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EMPIRE MEDICARE SERVICES HCFA Medicare Part A and Part B Contracted Agent Medicare Part A www.hcfa.gov Introduction to Skilled Nursing Facility Billing

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EMPIRE MEDICARE SERVICESHCFA Medicare Part A and Part B Contracted Agent

Medicare Part A

www.hcfa.gov

Introduction to Skilled Nursing Facility Billing

Empire Medicare Services Orientation 2000

Medicare BillingSkilled 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

Medicare SNF Billing

Empire Medicare ServicesOrientation 2000 Page 1

EXTENDED CARE BENEFIT IN A SNF

Medicare 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. The benefit is dependent upon the resident’s need for skilled care. Medicaredoes 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 SNFadmission 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 treatedin the hospital

Benefit Periods

There is no limit to the number of benefit periods that a beneficiary may qualify for. 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 change

Medicare SNF Billing

Empire Medicare ServicesOrientation 2000 Page 2

If 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 coverage.

Medicare SNF Billing

Empire Medicare ServicesOrientation 2000 Page 3

RE-ESTABLISHING BENEFITS IN A SKILLED NURSING FACILITY

6/1 7/15 30 Days 8/14 9/1445 benefit days used

60 DaysOccurrence Code 22

orDischarge

♦ 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).

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 apply.

NOTE: Any unused benefit days from prior benefit period are “lost” if the patient enters anew benefit period.

NOTE: 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 stay.

Medicare SNF Billing

Empire Medicare ServicesOrientation 2000 Page 4

RENEWAL OF BENEFITS IN A SKILLED NURSING FACILITY

EXAMPLE 1

SNF HOSP

1/10/99 3/15/99 9/1/9937 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

Medicare SNF Billing

Empire Medicare ServicesOrientation 2000 Page 5

EXAMPLE 2

SNF HOSP

1/10/99 4/18/99 9/1/99100 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 inpatientfrom 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 9/1/99100 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 daysbeginning 6/1/99

♦ Spells of illness will not link

NEW BENEFITS WILL BE AVAILABLE TO PATIENT

Medicare SNF Billing

Empire Medicare ServicesOrientation 2000 Page 6

UB-92 HCFA-1450 (FACSIMILE)

PS

23 PATIENT CONTROL NO.

4 TYPE OFBILL

6 STATEMENT COVERS 115 FED. TAX NO. FROM THROUGH

7 COVD.

8 N-CD.

9 C-ID.

10 L-RD.

12 PATIENT NAME 13 PATIENT ADDRESS

ADMISSION CONDITION CODES 3114BIRTHDATE

15SEX

16MS

17 DATE 18 HR 19TYPE

20SRC

21 DHR

22STAT 23 MEDICAL RECORD NO. 24 25 26 27 28 29 30

32 OCCURRENCE

33 OCCURRENCE

34 OCCURRENCE

35 OCCURRENCE

36 OCCURRENCE SPAN 37CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH A

BC

38 39 VALUE CODE 40 VALUECODES

41 VALUECODESCODE AMOUNT CODE AMOUNT CODE AMOUNT

abcd

42REV.CD. 43 DESCRIPTION 44 HCPCS/RATES 45

SERV.DATE46SERV.UNITS 47 TOTAL CHARGES 48 NON-COVERED

CHARGES 49

52 REL 53ASG50 PAYER 51 PROVIDER NO. INFO BEN 54 PRIOR PAYMENTS

55 EST. AMOUNTDUE 56

57DUE FROM

PATIENT Ø58 INSURED'S NAME 59P.REL 60 CERT.-SSN-HIC.-ID NO. 61 GROUP NAME 62 INSURANCE GROUP NO.

