evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
If a facility has a separate, distinct non -skilled area or wing then beneficiaries may be discharged to this area using the appropriate patient discharge status code and no-  payment bills would not be required.  In addition, SNF CB legislation for therapy services would not apply for these beneficiaries.   No-payment bills are not required for non- skilled beneficiary admissions.  As indicated above, they are only required for beneficiaries that have previously received covered care and subsequently dropped to non- covered care and continue to reside in the certified area of the facility.   NOTE:   Providers may bill benefits exhaust and no payment claims using the default HIPPS code AAA00 prior to October 1, 2019 and ZZZZZ October 1, 2019 and after, in addition to an appropriate room & board revenue code only.  No further ancillary services need b e billed on these claims.   SNF providers and A/B MACs (A) shall follow the billing guidance provided below for the proper billing of benefits exhaust bills and no- payment bills.   1) SNF providers shall submit benefits exhaust claims for those beneficiaries that continue to receive skilled services as follows:   a)   Full or partial benefits exhaust claim. (Submitted monthly)   i) Bill Type = Use appropriate covered bill type (i.e., 211, 212, 213 or 214 for SNF and 181, 182, 183 or 184 for Swing Bed (SB).  NOTE:   Bill types 210 or 180 should not be used for benefits exhaust claims submission).   ii) Occurrence Span Code 70 with the qualifying hospital stay dates.  iii) Covered Days and Charges = Submit all covered days and charges as if beneficiary had days available.   iv) Value Code 09 (First year coinsurance amount) 1.00 (If applicable, the FISS will assign the correct coinsurance amount based off the CWF response).   v) Patient Status Code = Use appropriate code.   b)   Benefits  exhaust claim with a drop in level of care within the month; Patient remains in the Medicare- certified area of the facility after the drop in level of care.   i) Bill Type = Use appropriate bill type (i.e., 212 or 213 for SNF and 182 or 183 for SB.   NOTE:   Bill types 210 or 180 should not be used for benefits exhaust claims submission).
(Medicare Claims Processing Manual)
i) Bill Type = Use appropriate bill type (i.e., 212 or 213 for SNF and 182 or 183 for SB.   NOTE:   Bill types 210 or 180 should not be used for benefits exhaust claims submission).   ii) Occurrence Span Code 70 with the qualifying hospital stay dates.  iii) Occurrence Code 22 (date active care ended, i.e., date covered SNF level of care ended) = include the date active care ended; this should match the statement covers through date on the claim.   iv) Covered Days and Charges = Submit all covered days and charges as if the beneficiary had days available up until the date active care ended.   v) Value Code 09 (First year coinsurance amount) 1.00 (If applicable, the FISS will assign the correct coinsurance amount based off the CWF response).   vi) Patient Status Code = 30 (still patient).   c)   Benefits exhaust claim with a patient discharge.   i) Bill Type = 211 or 214 for SNF and 181 or 184 for SB ( NOTE:  Bill types 210 or 180 should not be used for benefits exhaust claims submission).   ii) Covered Days and Charges = Submit all covered days and charges as if beneficiary had days available up until the date active care ended.   iii) Value Code 09 (First year coinsurance amount) 1.00 (If applicable, the FISS will assign the correct coinsurance amount based off the CWF response).   iv) Patient Status Code = Use appropriate code other than patient status code 30 (still patient).   NOTE:   Billing all covered days and charges allow the Common Working File (CWF) to assign the correct benefits exhaust denial to the claim and appropriately post the claim to the patients benefit period.  Benefits exhaust bills must be submitted monthly.   2) SNF providers shall submit no- payment claims for beneficiaries that previously dropped to non- skilled care and continue to reside in the Medicare -certified area of the facility using the following options.   a)   Patient previously dropped to non- skilled care.   Provider needs Medicare denial notice for other insurers.   i) Bill Type = 210 (SNF no -payment bill type) or 180 (SB no- payment bill type)
(Medicare Claims Processing Manual)
