Skilled Nursing Facility (SNF) Billing Reference

DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Medicare & Medicaid ServicesSkilled Nursing Facility (SNF) Billing ReferencePlease note:The information in this publication applies only to the Medicare Fee-For-Service Program(also known as Original Medicare).ICN 006846 August 2014

Table of ContentsSNF Coverage . 1Coverage Requirements. 1Benefit Period . 2SNF Payment. 3Medicare Part A. 3Consolidated Billing . 3Medicare Part B. 3SNF Billing Requirements. 4Billing Tips . 5Special Billing Situations . 6Readmission Within 30 Days . 6Benefits Exhaust . 7No Payment Billing. 8Expedited Review Results. 9Noncovered Days. 10Other SNF Billing Situations. 10Resources . 12The American Hospital Association (the “AHA”) has not reviewed, and is not responsible for, the completenessor accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in thepreparation of this material, or the analysis of information provided in the material. The views and/or positionspresented in the material do not necessarily represent the views of the AHA. CMS and its products and servicesare not endorsed by the AHA or any of its affiliates.

Medicare Part A covers skilled nursing and rehabilitation care in a Skilled Nursing Facility (SNF)under certain conditions for a limited time. This billing reference provides information forSNF providers about: SNF coverage; SNF payment; SNF billing; and Resources for more detailed information.SNF CoverageCoverage RequirementsTo qualify for Medicare Part A coverage of SNFservices, the following conditions must be met: The beneficiary was an inpatient of a hospital for amedically necessary stay of at least 3 consecutive days; The beneficiary transferred to a participating SNFwithin 30 days after discharge from the hospital(unless the beneficiary’s condition makes it medicallyinappropriate to begin an active course of treatmentin a SNF immediately after discharge and it ismedically predictable at the time of the hospitaldischarge the beneficiary will require covered carewithin a predictable time period); The beneficiary requires skilled nursing servicesor skilled rehabilitation services on a daily basis.Skilled services must be: Performed by or under the supervision ofprofessional or technical personnel; Ordered by a physician; and Rendered for an ongoing condition for which thebeneficiary had also received inpatient hospitalservices or for a new condition that arose duringthe SNF care for that ongoing condition; As a practical matter, considering economy andefficiency, the daily skilled services can be providedonly on an inpatient basis in a SNF; and The services delivered are reasonable andnecessary for the treatment of the beneficiary’sinpatient illness or injury and are reasonable interms of duration and quantity.1Skilled ServicesSkilled nursing and skilled rehabilitationservices are those services furnishedpursuant to physician orders that: Require the skills of qualifiedtechnical or professional healthpersonnel, such as registerednurses, licensed practical nurses,physical therapists, occupationaltherapists, and speech-languagepathologists or audiologists; and Must be provided directly by orunder the general supervision ofthese skilled nursing or skilledrehabilitation personnel to assurethe safety of the beneficiary and toachieve the medically desired result.NOTE: For more information, refer /MM8458.pdf on the Centersfor Medicare & MedicaidServices (CMS) website.

Benefit PeriodCoverage for care in SNFs is measured in “benefitperiods” (sometimes called a “spell of illness”). In eachbenefit period, Medicare Part A covers up to 20 daysin full. After that, Medicare Part A covers an additional80 days with the beneficiary paying coinsurance foreach day. After 100 days, the SNF coverage availableduring that benefit period is “exhausted,” and thebeneficiary pays for all care, except for certain MedicarePart B services.A benefit period begins the day the Medicare beneficiaryis admitted to a hospital or SNF as an inpatient andends after the beneficiary has not been in a hospital(or received skilled care in a SNF) for 60 consecutivedays. Once the benefit period ends, a new benefit periodbegins when the beneficiary has an inpatient admissionto a hospital or SNF. New benefit periods do not begindue to a change in diagnosis, condition, or calendar year.Understanding the benefit period is important becauseSNFs must sometimes submit claims for which theydo not expect to receive payment to ensure the benefitperiod is properly tracked in the Common WorkingFile (CWF).Common Working File (CWF)The CWF contains informationabout Medicare beneficiaries thatMedicare Administrative Contractor(MAC) claims processing systemsaccess to ensure proper paymentof claims. The CWF tracks the SNFbenefit period.Figure 1 helps you understand the relationships between coverage, skilled care, the benefitperiod, and whether you submit a claim to Medicare.Figure 1. Summary of SNF Coverage and BillingHas the patienthad a qualifyinghospital stay?Patient does not qualify for Medicare SNFcare. If the patient was admitted with askilled level of care, submit a no-pay claim.NOYESIs the patient’slevel of careskilled?NOYESHas the patientexhausted Part Abenefits?YESWas the patientadmitted to thefacility as skilled?NOSubmit a no-pay claim with discharge statuscode when patient leaves certified area.YESNOIs the patient in acertified area ofthe facility?Do not submita claim.NOYESFacility should determine whether it wouldbe appropriate to send patient back to acertified area for Medicare coverage.Submit monthly covered claim.2

