January 9, 2015
SNF Updates, Benefits Exhaust and No-Payment Billing Reminders Ask-the-Contractor Teleconference
Wednesday, December 10, 2014
2015 Updates
- CMS MLN Matters Article MM 8828 – Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer Update FY 2015
- CMS MLN Matters Article MM 8943 – 2015 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update
- CMS MLN Connects Call – Certifying Patients for the Home Health Benefit, 12/16/2014 1:30-3:00 ET
SNF Top RTP Reason Codes
| Reason Code | Description |
|---|---|
38117 |
Effective with admissions on and after 4/1/95, all inpatient SNF and non-PPS bills must be processed in sequence. There is a prior claim for this admission pending in our system. Verify the admission ate and from date on this claim. If admission and from dates are correctly reported, please hold this claim until the pending bill shown on your remittance advice. Once the prior claim has shown on the remittance advice, you may resubmit the next claim. Please verify billing and if appropriate, correct. **Online providers: Press PF9 to store the claim. **Other providers: Return to the Intermediary. Preventing Delays in Payment for Reason Code 38117 To ensure that your claims don't RTP with reason code 38117, verify that the prior month's claim in a continuing stay has been submitted and finalized before submitting the next claim in the sequence.
|
38119 |
Effective with admission on and after 4/1/95, all inpatient SNF and non-PPS bills must be processed in sequence. We have not received the claim immediately preceding the dates of service on this bill.
Preventing Delays in Payment for Reason Code 38119 To ensure that your claims don't RTP with reason code 38119, verify that the prior month's claim in a continuing stay has been submitted and has finalized.
|
Benefits Exhaust and No-Payment Billing
CMS keeps a record of all inpatient services for each beneficiary, including those which are not covered by Medicare. The information from the claims is used for national healthcare planning and also helps CMS keep track of each beneficiary's benefit period.
A SNF is required to submit a claim to Medicare when the beneficiary:
- Has exhausted his/her 100 covered days under the Medicare SNF benefit (benefits exhaust); or
- No longer needs a Medicare covered level of care (no-payment bills).
Benefits Exhaust Situations
A SNF must submit a benefits exhaust claim on a monthly basis for their patients who continue to receive skilled care and when there is a change in the patient's level of care.
These claims are required so that the beneficiary's applicable benefit period posted in the Common Working File (CWF) can be extended. When a change in the level of care occurs after that beneficiary has exhausted his/her covered days of care, the SNF must submit a claim in the next billing cycle showing that active care for that beneficiary has ended.
There are two types of benefits exhaust claims:
- Full benefits exhaust claims: No benefit days remain for the from/through date of the claim.
- Partial benefits exhaust claims: Only one or just a few days remain for the from/through date of the claim.
Billing for Benefits Exhaust
Full or partial benefits exhaust claim:
- Bill Type – Use TOB 211, 212, 213 or 214 for SNF claims. Use 181, 182, 183 or 184 for Swing Bed claims. Note: Do not use TOBs 210 or 180 for benefits exhaust claim.
- Occurrence Span Code (OSC) 70 with the qualifying hospital stay dates.
- Covered Days and Charges - Submit all covered days and charges as if the beneficiary still had days available.
- Value Code 09 (First Year Coinsurance Amount) or Value Code 11 (Second Year Coinsurance Amount) - 1.00 (if applicable, the FISS will assign the correct insurance amount)
Benefits exhaust claim with a drop in the level of care within the month. The patient remains in the Medicare-certified area of the facility after the drop in level of care:
- Bill Type – Use TOB 212 or 213 for SNF and 182 or 183 for swing bed. Note: Do not use TOBs 210 or 180 for benefits exhaust claim.
- Occurrence Code 22 (date active care ended) – Include the date the patient's active care ended. It should match the statement covers through date on the claim.
- Covered Days and Charges – Submit all covered days and charges as if the beneficiary still had days available up until the date that active care ended.