a)   Patient previously dropped to non- skilled care.   Provider needs Medicare denial notice for other insurers.   i) Bill Type = 210 (SNF no -payment bill type) or 180 (SB no- payment bill type)   ii) Statement Covers From and Through Dates = days provider is billing, which may be submitted as frequently as monthly, in order to receive a denial for other insurer purposes.  No-payment billing shall start the day following the date active care ended.   iii) Days and Charges = Non -covered days and charges beginning with the day after active care ended.   iv) Condition Code 21 (billing for denial).   v) Patient Status Code = Use appropriate code.   b)   Patient previously dropped to non- skilled care.   In these cases, the provider must only submit the final discharge bill that may span multiple months but must be as often as necessary to meet timely filing guidelines.   i) Bill Type = 210 (SNF no -payment bill type) or 180 (SB no- payment bill type)   ii) Statement Covers From and Through Dates = days billed by the provider, which may span multiple months, in order to show final discharge of the patient.   No-payment billing shall start the day following the date active care ended.   iii) Days and Charges = Non -covered days and charges beginning with the day after active care ended.   iv) Condition Code 21 (billing for denial).   v) Patient Status Code = Use appropriate code other than patient status code 30 (still patient).   NOTE:  No pay bills may span both provider and Medicare fiscal year end dates.  Refer to Chapter 25 for further information about billing.   40.8.1  SNF Spell of Illness Quick Reference Chart  (Rev.4409, Issued: 10 -04-19, Effective: 11 -05-19, Implementation: 11 -05-19)
(Medicare Claims Processing Manual)
40.8.1  SNF Spell of Illness Quick Reference Chart  (Rev.4409, Issued: 10 -04-19, Effective: 11 -05-19, Implementation: 11 -05-19)   Level of Care  Patient's Medicare SNF Part A Benefits Are Exhausted  Patient Is In Medicare Certified Area of the Facility *  If in non -Medicare Area, the Facility Meets the Definition of a SNF **  Is the Inpatient Spell of Illness Continued?                                Billing Action  Medicare Skilled  YES  YES  N/A  YES  Submit Monthly Covered Claim.  NO YES  N/A  YES  Submit Monthly Covered Claim.  YES  NO YES  YES  Submit Monthly Covered Claim.  NO NO YES  YES  Patient should be returned to certified area for Medicare to be  billed. Submit Monthly Covered Claim.  NO NO NO NO Facility should determine whether it would be  appropriate to send patient back to a certified area for  Medicare coverage.  Not Medicare Skilled  YES  NO NO NO Do not submit claim if pt came in non -skilled.  Otherwise,  submit no- pay claim w/ discharge status code when patient  leaves the certified area.  YES  YES  N/A  NO Do not submit claim if pt came in non -skilled.  Otherwise,  submit no- pay claim w/ discharge status code when patient  leaves the certified area.  NO YES  N/A  NO Do not submit claim if pt came in non -skilled.  Otherwise,  submit no- pay claim w/ discharge status code when patient leaves the certified area.  NO NO YES  NO Do not submit claim if pt came in non -skilled.  Otherwise,   submit no- pay claim w/ discharge status code when patient  leaves the certified area.  YES  NO YES  NO Do not submit claim if pt came in non -skilled.  Otherwise,
(Medicare Claims Processing Manual)
submit no- pay claim w/ discharge status code when patient  leaves the certified area.  YES  NO YES  NO Do not submit claim if pt came in non -skilled.  Otherwise,   submit no- pay claim w/ discharge status code when patient  leaves the certified area.  * Whether the facility considers a patient's bed in the certified area to be a Medicare bed or not has no effect on whether t he spell of illness is continued and has no effect on the SNF's action.  ** In some states, licensing laws for all nursing homes have incorporated requirements of the basic SNF definition (Social Se curity Act 1819(a)(1)). When this is the case, any nursing home in such a state would be considered to meet this definition (see CMS Internet -Only Manual, Pub. 100 -7, Chapter 2, 2164 at www.cms.hhs.gov/manuals/ on the CMS website).   40.8.2 - Billing When Qualifying Stay or Transfer Criteria are Not Met  (Rev. 1618, Issued: 10- 24-08, Effective: 04 -01-09; Implementation: 04 -06-09) SNF providers are required to submit claims to Medicare for beneficiaries that receive a skilled level of care.  This includes beneficiaries that do not meet the qualifying stay or transfer criteria.  Although these claims will not be paid by Medicare, providers must submit these claims as covered in order to extend existing beneficiary spells of illness in CWF.  A prior qualifying hospital stay (occurrence span code 70) would not be applicable and shall not be included with these claims.  This will allow M edicare systems to deny the claim for the appropriate reason.  Note:  This instruction includes beneficiaries that were previously admitted for skilled care then subsequently drop to non- skilled for greater than 30 days and then require skilled care again but do not have a new qualifying hospital stay.  40.9 - Other Billing Situations  (Rev. 10880, Issued: 08- 06-21, Effective: 11 -08-21, Implementation: 11- 08-21)  A. Demand Bills
