all covered days and charges as if beneficiary had days available up until the date active care ended.   iii) Value Code 09 (First year coinsurance amount) 1.00 (If applicable, the FISS will assign the correct coinsurance amount based off the CWF response).   iv) Patient Status Code = Use appropriate code other than patient status code 30 (still patient).   NOTE:   Billing all covered days and charges allow the Common Working File (CWF) to assign the correct benefits exhaust denial to the claim and appropriately post the claim to the patients benefit period.  Benefits exhaust bills must be submitted monthly.   2) SNF providers shall submit no- payment claims for beneficiaries that previously dropped to non- skilled care and continue to reside in the Medicare -certified area of the facility using the following options.   a)   Patient previously dropped to non- skilled care.   Provider needs Medicare denial notice for other insurers.   i) Bill Type = 210 (SNF no -payment bill type) or 180 (SB no- payment bill type)   ii) Statement Covers From and Through Dates = days provider is billing, which may be submitted as frequently as monthly, in order to receive a denial for other insurer purposes.  No-payment billing shall start the day following the date active care ended.   iii) Days and Charges = Non -covered days and charges beginning with the day after active care ended.   iv) Condition Code 21 (billing for denial).   v) Patient Status Code = Use appropriate code.   b)   Patient previously dropped to non- skilled care.   In these cases, the provider must only submit the final discharge bill that may span multiple months but must be as often as necessary to meet timely filing guidelines.   i) Bill Type = 210 (SNF no -payment bill type) or 180 (SB no- payment bill type)   ii) Statement Covers From and Through Dates = days billed by the provider, which may span multiple months, in order to show final discharge of the patient.   No-payment billing shall start the day following the date active care ended.   iii) Days and Charges = Non -covered days and charges beginning with the day after active care ended.   iv) Condition Code 21 (billing for denial).   v) Patient Status Code = Use appropriate code other than patient status code 30 (still patient).   NOTE:  No pay bills may span both provider and Medicare fiscal year end dates.  Refer to Chapter 25 for further information about billing.   40.8.1  SNF Spell of Illness Quick Reference Chart  (Rev.4409, Issued: 10 -04-19, Effective: 11 -05-19, Implementation: 11 -05-19)   Level of Care  Patient's Medicare SNF Part A Benefits Are Exhausted  Patient Is In Medicare Certified Area of the Facility *  If in non -Medicare Area, the Facility Meets the Definition of a SNF **  Is the Inpatient Spell of Illness Continued?                                Billing Action  Medicare Skilled  YES  YES  N/A  YES  Submit Monthly Covered Claim.  NO YES  N/A  YES  Submit Monthly Covered Claim.  YES  NO YES  YES  Submit Monthly Covered Claim.  NO NO YES  YES  Patient should be returned to certified area for Medicare to be  billed. Submit Monthly Covered Claim.  NO NO NO NO Facility should determine whether it would be  appropriate to send patient back to a certified area for  Medicare coverage.  Not Medicare Skilled  YES  NO NO NO Do not submit claim if pt came in non -skilled.  Otherwise,  submit no- pay claim w/ discharge status code when patient  leaves the certified area.  YES  YES  N/A  NO Do not submit claim if pt came in non -skilled.  Otherwise,  submit no- pay claim w/ discharge status code when patient  leaves the certified area.  NO YES  N/A  NO Do not submit claim if pt came in non -skilled.  Otherwise,  submit no- pay claim w/ discharge status code when patient leaves the certified area.  NO NO YES  NO Do not submit claim if pt came in non -skilled.  Otherwise,   submit no- pay claim w/ discharge status code when patient  leaves the certified area.  YES  NO YES  NO Do not submit claim if pt came in non -skilled.  Otherwise,   submit no- pay claim w/ discharge status code when patient  leaves the certified area.  * Whether the facility considers a patient's bed in the certified area to be a Medicare bed or not has no effect on whether t he spell of illness is continued and has no effect on the SNF's action.  ** In some states, licensing laws for all nursing homes have incorporated requirements of the basic SNF definition (Social Se curity Act 1819(a)(1)). When this is the case, any nursing home in such a state would be considered to meet this definition (see CMS Internet -Only Manual, Pub. 100 -7, Chapter 2, 2164 at www.cms.hhs.gov/manuals/ on the CMS website).   