- Value Code 09 (First Year Coinsurance Amount) or Value Code 11 (Second Year Coinsurance Amount)- 1.00 (if applicable, the FISS will assign the correct insurance amount)
- Patient Status Code – 30 (still a patient)
Benefits exhaust claim with a patient discharge:
- Bill Type – Use TOB 211 or 214 for SNF and 181 or 184 for Swing Bed. Note: Do not use TOBs 210 or 180 for benefits exhaust claim.
- Covered Days and Charges - Submit all covered days and charges as if the beneficiary had days available until the date of discharge.
- Value Code 09 (First Year Coinsurance Amount) or Value Code 11 (Second Year Coinsurance Amount) - 1.00 (if applicable, the FISS will assign the correct insurance amount)
- Patient Status Code: Use appropriate code other than patient status 30 (still a patient).
No-Payment Claims
No-payment claims are submitted for beneficiaries who previously dropped to non-skilled care and who continue to reside in the Medicare-certified area of the facility. No-payment billing starts the day following the date that active care ended. There are two options for billing:
Patient previously dropped to non-skilled care within the month. The provider needs a denial notice for other insurers.
- Bill Type – 210 (no-payment TOB)
- Statement Covers From and Through Dates – Days the provider is billing, which may be submitted as frequently as monthly, in order to receive a denial for other insurers.
- Days and Charges – Include non-covered days and charges beginning with the day after active care ended.
- Condition Code 21 – Indicates provider is billing for a denial
- Patient Status Code – Use appropriate code
Patient previously dropped to non-skilled care. In these cases, the provider must only submit the final discharge bill, which may span multiple months.
- Bill Type – 210 (no-payment TOB)
- Statement Covers From and Through Dates – Days billed by the provider, which may span multiple months, in order to show final discharge of the patient.
- Condition Code 21 - Indicates provider is billing for a denial
- Patient Status Code – Use appropriate code
Reference: CMS MLN Article MM4292, Benefits Exhaust and No-Payment Billing for Medicare Fiscal Intermediaries (FIs) and Skilled Nursing Facilities (SNFs)
Questions and Answers
- 1. We submitted our claim for October and it got a RTP reason code of 38119. Our September claim had already processed. We called Customer Service and were told that the September claim had been canceled. Why was the September claim canceled?
-
Upon review, it was discovered that the claim for September included a day that was submitted as a full day and should have been submitted as a coinsurance day. You should make the correction and resubmit the claim. We apologize for the misinformation on this.
- 2. We are getting a message that says "units do not match" on a claim for a patient who was at our facility for 3 days not including a leave of absence day. Why is this?
-
Upon reviewing the claim, we found that the claim received reason code 15202.
When this reason code is received on an inpatient Skilled Nursing Facility (SNF) claim (Type of bill) 21X), it typically means that a discrepancy exists between the covered days billed and the covered accommodation units billed.
The following are some examples of billing issues associated with reason code 15202:
- Non-covered
- Revenue code 018x (leave of absence) is not counted as covered
- A line level edit has assigned on the accommodation unit/revenue code line
- Days billed do not match accommodation unit/revenue code and charges are billed as non-covered
- Non-covered days are present and only accommodation unit/revenue code lines have been billed as non-covered. Ancillary charges for non-covered days should be billed as non-covered
Here are some tips to avoid reason code 15202 and ensure your claim is submitted correctly:
- Verify the covered days and that the accommodation unit/revenue code lines are billed appropriately.
- All revenue code 0022 units must match the accommodation units/revenue codes.
- If reporting a leave of absence with occurrence span code (OSC) 74; report revenue code 0180 days without charges. The OSC 74 dates must reflect the days the patient was absent at midnight from the SNF and match the 0180 unit count.
- When billing patient status code 30; count the day/units as covered.
- When reporting a lower level of care (occurrence code 22); count the day/units. The date the patient moves to a lower level of care is the "Through" date of that claim.
If a correction is required to the accommodation units/revenue code line, delete the entire line and re-key the line before resubmitting the claim. This will ensure any prior reason code assigned on this line is removed.
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