63 TREATMENT AUTHORIZATIONCODES

64ESC 65 EMPLOYER NAME 66 EMPLOYER LOCATION

OTHER DIAG. CODES 7867PRIN.DIAG.CD. 68 CODE 69 CODE 70 CODE 71 CODE 72 CODE 73 CODE 74 CODE 75 CODE 76 ADM. DIAG. 77 E-CODE

80PRINCIPAL PROCEDURE 81OTHER PROCEDURE OTHER PROCEDURE 82 ATTENDING PHYS. ID79 P.C. CODE DATE CODE DATE CODE DATE

OTHER PROCEDURE OTHER PROCEDURE OTHER PROCEDURE 83 OTHER PHYS. IDCODE DATE CODE DATE CODE DATE

84 REMARKS OTHER PHY

85 PROVIDER REPRESENTATIVE 86 DATE

X UB-92 HCFA-1450 I CERTIFY THE CERTIFICATIONS ON THE REVERSE APPLY TO TYPE BILL AND ARE

MADE A PART

Medicare SNF Billing

Empire Medicare ServicesOrientation 2000 Page 7

SKILLED NURSING FACILITY BILL TYPES

SNF Part A

Type Span Type ofBill

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

Medicare SNF Billing

Empire Medicare ServicesOrientation 2000 Page 8

SNF CHARGE STRUCTURE REVENUE CODES

SNF PPS 0022

Room and Board 100 – 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) for demonstration SNFs

Pharmacy 25XIV Therapy 26XMedical/Surgical Supplies 27XOncology 28XLaboratory 30XLab-Pathology 31XRadiology 32XRadiology-therapeutic 33XNuclear Medicine 34XCT Scan 35XOperating Room Services 36XBlood Storage 39XImaging Services 40XRespiratory Services 41XPhysical Therapy 42XOccupational Therapy 43XSpeech Therapy 44XPulmonary Function 46XAudiology 47XCardiology 48XEKG/ECG 73XEEG 74XGastro-Intestinal 75XOther Diagnostic Services 92XOther Therapeutic Services 94X (Complex Medical Equipment)

***Ambulance 540 (SNF PPS Facilities)

See your UB-92 billing book for value of “X” in each category

6/98

Medicare SNF Billing

Empire Medicare ServicesOrientation 2000 Page 9

CODING FOR SKILLED NURSING FACILITIES

SNF Discharge Status

Required on 21X Bill Types Only

Most 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 Codes

Most often used: 07 Non-Hospice Related20 Demand Bill21 Denial Notice for Other Insurer39 Private Room Medically Necessary40 Same Day Transfer55 SNF Bed Not Available (When patient

admission is delayed by 30 days)56 Medical Appropriateness (When therapy is

delayed)57 SNF Readmission (Patient is readmitted within

30 days)77 Facility Accepts Other Insurance Payment in

FullA6 PPV/Flu Administered (not required)

(Plus codes for adjustments. See special listing)

Medicare SNF Billing

Empire Medicare ServicesOrientation 2000 Page 10

SNF Occurrence Codes

Most 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 Exhausted

SNF Occurrence Span Codes

Most often used: 70 – Qualifying Stay71 – Prior Inpatient Stay74 – Non-covered Level of Care

* While patient remains in SNF * Show non-covered charges

74 – Leave of Absence * While patient is on temporary leave * Do not show non-covered charges

78 – Prior SNF Stay M1 – Provider Liability on Non-covered Days

(Provider Reported)

SNF Value Codes

Most 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 B

Medicare SNF Billing

Empire Medicare ServicesOrientation 2000 Page 11

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 patientdies or is transferred back to an acute care facility on the day of admission.

1. Coding for same day transfer:

♦ Admit date = Through date♦ Patient status = 02♦ Condition code = 40♦ Covered days = 1

NOTE: 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 = Through date♦ Patient status = 20♦ Covered day = 1

NOTE: SNF will be reimbursed for one day.Intermediary does apply one SNF benefit day.

Medicare SNF Billing

Empire Medicare ServicesOrientation 2000 Page 12

NO-PAY DISCHARGE BILLS

Medicare requires that skilled nursing facilities (SNFs) submit no pay discharge bills forPart A residents who live in their facilities. Tracking is done by Medicare fiscalintermediaries for the purpose of benefit period management. Because a Medicarebeneficiary may have more than one benefit period in a lifetime, it is necessary to accountfor time lived in hospitals and skilled nursing homes.

