www.hcfa.gov
Medicare Part A
Introduction to
Skilled Nursing Facility Billing
EMPIRE MEDICARE SERVICES
HCFA Medicare Part A and Part B Contracted Agent
Medicare Billing
Skilled Nursing Facility
Table of Contents
EXTENDED CARE BENEFIT IN A SNF.............................................................................. 1
RE-ESTABLISHING BENEFITS IN A SKILLED NURSING FACILITY ..................................... 3
RENEWAL OF BENEFITS IN A SKILLED NURSING FACILITY ............................................. 4
NEW BENEFITS WILL BE AVAILABLE TO PATIENT ............................................................. 5
UB-92 HCFA-1450 (FACSIMILE)................................................................................... 6
SKILLED NURSING FACILITY BILL TYPES........................................................................ 7
SNF CHARGE STRUCTURE REVENUE CODES .................................................................. 8
CODING FOR SKILLED NURSING FACILITIES ................................................................... 9
ONE DAY STAY............................................................................................................... 11
NO-PAY DISCHARGE BILLS ........................................................................................... 12
RESUBMITTING COST AVOIDED CLAIMS ....................................................................... 13
MAJOR CHANGES FOR BILLING UNDER SNF PPS ........................................................ 14
MDS ASSESSMENT SCHEDULE...................................................................................... 15
MDS 2.0 RUG-III CODES ............................................................................................ 16
RUG CODES (HIPPS).................................................................................................. 18
HIPPS MODIFIERS/ASSESSMENT TYPE INDICATORS ................................................... 19
PART B BENEFITS ......................................................................................................... 21
PART B SNF CHARGE STRUCTURE REVENUE CODES ................................................... 23
SNF BILLING ................................................................................................................ 24
HCPCS CODING REQUIREMENTS ................................................................................. 24
BILLING THERAPY SERVICES ........................................................................................ 25
UNDER PART B IN A SNF .............................................................................................. 25
PART B THERAPY BILLING ............................................................................................ 26
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Medicare SNF Billing
EXTENDED CARE BENEFIT IN A SNF
Medicare beneficiaries may be eligible for up to 100 days of Part coverage in a skilled
nursing facility (SNF) if they meet both technical and medical qualifications for
coverage. The benefit is dependent upon the resident’s need for skilled care. Medicare
does not have a long term care custodial benefit.
Technical 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 (first
admission must be within 30 days of hospital discharge; next SNF
admission must be within 30 days of last covered day in 1st SNF)
enrolled in Medicare Part A and have benefit days available to use
Medical 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 the
hospital or for a condition which arose while the beneficiary was being treated
in the hospital
Benefit Periods
There is no limit to the number of benefit periods that a beneficiary may qualify for. You
may have more than one period of 100 days paid for in a SNF. In order to renew
benefits, the SNF resident must:
•
•
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be discharged to home for a period of at least 60 consecutive days (not
requiring 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 change
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Medicare SNF Billing
If these requirements are not met, the beneficiary remains in the same benefit period and may
potentially run out of Part A days (benefits exhaust). This beneficiary would be ineligible for
new coverage (technically) even if he experiences a new medical condition, had a new
hospitalization and return to the SNF meeting the medical requirements for coverage.
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Medicare SNF Billing
RE-ESTABLISHING BENEFITS IN A SKILLED NURSING FACILITY
6/1
7/15
30 Days
8/14
9/14
45 benefit days used
60 Days
Occurrence Code 22
or
Discharge
♦
If the resident is “cut” or discharged on 7/15, the balance of benefits available may be
used if the patient returns to the facility or is upgraded to “skilled level of care”
within 30 days (8/14).
NO NEW QUALIFYING HOSPITAL STAY IS REQUIRED
♦
If the resident returns to the facility or is upgraded to “skilled level of care at any
point between day 31 and day 60 (8/15 – 9/14), THAT PATIENT MUST HAVE A
QUALIFYING HOSPITAL STAY TO RESUME USING THE BALANCE OF REMAINING
BENEFITS.
♦
If the resident returns to the facility or is upgraded to “skilled level of care” at any
point after day 60 (9/15) that patient is eligible for a NEW BENEFIT PERIOD, BUT
MUST HAVE A QUALIFYING HOSPITAL STAY and meet all other criteria in order for
new benefits to apply.
NOTE:
Any unused benefit days from prior benefit period are “lost” if the patient enters a
new benefit period.
NOTE:
A change in “diagnosis” does not affect the benefit period. Regardless of having
a new diagnosis or readmission with the same diagnosis, application of benefits is
contingent upon the receipt of skilled care in a SNF for a condition which the
beneficiary was treated in a qualifying hospital stay.
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Medicare SNF Billing
RENEWAL OF BENEFITS IN A SKILLED NURSING FACILITY
EXAMPLE 1
SNF
HOSP
1/10/99
3/15/99
9/1/99
37 benefit days used
No pay discharge claim
Occurrence 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)
♦
No pay discharge bill 3/16/99 – 9/1/99
4
No special coding on discharge bill
♦
Benefit spells will not link
♦
New benefit period will be available
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Medicare SNF Billing
EXAMPLE 2
SNF
HOSP
1/10/99
4/18/99
9/1/99
100 benefit days used
No pay discharge claim
Benefits 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 inpatient
from date of service 4/19/99 – 9/1/99
♦
Spells of illness will link
♦
No new benefits will be available to patient
EXAMPLE 3
SNF
HOSP
1/10/99
4/18/99
6/1/99
9/1/99
100 benefit days used
No pay discharge claim
Benefits 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 days
beginning 6/1/99
♦
Spells of illness will not link
NEW BENEFITS WILL BE AVAILABLE TO PATIENT
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Medicare SNF Billing
UB-92 HCFA-1450 (FACSIMILE)
2
6 STATEMENT COVERS
5 FED. TAX NO.
12 PATIENT NAME
14
BIRTHDATE
32
CODE
4 TYPE
OF
BILL
3 PATIENT CONTROL NO.
PS
15
SEX
FROM
7 COV 8 N-C
D.