(Medicare Claims Processing Manual)
A. Demand Bills   Where the SNF believes that a covered level of care has ended but the beneficiary disagrees, they report occurrence code 21 (UR notice received) or 22 (date active care ended) as applicable and condition code 20 indicating the beneficiary believes the services are covered beyond the occurrence date.   See the Medicare Claims Processing Manual, Chapter 1, General Billing Requirements, 60.3, for instructions on advance beneficiary notices and demand bills.  Refer to the Medicare Claims Processing Manual, Chapter 25 for further information about billing.   B. Request for Denial Notice for Other Insurer   The SNFs complete a noncovered bill and enter condition code 21 to indicate a request for a Medicare denial notice.  Refer to Chapter 25 further information about billing.   C. Another Insurer is Primary to Medicare   See the Medicare Secondary Payer (MSP) Manual, Chapter 3, MSP Provider Billing Requirements and Chapter 5, Contractor Prepayment Processing Requirements, for submitting claims for secondary benefits to Medicare.  Refer to the Medicare Claims Processing Manual, Chapter 25 for further information about billing.   D. Special MSN Messages   The Medicare Prescription Drug Improvement and Modernization Act of 2003 requires that Medicare Summary Notices (including SNF claims for post -hospital extended care services provided under Part A) report the number of covered days remaining in the given spell of illness.  This requirement became effective July 6, 2004.  E. Interrupted Stay   Refer to the Medicare Claims Processing Manual, Chapter 6, Interrupted Stay Policy, 120.2, for information about billing when a patient returns to a covered level of care after an interrupted stay.   50 - SNF Payment Bans, or Denial of Payment for New Admissions (DPNA)  (Rev. 1555; Issued:  07-18- 08; Effective Date:  01 -01-09; Implementation Date: 01-05-09)
(Medicare Claims Processing Manual)
Under the Act at 1819(h)  and 1919(h)  and CMS regulations at 42 CFR 488.417, CMS may impose a denial of payment for new admissions (DPNA) against a SNF when a facility is not in substantial compliance with requirements of participation. To understand the effect on coverage of SNF services, see the Medicare Benefit Policy Manual, Chapter 8, Coverage of Extended Care (SNF) Services Under Hospital Insurance, 20.3 - 20.3.1.6.  50.1 - Effect on Utilization Days and Benefit Period  (Rev. 1555; Issued:  07-18- 08; Effective Date:  01 -01-09; Implementation Date: 01-05-09)   Payment sanctions are applied to days that would otherwise be Part A-payable; i.e., the care is covered but no payment will be made to the provider. Therefore, if the Medicare participating SNF assumes responsibility for the beneficiarys costs during the sanction period, it will be considered the same as a program payment, and the days will count towards the 100-day benefit period.  In situations where the beneficiary is subject to the payment ban, but the provider fails to issue the proper beneficiary liability notice, the provider is liable for all services normally covered under the Medicare Part A benefit.  Since the beneficiary i s receiving benefits, the days will be considered Part A days and charged against the beneficiarys benefit period.  The SNF may collect any applicable copayment amounts.  These days will be charged against the beneficiarys utilization as is currently done with other types of technical denials (i.e., late filing, late denial notices to the patient, etc.).   If the SNF issues the appropriate beneficiary liability 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 benefit period.  50.2 - Billing When Ban on Payment Is In Effect  (Rev. 1555; Issued:  07- 18-08; Effective Date:  01 -01-09; Implementation Date: 01-05-09)
(Medicare Claims Processing Manual)