A new benefit period is available to those individuals who are able to “break” or end abenefit period by meeting one of the following criteria:

♦ 60 consecutive days facility freeOR

♦ 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 (notcounting day of discharge) and be admitted to the SNF within 30 days of hospitaldischarge. The beneficiary will again be eligible for up to 100 days of Part A SNFcoverage if he meets medical criteria.

SNFs are required to submit no-pay discharge claims for their residents who are entitledto 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 forthe period of time the beneficiary was not paid under Medicare Part A. With the start ofnew 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 providerfor correction and resubmission.

Medicare SNF Billing

Empire Medicare ServicesOrientation 2000 Page 13

RESUBMITTING COST AVOIDED CLAIMS

Providers may submit electronic adjustments for impatient claims that have been costavoided because records show that another insurance company is responsible forpayment of charges.

Adjustment claims would be submitted with Type of Bill (TOB) 217.

When submitting the electronic adjustment request, use one of the following ConditionCodes as appropriate.

D7 CHANGE TO MAKE MEDICARE SECONDARY

Condition code D7 must be submitted with a MSP Value Code and amount paidby the other insurer must be present on the adjustment claim along with: nameand 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 thatMedicare should pay primary for the dates shown on the rejected claim.

Reasons might include:

♦ Insurance policy holder has retired. Code claim with Occurrence Code 18and date (beneficiary) or Occurrence Code 19 and date (spouse)

♦ Policy does not cover SNF services. Code claim with Occurrence Code 24and date other insurance denies

♦ Benefits are exhausted under policy. Code claim with Occurrence Code 24and 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 todemonstrate why Medicare is the primary will be returned to provider (RTP) with thefollowing reason code:

74002 “Remarks on this adjustment requesting primary payment for an inpatient costavoided claim are either missing or not sufficient to make primary payment.”

Medicare SNF Billing

Empire Medicare ServicesOrientation 2000 Page 14

MAJOR CHANGES FOR BILLING UNDER SNF PPS

♦ A new revenue code (0022) has been created to indicate that a RUG-IIIclassification 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 aRUG-III group code is present

4 Each line of data using revenue code 0022 will be separately calculated forreimbursement 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 interpretsMDS 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 beencompleted during the billing period

♦ Medicare beneficiaries must be assessed on a specific schedule to determine coveredlevel 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 billedseparately

Medicare SNF Billing

Empire Medicare ServicesOrientation 2000 Page 15

MDS ASSESSMENT SCHEDULE

Medicare AssessmentSchedule

AssessmentReference

Date

Reason for Assessment#AA8b

MDS 2.0 Users Guide

Number of ApplicableMedicare Days

DAY 5Comprehensive*

May be completedOR

at day 14

1 – 51

Medicare 5 DayAssessment

14

Days (1 - 5)

DAY 14Comprehensive 11 – 14 7

Medicare 14 Day16

Days (16 – 30)

DAY 30Full 21 – 29 2

Medicare 30 Day30

Days (31 – 60)

DAY 60Full 50 – 59 3

Medicare 60 Day30

Days (61 - 90)

DAY 90Full 80 – 89 4

Medicare 90 Day10

Days (91 – 100)

*If a resident expires or transfers to another facility before day 8, an MDS isprepared as completely as possible allowing for RUG classification and Medicarepayment.