D.
THROUGH
9 C-I
D.
10 L-R 11
D.
13 PATIENT ADDRESS
ADMISSION
19
20
17 DATE 18 HR TYPE
SRC
16
MS
CONDITION CODES
21 D
HR
22
STAT 23 MEDICAL RECORD NO.
OCCURREN 33
OCCURREN 34
OCCURREN 35
OCCURREN 36
CE DATE
CODE CE DATE
CODE CE DATE
CODE CE DATE
CODE
38
24
OCCURRENCE SPAN
FROM
39
AMOUNT
26
27
28
29
30
37
A
B
C
THROUGH
VALUE CODE
CODE
25
31
40
CODE
VALUE
CODES
AMOUNT
41
CODE
VALUE
CODES
AMOUNT
a
b
c
d
42
REV.CD.
46
48 NON-COVERED
44 HCPCS/RATES 45
SERV.DATE SERV.UNITS 47 TOTAL CHARGES CHARGES
43 DESCRIPTION
50 PAYER
ASG
INFO
BEN
55 EST. AMOUNT
54 PRIOR PAYMENTS DUE
56
DUE FROM
Ø
57
59
PATIENT NO.
P.REL 60 CERT.-SSN-HIC.-ID
58 INSURED'S NAME
63 TREATMENT AUTHORIZATION
CODES
67
PRIN.DIAG.CD.
61 GROUP NAME
64
ESC 65 EMPLOYER NAME
62 INSURANCE GROUP NO.
66 EMPLOYER LOCATION
OTHER DIAG. CODES
68 CODE
69 CODE
80PRINCIPAL PROCEDURE
79 P.C.
52 REL 53
51 PROVIDER NO.
49
CODE
DATE
OTHER PROCEDURE
CODE
DATE
70 CODE
71 CODE
81OTHER PROCEDURE
CODE
DATE
OTHER PROCEDURE
CODE
DATE
72 CODE
78
73 CODE
OTHER PROCEDURE
CODE
75 CODE
76 ADM. DIAG. 77 E-CODE
82 ATTENDING PHYS. ID
DATE
OTHER PROCEDURE
CODE
74 CODE
83 OTHER PHYS. ID
DATE
84 REMARKS
OTHER PHY
85 PROVIDER REPRESENTATIVE
86 DATE
X
UB-92 HCFA-1450
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I CERTIFY THE CERTIFICATIONS ON THE REVERSE APPLY TO TYPE BILL AND ARE
MADE A PART
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Medicare SNF Billing
SKILLED NURSING FACILITY BILL TYPES
SNF Part A
Type
Span
Type of
Bill
Discharge Status
Non-covered
Admit – Discharge
210
Anything but 30
Covered
Admit – Discharge
211
Anything but 30
Covered or Non-covered
Admit – Interim
212
30
Covered or Non-covered
Interim – Interim
213
30
Covered or Non-covered
Interim – Discharge
214
Anything but 30
215 – Late Charge Bill Part A Services (not permitted under PPS)
217 – Adjustment Bill Part A Services
218 – Cancel Only Bill Part A Services
Ancillary Claims
22X – Part B Coverage Only
23X – Outpatient Claims
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Medicare SNF Billing
SNF CHARGE STRUCTURE REVENUE CODES
SNF PPS
0022
Room and Board
100 – All Inclusive
120 – Semi-Private (two beds)
13X – Semi-Private (three/four beds)
14X – Private Room
15X – Ward
16X – Other (sterile environment)
18X – Leave of Absence
(9000-9044 RUGS II Groups) for demonstration SNFs
Pharmacy
IV Therapy
Medical/Surgical Supplies
Oncology
Laboratory
Lab-Pathology
Radiology
Radiology-therapeutic
Nuclear Medicine
CT Scan
Operating Room Services
Blood Storage
Imaging Services
Respiratory Services
Physical Therapy
Occupational Therapy
Speech Therapy
Pulmonary Function
Audiology
Cardiology
EKG/ECG
EEG
Gastro-Intestinal
Other Diagnostic Services
Other Therapeutic Services
25X
26X
27X
28X
30X
31X
32X
33X
34X
35X
36X
39X
40X
41X
42X
43X
44X
46X
47X
48X
73X
74X
75X
92X
94X (Complex Medical Equipment)
***Ambulance
540 (SNF PPS Facilities)
See your UB-92 billing book for value of “X” in each category
6/98
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Medicare SNF Billing
CODING FOR SKILLED NURSING FACILITIES
SNF Discharge Status
Required on 21X Bill Types Only
Most often used:
01
02
03
05
20
30
50
51
Discharged to Home
Transferred to Hospital (PPS)
Transfer to Another SNF
Transferred to Non-PPS Hospital
Expired
Still Patient (Interim Bills – 212/213)
Discharge to Hospice (Home)
Discharge to Hospice (Medical Facility)
07
20
21
39
40
55
Non-Hospice Related
Demand Bill
Denial Notice for Other Insurer
Private Room Medically Necessary
Same Day Transfer
SNF Bed Not Available (When patient
admission is delayed by 30 days)
Medical Appropriateness (When therapy is
delayed)
SNF Readmission (Patient is readmitted within
30 days)
Facility Accepts Other Insurance Payment in
Full
PPV/Flu Administered (not required)
SNF Condition Codes
Most often used:
56
57
77
A6
(Plus codes for adjustments. See special listing)
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Medicare SNF Billing
SNF Occurrence Codes
Most often used:
11
21
22
24
35
44
45
A3
–
–
–
–
–
–
–
–
Onset of Illness (Most Recent)
UR Notice Received
Date Active Care Ended
Date Other Insurance Denied
Date Treatment Started for Physical Therapy
Date Treatment Started for Occupational Therapy
Date Treatment Started for Speech Therapy
Benefits Exhausted
SNF Occurrence Span Codes
Most often used:
70 –
71 –
74 –
74 –
78 –
M1 –
Qualifying Stay
Prior Inpatient Stay
Non-covered Level of Care
* While patient remains in SNF
* Show non-covered charges
Leave of Absence
* While patient is on temporary leave
* Do not show non-covered charges
Prior SNF Stay
Provider Liability on Non-covered Days
(Provider Reported)
SNF Value Codes
Most often used:
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09 – Medicare Co-insurance
46 – Grace Days
50 – Physical Therapy Sessions
* Cumulative sessions under Part B
51 – Occupational Therapy Sessions
* Cumulative sessions under Part B
52 – Speech Therapy Sessions
* Cumulative sessions under Part B
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Medicare SNF Billing
ONE DAY STAY
Reimbursement for One Day Stays
The Medicare Program does not normally reimburse a SNF for date of discharge,
death, or when the patient does not meet “midnight census” criteria.
