(Medicare Claims Processing Manual)

New stay  Assessment Schedule: Reset; stay begins with new 5- day assessment.  Variable Per Diem (VPD): Reset: stay begins on Day 1 of VPD Schedule.  2) Patient is admitted to SNF on 11/07/19 and in a covered Part A stay.  The patient is discharged from Part A on 11/20/19 but remains in the facility.  The patient returns to a covered Part A stay on 11/22/19.  This is a continuation of a previous stay because the patient returned to a covered Part A stay within 3 days of being discharged from a covered Part A stay.   Continuation of previous stay Assessment Schedule: No PPS assessments required, IPA optional VPD: Continues from Day 14 (Day of Part A Discharge).  Billing Example : Patient is admitted to SNF on 10/1/2019 and discharged to home on 12/25/2019, with an interrupted stay to an IPPS on 10/20/2019-10/22/2019. This was an admission to an IPPS on 10/20/2019-10/22/2019.  10/1/2019  10/31/2019 first interim claim,  Claim must be billed with occurrence span code 74 and occurrence span dates 10/20  10/21/2019 to represent the interrupted stay, 11/1/2019  11/30/2019 second interim claim,  12/1/2019  12/25/2019 final interim claim,  (Occurrence span code 74 only appears on the claim in which its dates fall within the statement covers period  in this example only on October claim).   Accommodation revenue code 018x is reported during the interrupted stay and is when the beneficiary is not present at the midnight census taking time.  Occurrence span code 74 and date range for the interruption.  Days for the interruption shall be reported as non-covered, not to exceed 3 days or it will be considered a new admission.  On the SNF Medicare bill, the presence of occurrence span code 74 indicates an interrupted stay has occurred.  Report occurrence span code 74 with the FROM and THROUGH dates of the interruption in the stay.  The day of discharge from the SNF is the FROM da te and the last day the patient is not in the SNF at midnight is the THROUGH date.  Report accommodation revenue code 18X (leave of absence) and the quantity of leave days.  Occurrence span code 74 should be reported for each interruption of more than 1 day along with the dates of each interruption.  Revenue code 018X should reflect the total number of days for all occurrence span code 74 entries.  In other words, revenue code 018X should be listed on one line, with all interrupted days included in the units column.  No charges should be added to this charge line.  120.3 - Variable Per Diem (VPD) Adjustment  (Rev.4409, Issued: 10- 04-19, Effective: 11-05-19, Implementation: 11-05-19)  The Social Security Act requires that Medicare Part A -covered SNF stays be paid on a per-diem basis. PDPM SNF PPS per diem payments will be reduced according to a prescribed schedule, referred to as the VPD adjustment. Specifically, the PDPM provides for an adjustment factor that is applied to certain components and changes the per diem rate over the course of the stay.  Thus, under PDPM, the per diem rate for a given day of the SNF PPS stay may be different from the prior day, depending on an adjustment factor that may be applied against the SNF PPS rate connected with the HIPPS code. Moreover, the VPD schedule applies only to the PT, OT, and NTA components of the per diem rate, with different schedules for the PT/OT components than for the NTA component. A similar adjustment exists under the Inpatient Psychiatric Facility (IPF) PPS.  For the PT, OT, and NTA components, the case- mix adjusted per diem rate is multiplied against the variable per diem adjustment factor, following a schedule of adjustments for each day of the patients stay   VPD Adjustment Schedules   PT & OT Components   Day in Stay Adjustment Factor  Day in Stay Adjustment Factor      1-20 1.00 63-69 0.86 21-27 0.98 70-76 0.84 28-34 0.96 77-83 0.82 35-41 0.94 84-90 0.80 42-48 0.92 91-97 0.78 49-55 0.90 98-100 0.76 56-62 0.88    NTA Component   Day in Stay Adjustment Factor    1-3 3.00 4-100 1.00  120.4 - AIDS Adjustments  (Rev. 4409, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19) As under the previous RUG -IV model, patients with a B20 ICD -10 diagnosis code on the SNF claim, meaning the patient has AIDS/HIV, receive an adjustment factor for their PPS rate. Under PDPM, the adjustment factor is different from that used under RUG -IV. Rather than a 128 percent adjustment for the entire PPS per diem rate, the adjustment under PDPM is an increase of 18 percent in the nursing component of the per diem rate and a reclassification under the NTA component to a higher rate category.  