*Full Assessment = Entire MDS*Comprehensive Assessment = MDS + RAP’s

Medicare SNF Billing

Empire Medicare ServicesOrientation 2000 Page 16

MDS 2.0 RUG-III CODES

CATEGORY ADLINDEX

ENDSPLITS

MDSRUG-IIICODES

REHABILITATION

ULTRA HIGHRx 720 minutes a week minimumAt least 2 disciplines, 1st -5 days, 2nd - at least 3 days

16-189-154-8

NOT USEDNOT USEDNOT USED

RUCRUBRUA

VERY HIGHRx 500 minutes a week minimumAt least 1 discipline - 5 days

16-189-154-8

NOT USEDNOT USEDNOT USED

RVCRVBRVA

HIGHRx 325 minutes a week minimum1 discipline 5 days a week

13-188-124-7

NOT USEDNOT USEDNOT USED

RHCRHBRHA

MEDIUMRx 150 minutes a week minimum5 days across 1, 2 or 3 disciplines

15-188-144-7

NOT USEDNOT USEDNOT USED

RMCRMBRMA

LOW Nrsg. Rehab 6 days in at least 2 activities andRehabilitation therapy Rx 3 days/ 45 minutes a week minimum

14-184-13

NOT USEDNOT USED

RLBRLA

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)

7-187-187-18

new grouping:count of other categoriescode into plus IV Meds +

Feed

SE3SE2SE1

SPECIAL CARE -- (if ADL <7 beneficiary classifies to Clinically Complex)Multiple Sclerosis (I1w) and an ADL score of 10 or higherQuadriplegia (Ilz) and an ADL score of 10 or higherCerebral Palsy (Ils) and an ADL score of 10 or higherRespiratory 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 percentof daily calories (K6a=3 or4) OR at least 26 percent of daily calories and501cc daily intake (K6b=2,3,4 or 5)Fever (J1h) with Dehydration (J1c), Pneumonia (Ie2),Vomiting (J1o) orWeight loss (K 3a)Fever (J1h) with Tube Feeding (K5b) and, as above, (K6a=3 or 4) &/or(K6b = 2,3,4,or 5)

17-1815-16

7-14

NOT USEDNOT USED

NOT USED

SSCSSB

SSA

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, 4or 5)Dehydration (J1c)Oxygen therapy (P1ag)Transfusions (P1ak)Hemiplegia (I1v) and an ADL score or 10 or higherChemotherapy (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 orderchanges on >=2 daysDiabetes mellitus (I1a) and injections on 7 days (O3 >= 7) and order changes>=2 days (P8 >= 2)

17-18D17-18

12-16D12-164-11D4-11

Signs of Depression

Signs of Depression

Signs of Depression

CC2CC1CB2CB1CA2CA1

Medicare SNF Billing

Empire Medicare ServicesOrientation 2000 Page 17

IMPAIRED COGNITIONScore on MDS2.0 Cognitive Performance Scale >= 3 6-10

6-104-54-5

Nursing Rehabilitation*not receiving

Nursing Rehabilitationnot receiving

IB2IB1IA2IA1

BEHAVIOR ONLYCoded on MDS 2.0 items:4+ days a week - wandering, physical or verbal abuse,inappropriate behavior or resists care;or hallucinations, or delusions checked

6-106-104-54-5

Nursing Rehabilitation*not receiving

Nursing Rehabilitationnot receiving

BB2BB1BA2BA1

PHYSICAL FUNCTION REDUCED

No clinical conditions used

16-1816-1811-1511-159-109-106-8

6-84-54-5

Nursing Rehabilitation*not receiving

Nursing Rehabilitationnot receiving

Nursing Rehabilitationnot receiving

Nursing Rehabilitation

not receivingNursing Rehabilitation

not receiving

PE2PE1PD2PD1PC2PC1PB2

PB1PA2PA1

Default

*To qualify as receiving Nursing Rehabilitation, the rehabilitation must be in at least 2activities, 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 braceassistance and care, training in dressing or grooming, eating or swallowing, transfer, bedmobility or walking, communication, scheduled toileting program or bladder retraining

Medicare SNF Billing

Empire Medicare ServicesOrientation 2000 Page 18

RUG CODES (HIPPS)

RUG-IIICode

Payment Code

Rehab Groups

RUC RUCXXRUB RUBXXRUA RUAXXRVC RVCXXRVB RVBXXRVA RVAXXRHC RHCXXRHB RHBXXRHA RHAXXRMC RMCXXRMB RMBXXRMA RMAXXRLB RLBXXRLA RLAXX