In certain instances, a SNF can be reimbursed for a single day stay if that patient
dies or is transferred back to an acute care facility on the day of admission.
1. Coding for same day transfer:
♦
♦
♦
♦
Admit date
Patient status
Condition code
Covered days
NOTE:
=
=
=
=
Through date
02
40
1
SNF will be reimbursed for one day.
Intermediary does not take a SNF benefit day.
(Hospital benefit day will be applied).
2. Coding when admit and date of death are the same:
♦
♦
♦
Admit date
Patient status
Covered day
NOTE:
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=
=
=
Through date
20
1
SNF will be reimbursed for one day.
Intermediary does apply one SNF benefit day.
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Medicare SNF Billing
NO-PAY DISCHARGE BILLS
Medicare requires that skilled nursing facilities (SNFs) submit no pay discharge bills for
Part A residents who live in their facilities. Tracking is done by Medicare fiscal
intermediaries for the purpose of benefit period management. Because a Medicare
beneficiary may have more than one benefit period in a lifetime, it is necessary to account
for time lived in hospitals and skilled nursing homes.
A new benefit period is available to those individuals who are able to “break” or end a
benefit period by meeting one of the following criteria:
♦
60 consecutive days facility free
OR
♦
60 consecutive days living in a SNF at a custodial (non-skilled) level of care
The Medicare patient must then have a new qualifying hospital stay of at least 3 days (not
counting day of discharge) and be admitted to the SNF within 30 days of hospital
discharge. The beneficiary will again be eligible for up to 100 days of Part A SNF
coverage if he meets medical criteria.
SNFs are required to submit no-pay discharge claims for their residents who are entitled
to Part A according to Section 527 of the HCFA Intermediary Manual 12.
In the past, Empire Medicare Services has accepted a single no-pay discharge claim for
the period of time the beneficiary was not paid under Medicare Part A. With the start of
new billing requirements due to the RUGS III Demonstration Project and SNF PPS,
no-pay discharge claims MUST be split to reflect the changes in billing methodologies.
In addition to all other billing requirements, discharge claims must include:
For RUGS III demonstration providers
♦ a 9000 revenue code for accommodation charges (FL 42)
For SNF PPS providers
♦ A line of data using revenue code 0022 (FL 42)
♦ A HIPPS code (you may use AAA00) (FL 44)
♦ 0 in the units field (FL 46)
♦ 0 in the charges field (FL 47)
♦ Semi-private accommodation revenue code, rate, units, charges (non-covered)
Claims that do not include the special coding requirements will be returned to provider
for correction and resubmission.
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Medicare SNF Billing
RESUBMITTING COST AVOIDED CLAIMS
Providers may submit electronic adjustments for impatient claims that have been cost
avoided because records show that another insurance company is responsible for
payment of charges.
Adjustment claims would be submitted with Type of Bill (TOB) 217.
When submitting the electronic adjustment request, use one of the following Condition
Codes as appropriate.
D7
CHANGE TO MAKE MEDICARE SECONDARY
Condition code D7 must be submitted with a MSP Value Code and amount paid
by the other insurer must be present on the adjustment claim along with: name
and address of the other insurer and employment information (if any).
* See MSP section of training manual
D8
CHANGE TO MAKE MEDICARE PRIMARY
Condition code D8 must be accompanied by remarks indicating the reason that
Medicare should pay primary for the dates shown on the rejected claim.
Reasons might include:
♦
♦
♦
♦
Insurance policy holder has retired. Code claim with Occurrence Code 18
and date (beneficiary) or Occurrence Code 19 and date (spouse)
Policy does not cover SNF services. Code claim with Occurrence Code 24
and date other insurance denies
Benefits are exhausted under policy. Code claim with Occurrence Code 24
and date policy B/E.
MSP files have been updated to show Medicare is primary.
Adjustment requests which do not contain sufficient information in the remarks field to
demonstrate why Medicare is the primary will be returned to provider (RTP) with the
following reason code:
74002
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“Remarks on this adjustment requesting primary payment for an inpatient cost
avoided claim are either missing or not sufficient to make primary payment.”
