Search Result - JE Part A
SNF and PPS Swingbed Billing
Does not apply to CAH Swing Bed Claims
| Description & Regulation | Covered Charge Claim | Benefits Exhaust Claim | No Qualifying Stay/Transfer Criteria Not Met | Demand Bill Claim | No-Pay Claim | Ancillary Claim |
|---|---|---|---|---|---|---|
| Bill Type Quick Reference Guide | SNF 211 - admit to discharge 212 - 1st sequential 213 - cont sequential 214 - discharge PPS Swing Bed 181 - admit to discharge 182 - 1st sequential 183 - cont sequential 184 - discharge 217/187 adjustments to change the RUG code needs to be done within 120 days | SNF 211 - admit to discharge 212 - 1st sequential 213 - cont sequential 214 - discharge PPS Swing Bed 181 - admit to discharge 182 - 1st sequential 183 - cont sequential 184 - discharge
(when claim is finalized FISS changes TOB to 210/180 for BE reject) | SNF 211 - admit to discharge 212 - 1st sequential 213 - cont sequential 214 - discharge PPS Swing Bed 181 - admit to discharge 182 - 1st sequential 183 - cont sequential 184 - discharge
(when claim is finalized FISS changes TOB to 210/180 for reject due to SNF coverage criteria not met) | SNF 210 PPS Swing Bed 180 If MR reviews and overturns any portion of the stay the covered days are separated onto a payable bill type for processing & 20 CC stays on claim | SNF 210 PPS Swing Bed 180 | SNF 22x, 23x PPS Swing Bed No ancillary benefit in Swing Bed switch back to ancillary hospital 12x TOB and use hospital provider number not swing bed provider number |
| Frequency of Billing IOM, Publication 100-04, Chapter 1, Sections 50.2-50.2.3 IOM, Publication 100-04, Chapter 6, Sections 40, 40.8, 40.8.2, 40.9, 40.8.1 | 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 you can 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 you can 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 you can 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 you can 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 you can 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 | 66 RUG codes 52 usually considered payable Note: Before billing, MDS MUST be submitted successfully to extract. AAA00-default when no MDS completed | Partial BE Claim 66 RUG codes 52 usually considered payable AAA00-default when no MDS completed Full BE Claim AAA00 | AAA00-default when no MDS completed | Any completed MDSs then switch to AAA00 for subsequent months | Any completed MDSs then switch to AAA00 for subsequent months | NA |
| Billing for Days IOM, Publication 100-04, Chapter 6, Sections 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, 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 | NA |
| Charges IOM Publication 100-04, Chapter 6, Sections 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 | All Charges billed as covered |
| Condition Codes Quick Reference Guide IOM, Publication 100-04, Chapter 6, Sections 30.5.1, 40.8, 40.8.2, 40-9 | Payer/QIO Expedited Review if applicable 04 - Medicare Advantage bene CR5653 40-same day transfer 55/56/57 - As applicable D2-adjustment claim for HIPPS Change due to MDS correction | Payer codes if applicable D9 -When adjusting a 210/180 to reject as benefits exhaust. Be sure to add remarks for adjustment. | Payer codes if applicable 04 - Medicare Advantage bene (if applicable) | 20 Condition Code & QIO Expedited Review if applicable | 21 Condition Code | Payer codes if applicable |
| Occurrence Codes Quick Reference Guide IOM, Publication 100-04, Chapter 6, Sections 40.8, 40.8.2, 40.9 | Payer codes if applicable 16 - Date of last therapy 21 - UR notice received 22 - Date active care ended and would equal through date on claim as all days after would be billed as no-pay/demand bill (only add when bene drops below skilled level of care) 50 - Assessment Reference Date (ARD) | System will auto plug the A3 for benefits exhaust on claims for DOS 10/1/06 & greater. 16 - Date of last therapy 22 -Date active care ended and would equal through date on claim as all days after would be billed as no-pay/demand bill (only add when bene drops below skilled level of care) 50 - Assessment Reference Date (ARD) | Payer codes if applicable | Payer codes if applicable 16 - Date of last therapy 21 - UR notice received 22 - Date active care ended and would equal through date on claim as all days after would be billed as no-pay/demand bill (only add when bene drops below skilled level of care) 50 - Assessment Reference Date (ARD) | Payer codes if applicable | Only for PT/OT/SLP 11- Onset (only use 1 on claim) 29-PT POC establish 35-PT treat started 17-OT POC establish 44-OT treat started 30-SLP POC establish 45-SLP treat started + any other payer codes |