Extensive Care

SE3 SE3XX SE2 SE2XX SE1 SE1XX

Special Care

SSC SSCXX SSB SSBXX SSA SSAXX

Clinically Complex

CC2 CC2XX CC1 CC1XX CB2 CB2XX CB1 CB1XX CA2 CA2XX CA1 CA1XX

RUG-IIICode

Payment Code

Impaired Cognition

IB2 IB2XX IB1 IB1XX IA2 IA2XX IA1 IA1XX

Behavior Only

BB2 BB2XX BB1 BB1XX BA2 BA2XX BA1 BA1XX

Physical Function Reduced

PE2 PE2XX PE1 PE1XX PD2 PD2XX PD1 PD1XX PC2 PC2XX PC1 PC1XX PB2 PB2XX PB1 PB1XX PA2 PA2XX PA1 PA11XX

Default AAA00

Medicare SNF Billing

Empire Medicare ServicesOrientation 2000 Page 19

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 ofthe SNF resident plus a two position modifier to indicate which assessment wascompleted. Together they consist of a 5-position HIPPS rate code for the purpose ofbilling Part A covered days to the fiscal intermediary.

Each of the 19 modifiers refers to a specific assessment as explained in the followingtable.

DESCRIPTION OF ASSESSMENT MODIFIER CODE

Regular Assessments

Admission/Medicare 5 Day Comprehensive 11 Medicare 5 Day (Full) 01 Medicare 14 Day (Full or Comprehensive) 07 Medicare 30 Day (Full) 02 Medicare 60 Day (Full) 03 Medicare 90 Day (Full) 04 Quarterly Review–Medicare 90 Day (Full) 54 Significant Change in Status Assessment (SCSA) 38 Other Medicare Required Assessment (OMRA) 08

EXAMPLE: 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 41Significant Correction of Prior Full – 14 Day 47Significant Correction of Prior Full – 30 Day 42Significant Correction of Prior Full – 60 Day 43Significant Correction of Prior Full – 90 Day 44

EXAMPLE: Correction to above 30 day assessment example with a new RUG-III groupof SEC would have a HIPPS code of = SEC42

Medicare SNF Billing

Empire Medicare ServicesOrientation 2000 Page 20

DESCRIPTION OF ASSESSMENT MODIFIER CODE

OMRA (Replacement)Significant Change in Status Assessment (SCSA) (Replacement)

Significant Change in Status – Replacing 14 Day 37Significant Change in Status – Replacing 30 Day 32Significant Change in Status – Replacing 60 Day 33Significant Change in Status – Replacing 90 Day 34

EXAMPLE: If a resident experienced a change in medical status outside the regularschedule, a SCSA is required. A SCSA the assessment completed within thewindow of a regularly scheduled assessment it replaces that assessment. Anassessment done on day 27 would replace the 30-day assessment. TheHIPPS 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 onthe 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

Medicare SNF Billing

Empire Medicare ServicesOrientation 2000 Page 21

PART B BENEFITS

Who is eligible?

Payment can be made under Part B for medical and other health services forinpatients in a SNF if:

1. Part A benefits are exhausted. 2. Part A benefits have been “cut.” 3. Patient is not enrolled in Part A. 4. Patient does not qualify for Part A coverage because the qualifying hospital

stay or transfer requirements were not met. (Patient was admitted from homeor admitted more than 30 days from qualifying stay).

What services are covered?

Part B benefits cover the following services:

1. Diagnostic x-rays, labs, tests (if SNF is hospital based). 2. X-rays, radium and radioactive isotope therapy, including materials and

services of technician (If SNF is hospital -based). 3. Surgical dressings, splints, casts, and other devices used for the reduction of

fractures and dislocations. 4. Prosthetic devices (other than dental). 5. Leg, arm, back, and neck braces, trusses and artificial legs, arms and eyes

(including adjustment and repair and replacement parts). 6. Physical, Occupational and speech therapy; or outpatient speech pathology

services. 7. Drugs-limited to PPV, flu, hepatitis B vaccines, oral cancer. 8. Hemophilia clotting factors. 9. 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 specialcertification to treat outpatients.