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Medicare SNF Billing
MAJOR CHANGES FOR BILLING UNDER SNF PPS
♦
♦
A new revenue code (0022) has been created to indicate that a RUG-III
classification group identifier is being billed on a Part A claim.
4
Revenue code 0022 is to appear on 21X bills for each line of data indicating a
RUG-III group code is present
4
Each line of data using revenue code 0022 will be separately calculated for
reimbursement based on payment tables in FI pricer software
A HIPPS code has been created to indicate the 44 RUG-III groups will be utilized to
indicate the medical classification assigned by the grouper program that interprets
MDS 2.0 data
4
RUG-III codes are a 3 position alpha code
♦
For billing purposes, 19 two position modifiers have been developed and will be
added to the RUG-III classification group to indicate what assessment has been
completed during the billing period
♦
Medicare beneficiaries must be assessed on a specific schedule to determine covered
level of care for billing Part A claims
♦
Each Medicare assessment provides a specific number of covered days which can be
billed for the resident who is determined to be at a “skilled level of care”
♦
All services received by SNF resident must be coded on the Part A claim (no vendor
billing)
♦
Part B benefits (not covered under the extended care services, i.e., flu shots) are billed
separately
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Medicare SNF Billing
MDS ASSESSMENT SCHEDULE
Assessment
Reference
Date
Reason for Assessment
#AA8b
MDS 2.0 Users Guide
Number of Applicable
Medicare Days
1–5
1
Medicare 5 Day
Assessment
14
DAY 14
Comprehensive
11 – 14
7
Medicare 14 Day
DAY 30
Full
21 – 29
2
Medicare 30 Day
DAY 60
Full
50 – 59
3
Medicare 60 Day
DAY 90
Full
80 – 89
4
Medicare 90 Day
Medicare Assessment
Schedule
DAY 5
Comprehensive*
May be completed
OR
Days (1 - 5)
at day 14
16
Days (16 – 30)
30
Days (31 – 60)
30
Days (61 - 90)
10
Days (91 – 100)
*If a resident expires or transfers to another facility before day 8, an MDS is
prepared as completely as possible allowing for RUG classification and Medicare
payment.
*Full Assessment
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=
Entire MDS
*Comprehensive Assessment =
MDS + RAP’s
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Medicare SNF Billing
MDS 2.0 RUG-III CODES
ADL
INDEX
END
SPLITS
MDS
RUG-III
CODES
ULTRA HIGH
Rx 720 minutes a week minimum
At least 2 disciplines, 1st -5 days, 2nd - at least 3 days
16-18
9-15
4-8
NOT USED
NOT USED
NOT USED
RUC
RUB
RUA
VERY HIGH
Rx 500 minutes a week minimum
At least 1 discipline - 5 days
16-18
9-15
4-8
NOT USED
NOT USED
NOT USED
RVC
RVB
RVA
HIGH
Rx 325 minutes a week minimum
1 discipline 5 days a week
13-18
8-12
4-7
NOT USED
NOT USED
NOT USED
RHC
RHB
RHA
MEDIUM
Rx 150 minutes a week minimum
5 days across 1, 2 or 3 disciplines
15-18
8-14
4-7
NOT USED
NOT USED
NOT USED
RMC
RMB
RMA
LOW
Nrsg. Rehab 6 days in at least 2 activities and
Rehabilitation therapy Rx 3 days/ 45 minutes a week minimum
14-18
4-13
NOT USED
NOT USED
RLB
RLA
EXTENSIVE SERVICES - (if ADL <7, beneficiary classifies to Special Care)
IV feeding in the past 7 days (K5a)
IV medications in the past 14 days (P1ac)
Suctioning in the past 14 days (P1ai)
Tracheostomy care in the last 14 days (P1aj)
Ventilator/respirator in the last 14 days (P1al)
7-18
7-18
7-18
new grouping:
count of other categories
code into plus IV Meds +
Feed
SE3
SE2
SE1
17-18
15-16
NOT USED
NOT USED
SSC
SSB
7-14
NOT USED
SSA
17-18D
17-18
12-16D
12-16
4-11D
4-11
Signs of Depression
CC2
CC1
CB2
CB1
CA2
CA1
CATEGORY
REHABILITATION
SPECIAL CARE -- (if ADL <7 beneficiary classifies to Clinically Complex)
Multiple Sclerosis (I1w) and an ADL score of 10 or higher
Quadriplegia (Ilz) and an ADL score of 10 or higher
Cerebral Palsy (Ils) and an ADL score of 10 or higher
Respiratory therapy (P1bdA must = 7 days)
Ulcers, pressure or stasis; 2 or more of any stage (M1a,b,c,d) and treatment
(M5a, b,c,d,e,g,h)
Ulcers, pressure; any stage 3 or 4 (M2a) and treatment (M5a,b,c,d,e,g,h)
Radiation therapy (P1ah)
Surgical, Wounds (M4g) and treatment (M5f,g,h)
Open Lesions (M4c) and treatment (M5f,g,h)
Tube Fed (K5b) and Aphasia (I1r) and feeding accounts for at least 51 percent
of daily calories (K6a=3 or4) OR at least 26 percent of daily calories and
501cc daily intake (K6b=2,3,4 or 5)
Fever (J1h) with Dehydration (J1c), Pneumonia (Ie2),Vomiting (J1o) or
Weight loss (K 3a)
Fever (J1h) with Tube Feeding (K5b) and, as above, (K6a=3 or 4) &/or
(K6b = 2,3,4,or 5)
CLINICALLY COMPLEX -Burns (M4b)
Coma (B1) and Not awake (N1 = d) and completely ADL dependent (G1aa,
G1ba, G1ha, G1ia = 4 or 8)
Septicemia (I2g)
Pneumonia (I2e)
Foot / Wounds (M6b,c) and treatment (M6f)
Internal Bleed (J1j)
Dialysis (P1ab)
Tube Fed (K5b) and feeding accounts for: at least 51% of daily calories (K6a
= 3 or 4) OR 26 percent of daily calories and 501cc daily intake (K6b = 2, 3, 4
