(Medicare Claims Processing Manual)

Home health services are not payable unless the patient is confined to his home, and under Medicare regulations, a SNF cannot qualify as a home.  Where the beneficiary receives services from a home health agency, the home health agency is responsible for billin g.  If the beneficiary is formally discharged or otherwise departs for reasons other than described above but then, is readmitted or returns before the following midnight, he is not considered discharged.  The SNF is responsible for billing for services during the period of absence, unless such services are otherwise excluded from Part A PPS payment or are excluded from Medicare coverage (see 10.1).  NOTE:   This instruction only applies to Medicare fee- for-service beneficiaries in a participating SNF.   40.3.5 - Determine Utilization on Day of Discharge, Death, or Day Beginning a Leave of Absence  (Rev.  4001, Issued: 03- 16-18, Effective: 06-19-18, Implementation: 06-19-18) SNF -517.6.B, A3-3103.4   Generally, the day of discharge, death, or a day on which a patient begins a leave of absence, is not counted as a utilization day. (See the Medicare Benefit Policy Manual, Chapter 3, Duration of Covered Inpatient Services.) This is true even where one o f these events occurs on a patients first day of entitlement or the first day of a providers participation in the Medicare program. In addition, a benefit period may begin with a stay in a hospital or SNF, on that day.   The exception to the general rule of not charging a utilization day for the day of discharge, death, or day beginning a leave of absence is where the patient is admitted with the expectation that he will remain overnight but is discharged, dies, or is transferred to another, nonparticipating provider (or to a nonparticipating portion of the same provider) before the following midnight. In these instances, such a day counts as a utilization day. This exception includes the situation where the beneficiary was admitted (with the expectation that he would remain overnight) on either the first day of his entitlement or the providers first day of participation, and on the same day he was discharged, died, or transferred to a nonparticipating provider.   Payment is not made under PPS unless a covered day can be billed. Also, for a noncovered day such as the day of discharge (for which no payment is possible under PPS), separate billing is not allowed for ancillary services. Ancillary charges for such days have already been included in the PPS rates for those days that can be billed. This is because, in accordance with the longstanding instructions in Pub. 15-1, Provider Reimbursement Manual, Part I, chapter 22, section 2205.1, ancillary charges for services furnished on the day of (but before the actual moment of) discharge are included on the SNFs cost report and reflected in final cost settlement (see also 40.6.3). Ac cordingly, such charges have been built into the PPS base. As a result, even though the day of discharge itself is not a Medicare- covered day for the SNF, the PPS per diem for all of the covered days leading up to the day of discharge is somewhat higher th an it otherwise would have been, reflecting the historical cost of these day- of-discharge services.   When a patient is discharged on the first day of a providers participation or the first day of the patients entitlement, complete the bill as follows:    Admission date is the actual date of admission;    From date of service is the date the patient became entitled or date the SNF began participation; and    The number of noncovered days = 1.   40.3.5.1 - Day of Discharge or Death Is the Day Following the Close of the Accounting Year  (Rev. 1, 10- 01-03) SNF -517.2  Where the day of discharge or death is the day following the close of the cost reporting period, the ancillary charges for services rendered on that day must be included in the bill submitted for services in the prior accounting year, which includes the covered days for the billing period in that year.  In such cases, Statement Covers Period, should show the date of discharge or death as the through date.  The Patient Status should reflect the date of discharge or death, as appropriate.  The SNF uses the same billing method when developing accrued non -Medicare charges.  For cost settlement purposes, ancillary charges incurr ed in the new fiscal year, but billed under the prior fiscal year, are considered charges for the prior fiscal year.   40.3.5.2 - Leave of Absence  (Rev.  4001, Issued: 03- 16-18, Effective: 06 -19-18, Implementation: 06- 19-18)  A leave of absence for the purposes of this instruction is a situation where the patient is absent, but not discharged, for reasons other than admission to a hospital, other SNF, or nonparticipating portion of the same  institution . If the absence exceeds 30 consecutive days, the 3- day prior stay and 30- day transfer requirements, as appropriate, must again be met to establish re -entitlement to SNF benefits.   Leave of absence (LOA) days are shown on the bill with revenue code 018X and LOA days as units. However, charges for LOA days are shown as zero on the bill, and the SNF cannot bill the beneficiary for them except as specified in Chapter 1 of this manual at  30.1.1.1. Occurrence span code 74 is used to report the LOA from and through dates. Providers should review the RAI manual to clarify situations where an LOA is not appropriate, for example observation stays in a hospital lasting greater than 24 hours.  