40.8.2 - Billing When Qualifying Stay or Transfer Criteria are Not Met  (Rev. 1618, Issued: 10- 24-08, Effective: 04 -01-09; Implementation: 04 -06-09) SNF providers are required to submit claims to Medicare for beneficiaries that receive a skilled level of care.  This includes beneficiaries that do not meet the qualifying stay or transfer criteria.  Although these claims will not be paid by Medicare, providers must submit these claims as covered in order to extend existing beneficiary spells of illness in CWF.  A prior qualifying hospital stay (occurrence span code 70) would not be applicable and shall not be included with these claims.  This will allow M edicare systems to deny the claim for the appropriate reason.  Note:  This instruction includes beneficiaries that were previously admitted for skilled care then subsequently drop to non- skilled for greater than 30 days and then require skilled care again but do not have a new qualifying hospital stay.  40.9 - Other Billing Situations  (Rev. 10880, Issued: 08- 06-21, Effective: 11 -08-21, Implementation: 11- 08-21)  A. Demand Bills   Where the SNF believes that a covered level of care has ended but the beneficiary disagrees, they report occurrence code 21 (UR notice received) or 22 (date active care ended) as applicable and condition code 20 indicating the beneficiary believes the services are covered beyond the occurrence date.   See the Medicare Claims Processing Manual, Chapter 1, General Billing Requirements, 60.3, for instructions on advance beneficiary notices and demand bills.  Refer to the Medicare Claims Processing Manual, Chapter 25 for further information about billing.   B. Request for Denial Notice for Other Insurer   The SNFs complete a noncovered bill and enter condition code 21 to indicate a request for a Medicare denial notice.  Refer to Chapter 25 further information about billing.   C. Another Insurer is Primary to Medicare   See the Medicare Secondary Payer (MSP) Manual, Chapter 3, MSP Provider Billing Requirements and Chapter 5, Contractor Prepayment Processing Requirements, for submitting claims for secondary benefits to Medicare.  Refer to the Medicare Claims Processing Manual, Chapter 25 for further information about billing.   D. Special MSN Messages   The Medicare Prescription Drug Improvement and Modernization Act of 2003 requires that Medicare Summary Notices (including SNF claims for post -hospital extended care services provided under Part A) report the number of covered days remaining in the given spell of illness.  This requirement became effective July 6, 2004.  E. Interrupted Stay   Refer to the Medicare Claims Processing Manual, Chapter 6, Interrupted Stay Policy, 120.2, for information about billing when a patient returns to a covered level of care after an interrupted stay.   50 - SNF Payment Bans, or Denial of Payment for New Admissions (DPNA)  (Rev. 1555; Issued:  07-18- 08; Effective Date:  01 -01-09; Implementation Date: 01-05-09)   Under the Act at 1819(h)  and 1919(h)  and CMS regulations at 42 CFR 488.417, CMS may impose a denial of payment for new admissions (DPNA) against a SNF when a facility is not in substantial compliance with requirements of participation. To understand the effect on coverage of SNF services, see the Medicare Benefit Policy Manual, Chapter 8, Coverage of Extended Care (SNF) Services Under Hospital Insurance, 20.3 - 20.3.1.6.  50.1 - Effect on Utilization Days and Benefit Period  (Rev. 1555; Issued:  07-18- 08; Effective Date:  01 -01-09; Implementation Date: 01-05-09)   Payment sanctions are applied to days that would otherwise be Part A-payable; i.e., the care is covered but no payment will be made to the provider. Therefore, if the Medicare participating SNF assumes responsibility for the beneficiarys costs during the sanction period, it will be considered the same as a program payment, and the days will count towards the 100-day benefit period.  In situations where the beneficiary is subject to the payment ban, but the provider fails to issue the proper beneficiary liability notice, the provider is liable for all services normally covered under the Medicare Part A benefit.  Since the beneficiary i s receiving benefits, the days will be considered Part A days and charged against the beneficiarys benefit period.  The SNF may collect any applicable copayment amounts.  These days will be charged against the beneficiarys utilization as is currently done with other types of technical denials (i.e., late filing, late denial notices to the patient, etc.).   If the SNF issues the appropriate beneficiary liability 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 benefit period.  50.2 - Billing When Ban on Payment Is In Effect  (Rev. 1555; Issued:  07- 18-08; Effective Date:  01 -01-09; Implementation Date: 01-05-09)