SNF and Swingbed Billing - JE Part A
SNF and Swingbed Billing
Does not apply to CAH Swingbed Claims
| Description & Regulation | Covered Charge Claim | Benefits Exhaust Claim | No Qualifying Stay/Transfer Criteria Not Met | Demand Bill Claim | Discharges occurring on October 1st | No-Pay Claim | Inpatient Part B Claim |
|---|---|---|---|---|---|---|---|
| Bill Type | SNF PPS Swing Bed 217/187 adjustments to change RUG code must be done within 120 days | SNF PPS Swing Bed (when claim is finalized FISS changes TOB to 210/180 for BE reject) | SNF PPS Swing Bed (when claim is finalized FISS changes TOB to 210/180 for reject due to SNF coverage criteria not met) | SNF PPS Swing Bed If MR reviews and overturns any portion of stay covered days are separated onto a payable bill type for processing and 20 CC stays on claim | SNF PPS Swing Bed | SNF PPS Swing Bed | SNF PPS Swing Bed |
| Frequency of Billing IOM, Publication 100-04, Chapter 1, Section 50.2-50.2.3 IOM, Publication 100-04, Chapter 6, Section 40, 40.8, 40.8.2, 40.9 | Monthly or upon discharge, death or drop below skilled level of care If beneficiary admitted on last day of month or discharged first day of next month, providers may combine both months' claims Bills for a continuous stay or admission must be submitted in same sequence in which services are furnished | Monthly or upon discharge, death or drop below skilled level of care If beneficiary admitted on last day of month or discharged first day of next month, providers may combine both months' claims Bills for a continuous stay or admission must be submitted in same sequence in which services are furnished | Monthly or upon discharge, death or drop below skilled level of care If beneficiary admitted on last day of month or discharged first day of next month, providers may combine both months' claims Bills for a continuous stay or admission must be submitted in same sequence in which services are furnished | Monthly or upon discharge, death or drop below skilled level of care If beneficiary admitted on last day of month or discharged first day of next month, providers may combine both months' claims Bills for a continuous stay or admission must be submitted in same sequence in which services are furnished | Discharge from and through date October 1 with discharge patient status code | Monthly or upon discharge, death or drop below skilled level of care If beneficiary admitted on last day of month or discharged first day of next month, providers may combine both months' claims Bills for a continuous stay or admission must be submitted in same sequence in which services are furnished | Monthly for PT/OT/SLP and if only billing for lab-anytime Claims can be submitted same time as No-pay , not at same time as Demand Bill or Benefits Exhaust claims |
| RUG Codes IOM, Publication 100-04, Chapter 6, Section 30 MDS RAI Manual, Chapter 6 | 66 RUG codes 52 usually considered payable Note: Before billing, MDS MUST be submitted successfully to the extract. | Partial BE Claim Full BE Claim | AAAXX-default when no MDS completed | Any completed MDSs then switch to AAAXX for subsequent months | Bill Default RUG Code = AAAXX | Any completed MDSs then switch to AAAXX for subsequent months | NA |
| Adjusting a SNF RUG IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 30.3 | Increased RUG - Submit adjustment within 120 days from "through date" listed on claim Decreased RUG - Allowed to submit adjustment after 120 days to refund Medicare | NA | NA | NA | NA | NA | NA |
| Billing for Days IOM, Publication 100-04, Chapter 6, Section 40.3, 40.6.4, 40.8, 40.8.2, 40.9, 40.3.5.2 | All days should be billed as covered/co-insurance, the only non-covered days would be for LOA | All days billed as covered, first claim is usually partial benefits exhaust claim then next month is total benefits exhaust claim | All days billed as covered | All days billed as non-covered | All days billed as non-covered | All days billed as non-covered | NA |