40.4 - Accommodation Charges Incurred in Different Accounting Years  (Rev. 1, 10-01-03) SNF -517.1  The SNF must not put accommodation charges incurred in different accounting years on the same bill.  (See 40.3.5.1 when billing for ancillary charges for services furnished on the day of discharge or death when it is also the day after the end of the accounting year.)  At the end of the accounting year, the SNF must submit a bill that contains the charges for all serv ices furnished to the patient since the last bill and through the end of that year.  The SNF shows services furnished in the following accounting year on a separate bill.   40.5 - Billing Procedures for Periodic Interim Payment (PIP) Method of Payment  (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)  The SNFs using the PIP method of payment follow the regular billing instructions in Medicare Claim Processing Manual, Chapter 25.   See the Medicare Claims Processing Manual, Chapter 1, General Billing Requirements, 80.4, for requirements SNFs must meet and A/B MACs (A) must monitor to continue PIP reimbursement.  Refer to the Medicare Claims Processing Manual, Chapter 25 for furthe r information about completing the claim.  40.6 - Total and Noncovered Charges  (Rev. 10569, Issued: 01-14-21, Effective: 04-01-21, Implementation: 04-05-21)  ASC X12 837 Institutional Claim See the related implementation guide on the official Washington Publishing Company website. Form CMS -1450 For each cost center for which a separate charge is billed (type of accommodation or ancillary), a revenue code is assigned and is entered on the claim with the related charges. On Form CMS-1450 the appropriate numeric revenue code is entered in FL 42 to explain each charge in FL 47. Additionally, there is no fixed Total line in the charge area. Instead, revenue code 0001 is always entered last in FL 42. Thus, the adjacent charge entry, in FL 47, is the sum of charges billed. This is also the same line on which noncovered charges, if any, in FL 48, are summed. The total charge for all services, covered and noncovered, will generally be shown. See 40.6.1 below, for certain exceptions. In the noncovered charges column (FL48) enter the amount of any noncovered charge except where:  The A/B MAC (A) has notified the SNF that payment can be made under the limitation of liability provisions; and  A payer primary to Medicare is involved. (See the Medicare Secondary Payer [MSP] Manual, Chapter 3, MSP Provider Billing Requirements, and Chapter 4, Contractor Prepayment Processing Requirements.) Where a bill is submitted for a period including both covered and noncovered days (e.g., days submitted for noncovered level of care), the SNF must list the charges for noncovered days under nonc overed charges. Refer to the Medicare Claims Processing Manual, Chapter 25 for further information about completing the claim. For claims that contain both covered days and noncovered days, and those noncovered days are the responsibility of the beneficiar y (e.g., days submitted for noncovered level of care), the provider should append span code 76 to indicate the days the beneficiary is liable.   40.6.1 - Services in Excess of Covered Services  (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)  Where items and services are furnished which are more expensive or in excess of the services covered by the program, the SNF will make the following entries in the Total Charges and Noncovered fields on the bill:    If the patient did not request such excess or more expensive services, the patient may not be charged for them, and only the services covered by the program are shown in total charges.  No entry is made in noncovered charges in this situation.  (However, w here all patients are routinely billed for such excess or more expensive items, total charges may reflect the excess items or services as discussed in total and noncovered charges, above.);    If the patient did request such excess or more expensive services, the SNF may charge the patient for them.  In this case, the SNF show the line item total charge (any customary charges covered by the program plus the excess charges).  The excess charges that will be billed to the patient are shown in noncovered charges.    In the same situation as above, except that the SNF will not bill the patient for the excess services.  Instead the SNF will show only the customary charges for covered services in total charges and make no entry in noncovered charges.   40.6.2 - Showing Discounted Charges  (Rev. 1, 10- 01-03) SNF -517.11  The SNFs do not show credit or minus entries on the bill.  Where the SNF gives a discount to some patients, they show charges in one of two ways:   1. SNFs show the charges as the full, undiscounted charge if full undiscounted charge data is accumulated for all patients for the purposes of the final cost report; or   2. They show the discounted charges as the only charges, if the SNF, for the purposes of the final cost report, accumulates charges for all patients at the discounted rate.   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.