Medicare Part A Introduction to Skilled Nursing …

1 EMPIRE Medicare SERVICESHCFA Medicare Part A and Part B Contracted AgentMedicare Part to Skilled Nursing facility BillingEmpire Medicare ServicesOrientation 2000 Medicare BillingSkilled Nursing FacilityTable of ContentsEXTENDED CARE BENEFIT IN A BENEFITS IN A Skilled Nursing OF BENEFITS IN A Skilled Nursing BENEFITS WILL BE AVAILABLE TO HCFA-1450 (FACSIMILE)..6 Skilled Nursing facility BILL CHARGE STRUCTURE REVENUE FOR Skilled Nursing DAY DISCHARGE COST AVOIDED CHANGES FOR BILLING UNDER SNF ASSESSMENT RUG-III CODES (HIPPS)..18 HIPPS MODIFIERS/ASSESSMENT TYPE B B SNF CHARGE STRUCTURE REVENUE CODING THERAPY PART B IN A B THERAPY SNF BillingEmpire Medicare ServicesOrientation 2000 Page 1 EXTENDED CARE BENEFIT IN A SNFM edicare beneficiaries may be eligible for up to 100 days of Part coverage in a skillednursing facility (SNF) if they meet both technical and medical qualifications forcoverage.

2 The benefit is dependent upon the resident s need for Skilled care. Medicaredoes not have a long term care custodial Qualifications: 3 day qualifying hospital stay- must occur while patient is enrolled in Medicare transfer to the SNF within 30 days of discharge- may exceed 30 days if patient is on hold for therapy- may exceed 30 days if patient transfers from one SNF to another (firstadmission must be within 30 days of hospital discharge; next SNFadmission must be within 30 days of last covered day in 1st SNF) enrolled in Medicare Part A and have benefit days available to useMedical Qualifications: requires Skilled care (from a nurse or therapist) on a daily basis as a practical matter services can only be provided in a SNF services are provided for a condition which the patient was treated in thehospital or for a condition which arose while the beneficiary was being treatedin the hospitalBenefit PeriodsThere is no limit to the number of benefit periods that a beneficiary may qualify for.

3 Youmay have more than one period of 100 days paid for in a SNF. In order to renewbenefits, the SNF resident must: be discharged to home for a period of at least 60 consecutive days (notrequiring inpatient care under Part A in a SNF or hospital) remain in the SNF at a non- Skilled level of care (custodial)- this requires claims coding by the SNF to indicate the changeMedicare SNF BillingEmpire Medicare ServicesOrientation 2000 Page 2If these requirements are not met, the beneficiary remains in the same benefit period and maypotentially run out of Part A days (benefits exhaust). This beneficiary would be ineligible fornew coverage (technically) even if he experiences a new medical condition, had a newhospitalization and return to the SNF meeting the medical requirements for SNF BillingEmpire Medicare ServicesOrientation 2000 Page 3RE-ESTABLISHING BENEFITS IN A Skilled Nursing FACILITY6/17/1530 Days8/14 9/1445 benefit days used60 DaysOccurrence Code 22orDischarge If the resident is cut or discharged on 7/15, the balance of benefits available may beused if the patient returns to the facility or is upgraded to Skilled level of care within 30 days (8/14).

4 NO NEW QUALIFYING HOSPITAL STAY IS REQUIRED If the resident returns to the facility or is upgraded to Skilled level of care at anypoint between day 31 and day 60 (8/15 9/14), THAT PATIENT MUST HAVE AQUALIFYING HOSPITAL STAY TO RESUME USING THE BALANCE OF REMAININGBENEFITS. If the resident returns to the facility or is upgraded to Skilled level of care at anypoint after day 60 (9/15) that patient is eligible for a NEW BENEFIT PERIOD, BUTMUST HAVE A QUALIFYING HOSPITAL STAY and meet all other criteria in order fornew benefits to :Any unused benefit days from prior benefit period are lost if the patient enters anew benefit :A change in diagnosis does not affect the benefit period. Regardless of havinga new diagnosis or readmission with the same diagnosis, application of benefits iscontingent upon the receipt of Skilled care in a SNF for a condition which thebeneficiary was treated in a qualifying hospital SNF BillingEmpire Medicare ServicesOrientation 2000 Page 4 RENEWAL OF BENEFITS IN A Skilled Nursing FACILITYEXAMPLE 1 SNFHOSP1/10/993/15/999/1/9937 benefit days usedNo pay discharge claimOccurrence Code 22 Patient cut 3/15/99 Occurrence Code 22 = 3/15/99 on last Part A covered claim Patient remained non- Skilled (custodial care) until new hospital admit (9/1/99)

