Medicare Home DME MAC Jurisdiction C Home Health & Hospice Kentucky Part B Ohio Part B Kentucky & Ohio Part A
Skip Navigation

Send this page to a colleague

Skilled Nursing Facility FAQs

  1. Where can Skilled Nursing Facilities (SNFs) find current data concerning RUG weights and supporting data, the County/MSA/CBSA crosswalk file, and files for the Fiscal Year Software Releases?
  2. A patient has utilized 150 days of the Part A inpatient benefit and has also utilized 100 days of the skilled nursing facility (SNF) benefit of that benefit period. What does this mean?
  3. Are skilled nursing facilities required to bill Medicare for patients who have exhausted their Part A benefit?
  4. Can a provider bill a skilled nursing facility (SNF) or swing bed (SB) claim if the patient does not have a qualifying hospital stay?
  5. If a patient is admitted into inpatient or skilled nursing facility care within 60 days of the benefits, does Medicare adjust claims to assign benefits sequentially for dates of service?
  6. Where can I find the SNF consolidated billing list? I have researched this on the CMS website and went to the SNF consolidated billing section, but I was never able to locate an actual list that shows any codes.
  7. How can we avoid getting a denial that results in our claim being down coded?
  8. What type of clinical documentation should we send to support medical necessity?
  9. NEW: Can you provide clarification for the following? We provide outpatient services to SNF patients who are brought to our hospital and returned to the SNF via an ambulance. We send claims to Medicare for the patientís outpatient service and it was rejected stating that it overlapped the SNF services. When we billed the SNF, they responded that it is not part of SNF consolidated billing and they do not owe the hospital for the ambulance service.
  10. NEW: If a SNF patient goes to the outpatient hospital to have Part B services such as therapy, does the facility have to provide it under consolidated billing even though the patient is not under a Part A stay?

Where can SNFs find current data concerning RUG weights and supporting data, the County/MSA/CBSA crosswalk file, and files for the Fiscal Year Software Releases?

Go to the CMS Skilled Nursing Facilities (SNF) PC Pricer page to locate RUG rates. Select the SNF Main Frame Pricing Programs for the current fiscal year located under Downloads.

Back to the Top of the PageTop

A patient has utilized 150 days of the Part A inpatient benefit and has also utilized 100 days of the skilled nursing facility (SNF) benefit of that benefit period. What does this mean?

This means that the patient's inpatient benefits are exhausted. Per the CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 3, section 20:

"A patient having hospital insurance coverage is entitled to have payment made on his/her behalf for up to 90 days of covered inpatient hospital services in each benefit period. Also, the patient has a lifetime reserve of 60 additional days.' In addition, 'a patient having hospital insurance coverage is entitled to have payment made on his/her behalf for up to 100 days of covered inpatient extended care services (i.e. Skilled Nursing Facility (SNF) services) in each benefit period."

Back to the Top of the PageTop

Are skilled nursing facilities required to bill Medicare for patients who have exhausted their Part A benefit?

A skilled nursing facility (SNF) is required to submit a bill for a Medicare patient who 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. The Centers for Medicare & Medicaid Services (CMS) maintains a record of all inpatient services for each beneficiary, whether covered or not. A SNF must submit a benefits exhaust bill monthly for those patients that continue to receive skilled care and also when there is a change in the level of care, regardless of whether the benefits exhaust bill will be paid by Medicaid, a supplemental insurer or private payer.

A benefits exhaust claim that indicates a drop in level of care and the patient remains in the Medicare-certified area of the facility after the drop in level of care, would be submitted on a 212 or 213 bill type. The claim must include an Occurrence Code 22, with the date covered SNF level of care ended, and covered days and charges as if the Medicare patient had days available up until the date active care ended. The Patient Status Code is 30 - still patient. A 210 bill type should not be used for benefits exhaust claims submission.

You may refer to the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 6, section 40.8

Back to the Top of the PageTop

Can a provider bill a skilled nursing facility (SNF) or swing bed (SB) claim if the patient does not have a qualifying hospital stay?

SNF and swing bed SB providers must submit a qualifying hospital stay or an appropriate condition code for bypassing the qualifying stay, if applicable, on all claims including initial and subsequent claims that are submitted as covered. This is applicable for submitted bill types 21x (SNF inpatient) and 18x (SB inpatient). This also includes all covered claims (e.g., claims submitted for benefits exhaust denials). Covered claims submitted on 21x and 18x bill types that do not contain a qualifying hospital stay (using occurrence span code 70 with the qualifying hospital stay dates) or an appropriate condition code indicating why a qualifying hospital stay is not applicable will be denied.

