(Medicare Benefit Policy Manual)

Medicare Benefit Policy Manual  Chapter 8 - Coverage of Extended Care (SNF) Services  Under Hospital Insurance    Table of Contents  (Rev. 12283; Issued: 10-05-23)  Transmittals Issued for this Chapter  10 - Requirements - General  10.1 - Medicare SNF PPS Overview  10.2 - Medicare SNF Coverage Guidelines Under PPS  10.3 - Hospital Providers of Extended Care Services  20 - Prior Hospitalization and Transfer Requirements  20.1 - Three -Day Prior Hospitalization  20.1.1 - Three -Day Prior Hospitalization - Foreign Hospital  20.2 - Thirty -Day Transfer  20.2.1 - General  20.2.2 - Medical Appropriateness Exception  20.2.2.1 - Medical Needs Are Predictable  20.2.2.2 - Medical Needs Are Not Predictable  20.2.2.3 - SNF Stay Prior to Beginning of Deferred Covered Treatment  20.2.2.4 - Effect of Delay in Initiation of Deferred Care  20.2.2.5 - Effect on Spell of Illness  20.2.3 - Readmission to a SNF  20.3  Payment Bans  20.3.1 - Payment Bans on New Admissions  20.3.1.1 - Beneficiary Notification  20.3.1.2 - Readmissions and Transfers  20.3.1.3 - Sanctions Lifted:  Procedures for Beneficiaries Admitted During the Sanction Period 20.3.1.4 - Payment Under Part B During a Payment Ban on New Admissions  20.3.1.5 - Impact of Consolidated Billing Requirements  20.3.1.6 - Impact on Spell of Illness  30 - Skilled Nursing Facility Level of Care - General  30.1  Administrative Level of Care Presumption  30.2 - Skilled Nursing and Skilled Rehabilitation Services  30.2.1 - Skilled Services Defined  30.2.2 - Principles for Determining Whether a Service is Skilled  30.2.2.1  Documentation to Support Skilled Care Determinations  30.2.3 - Specific Examples of Some Skilled Nursing or Skilled Rehabilitation Services  30.2.3.1 - Management and Evaluation of a Patient Care Plan  30.2.3.2 - Observation and Assessment of Patients Condition  30.2.3.3 - Teaching and Training Activities  30.2.4 - Questionable Situations  30.3 - Direct Skilled Nursing Services to Patients  30.4. - Direct Skilled Therapy Services to Patients  30.4.1  Skilled Physical Therapy  30.4.1.1 - General  30.4.1.2 - Application of Guidelines  30.4.2 - Speech -Language Pathology 30.4.3 - Occupational Therapy  30.5 - Nonskilled Supportive or Personal Care Services  30.6 - Daily Skilled Services Defined  30.7 - Services Provided on an Inpatient Basis as a Practical Matter  30.7.1 - The Availability of Alternative Facilities or Services  30.7.2 - Whether Available Alternatives Are More Economical in the Individual Case  30.7.3 - Whether the Patients Physical Condition Would Permit Utilization of an Available, More Economical Care Alternative  40 - Physician Certification and Recertification  for Extended Care Services  40.1 - Who May Sign the Certification or Recertification for Extended Care Services  50 - Covered Extended Care Services  50.1 -  Nursing Care Provided by or Under the Supervision of a Registered Professional Nurse  50.2 -  Bed and Board in Semi -Private Accommodations Furnished in Connection With Nursing Care  50.3 -  Physical, Therapy, Speech -Language Pathology and Occupational Therapy Furnished by the Skilled Nursing Facility or by Others Under Arrangements With the Facility and Under Its Supervision 50.4 -  Medical Social Services to Meet the Patients Medically Related Social Needs  50.5 -  Drugs and Biologicals  50.6 -  Supplies, Appliances, and Equipment  50.7 -  Medical Service of an Intern or Resident -in-Training 50.8 -  Other Services  50.8.1 -  General  50.8.2 -  Respiratory Therapy 60 - Covered Extended Care Days  70 - Medical and Other Health Services Furnished to SNF Patients  70.1 -  Diagnostic Services and Radiological Therapy 70.2 -  Ambulance Service  70.3 -  Inpatient Physical Therapy, Occupational Therapy, and Speech -Language Pathology Services  70.4 -  Services Furnished Under Arrangements With Providers   10 - Requirements - General  (Rev. 228, Issued: 10- 13-16, Effective: 10 -18-16, Implementation: 10- 18-16)  The term extended care services means the following items and services furnished to an inpatient of a skilled nursing facility (SNF) either directly or under arrangements as noted in the list below:    Nursing care provided by or under the supervision of a registered professional nurse;    Bed and board in connection with furnishing of such nursing care;    Physical or occupational therapy and/or speech -language pathology services furnished by the skilled nursing facility or by others under arrangements with them made by the facility;   Medical social services;    Such drugs, biologicals, supplies, appliances, and equipment, furnished for use in the skilled nursing facility, as are ordinarily furnished by such facility for the care and treatment of inpatients;    Medical services provided by an intern or resident -in-training of a hospital with which the facility has in effect a transfer agreement (see 50.7) under an approved teaching program of the hospital, and other diagnostic or therapeutic services provided by a hospital with which the facility has such an agreement in effect, and    Other services necessary to the health of the patients as are generally provided by skilled nursing facilities, or by others under arrangements.  Post-hospital extended care services furnished to inpatients of a SNF or a swing bed hospital are covered under the hospital insurance program.  