evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
The determination of charges does not affect the determination of inpatient utilization days or when a patient may be considered an inpatient for Medicare purposes as outlined in the Medicare Benefit Policy Manual, Chapter 8, Coverage of Extended Care (SN F) Services Under Hospital Insurance, 50 and 60.2.  Refer to the Medicare Claims Processing Manual, Chapter 25 for further information about billing.  SNFs show total charges for accommodation for the entire billing period and charges for any noncovered days in noncovered charges.)  The accommodation days do not include the day of death or discharge, even where the discharge was late.  However, where the SNF customarily makes an extra charge for a late discharge, they include this amount in total charges with the appropriate accommodation revenue code.  The day of discharge is not included in Covered Days even though an extra charge is included.  Where the late discharge was for the patients convenience and not for any medical necessity, SNFs enter the charge for late discharge as a noncovered charge.  Where the late discharge is for a medical reason, the charge is covered.  (See the Medicare Benefit Policy Manual, Chapter 8, Coverage of Extended Care (SNF) Services Under Hospital Insurance, 60.3.)  The charges for accommodations reflect only the total charges for general routine services as defined in 2202.6 and 2203.1 of the Medicare Provider Reimbursement Manual.  All charges, which are charged to every patient for every patient day, are included in the routine accommodation charge.  SNFs bill ancillary charges for day of discharge, death or the day on which a leave of absence begins, under the proper revenue code.  Where the patient is discharged on his first day of entitlement or the first day of the SNF participation in the Medicare program, they submit a bill with no accommodation charge, but with ancillary charges.  Where some of the days cannot be paid under Part A because benefits were exhausted before discharge, death, or the day on which a leave of absence began, SNFs show the charges for days after benefits where exhausted under noncovered charges, and enter the appropriate occurrence code, e.g., A3, and the date benefits are exhausted.  See the Medicare Claims Processing Manual, Chapter 7, SNF Part B Billing, 10, for billing under Part B in such circumstances.
(Medicare Claims Processing Manual)
40.6.4 - Bills with Covered and Noncovered Days (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)  Any combination of covered and noncovered days may be billed on the same bill.  It is important to record a day or charge as covered or noncovered because of the following:    Beneficiary utilization is recorded based upon days during which the patient received hospital or SNF accommodations, including days paid by Medicare and days for which the provider was held liable for reasons other than medical necessity or custodial care.   The provider may claim credit on its cost report only for covered accommodations, days and charges for which actual payment is made.  Provider liable days and charges are not included on the cost report.  Data from the bill payment process are used in preparing the cost report.  SNFs show noncovered charges for denied or noncovered days, which will not be paid.  The SNF submits the bill with occurrence span code 76 and completes the from/through dates to report periods where the beneficiary is liable.  Occurrence span code 77 is used to report periods  of noncovered care where the SNF is liable.  If applicable, the FISS system will automatically assign occurrence code A3 indicating the last date for which benefits are available or the date benefits were exhausted.   The A/B MAC (A) will use Occurrence Span Code 79 (a payer only code sent to CWF) to report periods of noncovered care due to lack of medical necessity or custodial care for which the provider is held liable.  Periods of beneficiary liability and provider l iability may be reported on one bill.  Report all noncovered days.  See Chapter 25, Completing and Processing the CMS -1450 Data Set, for a complete description of billing data elements.  See the Medicare Claims Processing Manual, Chapter 30, Limitation on Liability, for determining SNF liability.
