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Skilled Nursing Facilities FAQ

If a beneficiary is admitted into a SNF with all Medicare-certified beds, does the provider have to submit no-pay bills for the patient’s inpatient stay?

Per Transmittal 1394, Change Request 5840, dated 12/14/07 states CMS is not requiring SNF providers to submit no payment bills for non-skilled beneficiary admissions. No pay bills are only required for beneficiaries that have previously received skilled care and subsequently dropped to non-skilled care and continue to reside in the Medicare-certified area of the SNF. (02/12/2008)

Do no-pay claims have to split Medicare’s fiscal year end?

Per Transmittal 1394, Change Request 5840, dated 12/14/07, no payment bills may span both Medicare and Provider’s fiscal year end dates. (02/12/2008)

What type of bill should be submitted on the Medicare Advantage no-pay claims?

Per Transmittal 1290, Change Request 5653, dated 07/13/07, states the claims for SNF beneficiaries enrolled in Medicare Advantage plans are to submit the claims as covered claims. Covered claims for Skilled Nursing Facility or Swing Bed services will have type of bill 21X or 18X. (02/12/2008)

Does Occurrence Code A3 note benefits are exhausted on the claim?

Occurrence Code A3 is defined as the last date for which benefits are available and after which no payment can be made. This means that the date listed corresponding to the A3 is the last covered day of stay. Occurrence Code A3 should only be used where there are both covered and non-covered days on the claim. To list non-covered level of care use Occurrence Span Code 74 with the respective to/from dates. (7/6/2007)

Physician Certification Statement (PCS) clarification: If an ambulance service responds as a non-emergency to a Skilled Nursing Facility and prior to or upon arrival finds that the patient has a bona fide emergency (e.g., heart attack), although it has been made clear that this does not qualify for emergency level claims submission, it does not appear that this would be a claim where a PCS should be required. In these special circumstances, can we assume that even though this claim may not qualify for purposes of emergency level payment, due to the need to concentrate on emergent treatment of the patient once on the scene, that this would eliminate the need to obtain a PCS?

No. For Medicare purposes, the scenario described by the question is a non-emergency transport and, therefore, the non-emergency rules apply, including the rules pertaining to obtaining a PCS. Because Medicare does not require that the PCS be obtained at the time of the transport, the necessity to obtain a PCS need not preclude the ambulance crew from concentrating on emergent treatment of the patient. (7/6/2007)

Why does an Intermediary need to review a Skilled Nursing Facility demand bill?

Your facility may determine upon admission that the level of care will be non-covered or excluded and therefore Medicare will not pay. You must advise the beneficiary that, in your opinion, Medicare will not pay for these services. If the beneficiary disagrees and requests you to submit a bill to the Intermediary, you must submit a "demand bill".

The Intermediary will determine whether the provider is incorrectly advising beneficiaries and/or the beneficiaries' representatives that services are not covered by Medicare in cases where services may be covered in full or in part.

The Intermediary also determines by review of the "demand bill" if adequate notice of non-coverage of skilled care was provided to the beneficiary and/or the beneficiary's representatives. (7/6/2007)

Our facility has been informed that the bill type 22X and 23X definitions have changed. How will this affect our facility?

Medi letter 1432-03 appends Program Memorandum (PM) A-03-040 published May 9, 2003 that provides clarification regarding the 22X and 23X type of bills for skilled nursing facilities. The Centers of Medicare and Medicaid Services (CMS) states that bill type 22X should be used for beneficiaries who are in non-covered stays but are placed in the Medicare-certified distinct part of the skilled nursing facility. Bill type 23X should be used for beneficiaries who are placed in the Medicare non-certified part of the skilled nursing facility. These placements are very important for the therapy cap limitation beginning with dates of service July 1, 2003 forward. (6/12/2003)

Our facility is a Skilled Nursing Facility (SNF); we have seen several claims returned for correction with the reason code 31486. Our facility does not understand this reason code.

The narrative for the reason code 31486 states: ?The claim is a SNF claim with a statement covers date of 7/1/98 or greater and the sum of all revenue codes 0022 does not equal the claim covered days count less occurrence span code 77 days. Review the claim from and through dates to ensure they are correct. If these dates are correct review the covered days and the number of days billed. The days billed and the units should add up to the same number of days. If you submit electronically, you can access the claim through Direct Data Entry (DDE) under Claims Correction. Correct either the number of days or the units and press F9 to reactivate the claim. If you submit hardcopy correct the error and re-submit the hardcopy claim. (7/6/2007)

Effective 10/1/06 facilities are to bill benefits exhaust claims with charges as covered as outlined in MM4292. If we have a Part B claim, will it reject as over lapping the benefits exhaust claim?

Although benefits are exhausted, the inpatient bill is still considered open; you should file the benefits exhaust first and then the part B claim. (7/9/2007)

When the attending physician of a SNF resident orders a Fiberoptic Endoscopy Evaluation of Swallowing (FEES), may the procedure be performed at the SNF by an outside endoscopist who is a speech-language pathologist, at bedside, w/ endoscopic equipment brought into the facility? The physician is present in the building and no contrast dye is used.

FEES may be performed by a physician or speech-language pathologist with direct physician supervision. This service would be subject to consolidated billing guidelines. (7/9/2007)