| Occurrence Span Codes Quick Reference Guide IOM, Publication 100-04, Chapter 6, Sections 30, 40.6, 40.3.5.2, 40.8, 40.8.2, 40.9 | 70 - 3 day qualifying stay If no qualifying stay do not add 70 occ span code (add remarks) 74 - LOA if applicable 78 - SNF prior stay dates if applicable | 70 - 3 day qualifying stay 74 - LOA if applicable | If no qualifying stay do not add 70 occ span code (add remarks) | 70 - 3 day qualifying stay 74 - LOA if applicable | 70 - 3 day qualifying stay 74 - LOA if applicable | |
| Value Codes Quick Reference Guide IOM, Publication 100-04, Chapter 6, Sections 30, 40.6, 40.3.5.2, 40.8, 40.8.2, 40.9 | 09 - Co-Insurance amt if applicable for specific year, $144.50 per day 2012 + Any applicable payer codes | 09 - Co-Insurance = with $1.00 | 09 - Co-Insurance = with $1.00 | Any applicable payer codes | ||
| Revenue Codes Quick Reference Guide IOM, Publication 100-04, Chapter 6, Sections 30, 40.6, 40.3.5.2, 40.8, 40.8.2, 40.9 | 0022 - RUG code 0120 - room and board 0180 - LOA if applicable 0420 - PT if therapy RUG code 0430 - OT if therapy RUG code 0440 - if SLP if therapy RUG code 0300 - if lab billed + Any other ancillary 0001 - Total Charge If all therapy stopped at end of month an 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 0022 - RUG code AAA 0120 - room and board 0001 - Total Charge Partial BE claim bill as covered claim | 0022-RUG code AAA00 when you don't have any other MDS 0120 - room and board 0001 - Total Charge | 0022-RUG code AAA00 when you don't have any other MDS 0120 - room and board 0420 - PT if therapy RUG code 0430 - OT if therapy RUG code 0440 - if SLP if therapy RUG code 0300 - if lab billed + Any other ancillary 0001 - Total Charge | 0022-RUG code AAA00 when you don't have any other MDS 0120 - room and board 0001 - Total Charge | Normally only provide these services: 30x-lab 420-PT 430-OT 440-SLP Paid by Fee Schedule Reminder: drugs are not a ancillary benefit |
| HIPPS Codes HCPC Codes | 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 | 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 proc. |
| Line Item Service Dates Change Request (CR) 7019 | ARD is no longer reported in service date field | ARD is no longer reported in service date field | ARD is no longer reported in service date field | ARD is no longer reported in service date field | ARD is no longer reported in service date field | Required on all line items |
| Co-Insurance | Can only collect co-insurance until determination is made by MR | NA | Lab paid 100% all other 20% of MPFS | |||
| Deductible | NA | NA | NA | NA | NA | |
| Exclusions: Physician, PA, NP, CNS, Psychologist, CRNA, & Major Cat I-V IOM, Publication 100-04, Chapter 6, Sections 20.1.1 - 20.1.1.2 | ||||||
| Major Category I Cardiac Cath, CT, MRI, ASCs, Radiation Therapy, Angiography, Lymphatic & 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 If done by provider billing CMS-1500 claim form it is bundled back to SNF 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 | Not a Ancillary 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 | Not a Ancillary 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 |
| 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 |
| Major Category V Physical Therapy Occupational Therapy Speech Language Pathology | All therapy services provided need to be billed on SNF claim | All therapy services provided need to be billed on SNF claim | All therapy services provided need to 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 need to be billed on SNF claim | All therapy services provided need to 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 need to 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 need to 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 need to 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 Part A resident, if they do go to ER, hospital may bill but need to add ET modifier to all services provided in ER |