| Charges IOM, Publication 100-04, Chapter 6, Section 30, 40.6, 40.3.5.2, 40.8, 40.8.2, 40.9 | All charges billed as covered (LOA charge = $0) | All charges billed as covered | All charges billed as covered | All charges billed as non-covered | All charges billed as non-covered Note: Include nominal fee for room and board charges (E.g. $0.01) | All charges billed as non-covered | All Charges billed as covered |
| Condition Codes IOM, Publication 100-04, Chapter 6, Section 30.5.1, 40.8, 40.8.2, 40-9 | Payer codes if applicable QIO Expedited Review as applicable: Adjustment condition codes | Payer codes if applicable | Payer codes if applicable | 20 Condition Code QIO Expedited Review as applicable: | 21 Condition code Payer codes if applicable QIO Expedited Review as applicable: Adjustment condition codes | 21 Condition Code QIO Expedited Review as applicable: | Payer codes if applicable |
| Occurrence Codes IOM, Publication 100-04, Chapter 6: Section 40.8, 40.8.2, 40.9 | Payer codes if applicable 21 - UR notice received | System will auto plug A3 for benefits exhaust on claims for DOS 10/1/06 and greater 22 - Date active care ended and would equal the through date on the claim as all days after would be billed as no-pay/demand bill (only add when bene drops below skilled level of care) | Payer codes if applicable | Payer codes if applicable 21 - UR notice received | Payer codes if applicable 21 - UR notice received | Payer codes if applicable | Only for PT/OT/SLP |
| Occurrence Span Codes IOM, Publication 100-04, Chapter 6, Section 30, 40.6, 40.3.5.2, 40.8, 40.8.2, 40.9 | 70 - 3 day qualifying stay | 70 - 3 day qualifying stay | If no qualifying stay do not add 70 occurrence span code (add remarks) | 70 - 3 day qualifying stay | 70 - 3 day qualifying stay | 70 - 3 day qualifying stay | |
| Value Codes IOM, Publication 100-04, Chapter 6, Section 30, 40.6, 40.3.5.2, 40.8, 40.8.2, 40.9 | 09 - Co-Insurance amount if applicable for specific year (day 21-80), + Any applicable payer codes | 09 - Co-Insurance = with $1.00 | 09 - Co-Insurance = with $1.00 | NA | Any applicable payer codes. | NA | Any applicable payer codes |
| Revenue Codes IOM, Publication 100-04, Chapter 6, Section 30, 40.6, 40.3.5.2, 40, 40.8.2, 40.9 | 0022 - RUG code If all therapy stopped at end of month and no therapy provided next month submit applicable therapy rev code with 1 unit and $1.00 to bypass edit until OMRA done to re-RUG MDS | Total BE claims Partial BE claim bill as covered claim | 0022 - RUG code AAA00 when you don't have any other MDS | 0022-RUG code AAA00 when you don't have any other MDS | 0022-RUG code AAA00 when you don't have any other MDS | 0022-RUG code AAA00 when you don't have any other MDS | Normally only provide these services: 30x-lab Paid by Fee Schedule Reminder: Drugs are not an inpatient Part B benefit |
| HIPPS Codes HCPC Codes MDS Manual-Assessment Indicators IOM, Publication 100-04, Chapter 6, Section 30 | HIPPS codes required on 0022 revenue lines | HIPPS codes required on 0022 revenue lines | HIPPS codes required on 0022 revenue lines | HIPPS codes required on 0022 revenue lines | HIPPS codes required on 0022 revenue lines | HIPPS codes required on 0022 revenue lines | HCPCs required on all line items |
| Modifiers | NA | NA | NA | NA | NA | NA | Most common GP - PT Codes GO - OT Codes GN - SLP Codes KX - Therapy CAP med necessary, apply on all lines in that month for PT/OT/SLP 91 - Repeat lab 59 - separate procedure |
| Line Item Service Dates | ARD is no longer reported in service date field eff. 1/1/11 Use occurrence code 50 with Assessment Reference Date (ARD) | ARD is no longer reported in service date field eff. 1/1/11 Use occurrence code 50 with Assessment Reference Date (ARD) | ARD is no longer reported in service date field eff. 1/1/11 Use occurrence code 50 with Assessment Reference Date (ARD) | ARD is no longer reported in service date field eff. 1/1/11 Use occurrence code 50 with Assessment Reference Date (ARD) | ARD is no longer reported in service date field eff. 1/1/11 Use occurrence code 50 with Assessment Reference Date (ARD) | ARD is no longer reported in service date field eff. 1/1/11 Use occurrence code 50 with Assessment Reference Date (ARD) | Required on all line items |
