The Part A SNF benefit covers skilled nursing care, therapy services, and other services for Medicare beneficiaries. In recent years, the Office of Inspector General (OIG) has identified a number of problems with SNF billing for Medicare Part A payments. Notably, an OIG report found that 26 percent of claims submitted by SNFs were not supported by the medical record, representing over $500 million in potential overpayments.
Further, the Medicare Payment Advisory Commission has raised concerns about SNFs’ improperly billing for therapy to obtain additional Medicare payments. In this article, we discussed special SNF billing scenarios which will help you to bill Medicare appropriately. When you are billing for private payers, you can consider following billing scenarios as general guidelines.
The patient admits needing skilled care but doesn’t have a qualifying hospital stay. This includes patients initially admitted as skilled, following a qualifying hospital stay, who then dropped to a non-skilled level of care for more than 30 days. This ended their connection to the original qualifying hospital stay, but the patient became skilled again without a new qualifying hospital stay. In such cases bill normally, but don’t report occurrence span code 70.
Patient admits to the SNF and is expected to remain overnight but transfers before the following midnight to a Medicare-participating facility. In such cases report same admission from and through dates zero covered days with condition code 40.
The patient leaves the SNF but isn’t admitted as an inpatient to any other facility. In such cases report revenue code 018X; the number of LOA days as units; zero charges; and occurrence span code 74 showing from and through dates for the LOA and the number of non-covered days.
The patient leaves the SNF and admits as an inpatient to another facility. Bill as a discharge.
The patient drops to a non-skilled level of care and moves to a non-Medicare-certified area of the institution. In such cases, discharge the patient on a final discharge claim. Submit services provided after discharge on TOB 23X.
SNF believes covered skilled care is no longer medically necessary, and the patient disagrees. Report condition code as 20; and occurrence code as 22 with the date SNF care ended or occurrence code 21 with the date you got the utilization review notice.
Submit information-only claims to Medicare so the Common Working File (CWF) can track the benefit period. Also, report condition code 04; appropriate HIPPS code; and room and board charges.
The patient is discharged from a Part A-covered stay and then resumes SNF care in the same SNF for a Part A-covered stay during a 3-day period, starting with the calendar day of Part A discharge and including the 2 calendar days immediately following (known as an interruption window). Medicare would require an Omnibus Budget Reconciliation Act (OBRA) Discharge Assessment. Medicare will require an entry tracking record on re-entry, but not a 5-day MDS assessment.
Medical Billers and Coders (MBC) Is a leading revenue cycle company and providing complete medical billing and coding services. We used the ‘CMS Skilled Nursing Facility Billing’ document as a reference for sharing special SNF billing scenarios. In case of any assistance needed for your Skilled Nursing Facility (SNF), email us at: email@example.com or call us: 888-357-3226.