or 5)
Dehydration (J1c)
Oxygen therapy (P1ag)
Transfusions (P1ak)
Hemiplegia (I1v) and an ADL score or 10 or higher
Chemotherapy (P1aa)
No. Of Days in last 14 there were Physician Visits and order changes:
visits >=1 days and order changes >=4 days; or visits >=2 days and order
changes on >=2 days
Diabetes mellitus (I1a) and injections on 7 days (O3 >= 7) and order changes
>=2 days (P8 >= 2)
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Signs of Depression
Signs of Depression
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Medicare SNF Billing
IMPAIRED COGNITION
Score on MDS2.0 Cognitive Performance Scale >= 3
BEHAVIOR ONLY
Coded on MDS 2.0 items:
4+ days a week - wandering, physical or verbal abuse,
inappropriate behavior or resists care;
or hallucinations, or delusions checked
PHYSICAL FUNCTION REDUCED
No clinical conditions used
6-10
6-10
4-5
4-5
Nursing Rehabilitation*
not receiving
Nursing Rehabilitation
not receiving
IB2
IB1
IA2
IA1
6-10
6-10
4-5
4-5
Nursing Rehabilitation*
not receiving
Nursing Rehabilitation
not receiving
BB2
BB1
BA2
BA1
16-18
16-18
11-15
11-15
9-10
9-10
6-8
Nursing Rehabilitation*
not receiving
Nursing Rehabilitation
not receiving
Nursing Rehabilitation
not receiving
Nursing Rehabilitation
PE2
PE1
PD2
PD1
PC2
PC1
PB2
6-8
4-5
4-5
not receiving
Nursing Rehabilitation
not receiving
PB1
PA2
PA1
Default
*To qualify as receiving Nursing Rehabilitation, the rehabilitation must be in at least 2
activities, at least 6 days a week. As defined in the Long Term Care RAI Users Manual,
Version 2 activities include: Passive or Active ROM, amputation care, splint or brace
assistance and care, training in dressing or grooming, eating or swallowing, transfer, bed
mobility or walking, communication, scheduled toileting program or bladder retraining
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Medicare SNF Billing
RUG CODES (HIPPS)
RUG-III
Code
Payment Code
Rehab Groups
RUC
RUB
RUA
RVC
RVB
RVA
RHC
RHB
RHA
RMC
RMB
RMA
RLB
RLA
RUCXX
RUBXX
RUAXX
RVCXX
RVBXX
RVAXX
RHCXX
RHBXX
RHAXX
RMCXX
RMBXX
RMAXX
RLBXX
RLAXX
Extensive Care
SE3
SE2
SE1
SE3XX
SE2XX
SE1XX
Special Care
SSC
SSB
SSA
SSCXX
SSBXX
SSAXX
RUG-III
Code
Payment Code
Impaired Cognition
IB2
IB1
IA2
IA1
IB2XX
IB1XX
IA2XX
IA1XX
Behavior Only
BB2
BB1
BA2
BA1
BB2XX
BB1XX
BA2XX
BA1XX
Physical Function Reduced
PE2
PE1
PD2
PD1
PC2
PC1
PB2
PB1
PA2
PA1
PE2XX
PE1XX
PD2XX
PD1XX
PC2XX
PC1XX
PB2XX
PB1XX
PA2XX
PA11XX
Default
AAA00
Clinically Complex
CC2
CC1
CB2
CB1
CA2
CA1
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CC2XX
CC1XX
CB2XX
CB1XX
CA2XX
CA1XX
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Medicare SNF Billing
HIPPS MODIFIERS/ASSESSMENT TYPE INDICATORS
The HIPPS rate codes established by the Health Care Financing Administration (HCFA)
contains a 3-position alpha code to represent the RUG-III group medical classification of
the SNF resident plus a two position modifier to indicate which assessment was
completed. Together they consist of a 5-position HIPPS rate code for the purpose of
billing Part A covered days to the fiscal intermediary.
Each of the 19 modifiers refers to a specific assessment as explained in the following
table.
DESCRIPTION OF ASSESSMENT
MODIFIER CODE
Regular Assessments
Admission/Medicare 5 Day Comprehensive
Medicare 5 Day (Full)
Medicare 14 Day (Full or Comprehensive)
Medicare 30 Day (Full)
Medicare 60 Day (Full)
Medicare 90 Day (Full)
Quarterly Review–Medicare 90 Day (Full)
Significant Change in Status Assessment (SCSA)
Other Medicare Required Assessment (OMRA)
EXAMPLE:
11
01
07
02
03
04
54
38
08
A completed assessment for a SNF resident at day 30 who scores in the
RUG-III group SSC would have a HIPPS rate code of SSC02
Significant Correction of Prior Full Assessment
Significant Correction of Prior Full – 5 Day
Significant Correction of Prior Full – 14 Day
Significant Correction of Prior Full – 30 Day
Significant Correction of Prior Full – 60 Day
Significant Correction of Prior Full – 90 Day
EXAMPLE:
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41
47
42
43
44
Correction to above 30 day assessment example with a new RUG-III group
of SEC would have a HIPPS code of = SEC42
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DESCRIPTION OF ASSESSMENT
MODIFIER CODE
OMRA (Replacement)
Significant Change in Status Assessment (SCSA) (Replacement)
Significant Change in Status – Replacing
Significant Change in Status – Replacing
Significant Change in Status – Replacing
Significant Change in Status – Replacing
EXAMPLE:
14 Day
30 Day
60 Day
90 Day
37
32
33
34
If a resident experienced a change in medical status outside the regular
schedule, a SCSA is required. A SCSA the assessment completed within the
window of a regularly scheduled assessment it replaces that assessment. An
assessment done on day 27 would replace the 30-day assessment. The
HIPPS code for a resident who had a SCSA on day 28 would be SEC32.
