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

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

IOM, Publication 100-04, Chapter 7

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 RUG code must 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 stay covered days are separated onto a payable bill type for processing and 20 CC stays on claim

SNF
210

PPS Swing Bed
180

SNF
210

PPS Swing Bed
180

SNF
22x, 23x

PPS Swing Bed
No Part B benefit in Swing Bed switch back to Inpatient Part B hospital 12x TOB and use the hospital provider number not swing bed provider number

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

IOM, Publication 100-04, Chapter 7

IOM, Publication 100-04, 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, 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.
AAAXX-default when no MDS completed. XX=varied AI codes. See MDS Manual

Partial BE Claim
66 RUG codes 52 usually considered payable
AAAXX-default when no MDS completed

Full BE Claim
AAAXX
XX=varied AI codes. See MDS Manual

AAAXX-default when no MDS completed
XX=varied AI codes. See MDS Manual

Any completed MDSs then switch to AAAXX for subsequent months
XX=varied AI codes. See MDS Manual

Bill Default RUG Code = AAAXX

Any completed MDSs then switch to AAAXX for subsequent months
XX=varied AI codes. See MDS Manual

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

IOM, Publication 100-04, Chapter 7

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

IOM, Publication 100-04, Chapter 1, Section 150.3.3

Payer codes if applicable
04 - Medicare Advantage bene CR5653
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

Adjustment condition codes
when 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. Add remarks for adjustment

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

20 Condition Code

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

21 Condition code

Payer codes if applicable
04 - Medicare Advantage bene CR5653
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

Adjustment condition codes
when applicable:
D2 - Adjustment claim for HIPPS Change due to MDS correction

21 Condition Code

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

IOM, Publication 100-04, Chapter 6: Section 40.8, 40.8.2,  40.9

IOM, Publication 100-04, Chapter 7

IOM, Publication 100-04, Chapter 5

Payer codes if applicable

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 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) 
50 - Assessment Reference Date (ARD)

Payer codes if applicable

Payer codes if applicable

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

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) 
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

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
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
If  no qualifying stay do not add 70 occurrence span code (add remarks)
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

70 - 3 day qualifying stay
74 - LOA if applicable

 

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),
$157.50 per day 2015
$152.00 per day 2014

+ 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

IOM, Publication 100-04, Chapter 7

IOM, Publication 100-04, Chapter 5

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 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
0022 - RUG code AAAXX
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

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 an inpatient Part B benefit

HIPPS Codes HCPC Codes

MDS Manual-Assessment Indicators

IOM, Publication 100-04, Chapter 6, Section 30

IOM, Publication 100-04, Chapter 7

IOM, Publication 100-04, Chapter 5

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

IOM, Publication 100-04, Chapter 7

IOM, Publication 100-04, Chapter 5

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

IOM, Publication 100-04, Chapter 7

IOM, Publication 100-04, Chapter 5

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:
Physician, PA, NP, CNS, Psychologist, CRNA, and Major Cat I-V

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

IOM, Publication 100-04, Chapter 6, Section 20.1.2

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

IOM, Publication 100-04, Chapter 6, Section 20.2.1

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

IOM, Publication 100-04, Chapter 6, Section 20.3

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

IOM, Publication 100-04, Chapter 6, Section 20.4

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
Occupational Therapy
Speech Language Pathology

IOM, Publication 100-04 Chapter 6, Section 20.5

Chapter 5 Part B Rehab/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

IOM, Publication 100-04, Chapter 6, Section 90

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

IOM, Publication 100-04, Chapter 6, Section 50

             

Hospital Outpatient Department Billing

IOM, Publication 100-04, Chapter 6, Section 20.1.2.2

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            

 

Last Updated Fri, 28 Feb 2020 15:37:48 +0000