The beneficiary must have been an inpatient of a hospital for a medically necessary stay of at least 3 consecut ive calendar days.  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 statu s commences with the calendar day of hospital admission.  See 31 Fed. Reg. 10116, 10118- 19 (July 27, 1966).  The beneficiary must also have been transferred to a participating SNF within 30 days after discharge from the hospital, unless the exception in 20.2.2 applies.  In addition, the beneficiary must require SNF care for a condition that was treated during the qualifying hospital stay, or for a condition that arose while in the SNF for treatment of a condition for which the beneficiary was previously treated  in the hospital.  Extended care services include SNF care for beneficiaries involuntarily disenrolling from Medicare Advantage plans as a result of a Medicare Advantage plan termination when they do not have a 3-day hospital stay before SNF admission, if admitted to the SNF before the effective date of disenrollment (see Pub. 100 -04, Medicare Claims Processing Manual, chapter 6, section 90.1).  10.1 - Medicare SNF PPS Overview (Rev. 261, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19)  Section 1888(e) of the Social Security Act provides the basis for the establishment of the per diem federal payment rates applied under the PPS to SNFs that received their first payment from Medicare on or after October 1, 1995. A transition period applied for those SNFs  that first accepted payment under the Medicare program prior to October 1, 1995. The Balanced Budget Act (BBA) of 1997 sets forth the formula for establishing the rates as well as the data on which they are based. See also Pub. 15 -1, Provider Reimbursement Manual, Part I, chapter 28, section 2836 for background information on the SNF PPS; Pub. 100-04, Medicare Claims Processing Manual, chapter 6, sections 30ff. for SNF PPS billing instructions; and Pub. 100-08, Medicare Program Integrity Manual, chapter 6, sections 6.1ff. regarding medical review of SNF PPS claims.   10.2 - Medicare SNF Coverage Guidelines Under PPS  (Rev. 12283, Issued:10 -05-23, Effective:01-08-24, Implementation:01-08-24)    Under SNF PPS, covered SNF services include post-hospital SNF services for which benefits are provided under Part A (the hospital insurance program) and all items and services which, prior to July 1, 1998, had been paid under Part B (the supplementary medi cal insurance program) but furnished to SNF residents during a Part A covered stay other than the following:     Physician services, physician assistant services, nurse practitioner and clinical nurse specialist services, certified mid -wife services, qualified psychologist services, marriage and family therapist services, mental health counselor services,  certified registered nurse anesthetist services, certain dialysis -related services, erythropoietin (EPO) for certain dialysis patients, hospice care related to a terminal condition, ambulance trips that convey a beneficiary to the SNF for admission or from the SNF fo llowing discharge, ambulance transportation related to dialysis services, certain services involving chemotherapy and its administration, radioisotope services, certain customized prosthetic devices, certain blood clotting factors and, for services furnish ed during 1998 only, the transportation costs of electrocardiogram equipment for electrocardiogram test services.    Certain additional outpatient hospital services (along with ambulance transportation that conveys a beneficiary to a hospital or CAH to receive the additional services) are excluded from coverage under SNF PPS and are billed separately.  The additional services are:     Cardiac catheterization services;     Computerized axial tomography (CT scans);     Magnetic resonance imaging (MRIs);     Radiation therapy;     Ambulatory surgery involving the use of a hospital operating room;     Emergency services;     Angiography services; and     Lymphatic and venous procedures.    The CMS identifies the above services using HCPCS codes that are periodically updated.    The CMS publishes the HCPCS coding changes in each year via a Recurring Update Notification.  Other updates for the remaining quarters of the FY will occur as needed due to the creation of new temporary codes representing services included in SNF PPS prior  to the next annual update.  To view the online code list of exclusions from consolidated billing (CB, the SNF bundling requirement), go to the CB Overview page at www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/index.html  and proceed as follows:     In the left -hand column of the CB Overview page, scroll down to the applicable Part A MAC (Medicare Administrative Contractor) Update  to access the list of excluded codes that are billable by institutional providers (similar information is available for practitioners and other noninstitutional suppliers on the applicable Part B MAC Update).  To view the most current update (the one that displays the most recent set of revisions to the code list), click on the Part A MAC Update link for the current year.  This directs to a page that lists by Major Category (indicating the type of service) the specific changes in coding for this year.     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.)