In addition to the services mentioned above, the facility may provide and bill fordurable medical equipment if it is being provided for residents for use in theirhomes.

NOTE: 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 ofSNF 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 aninpatient at an acute care hospital.

Part B ancillary claims will overlap inpatient claims and require adjustments tocorrect.

Do we have to submit no-pay discharge bills if we are currently billing Part B benefitsonly?

Yes, if you have ever billed Part A services for that patient, unless the last coveredday 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 thePart B services?

No. The Part B services are included in the Part A reimbursement as long as thepatient 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

30X31X32X73X74X

X-RAYS, RADIUM AND RADIOACTIVE ISOTOPE THERAPY(including materials and services of technicians):

33X34X35X

MEDICAL AND SURGICAL SUPPLIES AND DEVICES

27X

PROSTHETIC DEVICES (other than dental) which replace all or part of an internal bodyorgan (including contiguous tissue) or all or part of the function of the permanentlyinoperable or malfunctioning internal body organ, including replacement or repairs ofsuch items 274 *

PHYSICAL THERAPY 42X*OCCUPATIONAL THERAPY 43X*SPEECH THERAPY 44X*

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 yourfacility

Until Part B Consolidated Billing is in effect, vendors may continue to bill directly fortheir services to the carrier, and outpatient hospitals may bill services directly to the fiscalintermediary.

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SNF BILLINGHCPCS 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 types221 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 devices420 – 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 onPart 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 codes31X – all lab path revenue codes320 – angiocardiography323 – arteriography274 – prosthetic/orthotic devices636 – 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 HCPCSreference. If your billers select a code from their reference source, the validity of thiscode can be checked using the OmniPro system. As is the case for diagnosis and revenuecodes, the OmniPro files will mirror our internal computer (Fiscal Intermediary SharedSystem) and allow the biller to determine if the selected code will be accepted duringclaims processing.

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BILLING THERAPY SERVICESUNDER PART B IN A SNF

Physical, occupational and speech therapy are billable to theMedicare 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 notrequired on Part A claims)

♦ If the Part B services are a continuation of therapy begun when the resident was firstadmitted 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 SNFPart A admission), determine the date for Occurrence Code 11 based on when it wasnoted in the patient's medical record that there has been a change in conditionrequiring a restorative therapy program.

START DATE OF THERAPY

Occurrence Code 35 for physical therapy (PT), 44 for occupational therapy (OT), and45 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 startdate 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 bethe first services rendered after the patient was noted to have had a change incondition requiring a restorative therapy program.

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PART B THERAPY BILLING

Type of Bill

12X Hospital inpatient ancillary13X Hospital outpatient22X SNF inpatient ancillary23X SNF outpatient74X ORF (Outpatient Rehabilitation Facility)75X CORF (Comprehensive Outpatient Rehabilitation Facility)83X Ambulatory surgery center

Billing Frequency

Repetitive services, such as PT, OT, and SLP, must be billed on a monthly basis and not on avisit by visit basis.

Revenue Codes

420 Physical Therapy430 Occupational Therapy440 Speech-language Pathology

Primary Diagnosis

The primary diagnosis on the claim should be the diagnosis for which the patient is receivingtherapy services.

Occurrence Codes

Occurrence codes and associated dates define a significant event relating to the bill that mayaffect processing. The following occurrence codes need to be used by all outpatient therapyproviders:

11 Date of onset of symptoms or illness which resulted in the patient’s current need forthe therapy. This code must be present on all physical, occupational and speechtherapy and CORF claims. It should not change during the episode of care unless thepatient has a new onset or exacerbation of an illness.

