SNF Medicare Billing Frequently Asked Questions

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1 CPAs & ADVISORS experience clarity // SNF Medicare Billing Frequently Asked Questions HEALTH CARE GROUP Julie Bilyeu, Director Lisa McIntire, CPA, Senior Managing Consultant TO RECEIVE CPE CREDIT Individual Attendee Participate in entire webinar Answer polls when they are provided Group Attendees Complete group attendance form with Title & date of live webinar Your company name Your printed name, signature & address All group attendance sheets must be submitted to within 24 hours of live webinar Answer polls when they are provided If all eligibility requirements are met, each participant will be ed a CPE certificate within 15 business days of live webinar 2 // experience clarity 1

2 SNF MEDICARE BILLING FAQ HOSPICE HOSPITAL STAY LEAVE OF ABSENCE SAME DAY DISCHARGE BILLING FREQUENCY UNSCHEDULED MDS ASSESSMENTS EARLY/LATE MDS MISSED ASSESSMENTS PROVIDER LIABILITY OVERLAP AIDS ADD ON 3 // experience clarity HOSPICE If a patient is on hospice, can I bill Medicare for non-related services? This depends on whether the services are related to the beneficiary s terminal condition Reference: Medicare Claims Processing Manual, Chapter 6, Section // experience clarity 2

3 HOSPICE We have a patient who is enrolled in a Medicare replacement plan & a hospice election. The patient is receiving skilled care for treatment unrelated to hospice services. The managed care plan is refusing to pay, stating Medicare is responsible. Who is responsible for paying the claim? If the services are not related to the terminal illness, the Medicare Administrator Contractor (MAC) would Reference: Medicare Benefit Policy Manual, Chapter 9, section // experience clarity HOSPICE We have a patient who is enrolled in a Medicare replacement plan & a hospice election. The hospice election was termed mid-month. When we billed the replacement plan for the skilled stay, they rejected our claim, stating Medicare was primary. Who is responsible for paying the claim? In this unusual situation, it is possible for both traditional Medicare and the Medicare replacement plan to play a role, depending on timing Reference: Medicare Benefit Policy Manual, Chapter 9, section // experience clarity 3

4 HOSPICE We provided vaccines to patients in an active hospice election & our MAC has rejected those claims even though they contained condition code 07. Why are my claims being rejected? A billing requirement change for hospice patients receiving vaccines in a SNF became effective October 1, 2013 Reference: CMS Transmittal // experience clarity HOSPITAL STAY We have a potential Medicare Part A admission who was in the hospital under observation for two days & was then admitted for two days. Will this meet the requirement for the three-day qualifying hospital stay? There has been a lot of discussion about this topic in the industry. The current regulations state that days spent in observation or in the emergency room Reference: Medicare Benefit Policy Manual, Chapter 8, Section 10 8 // experience clarity 4

5 HOSPITAL STAY I have a Part A claim that rejected, stating the hospital stay was prior to the patient s enrollment with Medicare. The patient was enrolled in Medicare November 1 & was in the hospital October Why is the claim rejecting? The hospital discharge date must have occurred on or after... Reference: Medicare Benefit Policy Manual, Chapter 8, Section // experience clarity HOSPITAL STAY I have a potential admission who has a three-day hospital stay, but two days were in one hospital & one day was in another hospital The three consecutive day requirement can be met by a stay in one or more hospitals Reference: Medicare Benefit Policy Manual, Chapter 8, Section // experience clarity 5

6 HOSPITAL STAY We have a Part A admission who is non-weight bearing & will not be able to participate in therapy for at least 45 days. How can we bill Part A since the hospital discharge will be more than 30 days from the Part A admission date? In most circumstances, the SNF Part A admission must take place within 30 days of the hospital discharge. However, Medicare does allows an exception Reference: Medicare Benefit Policy Manual, Chapter 8, Section // experience clarity HOSPITAL STAY We admitted a patient to skilled care that was covered by a managed care replacement plan. Their plan did not require a qualifying hospital stay. The patient has since disenrolled but still meets the criteria for skilled care. Can we bill Part A with no qualifying stay? There is a way to bill Medicare Part A if the patient disenrolled from a managed care plan & the three-day stay requirement was not met Reference: Medicare Claims Processing Manual, Chapter 6, section // experience clarity 6

7 HOSPITAL STAY If a patient had a three-day hospital stay but was on hospice, does that count as a qualifying stay for Part A? If a hospice patient receives general inpatient care for three days or more, & elects to revoke hospice, then... Reference: Medicare Benefit Policy Manual, Chapter 9, section // experience clarity HOSPITAL STAY We have a potential admission who had a three-day hospital stay outside of the United States. Will this meet the criteria for a qualifying stay? A hospital stay in a foreign country may meet the requirement if the hospital qualifies as an emergency hospital References: Medicare Claims Processing Manual, Chapter 3, section 110 Medicare Benefit Policy Manual, Chapter 8, Section // experience clarity 7

8 HOSPITAL STAY If a patient had a three-day stay in a psychiatric hospital, can they qualify for a Part A stay? A three-day stay in a psychiatric hospital does meet the qualifying stay requirement; however, there is a caveat Reference: Medicare Benefit Policy Manual, Chapter 8, Section // experience clarity LEAVE OF ABSENCE We have a Part A patient that went to the hospital & was under observation for two days before returning to us. Can this be billed as a Medicare leave of absence? To qualify as a Medicare leave of absence, Medicare provides specific guidance regarding hospital observation or emergency room visits Reference: RAI Manual, Chapter 2, Page // experience clarity 8