(Medicare Claims Processing Manual)
The provider is always liable unless the appropriate notice is issued.  If the SNF issues the appropriate 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 be nefit period.  Notice requirements for periods of noncoverage are found in Chapter 30, 70.   40.6.5 - Notification of Limitation on Liability Decision  (Rev. 133, 04- 02-04) SNF -517.8  Detailed instructions and application of limitation on liability is found in The Medicare Claims Processing Manual, Chapter 30, Limitation on Liability.  The limitation on liability decision is made by the A/B MAC (A) when the medical evidence and admiss ion notice, or the bill is submitted.  When coverage is denied, notification will be by telephone, if possible, so written notice can be provided to the patient immediately.  When it is determined during the course of a beneficiarys stay in an SNF that the care is not covered but both the beneficiary and the SNF are entitled to limitation on liability, the Medicare program may make payment for the noncovered services for a grace period of one day (24 hours) after the date of notice to the SNF or to the beneficiary, whichever is earlier.  If it is determined that more time is required in order to arrange post- discharge care, up to 1 additional grace period day may be paid for.   Limitation of liability may apply to Part A and Part B services furnished by the provider.   40.7 - Ending a Benefit Period  (Rev. 930, Issued: 04- 28-06, Effective: 10 -01-06, Implementation: 10- 02-06)  A benefit period ends 60 days after the beneficiary has ceased to be an inpatient of a hospital and has not received inpatient skilled care in a SNF during the same 60- day period.  When the SNF resident's health has improved to the point where he or she no longer needs or receives the level of skilled care required for Part A coverage, the SNF must bill one of the two following scenarios:   1. For the resident that leaves the Medicare- certified SNF or DPU:   a. Submit a final discharge bill, and
(Medicare Claims Processing Manual)
1. For the resident that leaves the Medicare- certified SNF or DPU:   a. Submit a final discharge bill, and   b. Any services rendered after the discharge and billed by the SNF should be submitted on a 23x.  2. For the resident that remains in the Medicare- certified SNF or DPU after the skilled level of care has ended:   a. Submit the last skilled care claim with an occurrence code 22 to indicate the date active care ended. i.e.,  date covered SNF level of care ended,  and patient status code 30 to indicate the patient is still a resident in the Medicare -certified SNF or DPU;   b. Any Part B covered services rendered and billed by the SNF after the skilled care ended should be submitted on a 22x; and  c. All therapies must be billed by the SNF on the 22x.  For additional instructions on ending a benefit period go to the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, 10.4.2.  40.8 - Billing in Benefits Exhaust and No- Payment Situations  (Rev. 4491, Issued: 01- 09- 20, Effective: 04-01-20, Implementation: 04-06-20)
(Medicare Claims Processing Manual)
An SNF is required to submit a bill for a beneficiary that has started a spell of illness under the SNF Part A benefit for every month of the related stay even though no benefits may be payable.   CMS maintains a record of all inpatient services for each beneficiary, whether covered or n ot.  The related information is used for national healthcare planning and also enables CMS to keep track of the beneficiarys benefit period.  These bills have been required in two situations:  1) when the beneficiary has exhausted his/her 100 covered days  under the Medicare SNF benefit (referred to below as benefits exhaust bills) and 2) when the beneficiary no longer needs a Medicare covered level of care (referred to below as no-payment bills).  For benefits exhaust bills, an SNF must submit monthly a benefits exhaust bill for those patients that continue to receive skilled care and also when there is a change in the level of care regardless of whether the benefits exhaust bill will be paid by Medicaid, a supplemental insure, or private payer.  There are two types of benefits exhaust claims:  1) Full benefits exhaust claims: no benefit days remain in the beneficiarys applicable benefit period for the submitted statement covers from/through date of the claim and 2) Partial benefits exhaust claims: only one or some benefit days, in the beneficiarys applicable benefit period, remain for the submitted statement covers from/through date of the claim.   Monthly claim submission of both types of benefits exhaust bills are required in order to extend the beneficiarys applicable benefit period posted in the Common Working File (CWF).  Furthermore, when a change in level of care occurs after exhaustion of a beneficiarys covered days of care, the provider must submit the benefits exhaust bill in the next billing cycle indicating that active care has ended for the beneficiary.   NOTE :  Part B 22x bill types must be submitted after the benefits exhaust claim has been submitted and processed.  In addition, SNF providers must submit no- payment bills for beneficiaries that have previously received Medicare-covered skilled care and subsequently dropped to a non-covered level of care but continue to reside in a Medicare- certified area of the facility.  Consolidated Billing (CB) legislation indicates that physical therapy, occupational therapy, and speech language pathology services furnished to SNF
(Medicare Claims Processing Manual)
care and subsequently dropped to a non-covered level of care but continue to reside in a Medicare- certified area of the facility.  Consolidated Billing (CB) legislation indicates that physical therapy, occupational therapy, and speech language pathology services furnished to SNF residents are always subject to SNF CB.   This applies even when a resident receives the therapy during a non-covered stay in which the beneficiary who is not eligible for Part A extended care benefit still resides in an institution (or part thereof) that is Medicare -certified as a SNF.   SNF CB edits require the SNF to bill for these services on a 22x (inpat ient part B) bill type.   NOTE : Unlike with benefits exhaust claims, Part B 22x bill types may  be submitted prior to the submission of bill type 210 no payment claims.