5 No pay discharge bill 3/16/99 9/1/994 No special coding on discharge bill Benefit spells will not link New benefit period will be availableMedicare SNF BillingEmpire Medicare ServicesOrientation 2000 Page 5 EXAMPLE 2 SNFHOSP1/10/994/18/999/1/99100 benefit days usedNo pay discharge claimBenefits Exhausted (A3) Patient exhausts benefits on 4/18/99 Patient remains at Skilled level of care until new hospital admission (9/1/99) No pay discharge bill must be submitted (per regulations) to place patient as inpatientfrom date of service 4/19/99 9/1/99 Spells of illness will link No new benefits will be available to patientEXAMPLE 3 SNFHOSP1/10/994/18/996/1/999/1/99100 benefit days usedNo pay discharge claimBenefits Exhausted (A3) Patient exhausts benefits on 4/18/99 Patient remains at Skilled level of care until 6/1/99 No pay discharge bill DOS 4/19/99 10/1/99 may be coded with Occurrence Code 22= 6/1/99 as long as the patient remained non- Skilled for 60 consecutive daysbeginning 6/1/99 Spells of illness will not linkNEW BENEFITS WILL BE AVAILABLE TO PATIENTM edicare SNF BillingEmpire Medicare ServicesOrientation 2000 Page 6UB-92 HCFA-1450 (FACSIMILE)

6 PS23 PATIENT CONTROL TYPE OFBILL6 STATEMENT COVERS115 FED. TAX PATIENT NAME13 PATIENT ADDRESSADMISSIONCONDITION CODES3114 BIRTHDATE 15 SEX16MS17 DATE18 HR 19 TYPE 20 SRC21 DHR22 STAT23 MEDICAL RECORD SPAN37 CODEDATECODEDATECODEDATECODEDATECODEFROM THROUGHABC3839 VALUE DESCRIPTION44 TOTAL CHARGES48 NON-COVEREDCHARGES4952 REL 53 ASG50 PAYER51 PROVIDER NO. INFO BEN54 PRIOR PAYMENTS55 EST. AMOUNTDUE5657 DUE FROMPATIENT 58 INSURED'S GROUP NAME62 INSURANCE GROUP TREATMENT AUTHORIZATIONCODES64 ESC65 EMPLOYER NAME66 EMPLOYER LOCATIONOTHER DIAG. CODE69 CODE70 CODE71 CODE72 CODE73 CODE74 CODE75 CODE76 ADM. E-CODE80 PRINCIPAL PROCEDURE 81 OTHER PROCEDUREOTHER PROCEDURE82 ATTENDING PHYS. ID79 PROCEDUREOTHER PROCEDUREOTHER PROCEDURE 83 OTHER PHYS.