Beneficiaries admitted before the effective date of the denial of payment and taking temporary leave, whether to receive inpatient hospital care, outpatient services or as therapeutic leave, are not considered new admissions, and are not subject to the denial of payment upon return. This policy applies even if there are multiple hospitalizations and returns to the SNF during the period sanctions are in effect.  When determining if the beneficiary was admitted prior to the imposition of the ban, the actual status of the beneficiary rather than the primary payor is the determining factor.  Therefore, there may be situations where the beneficiary is a private pay patient or a dual eligible who was receiving Medicaid benefits prior to the imposition of the payment ban.  If this private pay patient or dual eligible goes to the hospital for need ed care, and meets the Medicare Part A criteria for SNF coverage upon return to the SNF, the readmission is exempt from the denial of payment sanction.  When billing for a readmission that is NOT subject to the payment ban, providers must enter occurrence span code 80, Prior Same -SNF Stay Dates for Payment Ban Purposes, on the claim to identify the prior same -SNF stay dates, in addition to reporting any LOA and prior hospital stay dates, using occurrence span codes, that may affect the A/B MACs (A)s determ ination of payment ban exemption status.  See Chapter 25 of this manual for occurrence span code titles and definitions.  50.2.1 - Effect of an Appeal to a DPNA on Billing During the Period the SNF is Subject to a DPNA (Rev. 1555; Issued:  07- 18-08; Effective Date:  01 -01-09; Implementation Date: 01-05-09)  In those situations where the SNF decides to appeal the imposition of a DPNA, it must still bill the program as set forth in the instructions below.   50.2.2 - Provider Liability Billing Instructions  (Rev. 1555; Issued:  07- 18-08; Effective Date:  01 -01-09; Implementation Date: 01-05-09)
(Medicare Claims Processing Manual)
50.2.2 - Provider Liability Billing Instructions  (Rev. 1555; Issued:  07- 18-08; Effective Date:  01 -01-09; Implementation Date: 01-05-09)  The SNF must file a covered bill with the A/B MAC (A) using occurrence span code 77 that indicates the facility is liable for the services in situations where the SNF failed to issue the proper beneficiary liability notice and any applicable copayments wil l be charged to the beneficiarys Part A benefit period.  Furthermore, the sum of all covered units reported on all revenue code 0022 lines should be equal to the covered days field less the number of provider liable days reported in the occurrence span code 77.  See 60 of Chapter 1 in this manual for detailed instructions on nonpayment billing requirements.   When the SNF is liable for the Part A stay, the SNF is required to provide all necessary covered Part A services, including those services such as therapies and radiology mandated under consolidated billing.  For example, if the beneficiary goes to the hos pital for a non- emergency chest x -ray, the SNF will be responsible for the outpatient hospital radiology and any ambulance charges.  In this case, the SNF may not charge the beneficiary or family members for any services that, in the absence of a payment sanctio n, would have been covered under the Part A PPS payment.  50.2.3 - Beneficiary Liability Billing Instructions  (Rev. 1555; Issued:  07-18- 08; Effective Date:  01 -01-09; Implementation Date: 01-05-09)   The SNF shall file a non -payment bill for noncovered Part A services, using condition code 21 that indicates beneficiary liability.  Services that would have been eligible for Part A benefits in the absence of sanctions cannot be billed as Part B charges.  However, the SNF may directly bill the beneficiary, family members or other third party insurers for services provided to that beneficiary.  50.2.4 - Part B Billing (Rev. 1, 10-01-03)  PM AB -01-131
(Medicare Claims Processing Manual)
Facilities subject to a payment ban may continue to bill services for beneficiaries who are not in a Part A stay in the same way as any other SNF.  However, services that would have been payable to the SNF as Part A benefits in the absence of a payment sanction must not be billed to either the A/B MAC (A) or the A/B MAC (B) as Part B services.   50.3 - Sanctions Lifted: Procedures for Beneficiaries Admitted During the Sanction Period  (Rev. 1, 10-01-03)  PM AB -01-131  For new admissions to certified beds, Medicare payments for eligible beneficiaries should begin on the date the sanction is lifted.  The beneficiary must meet technical eligibility requirements (e.g., a 3- day hospital stay, etc.), services must be reasonable and necessary and the beneficiary must be receiving skilled care.  The date the sanction is lifted is considered the first day of the Part A stay.  For Part A PPS payment purposes, the period between the actual date of admission and the last day the sanction was in effect should be billed as noncovered days.  (See 50.3.1 below on procedures to track these noncovered days for benefit period and break in spell of illness calculations.  RAI requirements are discussed in 30.5.)  50.3.1 - Tracking the Benefit Period  (Rev. 1555; Issued:  07-18- 08; Effective Date:  01 -01-09; Implementation Date: 01-05-09)   SNF days during the sanction period will be used to track breaks in the spell of illness if a beneficiarys care in the SNF meets the skilled level of care requirements.  If the patient is receiving a skilled level of care the benefit period cannot end.  T herefore, it will be tracked in CWF.   50.3.2 - Determining Whether Transfer Requirements Have Been Met  (Rev. 1, 10- 01-03)  PM AB -01-131