| Co-Insurance | $157.50 per day for 2015 $152.00 per day for 2014 | $157.50 per day for 2015 $152.00 per day for 2014 | Can only collect co-insurance until determination is made by MR | NA | NA | Lab paid 100% all other 20% of MPFS | |
| Deductible | NA | NA | NA | NA | NA | NA | Annual - $147.00 for 2015 and 2014 |
| Exclusions: IOM, Publication 100-04, Chapter 6, Section 20.1.1 - 20.1.1.2 | |||||||
| Major Category I Cardiac Cath, CT, MRI, ASCs, Radiation Therapy, Angiography, Lymphatic and Venous, ER, Ambulance related to excluded service within this list, Ambulance for Dialysis | Excluded only if done in hospital outpatient department or CAH (13x or 85x) TOB It's bundled back to SNF if performed by provider billing CMS-1500 claim form For ER services other provider uses ET modifier on 13x/85x TOB | Entity providing service can bill | Entity providing service can bill | Entity providing service can bill | Entity providing service can bill | Entity providing service can bill | Not a inpatient Part B benefit so entity providing service can bill |
| Major Category II Certain Dialysis services & Hospice | Excluded for: Dialysis provided in hospital based dialysis unit or free standing renal dialysis facility (RDF), EPO by RDF, and ambulance transport | Entity providing service can bill | Entity providing service can bill | Entity providing service can bill | Entity providing service can bill | Entity providing service can bill | Not a inpatient Part B benefit so entity providing service can bill |
| Major Category III Chemotherapy, Radioisotopes, Prosthetic Devices | Excluded by individual code | Entity providing service can bill | Entity providing service can bill | Entity providing service can bill | Entity providing service can bill | Entity providing service can bill | Entity providing service can bill |
| Major Category IV Preventive Services | Excluded from SNF Part A claim and billed on Part B 22x TOB if Swg Bed bill on 12x TOB | Entity providing service can bill | Entity providing service can bill | Entity providing service can bill | Entity providing service can bill | Entity providing service can bill | Entity providing service can bill |
| Major Category V Physical Therapy | All therapy services provided must be billed on SNF claim | All therapy services provided must be billed on SNF claim | All therapy services provided must be billed on SNF claim unless patient is a non-patient 23x TOB or in non-certified bed then entity providing service can bill | All therapy services provided must be billed on SNF claim | All therapy services provided must be billed on SNF claim unless patient is a non-patient 23x TOB or in non-certified bed then entity providing service can bill | All therapy services provided must be billed on SNF claim unless patient is a non-patient 23x TOB or in non-certified bed then entity providing service can bill | All therapy services provided must be billed on SNF claim unless patient is a non-patient 23x TOB or in non-certified bed then entity providing service can bill |
| Billing for Beneficiary Dis-enrolled from MA Plans | If beneficiary voluntarily dis-enrolls from a risk MA plan and converts to original Medicare before admission must meet Medicare requirements + 3-day stay. If 3-day stay requirement is waved submit first claim with 58 condition code to bypass 70-span code 3-day stay edit | If beneficiary voluntarily dis-enrolls from a risk MA plan and converts to original Medicare before admission must meet Medicare requirements + 3-day stay. If 3-day stay requirement is waved submit first claim with 58 condition code to bypass 70-span code 3-day stay edit | |||||
| Billing for Payment Bans | |||||||
| Hospital Outpatient Department Billing | When providing services to a Part A resident, if they are done in ER, hospital may bill but must append ET modifier to all services provided in ER |
