Swing Bed Critical Access Hospital Billing Chart

FY 2016

Description & Regulation Covered Charge Claim Benefits Exhaust Claim No Qualifying Stay/Transfer Criteria Not Met Demand Bill Claim No-Pay Claim Discharges occurring the 1st of the month following the end of the Facility's Fiscal Year (FY) End Inpatient Part B Claim

Bill Type

CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 30, 40.8, 40.8.2, 40.9, 30.4

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 240

Swing Bed
181 - admit to discharge
182 - 1st sequential
183 - cont sequential
184 - discharge

Swing Bed
181 - admit to discharge
182 - 1st sequential
183 - cont sequential
184 - discharge

(when claim is finalized in FISS changes TOB to 180 for BE reject)

Swing Bed
181 - admit to discharge
182 - 1st sequential
183 - cont sequential
184 - discharge

(when claim is finalized in FISS changes TOB to 180 for reject due to SNF coverage criteria not met)

Swing Bed
180

If QIO 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

Swing Bed
180
Swing Bed
180
Swing Bed
No Part B benefit in Swingbed;
switch to hospital inpatient Part B 12x TOB and use the hospital provider number not Swingbed

Frequency of Billing

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 50.2-50.2.3

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 40, 40.8, 40.8.2, 40.9

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 240

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 5

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 the 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 the 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 the same sequence in which services are furnished.

Start day following date active care ended and bill up to 30- day period of noncovered care

Claims need to process sequentially by Date of admission

MAY be submitted as often as monthly, but must be as often as necessary to meet timely filing requirements. Start day following the date active care ended.

Claims need to process sequentially by Date of admission

Discharge from and through date will be the 1st of the month following the FY end with discharge patient status code

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

Billing for Days

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, 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 Leave of Absence (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

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 40.3, 40.6.4, 40.8, 40.8.2, 40.9, 40.3.5.2

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 240

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 5

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 non-covered All Charges billed as covered

Condition Codes

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 30.5.1, 40.8, 40.8.2, 40-40.9

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 150.3.3

Payer codes if applicable
04 - Medicare Advantage beneficiary Change Request (CR) 5653
40 - Same day transfer
55 - SNF bed not available
56 - Medical Appropriateness
57 - SNF Readmission
58 - Terminated Medicare Advantage Enrollee

QIO Expedited Review as applicable:
C1 - Approved as billed
C2 - Partial approval
C4 - Admission denied
C5 - Post-payment review
C6 - Admission preauthorization
C7 - Extended authorization

Payer if applicable
D9 -When adjusting a 210/180 to reject as benefits exhaust. Be sure to add remarks for the adjustment.

Payer codes if applicable
04 - Medicare Advantage beneficiary (if applicable)

20 Condition Code

QIO Expedited Review if applicable:
C1 - Approved as billed
C2 - Partial approval
C4 - Admission denied
C5 - Post-payment review
C6 - Admission preauthorization
C7 - Extended authorization

21 Condition Code

QIO Expedited Review if applicable:
C1 - Approved as billed
C2 - Partial approval
C4 - Admission denied
C5 - Post-payment review
C6 - Admission preauthorization
C7 - Extended authorization

21 Condition Code

Payer codes if applicable
04 - Medicare Advantage beneficiary Change Request (CR) 5653
55 - SNF bed not available
56 - Medical Appropriateness
57 - SNF Readmission
58 - Terminated Medicare Advantage Enrollee

QIO Expedited Review as applicable:
C1 - Approved as billed
C2 - Partial approval
C4 - Admission denied
C5 - Post-payment review
C6 - Admission preauthorization
C7 - Extended authorization

Payer codes if applicable

Occurrence Codes

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 30, 30.4, 40.8, 40.8.2, 40.9

CMS IOM, Publication 100-04, Chapter 4, Section 240

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 5

Payer codes if applicable
21 - Utilization Review (UR) notice received
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 beneficiary drops below skilled level of care)
System will auto plug the A3 for benefits exhaust on claims for date of service (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
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 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 if applicable

Occurrence Span Codes

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 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 occurrence 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 occurrence span code (add remarks) 70 - 3 day qualifying stay
74 - LOA if applicable
70 - 3 day qualifying stay
74 - LOA if applicable
77 - Provider liability for non-utilization discharge day. Bill First day of month in the from and through dates of the span code. Be sure to add remarks stating "Discharge on the first of the month following the end of fiscal year"
70 - 3 day qualifying stay
If no qualifying stay do not add 70 occurrence span code (add remarks)
74 - LOA if applicable
77 - Provider liability for non-utilization discharge day. Bill October 1 through October 1. Add remarks stating "Discharge on October 1st"
78 - SNF prior stay dates if
applicable
NA