(Medicare Claims Processing Manual)
50.3.2 - Determining Whether Transfer Requirements Have Been Met  (Rev. 1, 10- 01-03)  PM AB -01-131  It is very important to safeguard the beneficiary while applying necessary sanctions to the provider.  It is certainly possible that a beneficiary may remain at a facility under sanction for a period of time and later transfer to a second SNF.  The 30- day transfer requirement will be applied in the same way it would be for a beneficiary transferring between two SNFs that are not under sanction.  Part A coverage will be available to the second SNF for all remaining days in the benefit period as long as the beneficiary:   1. Had a qualifying hospital stay  2. Was admitted to a Medicare -certified bed in the first (sanctioned) SNF within 30 days of the hospital discharge, and   3. Is receiving a covered level of care at the time of transfer.   50.4 - Conducting Resident Assessments  (Rev. 10880, Issued: 08- 06-21, Effective: 11 -08-21, Implementation: 11- 08-21)  The imposition of sanctions does not waive the SNFs responsibility to perform assessments in accordance with the clinical schedule defined in the SOM.  Comprehensive admission assessments are still due within 14 days of admission to the SNF. Facility staf f must also maintain the schedule for quarterly and annual assessments, and perform SCSAs and SCPAs when clinically appropriate.   Medicare- required assessments are also necessary for all beneficiaries in the SNF whose stays are not subject to the payment ban.  If, during the sanction period, staff do not perform Medicare- required assessments for beneficiaries in covered Part A stays,  no payment is made and the SNF must submit a claim using the HIPPS default rate code and an occurrence code 77 indicating provider liability, in order to ensure that the beneficiarys spell of illness (benefit period) is updated.
(Medicare Claims Processing Manual)
Part A benefits are NOT available for beneficiaries admitted after the effective date of the payment ban.  Therefore, the facility is not required to perform Medicare PPS assessments.  Medicare payments can begin no earlier than the date the sanction is li fted.  For Medicare PPS assessment scheduling purposes, the date the sanction is lifted should be considered day 1.  In this case, if the sanctions are lifted effective June 15, the assessment reference date for the Medicare 5 -day assessment must be set between June 15 and June 22 (i.e., the eighth day of the covered stay).  An SNF may choose to perform the Medicare -required assessments during the sanction period, but is not required to do so.  Generally, a facility should continue to do the Medicare PPS assessments if SNF staff believe the sanction was in error and may be lifted retroactively.  In this case, the SNF would be able to bill Medicare at the correct rate.  When the SNF does not receive timely notification that a payment ban has been lifted, and staff is unaware of the need to start the Medicare- Required schedule (the beneficiary meets all applicable eligibility and coverage requirements), the SNF shall bill the Medicare 5 -day and 14- day assessment using the HIPPS code generated by the 14- day OBRA required assessment.  If the SNF did not perform any assessments with an assessment reference date during the assessment window for the Medicare -Required 5-day or 14- day assessment, the SNF shall bill the default rate for those covered days associated with the assessment.  Where the SNF did not perform an assessment with an ARD that fell in the applicable Medicare -Required Assessment window for the 30, 60 and 90- day M edicare- Required Assessments it shall bill the default rate.  If the SNF did perform an assessment, including a SCSA, where the ARD fell in the window of a 30, 60 or 90- day Medicare- Required Assessment (including grace days), the SNF shall bill using the H IPPS code generated from the assessment in accordance with the payment policies found in Chapter 28 of the Provider Reimbursement Manual.  The date the sanction is lifted is Day 1 for purposes of the Medicare assessment schedule.   NOTE : In order to bill with the default code the beneficiary must at least meet the requirements for SNF coverage.