Default Code:
A modifier is required with the use of the default code (AAA) when days are billed on
the UB-92 to the Medicare fiscal intermediary for services which are determined to be
“covered care”, but no assessment has been completed to classify the resident.
The default modifier is 00 . . . the HIPPS code would appear as AAA 00.
Updated 7/98
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Medicare SNF Billing
PART B BENEFITS
Who is eligible?
Payment can be made under Part B for medical and other health services for
inpatients in a SNF if:
1.
2.
3.
4.
Part A benefits are exhausted.
Part A benefits have been “cut.”
Patient is not enrolled in Part A.
Patient does not qualify for Part A coverage because the qualifying hospital
stay or transfer requirements were not met. (Patient was admitted from home
or admitted more than 30 days from qualifying stay).
What services are covered?
Part B benefits cover the following services:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Diagnostic x-rays, labs, tests (if SNF is hospital based).
X-rays, radium and radioactive isotope therapy, including materials and
services of technician (If SNF is hospital -based).
Surgical dressings, splints, casts, and other devices used for the reduction of
fractures and dislocations.
Prosthetic devices (other than dental).
Leg, arm, back, and neck braces, trusses and artificial legs, arms and eyes
(including adjustment and repair and replacement parts).
Physical, Occupational and speech therapy; or outpatient speech pathology
services.
Drugs-limited to PPV, flu, hepatitis B vaccines, oral cancer.
Hemophilia clotting factors.
Ambulance services.(submit to carrier)
Is there any coverage for “outpatient” SNF patients?
Yes, facilities that provide “walk-in” services at their SNF must have special
certification to treat outpatients.
In addition to the services mentioned above, the facility may provide and bill for
durable medical equipment if it is being provided for residents for use in their
homes.
NOTE:
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DME is billed to a special carrier; not to Medicare Part A.
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What revenue codes are used?
1.
For all inclusive ancillary billers Revenue Code – 24X (not valid after the start of
SNF PPS)
2.
Charge structure providers – see attached listing
How often should Part B services be billed?
Part B services should be billed on a monthly basis.
It is also allowable to bill quarterly (every 3 months) for all-inclusive providers.
Facilities must be very careful not to bill for periods of time in which a person is an
inpatient at an acute care hospital.
Part B ancillary claims will overlap inpatient claims and require adjustments to
correct.
Do we have to submit no-pay discharge bills if we are currently billing Part B benefits
only?
Yes, if you have ever billed Part A services for that patient, unless the last covered
day was coded with Occurrence code 22 (and date).
If a patient is within their 100 days of Part A benefits, do we also bill separately for the
Part B services?
No. The Part B services are included in the Part A reimbursement as long as the
patient is covered by the Part A benefits.
Part B benefits are only billable if the patient is not being covered under Part A.
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PART B SNF CHARGE STRUCTURE REVENUE CODES
DIAGNOSTIC X-RAYS, DIAGNOSTIC LABORATORY TESTS
30X
31X
32X
73X
74X
X-RAYS, RADIUM AND RADIOACTIVE ISOTOPE THERAPY
(including materials and services of technicians):
33X
34X
35X
MEDICAL AND SURGICAL SUPPLIES AND DEVICES
27X
PROSTHETIC DEVICES (other than dental) which replace all or part of an internal body
organ (including contiguous tissue) or all or part of the function of the permanently
inoperable or malfunctioning internal body organ, including replacement or repairs of
such items
274 *
42X*
43X*
44X*
PHYSICAL THERAPY
OCCUPATIONAL THERAPY
SPEECH THERAPY
SPECIALTY DRUGS
63X *
(PPV, FLU, HEP B, Immunosuppressive Drugs,
Hemophelia Clotting, Oral Cancer and anti-emetic drugs)
* Requires HPCPS
NOTE:
Lab and X-ray services may only be billed if you have certified units within your
facility
Until Part B Consolidated Billing is in effect, vendors may continue to bill directly for
their services to the carrier, and outpatient hospitals may bill services directly to the fiscal
intermediary.
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SNF BILLING
HCPCS CODING REQUIREMENTS
There are no HCPCS codes required on Medicare Part A claims.
In the realm of Part B billing, the requirements differ from inpatient billing (bill types
221 and 223) to outpatient billing (bill types 231 and 233).
For inpatient Part B billing, HCPCS codes are required on the following revenue codes:
274 – prosthetic/orthotic devices
420 – physical therapy *
430 – occupational therapy *
440 – speech therapy *
636 – drugs requiring detailed coding (PPV, flu, etc.)
771 – administration of a drug (used when 636 is billed)
* See Medicare News Update 1997-13, 1998-3, 1998-8
Effective for dates of service 7/1/98 HCPCS are required for therapy services on
Part B claims.