9 LEAVE OF ABSENCE We have a Part A patient that went to a family gathering & is going to be away for two days. Can this be billed as a Medicare leave of absence? A personal leave of absence for home visits does not have a set time limitation to qualify as a leave of absence. However... Reference: RAI Manual, Chapter 2, Page // experience clarity LEAVE OF ABSENCE How do I bill a leave of absence to Medicare? A Part A claim for a leave of absence would contain several unique elements Medicare does not pay for leave of absence days Reference: Medicare Claims Processing Manual, Chapter 6, Section 30 18// experience clarity 9

10 SAME DAY DISCHARGE If a patient is admitted to the SNF & decides to go home the same day, can the SNF be reimbursed by Medicare? If the patient is admitted & discharged on the same day, the SNF can be reimbursed in a certain instance Reference: Medicare Claims Processing Manual, Chapter 6, Section // experience clarity BILLING FREQUENCY Can Part A claims be billed weekly? Inpatient SNF claims must be submitted... Reference: Medicare Claims Processing Manual, Chapter 1, Section // experience clarity 10

11 BILLING FREQUENCY Can Part B claims be billed weekly? Claims for Part B services must be billed on a single monthly bill or... Reference: Medicare Claims Processing Manual, Chapter 1, Section // experience clarity UNSCHEDULED MDS How is an end of therapy (EOT) assessment billed? The non-therapy HIPPS code from section Z0150 of the EOT MDS is billed beginning day one of no therapy services & is billed until the next scheduled or unscheduled assessment is effective 22// experience clarity 11

12 UNSCHEDULED MDS 23 // experience clarity UNSCHEDULED MDS How is an end-of-therapy resumptive (EOT-R) assessment billed? The non-therapy HIPPS code from section Z0150 of the EOT is billed day one of non therapy. When therapy resumes, the previous MDS HIPPS code is billed until the next scheduled or unscheduled assessment takes effect 24 // experience clarity 12

13 UNSCHEDULED MDS How do I bill a start-of-therapy (SOT) assessment? When billing for an SOT assessment, the HIPPS code from section Z0100 of the SOT is billed beginning day one of therapy services (day of evaluation) & is billed until the next scheduled or unscheduled MDS is effective 25 // experience clarity ASSESSMENTS How do I bill a change of therapy (COT) assessment? When billing a COT assessment, the HIPPS codes from section Z0100 of the MDS is billed day one of the therapy observation period 26 // experience clarity 13

14 EARLY/LATE MDS How do you bill a claim that contains assessments with reference dates outside of the allowed assessment reference date (ARD) window? An assessment that does not have an ARD within the defined ARD window will be paid at the default rate for the number of days the assessment was out of compliance. However, there are some special billing requirements Reference: RAI Manual, Chapter 2, Page // experience clarity MISSED ASSESSMENTS If an assessment was not completed, can the days impacted be billed at default? If a required MDS was not completed & the patient had been discharged from Part A when the error was discovered, the MDS cannot be completed & is considered a missed assessment. The days would be considered... Reference: RAI Manual, Chapter 2, Page 2-75 & Chapter 6, Page // experience clarity 14

15 PROVIDER LIABILITY How do I bill a claim that has provider liability days? Claims impacted by provider liability are still billed as covered claims, & days will be deducted from the beneficiary s Part A SNF benefit period. Certain billing codes will need to be included for the MAC to process the claims properly Reference: Medicare Claims Processing Manual, Chapter 6, Section // experience clarity OVERLAP A patient discharged off Part A & remained in our facility for two more weeks before being discharged. We received a phone call from a hospital that their claim was not processing because Medicare still shows the patient in our facility. How is this possible? The reason is that your patient s last Part A claim is overlapping with the hospital s claim. Don t worry. No-pay claims to the rescue! Reference: Medicare Claims Processing Manual, Chapter 6, Section // experience clarity 15

16 AIDS ADD ON Is there additional Medicare payment for treating AIDS patients? Yes. Medicare pays an additional amount for claims billed with certain diagnosis codes Reference: Federal Register 31// experience clarity RESOURCES Medicare Claims Processing Manual Part A (Chapter 6) Guidance/Guidance/Manuals/Downloads/clm104c06.pdf Part B (Chapter 7) Guidance/Guidance/Manuals/Downloads/clm104c07.pdf 32// experience clarity 16

17 RESOURCES Link to RAI Manual (Chapters 2 & 6) Instruments/NursingHomeQualityInits/MDS30RAIManual.html Link to Medicare Benefit Policy Manual (Chapter 8) Guidance/Guidance/Manuals/Downloads/bp102c08.pdf 33 // experience clarity QUESTIONS Julie Bilyeu, Director, BKD, LLP jbilyeu@bkd.com Lisa McIntire, CPA, Senior Managing Consultant, BKD, LLP lmcintire@bkd.com // experience clarity 17

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19 THANK YOU FOR MORE INFORMATION // For a complete list of our offices and subsidiaries, visit bkd.com or contact: Julie Bilyeu //Director jbilyeu@bkd.com // Lisa McIntire//Senior Managing Consultant lmcintire@bkd.com //