All other adjustment factors, such as adjustments for geographic variation in wage costs, remain the same under PDPM as under the previous RUG -IV model.   120.5 - Transition Claims  (Rev. 4409, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19)  With regard to transition between RUG -IV and PDPM, a hard transition between the two systems has been implemented, such that days paid under RUG -IV would stop on September 30, 2019 and days would be paid under PDPM beginning October 1, 2019.  In order to receive a RUG -IV HIPPS code that can be billed for services furnished prior to October 1, 2019, providers must use an assessment with an ARD set for on or prior to September 30, 2019.  If the patients stay begins on or after October 1, 2019, then the provider would begin with the 5 -day assessment, as usual.   For patients admitted prior to October 1, 2019, but whose stays continue past this date, in order to receive a PDPM HIPPS code that can be used to bill for services furnished on or after October 1, 2019, providers must complete an IPA with an ARD no later than October 7, 2019 (i.e., transitional IPA):  October 1, 2019, will be considered Day 1 of the VPD schedule under PDPM, even if the patient began their stay prior to October 1, 2019.  Any transitional IPAs with an ARD after October 7, 2019, will be considered late and relevant penalty for late assessments would apply (described below).   120.6 - Default Billing  (Rev. 4409, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19)  As under RUG -IV, there may be instances in which providers may bill the default rate on a SNF claim (e.g., when an MDS assessment is considered late).   The default rate refers to the lowest possible per diem rate.   The default code under PDPM is ZZZZZ, as compared to the default code under RUG- IV of AAA00.   Billing the default code under PDPM represents the equivalent of billing the following PDPM groups:   PT Payment Group: TP   OT Payment Group: TP   SLP Payment Group: SA   Nursing Payment Group: PA1  NTA Payment Group: NF    Transmittals Issued for this Chapter  Rev#  Issue Date  Subject  Impl Date  CR#  R12283CP  10/05/2023 Internet Only Manual Updates to Pub. 100-02 and 100-04 to Implement Consolidated Appropriations Act 2023 Changes for Skilled Nursing Facility (SNF)  01/08/2023 13271 R11109CP  11/04/2021 Skilled Nursing Facility (SNF) Claims Processing Updates  01/03/2022 12344 R10904CP  08/10/2021 Skilled Nursing Facility (SNF) Claims Processing Updates   Rescinded and replaced by Transmittal 11109 01/03/2022 12344 R10880CP  06/08/2021 Internet Only Manual Updates to Pub. 100-01, 100-02, and 100-04 to Implement Consolidated Appropriations Act Changes and Correct Errors and Omissions (SNF) 11/08/2021 12009  R10569CP  01/14/2021 Updates to Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) Claims   04/05/2021 11992 R10448CP  11/06/2020 Updates to Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) Claims  Rescinded and replaced by Transmittal 10569  04/05/2021 11992 R10236CP  07/31/2020 Update to the IOM Publication (Pub) 100-04, Medicare Claims Processing Manual, Chapters 1, 6, 8, 17, 20, 22, 24, and 31 Referencing the Active Universal Resource Locators (URLs) for the Washington Publishing Company (WPC) and the ASC X12 Organizations, and Updates to the HIPAA Eligibility Transaction System (HETS)  08/31/2020 11857 R10222CP  07/14/2020 Updates in the Fiscal Intermediary Shared System (FISS) Inpatient Provider Specific Files (PSF)  10/05/2020 11797 Rev#  Issue Date  Subject  Impl Date  CR#  R10140CP  05/15/2020 Updates in the Fiscal Intermediary Shared System (FISS) Inpatient Provider Specific Files (PSF) - Rescinded and replaced by Transmittal 10222 10/05/2020 11797  01/09/2020 Updates to CR 11152 Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)  04/06/2020 11513 R4409CP  10/04/2019 Manual Updates for CR11152 Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) 11/05/2019 11454 R4247CP  03/01/2019 Update to Publication 100-04 Chapters 2, 6, and 18 to Provide Language-Only Changes for the New Medicare Card Project  04/01/2019 11155 R4157CP