7 IDCODEDATECODEDATECODEDATE84 REMARKS OTHER PHY85 PROVIDER REPRESENTATIVE 86 DATEX UB-92 HCFA-1450I CERTIFY THE CERTIFICATIONS ON THE REVERSE APPLY TO TYPE BILL AND AREMADE A PARTM edicare SNF BillingEmpire Medicare ServicesOrientation 2000 Page 7 Skilled Nursing facility BILL TYPESSNF Part ATypeSpanType ofBillDischarge StatusNon-coveredAdmit Discharge210 Anything but 30 CoveredAdmit Discharge211 Anything but 30 Covered or Non-coveredAdmit Interim21230 Covered or Non-coveredInterim Interim21330 Covered or Non-coveredInterim Discharge214 Anything but 30215 Late Charge BillPart A Services (not permitted under PPS)217 Adjustment BillPart A Services218 Cancel Only BillPart A ServicesAncillary Claims22X Part B Coverage Only23X Outpatient ClaimsMedicare SNF BillingEmpire Medicare ServicesOrientation 2000 Page 8 SNF CHARGE STRUCTURE REVENUE CODESSNF PPS0022 Room and Board100 All Inclusive120 Semi-Private (two beds)13X Semi-Private (three/four beds)14X Private Room15X Ward16X Other (sterile environment)18X Leave of Absence(9000-9044 RUGS II Groups)

8 For demonstration SNFsPharmacy25 XIV Therapy26 XMedical/Surgical Supplies27 XOncology28 XLaboratory30 XLab-Pathology31 XRadiology32 XRadiology-therapeutic33 XNuclear Medicine34 XCT Scan35 XOperating Room Services36 XBlood Storage39 XImaging Services40 XRespiratory Services41 XPhysical Therapy42 XOccupational Therapy43 XSpeech Therapy44 XPulmonary Function46 XAudiology47 XCardiology48 XEKG/ECG73 XEEG74 XGastro-Intestinal75 XOther Diagnostic Services92 XOther Therapeutic Services94X (Complex Medical Equipment)**Ambulance540 (SNF PPS Facilities)See your UB-92 billing book for value of X in each category6/98 Medicare SNF BillingEmpire Medicare ServicesOrientation 2000 Page 9 CODING FOR Skilled Nursing FACILITIESSNF Discharge StatusRequired on 21X Bill Types OnlyMost often used:01 Discharged to Home02 Transferred to Hospital (PPS)03 Transfer to Another SNF05 Transferred to Non-PPS Hospital20 Expired30 Still Patient (Interim Bills 212/213)50 Discharge to Hospice (Home)51 Discharge to Hospice (Medical facility )SNF Condition CodesMost often used.

9 07 Non-Hospice Related20 Demand Bill21 Denial Notice for Other Insurer39 Private Room Medically Necessary40 Same Day Transfer55 SNF Bed Not Available (When patientadmission is delayed by 30 days)56 Medical Appropriateness (When therapy isdelayed)57 SNF Readmission (Patient is readmitted within30 days)77 facility Accepts Other Insurance Payment inFullA6 PPV/Flu Administered (not required)(Plus codes for adjustments. See special listing) Medicare SNF BillingEmpire Medicare ServicesOrientation 2000 Page 10 SNF Occurrence CodesMost often used:11 Onset of Illness (Most Recent)21 UR Notice Received22 Date Active Care Ended24 Date Other Insurance Denied35 Date Treatment Started for Physical Therapy44 Date Treatment Started for Occupational Therapy45 Date Treatment Started for Speech TherapyA3 Benefits ExhaustedSNF Occurrence Span CodesMost often used.

10 70 Qualifying Stay71 Prior Inpatient Stay74 Non-covered Level of Care * While patient remains in SNF * Show non-covered charges74 Leave of Absence * While patient is on temporary leave * Do not show non-covered charges78 Prior SNF Stay M1 Provider Liability on Non-covered Days(Provider Reported)SNF Value CodesMost often used:09 Medicare Co-insurance46 Grace Days50 Physical Therapy Sessions * Cumulative sessions under Part B51 Occupational Therapy Sessions * Cumulative sessions under Part B52 Speech Therapy Sessions * Cumulative sessions under Part BMedicare SNF BillingEmpire Medicare ServicesOrientation 2000 Page 11 ONE DAY STAYR eimbursement for One Day StaysThe Medicare Program does not normally reimburse a SNF for date of discharge,death, or when the patient does not meet midnight census certain instances, a SNF can be reimbursed for a single day stay if that patientdies or is transferred back to an acute care facility on the day of Coding for same day transfer.