Critical Access Hospital Swing Bed Billing Guide

Requirement Description
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
CMS Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section10.2		 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
CMS IOM, Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 3, Section 20		 Annual Benefits
  • 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
Refer to National Uniform Billing Committee NUBC		 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
Value Codes Codes and related dollar amount that are necessity to process claims
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 Annual Benefits
Beneficiary Deductible Annual Benefits
Last Updated Dec 09 , 2023