Provider Types Affected

Skilled nursing facilities (SNF) that bill Medicare Administrative Contractors (A/B MAC) or fiscal intermediaries (FI) for SNF services provided to Medicare beneficiaries enrolled in traditional Medicare or a Medicare Advantage (MA) plan

Impact on Providers

This article is informational in nature and meant to clarify existing Medicare policies.

Background

A SNF is required to submit a bill for a beneficiary that has started a spell of illness under the SNF Part A benefit for every month of the related stay even though no benefits may be payable. In addition, SNF providers must submit no-payment bills for beneficiaries that have previously received Medicare-covered skilled care and subsequently dropped to a noncovered level of service but continue to reside in a Medicare-certified area of the facility. CMS maintains a record of all inpatient services whether covered or not to provide input to national healthcare planning and to keep track of the beneficiary’s Part A benefit period.

Key Points

This article is based on Change Request (CR) 5840, which provides clarification to Chapter 6 of the Medicare Claims Processing Manual, SNF Inpatient Part A Billing. There is no change in policy. The key points clarified by CR5840 are:

• If a facility has a separate, distinct nonskilled area or wing, then beneficiaries may be discharged to this area using the appropriate patient discharge status code and no-payment bills would not be required. In addition, SNF consolidated billing legislation for therapy services would not apply to these beneficiaries.
• SNF providers are not required to submit no-payment bills for non-skilled beneficiary admissions.
• SNF providers must submit no-payment bills for beneficiaries that have previously received Medicare-covered skilled care and drop to a noncovered level of care but continue to reside in a Medicare-certified area of the facility.
• Note that providers may bill benefits exhaust and no payment claims using the default HIPPS code of AAA00 in addition to an appropriate room and board revenue code only.
• SNF providers are not required to submit no-payment bills for beneficiaries that are in current Medicare Advantage (MA) plans and no longer require skilled care while still under the plan.
• If a beneficiary no longer requires skilled care under the MA plan, the SNF may discharge the patient using a patient status code of 04. If the beneficiary then requires skilled care again after a period of nonskilled care, the SNF should begin a new admission claim for Medicare to continue the spell of illness.
• When admitting an MA beneficiary, if a SNF is nonparticipating with the MA plan, the beneficiary must be notified of his or her status because he/she may be private pay in this circumstance, depending upon the type of MA plan in which the beneficiary is enrolled.
• No-payment bills may span both Medicare and the provider’s fiscal year end dates.

Additional Information

To see the official instruction, CR5840, issued to your Medicare FI or A/B MAC, go to http://www.cms.hhs.gov/Transmittals/downloads/R1394CP.pdf on the CMS Web site.

If you have questions, please contact your Medicare FI or A/B MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2006 American Medical Association.