35 Date of initial PT service at provider44 Date of initial OT service at provider45 Date of initial SLP service at provider

ORFs also use the following occurrence codes:17 Date OT treatment plan was established or last reviewed29 Date PT treatment plan was established or last reviewed30 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. Rightjustify the whole number therapy visit amount to the left of the dollar/cents delimiter andzero fill the cents field. The following value codes need to be used when billing therapyservices:50 Number of PT visits from the start of care at the billing provider through the

current billing period51 Number of OT visits from the start of care at the billing provider through the

current billing period52 Number of SLP visits at the billing provider from the start of care through the

current billing periodEXAMPLE: 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 ofphysical therapy visits would be 30, this would be shown on the claim asvalue code: 50

Health Care Financing Administration Common Procedure Coding System (HCPCS)

HCPCS codes are comprised of two levels. Level I contains the American MedicalAssociation's (AMA) Physicians' Current Procedural Terminology, Fourth Edition (CPT-4) codes. These consist of all numeric codes. Level II contains the codes for physicianand non-physician services that are not included in CPT-4, e.g., ambulance, durablemedical equipment (DME), orthotics, and prosthetics. These are alpha/numeric codesmaintained jointly by the Health Care Financing Administration (HCFA), the Blue Crossand Blue Shield Association (BCBSA), and the Health Insurance Association of America(HIAA).

Providers rendering outpatient therapy services are required to submit claims withHCPCS codes for dates of service on or after April 1, 1998. A grace period was alloweduntil July 1, 1998 dates of service.

HCPCS codes for reporting outpatient physical, occupational, and speech therapy includethe 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 V5364

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

*These codes apply in all settings (bill types 12X, 22X, 23X, 74X, and 75X), excepthospital outpatient departments (bill types 13X and 83X). When delivered in hospitaloutpatient settings, these services are not considered rehabilitation services and will notbe 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. Othercodes may be considered for payment if they are determined to be medically necessaryand 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 nota specific code available for every service, e.g., transfer training.

♦ Use unlisted HCPCS code only when absolutely necessary. A description of what isbeing 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 bebilled 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 requirecovered therapy services.

Re-evaluations can be billed when the patient exhibits a demonstrable change in physicalfunctional ability necessitating revised treatment goals. Monthly re-evaluations/assessments for a patient undergoing restorative SLP programs areconsidered 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 theHCPCS code, is performed.

♦ If the HCPCS code has a time definition, the units are based on a multiple of that timefactor. If more than one type of treatment is rendered that fit the same HCPCS, add allof 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 billmore than one unit there must be a physician order/certification that the therapysession should be rendered more than once daily. It must be reasonable and necessaryfor 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 theprovider (use of dynamic activities to improve functional performance) each15 minutes

REPORT: 43097530

4

Revenue CodeHCPCS/RateService 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: 44092526

1

Revenue CodeHCPCS/RateService 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

971161

Revenue CodeHCPCS/RateService 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 October1, 1998.

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Discipline Specific Modifiers

Providers are required to report the following modifiers to distinguish the type of therapistwho performed the outpatient rehabilitation service. If the service was not delivered by atherapist, then the discipline of the plan of treatment under which the service is deliveredshould be reported. Modifiers are added to the end of the HCPCS code.

GN Speech-language pathologist or under SLP plan of treatmentGO Occupational therapist or under OT plan of treatmentGP Physical therapist or under PT plan of treatment

EXAMPLE: 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 foroutpatient physical and occupational therapy services. The following HCPCS codes wereused.

PT Evaluation Q0103 for dates of service 10/01/97 – 12/31/9797001 for dates of service beginning 1/1/98

PT Re-evaluation Q0104 for dates of service 10/01/97 – 12/31/9797002 for dates of service beginning 1/01/98

PT Treatments 97010 – 97799

OT Evaluation Q0109 for dates of service 10/01/97 – 12/31/9797003 for dates of service beginning 1/1/98

OT Re-evaluation Q0110 for dates of service 10/01/97 – 12/31/9797004 for dates of service beginning 1/01/98

OT Treatments 97010 – 97799

Units of service: Each HCPCS code was counted as one unit per day regardlessof 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 wasbilled on a visit basis. Under this system, each therapy visit was counted as one unit nomatter how many treatments were done during that visit. No HCPCS codes were required.

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Notes