Effective with consolidated billing HCPCS will be required for all Part B services.
For outpatient Part B billing, HCPCS codes are required on the following revenue codes:
30X – all lab revenue codes
31X – all lab path revenue codes
320 – angiocardiography
323 – arteriography
274 – prosthetic/orthotic devices
636 – drugs requiring detailed coding (PPV, flu, etc.)
*See Medicare News Update 1996-1, 1996-13
Empire Medicare Services uses the St. Anthony's Level II Code Book for HCPCS
reference. If your billers select a code from their reference source, the validity of this
code can be checked using the OmniPro system. As is the case for diagnosis and revenue
codes, the OmniPro files will mirror our internal computer (Fiscal Intermediary Shared
System) and allow the biller to determine if the selected code will be accepted during
claims processing.
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BILLING THERAPY SERVICES
UNDER PART B IN A SNF
Physical, occupational and speech therapy are billable to the
Medicare fiscal intermediary (FI) if those services are
deemed to be “restorative” in nature by Medicare definition .
(See sections 220, 230.3, 542 of HIM-12)
Coding Requirements on the UB-92
ONSET OF ILLNESS
Occurrence Code 11 and date are required on Part B claims (they are not
required on Part A claims)
♦
♦
♦
If the Part B services are a continuation of therapy begun when the resident was first
admitted to the SNF (under Part A) the onset of illness date should reflect this.
If you do not know when the patient became ill or was injured (prior to admission)
you may use the SNF admission date for the Occurrence Code 11 date
If the Part B services are based on new injury or illness (not associated with a SNF
Part A admission), determine the date for Occurrence Code 11 based on when it was
noted in the patient's medical record that there has been a change in condition
requiring a restorative therapy program.
START DATE OF THERAPY
Occurrence Code 35 for physical therapy (PT), 44 for occupational therapy (OT), and
45 for speech therapy (ST) and date are required on Part B claims
♦
♦
If the Part B services are a continuation of therapy that began under Part A, the start
date for therapy would be when services were originally initiated under Part A.
If the Part B services are not associated with Part A services, the start date would be
the first services rendered after the patient was noted to have had a change in
condition requiring a restorative therapy program.
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Medicare SNF Billing
PART B THERAPY BILLING
Type of Bill
12X
13X
22X
23X
74X
75X
83X
Hospital inpatient ancillary
Hospital outpatient
SNF inpatient ancillary
SNF outpatient
ORF (Outpatient Rehabilitation Facility)
CORF (Comprehensive Outpatient Rehabilitation Facility)
Ambulatory surgery center
Billing Frequency
Repetitive services, such as PT, OT, and SLP, must be billed on a monthly basis and not on a
visit by visit basis.
Revenue Codes
420
430
440
Physical Therapy
Occupational Therapy
Speech-language Pathology
Primary Diagnosis
The primary diagnosis on the claim should be the diagnosis for which the patient is receiving
therapy services.
Occurrence Codes
Occurrence codes and associated dates define a significant event relating to the bill that may
affect processing. The following occurrence codes need to be used by all outpatient therapy
providers:
11
Date of onset of symptoms or illness which resulted in the patient’s current need for
the therapy. This code must be present on all physical, occupational and speech
therapy and CORF claims. It should not change during the episode of care unless the
patient has a new onset or exacerbation of an illness.
35
44
45
Date of initial PT service at provider
Date of initial OT service at provider
Date of initial SLP service at provider
ORFs also use the following occurrence codes:
17
Date OT treatment plan was established or last reviewed
29
Date PT treatment plan was established or last reviewed
30
Date SLP treatment plan was established or last reviewed
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CORFs use:
28
Date CORF treatment plan was established or last reviewed.
Value Codes
A value code is a code that relates amounts or values to specific data elements. Right
justify the whole number therapy visit amount to the left of the dollar/cents delimiter and
zero fill the cents field. The following value codes need to be used when billing therapy
services:
50
Number of PT visits from the start of care at the billing provider through the
current billing period
51
Number of OT visits from the start of care at the billing provider through the
current billing period
52
Number of SLP visits at the billing provider from the start of care through the
current billing period
EXAMPLE:
If the patient had 10 physical therapy visits in the first billing period, and20
physical therapy visits in the second billing period, the cumulative number of
physical therapy visits would be 30, this would be shown on the claim as
value code: 50
Health Care Financing Administration Common Procedure Coding System (HCPCS)
HCPCS codes are comprised of two levels. Level I contains the American Medical
Association's (AMA) Physicians' Current Procedural Terminology, Fourth Edition (CPT4) codes. These consist of all numeric codes. Level II contains the codes for physician
and non-physician services that are not included in CPT-4, e.g., ambulance, durable
medical equipment (DME), orthotics, and prosthetics. These are alpha/numeric codes
maintained jointly by the Health Care Financing Administration (HCFA), the Blue Cross
and Blue Shield Association (BCBSA), and the Health Insurance Association of America
(HIAA).
Providers rendering outpatient therapy services are required to submit claims with
HCPCS codes for dates of service on or after April 1, 1998. A grace period was allowed
until July 1, 1998 dates of service.