Reference:

Back to the Top of the PageTop

If a patient is admitted into inpatient or skilled nursing facility care within 60 days of the benefits, does Medicare adjust claims to assign benefits sequentially for dates of service?
No. Medicare does not adjust claims to be sequential by dates of service to the providers. Benefit utilization is calculated as claims are received.

Back to the Top of the PageTop

Where can I find the SNF consolidated billing list? I have researched this on the CMS website and went to the SNF consolidated billing section, but I was never able to locate an actual list that shows any codes.

The SNF consolidated billing list is located on the CMS website. Access the individually excluded codes by completing the following steps:

  1. Go to the CMS SNF Consolidated Billing website.
  2. Select the appropriate year for the claim date of service (e.g., if the dates of service on your claim are for 020113 through 022813, you would select the 2013 A/B MAC update).
  3. Scroll to the bottom of the page and select the appropriate year for the SNF Consolidated Billing Annual Update.

Back to the Top of the PageTop

How can we avoid getting a denial that results in our claim being down coded?

To prevent denials as a result of down coding, be sure to:

  • Submit all documentation to support the Resource Utilization Group (RUG) code(s) billed.
  • The Minimum Data Set (MDS) assessment that established the RUG code billed must be supported by the clinical documentation.

If any portion of documentation to support the RUG code billed is missing from the records submitted, CGS may down code the RUG code.

Back to the Top of the PageTop

What type of clinical documentation should we send to support medical necessity?

The type of documentation that will help support medical necessity includes:

  • Physician orders for care and treatments
  • Medical diagnoses
  • Rehabilitation diagnosis (as appropriate)
  • Patient's past medical history
  • Progress notes that describe the beneficiary' response to treatments and his physical/mental status
  • Lab and other test results
  • Other documentation supporting the beneficiary' need for the skilled services being provided in the SNF

Back to the Top of the Page Top

Can you provide clarification for the following? We provide outpatient services to SNF patients who are brought to our hospital and returned to the SNF via an ambulance. We send claims to Medicare for the patient's outpatient service and it was rejected stating that it overlapped the SNF services. When we billed the SNF, they responded that it is not part of SNF consolidated billing and they do not owe the hospital for the ambulance service.

If a SNF resident is taken to the hospital for outpatient services other than for those excluded from consolidated billing and they are returned to the SNF, they retain their resident status. In that case the ambulance services remains subject to consolidated billing even if the purpose of the trip is to receive a service that is itself excluded from CB."

CMS Article SE0433 "Skilled Nursing Facility Consolidated Billing As It Relates to Ambulance Services" states: "Medicare regulations specify the receipt of certain exceptionally intensive or emergency services furnished during an outpatient visit to a hospital as one circumstance that ends a beneficiary's status as a SNF resident for consolidated billing purposes. Such outpatient hospital services are, themselves, excluded from the CB requirement on the basis that they are well beyond the typical scope of the SNF care plan. These services are the following:

  • Cardiac catheterization
  • Computerized axial tomography (CT) scans
  • Magnet resonance imaging (MRIs)
  • Ambulatory surgery involving the use of an operating room, including the insertion, removal or replacement of a percutaneous esophageal gastrostomy (PEG) tube in the hospital's gastrointestinal (GI) or endoscopy suite
  • Emergency services
  • Angiography
  • Lymphatic and Venous Procedures
  • Radiation therapy

In these cases, any associated ambulance trips will also be considered excluded from consolidated billing. Therefore, an ambulance trip from the SNF to the hospital for one of the above listed services should be billed separately under Part B. This also holds true for return trips from the hospital to the SNF as the patient will not be considered a SNF resident until they are returned to the SNF.

Back to the Top of the Page Top

If a SNF patient goes to the outpatient hospital to have Part B services such as therapy, does the facility have to provide it under consolidated billing even though the patient is not under a Part A stay?

The CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 6, section 10.3 ,states: "Physical therapy, occupational therapy, and/or speech-language pathology services (other than audiology services, which are considered diagnostic tests rather than therapy services) furnished to a SNF resident during a non-covered stay must still be billed by the SNF itself. "

Back to the Top of the Page Top

Last Updated: 04.04.14


An ISO 9001:2008 certified company

CGS Home | Site Maps | About Us | Disclaimer | Web Site Feedback | Contact Us

Centers for Medicare & Medicaid Services