CAH Swing Bed Billing Guide - JE Part A
Critical Access Hospital Swing Bed Billing Guide
Unique Identifying Provider Number Ranges
3rd - 6th digits:
- Z300-Z399
Bill Type
- 181 - Admit to discharge
- 182 - 1st sequential
- 183 - Continue sequential
- 187 - Adjustment
- 188 - Cancel
- 180 - No payment (Demand bill or skilled coverage criteria not met)
Billable Visit/Services
Skilled level of care in approved CAH hospital certified swing-bed. Subject to hospital bundling requirements. Nonprofessional services and applicable Certified Registered Nurse Anesthetist (CRNA) service must be included on CAH's swing-bed bill.
A swing bed is not considered hospital level care. It is defined in the payment regulations as SNF level care and is reimbursed at a lesser amount.
Must have a discharge summary following acute care services. When discharged from the swing bed a discharge summary of skilled nursing level services is required.
Payment Type
CMS, IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 30.1.2
Skilled nursing level services are paid at 101% of reasonable cost.
Frequency of Billing
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 50.2-50.2.3
- Monthly or upon discharge/transfer, death or drop below skilled level of care
- If beneficiary admitted on last day of month or discharged first day of next monthly combine both month's claims
- Bill continuous stay or admission must be submitted in same sequence in which services are furnished
Benefit Period - Billing for Days
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 40.3.5
- All days should be billed a covered/coinsurance, unless days would be for Leave of Absence (LOA)
- All charges billed as covered except LOA
- LOA days are billed non-covered
- Bill charges as $0
- Demand bill and No-Pay Claim days all charges are billed non-covered
Swing Bed Days - Cost Reporting
In accordance with PRM-II, 3605.1 M+C (Medicare + Choice, Medicare Advantage, Medicare HMO) swing bed days should be excluded from Worksheet S-3, Part I, Line 3, Column 4 and only reported on Worksheet S-3, Part I, Line 3, Column 6.
Only Medicare fee-for-service swing bed days should be reported on Worksheet S-3, Part I, Line 3, Column 4.
Revenue Codes
Not an all-inclusive list
- Bed and board
- Leave of absence
- CRNA services
- Nursing services
- Rehabilitation services
- Medical social services
- Laboratory services
- Drugs and biologicals
- Supplies
- Diagnostic or therapeutic items/services
- Services ordinarily furnished to inpatients either by the hospital or under arrangement
Condition Codes
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 200.2
Transmittal 1290, Change Request 5653
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 150.3.3
Payer codes if applicable
- 04 - Information Only Medicare Advantage (MA) plan days beneficiary Change Request
- 20 - Beneficiary requested billing (provider understands services are not covered)
- 21 - Denial notice requested
- 40 - Same day transfer
- 55 - SNF bed not available
- 56 - Medical Appropriateness
- 57 - SNF Readmission
- 58 - Terminated Medicare Advantage Enrollee
Quality Improvement Organization (QIO) Expedited Review as applicable:
- C1 - Approved as billed
- C3 - Partial approval
- C4 - Admission denied
- C5 - Post-payment review
- C6 - Admission preauthorization
- C7 - Extended authorization
Interrupted Stays/LOA
Three-day interrupted stay policy is defined as "a greater than 3-day interruption of stay". When the hospital discharges and beneficiary returns by midnight on the third consecutive day; bill days in non-covered, use 74 occurrence span code and date.
Benefit Exhaust
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 40.8
First claim usually partial benefits exhaust claim then next month total benefits exhaust.
- Condition Code D9 - use when adjusting to reject as benefits exhaust
- Add remarks for adjustment
- Occurrence code 22 and date
- Date active care ended, and beneficiary drops below skilled level of care
- Billing all the days under the value codes and revenue code in covered
- Value Code 09 - Co-Insurance = with $1.00
Occurrence Codes and Date
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 80.3.2.2
Payer codes if applicable
- 21-Date Utilization Review (UR) or QIO notice is received
- 22-Date Active Care Ended
- Covered level of care ended, this date would equal the through date on the claim, all days after would be billed as non-covered (No-pay/Demand bill)
Occurrence Span Codes and Date
CMS, IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6 Section 30 and 40
Three-day hospital stays required on claims for coverage and Medicare payment
- 70-Qualifying stay dates
- At least three hospital stay dates; time spent in observation status or emergency room prior to inpatient hospital admission does not count toward three-day dates
- Add remarks when claim does not have a qualifying stay
Payer codes if applicable
- 74-LOA
- 77-Provicer liability for non-utilization discharge day
- 78-SNF prior stay dates
Value Codes
Codes and related dollar amount that are necessity to process claims
- 837I, version 5010: Sequence of qualifier HI01=BE, HI01-2=value code, and Hi01-4=amount
Ancillary Services
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 240
Medicare pays Part B inpatient services when beneficiary is not entitled to benefits under Part A, benefits exhaust, or stay not medically necessary
- Submit 12X type of bill and use hospital provider number
- Review the revenue codes that are not allowed prior to billing
Medicare Advantage (MA)
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 90
- Follow the requirement of the agreement with the plan
- Medicare beneficiary enrolled or disenrolled from plan during billing period, split the bill
- Voluntary disenroll from risk MA and converts to fee-for-service Medicare
- Must meet all Medicare requirements including three-day inpatient hospital stay
- Voluntary disenroll from risk MA plan while receiving skilled services in CAH swing bed
- Three-day is waived if beneficiary meets level of care
- Submit claim with 58 condition code (Terminated Medicare Advantage Enrollee)
Beneficiary Coinsurance
Beneficiary Deductible