Value Codes

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 30; 40.6, 40.3.5.2, 40.8, 40.8.2, 40.9

09 - Coinsurance amt (if applicable) for specific year $157.50 per day for 2015
$152.00 per day for 2014
09 - Coinsurance amt (if applicable) for specific year $157.50 per day for 2015
$152.00 per day for 2014
09 - Coinsurance amt (if applicable) for specific year
$157.50 per day for 2015
$152.00 per day for 2014
NA NA NA Any other applicable payer codes

Revenue Codes

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 30; 40.6, 40.3.5.2, 40.8, 40.8.2, 40.9

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 240

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 5

CMS IOM, Publication 100-02, Benefit Policy Manual, Chapter 8, Section 10

0120 - room and board
0180 - LOA if applicable
0420 - PT
0430 - OT
0440 - SLP
0300 - if lab billed
+ any other ancillary services
0001 - Total Charge line

Total BE claims
0120 - room and board
0001 - Total Charge line

Partial BE claim bill as covered claim

0120 - room and board
0001 - Total Charge

0120 - room and board
0420 - PT
0430 - OT
0440 - SLP
0300 - if lab billed
+ any other ancillary services
0001 - Total Charge line

 

0120 - room and board
0001 - Total Charge line

Note: Include nominal fee for room and board charges (E.g. $0.01)

Normally only provide these services:

030x-lab
0420-PT
0430-OT
0440-SLP

Paid by Fee Schedule

Reminder: drugs are not a Part B ancillary benefit

HCPC Codes

CMS IOM, Publication 100-04, Chapter 4

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 5

NA NA NA NA NA NA Required on all line items

Modifiers

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 5

NA NA NA NA NA NA Most common
GP - PT Codes
GO - OT Codes
GN - SLP Codes
KX - Therapy CAP medically necessary, apply on all lines in that month for PT/OT/SLP
CH-CN - Severity/Complexity modifiers for use with Functional Therapy G-codes
91 - Repeat lab
59 - separate procedure

Line Item Service Dates

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 5

NA NA NA NA NA NA 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
NA Can only collect co-insurance until determination is made by Medical Review NA NA Lab paid 100% all other 20% of MPFS

Deductible

NA NA NA NA NA NA Annual $147.00 for 2015 and 2014

Billing for Beneficiary Disenrolled from MA Plans

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 90

If beneficiary voluntarily disenrolls from a risk MA plan and converts to original Medicare before admission need to meet Medicare requirements which includes a 3 day qualifying stay.

If 3-day qualifying stay requirement is waved submit first claim with 58 condition code to bypass 70-span code 3-day qualifying stay edit

If beneficiary voluntarily disenrolls from a risk MA plan and converts to original Medicare before admission need to meet Medicare requirements which includes a 3 day qualifying stay.

If 3-day qualifying stay requirement is waved submit first claim with 58 condition code to bypass 70-span code 3-day qualifying stay edit

If beneficiary voluntarily disenrolls from a risk MA plan and converts to original Medicare before admission need to meet Medicare requirements which includes a 3 day qualifying stay.

If 3-day qualifying stay requirement is waved submit first claim with 58 condition code to bypass 70-span code 3-day qualifying stay edit

NA NA

If beneficiary voluntarily disenrolls from a risk MA plan and converts to original Medicare before admission need to meet Medicare requirements which includes a 3 day qualifying stay.

If 3-day qualifying stay requirement is waved submit first claim with 58 condition code to bypass 70-span code 3-day qualifying stay edit

NA

Billing for Payment Bans

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 50.2.2

Bill with Occurrence Span Code 77
When multiple admissions during the same imposition include Occurrence Span code 80 with prior stay dates
Bill covered units and days
Bill with Occurrence Span Code 77
When multiple admissions during the same imposition include Occurrence Span code 80 with prior stay dates
Bill covered units and days
NA NA NA Bill with Occurrence Span Code 77
When multiple admissions during the same imposition include Occurrence Span code 80 with prior stay dates
Bill covered units and days
NA

 

Last Updated Fri, 28 Feb 2020 12:31:38 +0000