evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
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 -
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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
(Medicare Benefit Policy Manual)
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).
(Medicare Benefit Policy Manual)
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)
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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.
(Medicare Benefit Policy Manual)
 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.)
(Medicare Benefit Policy Manual)
For further information on the SNF CB provision, see Pub. 100-04, Medicare Claims Processing Manual, chapter 6, sections 10 through 20.6.   10.3 - Hospital Providers of Extended Care Services  (Rev. 228, Issued: 10-13-16, Effective: 10-18-16, Implementation: 10-18-16)  In order to  address the shortage of rural SNF beds for Medicare patients, rural hospitals with fewer than 100 beds may be reimbursed under Medicare for furnishing post-hospital extended care services to Medicare beneficiaries.  Such a hospital, known as a swing bed facility, can swing its beds between the hospital and SNF levels of care, on an as -needed basis, if it has obtained a swing bed approval from the Department of Health and Human Services.  See Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, Section 30.3 (Hospital Providers of Extended Care Services) for a description of general rules applicable to SNF -level services furnished in hospital swing beds; also, see Pub. 100-04, Medicare Claims Processing Manual, chapte r 6, sections 100ff regarding SNF PPS billing procedures for SNF- level services furnished in rural (non- CAH) swing -bed hospitals.  When a hospital is providing extended care services, it will be treated as a SNF for purposes of applying coverage rules.  This means that services provided in the swing bed are subject to the same Part A coverage, deductible, coinsurance and physician certification/recertification provisions that are applicable to SNF extended care services.  The SNF coverage provisions are set forth in 42 CFR 409 Subpart D and are more fully explained in this chapter.  A patient in a swing bed cannot simultaneously receive coverage for both SNF-level services under Part A and inpatient hospital ancillary services under Part B.
(Medicare Benefit Policy Manual)
and are more fully explained in this chapter.  A patient in a swing bed cannot simultaneously receive coverage for both SNF-level services under Part A and inpatient hospital ancillary services under Part B.   Swing bed patients who no longer qualify for Part A coverage of SNF- level services under the Medicare program (due to exhaustion of Part A SNF benefits, dropping below a SNF level of care, etc.) revert to receipt of a hospital level of care in the swing bed (see the Medicare Benefit Policy Manual, Chapter 6, Hospital Services Covered Under Part B, 10).  Thus, any further Medicare coverage in the swing bed would be for inpatient hospital ancillary services under Part B, notwithstanding a patients eligibi lity for Medicaid NF coverage.   A dually-eligible patient who continues to receive a SNF level of care or who has dropped below the SNF level may nonetheless still qualify for Medicaid coverage of nursing facility (NF) services, if the hospital has a Medicaid swing bed agreement that has been approved by the State in which the facility is located.  Such agreements permit Medicaid -participating rural hospitals to use their beds interchangeably to furnish both acute hospital care and NF care to Medicaid recipients, when no beds are availabl e in area nursing facilities (see Pub. 45, State Medicaid Manual, chapter 4, section 4560).    20 - Prior Hospitalization and Transfer Requirements  (Rev. 1, 10-01-03)  A3-3131, SNF-212  In order to  qualify for post-hospital extended care services, the individual must have been an inpatient of a hospital for a medically necessary stay of at least three consecutive calendar days.  In addition, effective December 5, 1980, the individual must have been transferred to a participating SNF within 30 days after discharge from the hospital, unless the exception in 20.2 applies.   20.1 - Three -Day Prior Hospitalization  (Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21)  In accordance with section 226(c)(1)(B)
(Medicare Benefit Policy Manual)
of the Social Security Act and the implementing regulations at 42 CFR 409.30(a)(2) , the hospital discharge must have occurred on or after the first day of the month in which the individual attained age 65 or, effective July 1, 1973, became entitled to health insurance benefits under the disability or chronic renal disease provisions of the law.  The 3 consecutive calendar day stay requirement can be met by stays totaling 3 consecutive days in one or more hospitals.  In determining whether the requirement has been met, the day of admission, but not the day of discharge, is counted as a hospital inpatient day.
(Medicare Benefit Policy Manual)
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 status commences with the  calendar day of hospital admission.  See 31 Fed. Reg. 10116, 10118-19 (July 27, 1966).  To be covered, the extended care services must have been for the treatment of a condition for which the beneficiary was receiving inpatient hospital services (including services of an emergency hospital) or a condition which arose while in the SNF for trea tment of a condition for which the beneficiary was previously hospitalized.  In this context, the applicable hospital condition need not have been the principal diagnosis that actually precipitated the beneficiarys admission to the hospital, but could be any one of the conditions present during the qualifying hospital stay.  In addition, the qualifying hospital stay must have been medically necessary.  Medical necessity will generally be presumed to exist.  When the facts that come to the A/B MACs (A) attention during the course of its normal claims review process indicate tha t the hospitalization may not have been medically necessary, it will fully develop the case, checking with the attending physician and the hospital, as appropriate.  The A/B MAC will rule the stay unnecessary only when hospitalization for 3 days represents  a substantial departure from normal medical practice.  However, in accordance with Pub. 100-04, Medicare Claims Processing Manual, Chapter 30, 130.2.A, when a beneficiary qualifies for limitation on liability in connection with the hospital stay (or a po rtion thereof), this conclusively establishes that the hospital stay (or portion thereof) was not medically necessary.
(Medicare Benefit Policy Manual)
Even if a beneficiarys care during a qualifying hospital stay becomes less intensive during the latter part of the stay, the date of hospital discharge in this context is still considered to be the day that the beneficiary physically leaves the hospital , and the level of care being furnished at that particular point is not a determining factor as long as some portion of the stay included at least 3 consecutive days of medically necessary inpatient hospital services.  In addition, when a hospital inpatients care needs drop from acute - to SNF-level but no SNF bed is available, the regulations at 42 CFR 424.13(c) permit a physician to certify that the beneficiarys continued inpatient stay in the hospital is, in fact, medically necessary under this particul ar set of circumstances (see also Pub. 100- 01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, 10.6).  Accordingly, such additional, alternate placement days spent in the hospital can be included in the 3- day count toward m eeting the SNF benefits qualifying hospital stay requirement.
(Medicare Benefit Policy Manual)
The 3 -day hospital stay need not be in a hospital with which the SNF has a transfer agreement (see Pub. 100- 01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, 30.2 for a discussion of the SNFs required transfer agreement with a hospital) .  However, the hospital must be either a Medicare- participating hospital or an institution that meets at least the conditions of participation for an emergency services hospital (see Pub. 100- 01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, 20.2 , for the definition of an emergency services hospital).  A nonparticipating psychiatric hospital need not meet the special requirements applicable to psychiatric hospitals (see Pub. 100- 01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, 20.3) .  Stays in Religious Nonmedical Health Care Institutions (see Pub. 100 -01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, 40, for definition of RNHCIs) are excluded for the purpose of satisfying the 3- day period of hospitalization.  See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 9, 40.1.5, regarding a qualifying stay that consists of general inpatient care furnished in a hospital under the hospice benefit.  NOTE:  While a 3 -day stay in a psychiatric hospital satisfies the prior hospital stay requirement, institutions that primarily provide psychiatric treatment cannot participate in the program as SNFs.  Therefore, a patient with only a psychiatric condition who is  transferred from a psychiatric hospital to a participating SNF is likely to receive only non-covered care.  In the SNF setting, the term non- covered care refers to any level of care less intensive than the SNF level of care that is covered under th e program.  (See 30ff.).   20.1.1 - Three -Day Prior Hospitalization - Foreign Hospital  (Rev. 261, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19)