SNF PaymentMedicare Part AThe SNF Prospective Payment System (PPS) paysfor all SNF Part A inpatient services. Part A payment isprimarily based on the Resource Utilization Group (RUG)assigned to the beneficiary following required MinimumData Set (MDS) 3.0 assessments. As a part of theResident Assessment Instrument (RAI), the MDS 3.0 isa data collection tool that classifies beneficiaries intogroups based on the average resources needed to carefor someone with similar needs. The MDS 3.0 providesa core set of screening, clinical, and functional statuselements, including common definitions and codingcategories. It standardizes communication about residentproblems and conditions.Consolidated BillingUnder the consolidated billing provision, SNF Part Ainpatient services include all Medicare Part A servicesconsidered within the scope or capability of SNFs. Insome cases, the SNF must obtain some services it doesnot provide directly. For these services, the SNF mustmake arrangements to pay for the services and must notbill Medicare separately for those services.Medicare Part BMedicare Part B may pay for: Some services provided to beneficiaries residingin a SNF whose benefit period exhausted or whoare not otherwise entitled to payment under Part A; Outpatient services rendered to beneficiaries whoare not inpatients of a SNF; and Services excluded from SNF PPS and SNFconsolidated billing.General Payment Tips Medicare will not pay underthe SNF PPS unless you bill acovered day. Ancillary charges are only allowedfor covered days and are includedin the PPS rate.Consolidated Billing ResourcesFor more information, visithttp://go.cms.gov/MLNGenInfoon the CMS website and refer tothe Web-Based Training coursessection to learn more about SNFconsolidated billing. To help youdetermine how consolidated billingapplies to specific services, referto the flow charts in the “SkilledNursing Facility ProspectivePayment System” fact sheet Items/CMS1243671.html on the CMS website.SNF Part B BillingSome services must be billedto Part B. Bill repetitive servicesmonthly or at the conclusion oftreatment. Bill one-time services oncompletion of the service.For more information on SNF Part Bbilling, refer to the “Medicare ClaimsProcessing Manual,” Chapter 7, nce/Manuals/Downloads/clm104c07.pdf on theCMS website.3

SNF Billing RequirementsSNFs bill Medicare Part A using Form CMS-1450(also called the UB-04) or its electronic equivalent. Sendclaims sequentially, monthly, and upon: Decrease to less than skilled care; Discharge; or Benefit period exhaustion.NOTE: When a benefit period exhausts, continue tosubmit monthly noncovered claims to ensurethe claims processing system accurately tracksthe benefit period.For general information on billing, refer to the “MedicareClaims Processing Manual,” Chapter 25 at ce/Manuals/Downloads/clm104c25.pdf on the CMS website. Inaddition to the fields required for all claims, SNFs mustpopulate the elements in Table 1 for Part A claims.Bill in SequenceMACs return a continuing stay billif the prior bill has not processed. Ifyou previously submitted the priorbill, hold the returned continuingstay bill until you receive theRemittance Advice (RA) for theprior bill.Table 1. SNF Billing RequirementsUB-04 FieldReportFL 04Type of Bill (TOB)FL 06Statement CoversPeriod – From/ThroughFL 31 – FL 34Occurrence Code/Date21X for SNF inpatient services.18X for swing bed services.The “from” date must be the admission date or, for a continuingstay bill, the day after the “through” date on the prior bill.The “through” date is the last day of billing for the period.50 with the Assessment Reference Date (ARD) for eachassessment period represented on the claim with revenue code0022 (not required for the default Health Insurance ProspectivePayment System [HIPPS] code).70 with the dates of the 3-day qualifying stay.FL 35 & FL 36Occurrence SpanCode – From/ThroughFL 42Revenue Code0022 to indicate you are submitting the claim under the SNFPPS. You can use this revenue code as often as necessary toindicate different rate codes and periods.Copyright 2013, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portionof this publication may be copied without the express written consent of the AHA.4

Table 1. SNF Billing Requirements (cont.)UB-04 FieldReportFL 44Healthcare CommonProcedure CodingSystem (HCPCS)/Rate/HIPPS codeHIPPS rate code (a five-digit code consisting of a three-digit RUGcode and a two-digit Assessment Indicator [AI] code*).Must be in the order in which the beneficiary received that levelof care.Certain HIPPS rate codes require additional rehabilitationtherapy ancillary revenue codes. The MAC returns claims forresubmission when these corresponding codes are missing.The number of covered days for each HIPPS rate code.FL 46Units of ServiceFL 47Total ChargesFL 67Principal DiagnosisCodeFL 67a – FL67qOther DiagnosesZero for 0022 revenue code lines.International Classification of Diseases, Clinical Modification(ICD-CM) code for the principal diagnosis.ICD-CM codes for up to eight additional conditions.AI code describes the assessment that determined the RUG code. For a full explanation* Theof the assessments required, refer to the “Medicare Claims Processing Manual,” Chapter 6,Section 30 at ce/Manuals/Downloads/clm104c06.pdf on the CMS website.Billing Tips Generally, the day of discharge, death, or a day on which a patient begins a leave ofabsence (LOA) is not counted as a utilization day. If a beneficiary is discharged and returns before midnight on the same day, Medicare doesnot count this as a discharge. The HIPPS rate code that appears on the claim must match the assessment that wastransmitted and accepted by the state in which the facility operates. For additional HIPPSinformation, visit ml on the CMS website.Copyright 2013, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portionof this publication may be copied without the express written consent of the AHA.5