HCPCS codes for reporting outpatient physical, occupational, and speech therapy include
the following:
11040*
29105*
29260
29520*
90911
92598
96110
97012
11041*
29125*
29280
29530*
92506
95831
96111
97014
11042*
29126*
29345*
29540*
92507
95832
96115
97016
11043*
29130*
29365*
29550*
92508
95833
97001
97018
11044*
29131
29405*
29580*
92510
95834
97002
97020
29065*
29200*
29445*
29590*
92525
95851
97003
97022
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29075*
29220
29505*
64550
92526
95852
97004
97024
29085
29240
29515*
90901
92597
96105
97010
97026
97028
97036
97116
97150
97504***
97542
97770
97032
97039
97122**
97250**
97520
97545
97799
97033
97110
97124
97260**
97530
97546
G0169****
97034
97112
97139
97261**
97535
97703
V5362
97035
97113
97140
97265**
97537
97750
V5363
V5364
*These codes apply in all settings (bill types 12X, 22X, 23X, 74X, and 75X), except
hospital outpatient departments (bill types 13X and 83X). When delivered in hospital
outpatient settings, these services are not considered rehabilitation services and will not
be subject to the outpatient rehabilitation prospective payment system.
**1998 codes
***97504 should not be billed with 97116.
****G0169 is a new code for 2000.
These codes are the ones commonly utilized for outpatient rehabilitation services. Other
codes may be considered for payment if they are determined to be medically necessary
and are performed within the scope of practice of the therapist rendering the service.
Inclusion of a HCPCS code on this list does not assure coverage of a specific service.
Current coverage criteria still apply.
SELECTING HCPCS CODES
♦
Use the HCPCS code available that best describes the service rendered. There is not
a specific code available for every service, e.g., transfer training.
♦
Use unlisted HCPCS code only when absolutely necessary. A description of what is
being billed under the unlisted code must be put in the remarks field of the claim.
♦
HCPCS 97010, 97545, and 97546 are considered bundled charges and should not be
billed on Medicare claims.
EVALUATIONS
Evaluation HCPCS codes are inclusive of all procedures needed to evaluate the patient.
Initial evaluations can be billed when there is an expectation that the patient will require
covered therapy services.
Re-evaluations can be billed when the patient exhibits a demonstrable change in physical
functional ability necessitating revised treatment goals. Monthly reevaluations/assessments for a patient undergoing restorative SLP programs are
considered part of the treatment session and are not separately billable.
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UNITS OF SERVICE
Units of service are based on the number of times the procedure, as defined by the
HCPCS code, is performed.
♦
If the HCPCS code has a time definition, the units are based on a multiple of that time
factor. If more than one type of treatment is rendered that fit the same HCPCS, add all
of the time together for these treatments before figuring units.
♦
If the HCPCS code is not defined by a specific time frame, report one unit. To bill
more than one unit there must be a physician order/certification that the therapy
session should be rendered more than once daily. It must be reasonable and necessary
for the patient’s condition, and it must be reflected on the plan of treatment.
♦
Only whole numbers are used for units.
EXAMPLES
A.
A patient receives OT, HCPCS code 97530 for 60 minutes.
97530 is therapeutic activities, direct (one on one) patient contact by the
provider (use of dynamic activities to improve functional performance) each
15 minutes
REPORT:
430 Revenue Code
97530 HCPCS/Rate
4 Service Unit
B.
A patient receives ST, HCPCS code 92526 for 30 minutes.
92526 is treatment of swallowing dysfunction and/or oral function for feeding
REPORT:
440 Revenue Code
92526 HCPCS/Rate
1 Service Unit
C.
A patient receives PT, HCPCS code 97116 for 10 minutes.
97116 is therapeutic procedure, one or more areas, each 15 minute gait training
(includes stair climbing)
REPORT:
420 Revenue Code
97116 HCPCS/Rate
1 Service Unit
CPT codes and descriptions only are copyright 1998 American Medical Association (or such other date publication of CPT).
Line Item Dates of Service
Line item dates of service must be reported beginning with services provided on October
1, 1998.
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Discipline Specific Modifiers
Providers are required to report the following modifiers to distinguish the type of therapist
who performed the outpatient rehabilitation service. If the service was not delivered by a
therapist, then the discipline of the plan of treatment under which the service is delivered
should be reported. Modifiers are added to the end of the HCPCS code.
GN
GO
GP
EXAMPLE:
Speech-language pathologist or under SLP plan of treatment
Occupational therapist or under OT plan of treatment
Physical therapist or under PT plan of treatment
Therapeutic activities rendered by a Certified Occupational Therapist Assistant
(COTA) would be billed: 430
97530GO
Billing for Prior Dates of Service
DATES OF SERVICE 10/01/97 THROUGH 4/01/98 – HOSPITALS ONLY
Beginning with dates of 10/01/97, hospitals were required to use HCPCS codes for
outpatient physical and occupational therapy services. The following HCPCS codes were
used.
PT Evaluation
PT Re-evaluation
PT Treatments
OT Evaluation
OT Re-evaluation
OT Treatments
Q0103 for dates of service 10/01/97 – 12/31/97
97001 for dates of service beginning 1/1/98
Q0104 for dates of service 10/01/97 – 12/31/97
97002 for dates of service beginning 1/01/98
97010 – 97799
Q0109 for dates of service 10/01/97 – 12/31/97
97003 for dates of service beginning 1/1/98
Q0110 for dates of service 10/01/97 – 12/31/97
97004 for dates of service beginning 1/01/98
97010 – 97799
Units of service: Each HCPCS code was counted as one unit per day regardless
of the length of time performed or time element in the HCPCS description.
DATES OF SERVICE PRIOR TO 4/01/98 (PRIOR TO 10/01/97 FOR HOSPITALS)
Prior to 10/01/97 for hospitals and prior to 4/01/98 for SNF, ORF, and CORF, therapy was
billed on a visit basis. Under this system, each therapy visit was counted as one unit no
matter how many treatments were done during that visit. No HCPCS codes were required.
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Notes
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