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CAH Swing Bed Billing Guide - JF Part A

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 criterial 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 Quick Reference Billing Guide-Reveune Codes
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 Quick Reference Guide-Occurrence Codes
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 Quick Reference Billing Guide-Value Codes
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 Fri, 08 Sep 2023 17:09:50 +0000